Symptoms of urination disorders

Cortical innervation of the spinal centers of urination and defecation is two-sided; with unilateral damage to the cortical center, symptoms of impaired urination and defecation are not observed, as well as with unilateral involvement of the side column. The so-called central symptoms of micturition and defecation are developed only with bilateral damage to cortical centers or lateral columns.

Bilateral lesion of cortical centers of urination and defecation of any etiology causes persistent symptoms of urination disorders: in the initial period there is a delay in urination and defecation, which in the later period is replaced by automatic action. Defeats of cortical centers can cause a transient difficulty in urination. Defecation does not suffer from this. Bubble disorders of the type of short-term delay are observed in the defeat of subcortical centers, especially in the hypothalamic region. In cerebral lesions, in contrast to spinal lesions outside of urinary retention, bladder emptying is almost complete, without residual urine, and therefore uroseptic complications are rare. Causes of cerebral injury: atrophic process, tumors, trauma, stroke, cerebral arteriosclerosis.

The most severe symptoms of urination disorders occur when the conductors and nuclei of the spinal cord are damaged, when acts of urination and defecation cease to be arbitrary. At the same time, these disorders are combined with other clinical syndromes of nervous system damage at the appropriate level. Such disorders occur in acute transverse lesions of the cervical and thoracic parts of the spinal cord, usually of an infectious or traumatic origin, less often they occur with intramedullary hemorrhages, tumors, and leukemic foci. When the spinal cord is compressed by extramedullary tumors, hematoma, abscess or deformed vertebra, urinary and defecation disorders occur late in the course of development of complete spinal compression.

Violation of the connections of the cerebral centers with the spinal leads to severe disorders of urination and defecation of the central type. The patient can not arbitrarily influence urination, the urge disappears, the urine passes through the urethra. There is a complete retention of urine (complete retention). In the initial period of the disease, when the entire reflex activity of the spinal cord is inhibited, the spinal reflex functions of the bladder disappear. At the same time, the emptying reflex disappears - the sphincters are in a contraction state, and the detrusor is relaxed and does not function. Urine, accumulating in the bladder and not having an outlet, can stretch it to large sizes, when the upper border in the abdominal cavity is determined at the level of the navel and above. Without catheterization, the wall of the bladder can break.

Later, the so-called paradoxical ishuria develops, when as a result of a constant high intravesical pressure, a passive stretching of the bladder neck and bladder sphincters begins with periodic excretion of urine with drops or small portions. A small amount of urine is released and at pressure through the abdominal wall on the area of the bladder. Symptoms of urination disorders in the form of paradoxical urination, especially with the addition of cystitis, can go into permanent incontinence with residual urine in the bladder, which contributes to the connection of the uroseptic infection.

After 2-3 weeks, and sometimes even more distantly, as the spinal reflex arc is disinhibited, the urinary retention is replaced by its incontinence. Urine is excreted in a small amount, which is defined as periodic (intermittent) incontinence. This syndrome is based on the automatic emptying of a bubble on the basis of a spinal reflex arc, when a certain degree of filling causes a relaxation of the smooth muscle sphincter and a reduction in the detrusor.

Reflexive urination can be caused by other stimuli from the periphery, for example, with the flexion defensive reflex of the feet or the prolonged generation of the clonus of the feet.

An arbitrary effect on urination in this phase is still absent. In later periods, with full transverse lesion of the spinal cord, fainting of reflexes, including automatic urination, is observed, and complete incontinence occurs.

In the case of a partial bilateral spinal lesion at the level of the cervical and thoracic segments, the symptoms of urination disturbance are a feeling of urgency, but it is not possible to detain the patient arbitrarily, because simultaneously with the urge, the bubble empties-imperative urges. Essentially, they are based on the strengthening of the emptying reflex, which is combined with other clinical manifestations of disinhibition of spinal reflexes (high tendon reflexes with expansion of reflex zones, clonus of feet, protective reflexes, etc.).

Disturbances of defecation with complete transverse lesion of the cervical and thoracic localization of the spinal cord are similar to urinary disorders. The patient ceases to feel the urge to defecate, filling the rectum, departing feces. Both sphincters of the rectum are in a spasm. There is a persistent stool delay. With a significant accumulation of stools, passive sphincter stretching is possible, with a small amount of feces occurring.

Violations of the functions of the pelvic organs of the peripheral type occur in the myelitis of the lumbar and sacral localization, traumatic, vascular, tumor and other processes in the region of the spinal centers, as well as in the lesions of the spinal roots of the cauda equina and peripheral nerves that reach the bladder, rectum and their sphincters . Chronic diseases, such as, for example, diabetes mellitus, amyloidosis, can lead to damage to the autonomic nerves.

With acute disabling of the function of the spinal centers or lesion of the roots and nerves, the initial phase produces more severe symptoms of urination disturbance than with subacute or chronic development of the disease. In the acute period, due to paralysis of the detrusor and maintaining the elasticity of the neck of the bladder, a complete urinary retention or paradoxical urination can be observed, with urine precipitation in droplets or small portions. In this case, a large amount of residual urine is detected in the bladder. However, soon the cervix of the bladder loses its elasticity. Since both sphincters are uncovered in the peripheral paresis, true incontinence occurs with a constant release of urine as it enters the bladder. Sometimes the bubble is emptied automatically, but not at the expense of a spinal reflex arc, the integrity of which remains permanently impaired, but in connection with the preservation of the function of the bladder intramural ganglia.

In pathological processes in the region of the ponytail, as well as along the course of the hypogastric nerves (abscesses, trauma, scars), frequent painful urges can be noted even when a small amount of urine accumulates in the bladder. The reason for this is irritation of the afferent fibers of the hypogastric nerves and rootlets.

Defecation disorders in the defeat of spinal centers in the cone, spinal cone roots and peripheral nerves of the rectum and its sphincters have the same mechanism as the symptoms of urination disorders. At their acute switching off there is a paralysis of sphincters of peripheral type with full or partial impossibility of any defecation. The anal reflex falls out, the reflexive peristalsis of the rectum is absent. In the future, a true incontinence of the feces is formed with its departure in small portions upon admission to the rectum. The internal sphincter can partially compensate for the function of the transversely striated external sphincter. However, this compensation is very limited. In the more distant period, the automatic functioning of the rectum occurs due to the intramural plexus - there is an easy peristalsis. Arbitrary management of the act of defecation with automatic action of the rectum is absent.

With irritation of the spinal roots and peripheral nerves due to their compression, rectal tenesms, which are very painful for the patient, can be observed; usually they are combined with the tenesmus of the bladder in a single paroxysm or arise separately.

Symptoms of a violation of urination of a psychogenic nature

The role of the psyche in the implementation of the function of urinary excretion was never challenged by anyone, at least in view of its obviousness. However, in practice, the possibility of urinary dysfunction of psychogenic nature is not always taken into account.

Often involuntary outflow of urine is due mainly or even purely to psychogenic reasons. The possibility of stress urinary incontinence as an acute spastic reaction at the height of affect is well known, and it is not by chance that "wet pants" are played out in alternative art from time immemorial as the most obvious evidence of extreme degrees of fear.

Purely psychogenic character can also have reflex incontinence of urine. Similar symptoms of urination disorders are encountered in everyday practice, not only with gross disorders of consciousness or senile marasm, but also in the clinic of affective pathology. The psychogenic incontinence of urine can be based on the same mechanism as in the pathology developing in childhood, described as a decrease in the sensitivity of the bladder.

Rapidly increased urination has long been regarded as one of the most important clinical signs of the "irritated bladder" in the clinic of neurotic disorders. The specific cause of this dysfunction is the "unstable detrusor", which creates between the acts of urination an increased pressure in the bladder in response to any (even very weak) stimuli, which is clinically manifested by pollakiuria, nicturia and urinary incontinence.

Pathological introspection and hypochondriacal representations about, for example, presumed diabetes mellitus can lead to an increase in urinary output to 20-50 times a day, but without increasing the daily volume of urine. Symptoms of urination disorders in neurotic disorders are the development of predominantly (as with bladder stones) diurnal pollakiuria, although concrements in the urinary tract in these patients do not show. Purely psychogenic character (without any connection with prostate adenoma) can also have a rapid (up to 5-10 times) urination at night (a sense of imperative urges due to all the same specific worries and anxieties that leave the patient neither in wakefulness, nor in sleep) with a normal daily volume of urine.

Such symptoms of urinary disorders, such as true urinary retention in the clinic of neurotic states, usually cause legitimate doubts among clinicians. The so-called hysterical anuria is considered even as "a fiction, a simulation of myths, which disappears as soon as the subject is under observation." Nevertheless, spastic urinary retention (up to 24-36 h) can occur after a hysterical fit or "nervous shock" against the background of severe asthenia, and is often combined with fears, hypochondriacal ideas and doubts. Psychogenic polyuria is characteristic of vegetative crises.

The differential diagnostic tests used to establish the genesis of polyuria are based on the assumption that a patient capable of concentrating urine in such a way that its density exceeds 1.009 does not suffer from diabetes insipidus. Domestic clinicians recommend in such cases "water deprivation" - a sample with dry eating or "experience with thirst", when the patient does not consume any liquid for 6-8 hours. Patients with psychogenic polydipsia tolerate this test relatively easily; the volume of excreted urine is reduced, and its density increases to 1.012 and higher.

To date, there are no direct methods of research, with the help of which it would be possible to directly assess the state of nerve devices of the bladder and rectum. However, some urological techniques that, albeit indirectly, allow one to analyze the symptoms of urination disorders, to determine the type of disorders and the level of lesion of the nervous system, and to confirm or exclude urological pathology have been developed and are widely used.