Symptoms of urinary dysfunction

The cortical innervation of the spinal centers of urination and defecation is bilateral; with unilateral damage to the cortical center, symptoms of urination and defecation disorders are not observed, as is the case with unilateral damage to the lateral column. The so-called central symptoms of urination and defecation disorders develop only with bilateral damage to the cortical centers or lateral columns.

Bilateral lesions of the cortical centers of urination and defecation of any etiology cause persistent symptoms of urination disorders: in the initial period, there is a delay in urination and defecation, which in the late period is replaced by an automatic action. Lesions of the cortical centers can cause transient difficulty in urination. Defecation does not suffer. Bladder disorders of the short-term delay type are observed with lesions of the subcortical centers, especially in the hypothalamic region. With cerebral lesions, in contrast to spinal lesions, outside of urinary retention, emptying of the bladder is almost complete, without residual urine, due to which uroseptic complications are rare. Causes of cerebral lesions: 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 the acts of urination and defecation cease to be voluntary. In this case, these disorders are combined with other clinical syndromes of damage to the nervous system of the corresponding level. Such disorders occur with acute transverse lesions of the cervical and thoracic sections of the spinal cord, usually of infectious or traumatic genesis; less often, they occur with intramedullary hemorrhages, tumors, and leukemic foci. When the spinal cord is compressed by extramedullary tumors, hematoma, abscess, or a deformed vertebra, urination and defecation disorders occur at a later stage, with the development of complete spinal compression.

Disruption of connections between the cerebral and spinal centers leads to severe disorders of urination and defecation of the central type. The patient cannot voluntarily influence urination, the urge, the feeling of urine passing through the urethra disappear. Complete urinary retention occurs. In the initial period of the disease, when all reflex activity of the spinal cord is suppressed, the spinal reflex functions of the bladder also disappear. In this case, the emptying reflex disappears - the sphincters are in a state of contraction, and the detrusor is relaxed and does not function. Urine, accumulating in the bladder and having no 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, a rupture of the bladder wall is possible.

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

After 2-3 weeks, and sometimes at a later date, as the spinal reflex arc is released, urinary retention is replaced by incontinence. In this case, urine is released in small quantities, which is defined as periodic (intermittent) incontinence. This syndrome is based on automatic emptying of the bladder based on the spinal reflex arc, when a certain degree of filling causes relaxation of the smooth muscle sphincter and contraction of the detrusor.

Reflex urination can also be caused by other stimuli from the periphery, such as the flexion protective reflex of the legs or prolonged induction of clonus of the feet.

Voluntary influence on urination is still absent in this phase. At later stages, with complete transverse damage to the spinal cord, reflexes, including automatic urination, fade, and complete urinary incontinence occurs.

In case of partial bilateral spinal lesions at the level of the cervical and thoracic segments, the symptoms of urination disorders consist of a sensation of urges, but the patient is unable to voluntarily hold it in, since simultaneously with the urge, the bladder is emptied - imperative urges. In essence, they are based on an increase in the emptying reflex, which is combined with other clinical manifestations of disinhibition of spinal reflexes (high tendon reflexes with expansion of reflexogenic zones, clonus of the feet, protective reflexes, etc.).

Defecation disorders in case of complete transverse lesion of the spinal cord of the cervical and thoracic localization are similar to urinary disorders. The patient stops feeling the urge to defecate, filling of the rectum, and passage of feces. Both sphincters of the rectum are in a state of spasm. Persistent fecal retention occurs. With a significant accumulation of feces, passive stretching of the sphincter is possible with the passage of an insignificant amount of feces.

Peripheral pelvic organ dysfunctions occur with myelitis of the lumbar and sacral localization, traumatic, vascular, tumor and other processes in the spinal centers, as well as with damage to the spinal roots of the equine tail and peripheral nerves going to the bladder, rectum and their sphincters. Chronic diseases, such as diabetes mellitus, amyloidosis, can lead to damage to the autonomic nerves.

In acute shutdown of the spinal centers or damage to the roots and nerves, more severe symptoms of urination disorders occur in the initial phase than in the subacute or chronic development of the disease. In the acute period, due to paralysis of the detrusor and preservation of the elasticity of the bladder neck, complete urinary retention or paradoxical urination with the release of urine in drops or small portions can be observed. In this case, a large amount of residual urine is detected in the bladder. However, the bladder neck soon loses its elasticity. Since both sphincters are open in peripheral paresis, true incontinence occurs with a constant release of urine as it enters the bladder. Sometimes the bladder empties automatically, but not due to the spinal reflex arc, the integrity of which remains persistently impaired, but due to the preservation of the function of the bladder intramural ganglia.

In case of pathological processes in the area of the equine tail, as well as along the hypogastric nerves (abscesses, injuries, scars), frequent painful urges may be observed even with the accumulation of an insignificant amount of urine in the bladder. The reason for this is irritation of the afferent fibers of the hypogastric nerves and roots.

Defecation disorders with damage to the spinal centers in the conus region, spinal roots of the equine tail and peripheral nerves of the rectum and its sphincters have the same mechanism as the symptoms of urination disorders. With their acute shutdown, paralysis of the sphincters of the peripheral type occurs with complete or partial impossibility of voluntary defecation. The anal reflex falls out, reflex peristalsis of the rectum is absent. Later, true fecal incontinence develops with its passage in small portions upon entry into the rectum. The internal sphincter can partially compensate for the function of the striated external sphincter. However, this compensation can be very limited. In a more remote period, automatic functioning of the rectum occurs due to the intramural plexus - its light peristalsis occurs. Voluntary control of the act of defecation with the automatic action of the rectum is absent.

When the spinal roots and peripheral nerves are irritated due to compression, rectal tenesmus may be observed, which is very painful for the patient; they are usually combined with bladder tenesmus in a single paroxysm or occur separately.

Symptoms of psychogenic urination disorders

The special role of the psyche in the implementation of the urination function, at least by virtue of its obviousness, has never been disputed by anyone. However, in practice, the possibility of urination dysfunction of a psychogenic nature is not always taken into account.

Often, involuntary leakage of urine is caused predominantly or even purely by psychogenic reasons. The possibility of stress urinary incontinence as an acute spastic reaction at the height of affect is well known, and it is no coincidence that “wet pants” have been played out in folklore since time immemorial as the most obvious evidence of extreme degrees of fear.

Reflex urinary incontinence may also be purely psychogenic. Similar symptoms of urinary disorders are encountered in everyday practice not only in cases of severe disorders of consciousness or senile dementia, but also in the clinic of affective pathology. Psychogenic urinary incontinence may be based on the same mechanism as in the pathology developing in childhood, described as decreased sensitivity of the bladder.

Sharply increased urination has long been considered one of the most important clinical signs of "irritable bladder" in the clinic of neurotic disorders. The specific cause of this dysfunction is "unstable detrusor", which creates increased pressure in the bladder between acts of urination in response to any (even very weak) irritants, which is clinically expressed by pollakiuria, nocturia and urinary incontinence.

Pathological self-observation and hypochondriacal ideas about, for example, supposed diabetes mellitus can lead to increased urination up to 20-50 times a day, but without increasing the daily volume of urine. Symptoms of urination disorders in neurotic disorders consist of the development of predominantly (as with bladder stones) daytime pollakiuria, although no stones are found in the urinary tract of these patients. Frequent urination (up to 5-10 times) at night (a feeling of imperative urges due to the same specific worries and anxieties that do not leave the patient either awake or asleep) with a normal daily volume of urine can also be of a purely psychogenic nature (without any connection with prostate adenoma).

Such symptoms of urination disorders as true urinary retention in the clinic of neurotic conditions, as a rule, cause legitimate doubts in clinicians. The so-called hysterical anuria is even considered as a "fiction, a simulation of mythomaniacs, which disappears as soon as the subject is under observation." Nevertheless, spastic urinary retention (up to 24-36 hours) can occur after a hysterical attack or "nervous shock" against the background of pronounced asthenia of the patient and is very often combined with fears, hypochondriacal ideas and doubts. Psychogenic polyuria is characteristic of vegetative crises.

The basis of differential diagnostic tests used to establish the genesis of polyuria is the position that a patient who is able to concentrate urine so that its density exceeds 1.009 does not suffer from diabetes insipidus. In such cases, Russian clinicians recommend "water deprivation" - a dry-eating test or "thirst test", when the patient does not consume any liquid for 6-8 hours. Patients with psychogenic polydipsia tolerate this test relatively easily; the volume of urine excreted decreases, and its density increases to 1.012 and higher.

To date, there are no direct research methods that could directly assess the condition of the nervous apparatus of the bladder and rectum. However, some urological techniques have been developed and are widely used, which, albeit indirectly, allow us to analyze the symptoms of urination disorders, determine the type of disorders and the level of damage to the nervous system, and confirm or exclude urological pathology.