CHAPTER XLVIII 



Central control of the bladder^ 



C. RUCH 



Department of Physiology and Biophysics, University of Washington 

 School of Medicine, Seattle, Washington 



CHAPTER CONTENTS 



Methods of Study 



Simple Pressure Recording 

 Cystometry 



Micturition Threshold Determinations in Intact Animal 

 Other Methods 

 Central Control of Bladder Tonus 

 Cystometrogram 



Absence of Higher Control of Bladder Tone 

 Cystometrogram and Physical State of Bladder Wall 

 Summary 



Pathophysiology of Bladder Tonus in Man 

 Higher Control of Micturition 

 Levels of Bladder Control 



Anterior pontine preparation 

 Rostral midbrain preparation 

 Posterior hypothalamic preparation 

 Stimulation experiments 

 Pathological Physiology of Human Micturition 

 Uninhibited neurogenic bladder (.McLellan) 

 Automatic bladder. Synonomy : normal and spastic reflex 

 neurogenic bladder, supranuclear neurogenic bladder, 

 'cord" bladder 

 Autonomous neurogenic bladder. Synonomy; infranuclear 

 neurogenic bladder dysfunction, decentralized blad- 

 der, denervated bladder 

 Tabetic bladder. Synonomy : atonic neurogenic bladder 

 Control of Bladder Sphincters 

 Aflferent Basis of Micturition 



Spinal Afferent and Efferent Pathways 



urinary bladder presents unique but little exploited 

 opportunities for study. It is the most accessible 

 smooth muscle of the body and can be studied quan- 

 titatively in vivo with relatively little interference with 

 it or with the body a.s a whole. Also, the bladder is 

 relatively independent of other visceral organs, so 

 that its control by the brain can be studied without 

 the complexities presented by, for example, the car- 

 diovascular system. 



Although neurologists, urologists and physiolo- 

 gists have a community of interest in the bladder, 

 they have little community of thought. The clinical 

 disciplines have developed a fairly uniform view, 

 apparently little influenced by physiological experi- 

 ments on animals although there is a substantial 

 similarity in methodology which should make 

 translation from aniinals to man easy. A further 

 paradox is that physiological thinking on the subject 

 has been more influenced by classic neurological 

 concepts, especially tho.se of Hughlings Jackson, and 

 by the now classic experiments of a urologist, F. J. 

 F. Harrington. This chapter will bring the neuro- 

 physiological and clinical data into juxtaposition. 



METHODS OF STUDY 



THE NEUR.\L CONTROL of the urinary bladder is a 

 matter of considerable clinical importance to neurolo- 

 gists and to urologists. To the physiologist, the 



' Based in part on studies aided by grants from the Washing- 

 ton State Research Fund for Biology and Medicine and by a 

 contract (Ni 13-150) between the Office of Naval Research, 

 Department of the Navy, and the University of Washington. 



Simple Pressure Recording 



The bladder containing an arbitrarily determined 

 volume of a fluid is connected to a manometer or a 

 tambour by means of a urethral catheter. The bladder 

 contracts under varying degrees of isometricity, 

 depending on the size of the connecting tube, the 

 density of the fluid or the stiffness of the tambour 

 membrane; the limiting case is a strain gauge or a 



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