For quotation: Shvarts P.G., Bryukhov V.V. Disturbances in the act of urination in diseases of the brain // RMZh. 2008. No. 29. S. 2002
Introduction An important stage in the development of modern neurology is the identification of interdisciplinary sections: cardioneurology, neuroophthalmology, otoneurology and neurourology. The emergence of these areas is primarily due to increased interest in the systemic organization of physiological functions regulated by the central nervous system. The subject of the neurourological direction is the study of the pathophysiological mechanisms of urination disorders in neurological patients and the development of diagnostic and treatment algorithms for their correction. For last decade Some success has been achieved in the diagnosis and treatment of urinary disorders in multiple sclerosis, Parkinson's disease, and acute cerebrovascular accident. At the same time, issues related to the pathogenetic mechanisms of the formation of neurogenic urination disorders in diseases of the brain remain poorly understood. To answer these questions, it is necessary to determine the role of individual brain structures, also called “micturition centers,” in the regulation of contractile activity and the coordinated work of the detrusor and urethral sphincter.
An important stage in the development of modern neurology is the identification of interdisciplinary sections: cardioneurology, neuroophthalmology, otoneurology and neurourology. The emergence of these areas is primarily due to increased interest in the systemic organization of physiological functions regulated by the central nervous system. The subject of the neurourological direction is the study of the pathophysiological mechanisms of urination disorders in neurological patients and the development of diagnostic and treatment algorithms for their correction. Over the past decade, some success has been achieved in the diagnosis and treatment of urinary disorders in multiple sclerosis, Parkinson's disease, and acute cerebrovascular accident. At the same time, issues related to the pathogenetic mechanisms of the formation of neurogenic urination disorders in diseases of the brain remain poorly understood. To answer these questions, it is necessary to determine the role of individual brain structures, also called “micturition centers,” in the regulation of contractile activity and the coordinated work of the detrusor and urethral sphincter.
History of opening centers
urination of the brain
The first works devoted to the study of the mechanisms of regulation of urination appeared in 1900 and 1914. Their authors are Guyon and Barrington F.D.F. showed in experiments on cats the role of spinal centers and the hypogastric nerve in the regulation of urination. Barin-g-ton was not satisfied with the results of the study, and in 1925 his work appeared, dedicated to the discovery of the urination center located in cats in the area of the Varoliev bridge. Barrington F.D.F. will be the first physical surgeon to understand the importance of the association between the "micturition centers" of the brain and the functioning of the lower urinary tract (LUT). His famous 1925 paper entitled “Effects of Damage to the Hindbrain and Midbrain on the Urination of the Cat,” which has been cited many times, according to F.I. MacDonald, was one of the most significant works on the study of the brain in the 20th century. The main conclusions of the work were as follows:
1. Destruction of a small part of the brain located ventral to the inner edge of the superior cerebellar peduncles from the level of the middle of the motor nucleus of the fifth nerve behind and the terminal parts of the hindbrain in front leads to complete urinary retention in case of bilateral damage and does not cause urinary impairment in case of unilateral damage.
2. Destruction of the midbrain, from the ventral half of the posterior sections, bypassing the end of the aqueduct, to the nucleus of the fifth nerve is accompanied, in case of bilateral damage, by a constant loss of the desire to urinate and defecate (the disappearance of characteristic behavioral reactions in a cat associated with the ritual of urination), but does not disrupt the functioning of these functions.
3. With more extensive damage, there is an increase in the frequency of urination and defecation. The first of these areas was subsequently called "Barrington's nucleus", "pontine micturition center" (PMC), "M" region (from the Latin medial), or medial micturition center (MCM). As Blok B.F. found out. and Holstege G. (1997), neurons of the “Barrington nucleus” are connected by direct synaptic messages with sacral parasympathetic preganglionic neurons and neurons of the posterior commissures at the sacral level (spinal representations of the pelvic nerve). According to Blok B.F. et al. (1998), the former neurons excite the bladder (via the pelvic ganglia), while the latter are believed to have an inhibitory effect on motor neurons that regulate the external urethral sphincter. As a result of these connections, modern ideas, the stem micturition center coordinates the synergy of the bladder and urethral sphincter. Roppolo J.R. et al. (1985) found that afferent impulses along sensory fibers coming from the vanilloid receptors of the bladder mucosa, bypassing the stem micturition center, rise to the paraventricular nuclei, where their primary processing occurs (Fig. 1). Similar data were obtained in the works of Liu R.P.C. (1983), Blok B.F. and Holstege G. (1994, 1995). A similar picture of urinary regulation has been described in cats and primates. The study of urination centers in humans became possible for the first time with the advent of intravital neuroimaging methods, in particular, positron emission tomography. In the work led by Blok B.F. (1997, 1998), urination in the human brain showed that blood flow increased in the dorsomedial pontine tegmentum, close to the fourth ventricle, and this, the authors hypothesized, was the location of the human MCM. Research Torrens M. (1987), Shefchyk S.J. (2001), Morrison J. et al. (2005) and de Groat W.C. (2006) showed similar areas of Barrington's nucleus in rats, dogs, guinea pigs, pigs and humans. These authors, using modern neurophysiological and urodynamic techniques, identified an additional region within the rostral portion of the posterolateral portion of the pons, responsible for the contraction of the external urethral sphincter, which was called the “L-region” (from the Latin lateral) or the sentinel micturition center (SCM). The SCM contains neurons that influence the motor neurons of the Onuf-Onufrievich nucleus (spinal representation of the somatic pudendal nerve) (Fig. 1, 2).
Holstege G. et al. (1979, 1986) showed the connection of the SCM with thoracolumbar sympathetic preganglionic neurons. Bilateral damage to the central nervous system in cats led to the development of hyperreflexia and urge urinary incontinence. Also described by Bar-ring-ton F.D.F. (1925), the picture of “high tone of the bladder and spastic state of the sphincter” was later called “detrusor-sphincter dyssynergia” (DSD). Modern concepts of the mechanisms of formation of stress urinary incontinence (urinary incontinence due to increased intra-abdominal pressure due to deep breathing, coughing, sneezing, laughing or sexual activity), according to Griffiths D.J. (2002) are also associated with damage to the SCM. Similar data are presented in the work of Minatullaev Sh.A. (2008) in patients with vertebrobasilar insufficiency.
Other important “micturition centers” are the nuclei located in the frontal and temporal lobes and the hypothalamus (Fig. 1). The centers of the frontal cortex are responsible for analyzing afferent impulses constantly arriving through the paraventricular nucleus of the hypothalamus from the bladder filled with urine. Most of these impulses are summed up and as a result are recognized by the person as the urge to urinate when the bladder is filled to 250-300 ml. This is followed by behavioral reactions associated with the search for an area convenient for urination (the basal ganglia are probably responsible for this). Finding a comfortable place to urinate is programmable social norms behavior. A change in urinary behavior and the removal of taboos may indirectly indicate a disruption in the coordinated work of the frontal and subcortical urination centers (this also applies to patients limiting their drinking regime). Such urination disorders are observed with severe cognitive impairment and may reflect the dynamics of changes in the personality core.
Subcortical ganglia are hierarchically subordinated to the hypothalamic centers that regulate the daily rhythm of urination. According to MRI data, the presence of lateral and subcortical leuko-areosis with the development of microinfarctions can lead to the appearance of dysuric disorders and a shift in biological rhythms towards night urination (with normal or reduced daytime urination). In particular, vascular damage to the brain stem in discirculatory encephalopathy (DE) is usually in the nature of microinfarctions and can affect the MCM described by Barrington F.J.F. in 1925, and paired SCMs that regulate detrusor contraction and urinary continence. In the MCM, the summation and redistribution of ascending spinal impulses from the bladder occurs. Both of these paired centers work synchronously and antagonistically. When the MCM, which has an effect on the parasympathetic centers of the spinal cord, is activated, the bladder contracts, and when the sentinel center associated with the sympathetic centers of the spinal cord (and, apparently, somatic) is activated, the involuntary urethral sphincter contracts.
Thus, the works of Barrington F.J.F. remain central to the modern understanding of central control of urination in humans and animals.
Brain diseases
leading to disorders
act of urination
Disturbances in the act of urination are a common complication of brain diseases, which is explained by the high concentration of cortical, subcortical and stem centers that regulate the contractile activity of the bladder and urethra, as well as “urinary behavior”. Damage to one or more urination centers, conductive nerve fibers between the centers, an imbalance of neurotransmitter systems - all this can become an independent cause of discoordinated work of the detrusor and urethral sphincters. In addition, taking a number of medications used in neurological practice can independently change the contractile activity of the uterine tract. The nature of the course (progressive or remitting) and development (acute or chronic) is also reflected in the dynamics of the development of dysfunctions of the urinary tract. It is also worth mentioning such a formidable iatrogenic complication of neurogenic urinary disorders as catheter-associated urinary tract infection, which accompanies bladder catheterization in acute and chronic urinary retention.
Stroke - damage to the centers
brain urination
The most common form of urinary dysfunction observed in patients who have suffered a stroke is urge urinary incontinence, which significantly reduces the quality of life and social adaptation, and, according to a number of authors, is a predictor of patient mortality and suicide attempts.
Acute and chronic urinary retention, as well as catheter-associated infection associated with intermittent or constant drainage of urinary tract, can lead to the development of chronic foci of infection and septic complications in the acute and subsequent periods of urinary tract.
The incidence of urological complications of cerebrovascular accident varies depending on the phase of cerebrovascular accident, gender and age of patients, the nature of brain damage (ischemic or hemorrhagic), localization of the lesion (Fig. 2) and tactics of patient management and, according to Langhorne P. et al . (2000) and Brittain K. R. et al. (1998), ranges from 24 to 87%.
Urinary disorders are manifested by lower urinary tract symptoms (LUTS). To assess LUTS, the following scales are used: IPSS, LISS, Madsen - Iversen, Boyarsky index. To date, there is no consensus on what diagnostic questionnaire scale could be used to assess LUTS in neurological patients (including stroke survivors). In urology, the division of LUTS into obstructive and irritative, proposed by P. Abrams (1988), has become widespread.
Obstructive symptoms include a sluggish urinary stream, a feeling of incomplete emptying of the bladder, intermittent urination, and the need to strain to start urinating. Irritative symptoms include: frequent urination (more than 8 times/day), urgency and urinary incontinence, as well as nocturia. Our studies showed that 91% of patients who suffered a stroke have LUTS, of which irritative symptoms were noted in 44%, obstructive symptoms in 23%, mixed symptoms in 14% of patients ( Fig. 3).
According to Lee A.H. et al. (2003), the frequency of occurrence of urge urinary incontinence is also influenced by the nature of the stroke. With subarachnoid hemorrhage (n=322), the authors noted urinary incontinence in 3.1%, with intracerebral hemorrhage (n=807) - 5.2%, with ischemic stroke (n=4681) - 6.7%, and with transient ischemic attacks (n=1974) - 2.0%. Daviet J.C. et al. (2004), note that for a period of 2 days LUTS are observed in 40% of patients, on the 15th day - in 32%, and on the 90th day only in 19%, that is, half as often as in the beginning of the disease. Doshi V.S. et al. (2003) indicate that urinary dysfunction, along with urinary tract infection and depression, is more common in women who have had a stroke compared to men. Devroe D. et al. (2003) indicate that concomitant complications of cerebral infarction, such as type 2 diabetes mellitus in the stage of decompensation, hemorrhagic stroke, coma and urinary incontinence can cause death.
Chronic urinary retention is characterized by the presence of residual urine in the bladder. A convenient, reliable and minimally invasive method for determining residual urine is ultrasound examination of the volume of the bladder after urination. A study of 123 patients who had suffered a stroke showed the presence of residual urine of more than 50 ml in 34 patients: of these, 18 were studied in the first 3 months. after a stroke, 16 patients in a more distant period. According to Daviet J.C. et al. (2004), the presence of residual urine more than 150 ml (normally, residual urine is not determined) on the first day after a stroke is observed in 36% of patients, and on the 90th day only in 19%. When residual urine is detected on the 90th day after a stroke, the death rate of patients increases from 16 to 22%. Dromerick A.W. et al. (2003) revealed the presence of residual urine more than 150 ml in 28 out of 101 patients.
It is important to note that the inability to urinate independently during the acute period of a stroke may also be due to a forced position (lying on the back), the presence of other patients in the ward, and an unusual hospital environment. Creating comfortable conditions for urination for this category of patients allows one to avoid unnecessary catheterizations of the bladder. The use of scales when weighing diapers and percussion determination of bladder filling allows you to minimize the use of a urethral catheter to determine urine output, and therefore minimizes the risk of developing infectious complications.
Nitti V.W. et al. (1996) point out in their work the need to conduct a comprehensive urodynamic study (CUDI) for stroke patients with LUTS. When conducting CUDI in 34 patients, 3 urodynamic variants (forms) of urinary dysfunction were identified: neurogenic detrusor overactivity (NDH) - in 17 (50%), impaired contractility - in 13 patients (38%) and impaired voluntary relaxation of the striated urethral sphincter in 4 (12%) patients.
When comparing data from the IPSS scale with brain MRI scores, C. Fowler et al. (1992) revealed a correlation between the presence of urinary disorders and the localization of brain damage in the frontal and temporal regions, the hypothalamus and the pons, which coincides with other data.
Discirculatory encephalopathy - ischemic damage to the urination centers and their conductors
in the brain
Impaired urination is a very common complication of DE and is observed in 9% of patients in the early stages of the disease. According to Sakakibara R. et al. (1999), even before the appearance of neuroimaging signs of the disease (leukoaraiosis), the incidence of neurogenic detrusor hyperactivity (NDH) (20%) prevails over motor (16%) and cognitive (10%) disorders. The author proposes to study LUTS as one of the early markers of DE in the elderly. As the phenomena of leukoaraiosis increase, an increase in the incidence of LUTS is also noted. The maximum value of this indicator was observed with widespread leukoaraiosis (anterior, middle and posterior) and reaches 93%. At the same time, cognitive and motor deficits increase.
It is noteworthy that in the later stages of the disease the most severe degree of urination disorders is observed, the frequency of which at all stages is higher compared to disorders of mental and motor functions. When distributing individual symptoms, it is possible to identify the relatively early onset of nocturnal urination (nocturia) and the later addition of urge urinary incontinence. An isolated symptom of nocturia can be regarded as a consequence of a violation of circadian rhythms, while night urination as part of overactive bladder syndrome (OAB) is a manifestation of pollakiuria.
In a study by Griffiths D.J. et al. (2002) showed the role of asymmetry of damage to cortical representations on the nature of urination disorders in patients with DE. With damage to the right anterior parts of the frontal cortex, a predominance of urge urinary incontinence was noted with a decrease in the sensitivity of the bladder, and with damage to the left hemisphere, these disorders were observed less frequently.
Thus, there is a certain topical semiotics of neurogenic urination disorders in DE and stroke. By observing the nature of LUTS, one can assume the level of brain damage, and by assessing the dynamics of their development, the clinical variant of DE. To confirm suspected brain damage, it is advisable to perform magnetic resonance imaging (Fig. 4).
The early development of LUTS with relatively preserved cognitive and motor functions, characteristic of some cases of DE, can serve as one of the criteria for the differential diagnosis of various dementias (in particular, Alzheimer's type, when these disorders appear with severe cognitive deficits).
When performing CADI in patients with DE, Minatulla-ev Sh.A. (2008) revealed NDH (motor form) in 60%, OAB without detrusor hyperactivity (sensory form) in 25%. Sphincter disorders were identified in 15% of patients and manifested as stress urinary incontinence (9%) and impaired voluntary relaxation of the striated urethral sphincter (6%). When distributing the types of urodynamic disorders according to the forms of DE, the author reveals the following patterns: in patients with vertebrobasilar insufficiency, sphincter disorders were more often observed, in patients with multi-infarction hypertensive encephalopathy and subcortical arteriosclerotic encephalopathy, an increase in bladder motility was noted, and in patients with a mixed form of DE - increased sensitivity of the bladder.
When comparing neuroimaging signs of DE with urodynamic forms of urination disorders, we identified the following correlations: 1) NDG (motor form) was identified in patients with anterior and posterior leukoaraiosis, lacunar infarctions in the paraventricular and preoptic areas, as well as in the area of the pons; 2) sensory disorders of urination were noted in patients with anterior leukoaraiosis; 3) sphincter disorders were identified in patients with lacunar infarctions in the area of the Varoliev bridge.
Multiple sclerosis - combined damage to the nerve conductors between the micturition centers of the brain and spinal cord
According to various authors, the incidence of urinary disorders ranges from 24 to 96% of MS cases. Using the I-PSS scale allowed us to identify LUTS in 253 of 325 patients (78%). Irritative symptoms, including urinary urgency, nocturia and urge incontinence, were identified in 48 (19%) patients. Obstructive symptoms, including difficulty starting urination, a thin stream of urine and a feeling of incomplete emptying of the bladder, were noted in 93 (37%) patients. Mixed symptoms, including various combinations of symptoms, were detected in 112 (44%) patients with MS. Disorders of urination in 191 (75%) patients with MS were clinically manifested in the first 5 years of the disease, and in 18 of them LUTS were noted at the onset of the disease, and in 5 of these patients LUTS were the only manifestation of the neurological disease during the first 3 years, and Only MRI of the brain and neurophysiological studies made it possible to establish the diagnosis of MS (Fig. 4). When comparing the data obtained from MRI of the brain with clinical manifestations of urinary dysfunction in MS patients (n=112), the following significant correlations were noted: 1) the presence of MS plaques in the corpus callosum was combined with irritative symptoms, 2) damage to the cerebellum - with a violation voluntary relaxation of the pelvic floor muscles, 3) damage to the brain stem was accompanied by obstructive and mixed symptoms, 4) the presence of MS plaques in cervical spine spinal cord was combined with detrusor-sphincter dyssynergia (DSD). The data obtained can be explained by the discoordination between the work of the centers located in the corresponding parts of the brain and spinal cord that regulate the normal act of urination, in particular, the stem and subcortical pressor centers that control the contractile activity of the detrusor, as well as the cerebellar centers that regulate the contractile activity of the voluntary component of the urethral sphincter (Fig. .3). In 105 MS patients (32%), ultrasound revealed residual urine in a volume of more than 50 ml. At the same time, 27 patients who had residual urine according to ultrasound did not feel its presence. At the same time, in 18 patients with a complaint of a feeling of incomplete emptying of the bladder, the presence of residual urine was not noted. KUDI data are presented in Table 1.
As can be seen from Table 1, CUDI identified all known types of urination disorders, each of which had characteristic urodynamic signs. Analysis of patients' complaints and comparison of them with the results of CUDI showed that various types dysfunction of the urinary tract may be accompanied by a similar clinical picture. NDH and OAB without detrusor hyperactivity are accompanied by severe irritative symptoms. Therefore, based on the symptoms of frequent daytime and night urination, as well as urgent urinary incontinence, these forms of dysfunction of the urinary tract may be suspected. Considering the absence of complaints characteristic of impaired bladder emptying in these patients, as well as the possibility of accurately determining residual urine using ultrasound, there is every reason to refuse to conduct CUDI in such cases.
In turn, in patients with impaired voluntary relaxation of the striated urethral sphincter and in patients with decreased contractility of the detrusor, identified according to a comprehensive urodynamic examination, obstructive symptoms, including all obstructive symptoms, were noted. Analysis of these symptoms did not reveal specific manifestations that make it possible to note the difference between these two forms. Consequently, in patients with obstructive symptoms, only CADI allows one to determine the type of dysfunction of the urinary tract and, based on this, select the appropriate type of treatment.
In patients with DSD and NDH in combination with reduced contractility of the detrusor, complaints are noted that are characteristic of both irritative and obstructive types of dysfunction of the urinary tract. This circumstance proves the impossibility of accurately determining these forms of dysfunction of the urinary tract based on complaints and the clinical picture of urinary dysfunction and emphasizes the need to perform CUDI.
The need for a specialized urological diagnostic set of measures to identify urinary disorders in patients with brain diseases with subsequent determination therapeutic tactics dictates the mandatory participation of a urologist in the examination of neurological patients.
Parkinson's disease -
urinary disturbance
as a manifestation of deficiency
dopamine and parasympathicotonia
In contrast to urination disorders, the cause of which was ischemic damage to the urinary centers and/or demyelinating damage to their conductors (vascular origin in DE or inflammatory in MS), dysfunction of the urinary tract in Parkinson's disease occurs due to dopamine deficiency caused by the death of the population of pigmented dopaminergic neurons of the pars densa substance and other dopamine-containing nuclei of the brain stem. Yoshimura N. et al. (2003) showed in their studies the role of D1/D5 receptors in the regulation of urination. Stimulation of these dopamine receptor subtypes suppressed detrusor overactivity, while stimulation with quinpirole, an agonist of the D2/D3/D4 dopamine receptor subtypes, resulted in a decrease in bladder storage function. Stimulation with PD128907, a selective agonist of the D3 receptor subtype, did not lead to changes in bladder function. Deficiency of excitation of D1/D5 receptors is not the only possible cause of the development of urinary hemorrhage and other urinary disorders in PD. In the later stages of the disease, by the 5-8th year of the disease, parasympathicotonia appears, the manifestations of which, in addition to NDH (normally, detrusor contractions occur due to the activation of the parasympathetic urination center located in the conus medularis), are sialorrhea, spastic constipation, etc. Therefore, it can be assumed that similar clinical and urodynamic phenomena in different periods of the disease are based on different mechanisms that form them. This, in turn, may explain the ineffectiveness of pharmacotherapy for these disorders using anticholinergics in the early stages of the disease and D1/D5 receptor stimulants in the later stages of the disease. The appearance of urinary disorders in PD in the later stages of the disease can be explained by the relative preservation of the frontal, subcortical and spinal micturition centers, the neurotransmitters of which are acetylcholine, norepinephrine, gamma-aminobutyric acid, serotonin, substance P and histamine.
Soler J.M. (2004) points to sphincter disorders in PD, which, according to his observations, are observed in 30-90% of cases. According to our observations, (Fig. 3) urinary disorders are observed in 48% of patients, among whom were patients with akinetic-rigid and rigid-trembling forms of the disease. Of these, irritative LUTS predominate in 29% and NDH is detected during CUD, 10% have impaired detrusor contractility, and 9% have mixed symptoms, caused in some cases by benign prostatic hyperplasia. Mazurenko D.A. (2005) in his work confirmed the opinion of Araki I. (2000) that the high risk of complications from surgical treatment Benign prostatic hyperplasia in patients with PD is due to the neurogenic rather than organic origin of LUTS in this category of patients.
Drug therapy for urinary disorders in brain diseases
Pharmacotherapy is the most effective method treatment of functional urinary disorders. The priority group of drugs used to treat NDH in diseases of the brain are anticholinergics. These drugs block muscarinic (M)-cholinergic receptors of the bladder with varying degrees of organ specificity and selectivity for different subtypes (Table 2). The main objectives of this type of treatment are to reduce the contractile activity of the detrusor and increase the functional capacity of the bladder, which is clinically expressed in a decrease in urination and a decrease in the severity of imperative urges, and in the presence of urgent urinary incontinence, the elimination of the latter.
The stable therapeutic effect of the use of drugs in this group creates conditions for their long-term use. Also, while taking tolterodine tartrate, patients noted relief of anal incontinence in patients with MS, and when using trospium chloride in patients who had suffered a stroke, normalization of intestinal function was noted due to a decrease in the phenomena of spastic constipation, and in patients with PD, the phenomena of sialorrhea decreased. When taking anticholinergic drugs, 5-54% of patients experience dry mucous membranes, the least pronounced with trospium chloride.
Less commonly observed are central effects such as hallucinations, atonic constipation, tachyarrhythmia, exacerbation of angle-closure glaucoma and the appearance of residual urine. When side effects it is possible to reduce the daily dose of the drug or discontinue the drug. It is important to note that in PD, the use of anticholinergic drugs that cross the BBB is not recommended due to the possible potentiation of antiparkinsonian therapy.
In the complex treatment of dysfunctions of the urinary tract in patients with spasticity of the pelvic floor muscles, botulinum toxin is used, which affects the GABAergic regulation of urination.
According to our observations, drugs of this group are most effective in patients with pseudodyssynergia and in some patients with decreased detrusor tone. α1-blockers (doxazosin mesylate, alfuzosin, terazosin and tamsulosin) help facilitate the onset of urination in patients with DSD.
In patients with reduced detrusor contractility, anticholinesterase agents are used that can inhibit the enzyme acetylcholinesterase (distigmine bromide and pyridostigmine bromide) with varying degrees of reversibility. The therapeutic effect develops on the 2-3rd day of use and is expressed in increased frequency of urination, disappearance of residual urine, increased sensation of the urge to urinate and easier onset of urination.
The use of symptomatic drugs that affect the act of urination is a necessary addition to the pathogenetic therapy of brain diseases.
The nature of the “positive” and “negative” side effects from neuropharmacological drugs allows us to trace some parallels between the processes occurring during neurogenic dysfunctions of various pelvic organs (intestines, bladder and genitals) and make assumptions not only about the commonality of their innervation, but also about their functional unity.
Literature
1. Mazurenko D.A. Differential diagnosis and treatment of urinary disorders in patients with Parkinson's disease. dis. ...cand. honey. Sciences - M., 2005. - 105 p.
2. Minatullaev Sh.A. chronic vascular diseases of the brain and functional disorders of urination. : Author's abstract. dis. ...cand. honey. Sci. M., 2008. 25 p.
3. Shvarts P.G. Disorders of urination in patients with relapsing-remitting multiple sclerosis. : Author's abstract. dis. ...cand. honey. Sci. M., 2004. 22 p.
4. Abrams P.H., Blaivas J.G., Stanton S.L., Anderson J.T. Standardization of terminology of lower urinary tract function. // Neurourol. Urodyn. - 1988. - Vol. 7 - P. 403-428.
5. Araki I. Kitahara M. at al., Voiding dysfunction and Parkinson’s disease: urodynamic abnormalities and urinary symptoms. : J Urol 2000 Nov;164(5):1640-3.
6. Barrington FJF The effect of lesions of the hind- and mid-brain on micturition in the cat. Q J Exp Physiol. 1925. 15, 81-102. Elsevier. 1992.
7. Blok BF & Holstege G. Ultrastructural evidence for a direct pathway from the pontine micturition center to the parasympathetic preganglionic motoneurons of the bladder of the cat. Neurosci Lett. 1997. 222, 195-198.
8. Blok BF, Sturms LM & Holstege G. A PET study on cortical and subcortical control of pelvic floor musculature in women. J Comp Neurol. 1997. 389, 535-544.
9. Blok BF, DeWeerdH & Holstege G. Ultrastructural evidence for a paucity of projections from the lumbosacral cord to the pontine micturition center or M-region in the cat: a new concept for the organization of the micturition reflex with the periaqueductal gray as central relay. J Comp Neurol. 1995. 359, 300-309.
10. Blok BF & Holstege G. Direct projections from the periaqueductal gray to the pontine micturition center (M-region). An anterograde and retrograde tracing study in the cat. Neurosci Lett. 1994. 166, 93-96.
11. Blok BF, Sturms LM & Holstege G. Brain activation during micturition in women. Brain. 1998. 121 (Pt 11), 2033-2042.
12. Blok BF, van Maarseveen JT & Holstege G. Electrical stimulation of the sacral dorsal gray commissure evokes relaxation of the external urethral sphincter in the cat. Neurosci Lett. 1998. 249, 68-70.
13. Brittain K.R. et al. // Stroke 1998. Vol. 29; 2: 524-528.
14. Daviet J.C. et al. // Ann Readapt Med. 2004. Oct 47(8). P. 531.
15. Devroey D et al. // Cerebrovasc Dis. 2003. No. 16(3). R. 272.
16. Dromerick A.W. et al. // Arch Phys Med Rehabil. 2003. No. 84(9). R. 1369.
17. Doshi V.S. et al. // Singapore Med J. 2003. vol. 44(12). R. 643.
18. Fowler C.J., Frohman E.M. Neurological bladder bowel and sexual dysfunction.
19. De GroatWC. Integrative control of the lower urinary tract: preclinical perspective. Br J Pharmacol. 2006. 147 Suppl 2, S25-S40.
20. De GroatWC. Nervous control of the urinary bladder of the cat. Brain Res. 1975. 87, 201-211.
21, Griffiths DJ. The pontine micturition centres. Scand J Urol Nephrol. 2002. Suppl 210, 21-26.
22. Holstege G, Griffiths D, deWall H & Dalm E. Anatomical and physiological observations on supraspinal control of bladder and urethral sphincter muscles in cats. J Comp Neurol.1986. 250, 449-461.
23. Holstege G, Kuypers HG & Boer RC. Anatomical evidence for direct brain stem projections to the somatic motoneuronal cell groups and autonomic preganglionic cell groups in cat spinal cord. Brain Res. 1979. 171, 329-333.
24. Langhorne et al. // Stroke. 2000. Vol. 31. 6. R. 1223.
25. Lee A.H. et al. // MJA 2003. No. 179 (6) R. 289.
26. Liu RPC. Laminar origins of spinal projection neurons to the periaqueductal gray of the rat. Brain Res. 1983. 264, 118-122.
27. Loewy AD, Saper CB & Baker RP. Descending projections from the pontine micturition center. Brain Res. 1979. 172, 533-538.
28. Morrison J, Fowler C, Birder L, Craggs M, de Groat W, Downie J, Drake M & Thor K Neural control of the bladder. Incontinence, ed. Abrams P, Cardozo L, Khoury S & Wein A, 2005. pp. 363-422. Health Publications Ltd, Paris.
29. Nitti V.W. et al. // J Urol. 1996. No. 155(1). R. 263.
30. Sakakibira R. et al. //Int. Urogynecol J Pelvic floor Dysfunction. 1999. No. 10(3).R. 192.
31. Roppolo JR, Nadelhaft I & de GroatWC. The organization of pudendal motoneurons and primary afferent projections in the spinal cord of the rhesus monkey revealed by horseradish peroxidase. J Comp Neurol. 1985. 234, 475-488.
32. Soler JM, Le Portz B Bladder sphincter disorders in Parkinson’s disease Ann Urol (Paris). 2004 Dec;38 Suppl 2:S57-61.
33. Shefchyk SJ. Sacral spinal interneurones and the control of urinary bladder and urethral striated sphincter muscle function. J Physiol. 2001. 533, 57-63.
34. TorrensM&Morrison JFB. The Physiology of the Lower Urinary Tract. Springer-Verlag, 1987. London.
35. Yoshimura N, Kuno S, at al., Dopaminergic mechanisms underlying bladder hyperactivity in rats with a unilateral 6-hydroxydopamine (6-OHDA) lesion of the nigrostriatal pathway. Br J Pharmacol. 2003 Aug;139(8):1425-32.
The daily amount of urine in a healthy person is on average 1500 ml. This volume is approximately 75% of the fluid taken per day, the remaining 25% is excreted from the body by the lungs, skin, and intestines. The frequency of urination per day ranges from 4 to 6 times. The bladder is completely emptied during urination. Urination itself lasts no more than 20 seconds at a urine flow rate of 20-25 ml/sec in women and 15-20 ml/sec in men.
Urination in a healthy person is a voluntary act, completely dependent on consciousness. Urination begins as soon as an impulse is given from the central nervous system. Once urination has begun, it can be arbitrarily interrupted by the appropriate command from the central nervous system.
The physiological volume of the bladder is 250-300 ml, but depending on a number of circumstances (ambient temperature, psycho-emotional state of a person), it can vary widely.
Disturbances in the act of urination are divided into 2 large groups: a) disturbances in the act of urination as symptoms of irritation of the lower urinary tract and b) disturbances in the act of urination as symptoms of bladder outlet obstruction (a mechanical obstruction to the outflow of urine at the level of the urethra).
Symptoms of lower urinary tract irritation include frequent and painful urination, sudden urge to urinate (a sudden strong urge to urinate, sometimes unable to hold in the urine), and frequent urination at night. Recently, these symptoms have been referred to as bladder filling phase symptoms. The cause of irritation symptoms is an inflammatory process in the bladder, prostate, and urethra. Tumors, foreign bodies, specific (tuberculous) inflammation, radiation therapy can also cause symptoms of irritation of the lower urinary tract.
Among the symptoms of irritation of the lower urinary tract, the most common is frequent urination - pollakiuria (daytime pollakiuria - more than 6 times a day, night pollakiuria - more than 2 times a night). This symptom appears in diseases of the lower urinary tract: bladder, urethra. The volume of urine for each urination decreases, but the total amount of urine excreted per day does not exceed the norm. The frequency of urination can be significant, reaching 15-20 times a day or more. Pollakiuria may be accompanied by an imperative (imperative) urge to urinate. Pollakiuria can be observed only during the day, disappearing at night and at rest; this often occurs with stones in the bladder. Nocturnal pollakiuria (nocturia) is often observed in patients with prostate tumors. Persistent pollakiuria can be observed in chronic bladder diseases. Pollakiuria is often accompanied by pain when urinating.
Oligakiuria– abnormally infrequent urination, most often the result of a violation of the innervation of the bladder at the level of the spinal cord (disease or injury).
Nocturia– predominance of nighttime diuresis over daytime due to an increase in the volume of urine excreted and the frequency of urination. Most often, this condition is observed in cardiovascular failure. Hidden edema that forms during the day due to heart failure decreases at night when conditions for cardiac activity improve. The entry of more fluid into the vascular bed leads to an increase in diuresis.
Strangury– difficulty urinating in combination with increased frequency and pain. Most often, strangury is observed in patients with a pathological process in the neck of the bladder and with urethral strictures.
Urinary incontinence– involuntary release of urine without the urge to urinate. There are true and false urinary incontinence. True urinary incontinence occurs in case of insufficiency of the urethral sphincter, with anatomical changes in urinary tract No. True urinary incontinence can be permanent, or it can only occur in certain situations (intense physical activity, coughing, sneezing, laughing, etc.). False urinary incontinence is observed in cases of congenital (exstrophy of the bladder, epispadias, ectopia of the ureteric orifice into the urethra or vagina) or acquired defects of the ureters, bladder or urethra (traumatic injuries of the urethra and ureter).
Currently, there are several types of true urinary incontinence:
stress urinary incontinence or stress urinary incontinence;
Urgent urinary incontinence (urinary incontinence) – involuntary loss of urine with a preceding imperative (urgent) urge to urinate;
mixed incontinence – a combination of stress and urge incontinence;
enuresis - any involuntary loss of urine;
nocturnal enuresis – loss of urine during sleep;
constant urinary incontinence, urinary incontinence from overflow (paradoxical ischuria);
other types of urinary incontinence can be situational, for example, during sexual intercourse, laughing.
Stress incontinence. It develops as a result of a violation of the normal anatomical relationship between the bladder and the urethra due to decreased tone of the pelvic floor muscles and weakening of the sphincters of the bladder and urethra. In this case, increased intra-abdominal pressure (laughter, coughing, lifting weights, etc.) affects only the bladder, and the urethra is beyond the influence of the vectors of increased pressure. In this situation, the pressure in the bladder is higher than the intraurethral pressure, which is manifested by the release of urine from the urethra throughout the entire time until the pressure in the bladder becomes lower than the pressure in the urethra.
Urinary incontinence or urge incontinence– inability to hold urine in the bladder when the urge to urinate occurs. More often observed in acute cystitis, diseases of the bladder neck, prostate gland. Urinary incontinence is a manifestation of an overactive bladder.
Nocturnal enuresis– urinary incontinence that occurs during sleep at night. It is observed in children due to neurotic disorders or intoxication due to an infectious disease, as well as due to the inferiority of the endocrine system, manifested by insufficient production of antidiuretic hormone. Under such unfavorable conditions, dissociation of impulses in the central nervous system occurs and stable connections between the cortex, subcortex and spinal cord centers are not formed during the formation of the urination reflex. As a result of this, there is insufficient inhibition by the cortex of the subcortical centers at night and impulses emanating from the bladder when it is filled with urine are switched at the level of the spinal cord and lead to automatic contraction of the bladder with urination, without causing the child to awaken.
Overflow incontinence. Overflow incontinence (paradoxical ischuria) occurs due to the loss of the ability of the bladder muscles to contract and passive overdistension of the bladder with urine. Overdistension of the bladder leads to stretching of the internal sphincter of the bladder and insufficiency of the external sphincter. In this case, spontaneous urination is absent and urine is almost constantly released from the urethra drop by drop due to the excess of intravesical pressure over intraurethral pressure. Urinary incontinence from overflow (paradoxical ischuria) is a manifestation of detrusor decompensation and occurs with bladder outlet obstruction of any origin (benign prostatic hyperplasia, urethral stricture).
Symptoms of bladder outlet obstruction are more often manifested by symptoms of impaired bladder emptying in the form of: difficulty starting urination, the need to strain when urinating; reducing the pressure and diameter of the urine stream; sensations of incomplete emptying of the bladder after urination; acute or chronic urinary retention (involuntary cessation of physiological emptying of the bladder); intermittent urine flow.
Difficulty urinating– noted in cases of obstruction to the outflow of urine through the urethra. The stream of urine becomes sluggish, thin, the pressure of the stream weakens until it comes out drop by drop, and the duration of urination increases. Difficulty urinating is observed with urethral strictures, benign hyperplasia and prostate cancer.
Retention of urination (ischuria). There are acute and chronic urinary retention. Acute urinary retention occurs suddenly. The patient cannot urinate due to an intense urge to urinate and intense pain in the bladder area. Acute urinary retention often occurs in cases of chronic obstruction to the outflow of urine (benign prostatic hyperplasia, stone and urethral stricture).
Chronic urinary retention develops in patients with partial obstruction of urine outflow in the urethra. In these cases, the bladder is not completely cleared of urine during urination and some of it remains in the bladder (residual urine). In healthy individuals, after urination, no more than 15-20 ml of urine remains in the bladder. With chronic urinary retention, the amount of residual urine increases to 100, 200 ml or more.
The invention relates to medicine and can be used to facilitate urination in men with benign prostatic hyperplasia (prostate adenoma), prostatitis and narrowing of the urethra (urethral stricture). When the urge to urinate occurs, the fingers of the hands guiding the penis are placed above its head so that the index finger is on the back surface of the penis directly below the place where the urethra passes, and the thumb is on top, on its front surface. After the beginning of the difficult flow of urine, the fingers of the hand squeeze the penis with a force sufficient to interrupt its flow and the formation of urine pressure in the urethra, which becomes equal to the urine pressure in the bladder and which expands the lumen of the urethra. Then, after a short wait, the fingers are unclenched, and as the stream of urine weakens, the cycle is repeated several times until the bladder is emptied. The method allows you to delay or avoid bougienage and surgical operations. 2 salary f-ly.
The invention relates to such a branch of medicine as urology, and is intended to facilitate the act of urination in men with benign prostatic hyperplasia (prostate adenoma), prostatitis and narrowing of the urethra (urethral stricture).
It is known that such problems are solved with the use of medications, for example tamsulosin, which is a blocker of postsynaptic α 1 -adrenergic receptors located in the smooth muscle of the prostate gland, bladder neck and prostatic urethra. Blockade of receptors leads to a decrease in muscle tone, which facilitates the outflow of urine. However, the use of this and similar methods is limited by existing contraindications and the high cost of medications.
In more advanced cases, to solve the problem of urination, they resort to surgical operations.
Even such a relatively gentle procedure as bougienage is quite painful and traumatic, and is fraught with complications, to prevent which antiseptic drugs are prescribed.
A number of conservative methods for treating chronic prostatitis are also known, for example, RU patents: 2175862, 99115358, 2205622, 2008105493A.
The idea of the proposed method is to force the urine flowing through the urethra to itself expand the channel, which is narrowed due to the presence of pathology.
The proposed method of facilitating the act of urination is called paradoxical in the sense that in addition to the existing internal obstacles that impede the normal flow of urine due to pathological condition genitourinary system, an external, man-made effect on the penis is added, completely interrupting its flow.
The proposed method is based on the following physical provisions:
The urine pressure along the canal during urination falls from a maximum value at the entrance to the urethra, where it is equal to the urine pressure in the bladder created by the detrusor, to zero at the outlet at the head of the penis. In this case, the greatest pressure drop will be where the canal is narrowed, as is the case in the area where the urethra passes through the thickness of the affected prostate gland, the length of which is about four centimeters, or where it is narrowed due to injury or an inflammatory process (urethral stricture).
The forces that stretch the walls of the urethra during urination and expand its lumen are proportional to two quantities: urine pressure and the diameter of the lumen. These quantities are interrelated in such a way that an increase in one of them leads to an increase in the other.
According to the proposed method, in order to start the process of expanding the lumen of the urethra and thereby facilitate the act of urination, it is necessary to increase the pressure of urine in the urethra after it is filled with urine.
This goal is achieved as follows.
When the urge to urinate occurs, the fingers of the hands guiding the penis are placed above its head so that the index finger is on the back surface of the penis directly below the place where the urethra passes, and the thumb is on top of its front surface.
The onset of urine flow occurs without pressure in the form of an intermittent stream or in the form of falling drops.
After filling the urethra with urine, the fingers squeeze the penis with enough force to interrupt the flow of urine. This leads to the fact that the urine pressure along the entire canal is equalized and reaches a maximum value, which is equal to the urine pressure in the bladder.
The finger lying on the back surface of the penis begins to feel the tension of the urethra and an increase in its diameter.
Dilatation of the urethra occurs both in the problematic prostatic area, where its lumen is extremely small, and in the area of urethral stricture.
After some time, the fingers unclench. Initially, a small volume of pressurized urine is released into the dilated urethra. It is followed by a stream of urine, corresponding to the increased lumen of the urethra, which has been preserved due to the fact that the urethra has been overstretched under the influence of pressure.
A sudden stop in the flow of urine when the fingers are squeezed causes microhydraulic shock. The corresponding jump in urine pressure in the bladder innervates the detrusor and increases its tone.
The duration of artificial interruption of urine flow, the duration of cycles and their number are selected independently.
Here two factors must be taken into account, the effects of which are in different directions.
The pressure of urine on the walls of the urethra, when fingers squeeze the penis, leads to its overstretching and an increase in its lumen. The longer this effect lasts, the longer its result will last after the fingers are unclenched, however, excessive duration of this phase of the cycle reduces the tone of the detrusor, the urine pressure in the bladder decreases, and the outflow of urine weakens.
The pressure of urine in the urethra, which expands its lumen, can be further increased by tensing the abdominal press or by pressing with the free hand on the lower abdomen in the area where the bladder is located. Pressing can be done with jerky movements of the hand.
If the action of this hand or the abdominal press is aimed at increasing the expulsion of urine, then the other, squeezing the penis, prevents expulsion.
The well-known expression “the right hand does not know what the left hand is doing” here literally has the opposite meaning.
The use of this allegory emphasizes the paradoxical nature of the proposed method.
The use of the proposed method, in addition to facilitating the act of urination, allows you to minimize the volume of residual urine in the bladder almost to a level corresponding to a healthy body.
The last circumstance is especially important, because otherwise the bladder itself is involved in the pathological process, the walls of which first thicken for better expulsion of urine, but then their tone decreases, and the bladder becomes atonic and overstretched and contains residual urine. Since the outflow of urine is impaired, chronic renal failure develops.
After a short application of the proposed method, appropriate reflex connections are established, which provide a stable positive result.
Using the proposed method allows you to improve the quality of life, reduce the drug load on the body and, thereby, save money. It creates a more favorable environment for subsequent treatment, such as delaying surgery.
The undeniable advantage of the proposed method is the possibility of its use by suffering men, the number of whom is immeasurable.
1. A paradoxical way to facilitate the act of urination in men with benign prostatic hyperplasia (prostate adenoma), prostatitis and narrowing of the urethra (urethral stricture), which consists in the fact that external, man-made, for which, when the urge to urinate occurs, the fingers of the hands guiding the penis are placed above its head so that the index finger is on the back surface of the penis directly under the place where the urethra passes, and the thumb is on top, on its front surface, after the onset of difficulty the flow of urine, the fingers of the hand squeeze the penis with a force sufficient to interrupt its flow and the formation of urine pressure in the urethra, which becomes equal to the pressure of urine in the bladder and which expands the lumen of the urethra, then, after a short delay, the fingers unclench, and as the stream of urine weakens, the cycle repeat several times until the bladder is completely emptied.
2. The paradoxical method of facilitating the act of urination in men according to claim 1, characterized in that in the phase of the cycle when the fingers compress the penis, an additional increase in urine pressure in the urethra is produced by pressing the lower abdomen in the area of the bladder with the free hand.
3. The paradoxical method of facilitating the act of urination in men according to claim 1, characterized in that in the phase of the cycle when the fingers squeeze the penis, an additional increase in urine pressure in the urethra is produced by tensing the abdominal press.
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The invention relates to medicine and can be used to facilitate urination in men with benign prostatic hyperplasia, prostatitis and narrowing of the urethra
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The bladder is an unpaired organ that serves to accumulate urine continuously flowing from the ureters and performs an evacuation function - urination. It has a variable shape and size, depending on the degree of filling with urine. Its capacity is individual and ranges from 250 to 700 ml.
The bladder is located in the pelvis behind the pubic symphysis. The relationship of the bladder with other organs is different in men and women. In men, the rectum, seminal vesicles and ampoules of the vas deferens are adjacent to it, and in women, the cervix and vagina.
The bladder has an apex, fundus, and body. The place of its transition into the urethra is the cervix. The wall of the bladder consists of three membranes: mucous, muscular and outer (serous). The mucous membrane is mobile and forms numerous folds, which are smoothed out when the bladder stretches. In the bottom area, there is a triangle-shaped area, devoid of folds. Its name is the Lieto Triangle. Here the mucous membrane tightly fuses with the muscular layer. The apexes of the triangle are the openings of the ureters and the mouth of the urethra.
The muscular layer has 3 layers: outer and inner - longitudinal and middle - circular. This membrane is often called the urinary ejector muscle. In the area of the mouth of the urethra, the circular layer forms the sphincter of the bladder, which plays an important role in urine retention.
Mechanism of urination. The bladder is filled with urine to a certain extent without changing intravesical pressure. With further accumulation of urine, the pressure begins to increase and at a certain point, irritation of the receptors of its mucous and muscular membranes occurs. Further, the inclusion of one or another urination mechanism depends on the age of the person and his individual characteristics. In infants, this process is controlled only by the spinal cord. It gives a signal and the bladder automatically empties, the internal sphincter contracts and relaxes.
From about two years of age, a urination center is formed in the cortex of the frontal lobes, which allows, through an effort of will, to delay urination for a while, or, conversely, to carry it out even when the bladder is not full. Contraction of the external sphincter can delay urination or interrupt something that has already begun.
It is impossible to hold urination for a very long period of time. When the bladder is critically filled, all sphincters relax and emptying follows.
Involuntary urination in older children and adults, as well as bedwetting (enuresis), indicate damage to the nervous system and require special examination and treatment.
The act of urination consists of two phases - the urine accumulation phase and the urine evacuation phase. In this case, the detrusor of the bladder and its sphincters (smooth muscle and external, striated) are in a reciprocal relationship: in the phase of urine accumulation, the detrusor relaxes, and the sphincter contracts and holds urine; in the phase of urine emptying, the detrusor contracts and the sphincter relaxes, and the bladder is emptied. This process is ensured by a complex regulatory system, the work of which involves the spinal cord, subcortical and cortical centers, a system of biologically active substances and sex hormones.
In the phase of urine accumulation, the main role belongs to the detrusor of the bladder, which ensures adequate reservoir function (due to the elasticity of the bladder muscles and thanks to the system of detrusor-stabilizing reflexes), while the pressure in the bladder, despite its filling, is maintained at a low level (5 -10 cm water column). Evacuation of urine is a complex reflex act, during which synchronous relaxation of the internal and external sphincters of the bladder and contraction of the detrusor muscle of the bladder occurs. The abdominal and perineal muscles also take part in the evacuation of urine. Normal urination is determined by the anatomical and functional usefulness of not only the sphincters and detrusor, but also the system of nervous structures that regulate this complex act.
The main autonomic center is the spinal center for regulating the act of urination, located at the level of the lumbosacral segments of the spinal cord, which, in turn, has sympathetic (Th XII - L II-III) and parasympathetic (LIV-V) representation. It should be remembered that the parasympathetic department is responsible for the autonomic support of the contractile activity of the detrusor, and the sympathetic department is responsible for its adaptation (as the bladder fills with urine, the pressure in it does not increase). Somatic support for the striated muscles of the pelvic floor is provided by the sacral segments. But the connection between the somatic and vegetative links is largely achieved thanks to the system of reflexes that stabilize the detrusor. It is thanks to this complex system and a reciprocal relationship between the detrusor and the sphincter is ensured (when the detrusor contracts, the sphincter relaxes, and, conversely, the cessation of urination and contraction of the sphincter leads to the restoration of the reservoir function of the bladder). From 6-8 months to one year, the child begins to feel and tries to somehow “signal” the need to urinate. There is an active formation of a conditioned reflex, cortico-visceral (vertical) connections are formed, carried out through the subcortical, pontine centers. As the child grows up, in developing urinary skills and developing a mature type of control over it, three main factors become especially important:
1. Increasing the capacity of the bladder to ensure its reservoir function.
2. The emergence of voluntary control over the striated muscles (external urethral sphincter) to ensure the voluntary start and end of the act of urination, which usually appears by the third year of a child’s life.
3. Formation of direct voluntary control over the miction reflex, which allows the child to control the process of detrusor contraction with his own volitional effort. Initially, the ability to control manifests itself in the daytime, and later during sleep. The last phase of developing urinary control is the most difficult. A formed mechanism for controlling the miction reflex, similar to that of an adult, develops in most children by the age of 5. It is also characterized by the absence of involuntary contractions of the detrusor during the accumulation phase, which is confirmed by special urodynamic studies.
Thus, taking into account the complexity and multicomponent regulatory mechanisms of the act of urination, one can imagine how diverse the etiopathogenesis of urinary incontinence in children can be. However, if you follow the diagnostic protocol developed on the basis of the recommendations of the International Society for Urinary Continence in Children, it is possible, after conducting the necessary research, to clearly differentiate the differences in the causes and nature of urinary incontinence, prescribe treatment that is pathogenetically justified, conduct a course of rehabilitation and achieve recovery.