Other rare but interesting disorders of sweating are Ross syndrome, Adie pupil (see Chap. 13), areflexia and segmental anhidrosis with compensatory hyperhydrosis in other regions of the body, and idiopathic pure sudomotor failure, characterized by urticaria, generalized anhidrosis and elevated IgE; in this syndrome there is no sweating to thermoregulatory needs but preserved sweating with emotional stimuli.
Disturbances of Bladder Function
With regard to the neurologic diseases that cause bladder dysfunction, multiple sclerosis, usually with urinary urgency, is by far the most common. In Fowler’s clinic, other spinal cord disorders accounted for 12 percent of cases, degenerative diseases (Parkinson disease and multiple system atrophy) for 14 percent, and frontal lobe lesions for 9 percent. These data and the physiologic principles elaborated earlier enable one to understand the effects of the following lesions on bladder function (see Fig. 25-4):
Complete destruction of the cord below T12 This occurs with lesions of the conus, as from trauma, myelodysplasias, tumor, venous angioma, and necrotizing myelitis. The bladder is paralyzed for voluntary and reflex activity and there is no awareness of the state of fullness; voluntary initiation of micturition is impossible; the tonus of the detrusor muscle is abolished and the bladder distends as urine accumulates until there is overflow incontinence; voiding is possible only by the Credé maneuver, that is, lower abdominal compression and abdominal straining. Usually the anal sphincter and colon are similarly affected, and there is “saddle” anesthesia and abolition of the bulbocavernosus and anal reflexes as well as the tendon reflexes in the legs. The cystometrogram shows low pressure and no emptying contractions.
Disease of the sacral motor neurons in the spinal gray matter, the anterior sacral roots, or peripheral nerves innervating the bladder The typical causes of this configuration are lumbosacral meningomyelocele and the tethered cord syndrome, in effect, a lower motor neuron paralysis of the bladder. The disturbance of bladder function is the same as above, except that sacral and bladder sensation are intact. Other causes of cauda equina disease are compression by epidural tumor or disc, neoplastic meningitis, and radiculitis from herpes or cytomegalovirus (Elsberg syndrome). It is noteworthy that a hysterical patient can suppress motor function and suffer a similar distention of the bladder (see later).
Interruption of sensory afferent fibers from the bladder Diabetes and tabes dorsalis are typical causes, leaving the motor nerve fibers unaffected. This is a primary sensory bladder paralysis. The disturbance in function is the same as in the two processes earlier. Although a flaccid (atonic) paralysis of the bladder may be purely motor or sensory, as described earlier, in most clinical situations there is interruption of both afferent and efferent innervation, as in cauda equina compression or severe polyneuropathy. Neuropathies affecting mainly the small fibers are the ones usually implicated (diabetes, amyloid, etc.), but urinary retention also occurs in certain acute neuropathies such as Guillain-Barré syndrome.