Functional Brain Imaging applied to bladder control

The new ( “ brain “ ) urodynamics

Brain Imaging Techniques

Technique

• SPECT• PET• fMRI

Tracing

99mTc-EC 15O in water

None (BOLD:blood oxygen level dependent)

fMRI BOLD

f-MRI (1.5 - 3 Tesla )

Esempi di compito

1 - Subject lies in the scanner

2 -Task is performed

( bladder filled manually or through distant urodynamic equipment)

3 - Scanner captures and process brain images

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Source : Fowler , AUA 2009

Source : Fowler C , AUA, 2009

How the brain works ?

Micturition Cycle

• Filling phase lasting 3 - 4 hours

• Voiding phase lasting 20 seconds

Bladder distention

Physiological• A- delta myelinated fibers ( low firing )

Pathological• C- unmyelinated fibers ( high firing )

Peak activation of brainstem areas during bladder filling

Fowler C , Griffiths D , 2010

L-region

Block,1996

M-region ( PMC )

Block , 1996

POSITRON EMISSION TOMOGRAPHY (PET) SCANS DURING BLADDER FILLING

PonsPeri-aqueductal grey

INSULA : “Visceral Cortex “The fifth lobe

Integrates internal sensations:

-Heart beat

-Gastric distention

-Bowel distention

-Bladder distention

-Orgasm-Addiction (cigarettes , cocaine , alcohol )

Insula activity during bladder filling

Peak activation of ACG during bladder filling

Fowler C ,Griffiths D, 2010

Peak deactivation of frontal areas with full bladder & activation during voiding

Fowler C ,Griffiths D , 2010

Brain representation of pelvic floor muscles

Buschbeck J , ICS 2009

Brain representation of pelvic floor muscles

Buschbeck J, ICS 2009

Kuhtz-Buschbeck J et a, Neuroimage ,2009

MICTURITION

Animated Work-up Model

Bladder Filling

Kavia and Fowler 04Courtesy CJF

Micturition

Kavia and Fowler 04Courtesy CJF

PMC

S2-4 in cauda equina

pelvic & pudendal ns

Brain Imaging & Micturition Literature to date

Poor Bladder Control ( urgency & DO)

Rosenberg LJ , Griffiths DJ, Resnick DM , J.Urol, 2005

DO &Urgency as different entities (Tadic ,2009)

STRESS INCONTINENCENeuroplastic Changes after PFM Training

Di Gangi H , 2009

BRAIN and BLADDERFrom Barrington cats

to human Functional Brain Imaging

Giancarlo VignoliUnità di Urodinamica & Uroginecologia

Casa Madre Fortunata Toniolo

Bologna

The twentiesNeuroanatomy

• Barrington FJF. The effect of lesion of the hind and mid brain on micturition in the cat. Q J Exp Physiol 1925;

The seventies Neurophysiology

“The understanding, diagnosis and management of neurologic dysfunction of the bladder have undergone considerablle changes during the last 2 decades. These changes were the result of animal experimentation into physiology and pharmacology and the accelerated use of biomedical engineering technology “ Bradley , WE J.Urol , 1976

Communications between brain and bladder

1. Cerebral Micturition Centre

2. Pontine Micturition Centre3. Spinal Cord4. Sacral Reflex Centre5. Pelvic nerve6. Pudendal nerve7. Urethra8. Sphincter9. Pelvic floor10. Bladder

11. Hypogastric nerve

The ninetiesNeuroscience

Brain Imaging sections

To be defined :Bladder afferent “noise”

Drake MJ ,Van Duyl WA BJU Int.,2005Drake MJ ,Van Duyl WA BJU Int.,2005

Bladder “ noise “ Structures involved ( Fry C , ICI 2008)

Application of Functional Imaging to Pathophysiological Conditions

URINARY RETENTIONBrain Activity in Fowler Syndrome

DasGupta R ,2005

• Healthy volunteer • Fowler S - Stimulator off

• Stimulator on