Neural control of continence

Urinary continence, while often thought to simply be achieved after the toilet training phase of childhood, actually requires an intricate neural network involving the brain, spinal cord, and peripheral ganglia. The slightest deviation in the coordination of this exceedingly complex neural network results in incontinence and other lower urinary tract symptoms. Deviations from the normal neural control of voiding is seen in various pathologic conditions. Understanding of this neural control is thus integral in determining potential therapeutic targets in the treatment of incontinence. This final chapter briefly reviews the role of the central nervous system in the coordination of continence followed by discussing the role of human brain imaging in furthering our understanding of these neural pathways and determining treatment modalities with cerebral therapeutic targets. A brief overview of the role of the peripheral nervous system and somatic innervation in the neural control of continence is then provided. The main focus of the latter part of the chapter is in discussing disruptions in neural control of voiding and the associated clinical findings. As mentioned above, various clinical conditions including bladder outlet obstruction, spinal cord injury, interstitial cystitis, and diabetes result from deviations in the normal neural circuitry involved in the control of continence. This chapter underscores new treatment modalities as well as multiple exciting potential future research directions including neuromodulation, nerve grafting, bladder tissue engineering, and the application of functional brain imaging, which can be potentially revolutionary in the treatment of incontinence secondary to neurological insults.