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Psychosocial aspects of micturition
PSYCHOSOCIAL C. J. GODEC, A. S. CASS,
ASPECTS
OF MICTURITION
M.D. M.D.
From the Department of Surgery, Division of Urology, Hennepin County Medical Center, Minneapolis, and Department of Urology, St. Paul-Ramsey Medical Center, St. Paul, Minnesota
ABSTRACT - The complex act of micturition is still insufficiently understood and a controversial neuromuscular phenomenon. In humans, the urinary bladder reflects the constant accommodation to physiologic, psychologic, and social aspects of micturition. This article deals with these additional dimensions of micturition of which the urologist should be aware.
The past decade has witnessed the development of sophisticated electronic urodynamic equipment and a multidisciplinary approach to micturition disorders with more objective and precise measurement of urethrovesical parameters. The complex act of micturition still remains poorly understood and a controversial neuromuscular mechanism. This article presents some thoughts on the psychological and social parameters of micturition. Awareness of the psychosocial aspects of micturition might improve the results of our therapeutic endeavors. Evolution
of Micturition
Early in the phylogenetic development of animals there was no diverticular formation between the kidney and external urinary meatus, and these animals leaked urine constantly. The strong smell of urine represented a significant disadvantage in the constant struggle for survival as stronger and more aggressive animals could readily smell their prey. The act of micturition started with the appearance of a pouch formation between the kidney and the exterior where urine could be stored - the urinary bladder. Animal micturition is basically under autonomic nervous control. Its primary function was evacuation of urine at certain intervals, which is different for different animal species. Macaca rhesus monkey empties his bladder in a large
332
morning micturition followed by long nonvoiding periods, averaging seventeen hours. l Some domesticated animals (dog, ape, cat), which become housebroken, can never achieve micturition on command. This sophisticated control is developed only in human beings. It can be explained on the gradual straightening of pelvic floor muscles after assuming the vertical posture which may represent an important stimulus in decreasing micturition reflex excitability. When there is a severe physiologic urge to empty the urinary bladder, the human can voluntarily contract his pelvic floor to inhibit the bladder. Among mammals, man alone is able to void voluntarily at any volume in the bladder. In children up to three years small bladder volume acts as a stimulus to trigger reflex bladder evacuation. With the maturation of nervous structure after the third year of age the primarily spinal reflex gets the characteristics of a complex viscera-somatic movements in which target structures (periphery) and the brain (center) are linked by chains of reciprocal signals to form an integrated phenomenon controlled micturition. This type of controlled micturition is specific for human species only. Social Aspects
of Micturition
In some mammals passing urine has acquired a social aspect. A male dog leaves his mark by expelling urine on upright objects such as
UROLOGY
/ APRIL 1931 / VOLUME
XVII, NUMBER 4
stones, bushes, and tree trunks. Once he has urinated on an object, the dog is inhibited by the smell of his own urine from doing so again, until another dog has used the site.’ The primary stimulus for the leg-raising pattern is the odor of the strange dog’s urine. Some dogs in a strange locality, which other dogs have not previously visited, will approach and urinate on any object which is slightly elevated. Urine spraying represents a type of territorial marking. The urinary pattern of male and female dogs is under hormonal control. If castrated when very young, the male pups do not develop the adult leg-raising micturition and continue to squat in the infantile way. Female dogs given male sex hormones will subsequently raise their legs in the male pattern during voiding. Emotional factors influence micturition pattern. A fearful dog will urinate, defecate, and even evacuate its anal gland. Submissive dogs will often pass a little urine when greeting a person or superior dog. Emotional conflicts within the pack sometimes lead the dominant dogs wetting on subordinate animals. The urine of different male cats carries individual odors, and objects such as trees, sides of a house, or car tires, when marked with urine, have a particular odor individual for the cat responsible for the spraying. Spraying does occur when a cat is excited or emotionally upset. The smell of his own urine makes the cat more self-assured and comfortable. During the breeding season this marking attracts sexually receptive females to his vicinity. Castrated cats have a much lower tendency to spray than intact cats. Even in some nondomesticated animals passing urine has acquired social aspects. Black rhinoceroses micturate as a warning signal before they attack. Some monkeys that live in the trees expel urine as a guided missile onto passing enemies below. The lorises and galagos have the unusual habit of urinating regularly on their hands and feet. It would appear that this would either improve their grip when climbing, or provide a possible territorial scent trail, or both.” Territorial marking with urine is also known in humans. Some nomadic tribes urinate around their camps, thus establishing territorial urinary markers to prevent the attacks from wild animals. When hunters make a fire in territory with wild animals (e.g. wolves), they urinate around the fireplace to prevent animal attacks. One physician reported how he protected his
UROLOGY
/ APRIL 1981 / VOLUME
XVII. NUMBER
4
roses against his dog by spraying his urine around the area with roses. The dog respected the urinary territorial marker and did not trespass between the grass and the roses area. Another example of the social aspect of micturition can be found among young boys competing by comparing the “casting distance” of their urinary streams. The boy with meatal stenosis may out-distance the other boys with a normal meatus. The “new baby syndrome” also has a social component. The older children start to bedwet to protest the arrival of a new baby and the resulting loss of parental attention. Uncontrollable urinary incontinence causes an emotionally loaded social problem. The smell of urine is poorly tolerated by society, and the patient feels ostracized. Aggressive surgical procedures may be the only option available. Psychology
of Micturition
The 4,000-year-old Chinese dictum, “the soul is in the bladder” can be applied to modern times, as well. There is a close relationship between the emotional state and micturition symptoms, but organic pathology has to be excluded first. About 30 per cent of all female incontinence is estimated to be psychogenic.4 One hundred years ago it was known that psychogenic stimuli may affect intravesical pressure and vesical contractions.5 Straub, Ripley, and Wolf6 documented that hyperactivity of the bladder followed anxiety-provoking situations. During subsequent periods of reassurance the bladder dysfunction resolved showing that bladder function was altered by emotional provocation. Alterations of micturition may occur as the only organic accompaniment of an emotional upset, or may be part of a general psychophysiologic reaction. Tension, anxiety, and other types of aggressive behavior were associated with detrusor hyperreflexia, and dejection and nonaggressive behavior with detrusor hyporeflexia. 6 Hypnotherapy can be effective in pediatric7 and adults age groups. Hypnotherapy did not only provide clinical cure or improvement, but also the hyperreflexic cystometric curve was changed during trance. Thirty-nine of 50 patients (86.7 per cent) were completely cured with psychologic therapy alone after a mean follow-up of 21.4 months.g Patients were proclaimed as cured if they were asymptomatic and abacteriuric. Urethral dysfunction can have psychogenic origin. The patient is unable to relax the striated
333
urethral muscles, due to tension and anxiety. Thus, functional disturbance of micturition can produce organic pathology. Turbulent urethral flow caused by external sphincter spasticity increases the likelihood of washing bacteria back into the bladder. r”,ll Repeated infections occur, not because of inadequate treatment, but because of persistence of the underlying urethral dysfunction. The synonym to urethral syndrome in male patients is prostatic syndrome. Significant numbers of patients with chronic prostatitis have a psychologic basis for their disorder. Less than 15 per cent of the patients had definite bacterial etiology. r2 The lack of privacy is sufficient stimulus for some patients to have difficulty voiding in the presence of other people. During the second World War some soldiers had a hysterical type of psychoneurosis, with acute urinary retention.13 When these patients were removed from front lines to noncombat area, their bladder function returned to normal. The intricate act of micturition reflects the evolution of the urinary bladder during the constant need to accommodate to human physiologic, psychologic, and social aspects. Therefore, even a small disturbance in any of these parameters can cause changes in micturition pattern. The urologist should be aware of these aspects.
334
Department of Surgery, Division of Urology, Hennepin County Medical Center, Minneapolis, Minnesota 55415 (DR. GODEC) References 1. Smith WK, Feldman A, and Levethal C: Diurnal variations in micturition and drinking in monkeys, Fed. Proc. 17: 151 (1958). 2. Von Uexkiill J, and Sari-is EG: Das Duftfeld des Hundes, Z. Hundesforschung. 1: 55 (1931). 3. Morris D: The Mammals, London, Hodder and Stoughton, 1965, p. 121. 4. Frewen WU: Urgency incontinence, J. Obstet. Cynecol. Br. Commonw. 79: 77 (1972). 5. Mosso A, and Pellicani P: Sulle junzioni della vessica, R. Accad. Natl. Linci (Rome) 12: l(1881). 6. Straub LR, Ripley HS, and Wolf S: Disturbances of bladder function associated with emotional stress, JAMA 141: 1139 (1949). 7. Baumann FW, and Hinman F: Treatment of incontinent boys with nonobstructive disease, J. Urol. 111: 114 (1974). 8. Godec CJ: Inhibition of hyperreflexic bladder during hypnosis, Am. J. Clin. Hypnosis 22: 170 (1979). 9. Rees DLP, and Farhoumand N: Psychiatric aspects of recurrent cystitis in women, Br. J. Urol. 49:651 (1971). 10. Cormere IN lr. McClure TM III. and Liushultz LI: Contamination of bladder urine b”y urethral particles during voidings: urethrovesical reflex, J. Urol. 107: 399 (1972). 11. Tanagho EA, Miller ER, Lyon RP, and Fisher R: Spastic striated external sphincter and urinary tract infection in girls, Br. J. Urol. 43: 69 (1971). 12. Fritjofsonn A, Kihl B, and Danielsson D: Chronic prostate - vesiculitis: incidence and significance of bacterial findings, Stand. J. Urol. Nephrol. 8: 173 (1973). 13. Straub LB, Ripley HS, and Wolf S: An experimental approach to the psychosomatic bladder disorders, N.Y. State J. Med. 49: 635 (1949).
UROLOGY
/
APRIL
1981
/
VOLUME
XVII, NUMBER
4
ASPECTS
OF MICTURITION
M.D. M.D.
From the Department of Surgery, Division of Urology, Hennepin County Medical Center, Minneapolis, and Department of Urology, St. Paul-Ramsey Medical Center, St. Paul, Minnesota
ABSTRACT - The complex act of micturition is still insufficiently understood and a controversial neuromuscular phenomenon. In humans, the urinary bladder reflects the constant accommodation to physiologic, psychologic, and social aspects of micturition. This article deals with these additional dimensions of micturition of which the urologist should be aware.
The past decade has witnessed the development of sophisticated electronic urodynamic equipment and a multidisciplinary approach to micturition disorders with more objective and precise measurement of urethrovesical parameters. The complex act of micturition still remains poorly understood and a controversial neuromuscular mechanism. This article presents some thoughts on the psychological and social parameters of micturition. Awareness of the psychosocial aspects of micturition might improve the results of our therapeutic endeavors. Evolution
of Micturition
Early in the phylogenetic development of animals there was no diverticular formation between the kidney and external urinary meatus, and these animals leaked urine constantly. The strong smell of urine represented a significant disadvantage in the constant struggle for survival as stronger and more aggressive animals could readily smell their prey. The act of micturition started with the appearance of a pouch formation between the kidney and the exterior where urine could be stored - the urinary bladder. Animal micturition is basically under autonomic nervous control. Its primary function was evacuation of urine at certain intervals, which is different for different animal species. Macaca rhesus monkey empties his bladder in a large
332
morning micturition followed by long nonvoiding periods, averaging seventeen hours. l Some domesticated animals (dog, ape, cat), which become housebroken, can never achieve micturition on command. This sophisticated control is developed only in human beings. It can be explained on the gradual straightening of pelvic floor muscles after assuming the vertical posture which may represent an important stimulus in decreasing micturition reflex excitability. When there is a severe physiologic urge to empty the urinary bladder, the human can voluntarily contract his pelvic floor to inhibit the bladder. Among mammals, man alone is able to void voluntarily at any volume in the bladder. In children up to three years small bladder volume acts as a stimulus to trigger reflex bladder evacuation. With the maturation of nervous structure after the third year of age the primarily spinal reflex gets the characteristics of a complex viscera-somatic movements in which target structures (periphery) and the brain (center) are linked by chains of reciprocal signals to form an integrated phenomenon controlled micturition. This type of controlled micturition is specific for human species only. Social Aspects
of Micturition
In some mammals passing urine has acquired a social aspect. A male dog leaves his mark by expelling urine on upright objects such as
UROLOGY
/ APRIL 1931 / VOLUME
XVII, NUMBER 4
stones, bushes, and tree trunks. Once he has urinated on an object, the dog is inhibited by the smell of his own urine from doing so again, until another dog has used the site.’ The primary stimulus for the leg-raising pattern is the odor of the strange dog’s urine. Some dogs in a strange locality, which other dogs have not previously visited, will approach and urinate on any object which is slightly elevated. Urine spraying represents a type of territorial marking. The urinary pattern of male and female dogs is under hormonal control. If castrated when very young, the male pups do not develop the adult leg-raising micturition and continue to squat in the infantile way. Female dogs given male sex hormones will subsequently raise their legs in the male pattern during voiding. Emotional factors influence micturition pattern. A fearful dog will urinate, defecate, and even evacuate its anal gland. Submissive dogs will often pass a little urine when greeting a person or superior dog. Emotional conflicts within the pack sometimes lead the dominant dogs wetting on subordinate animals. The urine of different male cats carries individual odors, and objects such as trees, sides of a house, or car tires, when marked with urine, have a particular odor individual for the cat responsible for the spraying. Spraying does occur when a cat is excited or emotionally upset. The smell of his own urine makes the cat more self-assured and comfortable. During the breeding season this marking attracts sexually receptive females to his vicinity. Castrated cats have a much lower tendency to spray than intact cats. Even in some nondomesticated animals passing urine has acquired social aspects. Black rhinoceroses micturate as a warning signal before they attack. Some monkeys that live in the trees expel urine as a guided missile onto passing enemies below. The lorises and galagos have the unusual habit of urinating regularly on their hands and feet. It would appear that this would either improve their grip when climbing, or provide a possible territorial scent trail, or both.” Territorial marking with urine is also known in humans. Some nomadic tribes urinate around their camps, thus establishing territorial urinary markers to prevent the attacks from wild animals. When hunters make a fire in territory with wild animals (e.g. wolves), they urinate around the fireplace to prevent animal attacks. One physician reported how he protected his
UROLOGY
/ APRIL 1981 / VOLUME
XVII. NUMBER
4
roses against his dog by spraying his urine around the area with roses. The dog respected the urinary territorial marker and did not trespass between the grass and the roses area. Another example of the social aspect of micturition can be found among young boys competing by comparing the “casting distance” of their urinary streams. The boy with meatal stenosis may out-distance the other boys with a normal meatus. The “new baby syndrome” also has a social component. The older children start to bedwet to protest the arrival of a new baby and the resulting loss of parental attention. Uncontrollable urinary incontinence causes an emotionally loaded social problem. The smell of urine is poorly tolerated by society, and the patient feels ostracized. Aggressive surgical procedures may be the only option available. Psychology
of Micturition
The 4,000-year-old Chinese dictum, “the soul is in the bladder” can be applied to modern times, as well. There is a close relationship between the emotional state and micturition symptoms, but organic pathology has to be excluded first. About 30 per cent of all female incontinence is estimated to be psychogenic.4 One hundred years ago it was known that psychogenic stimuli may affect intravesical pressure and vesical contractions.5 Straub, Ripley, and Wolf6 documented that hyperactivity of the bladder followed anxiety-provoking situations. During subsequent periods of reassurance the bladder dysfunction resolved showing that bladder function was altered by emotional provocation. Alterations of micturition may occur as the only organic accompaniment of an emotional upset, or may be part of a general psychophysiologic reaction. Tension, anxiety, and other types of aggressive behavior were associated with detrusor hyperreflexia, and dejection and nonaggressive behavior with detrusor hyporeflexia. 6 Hypnotherapy can be effective in pediatric7 and adults age groups. Hypnotherapy did not only provide clinical cure or improvement, but also the hyperreflexic cystometric curve was changed during trance. Thirty-nine of 50 patients (86.7 per cent) were completely cured with psychologic therapy alone after a mean follow-up of 21.4 months.g Patients were proclaimed as cured if they were asymptomatic and abacteriuric. Urethral dysfunction can have psychogenic origin. The patient is unable to relax the striated
333
urethral muscles, due to tension and anxiety. Thus, functional disturbance of micturition can produce organic pathology. Turbulent urethral flow caused by external sphincter spasticity increases the likelihood of washing bacteria back into the bladder. r”,ll Repeated infections occur, not because of inadequate treatment, but because of persistence of the underlying urethral dysfunction. The synonym to urethral syndrome in male patients is prostatic syndrome. Significant numbers of patients with chronic prostatitis have a psychologic basis for their disorder. Less than 15 per cent of the patients had definite bacterial etiology. r2 The lack of privacy is sufficient stimulus for some patients to have difficulty voiding in the presence of other people. During the second World War some soldiers had a hysterical type of psychoneurosis, with acute urinary retention.13 When these patients were removed from front lines to noncombat area, their bladder function returned to normal. The intricate act of micturition reflects the evolution of the urinary bladder during the constant need to accommodate to human physiologic, psychologic, and social aspects. Therefore, even a small disturbance in any of these parameters can cause changes in micturition pattern. The urologist should be aware of these aspects.
334
Department of Surgery, Division of Urology, Hennepin County Medical Center, Minneapolis, Minnesota 55415 (DR. GODEC) References 1. Smith WK, Feldman A, and Levethal C: Diurnal variations in micturition and drinking in monkeys, Fed. Proc. 17: 151 (1958). 2. Von Uexkiill J, and Sari-is EG: Das Duftfeld des Hundes, Z. Hundesforschung. 1: 55 (1931). 3. Morris D: The Mammals, London, Hodder and Stoughton, 1965, p. 121. 4. Frewen WU: Urgency incontinence, J. Obstet. Cynecol. Br. Commonw. 79: 77 (1972). 5. Mosso A, and Pellicani P: Sulle junzioni della vessica, R. Accad. Natl. Linci (Rome) 12: l(1881). 6. Straub LR, Ripley HS, and Wolf S: Disturbances of bladder function associated with emotional stress, JAMA 141: 1139 (1949). 7. Baumann FW, and Hinman F: Treatment of incontinent boys with nonobstructive disease, J. Urol. 111: 114 (1974). 8. Godec CJ: Inhibition of hyperreflexic bladder during hypnosis, Am. J. Clin. Hypnosis 22: 170 (1979). 9. Rees DLP, and Farhoumand N: Psychiatric aspects of recurrent cystitis in women, Br. J. Urol. 49:651 (1971). 10. Cormere IN lr. McClure TM III. and Liushultz LI: Contamination of bladder urine b”y urethral particles during voidings: urethrovesical reflex, J. Urol. 107: 399 (1972). 11. Tanagho EA, Miller ER, Lyon RP, and Fisher R: Spastic striated external sphincter and urinary tract infection in girls, Br. J. Urol. 43: 69 (1971). 12. Fritjofsonn A, Kihl B, and Danielsson D: Chronic prostate - vesiculitis: incidence and significance of bacterial findings, Stand. J. Urol. Nephrol. 8: 173 (1973). 13. Straub LB, Ripley HS, and Wolf S: An experimental approach to the psychosomatic bladder disorders, N.Y. State J. Med. 49: 635 (1949).
UROLOGY
/
APRIL
1981
/
VOLUME
XVII, NUMBER
4