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Published in final edited form as:
Neurourol Urodyn. 2010 ; 29(1): 63–76. doi:10.1002/nau.20761.

Changes in Afferent Activity After Spinal Cord Injury
William C. de Groat* and Naoki Yoshimura
Departments of Pharmacology and Urology, University of Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania, USA

Abstract
Aims—To summarize the changes that occur in the properties of bladder afferent neurons following
spinal cord injury.
Methods—Literature review of anatomical, immunohistochemical, and pharmacologic studies ofnormal and dysfunctional bladder afferent pathways.

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Results—Studies in animals indicate that the micturition reflex is mediated by a spinobulbospinal
pathway passing through coordination centers (periaqueductal gray and pontine micturition center)located in the rostral brain stem. This reflex pathway, which is activated by small myelinated (Aδ)
bladder afferent nerves, is in turn modulated by higher centers in the cerebral cortex involved in thevoluntary control of micturition. Spinal cord injury at cervical or thoracic levels disrupts voluntary
voiding, as well as the normal reflex pathways that coordinate bladder and sphincter function.
Following spinal cord injury, the bladder is initially areflexic but then becomes hyperreflexic due tothe emergence of a spinal micturition reflex pathway. The recovery of bladder function after spinal
cord injury is dependent in part on the plasticity of bladder afferent pathways and the unmasking ofreflexes triggered by unmyelinated, capsaicin-sensitive, C-fiber bladder afferent neurons. Plasticity
is associated with morphologic, chemical, and electrical changes in bladder afferent neurons andappears to be mediated in part by neurotrophic factors released in the spinal cord and the peripheral
target organs.
Conclusions—Spinal cord injury at sites remote from the lumbosacral spinal cord can indirectly
influence properties of bladder afferent neurons by altering the function and chemical environment
in the bladder or the spinal cord.
Keywords

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afferent neurons; micturition; neuropeptides; neuroplasticity; neurotrophic factors; urinary bladder;voltage-gated ion channels

INTRODUCTION
The functions of the lower urinary tract (LUT)—to store and periodically release urine—aredependent upon neural circuits located in the brain, spinal cord, and peripheral ganglia.1–7
This dependence on central nervous system (CNS) control distinguishes the LUT from manyother visceral structures (e.g., the gastrointestinal tract and cardiovascular system) thatmaintain a certain level of function even after elimination of extrinsic neural input.

© 2009 Wiley-Liss, Inc.
*
Correspondence to: Dr. William de Groat, W1352 BSTWR, 200 Lothrop St., Pittsburgh, PA 15261. degroat@server.pharm.pitt.edu.
Conflicts of interest: none.

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The dependence of LUT functions on complex central neural networks renders these functions
susceptible to a variety of neurologic disorders, including spinal cord injury.2,7 Spinal cord
injury rostral to the lumbosacral level eliminates the voluntary and supraspinal control ofvoiding, leading initially to an areflexic bladder and complete urinary retention and then to aslow development of automatic micturition and neurogenic detrusor overactivity (NDO) thatis mediated by spinal reflex pathways. However, voiding is commonly inefficient owing tosimultaneous contractions of the bladder and urethral sphincter (detrusor-sphincterdyssynergia, DSD).
The recovery of reflex bladder activity after spinal cord injury is dependent on the
reorganization of reflex pathways in the spinal cord, as well as alterations in the properties of
bladder afferent neurons.3,5,8 This review will summarize the morphologic,
electrophysiologic, and chemical changes in bladder afferent neurons after spinal cord injury
and the molecular mechanisms that might underlie these changes.

AFFERENT INNERVATION OF THE LOWER URINARY TRACT

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The LUT, which consists of (1) a reservoir (the urinary bladder) and (2) an outlet (the bladderneck, urethra, and striated muscles of the external urethral sphincter [EUS]), is regulated bythree sets of peripheral nerves: sacral parasympathetic (pelvic nerves), thoracolumbar
sympathetic (hypogastric nerves and sympathetic chain), and somatic nerves (pudendal nerves)(Fig. 1).5,6 The nerves consist of efferent and afferent axons originating at thoracolumbar andsacral spinal levels. Afferent innervation arises from neurons located in the dorsal root ganglia(DRG) (Fig. 1).9
Afferent axons, identified primarily by neuropeptide immunoreactivity/calcitonin-generelated peptide (CGRP), pituitary adenylate cyclase-activating polypeptide (PACAP), or
substance P are distributed throughout the bladder wall10–12 from the serosal layer to thelamina propria, including a dense suburothelial plexus that gives rise to axons extending into
the urothelium.5,13 Sacral afferents are more abundant in the muscularis than in thesuburothelium and have a more uniform distribution throughout the fundus and trigone regions,whereas the lumbar afferents are localized in the trigone and are more abundant in thesuburothelium than in the muscularis.13,14 In human and animal bladders, afferent axons
containing tachykinins and CGRP immunoreactivity are also located around blood vessels andin close proximity to intramural ganglion cells where they may make synaptic connections andparticipate in local reflex networks within the bladder wall.11,15 Afferent nerves arising in the
DRG on one side of the spinal cord appear to be distributed bilaterally in the bladder wall.16

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Retrograde axonal tracing methods have identified DRG cells innervating the bladder, urethra,and external urethral sphincter (Fig. 2). Relatively small numbers, less than 3% of the total
population of neurons in an individual DRG, innervate different parts of the LUT (e.g., lessthan 3,000 sacral afferent neurons innervate the bladder of the cat).9,17 The neurons are small
to medium size and are distributed randomly throughout the DRG.
When different axonal tracers are injected into multiple pelvic organs, for example, the bladderand colon, a small percentage (5–17%) of DRG neurons are double labeled,18–20 indicatingthat some sensory neurons can innervate multiple target organs. This pattern of innervation
may contribute to the phenomenon of cross-sensitization of afferent pathways and provide amechanism by which pathology in one organ can influence sensations in an adjacent organ.
18,21

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Page 3CENTRAL AFFERENT PATHWAYS
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Central projections of afferent neurons innervating the LUT, which have been labeled bytransganglionic transport of tracers, project to discrete regions of the dorsal horn (Figs. 3A and4) that contain interneurons (Fig. 3C) and efferent neurons controlling the LUT (Fig. 4).
Afferent pathways from the urinary bladder of the cat9,17 and rat22,23 project into Lissauer’s
tract in the lumbosacral spinal cord and then pass rostrocaudally, giving off collaterals at regularintervals in the rostrocaudal axis (Fig. 4), which extend through lamina I laterally and mediallyaround the dorsal horn into deeper laminae (laminae V–VII and X) at the base of the dorsal
horn. The lateral pathway (lateral collateral pathway, LCP), which is the most prominent
projection, terminates in the region of the sacral parasympathetic nucleus and also sends someaxons medially to the dorsal commissure. Bladder afferents have not been detected in the centerof the dorsal horn (laminae III–IV) or in the ventral horn (Fig. 4). Afferent axons from thepelvic viscera of the cat passing through sympathetic nerves to the rostral lumbar segments
have similar sites of termination in laminae I, V–VII, and X.24 Although afferents are
distributed primarily to the ipsilateral side of the spinal cord, an estimated 10–20% also projectto the opposite side of the cord.25,26

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Pudendal nerve afferent pathways from the EUS of the cat have central terminations thatoverlap in part with those of bladder afferents in lateral laminae I, V–VII, and X.9,27 Theseafferents differ markedly from other populations of pudendal nerve afferents innervating sex
organs or cutaneous and subcutaneous tissues of the perineum that terminate in the deeper
layers of the dorsal horn (laminae II–IV).27,28 Pudendal afferent projections in the LCP havea periodic distribution in the rostrocaudal axis similar to the distribution of pelvic nerve
afferents shown in Figure 4.
The spinal neurons involved in processing afferent input from the LUT have been identified
by the expression of the immediate early gene, c-fos (Fig. 3B). In the rat, noxious or nonnoxious stimulation of the bladder and urethra increases the levels of Fos protein primarily inthe dorsal commissure, the superficial dorsal horn, and in the area of the sacral parasympathetic
nucleus.29–31 Noxious stimulation induces c-fos expression in a greater number of spinal
neurons, particularly in the dorsal commissure (Fig. 3B). Some of these interneurons (Fig. 3C)
send long projections to the brain, whereas others make local connections in the spinal cordand participate in segmental spinal reflexes.8,30

HISTOLOGIC AND CHEMICAL PROPERTIES OF AFFERENT NERVES

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Light and electron microscopy have revealed that the visceral nerves innervating the LUT arecomposed primarily of small myelinated (Aδ-fiber) and unmyelinated (C-fiber) axons.32,33
DRG neurons give rise to the myelinated Aδ-fiber and unmyelinated C-fiber axons, which canbe distinguished by immunohistochemical staining for the 200 kDa neurofilament protein,which is exclusively expressed in myelinated Aδ-fiber DRG neurons but not in unmyelinatedC-fiber neurons.34 Approximately two thirds of bladder afferent neurons identified in rats byaxonal tracing methods (Fig. 2) are neurofilament-poor (i.e., C-fiber neurons), while theremaining one third of cells exhibit intense neurofilament immunoreactivity (Aδ-fiber
neurons).35 Approximately 80% of neurofilament-poor C-fiber-dissociated bladder afferent
neurons are sensitive to capsaicin (Fig. 5).35
Afferent neurons innervating the LUT exhibit immunoreactivity for various neuropeptides,
such as substance P, calcitonin gene-related peptide (CGRP), pituitary adenylate cyclaseactivating polypeptide (PACAP), leucine enkephalin, corticotrophin-releasing factor, andvasoactive intestinal polypeptide (VIP),9,19,36–39 as well as growth-associated protein-43(GAP-43), nitric oxide synthase,40 glutamic acid, and aspartic acid.41 These substances havebeen identified in many species and at one or more locations in the afferent pathways, including
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NIH-PA Author Manuscript(1) afferent neurons in the lumbosacral DRG, (2) afferent nerves in the peripheral organs, and(3) afferent axons and terminals in the lumbosacral spinal cord.6,42–44 The majority (>70%)of bladder DRG neurons in rats appear to contain multiple neuropeptides—CGRP, substanceP, or PACAP being the most common. In cats, VIP is also contained in a large percentage of
bladder DRG neurons and is coexpressed with other peptides.36
In the spinal cord of rats and cats, peptidergic afferents are present in Lissauer’s tract, in lamina
I where they are very prominent on the lateral edge of the dorsal horn (LCP), and in the regionof the parasympathetic nucleus.38,42,44 This distribution is similar to that of the central
projections of bladder afferent neurons labeled by axonal tracers (Fig. 4).9,23 VIP, which is amarker for C-fiber afferent projections in the cat sacral spinal cord, exhibits a periodic
distribution in the LCP on the lateral edge of the dorsal horn similar to the distribution of
bladder afferent axons (Fig. 4). Chronic treatment with C-fiber afferent neurotoxins, capsaicin,
or resiniferatoxin reduces peptidergic afferent staining in the bladder wall of animals andhumans, indicating that the majority of peptidergic bladder afferent nerves are capsaicinsensitive C-fibers.5,37

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Bladder afferent neurons and axons, especially C-fiber afferents, also express various
receptors,5,6,39 including the transient receptor potential vanilloid receptor 1 (TRPV1, thecapsaicin receptor); transient receptor potential ankyrin 1 receptor (TRPA1); transient receptor
potential cation channel subfamily M (TRPM8, a cold receptor); tropomyosin-related kinase
A (TrkA), which responds to nerve growth factor (NGF); α and β estrogen receptors;45
tropomyosin-related kinase B (TrkB), which responds to brain-derived neurotrophic factor(BDNF); glial cell line-derived neurotrophic factor (GDNF) receptors, which respond to GDNF
(GFRα1) and artemin (GFRα3);46 p75 neurotrophin receptor;47 isolectin B4 binding sites(IB4);48 muscarinic receptors; endothelin receptors; and purinergic receptors (P2X2, P2X3
P2Y) receptors, which can be activated by adenosine triphosphate (ATP).49–52 Many of thesereceptors have been detected not only in axons in the bladder, but also in the lumbosacral spinal
cord in the same locations as the projections of bladder afferent axons.

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C-fiber afferents innervating the LUT of the rat have been subdivided into two subpopulations
based on lectin-binding: (1) IB4-negative, peptidergic and (2) IB4-positive, nonpeptidergic.
48,49,53 The IB4 negative, peptidergic subgroup represents the largest population (70–80%)
of C-fiber afferents. IB4-binding has also been used to identify different types of somatic Cfiber afferents.49,54 One type that does not exhibit IB4 binding is NGF-dependent, which
expresses TrkA receptors and contains neuropeptides,54 whereas a second type that does bindIB4 expresses the GDNF family of growth factor receptors (GFRα) and is thought to be largely
nonpeptidergic.49 Bladder afferent neurons have a lower percentage of IB4-positive cells(approximately 30%) than somatic afferent neurons innervating the skin (43%).49 The smaller
number of IB4-positive bladder afferents is also reflected in the smaller number of GFRα
receptor positive neurons. GFRα1 is present in 15.4%, GFRα3 in 8.4%, and GFRα2 in only
1% of lumbosacral bladder DRG neurons.46 The total percentage of GFRα positive bladderneurons is similar to the percentage of IB4 positive bladder neurons.
The expression of multiple receptors in bladder afferent nerves indicates that sensory
mechanisms in the bladder are likely to be complex and involve the summation of a variety ofchemical and mechanical signaling mechanisms, many of which may interact to produce
excitation, while others may produce the opposite effect and suppress afferent firing. Activationof TRPV1, TRPA1, TRPM8, TrkA, P2X, nicotinic, muscarinic, or endothelin receptors byintravesical administration of receptor agonists in in vivo experiments, or by direct application
to nerves in in vitro preparations, can enhance afferent nerve activity, release afferent
transmitters, or stimulate reflex bladder activity.4,50,52,55–70 On the other hand, some putativetransmitters/neuromodulators, such as nitric oxide, nicotinic, and muscarinic agonists, also

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have inhibitory effects.65,68–71 The complex chemical modulation of bladder afferent activity
may be related not only to the expression of multiple receptors on afferent nerves but also toeffects on non-neural cells (urothelial cells and myofibroblasts) that can interact with afferent
nerves via chemical messengers.5,13,72

ELECTROPHYSIOLOGIC PROPERTIES OF BLADDER AFFERENT NEURONS
The most important afferents for initiating micturition are the small myelinated (Aδ) andunmyelinated (C) fibers passing in the pelvic nerve to the sacral spinal cord. Aδ bladderafferents in the cat respond in a graded manner to passive distension as well as active
contraction of the bladder and exhibit pressure thresholds in the range of 5–15 mm Hg, which
are similar to the pressures at which humans report the first sensation of bladder filling.2,5,6
These fibers also code for noxious stimuli in the bladder. On the other hand, C-fiber bladderafferents in the cat have high thresholds and commonly do not respond to even high levels of
intravesical pressure.73 However, activity in some of these afferents is unmasked or enhanced
by chemical irritation of the bladder mucosa. Thus the C-fiber afferents in the cat havespecialized functions, such as the signaling of inflammatory or noxious events in the LUT.
Nociceptive and mechanoceptive information is also carried in the hypogastric nerves to thethoracolumbar segments of the spinal cord.74

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In the rat and mouse, Aδ and C-fiber bladder afferents consist of both mechanosensitive andchemosensitive subpopulations and are not distinguishable on the basis of stimulus modality.
66,75–77 C-fiber afferents that respond only to bladder filling have also been identified in the
rat bladder and appear to be volume receptors that are activated by stretch of the mucosa.6
C-fiber afferents are sensitive to the neurotoxins capsaicin and resiniferatoxin,6,13,37,52,77,78
as well as to other substances, such as nitric oxide, ATP, prostaglandins, and neurotrophic
factors released in the bladder by afferent nerves, urothelial cells, and inflammatory cells.
Activation of TRPV1 receptors in C-fiber afferents releases tachykinins and induces bladdercontractions, as well as bladder inflammation.37,79,80

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The properties of lumbosacral DRG cells innervating the LUT in the rat have been studied withpatch-clamp recording techniques in combination with axonal tracing methods to identify thedifferent populations of neurons (Fig. 2).20,53,81–87 Capsaicin-sensitive C-fiber bladderafferent neurons exhibit high threshold tetrodotoxin-resistant sodium channels, action
potentials, and phasic firing (1–2 spikes) in response to prolonged depolarizing current pulses(Fig. 5). Approximately 90% of the bladder C-fiber afferent neurons also are excited by ATP,which induces a depolarization and firing by activating P2X3 or P2X2/3 receptors.52 A-fiber
afferent neurons resistant to capsaicin exhibit low threshold tetrodotoxin-sensitive sodium
channels, action potentials, and tonic firing (multiple spikes) to depolarizing current pulses(Fig. 5).
C-fiber bladder afferent neurons also express a slowly decaying A-type K+ current that controls
spike threshold and firing frequency.87 Suppression of this K+ current induces hyperexcitabilityof bladder afferent neurons. These properties of DRG cells are consistent with the different
properties of A-fiber and C-fiber afferent receptors in the bladder.

ROLE OF AFFERENT NEURONS IN THE NORMAL CONTROL OF THE LOWER
URINARY TRACT
Mechanosensitive afferents in the bladder are activated during bladder filling and transmit
information to the brain about the degree of bladder distension, and in turn, the amount of urine
stored in the bladder.5 Studies in healthy volunteers have shown that the first sensation of

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filling occurs when about 40% of bladder capacity is reached, but this sensation is indistinct
and easily disregarded. The first desire to void is reported at approximately 60% of capacity
and has been defined by the International Continence Society (ICS) standardization committee
as “the feeling during filling cystometry that would lead the patient to pass urine at the next
convenient moment, but voiding can be delayed if necessary.” At more than 90% of capacity,
people report a strong desire to void, which is defined by ICS as a “persistent desire to voidwithout fear of leakage.” Based on studies in animals that examined the effects of C-fiber
afferent neurotoxins on voiding, and studies in humans after transection of sympathetic orparasympathetic nerves, it appears that the normal sensations of bladder filling are dependent
on Aδ afferents carried in the pelvic nerves to the sacral spinal cord.5 These afferents are alsoessential for the generation of storage and voiding reflexes. Studies in anesthetized anddecerebrate cats and rats revealed that reflex activation of the bladder is mediated by aspinobulbospinal pathway passing through the pontine micturition center (PMC, Barrington’s
nucleus) at the level of the inferior colliculus.88,89 The reflex pathway is activated by Aδ
bladder afferents traveling in the pelvic nerve to the sacral spinal cord (Fig. 6).

EMERGENCE OF A C-FIBER AFFERENT-MEDIATED MICTURITION REFLEXAFTER SPINAL CORD INJURY
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Spinal-cord injury (SCI) rostral to the lumbosacral level eliminates voluntary and supraspinalcontrol of voiding, leading initially to an areflexic bladder and complete urinary retention,
followed by a slow development of automatic micturition and bladder hyperactivity mediatedby spinal reflex pathways.90 However, voiding is commonly inefficient due to simultaneouscontractions of the bladder and urethral sphincter, that is, DSD.
Electrophysiologic studies in cats revealed that the recovery of bladder function after SCI ismediated by a change in the afferent limb of the micturition reflex pathway and remodeling ofsynaptic connections in the spinal cord.8,88,90–92 In chronic spinal-cord injured cats,
unmyelinated C-fiber afferents rather than Aδ afferents initiate voiding (Fig. 6), and the spinal
micturition reflex occurs with a short central delay (15 msec) in contrast to the long central
delay (60 msec) of the reflex in cats with an intact spinal cord.88 These findings are supportedby pharmacologic studies showing that subcutaneous administration of capsaicin, a C-fiber
neurotoxin, completely blocks reflex bladder contractions induced by bladder distention inchronic spinal-cord injured cats (Fig. 6), whereas capsaicin has no inhibitory effect on reflex
bladder contractions in spinal-cord intact cats.91,92 Thus it is plausible that C-fiber bladderafferents, which usually do not respond to bladder distention (i.e., silent C-fibers),73 become
mechanosensitive and initiate automatic micturition after SCI.

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In the rat, both Aδ and C-fiber afferents are involved in evoking bladder reflexes after SCI.
90 Capsaicin treatment reduces nonvoiding contractions during cystometry but does not alter
voiding contractions.90 Thus C-fiber afferents are necessary for generating neurogenic detrusor
overactivity (NDO) during the storage phase, but Aδ afferents initiate voiding.
In humans with NDO, intravesical administration of C-fiber neurotoxins (capsaicin or
resiniferatoxin, RTX) increases bladder capacity and decreases the frequency and number of
episodes of urinary incontinence.5,6 In several randomized controlled trials in spinal cordinjured patients in which capsaicin was compared to RTX, both agents were effective in
improving both urodynamic and clinical parameters.4,5Chronic spinal injury in animals and humans also causes the emergence of an unusual bladderreflex that is elicited by infusion of cold water into the bladder (the Bors Ice Water Test).93,
94 The response to cold water does not occur in normal adults but does occur in: (1) infants,(2) patients with suprasacral cord lesions, (3) patients with multiple sclerosis and Parkinson’s

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disease, and (4) elderly patients with hyperactive bladders. Studies in animals indicate that cold
temperature activates TRPM8 and possibly other temperature-sensitive receptors in bladderC-fiber afferents (Fig. 6) and/or urothelial cells.93,95 Intravesical administration of capsaicinto spinal cord-injured patients blocks cold-induced bladder reflexes,96 indicating that they are
mediated by C-fiber afferents, as has been demonstrated by the reflex activity of cat urinary
bladders mediated by C-fiber afferents following cold stimulation.97,98 Cold stimulation of the
rat bladder also induces DSD, and capsaicin pretreatment prevents this response.99 The
presence of the cold reflex in infants, its disappearance with maturation of the nervous system,
and its reemergence under conditions in which higher brain functions are disrupted suggestthat it may reflect a primitive spinal involuntary voiding reflex activated by C-fiber afferents.

MORPHOLOGIC AND CHEMICAL PLASTICITY OF AFFERENT NEURONSINDUCED BY SPINAL CORD INJURY
Changes in Bladder Afferent Nerves

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Studies in patients with NDO resulting from multiple sclerosis or various types of SCI haverevealed increased TRPV1, P2X3, and pan-neuronal marker (PGP9.5) staining in suburothelial
nerves and increased TRPV1 staining in the basal layer of the urothelium.100–102 Treatment
of NDO patients with intravesical capsaicin or resiniferatoxin reduces the density of TRPV1,
P2X3, and PGP9.5 immunoreactive nerve fibers and urothelial TRPV1 immunoreactivity inthe subpopulation of these patients exhibiting symptomatic improvement.101–103 Injections
into the bladder wall of botulinum neurotoxin type A (BoNT/A), an agent that blocks the releaseof neurotransmitters from urothelial cells and from afferent and efferent nerves, also reduces
NDO104–106 and reduces the density of TRPV1- and P2X3-immunoreactive nerves but does
not alter TRPV1- and P2X3-staining in the urothelium.100,103,104 These results suggest that anabnormality of the C-fiber afferent innervation contributes to NDO.
Changes in DRG Neurons and in Spinal Afferent Pathways

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In the sacral spinal cord of the cat where VIP is expressed exclusively in C-fiber afferent
neurons,107 the VIP-IR C-fiber afferent projections expand and reorganize after SCI (Fig. 4).
42,108 This is evident as (1) a wider distribution of VIP-IR axons in the lateral lamina I of thedorsal horn (the LCP), forming an almost continuous band of axons in the rostrocaudal
direction, in contrast to a discontinuous distribution in normal cats, (2) the appearance ofrostrocaudal axons in this region where they are not normally present, and (3) a more extensive
projection to lateral lamina VII, which contains bladder preganglionic neurons (area 4 in Fig.
4).108 These observations raise the possibility that C-fiber bladder afferents sprout andcontribute to the synaptic remodeling in the spinal micturition reflex pathway that occurs after
SCI. The pharmacologic effect of VIP on bladder activity is also changed after SCI. Intrathecal
administration of VIP, which suppresses reflex bladder activity in cats with an intact spinal
cord, enhances or unmasks reflex bladder activity in chronic SCI cats.92
Pudendal afferent projections in the region of the sacral dorsal horn and sacral autonomic
nucleus are also increased in chronic SCI cats.108 Afferent axons labeled by transganglionictransport of horseradish peroxidase exhibited an expanded distribution in certain areas of thedorsal horn ipsilateral and contralateral to the labeled nerve. The change is most obvious inlateral lamina I where the afferents have a periodic distribution in the rostrocaudal axis in spinal
intact animals (Fig. 4) but have a continuous distribution in chronic SCI animals. The widthof this afferent projection also increases in the transverse axis and projects more densely into
the region of bladder preganglionic neurons in lateral lamina VII.
Changes in morphology, neuropeptide expression, and function of C-fiber afferents have also
been detected in the rat after SCI. The changes include: (1) somal hypertrophy of bladder

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afferent neurons (45–50% increase in cross-sectional area) in the L6-S1 DRG;35,83,109 (2)elimination of bladder afferent neuron hypertrophy by urinary diversion, which prevented
bladder overdistension and bladder hypertrophy;109 (3) an increase in expression of PACAPIR in bladder DRG neurons and expansion of PACAP-IR afferent axons in the lumbosacral
spinal cord;39,110 (4) expansion of CGRP- and IB4-containing primary afferent fibers in the
spinal cord prior to the recovery of reflex bladder activity;48,111,112 (5) association of CGRP
and IB4 staining with GAP-43 staining in afferent fibers in SCI rats, indicating that afferents
were sprouting;48,112 (6) neurotoxin damage with IB4-saporin treatment decreasing IB4
afferent staining in the spinal cord and improving voiding efficiency in SCI rats;48 (7) an
increase in Fos protein expression in the spinal cord in response to bladder distension;31 and(8) an increase in nNOS-IR, galanin-IR, TrkA-IR, and TrkB-IR in bladder DRG neurons andin the region of the lumbosacral parasympathetic nucleus.39
Involvement of PACAP-Containing C-Fiber Afferents in Plasticity After SCI

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Six weeks after SCI in the rat, PACAP-IR is markedly increased in spinal segments and DRG(L1, L2, L6, S1) involved in micturition reflexes, but no changes occur in adjacent spinal
segments (L4-L5).110 PACAP-IR increases in the superficial laminae (I–II) of the relevant
spinal segments and in a fiber bundle extending ventrally from Lissauer’s tract in lamina I
along the lateral edge of the dorsal horn to the sacral parasympathetic nucleus (SPN) in the L6S1 spinal segments. This is the same region in which VIP-IR increases in the cat after SCI.
108 After SCI, the percentage of bladder afferent cells expressing PACAP-IR significantly
increases in the lumbosacral DRG.
The pharmacologic effects of PACAP on voiding function raise the possibility that it may havea role as a neurotransmitter in bladder afferent pathways. Intrathecal administration of
PACAP-27113 or PACAP-38114,115 in spinal-cord intact unanesthetized rats decreases bladdercapacity, decreases micturition volume, and increases micturition pressure. PACAP-38114,
115 also reduces EUS EMG activity. Thus in spinal-cord intact rats, PACAP-38 seems tofacilitate micturition by enhancing the parasympathetic excitatory pathway to the bladder andinhibiting the somatic excitatory pathway to the EUS.
The effects of PACAP-38 in chronic SCI rats are somewhat different. During continuous
infusion cystometrograms (CMGs) in SCI rats, intrathecal injection of PACAP-38 decreases
the amplitude of bladder contractions and suppresses EUS EMG activity.115 These responses
have been attributed to the combined effect of PACAP-38 on bladder and sphincter, where theexcitatory effect of PACAP-38 on bladder activity is masked by a simultaneous inhibitory
effect on the EUS that in turn blocks DSD and reduces urethral outlet resistance. This would
indirectly lower intravesical pressure during voiding.

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The physiologic role of PACAP in the control of bladder function in chronic SCI rats was
examined by administering PACAP6–38, a PAC1 receptor antagonist, during continuous
infusion CMGs in awake SCI rats.116 Intrathecal administration of the antagonist reducespremicturition contractions during bladder filling and reduces maximal voiding pressure,suggesting that activation of PAC1 receptors by endogenous PACAP contributes to themicturition reflex and bladder hyperreflexia.
The site and mechanism of action of PACAP on spinal micturition reflex pathways were
explored using patch clamp recording in lumbosacral parasympathetic preganglionic neurons
in neonatal rat spinal-cord slice preparations.117 The experiments revealed that PACAP-38 hasdirect excitatory effects on the preganglionic neurons and enhances excitatory input to theneurons, suggesting that it might act at several sites in the spinal micturition reflex pathway.
In parasympathetic preganglionic neurons, PACAP-38 decreases the electrical threshold fortriggering action potentials, increases the number of action potentials induced by depolarizing
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CHANGES IN THE ELECTROPHYSIOLOGIC PROPERTIES OF BLADDER
AFFERENT NEURONS AFTER SPINAL CORD INJURY

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current pulses, increases input resistance, and suppresses a 4-aminopyridine-sensitive outward
current. PACAP-38 also induces spontaneous firing and increases the frequency of
spontaneous excitatory postsynaptic potentials in the presence of tetrodotoxin. Thus,
PACAP-38 could act presynaptically to enhance the firing of excitatory interneurons, enhanceglutamate release from interneuronal terminals, or act postsynaptically directly onparasympathetic neurons.

Plasticity in Sodium and Potassium Channels After Spinal Cord Injury

Changes in Action Potentials
The ionic mechanisms underlying the hyperexcitability of C-fiber bladder afferents after SCI
were investigated using whole-cell patch clamp recording in bladder DRG neurons.83,118
Dissociated bladder DRG neurons from chronic SCI in rats were larger in size and had increased
input capacitance. This is consistent with results from histologic studies showing that bladderafferent neurons in the L6-S1 DRG undergo somal hypertrophy (45–50% increase in crosssectional area) in SCI rats.109 The action potentials in bladder afferent neurons were also
different after SCI in rats and cats.83,118 In contrast to neurons from spinal intact rats where
the majority (approximately 70%) of bladder afferent neurons exhibit high-threshold TTXresistant action potentials,86 60% of bladder afferent neurons from chronic SCI rats exhibit
low-threshold TTX-sensitive action potentials. In SCI cats, bladder afferent neurons also
exhibit multiple action potentials (tonic firing) in response to long depolarizing current pulses,
whereas in cats with an intact spinal cord, the neurons usually respond with one or two action
potentials (phasic firing) (Fig. 7).119

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The alteration of electrophysiologic properties in bladder afferent neurons after SCI was also
reflected in changes in Na+ current distribution.83 Consistent with the increment in the
proportion of neurons with TTX-sensitive spikes, the number of bladder afferent neurons that
predominantly express TTX-sensitive Na+ currents (60–100% of total Na+ currents) also
increases. The density of TTX-sensitive Na+ currents in bladder afferent neurons significantly
increased from 32.1 to 80.6 pA/pF, while TTX-resistant current density decreased from 60.5
to 17.9 pA/pF following SCI. In addition, an increase in TTX-sensitive Na+ currents was
detected in some bladder afferent neurons that still retained a predominance of TTX-resistantcurrents (>50% of total Na+ currents) after SCI. These data indicate that SCI induces a switch
in expression of Na+ channels from the TTX-resistant to the TTX-sensitive type. Since TTXsensitive Na+ currents have a lower threshold for activation than TTX-resistant currents, it isreasonable to assume that these changes in expression of Na+ channels in bladder afferent
neurons after SCI contribute to a low threshold for spike activation in these neurons.
Bladder afferent neurons with TTX-sensitive spikes in chronic SCI rats stimulated by lowintensity depolarizing current pulses do not exhibit membrane potential relaxation, which ismediated by an A-type K+ channel.90 Furthermore, the voltage responses induced by current
injections are not altered, as in neurons from control animals, by application of 4aminopyridine, an A-type K+ channel blocking agent.87 Therefore it is likely that following
SCI, A-type K+ channels are suppressed in parallel with an increased expression of TTXsensitive Na+ currents, thereby increasing excitability of C-fiber bladder afferent neurons. If
the changes occurring in afferent cell bodies also occur at peripheral receptors in the bladder
or in the spinal cord, these changes could contribute to the emergence of the C-fiber-mediatedspinal micturition reflex following SCI.

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Neurotrophic factors, including nerve growth factor (NGF), have been implicated as chemical
mediators of pathology-induced changes in C-fiber afferent nerve excitability and reflex
bladder activity.119–121 After SCI in rats, the levels of NGF increase in the bladder,39,120 in
the lumbosacral spinal cord, and in the DRG.122 In the bladder, NGF could originate frommultiple sites, including smooth muscle and urothelial cells. The stimulus for increased levelsof NGF may be overdistension of the bladder due to DSD and decreased voiding efficiency(Fig. 8), because NGF levels also increase in the bladder of rats after partial obstruction of theurethral outlet.123,124
Intravesical administration of NGF in rats acutely increases bladder reflex activity.59 Chronic
administration of NGF into the spinal cord122,125 or the bladder wall of rats126,127 induces
bladder hyperactivity, increases the firing frequency of dissociated bladder afferent neurons(Fig. 9), and enhances Fos expression and CGRP-IR in the spinal cord.121,122,125–127 NGF
might act by multiple mechanisms, because it is known that it upregulates PACAP and TRPV1
expression in DRG neurons124,128,129 and downregulates A-type K+ channel currents.125

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Endogenous NGF seems to contribute to LUT dysfunction after SCI because intrathecal
application of NGF antibodies, which neutralize NGF in the spinal cord, suppresses detrusor
hyperreflexia and DSD in SCI rats.130,131 This treatment with NGF antibodies produces effects
similar to the effect of desensitizing C-fiber afferents with capsaicin or resiniferatoxin.90,132
Intrathecal administration of NGF antibodies also blocks autonomic dysreflexia induced bybladder or distal bowel distension in SCI rats.111
In humans with NDO or IDO, increased levels of NGF have been detected in bladdertissue133 and in urine.134 After treatment with BoNT/A injections into the bladder wall, patientsthat exhibited reduced symptoms also had reduced NGF levels.133,134 Thus it has been
proposed 134 that NGF may be a sensitive biomarker for the diagnosis of NDO and IDO andmay be a useful tool for evaluating the therapeutic effect of BoNT/A injections. In addition,
NGF and its receptors in the bladder and/or the spinal cord may be important targets for new
therapies to reduce voiding dysfunction after SCI.

BLADDER AFFERENT NERVES AND URETHRAL OUTLET OBSTRUCTION

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The probable contribution of DSD and bladder overdistension to afferent nerve plasticity after
SCI raises the possibility that a similar plasticity of bladder afferent fibers may be involved in
the irritative symptoms accompanying bladder outlet obstruction (BOO) resulting from benign
prostatic hyperplasia (BPH). Evidence obtained from ice water cystometry, which elicits a Cfiber–dependent spinal micturition reflex, suggests considerable C-fiber upregulation insymptomatic subjects with BOO.135,136 Among BOO patients with a positive ice-water test,
the incidence of detrusor overactivity (DO) is significantly greater in those who report nocturia
equal to or greater than three times per night than in those who reported fewer episodes.136
Histologic and electrophysiologic confirmation of neural plasticity in bladder afferent andbladder reflex pathways was obtained using a rat model of partial BOO. A significant increasein the size of bladder afferent23 and postganglionic efferent137 innervation in the enlarged
bladder was documented in animals following 6 weeks of partial urethral obstruction.
Remodeling of the spinal cord components of the micturition reflex pathway was also evident
following experimental BOO. Using axonal labeling to identify afferent axonal projections tothe spinal cord, it was demonstrated that bladder afferent terminals expand to cover a larger
area (60% increase) in the lateral dorsal horn and in the region of the sacral parasympathetic

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nucleus in rats with BOO.23,119,124 Electrophysiologic experiments revealed that a spinal
micturition reflex mechanism is unmasked in rats with BOO.138 Immunohistochemical
analysis of the distribution and density of growth-associated protein-43 (GAP-43) shows that
this protein is increased in the spinal cord in the region of the sacral parasympathetic nucleus
in BOO rats.124,139 Because this protein is a marker for axonal sprouting, its upregulation
provides further indirect support for morphologic plasticity in afferent pathways after BOO.
Subsequent experiments using the same BOO rat model revealed that hypertrophied bladdertissue contained significantly greater amounts of NGF protein than normal bladders.123 To
determine if the changes induced by BOO were due to an action of NGF, BOO was carried out
in NGF-immune animals in which endogenous NGF antibody prevents access of NGF tonerves. BOO in the NGF-immune animals does not elicit hypertrophy of bladder sensory
neurons, increase in afferent projections in the spinal cord, or increase in GAP-43 expression
in afferent pathways.139 Removal of the urethral obstruction in BOO rats causes a partial
reversal of both the elevated NGF levels in the bladder and the neuronal hypertrophy; however,bladder overactivity persists in the presence of the elevated NGF levels.

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The stimulus for NGF production in the bladder is due in part to urinary retention and stretchingof the bladder after BOO (Fig. 8). Stretching bladder smooth muscle cells in vitro increases
mRNA for NGF and stimulates the secretion of NGF.124 Protein synthesis inhibitors suppress
the stretch-evoked secretion. NGF levels also increase in the urothelium of BOO rats. These
results indicate that mechanical stretch activates cellular machinery for the production andsecretion of NGF, which in turn acts on sensory nerves in the bladder to enhance afferent input
to the spinal cord and enhance reflex bladder activity.
Patch-clamp recordings from bladder sensory neurons in BOO rats have explored themechanisms underlying the changes in afferent neuron excitability. The neurons exhibit
increased amplitude and altered kinetics of TTX-sensitive Na+ currents that result in lowered
firing thresholds.124 An experimental drug that preferentially blocks TTX-sensitive currents
reduces bladder overactivity in BOO rats.

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Human bladder tissue obtained from subjects undergoing suprapubic prostatectomy for outlet
obstruction had more than twice the level of NGF than tissue obtained by cystoscopy frompatients who were being evaluated for conditions other than obstruction.124 Increased levelsof urinary NGF have also been detected in BOO patients exhibiting overactive bladder (OAB)
symptoms.140 Total urinary NGF levels were low in controls and in patients with BOO without
OAB symptoms, but considerably higher in patients with BOO and OAB symptoms or BOO
and DO.140 Following successful medical treatment with a combination of an alpha adrenergic
blocking agent and a 5-alpha reductase inhibitor that reduced symptoms, the urinary NGF levels
were reduced to normal levels. It was concluded that urinary NGF levels can be used as abiomarker for OAB and BOO and as a method for assessing successful therapies.140

GENE THERAPY TO INCREASE GABAERGIC INHIBITION IN BLADDER
AFFERENT PATHWAYSGABA, which is synthesized from glutamate by glutamic acid decarboxylase (GAD), is known
to have an important role in the inhibitory regulation of micturition in spinal intact rats. In SCI
rats, both muscimol and baclofen (GABAA- and GABAB-receptor agonists, respectively)
produce a dose-dependent inhibition of the C-fiber-mediated nonvoiding bladder contractions
and a decrease in micturition pressure.141 The effects of muscimol and baclofen are
antagonized by bicuculline and saclofen, GABAA and GABAB antagonists, respectively.
Decreased activation of GABA inhibitory receptors due to hypofunction of GABAergic
mechanisms in the spinal cord could contribute to the development of NDO because GAD67

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mRNA levels are decreased by 55% in the spinal cord of SCI rats 4 weeks after spinal cord
transection.141 Therefore, stimulation of spinal GABAergic mechanisms could be effective forthe treatment of NDO after SCI. Baclofen, the GABAB-receptor agonist, is reportedly effective
for treatment of DO in SCI patients,142 but this agent has not been widely used, because its
therapeutic window is modest, and the dose is limited by side effects.

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Viral-mediated gene delivery targeting bladder afferent nerves has been evaluated in an attempt
to develop a more selective approach for increasing GABA inhibitory functions in the
lumbosacral spinal cord with fewer side effects (Fig. 10).143,144 The study used herpes simplex
virus (HSV), which is taken up by peripheral nerve terminals of small diameter sensory nerves
and transported to the cell bodies in sensory ganglia. Three weeks after a replication-defective
HSV vector encoding the GAD gene (HSV-GAD) was injected into the bladder of SCI rats,
the number and amplitude of nonvoiding bladder contractions were significantly decreased
compared with the nonvoiding contractions in untreated or HSV-LacZ (control vector)-treated
SCI rats. These effects occurred without a significant change in the amplitude of bladdercontractions during voiding.143,144 Similar changes were observed in chronic SCI rats afterC-fiber afferent desensitization induced by systemic capsaicin administration.132 Thus GAD
gene delivery using HSV vectors appears to inhibit NDO by suppressing C-fiber bladderafferents without affecting the voiding contractions triggered by Aδ bladder afferents. On theother hand, intrathecal administration of GABA receptor agonists in SCI rats decreases
nonvoiding contractions as well as voiding contractions.141 Therefore, GABA gene therapy
using nonreplicating HSV vectors that can restore urine storage function without affecting
voiding function might be more beneficial than drug therapy for the treatment of urinary
problems in SCI patients.

CONCLUSIONS

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Studies in animals and humans indicate that the emergence of reflex bladder activity anddevelopment of NDO after complete spinal cord injury rostral to the lumbosacral segments isdue in part to plasticity in bladder C-fiber afferent nerves.5 Because spinal lesions do notdirectly damage the C-fiber afferent neurons, plasticity must be induced indirectly by
pathologic changes in the peripheral or central nervous system. Thus multiple mechanisms
might be involved in afferent neuron plasticity. For example disruption of descending pathways
to the lumbosacral spinal cord results in denervation of segmental spinal neurons that could inturn lead to local release of neurotrophic factors that induce changes in the properties of theafferent neurons, afferent nerve sprouting, and remodeling of spinal synaptic connections. NGF
may play a role in plasticity because NGF levels increase in the spinal cord of SCI rats.122 A
peripheral mechanism of afferent neuron plasticity is very likely related to changes in thefunction of the LUT after SCI. DSD after SCI leads to decreased voiding efficiency, bladder
overdistension, and hypertrophy, as well as to increased levels of NGF in the bladder and theurine.39,133,134 Administration of exogenous NGF to the bladder or the spinal cord can induce
DO, and also increase bladder afferent neuron excitability, by altering the expression ofneuronal ion channels.125 Because intrathecal administration of antibodies to NGF reduces
NDO and DSD in SCI rats,130,131 it seems reasonable to conclude that endogenous NGF is an
important factor in the development of LUT dysfunction after SCI. Thus therapies to target
NGF overexpression, receptors, or signaling mechanisms may be effective in reducing bladder
symptoms in individuals with SCI.

Acknowledgments
Grant sponsor: NIH; Grant numbers: DK49430, DK 57267, P01 HD 39768.

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Fig. 1.

Diagram showing the sympathetic, parasympathetic, and somatic innervation of the urogenitaltract of the male cat. Sympathetic preganglionic pathways emerge from the lumbar spinal cordand pass to the sympathetic chain ganglia (SCG) and then via the inferior splanchnic nerves(ISN) to the inferior mesenteric ganglia (IMG). Preganglionic and postganglionic sympathetic
axons then travel in the hypogastric nerve (HGN) to the pelvic plexus and the urogenital organs.
Parasympathetic preganglionic axons, which originate in the sacral spinal cord, pass in thepelvic nerve to ganglion cells in the pelvic plexus and to distal ganglia in the organs. Sacral
somatic pathways are contained in the pudendal nerve, which provides an innervation to thepenis, the ischiocavernosus (IC), bulbocavernosus (BC), and external urethral sphincter (EUS)
muscles. The pudendal and pelvic nerves also receive postganglionic axons from the caudal
SCG. These three sets of nerves contain afferent axons from the lumbosacral dorsal root
ganglia. U, ureter; PG, prostate gland; VD, vas deferens.
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Fig. 2.

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Diagram illustrating the method for studying identified lower urinary tract afferent neurons in
the L6-S1 dorsal root ganglia (DRG) using immunohistochemistry or patch-clamp techniques.
(1) DRG neurons are labeled by axonal transport of fluorescent dyes injected into the bladder,urethra, or external sphincter several days prior to the experiment. (2) DRGs are removed forhistologic experiments or (3) enzymatically dissociated to liberate single neurons. (4)Individual dye-labeled neurons are studied with whole cell patch-clamps methods.

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Fig. 3.

Comparison of the distribution of bladder afferent projections to the L6 spinal cord of the rat(A) with the distribution of c-fos positive cells in the L6 spinal segment following chemical
irritation of the lower urinary tract of the rat (B), and the distribution of interneurons in the L6
spinal cord labeled by transneuronal transport of pseudorabies virus injected into the urinary
bladder (C). Afferents labeled by WGA-HRP injected into the urinary bladder. c-fos
immunoreactivity is present in the nuclei of cells. DH, dorsal horn; SPN, sacral parasympathetic
nucleus; CC, central canal. D: Drawing shows the laminar organization of the cat spinal cord.

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Fig. 4.

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Transverse section of the S2 spinal cord of the cat showing primary afferent axons andpreganglionic neurons after application of horseradish peroxidase (HRP) to the pelvic nerve.
Afferents enter Lissauer’s tract (LT) and then send collaterals through lamina 1 laterally aroundthe dorsal horn (DH) in a large bundle (the lateral collateral pathway, LCP) into the area of thesacral parasympathetic nucleus (SPN). A smaller group of afferents extend medially into thedorsal gray commissure (DCM). Axons of preganglionic neurons in the SPN project into theventral horn (VH). Diagram on the top right side shows that the distribution of VIPimmunoreactive (VIP-IR) afferent axons in the sacral spinal cord of the cat is similar to the
distribution of pelvic visceral afferent axons in the LCP, lamina V (1) and in the DCM (2, 3).
In addition, the VIP-IR axons and pelvic afferent axons in the LCP, which arise as collaterals
from longitudinal axons in LT, occur in bundles distributed at regular intervals along therostrocaudal axis of the cord. After chronic spinal cord injury (lower left diagram) the VIPIR afferent pathways expand and reorganize, leading to a continuous band of axons in the LCP
and more extensive projections into region of the SPN (4).

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Fig. 5.

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Comparison of the electrophysiologic characteristics of C-fiber (top traces) and Aδ-fiber (lower
traces) bladder afferent neurons isolated from the lumbar dorsal root ganglion (DRG) of therat. The left panels are voltage responses and action potentials evoked by 20 msec depolarizing
current pulses. Asterisks with dashed lines indicate thresholds for spike activation (20 and 29
mV in the top and bottom traces, respectively). C-fiber neurons have higher thresholds andlonger duration action potentials. The second panels show that C-fiber and Aδ-fiber afferent
neurons have tetrodotoxin (TTX)-resistant and -sensitive action potentials, respectively. The
third panel shows the firing patterns during long duration (600 msec) depolarizing currents
pulses. C-fiber neurons fire phasically (1–2 spikes), whereas Aδ-fiber neurons fire tonically(12–15 spikes). The fourth panel shows that C-fiber neurons are capsaicin sensitive, whereasAδ-fiber neurons are capsaicin insensitive.

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Fig. 6.

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Diagram showing the organization of the parasympathetic excitatory reflex pathway to thedetrusor muscle. Scheme is based on electrophysiologic studies in cats. In animals with anintact spinal cord, micturition is initiated by a supraspinal reflex pathway passing through acenter in the brain stem. The pathway is triggered by myelinated afferents (Aδ-fibers), which
are connected to the tension receptors in the bladder wall. Injury to the spinal cord above thesacral segments (X) interrupts the connections between the brain and spinal autonomic centers
and initially blocks micturition. However, over a period of several weeks following spinal cord
injury, a spinal reflex mechanism emerges, which is triggered by unmyelinated vesical afferents(C-fibers); the A-fiber afferent inputs are ineffective. The C-fiber reflex pathway is usually
weak or undetectable in animals with an intact nervous system. Stimulation of the C-fiber
bladder afferents by instillation of ice water into the bladder (cold stimulation) activates voiding
responses in patients with spinal cord injury. Capsaicin (20–30 mg, subcutaneously) blocks
the C-fiber reflex in chronic spinal cord injured cats, but does not block micturition reflexes

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in intact cats. Intravesical capsaicin also suppresses detrusor hyperreflexia and cold-evokedreflexes in patients with neurogenic bladder dysfunction.

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Fig. 7.

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Effect of chronic spinal cord injury on the firing of a bladder sacral dorsal root ganglion neuron.
Records on the left side, which are from an afferent neuron from a cat with an intact spinal
cord, show action potentials (top trace) elicited by short (10 msec) and long (600 msec) duration
depolarizing current pulses (bottom trace). This neuron is typical of small diameter bladderneurons which exhibit phasic firing. Records on the right side show tonic firing during a long
duration depolarizing current pulse in a small diameter bladder neuron from a spinal cord
injured (SCI) cat.

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Fig. 8.

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Diagram showing hypothetical mechanisms inducing lower urinary tract dysfunction following
spinal cord injury (SCI). Injury to the spinal cord (1) causes detrusor-sphincter-dyssynergia(DSD) (2), which leads to functional urethral obstruction, reduced voiding efficiency, urinary
retention, and bladder hypertrophy (3), resulting in increased levels of NGF in the bladder wall(4). NGF is taken up by afferent nerves and transported to the dorsal root ganglion cells (5)where it changes gene expression, which leads to increased cell size; regulation of ion channels,
including a decrease in K+ channel function; and increased neuronal excitability (6). The levelsof NGF also increase in the spinal cord after SCI. Hyperexcitability of bladder afferent
pathways causes or enhances neurogenic detrusor overactivity and DSD. Intrathecal
application of NGF antibodies reduces NGF levels in DRGs and suppresses neurogenic
detrusor overactivity and DSD.

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Fig. 9.

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The effect of nerve growth factor (NGF) treatment on voiding function (A) and bladder afferent
neuron firing pattern (B). NGF (2.5 µg/µl) was continuously infused into the intrathecal spaceat the L6-S1 level of the spinal cord for 1–2 weeks using osmotic minipumps (0.5 µl/hr). A:
Cystometrograms showing continuous infusion cystometry in awake vehicle-treated (sham)and NGF-treated animals one week (1 w) and two weeks (2 w) after the start of treatment. Notethe increased frequency of voiding after infusion of NGF. B: Firing patterns in response to 600
msec duration depolarizing current pulses in bladder afferent neurons, with TTX-resistantspikes from sham- and NGF-treated (2 w) rats. The current intensity was set to the thresholdvalue for inducing single spikes with 10 msec current pulses. Note NGF-induced tonic firing,whereas the sham animal exhibited phasic firing as noted for C-fiber neurons from normal
untreated animals (see Fig. 5).

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Fig. 10.

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Experimental gene therapy using a herpes simplex viral vector to increase the expression of
glutamic acid decarboxylase (GAD) in the afferent pathways to the bladder. GAD is an enzyme
involved in the synthesis of gamma aminobutyric acid (GABA), an inhibitory neurotransmitterin the spinal cord. Following injection of HSV-GAD into the bladder wall in SCI rats, the HSVGAD is transported to the L6-S1 bladder afferents in the dorsal root ganglia and increases
GABA synthesis and release from afferent terminals in the spinal cord. Three weeks after the
injection, cystometry in awake rats revealed decreased number and amplitude of non-voiding
contractions compared to the measurements in SCI rats receiving control vector (HSV-LacZ).
HSV-GAD treatment did not alter the amplitude of voiding contractions. Since the effect of
HSV-GAD is similar to the effect of capsaicin pretreatment, which targets C-fiber afferent
pathways, it is possible that HSV-GAD selectively suppresses reflex responses induced bycapsaicin-sensitive C-fiber afferents and does not affect Aδ-fiber-evoked reflexes which elicit
voiding reflexes in spinal cord intact and chronic SCI rats.

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