Textbook Reading

THE AUTONOMIC
NERVOUS SYSTEM

Presented by:
dr. Dya Anggraeni

Supervisor:
dr. Selly Marisdina, Sp.S, MARS
 Section 1,
Chapter 45,
Pages 645-662
 Definition

The autonomic nervous system (ANS) 

the system that controls nonstriated
muscles and glands
Three Division of ANS
Sympathetic • Preganglion (first order)
(Thoracolumbal) • Postganglion (second order)

Parasympathetic • Preganglion (first order)

(Craniosacral) • Postganglion (second order)

Enteric • Located in the wall of the GI tract

 The Peripheral ANS
Parasympathetic Sympathetic

- Cranial outflow  - Thoracalumbal outflow

n. III, VII, !X, X, and bulbar portion of
XI
- Sacral outflow 
S2-S4 segments of spinal cord
T1-L3 segments of spinal cord
 paravertebral ganglionic
chain sphlanchnic nerve 
collateral ganglia  organ

- LONG MYELINATED
- SHORT MYELINATED
preganglionic fibers
preganglionic fibers
- SHORT UNMYELINATED
- LONG UNMYELINATED
postganglionic fibers
postganglionic fibers

Ganglia:
Ganglia:
Sympathetic chain
- Terminal (on or in effector)
(=paravertebral)
- Collateral (=prevertebral)
SYMPATHETIC PARASYMPATHETIC
 Autonomic Afferent
General visceral afferent fibers convey both concious
and unconcious sensations from the viscera

Small myelinated and unmyelinated fibers carry

impulses from visceral receptors  cell bodies in the
DORSAL ROOT & CRANIAL NERVE GANGLIA
The visceral afferents that enter spinal cord 
synapse on neurons in the DORSAL HORN and
INTERMEDIOLATERAL GRAY COLLUMN

The sensations travels mainly in the spinothalamic

and spinoreticular tracts (except bowel and bladder
control  POSTERIOR COLLUMNS)

Synapse in the THALAMUS  project to area of the CORTEX

• Afferent fibers in the VAGUS nerve  synapse in the
NODOSE GANGLION
• Afferent fibers in the GLOSOPHARYNGEAL nerve 
synapse in the PETROSAL GANGLION
 Neurotransmitter
Sympathetic Parasympathetic
Preganglion Ach Ach
Postganglion Norepinephrine Ach

Most of postganglionic acetylcholine receptors are

MUSCARINIC (Mediate the cardiac effects, cause
pupillary constriction, lacrimal and salivary secretion,
bronchoconstriction, stimulates GI tract motility, evacuation
of bladder and rectum, erection)

Adrenergic receptors
- α-adrenergic  pupillary dilatation, vasoconstriction,
ejaculation, control internal spchincters of bladder and
rectum
- β-adrenergic  control the heart, cause vasodilatation,
bronchodilatation, mediate metabolic effects.
Neurotransmitter
 The Physiology of the Peripheral ANS

Governs the activities of

cardiac and smooth muscle

All vital to normal

existance

Respiration Metabolism

Temperature
Circulation Digestion
Adjusment

SYMPATHETIC PARASYMPATHETIC
Fight-or-flight Relax
(Catabolic and utilization of energy) (Anabolic and conserve of energy)
 The Physiology
of the Peripheral ANS
THE CENTRAL REGULATION OF
AUTONOMIC FUNCTION

The peripheral ANS is under the control of higher centers (in

the cortex), especially the amygdala, hypothalamus, basal
forebrain, ventral striatum, brainstem, and spinal cord
that regulate and influence the function of its peripheral
components.

The most important of these centers is the

hypothalamus
• Part of ventral diencephalon,
lying just below the thalamus
and above the pituitary
gland
• Measures only about
14x18x20 mm, weighs only
4g
• Forms most of the floor and
part of the lateral wall of the
third ventricle, extending
from the level of the chiasm
to the interpeduncular fossa.
 • Paraventricular nucleus has subpopulations of neurons that
produce vasopressin, oxytocin, corticotropine releasing
hormone, and other hormones involved in pituitary function
• Important in cardiovascular regulation
Periventricular
Zone

• Contains the medial preoptic and the anterior nucleus 

controls gonadotropin release  involved in
thermoregulation
Medial
Zone

• Contains the lateral preoptic and lateral hypothalamic nuclei

• Stimulation of the lateral nucleus causes eating, whereas
ablation causes starvation.
• The lateral zone  involved in arousal and sleep
Lateral mechanisms.
Zone
 Other Components of the Central
Autonomic Network
Other important centers  the periaqueductal gray matter (PAG) in the
midbrain, other brainstem nuclei, the cerebral cortex, and the amygdala.

The PAG  important in the micturition reflex, pain mechanism

Descending pathways from the PAG modulate, primarily inhibit pain.

• The NST in the medulla  cardiopulmonary and GI function.

• Receives afferents from arterial baroreceptors and chemoreceptors and
mediates important autonomic reflexes.
• Projections from the NST  activate nucleus ambiguus and dorsal
motor nucleus of the vagus  send parasympathetic fibers to heart and
lung

The primary cortical areas involved in autonomic function include the cortex
of insula, the medial prefrontal cortex, the cingulate gyrus, and nucleus of
amygdala
 Examination
History in patient
Symptoms of autonomic
insufficiency

Dysfunction of
Orthostatic Abnormalities of Dysfunction of
the genitourinary
hypotension sweating the GI tract
tract

•Dizziness
•Erectile dysfunction
•Feelings of
•Ejaculation failure
presyncope, syncope •Anorexia
•Retrograde
• Palpitation •Dysphagia
•Dryness of skin ejaculation
• Tremulousness •Early satiety
•Excessive •Urinary retention
• Weakness •Constipation
sweating •Urinary urgency
• Confusion •Diarrhea
•Recurrent infection
• Slurred speech
•Urinary
incontinence
worse with standing
 Clinical
Assessment

Thermoregulatory
Orthostatic Gland function
Bladder function & sudomotor
function (Tear production)
function

• Palpation &
• SSR
percussion
• QSART
Tilt-table test (distension) Schirmer test
• Sweat imprint
• Checking the
• TST
anal wink and
bulbocavernosus
reflexes
 DISORDERS OF THE ANS

Autonomic
Hypothalamus CENTRAL or PERIPHER ganglia
Brain stem Postganglionic
nerve fibers

LOCAL or GENERAL PRIMARY or SECONDARY

Acute Pure autonomic Amyloid

Adie’s pupil
pandysautonomia failure neuropathy
 Neuromuscular • Lambert-Eaton
transmission • Botulism

• Erectile
Dysautonomia Genitalia
dysfunction

• Raynaud’s
phenomenon
Vascular system
• Acrocyanosis
• Erythromelalgia
• Livedo reticularis
The Bladder
NEUROGENIC BLADDER

Bladder dysfunction caused by disease

of the NERVOUS SYSTEM
Older Newer Lesion Pathogenesis Bladder Bladder Tone & Residual
Terminology Terminology Sensation Capacity Urine

Uninhibited Neurogenic Supra- Loss of cortical Normal Bladder distension No residual

neurogenic detrusor pontine inhibition of reflex  contraction in urine
bladder over-activity voiding, bladder tone response to
normal stretch reflex

Reflex Detrusor- Infra- Interuption of both ± Bladder capacity Residual urine

neurogenic sphichter pontine descending is small, volume is
bladder dys-synergia Supra- autonomic tracts to micturition is variable
sacral bladder & ascending reflex and
lesion sensory pathways involuntary
above the sacral
segment

Autonomous Detrusor Conus, Loss of reflex and Absent Contractions Residual urine
neurogenic areflexia S2-4 roots voluntary control occur as the result volume is large
bladder in cauda or of stimulation of
nerves the intrinsic neural
plexus of the
bladder wall

Sensory - Sensory Interuption of the Absent Distention, Residual urine

paralytic root, dorsal sensory nerve (No desire dribbling, difficulty volume is large
bladder root supply to bladder to void) both in initiating
ganglia, and emptying
posterior bladder
collumn
Motor - Motor roots Interuption of the Normal Reduced Residual urine
paralytic and nerve motor nerve supply (variable capacity) and bladder
bladder to bladder capacity vary
The Sexual Function

ERECTION  parasympathetic EJACULATION  Sympathetic

function (mediated through S2-S4) function (mediated by lumbar nerve)
• Disturbed sexual function  common in
dysautonomia.
• In autonomic neuropathy, especially from diabetes,
retrograde ejaculation may precede the
development of impotence  internal vesical
spinchter does not close  milky-appearing urine