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tive, and since the patient is unable to inhibit the detrusor and control the external sphincter, urgency, precipitant micturition, and incontinence result Incomplete lesions result in varying degress of urgency in voiding With slowly evolving processes involving the upper cord, such as multiple sclerosis, the bladder spasticity and urgency worsen with time and incontinence becomes more frequent In addition, initiation of voluntary micturition is impaired and bladder capacity is reduced Bladder sensation depends on the extent of involvement of sensory tracts Bulbocavernosus and anal re exes are preserved The cystometrogram shows uninhibited contractions of the detrusor muscle in response to small volumes of uid Most puzzling to the authors have been cases of cervical cord injury in which re ex activity of the sacral mechanism does not return; the bladder remains hypotonic Mixed type of neurogenic bladder In diseases such as multiple sclerosis, subacute combined degeneration, tethered cord, and syphilitic meningomyelitis, bladder function may be deranged from lesions at multiple levels, ie, spinal roots, sacral neurons or their bers of exit, and higher spinal segments The resultant picture is a combination of sensory, motor, and spastic types of bladder paralysis Stretch injury of the bladder wall, as occurs with anatomic obstruction at the bladder neck and occasionally with voluntary retention of urine, as in hysteria Repeated overdistention of the bladder wall often results in varying degrees of decompensation of the detrusor muscle and permanent atonia or hypotonia, although the evidence for this mechanism is uncertain The bladder wall becomes brotic and bladder capacity is greatly increased Emptying contractions are inadequate, and there is a large residual volume even after the Crede maneuver and strong contraction of the abdominal muscles As with motor and sensory paralyses, the patient is subject to cystitis, ureteral re ux, hydronephrosis and pyelonephritis, and calculus formation Urinary retention has been observed in women with polycystic ovaries In one study of 62 such women, it was found that myotonic-like discharges activated the urethral sphincter, interfering with its relaxation during micturition There were increasing amounts of residual urine, followed, nally, by complete retention This obscure mechanism has been offered as an explanation of some cases of hysterical urinary retention Fowler describes unusual patterns of electromyographic (EMG) activity in the bladder and sphincter of patients we would have classi ed as hysterical urine retention Frontal lobe incontinence Often the patient, because of his abulic or confused mental state, ignores the desire to void and the subsequent incontinence There is also a supranuclear type of hyperactivity of the detrusor and precipitant evacuation These types of frontal lobe incontinence are considered on page 393 Nocturnal enuresis, or urinary incontinence during sleep, due presumably to a delay in acquiring inhibition of micturition, is discussed in Chap 19.

As discussed earlier, a role for pontine centers in human micturition is implied from animal experiments; to our knowledge, there are no well-studied examples of human bladder dysfunction due solely to a brainstem lesion There are few clinical data except perhaps the PET studies mentioned to support the existence of these

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A quantum algorithm is unlike any you have seen so far Its structure re ects the tension between the exponential private workspace of an n-qubit system and the mere n bits that can be obtained through measurement The input to a quantum algorithm consists of n classical bits, and the output also consists of n classical bits It is while the quantum system is not being watched that the quantum effects take over and we have the bene t of Nature working exponentially hard on our behalf If the input is an n-bit string x, then the quantum computer takes as input n qubits in state x Then a series of quantum operations are performed, by the end of which the state of the n qubits has been transformed to some superposition y y y Finally, a measurement is made, and the output is the n-bit string y with probability | y |2 Observe that this output is random But this is not a problem, as we have seen before with randomized algorithms such as the one for primality testing As long as y corresponds to the right answer with high enough probability, we can repeat the whole process a few times to make the chance of failure miniscule Now let us look more closely at the quantum part of the algorithm Some of the key quantum operations (which we will soon discuss) can be thought of as looking for certain kinds of patterns in a superposition of states Because of this, it is helpful to think of the algorithm as having two stages In the rst stage, the n classical bits of the input are unpacked into an exponentially large superposition, which is expressly set up so as to have an underlying pattern or regularity that, if detected, would solve the task at hand The second stage then consists of a suitable set of quantum operations, followed by a measurement, which reveals 295.

centers, but Sakakibara and colleagues have reported that half of their patients with brainstem strokes had urinary symptoms, for which lesions in the pons were most often responsible; the precision of anatomic localization of the strokes was limited and the symptoms varied Therapy of Disordered Micturition Several drugs are useful in the management of accid and spastic disturbances of bladder function In the case of a accid paralysis, bethanechol (Urecholine) produces contraction of the detrusor by direct stimulation of its muscarinic cholinergic receptors In spastic paralysis, the detrusor can be relaxed by propantheline (Pro-Banthine, 15 to 30 mg three times daily), which acts as a muscarinic antagonist, and by oxybutynin (Ditropan, 5 mg two to three times daily), which acts directly on the smooth muscle and also has a muscarinic antagonist action Atropine, which is mainly a muscarinic antagonist, only partially inhibits detrusor contraction More recently, alpha1 sympathomimetic blocking drugs such as terazosin, doxazosin, and tamsulosin have been used to relax the urinary sphincter and facilitate voiding Their widest use has been in men with prostatic hypertrophy, but they may be bene cial in patients with dyssynergia of the sphincter from neurologic disease Several other drugs may be useful in the treatment of neurogenic bladder but can be utilized rationally only on the basis of sophisticated urodynamic investigations (Krane and Siroky) Often the patient must resort to intermittent self-catheterization, which can be safely carried out with scrupulous attention to sterile technique (washing hands, disposable catheter, etc) Some forms of chronic antibiotic therapy and acidi cation of urine with vitamin C (1000 g/day) are practical aids, but their use has gone through cycles of popularity based on various studies with differing results In selected paraplegic patients, the implantation of a sacral anterior root stimulator may prove to be helpful in emptying the bladder and achieving continence (Brindley et al).

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