11 This dual innervation is through the autonomic nervous system (ANS) and the somatic nervous (33) system (S1-4) . The sacral parasympathetic motoneurons are controlled by a specic group of neurons in the pontine brainstem, the pelvic organ stimulating center (POSC). This POSC generates micturition, defecation and sexual activities through different groups of sacral parasympathetic (PS) motoneurons. The POSC is driven by the periaqueductal gray (PAG) which receives precise information regarding the pelvic organs. The PAG, receives instructions from the amygdala, bed nucleus of the stria terminalis (a limbic forebrain structure) and various regions of the hypothalamus. In humans, the brain region with the most access to the PAG is the medial orbitofrontal cortex. This region of the brain acts as a focal point for sensory integration, modulation of visceral responses as well as prediction and decision making for emotional and reward related behaviors, (which involves learning). The neurological system receives inputs from several higher centres, including the brain, spinal cord, and ANS, which enable both complex voluntary and involuntary control of the PFM. These inputs allow for socially adapted behaviours, such as voluntary control over passing of gas, urination or defecation, as well as involuntary responses to stimuli, such as reex contractions during sexual arousal or the relaxation of muscles during voiding. Optimal functioning of the PFM relies on healthy ANS (23) function as well as ne-tuned function of the somatic nervous system. The latter requires accurate proprioception and body awareness. These in turn, rely on the ability to hold attention on the body, on adequate feedback from body to brain, and on sufcient mobility. These functions are inhibited by injury, stress, fatigue and a sedentary lifestyle. Neurons within the PFM demonstrate high concentrations of various neurotransmitters and neuromodulators, including amino acids, neuropeptides, norepinephrine, serotonin, and dopamine. These neurotransmitters and neuromodulators, play a role in the neuropharmacologically affected responses of the neurons within the PFM. For example, norepinephrine and serotonin are involved in the regulation of muscle tone, while dopamine is implicated in the reward and pleasure pathways associated with sexual function and PFM response to sexual arousal. The parasympathetic bers, constitute the pelvic plexus, and the somatic bers come from the sacral plexus and form the pudendal nerve (S2-4). The pudendal nerve and it's three branches innervate the anterior pelvis (the dorsal nerve to the clitoris/penis, the perineal branch and the inferior (33) hemorroiodal nerve) . The complex interplay between these sensory inputs, higher centres, and neurochemical signalling within the PFM contributes to emotional responses in (26) this region . For example, during sexual arousal, the PFM may contract involuntarily in response to pleasurable sensations, contributing to the experience of orgasm. In contrast, during periods of stress or anxiety, the PFM may become tense or (4) tight, leading to discomfort or pain. Mindfulness Practice and the skilled use of biofeedback have been found to be very effective in modulating the emotional responses of the muscle. The PFM is made up of a pair of compound muscular sheets mostly comprised of striated muscle. The supercial PF or urogenital diaphragm includes bulbocavernosus, ischiocavernosis and transverse perinei. The deep PF or levator ani (LA) is divided into four parts: iliococcygeus, pubococcygeus, puborectalis, and ischiococcygeus (part of the sacrospinous ligament). Puborectalis originates from the back of the symphysis pubis and loops around the rectoanal exure. It forms the deep part of the external anal sphincter muscles (EAS). The EAS is a circular muscle with the left and right halves functioning together but innervated independently. The piriformis and obturator internus muscles are considered associated muscles. The deep transversus abdominis, lumbar multidi and diaphragm are considered synergistic groups as they together form the circle of integrity. The muscles of the pelvic region, work in unison with each other to provide pelvic stability. The core muscles, as they are often called, operate together, just as the instruments in an orchestra, where the brain serves as the conductor. Ideally, it brings about coordinated ring of these muscles as a team of musicians, making resonant and beautiful music through their interplay. When all is functioning well, the brain brings in the perfect amount of contraction of any one muscle at the perfect time. If one group of musicians from the orchestra played without “governance” disconcordant sound would ensue. When the muscles work in perfect harmony with each other and the brain is operating as a “present” conductor, the movement produced is smooth and uid. Conversely, when a dysfunction exists the poetry of movement and ne function is lost, and dysfunction and pain set in. Training, informed by this knowledge is called motion control and it is a form of mindful movement practice. It is often assumed that if a problem exists, it is always weakness, but it may be overactivity or delayed or over-zealous ring of any or all the core muscles. In the face of stress, overload, emotional overwhelm, fatigue, inadequate nutrition and other stressors, the PFM and diaphragm, (which operate like dance partners), are often rendered overactive. The circle of integrity is left non-circular and the abdominals and lower back muscles or only the abdominals are inhibited. The result is faulty movement patterns, inadequate stability, and overload with consequential pain in certain structures. The conductor (brain) needs to be retrained and the PFM needs to be taught to relax UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
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