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Sympathetic Pathways and Adrenergic Innervation of the Penis

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Sympathetic Pathways and Adrenergic Innervation of the Penis International Journal of Impotence Research (2000) 12, Suppl 1, S5±S12 ß 2000 Macmillan Publishers Ltd All rights reserved 0955-9930/00 $15.00 www.nature.com/ijir BASIC SCIENCE RESEARCH Sympathetic pathways and adrenergic innervation of the penis K-E Andersson1*, P Hedlund1 and P Alm2 1Department of Clinical Pharmacology, University of Lund, Lund University Hospital, Lund, Sweden; 2Department of Pathology, University of Lund, Lund University Hospital, Lund, Sweden; The sympathetic nervous system is important for penile function: it mediates detumescence and may contribute to the maintenance of the penis in a non-erect state. The sympathetic preganglionic neurons are found in the intermediolateral gray matter of the spinal cord. Postganglionic neurons are located to the sympathetic chain ganglia, the inferior mesenteric, hypogastric and pelvic ganglia, and possibly to ganglia near the target organ. Sympathetic ®bres can be found in the pelvic, cavernous, and pudendal nerves. Stimulation of the sympathetic pathways to the penis may, however, also produce erection. It has been suggested that the suprasacral vasodilator pathway is a sympathetic cholinergic pathway, operating through cholinergic neurons in the pelvic plexus. In the penis, there is a rich sympathetic, adrenergic innervation of the corpus cavernosum (CC) and the vasculature, and in particular of the helicine arteries. Sympathetic, adrenergic nerves also contain neuropeptide Y. Parasympathetic cholinergic nerves, which mediate CC relaxation and erection, contain not only acetylcholine, but also vasoactive intestinal polypeptide, nitric oxide synthase, and probably other mediators and=or mediator-synthesizing enzymes. Activation of sympathetic adrenergic nerves causes release of noradrenaline, acting on a-adrenoceptors in the trabecular smooth muscle of the CC and in penile vessels. The role of interactions between different transmitters and mediators, released from nerves or generated locally, in the regulation of contraction and relaxation of CC and penile vessels, needs further study. International Journal of Impotence Research (2000) 12, Suppl 1, S5±S12 Keywords: noradrenaline; sympathetic nerves; penile erection; penile detumescence; alpha adrenoceptors Introduction in the ¯accid state, in part, through release of noradrenaline (NA). NA stimulates a-adrenoceptors in the penile vasculature, contracting the helicine Penile erection is produced by an increased blood vessels, and in the CC, contracting the trabecular ¯ow to the corpora cavernosa (CC), made possible by smooth muscle.1 the opening of penile resistance vessels (helicine The different structures of the penis receive arteries), relaxation of the CC smooth muscle, and sympathetic, parasympathetic, somatic, and sensory occlusion of the venous out¯ow.1 The erectile innervation.1 The distribution of autonomic nerves response in several animal models has been shown within the CC has been studied by several investi- to depend upon nitric oxide (NO) relaxing both the gators,2 but the density of nerves and the quantita- vasculature and CC tissue. However, most of the tive relations between the number of nerve terminals time, both the vasculature and the CC are con- and the number of smooth muscle cells have not tracted, keeping the penis in a non-erected state. been established. The nerves contain different This is achieved in part, by tonic activity in the transmitters and the nerve populations have been sympathetic, adrenergic pathways to the penis. categorized as adrenergic, cholinergic, and non- Penile arteries, CC smooth muscle, and the principal adrenergic, non-cholinergic (NANC). The latter penile veins receive a rich adrenergic innervation, nerves may contain not only neuropeptides, but and it is generally accepted that the penis is kept also transmitters and transmitter=modulator gener- ating enzymes, such as nitric oxide synthase (NOS) and heme oxygenases (HO). NANC transmit- ters=modulators may be found in adrenergic and *Correspondence: Karl-Erik Andersson, MD, PhD, 3 Department of Clinical Pharmacology, Lund University cholinergic nerves, which should make it more Hospital, S-221 85 Lund, Sweden. meaningful to de®ne nerve populations based on Received 2 September 1999; accepted 15 November 1999 their transmitter content. Sympathetic pathways and adrenergic innervation of the penis K-E Andersson et al S6 Below, a short review is given of the sympathetic lateral gray matter of the lower thoracic (T10) and pathways to the penis, and of the penile adrenergic upper lumbar (L3) spinal cord segments (Figure 1). innervation and its relation to other nerve popula- The segmental levels show species variation.4,5 The tions believed to be involved in the control of penile origin in man is believed to be from T10 to T12.5,6 erectile function. The ventral roots of the corresponding spinal nerves leave the cord as preganglionic ®bres and then pass via the white rami communicantes to the sympa- Sympathetic pathways to the penis thetic chain ganglia. Synaptic connections are made with ganglion cells at various levels (Figure 1). The chain ganglion cells projecting to the penis The supraspinal adrenergic mechanisms involved in are located in the sacral and caudal lumbar gang- erection have not been established. In the spinal lia.2,5 Via the gray rami, the postganglionic axons cord, the sympathetic preganglionic nerve ®bres to reach the urogenital tract through the pelvic, the penis arise from neurons in the intermedio- cavernous, and pudendal nerves.2,5,7 Preganglionic ®bres may pass through the chain ganglia via the lumbar splanchnic nerves and reach the ganglia in the inferior mesenteric and superior hypogastric plexuses (presacral nerve), where synaptic contacts are made (Figure 1). Many of the noradrenergic cells in the inferior mesenteric and hypogastric ganglia (Figure 2a) are surrounded by ®ne terminals con- taining nitric oxide synthase (NOS; Figure 2b), but no ganglion cells containing NOS can be demon- Figure 2 A. Guinea pig, inferior mesenteric ganglion (IMG). Most neuronal cell bodies are adrenergic and express tyrosine hydro- xylase- (TH-) immunoreactivity. Fluorescein isothiocyanate Figure 1 A. Sympathetic pathways to the penis. B. Neurotrans- (FITC) immuno¯uorescence. B. Rat, IMG. Varicose NOS-immuno- mission in penile sympathetic pathways. IMP inferior mesen- reactive (IR) nerve terminal surrounding NOS-negative neuronal teric plexus, HP hypogastric plexus, PP pelvic plexus. cell bodies. FITC immuno¯uorescence. International Journal of Impotence Research Sympathetic pathways and adrenergic innervation of the penis K-E Andersson et al S7 Figure 4 A. Rat, MPG. Most neuronal cell bodies are cholinergic and express choline acetyltransferase (ChAT) immunoreactivity. TR immuno¯uorescence. B. Same section as in 4 A. Numerous NOS-(IR) cell bodies, which to a great extent correspond to the ChAT-IR cell bodies in 4 A. Figure 3 A. Rat, major pelvic ganglion (MPG). Numerous neuronal cell bodies showing cytoplasmic NOS-immunoreactiv- ity. FITC immuno¯uorescence. B. Same section as in 3A, with (Figures 3a and 3b), but not in cells containing NPY adrenergic neuronal cell bodies displaying TH-immunoreactivity, which lack NOS-immunoreactivity (arrow heads). Texas Red (TR) (Figure 6b). immuno¯uorescence. Sympathetic postganglionic axons originating in the pelvic plexus, as well as in paravertebral and prevertebral ganglia, travel to the penis as the strated. In humans, the superior hypogastric plexus cavernous nerve, which is identi®able in close lies on the great vessels at the level of the third proximity to the prostate, and possibly as other, lumbar to the ®rst sacral vertebrae.8 Stimulation of smaller nerves, which follow the blood vessels this plexus in humans can cause either erection or (Figure 1). penile shrinkage.9 Stimulation of the lumbar sympathetic chain, From the superior hypogastric plexus, the left and hypogastric nerves, or sympathetic ®bres in the right hypogastric nerves extend caudally toward the pudendal nerves, produced detumescence of an pelvic plexus (Figure 1). The hypogastric nerves erection elicited by electrical stimulation of the contain postganglionic ®bres from prevertebral sacral spinal roots in cats.10 In rabbits, electrical ganglion cells, as well as preganglionic axons that stimulation of the lowest parts of the sympathetic pass through the prevertebral ganglia to make trunks caused shrinkage of the penis, even when the synaptic connections in the pelvic plexus. This connections of the nerve trunks to the central plexus is an important integrator site for the penile nervous system were cut.11 In the dog, erection autonomic innervation (Figure 3). In rodents, the caused by stimulation of the cavernous nerves was major pelvic ganglion (MPG) thus contains not only blocked by simultaneous stimulation of the hypo- NA (Figure 3a), but also acetylcholine (ACh; Figure gastric nerves; additional hypogastric nerve stimula- 4a), NOS (Figures 3b, 4b, 5a), vasoactive intestinal tion caused a rapid detumescence once erection had peptide (VIP; Figure 5b and neuropeptide Y (NPY; been established by cavernous nerve stimulation.12 Figure 6a). NA (as indicated by the presence of Stimulation of the sympathetic trunk at the level of tyrosine hydroxylase, TH) is located in ganglion L4±S1, applied directly after discontinuation of cells different from those containing ACh and NOS cavernous nerve stimulation, accelerated this detu- International Journal of Impotence Research Sympathetic pathways
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