异搏定膀胱灌注治疗女性尿道综合征

目的：探讨异搏定膀胱灌注治疗女性尿道综合征的疗效。方法：对29例女性尿道综合征患者行异搏定溶液(1．0g／L,80ml)膀胱灌注治疗,治疗前后行IPSS、QOL、尿流率及尿动力学对比。结果：治疗后患者IPSS下降2．34分,QOL下降0．77分,Qmax上升8．03ml／s,Qavc上升4．26ml／s,排尿量上升98．91ml,初始尿意膀胱容量上升34．50ml,强烈尿意膀胱容量上升64．77ml。急迫尿意膀胱容量上升124．83ml。最大膀胱容量上升133．41ml,最大逼尿肌压下降1．42kPa,无明显副作用发生。结论：异搏定膀胱灌注治疗女性尿道综合征安全、有效。     

膀胱充盈对上尿路动力学的影响

对12例行肾切开取石术并造瘘的病人,经肾造瘘管行肾盂内压测定和恒压肾盂灌注试验。发现非利尿情况下膀胱充盈不影响肾盂内基础压,但增加肾盂蠕动频率;在膀胱充盈时恒压灌注肾盂,灌注液通过上尿路的速度较膀胱空虚时明显减慢。说明上尿路动力学可受膀胱充盈的影响。提示在评价上尿路扩张积水时应考虑到膀胱充盈这一因素。     

肠道新膀胱尿动力学检查的临床意义

目的 探讨全膀胱切除肠代膀胱术后患者新膀胱和尿道的尿动力学特点。方法 全膀胱切除回肠原位新膀胱术患者22例，术后6～55个月，平均28个月。尿动力学检查测定尿流率、剩余尿，充盈期、排尿期膀胱测压、直肠测压、括约肌肌电图和尿道压测定。结果 22例患者最大尿流率2．7～22．1ml／s，平均12．9ml／s；排尿时间17～240s，平均66s；剩余尿5～300ml，平均92ml；最大膀胱容量210～650ml，平均426ml；初次尿意膀胱容量137～540ml，平均296ml；急迫尿意膀胱容量200～620ml，平均388ml。充盈末期膀胱内压均〈50cmH2O，顺应性31～35ml／cmH2O，平均33ml／cmH2O。膀胱容量≤50％时充盈期新膀胱不自主收缩平均1．2次，容量〉50％～100％时2．6次。压力流率测定时患者排尿期新膀胱均未见主动收缩，排尿期最大腹压10～105cmH2O，平均64cmH2O。最大尿道闭合压33～114cmH2O，平均69cmH2O。功能性尿道长度17～56mm，平均37mm。结论 回肠新膀胱具有良好的储尿能力，新膀胱排尿主要依靠腹压和尿道的协同作用，保留尿道的控尿能力是保证术后控尿能力的关键。     

直肠扩张对膀胱和后尿道压影响的研究

目的 研究直肠扩张对膀胱和尿道功能的影响.方法 本研究共纳入20例健康志愿者.向志愿者直肠气囊内以50ml梯度缓慢充入气体,观察膀胱和后尿道压力的变化.将志愿者随机分为两组,每组10例,分别行直肠或膀胱后尿道黏膜表面麻醉,重复实验.结果 直肠气囊充气50ml时,膀胱和后尿道压力无明显改变(P>0.05);直肠气囊充气至100ml时,膀胱压显著性降低(P<0.0001)、后尿道压显著性升高(P<0.0001);直肠气囊充气至150ml时,膀胱压和后尿道压维持于气囊100ml时的压力状态,无显著性波动(P>0.05).在直肠或膀胱后尿道黏膜表面麻醉后,膀胱和后尿道压对直肠扩张刺激无明显改变.结论 直肠和膀胱后尿道之间可能存在着局部神经反射性联系,导致直肠扩张时引起膀胱压降低和后尿道压升高.在行尿流动力学检查前应先检查直肠是否处于充盈状态,以免影响膀胱和后尿道压力测定.     

电刺激治疗神经源性膀胱感觉功能障碍的疗效观察

目的:观察电刺激治疗神经源性膀胱感觉功能障碍的疗效。方法:在2009年3月~2010年10月收治的神经源性膀胱患者中,选取以膀胱感觉功能障碍为主诉、经查体和尿动力学检查证实存在膀胱感觉功能障碍的患者38例,其中18例接受电刺激治疗(治疗组),男11例,女7例,年龄23~50岁,平均31.4岁,完全性脊髓损伤患者10例,不完全性脊髓损伤患者8例,病程1~32个月,平均7.2个月;其余20例不接受电刺激治疗,为对照组,男15例,女5例,年龄21~48岁,平均28.6岁,完全性脊髓损伤患者13例,不完全性脊髓损伤患者7例,病程1~27个月,平均6.9个月。尿动力学检查:治疗组中10例膀胱感觉消失,8例膀胱感觉减弱;对照组中11例膀胱感觉消失,9例膀胱感觉减弱。两组年龄、性别、膀胱感觉障碍类型相匹配。治疗组除常规训练外,每天先后进行膀胱腔内电刺激和经皮膀胱电刺激各1次;对照组只进行常规膀胱训练,不行电刺激治疗,1个月后比较两组患者膀胱感觉变化情况。结果:治疗组11例膀胱感觉获得不同程度改善,7例膀胱感觉无变化;8例膀胱感觉减弱患者平均初始尿意膀胱容量和强烈尿意膀胱容量治疗前分别为414±46ml、540±42ml,治疗后分别为255±41ml、420±82ml,治疗前后比较有显著性差异(P<0.05)。对照组治疗前后膀胱感觉无明显变化,平均初始尿意膀胱容量和强烈尿意膀胱容量治疗前分别为466±37ml、562±45ml,治疗后分别为421±21ml、598±47ml,治疗前后比较无显著性差异(P>0.05)。治疗前平均初始尿意膀胱容量和强烈尿意膀胱容量两组间比较无显著性差异(P>0.05),治疗后平均初始尿意膀胱容量和强烈尿意膀胱容量两组间比较有显著性差异(P<0.05)。结论:综合电刺激治疗能改善部分神经源性膀胱患者的膀胱感觉功能。     

女性糖尿病患者膀胱功能障碍的尿动力学研究

目的：探讨尿动力学检查在糖尿病患者膀胱功能障碍诊断中的意义。方法：回顾性分析32例女性糖尿病膀胱病变患者的临床资料和尿动力学检查结果,明确尿动力学的特征性改变。结果：早期组最大尿流率、膀胱容量下降,逼尿肌压力增加,初始尿意、剩余尿量正常;晚期组最大尿流率、逼尿肌压力下降明显,初始尿意、剩余尿、膀胱容量显著增加。结论：女性伴有下尿路症状（LUTS）的糖尿病患者膀胱功能异常的发生率高,随着病程延长,膀胱功能改变明显。尿动力学检查可以明确膀胱功能,对合并糖尿病的LUTS患者的正确诊断和治疗具有重要的指导意义。     

同步膀胱膜部尿道测压的临床意义

目的 探讨同步膀胱膜部尿道压力测定的临床意义。方法 采用ANTEC Duet尿动力学仪同步测定412例泌尿系病人和6例健康者充盈和排尿时的膀胱和膜部尿道压力,肌电图用直肠电极测定。结果 （1）健康人充盈期膜部尿道压,男性为40－50cmH2O,女性为20－30cmH2O,充盈期膜部尿道压高于膀胱压,且全充盈期没有明显变化,排尿时膜部尿道压力明显下降低于膀胱压。（2）逼尿肌尿道协同失调的病人,排尿时膜部尿道压升高,其中逼尿肌外括约肌协同失调（EDES）时合并有肌电活动明显增加,逼尿肌膀胱颈协同失调（DBDS）肌电活动正常,排尿期尿道测压膀胱颈处压力呈斜坡样下降。（3）尿道关闭机制下降或不全时充盈期膜部尿道压明显低,且充盈期膜部尿道膀胱压力差为负值。（4）尿道不稳定充盈期膜部尿道压突然下降且幅度≥15cmH2O。（5）正常尿道腹压传递率为20％－35％,而压力性尿失禁（GUI）病人尿道腹压传递率＜20％。结论 同步膀胱膜部尿道压力测定操作简单,在判断尿道关闭机制的正常与否、逼尿肌尿道的协同与否、尿道稳定性及腹压向尿道的传递效率方面有重要价值。     

OOC患者血清胆囊收缩素与直肠肛管压力的相关性研究

目的：研究直肠肛菅压力及血清胆囊收缩素（CCK）的改变在功能性出口梗阻型便秘（OOC）患者发病中的作用。方法：采用四通道环状固态压力传感器测压导管测定50例OCC患者直肠肛管压力;采用酶联免疫吸附测定（ELISA）检测其中20例血清CCK水平,并与20例正常人做对照。结果：与正常对9最组相比,OCC患者的肛管静息压、最大缩榨压明显降低,引起直肠初始感觉、初始便意感觉和最大感觉阈值的容积均明显升高（P值均〈O．01）。OCC组血清CCK水平显著低于正常对照组,与最大感觉阈值呈负相关。结论：OCC患者存在直肠肛管压力异常、直肠感觉功能下降及血清CCK的异常。直肠容量的感知能力与血清CCK含量呈负相关。     

充盈性膀胱测压的影响因素及护理对策

对118例患者使用美国Life-Tech公司的UrolabV型尿流动力学检查仪进行充盈性膀胱测压。结果57例（48．3％）充盈性膀胱测压出现非真实图像，其中86．0％（49／57）与患者因素有关，14．0％（8／57）与操作者因素有关。提出患者的心理状态、配合程度、护士操作熟练程度等对充盈性膀胱测压有一定影响．做好患者检查前、检查中的心理护理和配合指导，护士操作技术熟练，是高质量完成膀胱测压的关键。     

动态尿动力学检查的临床应用进展

20世纪60年代尿动力学检查开始应用于临床,主要用于下尿路功能的检查和评估.但常规尿动力学检查(conventional cystometry,CMG)有许多不足之处,如检查是通过人工灌注膀胱而不是通过膀胱自然充盈的方法检查膀胱功能.人工灌注的速度明显影响了膀胱的顺应性,有时甚至诱发人为假象,使其诊断精确性受到很大影响,且检查中由于医护人员在场会影响患者排尿,导致结果不准确[1].     

Impact of rectal distention on the results of evaluations of lower urinary tract sensation

PURPOSE: To our knowledge no systematic studies have been performed in humans to test the interaction of normal bladder and rectal sensory function. However, symptoms affecting the different pelvic viscera often coexist. MATERIALS AND METHODS: In 15 healthy female volunteers sensations of bladder filling were evaluated during 2 consecutive cystometric studies, including 1 with an empty rectum and 1 with a full rectum. Similarly the electrical perception threshold was determined in the bladder when the rectum was empty and again when the rectum was full. RESULTS: Rectal distention did not change bladder compliance during filling. When the rectum was distended, sensations of bladder filling were reported at smaller volumes. On the other hand, electrical perception thresholds in the bladder were higher when the rectum was full. CONCLUSIONS: The state of the rectum significantly influences the sensations of bladder filling and electrical bladder stimulation. These results show that before sensory testing of the bladder rectal fullness should be examined and if necessary the rectum should be emptied. The different effect of rectal distention on filling and electrical sensations represents an additional argument for different innervation of the 2 sensations in the lower urinary tract.     

Interaction of filling related sensation between anorectum and lower urinary tract and its impact on the sequence of their evacuation. A study in healthy volunteers

AIMS: The anorectum and lower urinary tract (LUT) are closely related organs: anorectal and LUT dysfunction often occur concomitant, and therapeutic actions in one organ may influence function of the other. The aim of this study was to explore the physiologic relationship between anorectal and LUT function in healthy volunteers. METHODS: Two groups of healthy volunteers were studied. Anorectal and LUT sensory function was evaluated in ten volunteers during rectal balloon and bladder filling. The second group of 100 volunteers reported on defecation and micturition during five toilet visits. They graded perception on rectal and bladder fullness on a visual analogue scale and marked which organ evacuation started first. RESULTS: The volumes at which the different sensations of rectal filling during balloon distension were perceived was significantly higher with full bladder than with empty bladder (P<0.04). Five hundred toilet visits were described. Although mean perception grade of rectal fullness was significantly higher than for bladder fullness (P<0.0001), defecation started only in 36% of the reported visits before micturition. Only when the rectum was considered completely full, or the bladder completely empty, defecation occurred more frequently before micturition. In all other cases, micturition more frequently occurred before defecation. CONCLUSIONS: When the bladder is full, sensation of rectal filling is decreased. When healthy people visit the toilet to defecate, the initiation of micturition often precedes that of defecation, even if both organs are considered equally full.     

Frequency-volume charts: a tool to evaluate bladder sensation

AIMS: Bladder sensation is routinely evaluated by cystometric bladder filling and electrical stimulation. These methods require catheterization and stimulate the bladder artificially. In this study, we evaluated whether frequency-volume charts can be used as a non-invasive tool to study bladder sensation during normal daily life. Furthermore the agreement between sensory data obtained from frequency-volume charts and conventional cystometric bladder filling is studied. MATERIALS AND METHODS: Fifteen healthy female students filled out frequency-volume charts at home and scored the grade of perception of bladder fullness at each micturition. They also measured the volume of three voidings after postponing micturition as long as possible. Sensation of bladder filling was finally evaluated during cystometry. RESULTS: On frequency-volume charts, 65% of all voidings was made without desire to void, only 9.5% was with strong desire. Urgent desire to void was not reported except after voluntarily postponing micturition. Higher grades of perception of fullness were associated with significantly higher voided volumes. Mean volumes for the different sensations of fullness on the charts were not significantly different from volumes at different sensations reported during cystometry. CONCLUSIONS: In conclusion, bladder sensation during daily life can be evaluated by scoring the grade of perception of fullness on frequency-volume charts. During life voiding usually occurs without desire to void. The voided volumes at different sensations of fullness are comparable to the volumes at different sensations of filling during cystometry. Therefore, frequency-volume charts with evaluation of perception of fullness may provide an initial non-invasive tool to study bladder sensation.     

Effect of sacral neuromodulation on the rectum

BACKGROUND: Sacral neuromodulation (SNM) is a new treatment for faecal incontinence. At present the exact underlying mechanism is still unclear. Modulation of the sacral reflex arcs might have an effect on rectal sensitivity, wall tension and compliance. METHODS: Fifteen consecutive patients with faecal incontinence who qualified for SNM underwent barostat measurements before and during neuromodulation. An 'infinitely' compliant plastic bag with a volume of 600 ml was placed in the rectum and connected to a computer-controlled barostat system. An isobaric phasic distension protocol was used. Patients were asked to report rectal filling sensations: first sensation (FS), earliest urge to defaecate (EUD) and an irresistible, painful urge to defaecate (maximum tolerated volume; MTV). Rectal wall tension and compliance were calculated. RESULTS: During isobaric phasic distension each patient experienced all rectal filling sensations at the time of stimulation. Median volume thresholds decreased significantly during stimulation, from 98.1 to 44.2 ml for FS (P = 0.003), from 132.3 to 82.8 ml for EUD (P = 0.001) and from 205.8 to 162.8 ml for MTV (P = 0.002). Pressure thresholds tended to be lower for all filling sensations, but only that to evoke MTV was reduced significantly by stimulation (37.3 versus 30.3 mmHg; P = 0.005). Median rectal wall tension for all filling sensations decreased significantly with stimulation. There was no significant difference between compliance before and during stimulation. CONCLUSION: SNM affects rectal sensory perception, but further research is required to clarify the mechanism.     

Objective measurement of bladder sensation: use of a new patient-activated device and response to neuromodulation

Detrusor overactivity is the primary objective focus of most investigations into the diagnosis and management of patients with urgency incontinence. Patients with an overactive bladder are characteristically troubled by subjective sensations of bladder fullness and urinary urgency, and frequently void at low bladder volumes attained before noticeable detrusor overactivity occurs. Bladder sensations are therefore crucial to understanding voiding patterns and symptoms, but little progress has been made in objectively describing the range of these sensations, and adequate information is lacking about their response to neuromodulation. Towards this end, a keypad 'urge score' device was designed to measure sensations during bladder filling. This patient-activated device gathers information about patient perceptions of bladder filling and the successive stages of increasing bladder sensation, without prompting or intervention by the investigator. The accuracy of the 'urge keypad' during filling cystometrography was validated in patients with urgency incontinence, and compared with data abstracted from patient voiding diaries. The device provides reliable and repeatable measures of different bladder sensations, with excellent, statistically significant consistency between bladder volumes and corresponding levels of sensation. Subsequently, it was shown that the sensation of urgency can be suppressed by neuromodulation in most patients tested; this suppression occurs with improvements in bladder capacity and voided volumes. It is therefore suggested that urodynamics with concurrent sensory evaluation may offer a more useful assessment tool for selecting those patients for therapies such as neuromodulation who present predominantly with the symptom of urgency.     

Pharmacologic effect of thiphenamil HCl on lower urinary tract function of healthy asymptomatic volunteers.

The effect of thiphenamil HCl on the urodynamic parameters of bladder filling, voiding and isometric contraction was examined in controls. Data were obtained from 25 control female subjects with a mean age of 27.6 +/- 6.6 years. Three urodynamic studies were done on each subject on 3 different days. These studies were: (1) control study, (2) drug study with a single oral dose of 400 mg thiphenamil HCl and (3) another with 800 mg. Each urodynamic study involved filling and voiding cystometrograms to characterize stability, sensations of fullness and urgency, bladder capacity, urethral opening pressure, maximum flow rate, maximum detrusor pressure and residual urine. In addition, isometric detrusor pressure measurements were made at bladder volume increments of 100 ml. Each urodynamic study was done in the sitting position using medium fill water cystometry at 20 ml/min. Isometric pressures were made by catheterizing the subject with an 18-french three-way Foley catheter with a 30-ml balloon. One lumen was used to fill the bladder and the second to measure pressure. The results show that bladder capacity and the volume at which sensations of fullness and urgency are expressed are not significantly changed under the influence of thiphenamil HCl. Significant differences were seen in the maximum pressure generated by the detrusor during voiding and in the maximum urine flow rate. These differences were most pronounced at the 800-mg thiphenamil HCl dose. The isometric data show a highly significant increase in the maximum isometric pressure developed at the low bladder volumes.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of pelvic floor muscle contraction on vesical and rectal function with identification of puborectalis-rectovesical inhibitory reflex and levator-rectovesical excitatory reflex

 The effects of pelvic floor muscle contraction on rectal and vesical function were studied in 19 healthy volunteers with the aim of shedding light on some of the hitherto vague aspects of the mechanisms involved in micturition and defecation and their disorders. Rectal and vesical pressures were recorded during puborectalis (PR) and levator ani (LA) muscle stimulation with the rectum or urinary bladder empty and full. Muscle stimulation was effected by needle EMG electrode. The pressure responses to stimulation of the PR and LA muscles were also recorded with these muscles and the rectum and urinary bladder individually anesthetized in 12 of the 19 subjects. The test was repeated using saline instead of xylocaine. PR and LA muscle stimulation produced no pressure response in the empty rectum or bladder. Upon rectal balloon distension with a mean of 156.6 ± 34.2 ml of carbon dioxide the mean rectal pressure was 64.6 ± 18.7 cm H₂O, the subject felt the urge to evacuate and the balloon was expelled to the exterior. On PR muscle stimulation at rectal distension with the above volume, the subject did not feel the urge to evacuate, the rectal pressure was 8.2 ± 1.6 cm H₂O and the balloon was not expelled. Upon LA stimulation at the same volume, the urge persisted, the rectal pressure was higher and the balloon was expelled. Vesical filling with a mean of 378.2 ± 23.6 ml of saline initiated the urge to urinate and elevated the vesical pressure. PR muscle stimulation at this volume aborted the urge and pressure elevation, while LA stimulation caused more elevation of the vesical pressure and spontaneous micturition. Bladder filling with a mean of 423.6 ± 38.2 ml produced high vesical pressure and spontaneous urination, both of which were prevented by PR muscle stimulation but not by LA muscle stimulation. Stimulation of the PR and LA muscles during individual anesthetization of the rectum, bladder or PR and LA muscles resulted in no significant rectal or vesical pressure changes. Repetition of the test using saline instead of xylocaine resulted in rectal and vesical pressure responses similar to those without the use of saline. In conclusion, the decline in rectal and vesical responses upon PR muscle contraction indicates a reflex relationship which we term `puborectalis rectovesical inhibitory reflex'. This reflex is suggested to abort the urge to defecate or urinate. In contrast, LA muscle contraction produced rectal and vesical pressure elevation which is suggested to be mediated through the `levator rectovesical excitatory reflex'. `This reflex is probably evoked to promote rectal and vesical evacuation.     

Can a faked cystometry deceive patients in their perception of filling sensations? A study on the reliability of spontaneously reported cystometric filling sensations in patients with non‐neurogenic lower urinary tract dysfunction

AIMS: To evaluate the reliability of spontaneously reported bladder sensations during real and faked cystometry in patients with non-neurogenic lower urinary tract dysfunction. METHODS: Fifty-nine patients with non-neurogenic lower urinary tract dysfunction were submitted to a real and faked filling cystometry and were asked to describe all bladder-related sensations they experienced during the investigations. All patients were told that the bladder had to be filled twice, but during the faked cystometry, no water was infused in the bladder. RESULTS: During the real cystometry, the normal pattern of filling sensation was reported by 88%. During the faked cystometry, none of the patients reported the normal pattern of filling sensations. Five patients reported first sensation of filling, one first desire to void (FDV). None of the patients reported a strong desire to void (SDV) during the faked cystometry. CONCLUSIONS: Asking patients with a non-neurogenic lower urinary tract dysfunction to report on the bladder filling sensations during cystometry is a valid method for sensory evaluation. A minority of patients may report some sensation of bladder filling even without actual bladder filling. Memory and habituation may play a role in the perception of bladder sensation and one should be aware of this. However, reporting some sensation during faked cystometry not necessarily means the evaluation of the perception of bladder filling is unreliable.     

The influence of bladder filling on anorectal function

Objective The aim of this study was to develop a technique to simultaneously evaluate bladder and anorectal function. In particular, this study was designed to determine if anal sphincter resting pressure, anal sphincter squeeze pressure and rectal sensation change with bladder filling. Patient and methods A pilot study of ten female patients who presented to the pelvic physiology unit for assessment of urinary symptoms was performed. All patients completed a symptom questionnaire and quality of life assessment form. Following informed consent a baseline urodynamic test was performed with the bladder empty and subsequently followed by an anorectal manometric test. Changes in anal sphincter resting pressure, squeeze pressure and rectal pressure were recorded over a ten‐minute period. With the patient lying in the left lateral position, the bladder was then filled with isotonic saline at room temperature at a constant rate of 30ml/min. A continuous assessment of changes in anal sphincter resting pressure during bladder filling was made. Anal sphincter squeeze pressure and rectal sensation were measured at fixed intervals during bladder filling (50, 100, 150 ml etc.) and at fixed intervals relative to bladder capacity (25, 50, 75 and 100% capacity) by stopping bladder filling at the appropriate level. Results There was no significant change in anal sphincter resting pressure (Mean difference(s.d.) between bladder full and empty = 2.7(5.6) P = 0.92*), squeeze pressure (Mean(s.d.) difference = 9.5(26.3) P = 0.86*) and rectal sensation (Mean difference(s.d.) first sensation 10(15.2) P = 0.958; Mean difference(s.d.) urgency = 10(17.8) P = 0.07*) on bladder filling. Conclusion Under normal physiological circumstances, bladder filling does not influence anorectal function. *Stastistical analysis: Wilcoxon signed rank sum test. P < 0.05 considered significant. Units = mmHg     

A clinical study on subjective sensations during bladder filling

Subjective sensations during the tonic phase of a bladder filling during cystometry were determined in 649 patients with incontinence and/or micturition problems of neurogenic and non-neurogenic origin. In this study 354 patients perceived three distinct sensations: a ‘first sensation of filling’ at 40% of bladder capacity, a ‘first desire to void’ at 75% of bladder capacity and a ‘strong desire to void’ at maximum cystometric capacity; 184 patients had one or two different sensations. Volume seemed more important than intravesical pressure in eliciting the sensations. In the distinction by the patient between the three consecutive sensations, both changes in intensity of volume perception and the existence of a specific neurological pathway for each sensation might play a role. Sensations appeared earlier during filling when asymtomatic urinary tract infection was present. These data give additional information about the subjective proprioception of bladder filling.