RTX膀胱灌注治疗氯胺酮相关性下尿路症状的临床研究

目的：探对RTX膀胱灌注治疗氯胺酮相关性下尿路症状的有效性和安全性。方法：收治滥用氯胺酮1．5～6年患者16例,均因严重下尿路症状就诊,所有患者均行RTX1次性膀胱灌注,观察用药前及用药后1周、1个月、3个月时患者的临床症状情况（每日排尿次数、排尿量、尿疼痛程度评分）和生活质量评分（QOL）情况。结果：患者用药前及用药后1周、1个月和3个月时每日排尿次数分别为（48．41±10．77）、（14．30±4．77）、（14．63±3．70）和（15．19±4．06）次,用药后排尿次数明显减少;最大排尿量分别为（104．26±79．31）、（167．41±67．46）、（188．89±62．35）和（171．85±65．11）ml,用药后排尿量增加;疼痛程度评分分别为（6．74±1．38）、（3．89±1．15）、（4．63±1．31）和（4．85±1．67）分,较用药前明显下降,上述指标与用药前相比差异有统计学意义。患者用药前后生活质量评分分别为（5．92±0．51）、（5．20±0．47）、（5．33±0．46）、（5．34±0．51）分,差异无统计学意义。所有患者均坚持完成试验,使用RTX后患者生命体征均平稳,无全身不良反应。结论：用RTX膀胱灌注治疗能有效缓解氯胺酮相关性下尿路症状患者的临床症状和改善其生活质量,且耐受性及安全性好。     

Estrogens and the lower urinary tract

The urogenital tract is sensitive to the effect of oestrogen and progesterone throughout adult life. Epidemiological studies have implicated oestrogen deficiency in the aetiology of lower urinary tract symptoms occurring following the menopause. Although to date the role of oestrogen replacement therapy in the management of postmenopausal urinary incontinence remains controversial its use in the management of women complaining of urogenital atrophy is now well established. This aim of this paper is to review the recent evidence regarding the urogenital effects of hormone therapy with a particular emphasis on the management of postmenopausal urinary incontinence, overactive bladder, recurrent lower urinary tract infections and urogenital atrophy. In addition to a review of the available evidence suggestions are also made regarding priorities for further research in the field.     

Upper urinary tract damage caused by ketamine snorting—A report of nine cases

ObjectiveThe toxicity of ketamine to genitourinary system not only involved in lower urinary tract, which include urinary frequency, urgency, suprapubic pain, dysuria and hematuria, but also upper urinary tracts. However, the reports of ketmaine-induced upper urinary tract damage were rare.Materials and methodsHerein, we reported nine ketamine abusers presented with moderate flank pain with hydronephrosis and lower urinary tract symptoms from three medical centers located around Taiwan.ResultsAll patients were diagnosed of hydronephrosis by sonography or abdominal computed tomography scans and 7 cases combined with acute kidney injury. They all receive ureteroscopy exam and double-J stenting. All of their flank pain and renal function impairment improved during follow up.ConclusionTo the best of our knowledge, currently there is no standard therapy for ketamine-induced nephropathy, we therefore supplied a therapeutic choice for those ketamine abuser combined with hydronephrosis and/or acute kidney injury.     

The physiology and pharmacology of the urinary tract

The urinary bladder is a storage vessel for most of the time, when intravesical pressure remains low and the outflow resistance high. During voiding a switch occurs when intravesical pressure rises and the outflow relaxes. The control of this change of function is regulated by a complex interplay between sensations arising from the lower urinary tract (LUT), coordination of responses in the brain and sacral spinal cord and control over bladder and the outflow tract. LUT function can become disorganized and commonly shows as overactive bladder (OAB) with symptoms of urgency and frequency, with or without incontinence. Several pharmaceutical approaches to manage OAB are possible which rely predominantly on manipulating mechanisms that generate detrusor contraction, initiate sensations of bladder filling or reduce the magnitude of outflow obstruction. The introduction of successful agents requires knowledge of the mechanisms that generate contraction in LUT tissues both in the normal and overactive bladder. The upper urinary tract propels urine from the kidney to the bladder by peristalsis, a process modulated by agents such as prostaglandins, produced by the ureters. Urinary tract stones collect in the upper tract and cause considerable morbidity. They are commonly formed of Ca oxalate/phosphate or magnesium ammonium phosphate. Various endogenous and artificial agents promote or inhibit stone formation and along with various mechanical procedures are used to manipulate the formation of upper tract stones.     

The physiology and pharmacology of the lower urinary tract

The lower urinary tract comprises the urinary bladder, the urethra and prostate in men, and is concerned with the storage of urine and its voluntary expulsion from the body when socially convenient. These mutually exclusive states are mediated by complex neural networks that when dysfunctional generate bothersome and highly prevalent lower urinary tract symptoms (LUTS). Lower urinary tract symptoms are often idiopathic and not pathology specific and most result from bladder outflow obstruction, disorders of bladder contractility or conditions which increase bladder sensitivity and a combination of any of these states. Despite the precise mechanisms of symptom generation being unclear, the receptor mechanisms involved in controlling lower urinary tract function can be pharmacologically manipulated to achieve useful clinical outcomes.     

基因治疗在下尿路功台宦障碍治疗中的应用现状

下尿路功能障碍可由中枢和外周神经系统以及尿路上皮和逼尿肌的病变导致。随着人们对下尿路研究的不断深入，临床上出现多种治疗下尿路功能障碍的新方法和新药物，但是对症状严重的患者效果仍不尽如人意。基因治疗为下尿路功能障碍的治疗提供了一种全新的途径。本文对目前国内外基因治疗在下尿路功能障碍的应用及基因导人载体的种类和优缺点进行综述。     

The physiology and pharmacology of the lower urinary tract

The lower urinary tract consists of the bladder and urethra in both sexes, and the prostate additionally in men and is concerned with the storage of urine and its voluntary and controlled expulsion from the body when socially convenient. These mutually exclusive states are mediated by complex neural networks that when dysfunctional may generate bothersome and prevalent lower urinary tract symptoms (LUTS). These symptoms are often idiopathic and not pathology specific. Most may be caused by bladder outflow obstruction, disorders of bladder contractility or conditions which increase bladder sensitivity and a combination of any of these states. Despite the precise mechanisms of symptom generation remaining unclear, the receptor mechanisms involved in controlling lower urinary tract function can be pharmacologically manipulated to achieve useful clinical outcomes.     

The physiology and pharmacology of the lower urinary tract

The lower urinary tract comprises the urinary bladder, the urethra and prostate in men, and is concerned with the storage of urine and its voluntary expulsion from the body when socially convenient. These mutually exclusive states are mediated by complex neural networks that when dysfunctional generate bothersome and highly prevalent lower urinary tract symptoms (LUTS). Lower urinary tract symptoms are often idiopathic and not pathology specific and most result from bladder outflow obstruction, disorders of bladder contractility or conditions which increase bladder sensitivity and a combination of any of these states. Despite the precise mechanisms of symptom generation being unclear, the receptor mechanisms involved in controlling lower urinary tract function can be pharmacologically manipulated to achieve useful clinical outcomes.     

Assessment of lower urinary tract symptoms

Lower urinary tract symptoms (LUTS) encompass a range of symptoms commonly experienced by both men and women, and encountered by a wide range of healthcare practitioners (HCPs). This review summarizes the basic terminology and assessment that HCPs should be aware of, regardless of their professional discipline. Apart from emphasizing the need for standardization in terminology, there is a need to avoid misleading terms that suggest a causative mechanism until the mechanism has been identified by investigation. HCPs should also avoid arbitrary thresholds for judging severity of symptoms. The use of algorithms from evidence-based guidelines limits variation in management and avoids unnecessary investigations. However, a tailored approach is useful in understanding the underlying pathophysiology in individual patients. As symptoms are unreliable in predicting the underlying mechanism, a useful approach is to try and develop a urodynamic diagnosis mindful of the normal physiology of the lower urinary tract as the practitioner works through the symptoms, signs and appropriate urodynamic investigations, and use such investigations in a logical manner tailored to the individual to either support or refute assumptions and arrive at a working diagnosis.     

Assessment of lower urinary tract symptoms

Lower urinary tract symptoms (LUTS) encompass a range of symptoms commonly experienced by both men and women, and encountered by a wide range of healthcare practitioners (HCPs). This review summarizes the basic terminology and assessment that HCPs should be aware of, regardless of their professional discipline. Apart from emphasizing the need for standardization in terminology, there is a need to avoid misleading terms that suggest a causative mechanism until the mechanism has been identified by investigation. HCPs should also avoid arbitrary thresholds for judging severity of symptoms. The use of algorithms from evidence-based guidelines limits variation in management and avoids unnecessary investigations. However, a tailored approach is useful in understanding the underlying pathophysiology in individual patients. As symptoms are unreliable in predicting the underlying mechanism, a useful approach is to try and develop a urodynamic diagnosis mindful of the normal physiology of the lower urinary tract as the practitioner works through the symptoms, signs and appropriate urodynamic investigations, and use such investigations in a logical manner tailored to the individual to either support or refute assumptions and arrive at a working diagnosis.     

Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction

Study Type – Symptom prevalence (prospective cohort) Level of Evidence 1b What’s known on the subject? and What does the study add? Few prevalence studies used current ICS LUTS symptom definitions and to our knowledge no studies exist that estimate total worldwide prevalence of reported LUTS symptoms. One of the primary goals of this analysis was to estimate current and future worldwide prevalence of LUTS among adults. Our estimation model suggests that LUTS are highly prevalent worldwide, with an increasing burden predicted over time.

OBJECTIVE

? To estimate and predict worldwide and regional prevalence of lower urinary tract symptoms (LUTS), overactive bladder (OAB), urinary incontinence (UI) and LUTS suggestive of bladder outlet obstruction (LUTS/BOO) in 2008, 2013 and 2018 based on current International Continence Society symptom definitions in adults aged ≥20 years.

PATIENTS AND METHODS

? Numbers and prevalence of individuals affected by each condition were calculated with an estimation model using gender‐ and age‐stratified prevalence data from the EPIC study along with gender‐ and age‐stratified worldwide and regional population estimates from the US Census Bureau International Data Base.

RESULTS

? An estimated 45.2%, 10.7%, 8.2% and 21.5% of the 2008 worldwide population (4.3 billion) was affected by at least one LUTS, OAB, UI and LUTS/BOO, respectively. By 2018, an estimated 2.3 billion individuals will be affected by at least one LUTS (18.4% increase), 546 million by OAB (20.1%), 423 million by UI (21.6%) and 1.1 billion by LUTS/BOO (18.5%). ? The regional burden of these conditions is estimated to be greatest in Asia, with numbers of affected individuals expected to increase most in the developing regions of Africa (30.1–31.1% increase across conditions, 2008–2018), South America (20.5–24.7%) and Asia (19.7–24.4%).

CONCLUSIONS

? This model suggests that LUTS, OAB, UI and LUTS/BOO are highly prevalent conditions worldwide. Numbers of affected individuals are projected to increase with time, with the greatest increase in burden anticipated in developing regions. ? There are important worldwide public‐health and clinical management implications to be considered over the next decade to effectively prevent and manage these conditions.     

Animal models and their use in understanding lower urinary tract dysfunction

This review will highlight appropriate animal models for the study of a number of disorders involving changes to lower urinary tract function. A major hurdle to the development of animal models for human lower urinary tract disorders is that the clinical pathophysiology of the latter mostly remain idiopathic. Acute injury/inflammation of otherwise healthy animals has often been used to study effects on a target tissue/organ. However, these “acute” models may not adequately address the characteristics of “chronic” visceral disorders. In addition, the relevance of observed changes following acute injury/inflammation, in terms of possible therapeutic targets, may not reflect that which occurs in the human condition. We have therefore emphasized the situations when animal models are required to investigate lower urinary tract disorders and what they should set out to achieve. In particular we have discussed the merits and disadvantages of a number of paradigms that set out to investigate specific lower urinary tract disorders or situations associated with these conditions. These include animal models of overactive bladder, stress urinary incontinence, ageing and congenital defects of the urinary tract and bladder pain syndrome. Neurourol. Urodynam. 29:603–608, 2010. Copyright © 2010 Wiley‐Liss, Inc.     

Assessment of lower urinary tract symptoms

Lower urinary tract symptoms (LUTS) encompass a range of symptoms commonly experienced by both men and women. Discrepancies in interpretation require a standardized terminology, with an understanding of the different causations for each symptom. These should replace previous misleading words such as ‘prostatism’. The use of algorithms from evidence-based guidelines limits variations in management and avoids unnecessary investigations. Although symptoms do not predict the underlying pathophysiology, a useful approach is to try and develop a urodynamic diagnosis from the point of taking a history and using appropriate investigations in a logical, step-wise manner to arrive at a working diagnosis.     

Recreational ketamine: from pleasure to pain

Ketamine has become increasingly recognized as a drug of recreational use. Individuals using significant amounts have developed symptoms including a small painful bladder, ureteric obstruction, papillary necrosis and hepatic dysfunction. The present paper examines the current literature on the relationship between ketamine use and these symptoms. Our own clinical experience and the data available clarify the causal relationship, and further data help to elucidate the mechanism of damage. On the basis of continued work and development with patients who are ketamine users we suggest an assessment and treatment regime that includes cessation of ketamine use and adequate analgesia to overcome symptoms. In conclusion, it is important for medical practitioners who encounter patients with these symptoms to ask about recreational drug use. Ketamine remains a safe and effective drug to use under appropriate medical supervision. Patients identified as suffering from this syndrome will need to be referred to a urological unit with an interest in the treatment of the condition.