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。     

脊髓发育不良和隐性骶椎裂致神经源性膀胱功能障碍的尿动力学表现

为了解脊髓发育不良和隐性骶椎裂对泌尿系统的影响，对３４例有泌尿系统症状的患者行尿动力学检查和辅助检查。结果显示有反射性膀胱２１例（６１．７％），其中逼尿肌外括约肌协同失调１３例，排尿困难为主要表现；逼尿肌外括约肌协同正常８例，急迫性尿失禁为主要表现。无反射性膀胱１３例（３８．５％），排尿困难、尿潴留为主要表现。１２例膀胱颈口开放患者９例有尿失禁，最大尿道闭合压为３．１７±１．４０ｋＰａ（１ｋＰａ＝１０．２０ｃｍＨ２Ｏ），２２例膀胱颈口闭合患者最大尿道闭合压为７．７７±３．５０ｋＰａ（Ｐ＜０．０１）。１５例ＩＶＵ显示有上尿路损害的患者排尿期膀胱压力为平均８．０１±４．３０ｋＰａ，１９例无上尿路损害的患者排尿期膀胱压力平均为３．０６±１．２０ｋＰａ，（Ｐ＜０．０１）。综合分析显示患者临床症状和尿动力学表现与脊髓损伤平面无对应关系。     

腰椎术后排尿功能障碍患者尿动力学改变及治疗

目的：探讨腰椎术后排尿功能障碍患者的尿动力学改变及治疗方法。方法：对27例腰椎术后排尿功能障碍患者行尿动力学检查，根据检查结果，对逼尿肌反射亢进、膀胱感觉过敏、逼尿肌反射减弱但膀胱容量缩小、逼尿肌漏尿点压力超过40cmH2O的患者先采用M受体阻滞剂或肉毒毒素A膀胱壁注射治疗．待膀胱有足够大的容量、能够低压储尿时再应用间歇导尿、留置导尿等方法在无膀胱内高压的条件下实现膀胱的完全排空；逼尿肌无反射和逼尿肌外括约肌协同失调患者选择间歇导尿。结果：27例患者中逼尿肌反射亢进2例，逼尿肌无反射18例，逼尿肌反射减弱7例；排尿期膀胱颈开放7例，部分开放12例，未开放8例；外括约肌痉挛24例，逼尿肌和外括约肌协同失调3例：无膀胱输尿管返流22例，右侧膀胱输尿管返流1例，左侧膀胱输尿管返流2例，双侧膀胱输尿管返流2例；10例患者逼尿肌漏尿点压力超过40cmH2O。10例逼尿肌反射亢进或膀胱容量缩小的患者中7例采用M受体阻滞剂治疗后膀胱容量均增加；3例M受体阻滞治疗无效改用肉毒毒素A膀胱壁注射治疗后膀胱容量均增加；逼尿肌无反射患者首选间歇导尿。结论：腰椎手术后发生排尿障碍的患者应行尿动力学检查，并以尿动力学结果为基础决定处理方案。     

女性下尿路症状的尿动力学分析(附283报告)

目的 研究以下尿路症状为主诉的女性患者的尿动力学变化及其临床意义。方法女性患者．年龄6-89岁，临床表现为储尿期（刺激性）和（或）排尿期（梗阻性）症状，采用尿动力学方法检查尿流率、同步膀胱压力容积流率及肛门括约肌肌电图测定、部分同步透视下行影像尿动力学检查。结果 以排尿症状为主者86例，以储尿症状为主者197例。不稳定膀胱57例，感觉性尿急30例。神经原性膀胱尿道功能障碍32例，其中逼尿肌反射低下26例。逼尿肌反射亢进7例。逼尿肌收缩力低下26例。逼尿肌外括约肌协同失调1例。下尿路梗阻30例，其中膀胱颈梗阻6例，尿道远端狭窄11例，非神经原件逼尿肌外括约肌协同失调13例。压力性尿失禁68例，其中Ⅰ型19例，Ⅱ型12例。Ⅲ型14例，Ⅱ／Ⅲ型23例；TF常40例。结论 尿动力学检查能了解膀胱的功能状况和膀胱出口梗阻的部位，为临床治疗的选择提供了可靠的依据。     

K-2阿片受体激动剂诱发大鼠膀胱括约肌和尿道外括约肌失协调

目的：通过脊髓鞘内给与选择性K1（U50,488）和K-2（GR89,696）阿片受体激动剂来验证脊髓K阿片受体亚型在大鼠尿道外括约肌控制中的作用。方法：乌拉坦麻醉雌性大鼠,膀胱顶部插管充盈膀胱诱发排尿进行膀胱测压,肌电图评估尿道外括约肌（EUS）功能,脊髓鞘内或静脉注射给药。结果：大鼠排尿时EUS在基础的（连续的）收缩活动之上出现高频舒张收缩以利于排空尿道完成排尿。GR-89,696（0．05to5μg鞘内注射it）使EUS每次排尿时的舒张收缩的次数呈剂量依赖性减少。它使排尿效率降低,大剂量时导致EUS排尿时的舒张收缩消失,呈持续收缩状态,出现膀胱逼尿肌和EUS协同失调和充盈性尿失禁。非选择性阿片受体拮抗剂纳洛酮（1mg／kg静脉注射iv）可阻滞GR89,696的效应。U-50,488（0．05 to 5μg鞘内注射it）对膀胱内压和EUS肌电图参数无影响。结论：大鼠有效的排尿需要依靠脊髓信号发生器刺激EUS运动神经元产生信号．使EUS产生舒张收缩,从而导致尿道快速的舒张与收缩以利于排空。脊髓鞘内注射K2阿片受体激动剂可以抑制信号发生器,减少每次排尿期舒张收缩的次数,但并不影响与尿道关闭有关的基础收缩。由此产生膀胱逼尿肌和EUS协同失调,导致排尿效率降低。和大鼠脊髓损伤导致的膀胱逼尿肌和EUS协同失调排尿障碍相似。因此,应该进一步研究K-2阿片受体在脊髓损伤导致的排尿障碍中的作用。     

隐性骶椎裂致排尿障碍的尿动力学及X线影像学研究

分析了３１例隐性骶椎裂患者行尿动力学及Ｘ线影像学检查结果。尿动力学显示反射性膀胱１９例，无反射性膀胱１２例；括约肌协同正常１４例，外括约肌协同失调７例，内括约肌协同失调１０例。结果提示：Ｓ１或Ｓ２部位的隐性骶椎裂易引起排尿障碍；隐性骶椎裂部位、程度与排尿障碍表现、神经源膀胱类型无对应关系；隐性骶椎裂致排尿障碍的病理改变是一个慢性长期的过程，病程较长者临床症状较重。作者认为治疗应以纠正逼尿肌与括约肌失衡，改善排尿为目的。     

女性膀胱出口梗阻的研究进展

女性膀胱出口梗阻(FBOO)发病率尚无确切数据,有报道女性LUTS患者中FBOO者占2.7%～8.0%[1-2].根据ICS定义,FBOO是排尿期逼尿肌压力升高以及尿流率降低.FBOO可分为解剖型和功能型2大类.Goldman和Zimmern[3]将解剖型FBOO又分为外压、尿道、腔内等亚型.引起FBOO的病因包括盆腔脏器脱垂、膀胱颈瘢痕形成(通常继发于尿道和阴道前壁外科手术)、导致逼尿肌括约肌协同失诃的神经原性疾病、原发性膀胱颈梗阻(PBNC))、尿道狭窄性疾病、盆底肌肉过度活跃、功能失调性排尿等[4].     

排尿期尿道测压的临床应用

目的：确定下尿路梗阻及其梗阻部位。方法：对４１例有下尿路梗阻症状患者进行了排尿期尿道测压（ＭＵＰＰ）,其中包括前列腺增生症（ＢＰＨ）２９例,男性尿道狭窄３例,逼尿肌－外括约肌协同失调３例,女性压力性尿失禁４例,女性尿道末端缩窄综合征１例,前例腺炎１例。结果：２９例ＢＰＨ患者中,２６例有梗阻,其中梗阻位于膀胱颈部２０例;３例逼尿肌－外括约肌协同失调患者表现为外括约肌部压力下降;４例女性压力性尿失禁患     

245例前列腺增生患者尿流动力学的结果分析

本文采用自制半卧位尿动力测定床及Ｄａｎｅｃ尿动力仪器，常规行尿流率，压力－流率（同步测定尿道外括约肌肌电图），尿道测压。结果明确诊断ＢＯＯ１６１例，可疑５０例，合并逼尿肌功能受损６５例；膀胱顺应性降低７０例，外括约肌功能失调１１４例；逼尿肌不稳定５９例。最大尿流率受测压导管影响；功能尿道长度与经直肠Ｂ超测定的前列腺尿道长度相关联。结论：１、ＢＰＨ的排尿症状的机械因素与动力学因素共同作用的结果；尿动力学检查是诊断由ＢＰＨ所致ＢＯＯ的一个非常重要的手段，但分析结果时应考虑干扰因素的影响。２、功能性尿道长度与前列腺部尿道长度相关联。     

尿动力学测定对前列腺增生患者逼尿肌不稳定的应用价值

为探讨膀胱出口梗阻患者逼尿肌不稳定的情况，对８３例存在膀胱出口梗阻的前列腺增生患者进行尿动力学测定。结果表明：４０例（４８．２％）患者出现逼尿肌不稳定，压力－流率测定发现该组病例排尿期逼尿肌各压力值均增高，尤以膀胱颈部开口压增高为显著，不稳定组为１３．２±３．４ｋｐａ，稳定组为８．２±２．４ｋＰａ，不稳定组开口压增高速率（０．９±０．１ｋＰａ／ｓ）明显大于逼尿肌稳定组（０．３±０．１ｋＰａ／ｓ）；随开口压增高，逼尿肌不稳定的发生率相应增高。长期高压力、高输出状态可能为逼尿肌无抑制性收缩的形成条件     

The use of transrectal longitudinal real-time ultrasonography in urodynamics

A total of 63 combined transrectal ultrasonographic and urodynamic studies was performed to evaluate the voiding dysfunction in 49 spinal cord injury patients and 7 other patients. Ultrasonography provided excellent real-time imaging of the bladder neck, prostatic urethra, prostate and external sphincter, and allowed for accurate diagnosis of detrusor-sphincter dyssynergia, detrusor-bladder neck dyssynergia, prostatic hypertrophy and bladder neck strictures. In addition to offering these capabilities, ultrasonography is less expensive than x-ray and it does not involve exposure of either the patient or examiner to radiation. However, it does not provide a means to detect vesicoureteral reflux.     

Video urodynamics using transrectal ultrasonography for lower urinary tract symptoms in women

AIMS: To understand the properties of lower urinary tract disorders in women, we evaluated 60 female patients with lower urinary tract disorders or symptoms of recurrent cystitis by free uroflowmetry and video urodynamics using transrectal ultrasonography (VU-TRUS). METHODS: Results of urodynamic studies or symptoms of stress incontinence were used to divide 60 women into 7 normal controls and 53 with voiding dysfunctions. RESULTS: In normal controls, VU-TRUS showed that the mean posterior urethrovesical angle and anteroposterior diameter of the proximal urethra at maximum flow was 151.4 degrees and 4.9 mm, respectively. In patients with voiding dysfunction, VU-TRUS during voiding revealed various urethral abnormalities, including 16 detrusor sphincter dyssynergia, 4 detrusor bladder neck dyssynergia, and 13 insufficient opening of the entire urethra. VU-TRUS also showed pelvic floor abnormalities, including 24 urethral hypermobilities (group 1) and 11 cystoceles (group 2). Eighteen patients had neither urethral hypermobility nor cystocele (group 3). Major pressure-flow abnormalities in the 53 patients with voiding dysfunctions were weak detrusor (72%) and/or bladder outlet obstruction (25%). There were no significant differences in the distribution of the pressure-flow abnormalities among the three groups. However, the mean values of abdominal pressure at maximum flow of group 1 (20.9 cm H(2)O) and group 2 (17.9 cm H(2)O) were significantly higher than that of group 3 (6.3 cm H(2)O; each P < 0.05). The mean values of residual urine volume of group 2 (60.8 mL) and group 3 (77.6 mL) were significantly higher than that of group 1 (23.5 mL; each P < 0.05). CONCLUSIONS: The symptoms of women with lower urinary tract disorders were frequently accompanied by urethral and/or pelvic floor abnormalities during voiding that were clearly detected by VU-TRUS. VU-TRUS is useful for objective evaluation of female lower urinary tract symptoms.     

Modelized analysis of pressure-flow studies of patients with lower urinary tract symptoms due to benign prostatic enlargement

AIMS: To gain insight from an adaptable computer model of micturition into the pathophysiological phenomena occurring during voiding in men with lower urinary tract symptoms due to benign prostatic enlargement (BPE). METHODS: By using the Valentini-Besson-Nelson (VBN) micturition model, we proceeded with an in-depth and systematic analysis of the pressure-flow studies of 71 patients (119 tracings) provided by three different institutions. RESULTS: The modelized analysis identified and quantified several pathophysiological phenomena during voiding: compressive obstruction, variations in detrusor contraction force (enhanced or reduced), progressive relaxation of the prostatic fossa, occasional detrusor-bladder neck coupling, and sphincteric control dysfunctions. Once these phenomena were taken into account by using a set of new parameters, the computed flow rate and detrusor pressure curves became very similar to the recorded ones. CONCLUSIONS: The accuracy of this sophisticated analysis allows us to separate and to study during each voiding the phenomena belonging to the urethra, the detrusor, the bladder neck, the prostate, and their neurologic coordination in BPE patients.     

Nicht neurogene Blasenfunktionsst?rungen und vesikoureteraler Reflux bei Kindern

Various types of bladder dysfunction are associated with urinary tract infection, renal damage and vesicoureteral reflux (VUR). In this article the influence of functional bladder disturbances such as detrusor instability (overactive bladder, OAB) and bladder sphincter dyssynergia (dysfunctional voiding), on the resolution of vesicoureteral reflux are reviewed. In summary, it is important to distinguish between children with dysfunctional voiding (increased activity of the pelvic floor during voiding) and those with OAB (detrusor overactivity during filling) because the latter has less effects on VUR.     

Value of routine evaluation of the voiding phase when performing urodynamic testing in women with lower urinary tract symptoms

PURPOSE: Lower urinary tract symptoms in women are often evaluated by cystometrography. We only assessed the bladder response to filling and not the impact of abnormal voiding, which is known to cause lower urinary tract symptoms. We determined the prevalence of voiding abnormalities in women with lower urinary tract symptoms and compared cystometrography to cystometrography plus voiding pressure flow study for evaluating this condition. We also determined whether storage or voiding symptoms predicted abnormal voiding. MATERIALS AND METHODS: We reviewed the records of 134 women who underwent video urodynamics with cystometrography and voiding pressure flow study to evaluate lower urinary tract symptoms. Patients with a history of neurological disease, grade 4 pelvic prolapse or a primary complaint of stress incontinence were excluded from study. All participants completed an American Urological Association symptom index and scores were subclassified as total, storage and voiding. A diagnosis was made in each case based on cystometrography findings, while any additional diagnoses when applicable were based on the voiding pressure flow study. Symptom scores were compared in women in whom the voiding study did and did not add information. RESULTS: Mean patient age was 53.1 years (range 19 to 90). Voiding studies added information in 44 cases (33%), including dysfunctional voiding in 16, obstruction due to a moderate cystocele in 6, primary bladder neck obstruction in 6, external-detrusor sphincter dyssynergia as the initial presentation of neurological disease in 5, obstruction after incontinence surgery in 3, urethral stricture in 3, post-void contraction mimicking symptoms in 2, impaired contractility in 2 and an obstructing urethral diverticulum in 1. A total of 32 patients (24%) did not void during the study. Those with voiding abnormalities had higher total and voiding but similar storage symptom scores (23.1 versus 18.5, 12.3 versus 8.0 and 10.8 versus 10.5 points, p = 0.0008, 0.0001 and 0.58, respectively). CONCLUSIONS: Women with lower urinary tract symptoms may have voiding abnormalities that are missed by cystometrography only. Voiding studies are useful for properly diagnosing and treating such cases. Women with abnormal voiding seem to have more severe voiding symptoms than those without such abnormalities. Occult neurological disease may also be identified in patients with lower urinary tract symptoms and voiding abnormalities.     

影像尿动力检查在下尿路排尿障碍疾病诊断中的作用

目的 探讨影像尿动力检查在下尿路排尿障碍疾病中的应用价值.方法 2008年12月至2010年3月对115例下尿路排尿障碍患者行影像尿动力检查,确定排尿障碍类型,分析各类疾病的影像尿动力特点.结果 神经原性膀胱患者37例,男性25例,女性12例.其中逼尿肌无反射(DA)18例,膀胱过度活动(OAB)2例,低顺应性膀胱伴肾积水10例,逼尿肌-外括约肌协同失调7例.非神经原性排尿障碍患者59例,男性34例,女性25例;其中膀胱出口梗阻40例,DA 15例,单纯OAB 4例.膀胱扩大术后复查患者7例,男性4例,女性3例.可控回肠膀胱术后男性患者1例.输尿管再植术后男性患者1例.影像尿动力检查显示膀胱尿道功能基本正常者10例,男性6例,女性4例.结论 影像尿动力检查通过压力-流率曲线与实时影像结合分析,可为各类下尿路排尿障碍疾病提供准确的诊断及治疗依据.     

Voiding dysfunction due to neurosyphilis

Three patients with neurosyphilis presenting with urinary frequency, incontinence and voiding dysfunction were investigated. Unlike the previously reported finding of areflexia in tabes dorsalis, all 3 had hypocompliant detrusor hyper-reflexia with detrusor-sphincter dyssynergia and post-micturition residual urine. One patient also had bladder neck dyssynergia treated by bladder neck incision. The other 2 patients were initially managed by intermittent catheterisation but 1 ultimately underwent urinary diversion. The clinical relevance of these findings and the treatment of this condition are discussed.     

Urodynamic findings in children with cerebral palsy

AIM: More than one-third of children with cerebral palsy are expected to present with dysfunctional voiding symptoms. The voiding dysfunction symptoms of the cerebral palsy patients in the present study were documented. METHODS: Of the study group, 16 were girls and 20 were boys (mean age: 8.2 years). Children with cerebral palsy were evaluated with urodynamics consisting of flow rate, filling and voiding cystometry, and electromyography findings of the external urethral sphincter to determine lower urinary tract functions. Treatment protocols were based on the urodynamic findings. Anticholinergic agents to reduce uninhibited contractions and to increase bladder capacity were used as a treatment. Clean intermittent catheterization and behavioral modification were used for incomplete emptying. RESULTS: Of the children, 24 (66.6%) were found to have dysfunctional voiding symptoms. Daytime urinary incontinence (47.2%) and difficulty urinating (44.4%) were the most common symptoms. Urodynamic findings showed that neurogenic detrusor overactivity (involuntary contractions during bladder filling) with a low bladder capacity was present in 17 (47.2%) children, whereas detrusor-sphincter dyssynergia was present in four patients (11%). The mean bladder capacity of patients with a neurogenic bladder was 52.2% of the expected capacity. CONCLUSIONS: The present study concluded that voiding dysfunction was seen in more than half of the children with cerebral palsy, which is a similar result to other published studies. We propose that a rational plan of management of these patients depends on the evaluation of the lower urinary tract dysfunction with urodynamic studies. These children benefit from earlier referral for assessment and treatment.     

Transperineal ultrasonic voiding cystourethrography using a newly devised chair

Using a newly devised chair for transperineal sonography we performed ultrasonic voiding cystourethrography in a total of 219 male patients and volunteers. The study produced adequate images in more than 80% of the people examined. Valsalva's maneuver during urination elicited an intermittent depression of the bladder dome toward the bladder base. In patients with benign prostatic hyperplasia or bladder neck contracture the bladder neck did not open well. Urethral stricture was associated with a marked opening of the bladder neck and posterior urethra. In patients with detrusor-sphincter dyssynergia an involuntary contraction of the external sphincter was observed. These results indicate that this method is useful for screening male patients for diseases causing voiding disturbance and for making differential diagnosis of such diseases.