脊髓损伤后膀胱尿动力学检查及分类

尿动力学检查已成灰脊髓损伤后膀胱尿道功能障碍的常规检查技术,列举脊髓完全损伤后膀胱典型的尿动力学表及不同部位,程度和时期的脊髓损伤所致的非典型的逼尿肌、括约肌功能障碍与其相应的尿动力学表现。通过尿动力可对膀胱道功能障碍进行分类外,还可为临床的诊断、治疗及疗效评价提供更多的客观指标。     

脑血管意外后排尿障碍患者影像尿动力学分析

目的分析脑血管意外对下尿路功能的影响。方法回顾性分析19例脑血管意外后排尿障碍患者、19例同期胸椎脊髓损伤患者的影像尿动力学检查结果,比较两组患者膀胱逼尿肌和尿道外括约肌功能障碍的特点。结果脑血管意外排尿障碍患者以逼尿肌反射亢进为主,膀胱顺应性下降,尿道外括约肌多为松弛状态,逼尿肌反射亢进患者病灶集中于基底节和额叶;胸椎脊髓损伤患者影像尿动力检查与之有差异。结论脑血管意外后排尿障碍患者影像尿动力学改变以逼尿肌反射亢进和尿道外括约肌松弛为主,与胸椎脊髓损伤后导致的神经源性膀胱影像尿动力学检查差异明显。     

脑桥上神经损伤导致膀胱尿道功能障碍的影像尿动力学特点研究

目的探讨脑桥上神经损伤所致膀胱尿道功能障碍的影像尿动力学改变。方法回顾性分析2004年2月至2009年5月65例行影像尿动力学检查的脑桥上神经损伤患者的资料,包括临床表现、诊断、排尿方式、超声、尿流率、残余尿、充盈期膀胱压力容积测定、排尿期压力流率测定和影像学结果,并与骶上脊髓损伤患者进行比较。结果65例患者中,逼尿肌过度活动占61.5%、反射正常占24.6%、无反射占13.9%、逼尿肌-尿道外括约肌协同失调(DSD)占6.2%、输尿管返流占4.61%。脑桥上不同神经损伤类型尿动力表现无明显差异;与骶上脊髓损伤比较,DSD、输尿管返流、上尿路积水发生率少见,反射正常比例较高。结论脑桥上神经损伤所致膀胱尿道功能障碍的主要尿动力学特点是逼尿肌过度活动伴括约肌协同正常,较少出现DSD、输尿管返流、上尿路积水等并发症。     

肉毒毒素注射尿道外括约肌对逼尿肌 尿道外括约肌失协调患者逼尿肌厚度的影响

目的 观察肉毒毒素A（BTX-A）注射尿道外括约肌对脊髓损伤后逼尿肌-尿道外括约肌收缩失协调（DSD）患者逼尿肌厚度及膀胱功能的影响。 方法 选取脊髓损伤后DSD成年患者21例,所有患者均在会阴超声引导下向尿道外括约肌注射BTX-A（100U）。于治疗前、治疗后4周、8周时进行尿动力学检查和下尿道超声评估,测定患者逼尿肌厚度、逼尿肌漏尿点压、残余尿量及最大膀胱容量。 结果 治疗后4周时入选患者残余尿量显著下降（P<0.05）,而逼尿肌厚度、逼尿肌漏尿点压及最大膀胱容量均无明显改变（P>0.05）。治疗后8周时入选患者逼尿肌厚度为（0.93±0.17）mm,较治疗前下降了17.2%（P<0.05）;逼尿肌漏尿点压、残余尿量及最大膀胱容量亦较治疗前明显改善（P<0.05）。 结论 在超声引导下向尿道外括约肌注射BTX-A可显著降低脊髓损伤后DSD患者逼尿肌厚度,改善膀胱功能,该疗法值得临床推广、应用。     

脊髓损伤患者泌尿系结石形成高危因素分析:128例报道

目的探讨影响脊髓损伤患者泌尿系结石形成的高危因素及其防治措施。方法回顾性分析128例脊髓损伤后泌尿系结石患者的临床资料及治疗方法。结果 128例患者中,膀胱造瘘32例,留置尿管定期更换34例,间歇导尿12例,叩击排尿19例,腹压排尿11例,间断尿失禁应用外部集尿器20例。128例患者中120例存在泌尿系感染,11例血钙升高。影像尿动力学提示逼尿肌无反射39例,逼尿肌过度活动63例,逼尿肌-尿道外括约肌协同失调41例,逼尿肌-膀胱颈协同失调11例,尿道外括约肌过度活动27例,尿道括约肌功能不全11例。部分患者同时存在数种上述病理生理状况。结论膀胱管理方式对脊髓损伤后泌尿系结石的形成有重要影响,脊髓损伤后下尿路感染、逼尿肌-尿道外括约肌协同失调等下尿路功能障碍、长期留置尿管和膀胱造瘘是泌尿系结石形成的高危因素。钙代谢异常可能是诱发泌尿系结石形成的高危因素之一。     

自体骨髓干细胞移植治疗一例脊髓损伤患者尿动力学指标的变化

【目的】探讨自体骨髓干细胞移植对脊髓损伤患者神经源性膀胱的治疗效果。【方法】对1例脊髓损伤患者在伤后2周开始,给予自体骨髓于细胞移植治疗,检测治疗前后尿动力学指标。【结果】患者治疗2周后最大尿道压及尿道闭合压力明显升高,膀胱容量增大,治疗后4个月时患者膀胱感觉恢复,可诱发出逼尿肌自主收缩,最大压力达2．9kPa。【结论】在脊髓损伤后早期、规律的按疗程给予自体骨髓干细胞移植可有效的改善神经源性膀胱排尿功能障碍的症状。     

脊髓栓系神经源性膀胱尿道功能障碍20例诊治分析

目的：探讨脊髓栓系神经源性膀胱尿道功能障碍的诊治方法。方法：对20例脊髓栓，系神经原性膀胱尿道功能障碍患者的临床资料进行回顾性分析，治疗前所有患者均行尿动力学及腰骶MRI检查，并依尿动力学结果采用针对性的治疗方法，其中行解栓术10例，间歇性清洁导尿3例，膀胱扩大术2例，尿道周围胶原注射3例，骶神经调节2例。所有患者治疗后均行尿动力学随访。结果：16例获6个月至2年的随访，其中12例膀耽、尿道功能明显改善，2例需一直行间歇性清洁导尿，但无上尿路恶化，2例膀胱尿道功能无明显改善，总有效率87．5％。结论：对脊髓栓系神经源性膀胱尿道功能障碍应行尿动力学与MRI检查，并依尿动力学结果采用针对性的治疗方法，如解栓术、间歇性清洁导尿、膀胱扩大术、尿道周围胶原注射等，效果良好。     

骶3 神经电针治疗脊髓损伤后逼尿肌反射亢进的临床效果

目的观察骶3 神经根电针治疗脊髓损伤后逼尿肌反射亢进的疗效。方法采用骶3 神经根电针治疗脊髓损伤后逼尿肌反射亢进的患者32 例,观察治疗前和治疗8 周后的排尿日记、尿动力学检查和生活质量评分。结果治疗后,患者排尿次数、漏尿次数、充盈末期逼尿肌压减少(P<0.05),残余尿量无明显改变(P>0.05),排尿量、最大膀胱容量、膀胱顺应性、生活质量评分较治疗前改善(P<0.05)。结论骶3 神经根电针治疗脊髓损伤后逼尿肌反射亢进疗效满意。     

BTXA治疗脊髓损伤后神经原性膀胱的临床研究

目的：观察尿道括约肌内注射A型肉毒毒素BTXA对脊髓损伤后神经原性膀胱逼尿肌-尿道括约肌不协同的疗效。比较两种注射途径的优劣。方法：选择存在逼尿肌-括约肌不协同的17例脊髓损伤患者进行尿道外括约肌BTXA注射，分为经尿道（TU）注射组和经会阴（TP）注射组，TU组采用膀胱镜定位4点注射法，TP组采用肛门指检定位1点尿道周围注射法，每病例注射100U。结果：两组治疗前后排尿障碍情况均有显著性改善，注射后3天-2周开始出现漏尿次数及间断导尿次数减少，残余尿量减少，每次排尿量增加；治疗后1个月的统计结果显示，间断导尿次数、残余尿量减少，每次排尿量增加（P〈0．05），注射后1个月尿动力学检查提示第一次无抑制性收缩时膀胱容量及最大膀胱容量增加（P〈0．05），最大尿道压降低（P〈0．05）；注射后3个月上述指标虽有所回升，但并未回到注射前；两种注射途径在排尿日记及尿动力学参数的变化上差异无显著性意义。结论：尿道外括约肌的BTXA注射治疗可明显改善脊髓损伤后神经原性膀胱的逼尿肌-括约肌不协同，改善排尿功能，降低残余尿量及漏尿的发生，减少尿路感染及自主神经反射的发生：经会阴注射和经膀胱镜注射对神经原性膀胱的疗效无明显差异。     

脊髓损伤患者逼尿肌厚度与下尿道功能的关系

目的通过超声测量观察脊髓损伤后神经源性下尿道功能障碍（NLUTD）患者逼尿肌厚度（DWT）的变化,探讨患者DWT与膀胱容量（BC)及下尿道功能障碍类型的关系,并评估DWT在脊髓损伤患者风险预判中的作用。 方法选取成年脊髓损伤合并下泌尿道功能障碍的患者48例作为病例组;另选取正常成年受试者41例作为对照组。2组患者均进行尿流动力学和最大膀胱容量（MBC）检测,并采用8~13MHz线阵超声探头测定膀胱前壁的DWT。根据逼尿肌漏尿点压,将病例组分为高危患者（逼尿肌漏尿点压≥40cmH2O）和低危患者（逼尿肌漏尿点压<40cmH2O）,并鉴别高危患者与低危患者的DWT临界值。 结果MBC时,病例组DWT为（0.97±0.31）mm,对照组DWT为（0.59±0.08）mm,差异有统计学意义(P<0.05)。病例组中,逼尿肌-尿道外括约肌收缩失协调（A型）患者的DWT为（1.10±0.34）mm,较逼尿肌无收缩而尿道外括约肌有收缩（C型）患者的DWT增加显著（P<0.05）。病例组DWT与逼尿肌漏尿点压存在相关性（r=0.77, P<0.01）,当DWT≥0.87mm（敏感度为89.5%、特异度为58.6%）可作为预判NLUTD患者存在肾功能损伤风险的临界值。 结论脊髓损伤患者DWT显著增加,且DWT与逼尿肌漏尿点压呈正相关,表明DWT可用于脊髓损伤后NLUTD患者肾脏损害的风险评估。     

脊髓损伤后神经原性膀胱的分类及其治疗原则

脊髓损伤后神经原性膀胱的分类及其与治疗的关系近年来有了长足的进展。传统的分类和按膀胱功能及尿流动力学的分类方法与临床治疗不相适应。基于排尿时患者有无尿道外括约肌松弛 ,结合患者全身情况及康复治疗的需要 ,近年提出了新的4型分类法 ,即大脑脊髓束残留型、脊髓协同型、截瘫型和四肢瘫型。本文简要介绍了各种分类方法及其治疗原则 ,尤其是新分类法 ,简明实用。     

Value of sensory examination in predicting bladder function in patients with T12-L1 fractures and spinal cord injury

OBJECTIVE: To determine whether early sensory examination, voluntary anal sphincter contraction, or bulbocavernosus reflex (BCR) might predict bladder function in patients with a spinal fracture at the thoracolumbar level. DESIGN: Longitudinal study of consecutive patients admitted to a spinal cord injury (SCI) rehabilitation center. SETTING: Primary care center, university facility in Switzerland. PARTICIPANTS: Fifty-five patients with thoracolumbar fractures. INTERVENTIONS: Neurologic (American Spinal Injury Association [ASIA] protocol) and urodynamic examination during the first hospitalization and at follow-up. MAIN OUTCOME MEASURES: Neurologic sensory scores and type of neurogenic bladder. RESULTS: At first examination, there was no correlation between the sensory examination, voluntary anal sphincter contraction, BCR, and neurogenic bladder type. At follow-up (time since first examination: mean, 698+/-47.2d; median, 481d), the sensory examination remained of no value in distinguishing the neurogenic bladder type. However, voluntary anal sphincter contraction distinguished between complete and incomplete neurogenic bladders and BCR differentiated between complete bladder dysfunction of the lower motoneuron and upper motoneuron type. At follow-up, the bladder function (51 patients) remained unchanged in 44 cases and normalized in only 7 cases. Patients who improved their bladder function tended to have higher initial sensory ASIA scores (P<.05, Kruskal-Wallis test). Of the 7 patients who improved their bladder function, all but 1 (85%) had initial perineal pinprick sensation. Nevertheless, preservation of perineal pinprick sensation was of no positive predictive value, because 21 patients (48%) who initially had perineal pinprick sensation did not improve their voiding function, a finding similar to that of the 23 (52%) without initial perineal pinprick sensation whose bladder function also did not improve. CONCLUSIONS: In SCI patients with thoracolumbar fractures, neurogenic voiding dysfunction cannot be predicted by the sensory evaluation. In patients with an SCI at the thoracolumbar level, pinprick sensation in the perineal area is of negative predictive value: absence of pinprick sensation predicts poor bladder recovery. Most patients with a spinal fracture at T12-L1 did not improve in voiding function.     

对神经源性膀胱患者进行简易膀胱容量压力测定的可行性研究

目的:探讨简易膀胱容量压力测定在脊髓损伤(SCI)后神经源性膀胱患者康复中的可行性。方法:对我院骨科及康复医学科2008年3月—2010年5月60例SCI后神经源性膀胱患者分别采用简易膀胱容量压力测定法和尿动力学检测仪测量其膀胱安全容量。比较两种方法测量值,以及其相关性和简易膀胱容量压力测定的重测信度。结果:两种方法测量患者不同膀胱容量状态下膀胱压力值差异无显著性意义(P>0.05);两组结果相关性分析结果显示r值为0.78—0.94(P<0.05),呈显著相关;不同容量状态下膀胱压力重测信度系数均>0.8,示重测信度很好。结论:缺乏床旁B超测定膀胱内容量设备时,简易膀胱容量压力测定法可代替尿动力学监测仪测压法用于SCI患者膀胱容量变化的测量。     

Association of bladder trabeculation and neurogenic bladder with spinal cord injury

ObjectiveTo compare clinical findings and urodynamic parameters according to trabeculation grade and analyze their correlations with trabeculation severity in neurogenic bladder caused by suprasacral spinal cord injury (SCI).MethodsA retrospective chart review was performed of neurogenic bladder caused by SCI. Bladder trabeculation grade was compared with SCI-related clinical parameters and bladder-related urodynamic parameters.ResultsIn SCI patients, factors such as disease duration, bladder capacity, detrusor pressure, peak detrusor pressure values, and compliance were significantly different between different grades of bladder trabeculation, while neurological level of injury, completeness, and detrusor sphincter dyssynergia had no clear relationship with bladder trabeculation grade. In the correlation analysis, vesicoureteral reflux was moderately correlated with trabeculation grade (correlation coefficient 0.433), while the correlation coefficients of disease duration, involuntary detrusor contraction, and bladder filling volume were between 0.3 and 0.4.ConclusionBladder trabeculation with suprasacral-type neurogenic bladder was graded. Although disease duration was positively correlated with bladder trabeculation grade, differences in the neurological level of injury or American Spinal Injury Association Impairment Scale score were not observed. Bladder volume, peak detrusor pressure, compliance, reflex volume, and vesicoureteral reflux also showed significant differences according to trabeculation grade. Vesicoureteral reflux was moderately correlated with trabeculation grade.     

Abstract 9: Maximal bladder capacity as the predictor of response to desmopressin on nocturnal enuresis in patients with spinal cord injuries.

Objectives: To evaluate the efficacy of intranasal desmopressin inhalation on nocturnal enuresis in patients with spinal cord injury (SCI) and to investigate the validity of maximal bladder capacity as the predictor of response to intranasal desmopressin inhalation. Design: Before and after interventional trial. Setting: University-affiliated hospital. Participants: 22 adults SCI with nocturnal enuresis were divided into 2 groups: the large bladder capacity group (bladder capacity, >250mL; n=11) and the small bladder capacity group (bladder capacity, <250mL; n=11). Intervention: All participants were treated with intranasal desmopressin, 10μg daily at bedtime for 4 weeks. Main Outcome Measures: Total volume of daily nocturnal incontinence and serum electrolytes. Maximal bladder capacities were measured by urodynamic evaluation. Results: After intranasal desmopressin inhalation, mean volume of nocturnal incontinence decreased significantly in the large bladder capacity group (P<.05), but not in the small bladder capacity group (P>.05). The mean maximal bladder capacity of responders was larger than that of nonresponders (P<.05). Neither hyponatremia nor serum electrolytes abnormalities occurred. Conclusions: Intranasal desmopressin inhalation is safe and effective in symptomatic management of neurogenic bladder dysfunction in selected patients with SCI. Maximal bladder capacity is a valuable predictor of response to desmopressin.     

The neurogenic bladder: an update with management strategies for primary care physicians

Patients with lesions of the central nervous system often have neurogenic bladder dysfunction. Lifelong bladder monitoring and management in these patients is necessary to prevent severe complications, including renal?damage. The urodynamic test, performed by neurourologists or other specially trained providers, is the definitive test for diagnosis and management of neurogenic bladder dysfunction. This article describes the indications and technique of urodynamic testing and the interpretation of the results of such testing. The management of patients with neurogenic bladder dysfunction is also discussed.     

Neurogenic bladder in spinal cord injury

In the past, renal failure was the leading cause of death after spinal cord injury (SCI). Today mortality from SCI has declined dramatically partly owing to the improved management of urologic dysfunction associated with SCI. The goals of bladder management in spinal cord injury patients are intended to (1) ensure social continence for reintegration into community, (2) allow low-pressure storage and efficient bladder emptying at low detrusor pressures, (3) avoid stretch injury from repeated overdistension, (4) prevent upper and lower urinary tracts complications from high intravesical pressures, and (5) prevent recurrent urinary tract infections. This article provides an overview of neurogenic bladder dysfunction associated with SCI and current management options.     

Contribution of the preoperative urodynamic findings in the determination of risks factors of urinary incontinence after radical retropubic prostatectomy]

The aim of the study was to determine whether preoperative urodynamic evaluation helps the physiotherapist to adapt preoperative management of patients undergoing radical retropubic prostatectomy (RP) by identifying a group at risk of incontinence. MATERIAL AND METHODS: We compared the preoperative urodynamic evaluation of 229 men scheduled for RP with their continence status, evaluated by standardized pad-test and questionnaire, at 6 weeks and 4 months postoperatively. RESULTS: The primary urinary incontinence risk has been obtained for five patient's categories, namely normal, bladder instability, bladder outlet obstruction, hypocontractility, and mixed results. None of the patients diagnosed with detrusor instability and bladder outlet obstruction was continent at six weeks from surgery. At four months, although it improves, the continence status remains significantly poorer than observed in all other groups. CONCLUSION: Preoperative urodynamic evaluation of patients scheduled for RP allows identifying patients with a high risk of postoperative urinary incontinence.     

前列腺切除术后尿失禁影响因素分析

目的：总结良性前列腺增生癌患者耻骨上经膀胱前列腺切除术和经尿道前列腺电切除术术后尿失禁的影响因素、预防措施及手术时机的选择。方法：将415例患者分为2组：197例行耻骨上经膀胱前列腺切除术，218例行经尿道前列腺电切除术。术前行相关尿流动力学检查，术后2组患者行1个月，6个月，12个月追踪随访。结果：80％以上的良性前列腺增生症患者术前合并膀胱功能改变，术后尿失禁患者均发生于失代偿的患者。结论：前列腺切除术后尿失禁的因素是多方面，膀胱功能障碍是其主要原因之一，通过尿流动力学检查术前评估患者的膀胱和括约肌功能，合理把握手术时机，争取在膀胱代偿期解决梗阻，可以减少术后尿失禁的发病率。     

脊髓损伤并发膀胱结石32例

本文总结32例脊髓损伤患者并发膀胱结石的病例,从膀胱结石形成的原因、结石特征、诊断、治疗及预防等方面进行讨论。