骶神经根功能性磁刺激对脊髓损伤相关神经源性膀胱过度活动症的疗效分析

目的 探讨骶神经根功能性磁刺激(functional magnetic stimulation,FMS)治疗脊髓损伤(spinal cord injury,SCI)相关神经源性膀胱过度活动症(overactive bladder,OAB)的临床疗效.方法 纳入2018年8月～2019年8月于本院收治的94例SCI相关神...     

经表面电极电刺激胫神经治疗脊髓损伤后经源性逼尿肌过度活动

【摘要】 目的：观察经表面电极电刺激胫神经对脊髓损伤患者神经源性逼尿肌过度活动的抑制效应。方法：2013年6月~2014年4月,采用自主研发的膀胱盆底康复治疗仪行经表面电极电刺激胫神经治疗脊髓损伤后神经源性逼尿肌过度活动的患者23例,男19例,女4例;颈段脊髓损伤3例,胸段脊髓损伤15例,腰段脊髓损伤5例。完全性脊髓损伤18例;不完全性脊髓损伤5例。每周治疗2次,共治疗4周。治疗前及治疗2周、4周时分别记录患者3d排尿日记,并进行患者自我判别的膀胱状态评分（patient perception of bladder condition scale,PPBC-S）。排尿日记包括间歇导尿的次数、每次间歇导尿的尿量以及每天的漏尿量。在记录排尿日记的周期中,患者保持一致的饮水量以及每日间歇导尿的次数,并记录治疗过程中发生的不良反应。结果：患者均完成4周治疗,治疗过程中无不良反应发生。与治疗前相比,治疗2周后患者每次导尿量由258.7±14.7ml增加至282.5±15.2ml（P<0.05）,每天漏尿量由766.4±61.5ml降低到563.3±45.4ml（P<0.05）,PPBC-S评分由5.2±0.1分改善到4.6±0.1分（P<0.05）。治疗4周后,患者每次导尿量为294.1±15.4ml,每日漏尿量为541.4±47.5ml,PPBC-S评分为4.4±0.1分,与治疗前相比均有显著性差异（P<0.05）,与治疗2周相比无显著性差异（P>0.05）。治疗前、治疗2周、4周后记录排尿日记期间,间歇导尿次数分别为4.3±0.3、4.1±0.3和4.0±0.2次,差异无显著性（P>0.05）。结论：经表面电极电刺激胫神经能够抑制脊髓损伤患者神经源性逼尿肌过度活动,可增加膀胱容量,减少漏尿量。     

脊髓损伤后神经源性膀胱的综合康复护理

目的探讨针对脊髓损伤神经源性膀胱患者的有效康复护理模式。方法将84例脊髓损伤患者按对等原则分为常规康复护理组和综合康复护理组各42例,常规组给予间歇性清洁导尿及膀胱功能训练指导;综合组除间歇性清洁导尿外,给予膀胱功能训练、功能性电刺激、生物反馈等综合康复护理。连续8周后评价效果。结果综合组日排尿频次、膀胱容量、残余尿量及导尿间隔时间4项指标均显著优于常规组(P0.05,P0.01)。结论对脊髓损伤后神经源性膀胱患者采取综合康复护理有利于其膀胱功能的恢复。     

多节段脊髓平面损伤后大鼠神经源性膀胱模型的制备

目的研制一种具有临床相似性、可调控性、可重复性的脊髓损伤后神经源性膀胱尿道功能障碍动物模型的制模方法。方法采用改良Allen法,将10g重的柯氏针从20cm高以自由落体落下,撞击在动物脊柱背侧的垫片上,造成一定程度的脊髓损伤。结果在脊髓休克期,骶上脊髓损伤(胸腰段)组和骶髓损伤组动物平均每次挤压膀胱排尿量差异无统计学意义(P>0.05),在脊髓休克期后,两组之间差异有统计学意义(P<0.001)。结论改良Allen法具有临床相似性等优点,能为脊髓损伤后神经源性膀胱尿道功能障碍的研究提供理想的动物模型。     

A型肉毒杆菌毒素治疗神经源性膀胱过度活动症的新进展

简要介绍A型肉毒素的结构与功能,对其目前在治疗神经源性膀胱中的应用最新进展作一综述,并讨论尚待解决的问题以及今后的研究重点.     

骶神经电刺激治疗特发性女性膀胱过度活动症42例报告

膀胱过度活动症（overactive blad-der,OAB）是由尿频、尿急、急迫性尿失禁等症状组成的症候群,可分为特发型和继发型,2000年至2005年我们采用骶神经电刺激治疗女性特发性OAB患者42例,疗效满意,现报告如下。     

丹参酮ⅡA对骶上脊髓损伤后神经源性膀胱大鼠尿动力学的影响

目的 :观察丹参酮ⅡA对骶上脊髓损伤后神经源性膀胱大鼠尿动力学的影响,并探讨其可能的机制。方法:将40只SD雌性大鼠随机分为4组,每组10只,分别为对照组(Sham组)、模型组(SCI组)、丹参酮ⅡA组(TⅡA组)、甲泼尼龙组(MP组)。Sham组仅切除椎板,予尾静脉注射生理盐水1ml/d,连续7d;其他3组采用改良Allen法建立脊髓损伤后神经源性膀胱动物模型(用NYU脊髓打击器选择25mm高度打击T9节段脊髓背侧),SCI组造模成功后予尾静脉注射生理盐水1ml/d,连续7d;TⅡA组造模成功后予尾静脉注射丹参酮ⅡA磺酸钠注射液20mg/kg/d,连续给药7d;MP组造模成功后予尾静脉注射甲泼尼龙30mg/kg,仅给药1次。术后2周,每组大鼠取8只行尿动力学检查,记录膀胱内压力变化曲线并行相关参数测量;心脏灌注固定后取材T9节段脊髓组织并分离双侧L6-S1背根神经节,HE染色观察脊髓组织的结构并使用Image Pro-Plus(IPP)6.0病理分析软件测量脊髓背侧出血灶的面积占正常脊髓组织的比例,分离L6-S1背根神经节(dorsal root ganglion,DRG)后用TUNEL法(terminal deoxynucleotidyl transferase-mediated d UTP nick end labeling assay)标记凋亡细胞,用IPP 6.0测得各组大鼠DRG中凋亡细胞的累积光密度(integrated optical density,IOD)并进行统计分析。结果:(1)术后2周,各损伤组与Sham组比较膀胱基础压、最大排尿压和排尿阈均显著升高(P0.05);TⅡA组、MP组与SCI组相比膀胱内基础压力明显下降(P0.05),最大排尿压和排尿阈差异无统计学意义(P0.05);TⅡA组与MP组比较差异无统计学意义(P0.05)。损伤各组与Sham组相比,残余尿量明显增加,排尿量明显减小,排尿效率显著降低(P0.05);TⅡA组、MP组与SCI组相比残余尿量明显减小,排尿量明显增加,排尿效率显著提高(P0.05);TⅡA组残余尿量较MP组明显下降,同时TⅡA组排尿效率较MP组显著升高(P0.05)。损伤各组与Sham组相比收缩间期明显减小,无排尿性收缩明显增加(P0.05);TⅡA组、MP组与SCI组相比,收缩间期明显增加,无排尿性收缩明显减少(P0.05);TⅡA组、MP组相比收缩间期无显著性差异(P0.05),但TⅡA组较MP组无排尿性收缩明显减少(P0.05)。(2)术后2周,损伤各组脊髓背侧出血灶面积占正常组织面积的比例分别为:SCI组0.048±0.001,TⅡA组0.006±0.003,MP组0.012±0.001,TⅡA组、MP组与SCI组比较损伤面积占比显著减小(P0.05),TⅡA组和MP组比较差异无统计学意义(P0.05)。(3)术后2周,Sham组凋亡细胞IOD为0.67±0.37,SCI组为2.92±0.35,TⅡA组为1.81±0.27,MP组为2.16±0.18,损伤各组IOD与Sham组相比明显升高(P0.05),TⅡA组和MP组IOD与SCI组相比显著减小(P0.05),TⅡA组和MP组相比差异无统计学意义(P0.05)。结论:丹参酮ⅡA可以改善脊髓损伤后神经源性膀胱大鼠的尿动力学评价指标,改善膀胱功能并减少膀胱传入神经元细胞凋亡,其作用与甲泼尼龙相近,为脊髓损伤后神经源性膀胱的治疗提供了新的思路。     

肉毒素A治疗神经源性膀胱过度活动症的系统评价

目的分析肉毒素A治疗抗胆碱能药难治性神经源性膀胱过度活动症的有效性与安全性。方法计算机检索发表在Pubmed、MEDLINE、EMBASE、EBSCO、中国生物医学文献数据库(CBM)、中国期刊网、万方数据库和维普数据库的文献,由2位评价者分别按照纳入标准收集资料,进行质量评价,用Revman5.2进行Meta分析。结果共纳入6个随机对照试验911例患者。目前资料的Meta分析结果显示:与膀胱内注射安慰剂比较,注射肉毒素A能有效缓解尿失禁症状(WMD=-1.53;95%CI:-1.88~-1.18),增加最大膀胱容量(WMD=159.71;95%CI:111.47~204.95),降低最大逼尿肌压力(WMD=34.49;95%CI:-39.69~-29.29),改善生活质量(WMD=17.49;95%CI:13.99~21.00),但是也同时增加了尿路感染(RR=1.34;95%CI:1.06~1.70)和尿潴留(RR=7.19;95%CI:3.66~14.12)的风险。结论膀胱内注射肉毒素A能有效地改善抗胆碱药难治性神经源性膀胱过度活动症患者的生活质量,明显增加最大膀胱容量和提高膀胱顺应性,减少尿失禁次数及降低最大逼尿肌不自主收缩压,但同时也需要密切关注尿路感染和尿潴留等并发症的发生。     

脊髓损伤神经源性膀胱临床评估及治疗的研究进展

脊髓损伤患者经常合并有不同程度的神经源性膀胱症状,由此产生的各种泌尿系统并发症最终可能会导致肾功能衰竭,甚至死亡,不断的优化脊髓损伤神经源性膀胱患者的康复护理等治疗措施,对于提高患者生存质量,降低患者远期的死亡率,有重要的临床和社会意义。本文通过回顾文献,首先总结了神经源性膀胱在脊髓损伤不同阶段的表现,介绍了神经源性膀胱的临床评估,并详细概述了该类患者保守治疗,康复护理及手术治疗等措施,以便为此类患者的诊治提供参考。     

选择性骶神经根切断治疗脊髓损伤后痉挛性膀胱的实验研究

目的：观察选择性骶神经根切断治疗脊髓损伤痉挛性膀胱的实际疗效,探讨骶神经根高选择性切断的治疗机制及最佳手术方式。方法：雄性家犬１２ 只,制备成脊髓损伤后痉挛性膀胱模型,根据骶神经切断方式分为Ａ、Ｂ、Ｃ、Ｄ４ 组,通过尿流动力学检测及电生理观察,记录并计算骶神经切断前（ 对照组）及术后各组各项功能性指标的变化,并进行比较分析。结果：Ａ、Ｂ、Ｃ、Ｄ４ 组术后膀胱容量均明显高于术前对照组,尿道压力均低于术前对照组,其中Ｂ 组的膀胱贮尿功能、排空能力、尿道压力均接近正常,且对犬阴茎勃起功能无明显影响。结论：高选择性骶神经根切断治疗脊髓损伤后痉挛性膀胱有确实明显的疗效,是一种值得研究的新方法。     

Electrical stimulation of sacral nerves and roots for control of the neurogenic bladder and bowel

After damage to the spinal cord, some of the most frequent and severe complications are due to the neurogenic bladder and bowel, in spite of a variety of methods of management.Bladder and bowel emptying is usually impaired, but electrical stimulation of nerves surviving after spinal cord injury can produce controlled contraction of muscle, including the smooth muscle of the bladder and lower bowel, and this can be used to produce safe and effective bladder emptying on demand without catheters. It can also aid emptying of the bowel and reduce constipation. Hyper-reflexia of the bladder and lower bowel after spinal cord injury can produce reflex incontinence of urine and stool, and while this can sometimes be reduced by neuromodulation, it can be more predictably reduced by rhizotomy of the sacral sensory roots, while preserving the motor roots for stimulation. This combination of electrical stimulation and rhizotomy has restored bladder and bowel emptying and continence to several thousand patients, with reduced complications and improved quality of life over many years.     

神经根刺激器在治疗脊髓损伤所致神经原性膀胱功能障碍的应用价值

【摘要】〓目的〓探讨神经根刺激器在治疗脊髓损伤所致神经原性膀胱功能障碍(NBD)的应用价值。方法〓选取2009年3月至2013年5月期间我院确诊治疗的脊髓损伤所致NBD患者72例,分刺激组和对照组,两组患者均给予每天2次口服托特罗定(2 mg/次)治疗,刺激组患者在此基础上给予神经根刺激治疗,其中刺激组依据治疗方法又分为骶神经电刺激(SNS)治疗组和神经肌肉电刺激(NES)治疗组,对所有患者进行为期3个月的随访,观察患者尿流动力学、尿道压力和日均排尿次数。结果〓在尿流动力学方面,NES组残余尿量和最大膀胱容量明显优于SNS组(P<0.017),而SNS组残余尿量与最大膀胱容量明显优于对照组(P<0.017);在逼尿肌压力水平与日均排尿次数方面,治疗后60 d,NES组明显优于对照组(P<0.017);治疗后120 d,NES组明显优于SNS组与对照组,SNS组明显优于对照组(P<0.017)。结论〓神经根刺激治疗有利于改善脊髓损伤所致NBD患者膀胱功能。     

At-home genital nerve stimulation for individuals with SCI and neurogenic detrusor overactivity: A pilot feasibility study

Objective: Neurogenic bladder dysfunction, including neurogenic detrusor overactivity (NDO) is one of the most clinically significant problems for persons with spinal cord injury (SCI), affecting health and quality of life. Genital nerve stimulation (GNS) can acutely inhibit NDO-related reflex bladder contractions and increase bladder capacity. However, it is unknown if GNS can improve urinary continence or help meet individuals’ bladder management goals during sustained use, which is required for GNS to be clinically effective.

Design: Subjects maintained voiding diaries during a one-month control period without stimulation, one month with at-home GNS, and one month after GNS. Urodynamics and quality of life assessments were conducted after each treatment period, and a satisfaction survey was taken at study completion.

Setting: Subject screening and clinical procedures were conducted at the Louis Stokes Cleveland VA Medical Center. Stimulation use and voiding diary entries were conducted in subjects’ homes.

Participants: Subjects included five men with SCI and NDO.

Interventions: This study tested one month of at-home portable non-invasive GNS.

Outcome Measures: The primary outcome measure was leakage events per day. Secondary outcome measures included self-reported subject satisfaction, bladder capacity, and stimulator use frequency.

Results: GNS reduced the number of leakage events from 1.0?±?0.5 to 0.1?±?0.4 leaks per day in the four subjects who reported incontinence data. All study participants were satisfied that GNS met their bladder goals; wanted to continue using GNS; and would recommend it to others.

Conclusions: Short term at-home GNS reduced urinary incontinence and helped subjects meet their bladder management goals. These data inform the design of a long-term clinical trial testing of GNS as an approach to reduce NDO.     

Genital nerve stimulation is tolerable and effective for bladder inhibition in sensate individuals with incomplete SCI

Background: Neurogenic detrusor overactivity after spinal cord injury (SCI) causes urinary incontinence and reduces bladder capacity. Surface electrical genital nerve stimulation (GNS) acutely inhibits reflex bladder contractions. The stimulation amplitude selected for GNS is typically twice the amplitude that is required to evoke the pudendal-anal reflex. There is concern about the ability of persons with sensation to comfortably tolerate effective levels of GNS. The objective of this work is to determine if persons with incomplete SCI are able to tolerate acute GNS for bladder inhibition.

Methods: Twenty-four subjects with neurogenic detrusor overactivity, SCI, and pelvic sensation were enrolled in this case series. The setting was the Spinal Cord Injury Service of a Veterans Affairs Medical Center. Primary outcome measures were sensation threshold and tolerable stimulation amplitude; secondary outcome measures were bladder capacity and bladder contraction inhibition.

Results: GNS was tolerable up to 30±16?mA (range 8?mA to ≥60?mA) at amplitudes greater than twice the pudendal-anal (PA) reflex threshold, which was 8±5?mA (range 4?mA to 20?mA). Twelve subjects tolerated GNS at greater than twice the PA, six tolerated 1–1.5 times the PA, and five had no identifiable PA. GNS at tolerable amplitudes inhibited reflexive bladder contractions or increased bladder capacity 135±109?mL (n=23). GNS did not cause autonomic dysreflexia or intolerable spasticity.

Conclusions: GNS is tolerable at amplitudes that effectively inhibit neurogenic detrusor overactivity in individuals with pelvic sensation. GNS therefore is a tool with potential clinical applications for persons with preserved sensation.     

The acute effect of magnetic stimulation of the pelvic floor on involuntary detrusor activity during natural filling and overactive bladder symptoms

OBJECTIVE: To evaluate the effect of magnetic stimulation of the pelvic floor (MSPF) on involuntary detrusor activity observed during natural filling, and on the overactive bladder symptom complex. PATIENTS AND METHODS: Eighteen women with detrusor overactivity on conventional cystometry underwent ambulatory urodynamic monitoring over two filling cycles. Fluid intake was standardized, provocative manoeuvres applied at regular intervals and symptoms documented contemporaneously. During the second filling cycle MSPF was delivered whenever the detrusor pressure increased by > 5 cmH2O. The women were subsequently treated with MSPF for 6 weeks; their lower urinary tract symptoms were assessed before and after treatment. RESULTS: Comparing the second (stimulated) cycle with the first (unstimulated) cycle, cystometric capacity was higher (373 vs 224 mL, P < 0.03). and involuntary detrusor activity of shorter duration (370 vs 427 s, P < 0.82) and lower amplitude (53 vs 63 cmH2O, P < or = 0.05). All women tolerated the procedure comfortably, but nine found it too time-consuming and withdrew. In the nine women who completed treatment there was no consistent change in overactive bladder symptoms. CONCLUSIONS: In this pilot study, MSPF during natural filling was associated with a decrease in the amplitude of involuntary detrusor contractions and a significant increase in cystometric capacity. However, MSPF had a variable effect on sensations of urgency, both acutely and after treatment, and currently there is no evidence to suggest that MSPF has an enduring effect on symptoms of the overactive bladder.     

Genital nerve stimulation increases bladder capacity after SCI: A meta-analysis

Background: Neurogenic detrusor overactivity (NDO) often results in decreased bladder capacity, urinary incontinence, and vesico-ureteral reflux. NDO can trigger autonomic dysreflexia and can impair quality of life. Electrical stimulation of the genital nerves (GNS) acutely inhibits reflex bladder contractions and can increase bladder capacity. Quantifying the effect of GNS on bladder capacity and determining what study factors and subject factors influence bladder capacity improvements will inform the design of clinical GNS interventions.

Methods: We measured bladder capacity in 33 individuals with NDO, with and without GNS. These data were combined with data from seven previous GNS studies (n=64 subjects). A meta-analysis of the increase in bladder capacity and potential experimental factors was conducted (n=97 subjects total).

Results: Bladder capacity increased 131±101?ml with GNS across subjects in all studies. The number of individuals whose bladder capacity was greater than 300?ml increased from 24% to 62% with GNS. Stimulus amplitude was a significant factor predicting bladder capacity gain. The variance of the bladder capacity gain significantly increased with increasing infusion rate. Other factors did not contribute to bladder capacity gain.

Conclusion: GNS acutely increases bladder capacity in individuals with NDO. The consistent increase in magnitude of bladder capacities across the eight studies, and the lack of dependence on individual-specific factors, provide confidence that GNS could be an effective tool for many individuals with NDO. Studies of the chronic effect of GNS on bladder control, with clinical measures such as urinary continence, are needed.     

Electrical stimulation of the urethra evokes bladder contractions and emptying in spinal cord injury men: case studies

Objective

Electrical stimulation of the urethra can evoke bladder contractions in persons with spinal cord injury (SCI). The objective of this study was to determine whether electrical stimulation of the urethra could evoke bladder contractions that empty the bladder.

Methods

The first patient was a 45-year-old man with a T6 ASIA A SCI secondary to a gunshot wound 15 years prior. The second patient was a 51-year-old man with a T2 ASIA A SCI secondary to a fall from scaffolding 2 years prior. Both patients demonstrated neurogenic detrusor overactivity on urodynamics and managed their bladder with clean intermittent catheterization and oxybutynin medication. Following informed consent, each patient discontinued oxybutynin 2 days prior to urodynamic testing. Urodynamics were performed with a custom 12 French balloon catheter mounted with ring-shaped electrodes (3 mm) positioned in the prostatic urethra. After filling the bladder to approximately three-fourth of capacity at a rate of 25 ml/minute, the urethra was stimulated with a range of parameters to determine whether electrical stimulation could evoke a bladder contraction and empty the bladder.

Results

Electrical stimulation of the prostatic urethra evoked bladder contractions (peak detrusor pressures of 60–80 cm H₂O) that emptied the bladder in both subjects. In the first subject, stimulation (9–12 mA, 20 Hz) emptied 64–75%, leaving post-void residual volumes (PVRs) of 41–20 ml. In the second subject, stimulation (20 mA, 20 Hz) emptied 68–77%, leaving PVRs of 56–45 ml.

Conclusion

Urethral stimulation evoked bladder emptying in persons with SCI.     

膀胱壁内注射A型肉毒毒素治疗脊髓损伤患者神经原性膀胱的初步临床观察

目的：观察膀胱壁内注射A型肉毒毒素治疗脊髓损伤患者神经原性膀胱的临床效果。方法：78例脊髓损伤后神经原性膀胱患者，男59例，女19例，平均年龄38．9岁。将300单位A型肉毒毒素溶解于15ml生理盐水，使用膀胱镜注射针分30个点注射于膀胱壁，0．5ml／点。治疗前后均记录患者排尿日记，并观察药物毒副作用。结果：78例患者经第1次治疗后平均尿失禁次数由13．5次／d降至2．7次／d、平均导尿量由131ml／次增至389ml／次，平均尿失禁量由1690ml／d降至281ml／d，起效的平均时间为7．6d。10例患者在第1次注射8,9个月后接受第2次注射，平均尿失禁次数由9．7次/d降至3．7次/d，平均导尿量由108ml／次增至387ml／次。6例患者在第2次注射后5．8个月接受第3次注射，平均尿失禁次数由9．2次／d降至3．9次／d，平均导尿量由116ml／次增至364ml／次。随访期间未观察到任何毒副作用。结论：经尿道膀胱壁内A型肉毒毒素注射是治疗脊髓损伤患者神经原性膀胱的有效、安全、可多次重复应用的微创方法。     

An unresolved relationship: the relationship between lesion severity and neurogenic bladder in patients with spinal cord injury

Objectives

We aimed to investigate the relationship between the severity of the spinal lesion and urodynamic findings, bladder drainage method at discharge, and incidence of renal calculi in patients with spinal cord injury (SCI).

Studydesign

Retrospective.

Setting

In-patient rehabilitation unit of a tertiary research hospital.

Methods

A total of 131 patients who were admitted to our clinic with a diagnosis of SCI and placed into a rehabilitation program were included in the study. The severity of the lesion was determined according to the American Spinal Injury Association Impairment Scale (AIS). We evaluated the relationship between the severity of the lesion and the detrusor hyperactivity and compliance as determined by urodynamic investigation, the bladder drainage method used at discharge, and the renal calculi rate as determined by ultrasonography.

Results

While no difference was found between the patients with complete and incomplete injuries in terms of age, sex, disease duration, detrusor hyperactivity and compliance, the bladder drainage method was found to show a significant change according to the severity of the lesion. None of the patients were found to have hydronephrosis and the rate of renal calculi showed no statistically significant difference according to the severity of the lesion.

Conclusions

We concluded that urodynamic examination is required in each patient with SCI as the severity of the lesion is not sufficient to determine the bladder type, and patients with complete and incomplete injuries should be monitored with the same sensitivity in terms of complications.