电针神经刺激疗法治疗慢性排尿障碍课件

Electroacupunctureneurostimulationfortreatmentofchronicvoidingdysfunction

电针神经刺激疗法治疗慢性

排尿障碍Prof.WangSiyouShanghaiResearchInstituteofAcupunctureandMeridianStressUrinaryIncontinence

压力性尿失禁

Urinaryincontinencecanbeclassifiedunder7typesinWesternmedicine尿失禁在西医可分为7种类型。Nocturnalenuresis夜间遗尿Postvoiddribble排尿后滴尿Overflowurinaryincontinence充盈性尿失禁Stressurinaryincontinence(SUI)isdefinedasaninvoluntaryleakageofurinefromtheurethralmeatusatasuddenincreaseinintra-abdominalpressure(egcoughing,sneezing,laughing,runningorstrenuousactivities)withoutsimultaneousdetrusorcontraction.压力性尿失禁是指平时无尿失禁状态下，当腹压骤增时（如咳嗽、打喷嚏、大笑、奔跑、剧烈活动）尿液不自主从尿道口流出，同时不伴有膀胱逼尿肌收缩。Itoftenhappensinmultiparousandpostmenopausalwomen.ItcomesunderthecategoryofenuresisinTCM.临床多见于中年已生育的妇女。属中医学遗尿范畴。Overactivebladder&

Urgeincontinence

Etiology(3)historyofvaginal,urethralorprostaticsurgery;(4)perinealorurethralinjury;(5)pelvictumescenceresultinginahighintra-abdominalpressureandalowerpositionofbladderneck.Morethanonecausemaycoexist.（3）阴道、尿道及前列腺手术史；（4）会阴部及尿道损伤；（5）盆腔内肿物致腹压增高，膀胱颈位置降低。一个或多个病因可同时存在。PathogenesisTheaboveetiologiesproducetheabnormalitiesof(vesicalneckandurethra)sphincters,thatis,urethralhypermobilityor/andintrinsicsphincterdeficiency(intrinsicmalfunctionoftheurethralsphincteritself)toresultinSUI.二.发病机理上述原因可引起（膀胱颈和尿道）括约肌异常：尿道活动度增大或/和括约肌内在缺陷（尿道括约肌本身的内在机能异常，近端尿道失去括约肌作用），导致压力性尿失禁。Subtypesofstressincontinence

压力性尿失禁的亚分类Thereare2possiblereasonsforurodynamicstressincontinence:

尿流动力学压力性尿失禁的2个可能原因“Hypermobility”

“过度移动症”(weaknessofbladdersupport)

（薄弱的膀胱支持力）“Intrinsicsphincterdeficiency”“固有括约肌功能障碍”

(“ISD”-weaknessofurethralsphincter)

(“ISD”－尿道括约肌力弱)Videoorextratests(UPP,VLPP)helptomakethisdistinction

影像技术及其他辅助检查（尿道压力描计UPP，屏气时漏尿点压力VLPP）有助于区分腹压升高漏尿尿道无力StressUrinaryIncontinenceStressIncontinence:VLPP

Rest&StrainingClinicalmanifestations1.

SymptomInvoluntarylossofurineduringcoughing,sneezing,laughing,runningorphysicalexertionsuchassportactivitiesandsuddenchangesofposition.三.

临床表现1.

症状咳嗽、打喷嚏、大笑、奔跑或体育活动、突然改变体位等身体用力时尿液不自主从尿道口流出。Clinicalmanifestations2.

SignsTheobservationoflossofurinefromtheurethraduringcoughing,sneezing,orphysicalexertion.PositiveMarshell(bladderbaseelevation)test.Positivepadtest.Avaginalexaminationshowscystocele,enteroceleorrectocele.2.

体征咳嗽、打喷嚏或身体用力时观察到尿液从尿道口流出。指压（尿道抬举）试验阳性。护垫试验阳性。阴道检查可见膀胱、肠、直肠膨出。

Video-urodynamics2.

Intrinsicsphincterdeficiency

Thevesicalneckandproximalurethraareopenatrestintheabsenceofdetrusorcontraction.2.

括约肌内在缺陷静止、无逼尿肌收缩时，膀胱颈（和近端尿道）开放。Hypermobility(typeIIincontinence)

过度移动症（II型尿失禁）Easilydefinedonvideourodynamics

通过影像尿流动力学很容易确定butQ-tiptestorsimpleobservationwillhelp

但Q-tip试验及简单的观察有助于诊断Hypermobility

过度移动症(oncoughorValsalva,orpermanentdescent)

（咳嗽，Valsalva，或者持续下降）正常LPPmeasurement

漏尿点压力测量Strain:leaksat165cmH2O

用力屏气:在165cmH2O时漏尿（活动过度）

(hypermobility)Hyper-mobilitywithleakage(oncough)

活动过度伴漏尿（在咳嗽时）Startfilling

开始充盈Stopfillat200ml

在200ml时停止充盈Strain:leaksat45cmH2O

用力屏气:在45cmH2O时漏尿LPPmeasurement

漏尿点压力测量Initialpves

初始膀胱压(nohypermobility,ISD)

（无过度移动症，固有括约肌功能障碍）DagnosisBasedonThesymptom(history)ofstressincotinencePositivestresstest(lossofurineduringcoughingorphysicalexertion)andMarshelltestorpadtest.五.诊断根据：1.压力性尿失禁症状（病史）。2.应力试验阳性（咳嗽或用力腹压增高时有漏尿）和指压试验阳性或护垫试验阳性。DagnosisBasedonTheresultsofimagingurodynamicexamination:urethralhypermobilityor/andintrinsicsphincterdeficiency

;noinvoluntarydetrusorcontraction.

3.影象尿动力检查结果：尿道活动度增大或/和括约肌内在缺陷；无逼尿肌无抑制性收缩。Treatment1.WesternconservativetreatmentConservativetreatmentcanbeappliedtomildandmoderateSUI.Itsadvantagesaresafety,microinvasion,andmuchlowerincidenceandlessseverityofcomplicationscomparedwithsurgicaltreatment.六.

治疗方法1.西医保守治疗对于轻、中度压力性尿失禁可采用保守治疗，其优点是安全微创，并发症的发生率和严重程度远低于手术治疗。1.WesternconservativetreatmentConservativetreatmentmainlyincludespelvicfloormuscleexercises(PFME),electricalstimulation(ES),variousvaginalandurethraldevicesandmedication.PFMEandtransvaginalortrans-analES(TES)arethetwomostcommonlyusedformsofconservativetreatmentforSUI.保守治疗主要包括盆底肌锻炼、电刺激、各种阴道和尿道装置及药物治疗。其中盆底肌锻炼和经阴道或肛门电刺激（被动的盆底肌锻炼）是最常用的二种治疗方法。1.WesternconservativetreatmentPFMEcanbuildupthestructuralsupportofthepelvis,improveneuromuscularfunction,preventtheproximalurethraandbladderbasefromdescendingduringariseinabdominalpressureandincreaseurethralpressure.盆底肌锻炼具有增强盆底肌肉支持力量，改善神经肌肉功能，阻止腹内压增高时近端尿道和膀胱底部下降及增加尿道压的作用。1.WesternconservativetreatmentItsshortcomingsaremanypatients’difficultyidentifyingandisolatingtheirPFMandinabilitytoperformPFMEeffectively;lackoflong-termpatientcompliance.缺点是：许多患者不能正确收缩盆底肌；依从性差。1.WesternconservativetreatmentTESispassivePFMEthatproducesPFMcontractionsandhasgoodpatientcompliance.ItsshortcomingisthatitappliesvaginaloranalsurfaceelectrodeandinducesPFMcontractionsbyindirectnervestimulation,soitseffectisnotasgoodasthatofPFMEwhichisdonecorrectly.经阴道或肛门电刺激是被动的盆底肌锻炼，有很好的依从性。缺点是：因使用表面电极，作用是间接的，效果不及正确的盆底肌锻炼

。2.AcupuncturetreatmentAcupunctureoftraditionalChinesemedicinecanalsobeappliedtomildandmoderatestressincontinence.Itsadvantagesaresafety,convenience,andnosideeffectsandcomplications.2.中医针刺治疗对于轻、中度压力性尿失禁也可采用中医针刺治疗，其优点是安全、方便、无副作用和并发症。2.Acupuncturetreatment1)TherapeuticprincipleAccordingtoTCMtheory,itiscausedbydeficiencyofkidneyqiandfailureofthebladderinrestrainingtheurinedischarge,sothetherapeuticprincipleisreinforcingkidneyqiandimprovingvesicalrestrainingfunction.1)治疗原则中医认为，尿失禁是由于肾气不足，膀胱不固引起，因此治疗原则是补益肾气，固脬止遗。2)PointselectionTheBack-ShuandFront-Mupointsofthekidneyandbladderareselectedasthemainacupoints.TheacupointsoftenselectedareShenshu(B23),Pangguangshu(B28),Zhongji(Ren3),Guanyuan(Ren4),Mingmen(Du4),Huiyang(B35),Sanyinjiao(Sp6)andZusanli(S36).2)穴位选择主穴是肾和膀胱的背俞穴和募穴。常用穴位有：肾俞，膀胱俞，中极，关元，命门，会阳，三阴交，足三里。2)PointselectionThekidneyisexteriorly-interiorlyrelatedtothebladder,sotheBack-Shupointsofthekidneyandbladderareapplied.Zhongji(Ren3)istheFront-Mupointsofthebladder.Thecombineduseoftheabovethreeacupointscontributestoreinforcekidneyqiandimprovevesicalrestrainingfunction.肾和膀胱相表里，故选肾和膀胱的背俞穴。中极是膀胱的募穴。三穴合用有助于补益肾气，固脬止遗。2)PointselectionGuanyuan(Ren4)andMingmen(Du4)arethesourcesofprimordialqiandacupunctureofthemcantonifyprimordialyang(kidney-yang).Huiyang(B35)istheacupointofthefoot-taiyangmeridianandacupuinctureofitcaninvigoratethemeridionalqiofthebladder.关元、命门是元气之源，针之能补肾益元。会阳是足太阳经穴位，针之能振奋膀胱之经气。2)PointselectionSanyinjiao(Sp6)isthecrossingpointofthethreefoot-yinmeridiansandacupunctureofitcanregulatetheqiofthethreefoot-yinmeridians.Zusanli(S36)belongstotheyangmingmeridian,whichisfullofqiandblood,andacupunctureofitcantonifyqitostopincontinence.三阴交是足三阴经交会穴，针之能调节足三阴经气。足三里属阳明经，阳明经多气多血，针之能补气止遗。3)ShortcomingBecauseitusesageneralmethodofacupuncture,itisdifficultforconventionalacupuncture,likeelectricalnervestimulation,toimprovetheabilityincontrollingurinationbyexcitingthepudendalnerve,inducingtherhythmiccontractionofthepelvicfloormusclesandincreasingtheirstrength.3)不足之处因采用一般针刺方法，故难以象神经电刺激疗法那样通过兴奋阴部神经诱发盆底肌节律性收缩，增强盆底肌肉力量来改善控尿能力。3.ElectroacupuncturepudendalnervestimulationBycombiningtheadvantagesofPFMEandTESandincorporatingthetechniqueofdeepinsertionoflongneedles,wedevelopedelectracupuncturepudendalnervestimulation(“Foursacralpoints”electracupuncturetherapy),whichisacombinationoftraditionalChineseandWesternmedicine.3.电针阴部神经刺激疗法综合PFME和TES二种疗法优点，融入针灸长针深刺技术，我们发展成了(中西医结合的)电针阴部神经刺激疗法（电针“骶四穴”疗法）。3.ElectricalpudendalnervestimulationInthistherapy,foursacralspecificpointsareacupuncturedbyaspecialneedlingmethod(theneedletipinaspecificdirection)andelectrified3.电针阴部神经刺激疗法该疗法对骶部四个特定穴位采用特殊针刺方法（针尖向特定方向）并加以电刺激3.Electricalpudendalnervestimulationtoimprovetheabilityincontrollingurinationbyexcitingthepudendalnerveandinducingtherhythmiccontractionofthepelvicfloormuscles(includingtheurethralsphincter)tostrengththemuscles,restorethenormalpositionsofbladderneckandproximalurethraandincreaseurethralclosurepressure.能直接兴奋阴部神经诱发盆底肌（包括尿道括约肌）节律性收缩，从而增强盆底肌肉力量，恢复膀胱颈部和近端尿道的正常位置，提高尿道关闭压来改善控尿能力。Foursacralpoints

骶四穴Locationoffoursacralpointsandacupuncturemethods1)Thetwoupperpoints:locatedbythetwoedgesofthesacrumonalevelwiththefourthsacralforamina;定位和针刺方法1）上两针刺点：骶骨边缘旁，平第4骶后孔水平处（双侧）。Foursacralpoints

骶四穴Locationoffoursacralpointsandacupuncturemethods1)Thetwoupperpoints:usealongneedleof4cun(100mm);punctureperpendicularly3~3.5cunindepth;maketheneedlingsensationreachtheurethraoranus.使用4寸长针直刺，针刺深度为3-3.5寸，使针感达尿道或肛门。Foursacralpoints

骶四穴Locationoffoursacralpointsandacupuncturemethods2)Thetwolowerpoints:0.5cunbilateraltothetipofthecoccyx;usealongneedleof4or5cun(100or125mm);2）下两针刺点：尾骨旁开0.5寸（双侧），使用4寸或5寸长针，Foursacralpoints

骶四穴Locationoffoursacralpointsandacupuncturemethods2)Thetwolowerpoints:punctureobliquely(laterally)towardstheischiorectalfossa,3~4.5cunindepth;maketheneedlingsensationreachtheurethra.向外侧（坐骨直肠窝）斜刺，3-4.5寸深，使针感达尿道。ElectricalpudendalnervestimulationAftertheneedlingsensationreferredtotheabove