神经源性膀胱专家讲座

NeurogenicbladderRi曾志龍神经源性膀胱第1页PrefaceNeurogenicvoidingdysfunction(neurogenicbladder),neuropathicbladder/neuropathicurethra神经源性膀胱第2页InnervationAutonomic:Para.(S2~4)-pelvicn.-bladder(detrusorcontracture)Sym.(T11~L2)-paravertebralchain-hypogastricn.-bladder/urethra(detrusorrelaxation)Somatic:cortex-(S2~4)-pudendaln.-externalsphincter神经源性膀胱第3页Physiology排尿：pelvicfloormusculacture,externalsphincterrelaxurethralDetrusorcontractureTrigone(预防VUR)bladderpressureneckopen解畢：Detrusorrelax,bladderneckclose,externalsphinctertone排尿途中：externalsphinctercontracturedetrusorrelax神经源性膀胱第4页神经源性膀胱第5页Causeintracraniallesion：腦血管病變、巴金森氏症、老年痴呆症以及大腦退化等spinalcordlesions：外傷性脊髓損傷(spinalcordinjury)，多發性硬化症(multiplesclerosis)以及脊髓束緊症(tetheredcord)等等peripheralneuropathy：caudaequinasyndrome以及骨盆手術術後造成之骨盆神經叢受傷metabolicdisease：最常見是糖尿病所引發之周邊神經病變神经源性膀胱第6页Suprasacralcordlesion：detrusorhyperreflexia,detrusor-externalsphincterdyssynergia(DESD)Supra-T6：autonomicdysreflexia(膀胱漲尿時，病人交感神經張力會有異常增加現象，導致血壓上升、心跳加紧、患部以上潮紅及冒汗頭痛)神经源性膀胱第7页各種上神經元病變及下神經元病變之逼尿肌反射情形

逼尿肌反射亢進或正常反射低下或無反射上神經元病變腦血管病變4420(45%)24(55%)巴金森氏症4028(70%)12(30%)顱內病變2014(70%)6(30%)多發性硬化症128(67%)4(33%)頸椎或胸椎傷害3221(66%)11(34%)14891(61%)57(39%)下神經元病變薦椎傷害448(18%)36(82%)腦膜脊髓膨出症及脊椎裂346(18%)28(82%)骨盆腔內手術1324(3%)128(97%)糖尿病神經病變240(－)24(100%)23418(7.6%)216(92.4%)神经源性膀胱第8页逼尿肌反射亢進Coordinatedsphincter(括約肌協調)Non-relaxedstriatedsphincter(橫紋括約肌無放鬆性)Denervatedstriatedsphincter(橫紋括約肌去神經化)Non-relaxingsmoothmusclesphincter(BN)(平滑括約肌無放鬆性)逼尿肌無反射Coordinatedsphincter(括約肌協調)Striatedsphincterdyssynergia(橫紋括約肌共濟失調)Smoothmusclesphincter(BN)dyssynergia(平滑括約肌共濟失調)Krane&Sirokyclassification神经源性膀胱第9页StrokeInitiallyurinaryretentiondetrusorhyperreflexiaandinadequatecontractility(DHIC)incontinence,dysuriaFrontal,parietallobe,internalcapsuleexternalsphincterdysfunctiondysuria神经源性膀胱第10页StrokeCerebralhemorrhage-85%detrusorareflexia/Cerebralinfarction-10%detrusorhyperreflexia,maycombinewithobstruction(pseudo-dyssynergia,BPH)神经源性膀胱第11页Otherintracranialdiseases巴金森氏症：detrusorhyperreflexia,pseudo-synnergia,DHIC小腦病變（cerebellarataxia)：hyperreflexia,DESDCerebralpalsy：normalorhyperreflexiaSeniledementia：hyperreflexia,DHIC,areflexiad/dwithBPH神经源性膀胱第12页OthersMultiplesclerosis好發30~50y/ofemale(80~96%)60~70%detrusorhyperreflexia20~40%DESD15~40%hypocontractilityDM55~60%detrusorhyperreflexia35%detrusorhyporeflexia,areflexiaSym.tone?bladdernecktoned/dwithhypocontractility神经源性膀胱第13页DiagnosisHx,PE,NEX-raysofskullandspineKUBEEGCMG神经源性膀胱第14页ManagementStepbystep早期foley3~7days(膀胱攣縮,感染)穩定後CICorCISC(<500ml,adequateI/O)Cleanintermittent(self)catheterization尿路動力學檢查評估(when?,cons.clear,LEmotorfunctionrecover,orclampfoleytotest)Trocarcystostomy神经源性膀胱第15页MedicationIncreasecontractibility：cholinergic，比如bethanecholchloride，可選擇性地使膀胱及腸道肌肉收縮。αadrenergicantagonist。Decreaseoutletresistence：phenoxybenzamine、prazosin、terazosin、alfuzosin等對平滑括約肌有效。Valium、baclofen、dantrolenesodium等對橫紋括約肌之放鬆有幫助。BotulinumAtoxin直接注射也可麻痺括約肌。Decreasecontractibility：anticholinergic，比如Propanthelinebromide、oxybutyninchloride、dicyclomine等。其它如imipramine、verapamil等也有臨床上價值。Increaseoutletresistence：促進交感神經藥物，比如ephedrine等，但效果並不很確定。 retention>incontinence神经源性膀胱第16页症狀用藥增強逼尿肌活性bethanechol降低逼尿肌反射亢進(膀胱內灌注)oxybutynintolterodineimipramineflavoxatedicyclomine降低出口阻力alpha-adrenergicblockerskeletalmusclerelaxantnitricoxidedonors增強出口阻力methylephedrineimipramine神经源性膀胱第17页Surgery抗逆流手術Increasesubmucosaureterlength膀胱擴大手術(Bladderaugmentation)膀胱容積小、壓力高、compliance差、leakpointpressure高、括約肌不協調，当前最惯用加強膀胱頸或括約肌手術Reconstruction,slingUrethralstent神经源性膀胱第18页Conclusiond/dthemechanismMostarereversible!Regularfollowupbladderfunction(cystometrography)Treatunderlyingdisease(MM,PD,infection)神经源性膀胱第19页ReferenceBurneyTL,SenapatiM,DesaiS,ChoudharyST,BadlaniGH:Acutecerebrovascularaccidentandlowerurinarytractdysfunction:Aprospectivecorrelationofthesiteofbraininjurywithurodynamicfinding.JUrol1996;156:1748-1750.KuoHC:Effectofbotulinumatoxininthetreatmentofvoidingdysfunctionduetodetrusorunderactivity.Urology;61:550-554BlaivasJG:Theneurophysiologyofmicturition:Aclinicalstudyof550patients.JUrol1982;127:958-963.HaldT,BradleyWE:Neuropathology.In:TheUrinaryBladder:NeurologyandDynam