泌尿神經生理及婦女泌尿學 Neurourology and female urologylms.ndmctsgh.edu.tw/sysdata/48/10148/doc/adaaeedef0aa03cb/atta… · 泌尿神經生理及婦女泌尿學 Neurourology

泌尿神經生理及婦女泌尿學Neurourology and female urology

蒙恩醫師

國防醫學院三軍總醫院泌尿外科

22, Mar. 2018

Outlines

• Neurourology

– Normal lower urinary tract function

– Urodynamic study

– Neuropathic bladder

• Incontinence and female urology

– Overactive bladder

– Stress urinary incontinence

– Pelvic organ prolapse

ANATOMY OF LOWER URINARY TRACT

Normal urethral length?

ANATOMY OF BLADDER

Normal bladder capacity?

男性女性

Detrusor

Trigone

Internal

urethral

sphincterExternal urethral

sphincter

輸尿管開口Ureteral orifice

THE BLADDER WALL

Storage of urine at low intravesical pressure

without leakage

Intermittently, this storage function is interrupted by the

voluntary and complete expulsion of urine

Involve the coordination of the peripheral

autonomic, peripheral somatic, and central

nervous systems (CNS)

NORMAL LOWER URINARY TRACT

FUNCTION

BLADDER FILLING & EMPTYING CYCLE

The cycle ofbladder fillingand emptying

1. Bladder fills

2. First desire tourinate (bladder

half full)

Urination 3. Urinationvoluntarily inhibiteduntil time and place

are right

Detrusor musclecontracts

Detrusor muscle relaxes

Urethralsphinctercontracts

Urethralsphincterrelaxes

SYMPATHETIC,

PARASYMPATHETIC,

AND SOMATIC

INNERVATION OF THE

LUT

Nature Reviews Neuroscience 9, 453-466 (June 2008)

RECEPTORS

BLADDER COMPLIANCE

Change in bladder volume/change in intravesicalpressure, which is expressed in mL/cmH2O

Normal compliance is maintained throughout filling by…

• Reorientation of the detrusor smooth muscle fibers and connective tissue

• Thinning of the lamina propria

• Flattening of the urothelium

Chang SL, et al. Scand J Urol Nephrol Suppl 1999;201:38e45

BLADDER COMPLIANCE

Outlines

• Neurourology








Urodynamic study（尿路動力學檢查）

• measurement of flow rateUroflowmetry

• measurement of post-voiding residual urine (PVR)Bladder scan

• the recording of bladder pressure during bladder filling

Cystometry

• the simultaneous recording of bladder pressure during voiding

Pressure–flow studies (PFS)

• fluoroscopy (X-ray screening) combined with PFS during voiding

Videourodynamicstudy (VUDS)

UROFLOWMETRY

Normal urinary flow

rate?

Male: 20-25 ml/s

Female: 25-30 ml/s

21±13 sec

BLADDER SCAN

CYSTOMETRY & EMG

Pressure flow study

Outlines

• Neurourology








LOWER URINARY TRACT SYMPTOMS

(LUTS)

Storage Voiding Postmicturition

Urgency Hesitancy Terminal dribble

Frequency Poor flow Postvoid dribble

Nocturia Intermittency Sense of

incomplete

emptying

Urgency

incontinence

Straining

Lower urinary tract dysfunction following neurological disease

Causes of Neurogenic Underactive Bladder

Central nervous system diseasesNeurologic disorders:

a. Acute cerebrovascular accidents

b. Multiple sclerosis (MS)

c. Parkinson’s disease

Injury to the spinal cord and cauda equina

a. Herniated disc

b. Cauda equina syndrome

Peripheral neuropathyDiabetes Mellitus

Infectious neurologic problems

a. AIDS

b. Neurosyphilis (tabes dorsalis)

c. Herpes zoster and herpes simplex

d. Guillain–Barre´ syndrome

After pelvic surgery and radiation therapy

a. Pelvic surgery

b. Pelvic and sacral fractures

c. Lesions of the pudendal nerve

The neurological

status of a patient

with neuro-

urological

symptoms must be

described as

completely

as possible

Urodynamic tests for neuropathic

bladder

Voiding diaries are considered a valuable diagnostic tool in patients with neuro-urological disorders. A voiding diary should be recorded for at least 2-3 days

Uroflowmetry and ultrasound assessment of post-void residual should be repeated at least 2 or 3 times in patients able to void

Invasive urodynamic studies comprise mandatory assessment tools to determine the exact type of neuro-urological disorder

時間間隔

第一天第二天第三天

日期：年月日日期：年月日日期：年月日

正常排尿（排尿量）

mL

尿急感（ˇ）

尿失禁（ˇ）

喝水量（mL）


mL

尿急感（ˇ）

尿失禁（ˇ）

喝水量（mL）


mL

尿急感（ˇ）

尿失禁（ˇ）

喝水量（mL）

00（午夜）-01 50, 50 ˇ 100 ˇ ˇ 150

01-02 ˇ 100 ˇ,ˇ 50

02-03 ˇ或100 ˇ 100 ˇ ˇ

03-04 ˇ 50 ˇ

00（午夜）-01

01-02

02-03

03-04

04-05

05-06

06（早）-07

07-08

08-09

09-10

10-11

11-12

12（午）-13

13-14

14-15

15-16

16-17

17-18

18（晚）-19

19-20

20-21

21-22

22-23

23-24

起床時間 _______時＿＿＿分 _______時＿＿＿分 _______時＿＿＿分

就寢時間 _______時＿＿＿分 _______時＿＿＿分 _______時＿＿＿分

SUPRASACRAL SPINAL CORD INJURY

Detrusor-

Sphincter

Dyssynergia

Neuropathic bladder

following a spinal cord injury

Spastic bladder

Flaccid bladder

Spastic

Flaccid

Treatment goals

Protection of the upper urinary tract

Improvement of urinary continence

Restoration of (parts of) the LUT function

Improvement of the patient’s QoL

EAU guidelines on neuro-urology 2015

Medical therapy

Use antimuscarinic therapy as the first-line medical treatment for neurogenic detrusor overactivity (NDO)

Offer intravesical oxybutynin to NDO patients with poor tolerance to the oral route

Prescribe α-blockers to decrease bladder outlet resistance

For underactive bladder NO parasympathicomimetics should be prescribed

EAU guidelines on neuro-urology 2017

Minimally invasive treatment

Use intermittent catheterization, whenever possible aseptic technique, as a standard treatment for patients who are unable to empty their bladder

Avoid indwelling transurethral and suprapubic catheterization whenever possible

Use botulinum toxin injection in the detrusor to reduce NDO in multiple sclerosis or spinal cord injury patients if antimuscarinic therapy is ineffective

Outlines

• Neurourology








膀胱過動症(OAB)症狀之定義

• 膀胱過動症(overactive bladder) 是一個臨床症候群的名詞，是指膀胱功能過分亢進，以急尿、頻尿、夜尿、急迫尿失禁為主要症狀，且沒有其他病理狀況同時發生

▪Overall, 16.5% of the population aged >18 years (~33 million people) had symptoms of OAB

發生率隨著年齡的增長而昇高

0

5

10

15

20

25

30

35

40

18–24 25–34 35–44 45–54 55–64 65–74 75+

Men

Women

N = 5,204

Age (years)

Pre

vale

nce (

%)

Stewart W et al. World J Urol. 2002; 20: 327-336

OAB SYMPTOMS PREVALENT IN MEN

& WOMEN & INCREASES WITH AGEP

revale

nce, %

0

5

10

15

20

25

30

35

40

Age, years

18-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

Milsom I et al. BJU Int. 2001;87:760-766.

Irwin DE et al. Eur Urol. 2006;50:1306-1315.

Men – SIFO 1997

Women – SIFO 199716.6

Men – EPIC 2005

Women – EPIC 200511.8

Data from both the SIFO Study 1997 and the EPIC Study 2005

Irwin, D. E., et al. (2011). BJU Int 108, 1132-8

Diagnosis

• Careful history (document symptoms)

• Physical exam

• Urinalysis

Diagnosis of OAB

• Urine culture

• Post-void residual

• Bladder diaries

• Symptom questionnaires

Additional (optional) procedures and measures

• Cystoscopy

• Urodynamics

• Renal and bladder ultrasound

Unnecessary in initial evaluation of the uncomplicated patient

膀胱充填/尿液累積與儲存期排尿期膀胱壓力

膀胱充填/尿液累積與儲存期

膀胱放鬆

尿道括約肌收縮(含內和外括約肌)

β3

α1

膀胱收縮

尿道括約肌放鬆(含內和外括約肌)

M2/M3

正常的膀胱功能

M3b3

Normal bladder

M2

膀胱充填/尿液累積與儲存期排尿期膀胱壓力

膀胱充填/尿液累積與儲存期

膀胱過動症的膀胱功能

2. 膀胱儲存量半滿

逼尿肌突然收縮伴隨著膀胱內壓增加

1. Wein AJ, et al. Int J Fertil Womens Med. 1999;44:56-66.2. Ouslander JG. N Engl J Med. 2004;350:786-799.

Overactive bladder

口服藥物治療

M3b3

Normal bladder

M2

Overactive bladder

M3b3

M2

b3 agonist

Antimuscarinics

ANTIMUSCARINIC AGENTS

Oxybutynin (immediate-release and extended release)

Propiverine

Tolterodine (immediate-release and extended release)

Oxybutynin transdermal delivery system

Darifenacin (M3)

Solifenacin (M3)

Trospium

MIRABEGRON: 選擇性b3 AGONIST

OH

NH2

H

NO S

NN

H

Mirabegron的結構式

由日本開發，全球首創的選擇性β3腎上腺素受體作用劑，用來治療膀胱過動症。

Minimal invasive treatment

• Offer bladder wall injections of

onabotulinum toxin A (100 U) to patients

with urgency urinary incontinence

refractory to conservative therapy (such as

PFMT and/or drug treatment)

注射肉毒桿菌

Neuromodulation (神經調節)

Outlines

• Neurourology








何謂尿失禁?

• 尿失禁 (Urinary incontinence)

– 指任何尿液非自主性的漏出

尿失禁可分為那幾種?

• 25-45% adult women have urinary

incontinence

– ~50% stress urinary incontinence

– 7.5-25% mixed urinary incontinence

– 0.5-1% urgency incontinence

Abrams P, Cardozo L, Khoury S, Wein AJ. Incontinence. 5th ed: Health Publication; 2013.

Prevalence of OAB & UI in

Taiwanese women

Chen, G. D., et al. (2003). Neurourol Urodyn 22, 109-17

SUI

MI

OAB

應力性尿失禁成因

應力性尿失禁的診斷

輕微：只有在用力咳嗽之下，平常不需要任何保護。

中度：在較輕的用力咳嗽之下便會漏尿，而且漏尿

每星期至少有一次，病人需要護墊保護的時候。

嚴重：在很輕微的運動或是走動就會發生，病人平

常需要用護墊來保護，以防止漏尿造成褲子弄濕。

應力性尿失禁的評估

尿失禁的治療

• 保守治療– 行為治療– 骨盆肌肉強化訓練– 電磁波刺激療法

• 藥物治療– 女性荷爾蒙– a-腎上腺素受體促進劑– 選擇性血清素與正腎上腺素再吸收抑制劑 (千憂解)

• 手術療法– 注射膠原蛋白– 低張力尿道下人工韌帶(吊帶)術– 膀胱懸吊術– 人工括約肌

行為治療

• 減重

• 減少咖啡因攝取

• 注意水分攝取

• 高纖飲食，避免便秘

• 治療慢性咳嗽

• 定時解尿

• 姿勢改變

凱格爾運動

預防或改善陰道鬆弛或是尿失禁的現象。可以自我訓練，不受時間限制，也不受場所的限制。進行凱格爾訓練法時，想像你正試著停止排尿或放屁。一天做5組凱格爾訓練法，每次當你收縮骨盆肌肉時，慢慢數到5然後放鬆，如此重複10次就算是做完一組凱格爾訓練法。

電磁波刺激療法

經陰道無張力懸吊術 (TENSIONFREE TRANSVAGINAL TAPE, TVT)

經閉孔吊帶懸吊術 (TRASOBTURATORTAPE, TOT)

陰道前壁懸吊術 (BURCH PROCEDURE)

人工括約肌

Outlines

• Neurourology








(Pelvic organ prolapse, POP)

骨盆腔是女性身體上很重要的構造，裡頭的

器官由前向後排列，包含膀胱、子宮、直腸，

分別負責人體的泌尿、生殖和排便的功能。

骨盆的底部有尿道、陰道和肛門開口，穿過

骨盆底組織與外面相通。

骨盆底就像一個水桶底部，

當承載過多的重量，或底部

的支撐力減弱，容易造成

「骨盆腔鬆弛」，就會出現

大小便失禁、陰道鬆弛、

便秘，甚至骨盆腔器官脫垂

等問題，嚴重影響日常生活

品質。

一個或多個骨盆腔內器官發生下降的情形，脫垂的部位包括：陰道前壁，陰道後壁，陰道頂點（子宮頸至子宮），子宮切除術後陰道穹窿（Vault）或袖口（Cuff）

骨盆腔器官脫垂的定義

產生POP的原因

• 先天性：繼發於結締組織異常（脊柱裂，外翻 [exstrophy]，Ehlers–Danlos syndrome）

• 後天（多因素）：曾接受過陰道手術（脫垂修復，陰道懸吊手術，子宮切除術）;陰道分娩; 年齡（雌激素減少），肥胖，便秘，慢性緊張。

POPQ分期

骨盆器官脫垂的最前緣與處女膜的相對位置

描述

0 tvl-2 cm 脫垂部位超出陰道長度減2公分的長度

POP的治療

保守療法

• 改變生活方式（治療便秘及慢性咳嗽）

• 骨盆底肌肉訓練

• 陰道子宮托：選擇適合的子宮托(pessary)，每3-6個月更換一次，初期應在醫療院所更換並檢查有無陰道潰瘍或瘻管。若有陰道萎縮則應給予治療

脫垂的手術治療(>GR2)

Cystocele Uterine prolapse

脫垂的手術治療經陰道人工網膜俢補術

LAPAROSCOPIC SACROCOLPOPEXY

總結

正常的排尿和貯尿是由中樞與週邊神經共同協調來控制膀胱和

尿道括約肌所達成

尿路動力學檢查有助於診斷下泌尿道功能障礙

中樞或週邊神經病變會導致神經性排尿障礙，可以藥物治療膀

胱過動。若無法排空時，需藉由間歇性自我導尿來排尿

急尿感是膀胱過動症主要的症狀，可以藉由藥物改善症狀，藥

物治療無效時，可注射肉毒桿菌或以神經調節器治療

女性骨盆底支撐不足可能導致應力性尿失禁及骨盆脫垂，可藉

由手術矯治

Documents

泌尿神經生理及婦女泌尿學 Neurourology and female urologylms.ndmctsgh.edu.tw/sysdata/48/10148/doc/adaaeedef0aa03cb/atta… · 泌尿神經生理及婦女泌尿學 Neurourology