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
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
– Normal lower urinary tract function
– Urodynamic study
– Neuropathic bladder
• Incontinence and female urology
– Overactive bladder
– Stress urinary incontinence
– Pelvic organ prolapse
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
CYSTOMETRY & EMG
Pressure flow study
VUDS
Outlines
• Neurourology
– Normal lower urinary tract function
– Urodynamic study
– Neuropathic bladder
• Incontinence and female urology
– Overactive bladder
– Stress urinary incontinence
– Pelvic organ prolapse
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)
正常排尿(排尿量)
mL
尿急感(ˇ)
尿失禁(ˇ)
喝水量(mL)
正常排尿(排尿量)
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
– Normal lower urinary tract function
– Urodynamic study
– Neuropathic bladder
• Incontinence and female urology
– Overactive bladder
– Stress urinary incontinence
– Pelvic organ prolapse
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
– Normal lower urinary tract function
– Urodynamic study
– Neuropathic bladder
• Incontinence and female urology
– Overactive bladder
– Stress urinary incontinence
– Pelvic organ prolapse
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
– Normal lower urinary tract function
– Urodynamic study
– Neuropathic bladder
• Incontinence and female urology
– Overactive bladder
– Stress urinary incontinence
– Pelvic organ prolapse
(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
VUDS
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