本文選題：膀胱　切入點(diǎn)：外周神經(jīng)　出處：《山東大學(xué)》2014年博士論文

【摘要】：前言 膀胱過(guò)度活動(dòng)癥是一種以尿急癥狀為主的癥候群,常伴有尿頻和夜尿,可伴有或不伴有急迫性尿失禁。其病因和發(fā)病機(jī)制尚不明確,首選治療方案包括行為訓(xùn)練和藥物治療,其中藥物治療以抗膽堿能制劑為主。雖然大量研究證實(shí)抗膽堿能藥物的有效性,但常見(jiàn)的副作用如口干、便秘、視覺(jué)模糊和認(rèn)知損害以及病人耐受性差等因素影響其臨床應(yīng)用。當(dāng)保守治療效果不佳或藥物治療有明顯副作用時(shí),可以考慮選擇神經(jīng)電刺激進(jìn)行治療。 神經(jīng)電刺激主要是利用特定參數(shù)的電流,對(duì)骶髓的2-4節(jié)段(S2-4)神經(jīng)根及其分支進(jìn)行刺激,干預(yù)排尿反射的神經(jīng)通路從而達(dá)到調(diào)節(jié)膀胱和(或)尿道括約肌的作用。臨床最先應(yīng)用的刺激部位是骶神經(jīng),電極植入手術(shù)創(chuàng)傷大,存在電極移位、疼痛、感染和電池失效等術(shù)后并發(fā)癥。因此,臨床開(kāi)始應(yīng)用脛神經(jīng)和陰部神經(jīng)等外周神經(jīng)作為電刺激的部位,手術(shù)創(chuàng)傷小,安全有效。神經(jīng)電刺激的作用機(jī)理仍不明確,其研究可從以下兩方面入手：一是尋找電刺激發(fā)揮作用的解剖部位,二是明確神經(jīng)調(diào)節(jié)過(guò)程中的神經(jīng)遞質(zhì)及其藥理作用。 膀胱反射的神經(jīng)調(diào)節(jié)極為復(fù)雜,包括脊髓和外周神經(jīng),脊髓以上的大腦、腦橋和小腦等。生理狀態(tài)下,膀胱逼尿肌的張力感受器通過(guò)有髓鞘的A6傳入纖維傳遞膀胱內(nèi)壓力,經(jīng)脊髓傳遞到腦橋排尿中樞。通過(guò)脊髓下行傳導(dǎo)通路,介導(dǎo)非傷害性的脊髓腦脊髓膀胱反射。病理狀態(tài)下,感染、化學(xué)性刺激或冷刺激等激活無(wú)髓鞘的C傳入纖維,介導(dǎo)傷害性的脊髓膀胱反射。 研究發(fā)現(xiàn),外周神經(jīng)電刺激可通過(guò)中樞或外周神經(jīng)通路起作用,包括腦、脊髓和C傳入神經(jīng)纖維等。完全性脊髓損傷患者早期行骶神經(jīng)刺激可預(yù)防尿失禁發(fā)生,說(shuō)明骶神經(jīng)刺激可在脊髓水平起作用。動(dòng)物研究發(fā)現(xiàn),乙酸灌注膀胱后通過(guò)激活C傳入神經(jīng)纖維誘發(fā)傷害性脊髓膀胱反射。脛神經(jīng)電刺激(Tibial nerve stimulation, TNS)和陰部神經(jīng)電刺激(Pudendal nerve stimulation, PNS)后激活脊髓內(nèi)的抑制性中間神經(jīng)元,通過(guò)抑制副交感傳出通路進(jìn)而抑制膀胱的過(guò)度活動(dòng)。 對(duì)慢性脊髓損傷的貓進(jìn)行陰部神經(jīng)電刺激,發(fā)現(xiàn)不同頻率的電刺激可興奮或抑制膀胱收縮。低頻率的陰部神經(jīng)電刺激(3-10Hz)抑制膀胱活動(dòng),而高頻率電刺激(20-40Hz)可興奮膀胱收縮。采用不同頻率電刺激陰部神經(jīng)后可能激活不同的神經(jīng)傳導(dǎo)通路,從而產(chǎn)生興奮或抑制膀胱的作用。這一發(fā)現(xiàn)具有良好的臨床應(yīng)用前景,通過(guò)植入外周神經(jīng)電刺激器,有可能實(shí)現(xiàn)脊髓損傷患者的排尿和儲(chǔ)尿雙相控制。 已知多種神經(jīng)遞質(zhì)參與外周神經(jīng)電刺激對(duì)膀胱活動(dòng)的神經(jīng)調(diào)節(jié),如抑制性氨基酸Y-氨基丁酸(γ-aminobutyric acid, GABA)、五羥色胺(5-hydroxy tryptamine,5-HT)、阿片肽、谷氨酸。動(dòng)物研究發(fā)現(xiàn),脛神經(jīng)電刺激可抑制傷害性和非傷害性膀胱反射,阿片受體參與正常膀胱反射以及脛神經(jīng)刺激對(duì)傷害性膀胱反射的抑制過(guò)程,代謝型谷氨酸受體參與脛神經(jīng)調(diào)節(jié)。在陰部神經(jīng)電刺激抑制膀胱過(guò)度活動(dòng)的過(guò)程中,發(fā)現(xiàn)代謝型谷氨酸受體5和5-HT3參與其中,阿片受體不起作用。因此推測(cè),陰部神經(jīng)的抑制過(guò)程需要多種受體,其他抑制性神經(jīng)遞質(zhì)和受體如GABA受體和甘氨酸可能參與陰部神經(jīng)電刺激對(duì)膀胱過(guò)度活動(dòng)的調(diào)節(jié)。 GABA是哺乳動(dòng)物中樞神經(jīng)系統(tǒng)中重要的抑制性神經(jīng)遞質(zhì)之一,存在于脊髓和脊髓以上中樞神經(jīng)系統(tǒng)的突觸部位。貓鞘內(nèi)注射GABA或GABAA受體激動(dòng)劑,膀胱活動(dòng)受到抑制,膀胱副交感節(jié)前神經(jīng)元放電減弱。陰部神經(jīng)電刺激同樣可引起膀胱副交感節(jié)前神經(jīng)元產(chǎn)生抑制性突觸后電位。因此推測(cè),脊髓GABAA受體可能參與陰部神經(jīng)電刺激對(duì)膀胱過(guò)度活動(dòng)的神經(jīng)調(diào)節(jié)機(jī)制。 本研究分為兩個(gè)部分：第一部分通過(guò)向貓膀胱內(nèi)灌注生理鹽水和乙酸,誘發(fā)非傷害性和傷害性膀胱反射。行膀胱壓力容積測(cè)定,電刺激陰部神經(jīng)聯(lián)合GABAA受體拮抗劑印防己毒素(Picrotoxin, PTX)(靜脈注射或鞘內(nèi)注射)。分析膀胱容量變化,研究脊髓GABAA受體在非傷害性膀胱反射和傷害性膀胱反射以及陰部神經(jīng)電刺激的膀胱抑制過(guò)程中的作用。第二部分通過(guò)完全橫斷貓T9-10脊髓,建立傷害性脊髓膀胱反射的動(dòng)物模型。向貓膀胱內(nèi)灌注乙酸,行陰部神經(jīng)和脛神經(jīng)電刺激后分析膀胱容量變化,以研究外周神經(jīng)電刺激對(duì)傷害性脊髓膀胱反射的影響。等容量收縮條件下,用不同頻率刺激陰部神經(jīng)和脛神經(jīng),研究不同頻率的外周神經(jīng)電刺激對(duì)膀胱活動(dòng)的影響。等容量收縮條件下,先靜脈注射神經(jīng)節(jié)阻斷劑溴化六甲雙銨(Hexamethonium bromide, Hx),膀胱穩(wěn)定后鞘內(nèi)注射局部麻醉劑利多卡因,分析膀胱收縮強(qiáng)度的改變,研究傷害性脊髓膀胱反射的神經(jīng)機(jī)制。 第一部分：脊髓GABAA受體在陰部神經(jīng)電刺激治療膀胱過(guò)度活動(dòng)中的作用 目的： 研究脊髓GABAA受體在陰部神經(jīng)電刺激治療膀胱過(guò)度活動(dòng)中的作用,進(jìn)一步明確陰部神經(jīng)電刺激的神經(jīng)調(diào)節(jié)機(jī)制。 方法： 1、手術(shù)過(guò)程：本實(shí)驗(yàn)有33只貓,麻醉成功后行右側(cè)頸動(dòng)脈和氣管插管,記錄動(dòng)脈血壓和保持氣道通暢。左、右頭靜脈插管,建立靜脈輸液和藥物通道。離斷雙側(cè)輸尿管,單側(cè)接導(dǎo)管引流尿液。雙腔導(dǎo)管經(jīng)尿道插入膀胱,一端接灌注泵,分別向膀胱內(nèi)灌注生理鹽水或0.25%乙酸；另一端接膀胱壓力傳感器,進(jìn)行膀胱壓力容積測(cè)定(Cystometrogram, CMG)。分離右側(cè)陰部神經(jīng),置入刺激電極。取10只貓,在L3脊髓棘突水平暴露脊髓,打開(kāi)硬脊膜置入導(dǎo)管達(dá)S3脊髓水平,作為印防己毒素鞘內(nèi)給藥通道。 2、陰部神經(jīng)電刺激閾值強(qiáng)度確定：刺激頻率為5Hz,波寬0.2ms。逐漸增加刺激強(qiáng)度,觀察到明顯的肛門(mén)括約肌收縮的最小強(qiáng)度就是陰部神經(jīng)電刺激的閾值(Threshold, T)。實(shí)驗(yàn)中分別用2T和4T進(jìn)行刺激,以觀察陰部神經(jīng)電刺激對(duì)膀胱活動(dòng)的調(diào)節(jié)作用。 3、分組和給藥：共分為2組,第1組向膀胱灌注乙酸,包括靜脈給PTX和鞘內(nèi)給PTX兩個(gè)亞組。第2組向膀胱灌注生理鹽水,包括靜脈給PTX和鞘內(nèi)給PTX兩個(gè)亞組。記錄各組給予PTX前后陰部神經(jīng)電刺激對(duì)CMG的影響,進(jìn)行統(tǒng)計(jì)學(xué)分析。 4、數(shù)據(jù)分析：實(shí)驗(yàn)開(kāi)始時(shí)每只貓膀胱灌注生理鹽水,引起超過(guò)20秒大于30cmH2O的收縮時(shí)的膀胱容量為貓的初始膀胱容量。膀胱容量百分比指膀胱容量與同一只貓的初始膀胱容量的比值。統(tǒng)計(jì)數(shù)據(jù)以平均值加減標(biāo)準(zhǔn)誤表示,采用GraphPad Prism4統(tǒng)計(jì)軟件進(jìn)行t檢驗(yàn)或ANOVA分析。 結(jié)果： 1、與初始膀胱容量相比,乙酸組膀胱容量在乙酸刺激后顯著減少到34.3±7.1%(P0.01),2T-PNS和4T-PNS后顯著增加到84.0±7.8%和93.2±15.0%(P0.01)。 2、PTX (0.4mg,it)未改變乙酸組膀胱容量,陰部神經(jīng)電刺激對(duì)膀胱過(guò)度活動(dòng)的抑制作用完全消失。 3、高劑量PTX (0.3mg/kg iv)增加乙酸組膀胱容量,低劑量PTX(0.01-0.1mg/kg iv)后2T-PNS對(duì)膀胱過(guò)度活動(dòng)的抑制作用明顯減弱(P0.05)。 4、生理鹽水組中,與初始膀胱容量相比2T-PNS和4T-PNS后膀胱容量顯著增加147.0±7.6%和172.7±8.9%(P0.01)。鞘內(nèi)注射PTX (0.4mg)和靜脈注射PTX (0.03-0.3mg/kg)后膀胱容量顯著增加(P0.05)。 5、生理鹽水組中,PTX不改變陰部神經(jīng)電刺激對(duì)膀胱活動(dòng)抑制作用。 結(jié)論： 膀胱內(nèi)灌注乙酸可誘發(fā)傷害性膀胱反射,陰部神經(jīng)電刺激能夠抑制膀胱過(guò)度活動(dòng),脊髓GABAA受體參與此抑制過(guò)程。向膀胱內(nèi)灌注生理鹽水可誘發(fā)非傷害性膀胱反射,陰部神經(jīng)電刺激能夠抑制正常膀胱反射。脊髓GABAA受體在正常膀胱反射中起興奮性作用,不參與陰部神經(jīng)電刺激對(duì)正常膀胱反射的抑制過(guò)程。脊髓GABAA受體在傷害性和非傷害性膀胱反射以及陰部神經(jīng)電刺激的膀胱抑制過(guò)程中有不同的作用。 第二部分：外周神經(jīng)電刺激在傷害性脊髓膀胱反射中的作用 目的： 建立傷害性脊髓膀胱反射的動(dòng)物模型,研究外周神經(jīng)電刺激治療膀胱過(guò)度活動(dòng)癥的神經(jīng)調(diào)節(jié)機(jī)制。 方法： 1、手術(shù)過(guò)程 本實(shí)驗(yàn)有12只貓,麻醉成功后行右側(cè)頸動(dòng)脈和氣管插管,記錄動(dòng)脈血壓和保持氣道通暢。右頭靜脈插管,建立靜脈輸液和藥物通道。離斷雙側(cè)輸尿管,單側(cè)接導(dǎo)管引流尿液。雙腔導(dǎo)管經(jīng)尿道插入膀胱,一端接灌注泵,向膀胱內(nèi)灌注生理鹽水或0.25%乙酸；另一端接膀胱壓力傳感器,進(jìn)行膀胱壓力和容積的測(cè)定。分離右側(cè)陰部神經(jīng)和左側(cè)脛神經(jīng),分別置入刺激電極。在T9-10脊髓棘突水平行椎扳切除術(shù),膀胱容量穩(wěn)定后行脊髓完全橫向切斷術(shù)。在L6-7脊髓棘突水平行椎扳切除術(shù),用作實(shí)驗(yàn)中向鞘內(nèi)注射利多卡因。 2、陰部神經(jīng)、脛神經(jīng)電刺激閾值強(qiáng)度確定 刺激頻率為5Hz,波寬0.2ms。逐漸增加刺激強(qiáng)度,觀察到明顯的肛門(mén)括約肌收縮或左側(cè)腳趾收縮的最小強(qiáng)度就是陰部神經(jīng)和脛神經(jīng)電刺激的閾值(Threshold,T).實(shí)驗(yàn)中分別用2T和4T進(jìn)行刺激,以觀察陰部神經(jīng)和脛神經(jīng)電刺激對(duì)膀胱反射的調(diào)節(jié)作用。 3、膀胱壓力和容積的測(cè)定 向膀胱內(nèi)灌注生理鹽水測(cè)得初始膀胱容量,在T9-10棘突水平行脊髓完全橫向切斷術(shù),再向膀胱內(nèi)灌注0.25%的乙酸誘發(fā)膀胱過(guò)度活動(dòng)。待膀胱容量穩(wěn)定后,進(jìn)行如下CMG測(cè)定：(1)乙酸對(duì)照；(2)2T-PNS;(3)4T-PNS；(4)乙酸后對(duì)照。重復(fù)測(cè)定待膀胱容量穩(wěn)定后,進(jìn)行如下CMG測(cè)定：(1)乙酸對(duì)照；(2)2T-TNS；(3)4T-TNS；(4)乙酸后對(duì)照。 4、等容量收縮條件下,不同刺激頻率的陰部神經(jīng)和脛神經(jīng)電刺激對(duì)膀胱活動(dòng)的影響 等容量收縮條件下對(duì)陰部神經(jīng)和脛神經(jīng)進(jìn)行電刺激,刺激強(qiáng)度分別為2T和4T,波寬為0.2ms,頻率依次為5.40.1.20.0.5.10Hz。 5、等容量收縮條件下Hx和利多卡因?qū)Π螂资湛s強(qiáng)度的影響 等容量收縮條件下,靜脈注射Hx(10mg/kg)檢測(cè)膀胱壓力。5分鐘后在脊柱棘突L6-7水平行椎板切除術(shù),鞘內(nèi)注射2%利多卡因和去甲腎上腺素混合液1-2ml,以觀察膀胱壓力的改變。 6、數(shù)據(jù)分析 膀胱容量與同一動(dòng)物的初始膀胱容量對(duì)比,計(jì)算膀胱容量百分比。等容量收縮條件下,不同刺激頻率時(shí)與刺激前曲線下面積對(duì)比,計(jì)算膀胱活動(dòng)百分比以比較不同刺激頻率對(duì)膀胱活動(dòng)的影響。等容量收縮條件下,測(cè)量膀胱壓力平均值以表示膀胱收縮強(qiáng)度。統(tǒng)計(jì)數(shù)據(jù)以平均值加減標(biāo)準(zhǔn)誤表示,采用GraphPad Prism4統(tǒng)計(jì)軟件進(jìn)行t檢驗(yàn)或ANOVA分析。 結(jié)果 1、與初始膀胱容量相比,T9-10脊髓完全橫向切斷術(shù)后乙酸灌注使膀胱容量明顯減小68.8±6.4%(P0.01),2T-PNS和4T-PNS后膀胱容量明顯增大92.4±12.0%和107.6±14.7%(P0.01),2T-TNS和4T-TNS后膀胱容量無(wú)明顯改變。 2、等容量收縮條件下,靜脈注射Hx后膀胱壓力明顯減小(19.3±2.9vs.8.4±1.9cmH2O,P0.01)。鞘內(nèi)注射利多卡因后膀胱壓力再次減小(3.9±1.0cmH2O),膀胱收縮強(qiáng)度明顯減弱(P0.01)。 3、等容量收縮條件下,0.5、1、5、40Hz的2T-PNS抑制膀胱收縮,膀胱活動(dòng)百分比明顯降低(P0.05),10、20Hz的2T-PNS時(shí)膀胱活動(dòng)無(wú)明顯改變。 4、等容量收縮條件下,0.5、1、5、10、20、40Hz的4T-TNS未能抑制膀胱收縮,膀胱活動(dòng)百分比無(wú)明顯改變。 結(jié)論： 急性脊髓損傷后膀胱內(nèi)灌注乙酸可誘發(fā)膀胱過(guò)度活動(dòng),陰部神經(jīng)電刺激能抑制傷害性脊髓膀胱反射,脛神經(jīng)電刺激則不能。陰部神經(jīng)電刺激的膀胱抑制作用與刺激的頻率有關(guān)。Hx可部分阻斷傷害性脊髓膀胱反射。本研究建立一種新的傷害性脊髓膀胱反射的動(dòng)物模型,可用于進(jìn)行外周神經(jīng)電刺激治療膀胱過(guò)度活動(dòng)癥的神經(jīng)調(diào)節(jié)機(jī)制的研究。
[Abstract]:Preface
Overactive bladder is a urgency symptoms syndrome, usually with frequency and nocturia with or without urinary incontinence. Its etiology and pathogenesis is not clear, the preferred treatment including training and drug treatment, including drug treatment with anti cholinergic agents. Although a large number of the research confirmed the effectiveness of anticholinergic drugs, but common side effects such as dry mouth, constipation, blurred vision and the effect of cognitive impairment and poor patient tolerance factor in its clinical application. When conservative treatment ineffective or drug treatment has obvious side effect, can choose the nerve stimulation treatment.
Nerve stimulation is the main current use of specific parameters of the 2-4 sacral segment (S2-4) and its branches of nerve root stimulation, neural pathway intervention to adjust the micturition reflex bladder and (or) urethral sphincter function. Clinical application is the first site of stimulation of sacral nerve electrode implantation, surgical trauma, existence electrode displacement, pain, infection and battery failure and other postoperative complications. Therefore, clinical application of part of the tibial nerve and peripheral nerve pudendal nerve stimulation, surgical trauma, safe and effective. Nerve stimulation for mechanism is not clear, it can start from the following two aspects: one is to look for play the role of stimulating anatomy, two is to clear the neural regulation of neurotransmitter and its pharmacological effects in the process.
Bladder reflex nerve regulation is very complex, including spinal cord and peripheral nerve, spinal cord or brain, pons and cerebellum. Under physiological condition, tension receptors in bladder detrusor by myelinated afferent fibers transmit A6 bladder pressure, the spinal cord to the pontine micturition in the spinal cord. The pivot descending pathway, spinal cord the brain and spinal cord bladder reflex mediated by non noxious. Under pathological conditions, infection, chemical irritation or cold stimulation to activate unmyelinated afferent fibers C, spinal cord mediated nociceptive reflex bladder.
The study found that peripheral nerve stimulation may play a role, through the central or peripheral nerve pathways including the brain, spinal cord and C afferent nerve fibers. Spinal cord injury patients undergoing early sacral nerve stimulation can prevent urinary incontinence, that sacral nerve stimulation could play a role in the spinal cord. Animal studies found that acetic acid perfusion of bladder after activation by C afferent nerve fibers evoked nociceptive spinal cord bladder reflex. The tibial nerve stimulation (Tibial nerve, stimulation, TNS) and pudendal nerve stimulation (Pudendal nerve, stimulation, PNS) after activation of inhibitory interneurons in the spinal cord, by inhibiting parasympathetic efferent pathway and inhibit overactive bladder.
The chronic spinal cord injury of cat pudendal nerve stimulation, different frequency stimulation can excite or inhibit bladder contraction. The low rate of pudendal nerve stimulation (3-10Hz) inhibits bladder activity, and high frequency stimulation (20-40Hz) can be excited by different frequency of bladder contraction. Electrical stimulation of the pudendal nerve may activate nerve different signalling pathways, resulting in excitatory or inhibitory bladder role. This finding has good prospects for clinical application, through the implantation of peripheral nerve stimulator, possible in patients with spinal cord injury urination and urine storage phase control.
The known neurotransmitters involved in peripheral nerve stimulation on bladder activity such as neural regulation of inhibitory amino acid GABA (gamma Y- -aminobutyric acid, GABA), five hydroxytryptamine (5-hydroxy tryptamine, 5-HT), opioid peptide, glutamic acid. Animal studies found that tibial nerve stimulation can inhibit nociceptive and non nociceptive bladder reflex, opioid receptors in normal bladder reflex and tibial nerve stimulation on nociceptive reflex bladder, metabotropic glutamate receptors are involved in the regulation of the tibial nerve. The process of pudendal nerve stimulation inhibits bladder overactivity in the metabotropic glutamate receptor 5 and 5-HT3 involved in opioid receptor does not work. It was suggested that inhibition of the pudendal nerve need a variety of receptors, other inhibitory neurotransmitters and receptors such as GABA receptor and glycine may participate in pudendal nerve stimulation of overactive bladder. Adjust.
GABA is one of the most important inhibitory neurotransmitter in the mammalian central nervous system, the synapses exist in the spinal cord and spinal cord above the central nervous system. The injection of GABA or GABAA receptor agonist cat intrathecal, bladder activity inhibited bladder parasympathetic preganglionic neurons discharge decreases. Pudendal nerve stimulation can cause bladder parasympathetic preganglionic neurons produce inhibitory postsynaptic potential. So, probably GABAA receptors are involved in spinal cord pudendal nerve stimulation on bladder excessive activity of nerve regulation mechanism.
This study is divided into two parts: the first part through to the infusion of physiological saline and acetic acid induced cat bladder, non noxious and noxious bladder reflex. Cystometry, pudendal nerve stimulation combined with GABAA receptor antagonist picrotoxin (Picrotoxin, PTX) (intravenous or intrathecal) analysis. Study on the changes of bladder capacity, spinal GABAA receptor inhibition function in the process of non noxious and noxious bladder reflex bladder reflex and pudendal nerve stimulation of the bladder. The second part of the spinal cord transected cat T9-10 animal model of spinal cord injury, bladder reflex. The cat to intravesical instillation of acetic acid, analysis of bladder volume changes for pudendal nerve and tibial nerve after electrical stimulation, to study the effect of electrical stimulation on peripheral nerve injury of spinal cord bladder reflex. Isovolumic contraction conditions and pudendal nerve stimulation with different frequency Tibial nerve, peripheral nerve electrical stimulation of different frequency effects on bladder activity. Under the condition of isovolumic contraction, the first intravenous injection of ganglionic blocker hexamethonium bromide (Hexamethonium, bromide, Hx), stable bladder after intrathecal injection of local anesthetic lidocaine, analysis of bladder contraction intensity changes, the neural mechanism of injury spinal cord bladder reflex.
Part 1: the role of GABAA receptor in the treatment of overactivity of bladder in the perineum nerve electrical stimulation
Objective:
To study the role of GABAA receptor in the treatment of overactivity of bladder in the perineum nerve stimulation, and to further clarify the mechanism of nerve regulation of the perineal nerve electrical stimulation.
Method錛，

本文編號(hào)：1726608