發(fā)布時(shí)間：2018-06-24 03:36

  本文選題：神經(jīng)原性膀胱 + 尿流動(dòng)力學(xué)　； 參考：《鄭州大學(xué)》2014年碩士論文

【摘要】：背景和目的 神經(jīng)原性膀胱功能障礙（neuropathic bladder dysfunction,NBD）是指任何中樞、周?chē)窠?jīng)病變及損害導(dǎo)致膀胱或者尿道括約肌功能的障礙。神經(jīng)原性大小便失禁是其主要臨床癥狀，小兒神經(jīng)原性膀胱功能障礙大多是先天性脊柱裂或骶骨發(fā)育異常所致，分骶髓病變、骶髓上病變、骶髓下病變、周?chē)灾魃窠?jīng)病變和肌肉病變，骶骨發(fā)育不全通常包括2個(gè)或者多個(gè)椎體先天性完全或部分缺失，很少為后天獲得的，或因腦膜炎、腦癱、神經(jīng)系統(tǒng)腫瘤、中樞或周?chē)窠?jīng)損傷、外傷致脊髓損傷、盆腔手術(shù)神經(jīng)損傷等所致。該病很?chē)?yán)重的并發(fā)癥即是大小便失禁和上尿路損害。NBD主要是低順應(yīng)性膀胱或者逼尿肌-括約肌協(xié)同性失調(diào)，或伴有尿失禁的慢性尿潴留，可以阻礙尿液自腎臟從輸尿管膀胱結(jié)合部到膀胱的流通，從而引起腎臟積水，長(zhǎng)期致功能損害。膀胱高壓潴留尿?qū)е履I臟壞死已經(jīng)被McGuire等通過(guò)對(duì)好多骨髓發(fā)育不良（myelodysplastic）的兒童研究已證實(shí)，表明逼尿肌漏尿點(diǎn)壓力"g40cmH2O就會(huì)對(duì)上尿路的功能造成損害。兒童下尿路功能障礙可能是隱性脊柱裂的表現(xiàn)，大多數(shù)病例顯示，骶尾部、足部、下肢的畸形（如毛束征、皮膚血管瘤、跛行、單足或雙足高足弓、酒窩征、皮下脂肪瘤等）。以上畸形在有些病例中或許很輕微，但認(rèn)真考慮分析骶尾部正側(cè)位片能識(shí)別出與神經(jīng)系統(tǒng)異常有關(guān)的脊柱畸形。不同程度的隱性脊柱裂具有不同的意義，單純第四、五椎板未融合通常不是很?chē)?yán)重，如果椎管明顯擴(kuò)張很有可能會(huì)導(dǎo)致脊髓的損傷（脊髓栓系綜合征、縱形脊柱裂）該病主要臨床表現(xiàn)為：排便異常，尿急、尿頻、尿失禁，白天尿濕褲子夜晚尿床，也有部分患兒因排尿困難、費(fèi)力、尿線(xiàn)無(wú)力、尿液渾濁，反復(fù)發(fā)熱，走路異常或者肢體活動(dòng)障礙等。目前診斷該病的臨床檢查是行影像和尿流動(dòng)力學(xué)（影像尿動(dòng)力學(xué)）檢查是評(píng)估下尿路功能障礙的金標(biāo)準(zhǔn)，通過(guò)膀胱尿道造影或者超聲進(jìn)行形態(tài)學(xué)檢查，在臨床實(shí)踐、影像、神經(jīng)生理檢查懷疑有疾病時(shí)，可考慮進(jìn)行中樞神經(jīng)系統(tǒng)成像，PET功能性神經(jīng)成像將對(duì)膀胱尿道正常功能和異常功能相關(guān)的中樞神經(jīng)功能解剖提供一個(gè)新的診斷方法，神經(jīng)成像能彌補(bǔ)臨床神經(jīng)平面評(píng)估膀胱功能異常類(lèi)型之間的差別，超聲及MRU的上尿路影像學(xué)，在神經(jīng)原性下尿路功能障礙中被推薦為最基本和常用的隨訪檢查。膀胱低順應(yīng)性和伴有或不伴有尿失禁的慢性尿潴留提示腎臟風(fēng)險(xiǎn)時(shí)必須進(jìn)行影像學(xué)檢查。該病的治療方案應(yīng)該根據(jù)尿動(dòng)力評(píng)估結(jié)果制定，其目的保持膀胱低壓儲(chǔ)尿和膀胱排空尿液，以起到保護(hù)上尿路和獲得排尿控制。并非所有患兒都需要早期清潔間歇導(dǎo)尿和抗膽堿藥物治療，對(duì)一些逼尿肌-括約肌協(xié)同失調(diào)或括約肌功能不全但是能夠有效地排空膀胱的患兒應(yīng)密切觀察，膀胱排空困難的應(yīng)給以清潔間歇導(dǎo)尿術(shù)�？鼓憠A藥物對(duì)膀胱過(guò)度活動(dòng)或膀胱逼尿肌-括約肌協(xié)同失調(diào)的患兒效果較為滿(mǎn)意，其能夠有效增加膀胱出現(xiàn)無(wú)抑制性收縮前的容量，減少無(wú)抑制性收縮的次數(shù)，從而使膀胱總?cè)萘吭黾�。保守治療效果欠滿(mǎn)意的，膀胱容量較小，順應(yīng)性差的患兒應(yīng)選擇膀胱擴(kuò)大術(shù)，本研究選擇回腸去粘膜漿肌層補(bǔ)片膀胱擴(kuò)大術(shù)聯(lián)合術(shù)后膀胱功能訓(xùn)練，其目的建立一個(gè)充足容量的壓力較低的膀胱，并對(duì)術(shù)后患兒進(jìn)行遠(yuǎn)期隨訪調(diào)查，任何病例成功的治療都是多種因素綜合影響的結(jié)果，而不能單純認(rèn)為選擇好的外科手術(shù)治療就能達(dá)到很好的效果，術(shù)后患兒膀胱的康復(fù)功能訓(xùn)練也有不可缺少的關(guān)鍵因素。 方法 2008年7月-2013年6月5年間我院收治的神經(jīng)原性大小便失禁患兒手術(shù)病例75例，完整隨訪病人61例，男36例，女25例，，年齡6歲-23歲，平均年齡（10±0.5）歲。以脊髓脊膜膨出術(shù)后不自主遺尿?yàn)榕R床癥狀的患兒40例，夜間尿床患兒15例，大小便控制不住為臨床表現(xiàn)的患兒6例，椎管發(fā)育不良脂肪瘤術(shù)后1例。術(shù)前均行尿動(dòng)力、膀胱造影、腰骶椎DR、IVP、超聲、腎功能等術(shù)前檢查，膀胱造影提示：膀胱形態(tài)似“寶塔征、小袋狀膀胱或圣誕樹(shù)征”，并雙側(cè)輸尿管膀胱返流病例11例，膀胱頸口低于雙側(cè)閉孔連線(xiàn)上緣，說(shuō)明盆底肌松弛此類(lèi)病人有6例。尿動(dòng)力均提示：排尿期未見(jiàn)逼尿肌主動(dòng)收縮，小容量膀胱，膀胱順應(yīng)性差，少數(shù)有尿道壓力降低，逼尿肌-內(nèi)括約肌協(xié)同失調(diào)等改變。其中行回腸去粘膜漿肌層補(bǔ)片膀胱擴(kuò)大術(shù)術(shù)式42例，盆底肌松弛的行盆底肌加強(qiáng)的病例6例，尿動(dòng)力提示尿道壓力較低的真性壓力性尿失禁的患兒行錐狀肌膀胱頸懸吊術(shù)13例，術(shù)后均行尿道擴(kuò)張治療，術(shù)后切口完全愈合后拔除尿管，囑患兒每月定時(shí)連續(xù)尿道擴(kuò)張治療1周，堅(jiān)持3-6月，訓(xùn)練收縮肛門(mén)，定時(shí)排尿，逐漸學(xué)會(huì)鼓肚子腹壓排尿，可用手掌適當(dāng)輕壓下腹部協(xié)助加壓排尿，定時(shí)排大便，排尿間歇期可逐漸延長(zhǎng)憋尿時(shí)間，避免長(zhǎng)時(shí)間憋尿?qū)е掳螂灼屏选Ｐg(shù)后電話(huà)、復(fù)診、調(diào)查問(wèn)卷等形式隨訪3月-5年復(fù)查尿動(dòng)力、膀胱造影、超聲、尿常規(guī)等了解膀胱恢復(fù)情況。統(tǒng)計(jì)學(xué)分析采用配對(duì)資料比較的t檢驗(yàn)，P〈0.05差異有統(tǒng)計(jì)學(xué)意義。 結(jié)果 61例術(shù)后患兒堅(jiān)持?jǐn)U尿道及膀胱功能訓(xùn)練，術(shù)后完整隨訪患兒3月-5年顯示均為腹壓輔助排尿，術(shù)前排尿無(wú)感覺(jué)的患兒35例，術(shù)后有尿意或腹部、臍周疼痛不適提示有排尿感覺(jué)的占32例（91%），排尿癥狀較前明顯改善56例，占91.8%，術(shù)前夜間遺尿的患兒15例均較前好轉(zhuǎn)，偶有夜間遺尿現(xiàn)象，排尿控制時(shí)間55例大于2小時(shí)，1例小于1小時(shí)較術(shù)前改善不明顯，術(shù)前雙側(cè)輸尿管返流的11例患兒均較前減輕或消失，術(shù)后4例發(fā)現(xiàn)膀胱破裂漏尿的，返院行留置尿管后均能愈合，尿動(dòng)力學(xué)數(shù)據(jù)顯示術(shù)前膀胱容量（121.00±25.65）ml術(shù)后（236.45±30.50）ml，術(shù)前最大尿流率（3.18.±1.35）ml/s，術(shù)后（6.20±2.65）ml/s，術(shù)前膀胱順應(yīng)性（3.20±1.65）ml/cmH2O,術(shù)后（8.18±2.49）ml/cmH2O（1cmH2O＝0.098kpa）逼尿肌壓力術(shù)前為（0.42±0.09）cmH2O術(shù)后（0.20±0.08）cmH2O，P＜0.01。術(shù)后腎功能均正常，長(zhǎng)期并發(fā)癥15例反復(fù)泌尿系感染。 結(jié)論 （回腸去粘膜漿肌層帶血管蒂補(bǔ)片膀胱擴(kuò)大術(shù)、盆底肌加強(qiáng)術(shù)、錐狀肌膀胱頸懸吊術(shù)）聯(lián)合術(shù)后尿道擴(kuò)張，膀胱功能及盆底肌加強(qiáng)功能訓(xùn)練能有效治療神經(jīng)原性大小便失禁。
[Abstract]:Background and purpose
Neurogenic bladder dysfunction (neuropathic bladder dysfunction, NBD) is an obstacle to the function of the bladder or urethral sphincter in any center, peripheral neuropathy and damage. Neurogenic incontinence is the main clinical symptom. Most neurogenic bladder dysfunction in children is congenital spina bifida or abnormality of sacral development. Caudal lesions, sacral medullary lesions, sacral medullary lesions, peripheral autonomic neuropathy and muscular lesions, sacral dysplasia usually includes 2 or more congenital complete or partial loss of vertebral body, rarely acquired on the day later, or for meningitis, cerebral palsy, nerve system tumor, central or peripheral nerve injury, traumatic spinal cord injury, and pelvic injury. The severe complications of the disease, namely, incontinence and upper urinary tract damage,.NBD are mainly low compliance bladder or detrusor sphincter co disorder, or chronic urinary retention accompanied by urinary incontinence, which can prevent urine from the kidney from the uretero bladder junction to the circulation of the bladder, causing the kidney to cause the kidney. Hydronephrosis, long-term impairment of function. Renal necrosis in urinary bladder high pressure retention has been confirmed by McGuire and other children with a lot of bone marrow dysplasia (myelodysplastic). It indicates that the pressure of detrusor leak point "g40cmH2O will cause damage to the function of the upper urinary tract. The child's lower urinary dysfunction may be a recessive spina bifida Most cases show deformities of the sacrococcygeal, foot, and lower extremities (such as hair bundle sign, skin hemangioma, limp, single foot or bipedal high foot arch, dimple sign, subcutaneous lipoma, etc.). The above malformation may be mild in some cases, but serious consideration of the analysis of the sacrococcygeal lateral tablets can identify the spinal deformities associated with abnormal nervous system. The degree of recessive spina bifida is of different significance. The unfusion of fourth, fifth vertebral lamina is usually not very serious. If the spinal canal dilation is likely to cause spinal cord injury (tethered cord syndrome, longitudinal spina bifida), the main clinical manifestations are abnormality of the defecation, urgency of urine, frequency of urine, urinary incontinence, and daytime wetting pants at night bed wetting, Some children have difficulty in urination, difficulty, weakness of urine, turbid urine, repeated fever, abnormality of walking, or disturbance of limb activity. The current diagnosis of the disease is imaging and urodynamic (imaging urodynamics) examination as the gold standard for assessing lower urinary tract dysfunction, by vesical urethrography or ultrasound. In clinical practice, imaging, and neurophysiology, the central nervous system imaging can be considered when suspected of disease. PET functional neuroimaging will provide a new diagnostic method for the central nervous functional anatomy related to normal function of bladder and urethra and abnormal function. Neuroimaging can make up for the evaluation of bladder work in clinical nerve plane. The difference between abnormal types, ultrasound and MRU's upper urinary tract imaging, is recommended as the most basic and commonly used follow-up examination in neurogenic lower urinary tract dysfunction. Low compliance with bladder and chronic urinary retention associated with or without urinary incontinence suggest an imaging examination of renal risk. The treatment regimen of the disease should be based on The results of urodynamic assessment are designed to maintain urinary bladder pressure and bladder emptying in order to protect the upper urinary tract and obtain urination control. Not all children need early clean intermittent catheterization and anticholinergic treatment, and some detrusor sphincter dysfunction or sphincter dysfunction can be effectively emptied of the bladder. Children with cystine should be closely observed. Clean intermittent catheterization should be given to the difficulty of bladder emptying. Anticholinergic drugs are more satisfactory for children with overactivity of bladder or detrusor and sphincter dyssynergetic disorders, which can effectively increase the capacity of the bladder without inhibition before contraction and reduce the number of non inhibitory contraction. The total volume increased. The conservative treatment was less satisfactory, the bladder capacity was small, and the children with poor compliance should choose bladder enlargement. This study chose the ileum mucous membrane myometrium patch bladder enlargement combined with bladder function training. The purpose of this study was to establish a sufficient volume of bladder with low pressure, and to follow up the long-term follow-up of the postoperative children. Investigation, the successful treatment of any case is the result of a variety of factors, but it can not be considered a good surgical treatment to achieve a good effect. The rehabilitation function training of the bladder in children after operation is also essential key factors.
Method
In July 2008 -2013 June -2013, 75 cases of neurogenic and incontinence incontinence were treated in our hospital in 5 years. The patients were followed up with 61 cases, 36 men, 25 women, 6 years old and the average age (10 + 0.5) years. There were 40 patients with clinical symptoms after spinal meningeal swelling, 15 cases of nocturnal bed wetting. 6 cases of clinical manifestation and 1 cases of spinal dysplasia lipoma were performed before operation. Preoperative examination of urodynamics, cystography, DR, IVP, ultrasound, renal function and cystography showed that the bladder shape was like "pagoda sign, small bag like bladder or Christmas tree", 11 cases of bilateral ureteral bladder reflux, and lower bladder neck mouth than bilateral The upper margin of the obturator line showed that there were 6 cases of pelvic floor muscle relaxation. The urinary power showed that there was no active contraction of detrusor muscle, small volume of bladder, poor bladder compliance, a few urethral pressure, detrusor internal sphincter coordination disorder, and 42 cases of bladder enlargement of ileum mucous membrane musculocutaneous patch, pelvic floor. 6 cases of muscular relaxation of the pelvic floor muscle, 13 cases of the children with low pressure urinary incontinence with the lower urethral pressure incontinence of the true stress urinary incontinence, the urethral dilatation treatment was performed after the operation. After the operation, the urethral catheter was removed after the incision was completely healed, and the children were advised to extend the urethral dilatation for 1 weeks on a monthly regular basis, and persisted for 3-6 months and trained the constriction of the anus. The door, regularly urinating, gradually learning to urinate with abdominal pressure and abdominal pressure, can use the palm of the palm to press the abdomen to assist pressure urination, regular excretion of stool, the interval of urination can gradually extend the time of urination, avoid long urination, and avoid bladder rupture. Postoperative telephone, review, questionnaire, and other forms are followed up for -5 years in March to review urine power, bladder contrast, ultrasound, urine. Routine understanding of bladder recovery. Statistical analysis using paired data comparison t test, P < 0.05 difference was statistically significant.
Result
61 cases of postoperative children adhere to the urethra and bladder function training, after the complete follow-up of children in March -5 year showed that abdominal pressure assisted urination, 35 cases of no sense of urination before operation, after the operation, there were urine or abdomen, pain discomfort of the umbilical cord in 32 cases (91%), urinary symptoms were significantly improved 56 cases, 91.8%, nocturnal enuresis. 15 cases of children were all better than before, occasionally nocturnal enuresis, 55 cases of urination control more than 2 hours, 1 cases less than 1 hours less than 1 hours before the operation, 11 cases of bilateral ureteral reflux were less than before and disappeared, 4 cases of urinary bladder rupture after the operation, back hospital after indwelling catheter can heal, urodynamic data show The preoperative bladder capacity (121 + 25.65) ml (236.45 + 30.50) ml, preoperative maximum urinary flow rate (3.18. + 1.35) ml/s, postoperative (6.20 + 2.65) ml/s, preoperative bladder compliance (3.20 + 1.65) ml/cmH2O, postoperative (8.18 + 2.49) ml/cmH2O (1cmH2O = 0.098kpa) before operation (0.42 + 0.09) cmH2O (0.42 + 0.09) cmH2O, P < postoperative renal function All cases were normal, 15 cases had long-term complications and recurrent urinary tract infection.
conclusion
The bladder enlargement of the ileocecular muscularis muscular layer with vascular pedicle patch, the reinforcement of the pelvic floor muscle, the conical muscle bladder neck suspension operation combined with the urethral dilatation after the operation, the bladder function and the pelvic floor muscle strengthening function training can effectively treat the incontinence of the neurogenic and stool.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：R694.5

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