肛直肠功能紊乱与慢性前列腺炎关系的研究

发布时间：2018-01-16 05:22

本文关键词：肛直肠功能紊乱与慢性前列腺炎关系的研究　出处：《第三军医大学》2015年硕士论文　论文类型：学位论文

【摘要】：背景与目的男性慢性前列腺(Chronic Prostatitis,CP)通常是发生于前列腺的慢性炎症,发病率在男性人群中极高,其临床表现尿频、尿急、尿线变细、慢性下腹腹股沟区疼痛等症状,是青壮年中非常常见的症状。美国国家卫生研究院对前列腺炎有明确定义,然而部分前列腺炎发病机制仍未明确,慢性前列腺炎发病的机制有待研究。现行的前列腺炎定义前列腺炎为急性前列腺炎,CPI、慢性前列腺炎CPII、慢性非炎症性前列腺炎CPIIIa;CPIIIb、以及无症状性前列腺炎CPIV。而慢性非炎症性前列腺炎CPIIIb不仅有下尿路症状,同时也有伴发慢性盆底疼痛综合征,勃起功能障碍等其他病症;然而这种前列腺炎却缺乏实验室诊断依据,因此慢性非炎症性前列腺炎CPIIIb的诊断与治疗颇为棘手。大量临床病例表明慢性前列腺炎的产生往往不一定伴随前列腺的感染与炎症刺激,甚至与前列腺以及膀胱出口梗阻无关。过去15年大量的研究针对慢性前列腺炎CPIIIb,不仅仅因为前列腺炎引发的下尿路症状极为常见,诊断与治疗困难。由于前列腺炎的诊断治疗较为复杂,对前列腺炎致病机制的研究探讨从未停止过。事实上除外炎症与感染,自体免疫、其他原因导致的排尿功能紊乱、以及慢性系统炎症引发的神经、精神紊乱都认为与慢性前列腺炎的发病发作有关,同时有观点认为盆底肌痉挛被认为是与引发慢性前列腺炎CPIIIb盆底疼痛的重要因素。盆底肌痉挛是以盆底骨骼肌痉挛性病变引发的过度应激的会阴部,盆底肌筋膜疼痛。而尿道外括约肌作为盆底肌骨骼肌的重要组成部分,其肌张力改变会引起慢性前列腺CP同样的下尿路症状;同时盆底肌痉挛引起的肌肉筋膜痛被发现与前列腺炎CP引发的慢性疼痛范围与程度并无差异。而盆底疼痛与发生于前列腺中的感染与炎症并无关联,伴随盆底疼痛的诊断慢性前列腺炎通常在治疗之后1年症状有加重趋势。但是盆底肌张力改变与下尿路症状相互致病关系并不明确。同时,伴随慢性盆底疼痛综合症的并发症涉及多个系统引发非常广泛的症状,从焦虑,紧张状态到慢性疲劳综合症。下消化道症状与下尿道症状的共同发作日益引起关注;有报道指出肠易激综合征等便秘、排便不尽与慢性非炎症性前列腺炎的发生发作呈正性相关。因此我们通过采用排粪造影检查观察诊断有慢性非炎症性前列腺炎患者的直肛功能形态,评价患者盆底功能。希望对慢性非炎症性前列腺炎的诊治疗提供新的思路。方法第一部分:调查门诊因尿频、尿急等下尿路症状为主就诊患者,诊断为慢性前列腺炎的患者。对其进行ipss评分、泌尿b超、前列腺液化验、排粪造影。第二部分:调查门诊因尿频、尿急等下尿路症状就诊诊断为前列腺炎iiib的患者对比无症状正常人群行ipss评分,泌尿b超,排粪造影,iiib型前列腺炎患者行尿动力学检查,对比前列腺iiib患者与无症状患者直肛异常,并用各期直肛指标与最大尿流率时逼尿肌压、初始尿意膀胱容量作相关性分析。第三部分:选择门诊因尿频、尿急等下尿路症状就诊诊断为前列腺iiib的患者合并排粪造影诊断耻骨直肠肌痉挛分组两组,一组给予坦索罗辛0.2mg/qd,一组给予坦索罗辛0.2mg/qd合并cox2抑制剂塞来昔布2mg/bid。结果1.泌尿外科门诊就诊以下尿路症状、盆底疼痛不适、性生活质量下降诊断为慢性前列腺炎的患者经排粪造影检查发现极高的直肠粘膜脱垂、耻骨直肠肌痉挛等直肠肛门形态征象改变;直肠肛门形态改变与患者前列腺炎分型,前列腺炎症状分级无明显关系。2.前列腺炎iiib组排粪造影直肛形态比较无症状组人群,前者直肠肛门角、会阴水平在排便期以及两者活动度水平均比后者小,前列腺炎iiib组患者最大尿流率时逼尿肌压与排便期直肛角大小呈负强相关,静息期会阴水平呈正强相关;初始尿意膀胱容量逼尿肌压与排便期会阴水呈正强相关、会阴移动度较强负相关。3.合并耻骨直肠肌痉挛的前列腺炎iiib的男性患者,采用坦索罗辛联合塞来昔布治疗缓解患者耻骨直肠肌痉挛,联合用药患者ipss评分,以及尿频、尿急、疼痛以及生活指数qol疗效评价均比单用坦索罗辛症状改善明显。结论:1、以直肠粘膜脱垂以及耻骨直肠肌痉挛为主要表现的直肛异常在慢性前列腺炎中发病率非常高。各直肛异常诊断在不同前列腺炎分类,不同症状程度中的发病率无明显差异;但伴随直肠粘膜脱垂以及耻骨直肠肌痉挛的患者主要以尿频、尿急等下尿路症状为主,其可能是导致男性下尿路症状(luts)的独立致病因素。。2.男性慢性前列腺iiib患者的下尿路症状的发生发展与盆底肌张力改变以及盆底功能紊乱的病理改变有相关,耻骨直肠肌痉挛导致盆底肌张力增高促使膀胱出口阻力增加,同时膀胱本体感觉过敏产生尿频、尿急症状。3.耻骨直肠肌痉挛可能是前列腺炎IIIb发生临床症状的重要原因。而塞来昔布这类COX-2抑制剂即可通过改善外周血COX-2水平来改善耻骨直肠肌痉挛的程度缓解患者的精神紧张因素等作用,以缓解患者的临床症状,提高生活质量。
[Abstract]:Background and objective: male chronic prostatitis (Chronic Prostatitis CP) is a chronic inflammation of prostate usually occurs in the high incidence in the male population, the clinical manifestation of frequent micturition, urgency of urination, urine thinning, chronic abdominal pain in the groin area and other symptoms, young adults are quite common in the United States National Institutes of health symptoms. There is a clear definition of prostatitis, but not part of the pathogenesis of prostatitis research needs to be clear, the pathogenesis of chronic prostatitis. The prostatitis prostatitis definition for acute prostatitis, chronic prostatitis CPI, CPII, CPIIIa of chronic non inflammatory prostatitis; CPIIIb, and CPIV. and CPIIIb chronic prostatitis symptom of non inflammatory prostatitis is not only under the urinary tract symptoms, but also associated with chronic pelvic pain syndrome, erectile dysfunction and other symptoms; however this is prostatitis The lack of laboratory diagnosis, the diagnosis and treatment of CPIIIb chronic non inflammatory prostatitis is quite difficult. A large number of clinical cases showed that chronic prostatitis often is not necessarily accompanied by infection and inflammation of the prostate stimulation, even has nothing to do with the prostate and bladder outlet obstruction. A large number of studies over the past 15 years for chronic prostatitis CPIIIb, not only because of lower urinary tract symptoms cause prostatitis is very common. Diagnosis and treatment difficult. Due to the diagnosis and treatment of prostatitis is more complex, research on the pathogenesis of prostatitis never stop. In fact except inflammation and infection, autoimmune disorders, urinary function and other causes of chronic inflammation, nerve system caused by mental disorders are considered and the incidence of the onset of chronic prostatitis, but with a view of pelvic floor muscle spasm and is considered to be caused An important factor in chronic prostatitis CPIIIb pelvic pain. Pelvic floor muscle spasm is excessive stress in pelvic floor muscle spasticity lesions caused by the perineum, pelvic floor myofascial pain. And external urethral sphincter as an important part of the skeletal muscle of the pelvic floor muscles, the muscle tension change can cause chronic prostate CP also lower urinary tract symptoms; the muscle fascia pain and pelvic floor muscle spasm caused by chronic pain was found no difference between the scope and degree of CP. While the cause of prostatitis and pelvic pain occurs in the prostate infection and inflammation is not associated with pelvic pain, chronic pain in the treatment of prostatitis diagnosis is usually 1 years after symptoms have aggravated. But with the change of pelvic floor muscle tension lower urinary tract symptoms are pathogenic relationship is not clear. At the same time, with chronic pelvic pain syndrome complications involving multiple systems caused very extensive disease From the shape, anxiety, tension to chronic fatigue syndrome. Lower gastrointestinal symptoms and lower urinary tract symptoms of the common attack has attracted more and more attention; there have been reports of irritable bowel syndrome and constipation, defecation not with chronic non inflammatory prostatitis episode of positive correlation. So we adopted defecography to observe diagnosis anorectal function and morphology in patients with chronic non inflammatory prostatitis, evaluation of patients with pelvic floor function. Hope to provide new ideas for the diagnosis and treatment of chronic non inflammatory prostatitis. Methods the first part: the investigation of outpatient visits for frequent urination, urine and other emergency lower urinary tract symptoms from patients diagnosed as chronic prostatitis patients. IPSS scores of the urinary B Ultrasound, prostatic fluid test, defecography. The second part: investigation of outpatient visits for frequent urination, urgency and other symptoms of lower urinary tract diagnosed between asymptomatic prostatitis patients IIIB The shape of the normal population IPSS score, urinary B Ultrasound, defecography, III type prostatitis patients underwent urodynamic study, comparing prostate IIIB patients and asymptomatic patients with anorectal anomalies, and the anorectal index and maximum urinary flow rate when the detrusor pressure, the relationship between the initial urinary bladder capacity. The third part: the choice for outpatient frequent micturition, urgency and other symptoms of lower urinary tract diagnosed prostate IIIB patients combined with defecography in diagnosis of puborectalis muscle spasm were divided into two groups, one group received tamsulosin 0.2mg/qd group received tamsulosin combined with 0.2mg/qd COX2 Inhibitor Celecoxib 2mg/bid. results in 1. outpatient department of Urology following urinary tract symptoms, pelvic pain and discomfort, sexual life the decline in the quality of diagnosis for patients with chronic prostatitis after defecography found rectal mucosa prolapse high, puborectalis muscle spasm and other anorectal morphological signs change Change; anorectal changes and prostatitis type, prostatitis symptom classification had no obvious relationship between.2. prostatitis group IIIB defecography anorectal asymptomatic morphological comparison groups, the former anorectal angle, the level in the period of defecation and both perineal activity levels were smaller than the latter, prostatitis patients in the IIIB group and detrusor pressure at maximum urinary flow rate anorectal angle during defecation was negatively related to the level of strong, positive perineal resting strong correlation; initial urinary bladder capacity and detrusor pressure and defecation period of perineum Cheng Zhengqiang, male patients with perineal mobility strong negative correlation of.3. with puborectal muscle spasm of prostatitis IIIB, remission patients with puborectalis muscle spasm with tamsulosin combined with celecoxib, combined treatment of patients with IPSS score, and frequent urination, urgency, pain and life evaluation index QOL effects were compared with the single use of tamsulosin. The shape was improved significantly. Conclusion: 1, straight to the anal prolapse of rectal mucosa and puborectalis muscle spasm were abnormal in chronic prostatitis incidence rate is very high. The anorectal anomaly diagnosis classification in different degree in different symptoms of prostatitis, the incidence rate showed no significant difference; but with the prolapse of rectal mucosa and patients with puborectalis spasm mainly by frequent urination, urgency and other lower urinary tract symptoms, which may be the cause of male lower urinary tract symptoms (LUTS) and the development of pelvic floor muscle tension changes and pathological changes of pelvic floor disorders had lower urinary tract symptoms of independent risk factors in male patients with..2. related chronic prostate IIIB, puborectalis muscle spasm to increase muscle tension increased bladder outlet resistance and bladder body hypersensitivity produced frequent micturition, urgency symptoms.3. puborectal muscle spasm may be prostatitis IIIb It is an important reason for clinical symptoms. Celecoxib COX-2 inhibitors can improve the level of pubis and rectum muscle spasm by alleviating the COX-2 level of peripheral blood, relieve the patients' mental stress factors and so on, so as to relieve their clinical symptoms and improve their quality of life.

【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R697.33

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