神经原性尿失禁的外科治疗功能训练及随访调查

发布时间：2018-06-24 03:36

本文选题：神经原性膀胱 + 尿流动力学　；参考：《郑州大学》2014年硕士论文

【摘要】：背景和目的神经原性膀胱功能障碍（neuropathic bladder dysfunction,NBD）是指任何中枢、周围神经病变及损害导致膀胱或者尿道括约肌功能的障碍。神经原性大小便失禁是其主要临床症状，小儿神经原性膀胱功能障碍大多是先天性脊柱裂或骶骨发育异常所致，分骶髓病变、骶髓上病变、骶髓下病变、周围自主神经病变和肌肉病变，骶骨发育不全通常包括2个或者多个椎体先天性完全或部分缺失，很少为后天获得的，或因脑膜炎、脑瘫、神经系统肿瘤、中枢或周围神经损伤、外伤致脊髓损伤、盆腔手术神经损伤等所致。该病很严重的并发症即是大小便失禁和上尿路损害。NBD主要是低顺应性膀胱或者逼尿肌-括约肌协同性失调，或伴有尿失禁的慢性尿潴留，可以阻碍尿液自肾脏从输尿管膀胱结合部到膀胱的流通，从而引起肾脏积水，长期致功能损害。膀胱高压潴留尿导致肾脏坏死已经被McGuire等通过对好多骨髓发育不良（myelodysplastic）的儿童研究已证实，表明逼尿肌漏尿点压力"g40cmH2O就会对上尿路的功能造成损害。儿童下尿路功能障碍可能是隐性脊柱裂的表现，大多数病例显示，骶尾部、足部、下肢的畸形（如毛束征、皮肤血管瘤、跛行、单足或双足高足弓、酒窝征、皮下脂肪瘤等）。以上畸形在有些病例中或许很轻微，但认真考虑分析骶尾部正侧位片能识别出与神经系统异常有关的脊柱畸形。不同程度的隐性脊柱裂具有不同的意义，单纯第四、五椎板未融合通常不是很严重，如果椎管明显扩张很有可能会导致脊髓的损伤（脊髓栓系综合征、纵形脊柱裂）该病主要临床表现为：排便异常，尿急、尿频、尿失禁，白天尿湿裤子夜晚尿床，也有部分患儿因排尿困难、费力、尿线无力、尿液浑浊，反复发热，走路异常或者肢体活动障碍等。目前诊断该病的临床检查是行影像和尿流动力学（影像尿动力学）检查是评估下尿路功能障碍的金标准，通过膀胱尿道造影或者超声进行形态学检查，在临床实践、影像、神经生理检查怀疑有疾病时，可考虑进行中枢神经系统成像，PET功能性神经成像将对膀胱尿道正常功能和异常功能相关的中枢神经功能解剖提供一个新的诊断方法，神经成像能弥补临床神经平面评估膀胱功能异常类型之间的差别，超声及MRU的上尿路影像学，在神经原性下尿路功能障碍中被推荐为最基本和常用的随访检查。膀胱低顺应性和伴有或不伴有尿失禁的慢性尿潴留提示肾脏风险时必须进行影像学检查。该病的治疗方案应该根据尿动力评估结果制定，其目的保持膀胱低压储尿和膀胱排空尿液，以起到保护上尿路和获得排尿控制。并非所有患儿都需要早期清洁间歇导尿和抗胆碱药物治疗，对一些逼尿肌-括约肌协同失调或括约肌功能不全但是能够有效地排空膀胱的患儿应密切观察，膀胱排空困难的应给以清洁间歇导尿术。抗胆碱药物对膀胱过度活动或膀胱逼尿肌-括约肌协同失调的患儿效果较为满意，其能够有效增加膀胱出现无抑制性收缩前的容量，减少无抑制性收缩的次数，从而使膀胱总容量增加。保守治疗效果欠满意的，膀胱容量较小，顺应性差的患儿应选择膀胱扩大术，本研究选择回肠去粘膜浆肌层补片膀胱扩大术联合术后膀胱功能训练，其目的建立一个充足容量的压力较低的膀胱，并对术后患儿进行远期随访调查，任何病例成功的治疗都是多种因素综合影响的结果，而不能单纯认为选择好的外科手术治疗就能达到很好的效果，术后患儿膀胱的康复功能训练也有不可缺少的关键因素。方法 2008年7月-2013年6月5年间我院收治的神经原性大小便失禁患儿手术病例75例，完整随访病人61例，男36例，女25例，，年龄6岁-23岁，平均年龄（10±0.5）岁。以脊髓脊膜膨出术后不自主遗尿为临床症状的患儿40例，夜间尿床患儿15例，大小便控制不住为临床表现的患儿6例，椎管发育不良脂肪瘤术后1例。术前均行尿动力、膀胱造影、腰骶椎DR、IVP、超声、肾功能等术前检查，膀胱造影提示：膀胱形态似“宝塔征、小袋状膀胱或圣诞树征”，并双侧输尿管膀胱返流病例11例，膀胱颈口低于双侧闭孔连线上缘，说明盆底肌松弛此类病人有6例。尿动力均提示：排尿期未见逼尿肌主动收缩，小容量膀胱，膀胱顺应性差，少数有尿道压力降低，逼尿肌-内括约肌协同失调等改变。其中行回肠去粘膜浆肌层补片膀胱扩大术术式42例，盆底肌松弛的行盆底肌加强的病例6例，尿动力提示尿道压力较低的真性压力性尿失禁的患儿行锥状肌膀胱颈悬吊术13例，术后均行尿道扩张治疗，术后切口完全愈合后拔除尿管，嘱患儿每月定时连续尿道扩张治疗1周，坚持3-6月，训练收缩肛门，定时排尿，逐渐学会鼓肚子腹压排尿，可用手掌适当轻压下腹部协助加压排尿，定时排大便，排尿间歇期可逐渐延长憋尿时间，避免长时间憋尿导致膀胱破裂。术后电话、复诊、调查问卷等形式随访3月-5年复查尿动力、膀胱造影、超声、尿常规等了解膀胱恢复情况。统计学分析采用配对资料比较的t检验，P〈0.05差异有统计学意义。结果 61例术后患儿坚持扩尿道及膀胱功能训练，术后完整随访患儿3月-5年显示均为腹压辅助排尿，术前排尿无感觉的患儿35例，术后有尿意或腹部、脐周疼痛不适提示有排尿感觉的占32例（91%），排尿症状较前明显改善56例，占91.8%，术前夜间遗尿的患儿15例均较前好转，偶有夜间遗尿现象，排尿控制时间55例大于2小时，1例小于1小时较术前改善不明显，术前双侧输尿管返流的11例患儿均较前减轻或消失，术后4例发现膀胱破裂漏尿的，返院行留置尿管后均能愈合，尿动力学数据显示术前膀胱容量（121.00±25.65）ml术后（236.45±30.50）ml，术前最大尿流率（3.18.±1.35）ml/s，术后（6.20±2.65）ml/s，术前膀胱顺应性（3.20±1.65）ml/cmH2O,术后（8.18±2.49）ml/cmH2O（1cmH2O＝0.098kpa）逼尿肌压力术前为（0.42±0.09）cmH2O术后（0.20±0.08）cmH2O，P＜0.01。术后肾功能均正常，长期并发症15例反复泌尿系感染。结论（回肠去粘膜浆肌层带血管蒂补片膀胱扩大术、盆底肌加强术、锥状肌膀胱颈悬吊术）联合术后尿道扩张，膀胱功能及盆底肌加强功能训练能有效治疗神经原性大小便失禁。
[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.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R694.5

【参考文献】