神经源性膀胱课件.ppt

Neurogenicbladder Preface Neurogenicvoidingdysfunction neurogenicbladder neuropathicbladder neuropathicurethra Innervation Autonomic Para S2 4 pelvicn bladder detrusorcontracture Sym T11 L2 paravertebralchain hypogastricn bladder urethra detrusorrelaxation Somatic cortex S2 4 pudendaln externalsphincter Physiology 排尿 pelvicfloormusculacture externalsphincterrelax urethral Detrusorcontracture Trigone 防止VUR bladderpressure neckopen 解畢 Detrusorrelax bladderneckclose externalsphinctertone排尿途中 externalsphinctercontracture detrusorrelax Cause intracraniallesion 腦血管病變 巴金森氏症 老年痴呆症以及大腦退化等spinalcordlesions 外傷性脊髓損傷 spinalcordinjury 多發性硬化症 multiplesclerosis 以及脊髓束緊症 tetheredcord 等等peripheralneuropathy caudaequinasyndrome以及骨盆手術術後造成之骨盆神經叢受傷metabolicdisease 最常見的是糖尿病所引發之周邊神經病變 Suprasacralcordlesion detrusorhyperreflexia detrusor externalsphincterdyssynergia DESD Supra T6 autonomicdysreflexia 膀胱漲尿時 病人交感神經張力會有異常增加的現象 導致血壓上升 心跳加快 患部以上潮紅及冒汗頭痛 各種上神經元病變及下神經元病變之逼尿肌反射情形 Krane Sirokyclassification Stroke Initiallyurinaryretention detrusorhyperreflexiaandinadequatecontractility DHIC incontinence dysuriaFrontal parietallobe internalcapsule externalsphincterdysfunction dysuria Stroke Cerebralhemorrhage 85 detrusorareflexia Cerebralinfarction 10 detrusorhyperreflexia maycombinewithobstruction pseudo dyssynergia BPH Otherintracranialdiseases 巴金森氏症 detrusorhyperreflexia pseudo synnergia DHIC小腦病變 cerebellarataxia hyperreflexia DESDCerebralpalsy normalorhyperreflexiaSeniledementia hyperreflexia DHIC areflexia d dwithBPH Others Multiplesclerosis好發30 50y ofemale 80 96 60 70 detrusorhyperreflexia20 40 DESD15 40 hypocontractility DM55 60 detrusorhyperreflexia35 detrusorhyporeflexia areflexiaSym tone bladdernecktone d dwithhypocontractility Diagnosis Hx PE NEX raysofskullandspineKUBEEGCMG Management Stepbystep初期foley3 7days 膀胱攣縮 感染 穩定後CICorCISC 500ml adequateI O Cleanintermittent self catheterization尿路動力學檢查評估 when cons clear LEmotorfunctionrecover orclampfoleytotest Trocarcystostomy Medication Increasecontractibility cholinergic 例如bethanecholchloride 可選擇性地使膀胱及腸道肌肉收縮 adrenergicantagonist Decreaseoutletresistence phenoxybenzamine prazosin terazosin alfuzosin等對平滑括約肌有效 Valium baclofen dantrolenesodium等對橫紋括約肌之放鬆有幫助 BotulinumAtoxin直接注射也可麻痺括約肌 Decreasecontractibility anticholinergic 例如Propanthelinebromide oxybutyninchloride dicyclomine等 其他如imipramine verapamil等也有臨床上的價值 Increaseoutletresistence 促進交感神經的藥物 例如ephedrine等 但效果並不很確定 retention incontinence Surgery 抗逆流手術Increasesubmucosaureterlength膀胱擴大手術 Bladderaugmentation 膀胱容積小 壓力高 compliance差 leakpointpressure高 括約肌不協調 目前最常用加強膀胱頸或括約肌手術Reconstruction slingUrethralstent Conclusion d dthemechanismMostarereversible Regularfollowupbladderfunction cystometrography Treatunderlyingdisease MM PD infection Reference BurneyTL SenapatiM DesaiS ChoudharyST BadlaniGH Acutecerebrovascularaccidentandlowerurinarytractdysfunction Aprospectivecorrelationofthesiteofbraininjurywithurodynamicfinding JUrol1996 156 1748 1750 KuoHC Effectofbotulinumatoxininthetreatmentofvoidingdysfunctionduetodetrusorunderactivity Urology2003 61 550 554BlaivasJG Theneurophysiologyofmicturition Acli