A型肉毒桿菌素同時注射於逼尿肌和外括約肌治療神經性膀胱功能障礙之個案報告

A Case Report of Concomitant Injection of Botulinum Toxin Type A in Detrusor and External Sphincter for Treatment of Neurogenic Bladder Dysfunction

曾聖維(Sheng-wei Zeng) ； 黃玉慧(Yu-Hui Huang)

《台灣復健醫學雜誌》 44卷3期 (2016/09) Pp. 153-160

https://doi.org/10.6315/2016.44(3)04

摘要

薦髓以上的脊髓損傷常見痙攣型神經性膀胱功能障礙，此型膀胱障礙的特色包含逼尿肌過度反射及逼尿肌-外括約肌共濟失調，目前肉毒桿菌素在膀胱的注射已是主流的治療方式之一，過去常見的注射方式有:對逼尿肌注射或對外括約肌注射。本文提出一個新的注射模式:同時使用肉毒桿菌素注射逼尿肌及外括約肌於脊髓損傷的患者上。患者接受治療前尿路動力學顯示有升高的尿道壓、逼尿肌的過度反射、膀胱內壓的升高及顯著的逼尿肌-外括約肌共濟失調，經評估後我們給予逼尿肌Botox (onabotulinumtoxinA)200 U 注射及外括約肌100 U 注射，一段時間後的追蹤發現膀胱內壓明顯的下降並見到膀胱小樑化的改善，雖然仍有逼尿肌-外括約肌共濟失調但外括約肌的肌電圖活動明顯降低。經肉毒桿菌素注射後，膀胱容量增加、自解尿量增加並有較低的餘尿量，患者在注射完3 個月後間歇性導尿次數減少，在膀胱過動症狀問卷（Overactive Bladder Symptom Score, OABSS），簡版症狀困擾量表6 (the short-form Urogenital Distress Inventory, UDI-6)及簡版生活影響量表7（the short-form Incontinence Impact Questionnaire, IIQ-7）上都有明顯生活品質的改善。

關鍵字

肉毒桿菌素(botulinum toxin) ； 神經性膀胱功能障礙(neurogenic bladder) ； 尿路動力學(urodynamics) ； 解尿困難(voiding dysfunction)

並列摘要

Patients with spinal cord injury above the sacral level usually have spastic type neurogenic bladder dysfunction (NBD). Spastic NBD is usually manifested with detrusor overactivity and detrusor-external sphincter dyssynergia (DESD). Botulinum toxin type A (BoNT-A) injection has been used in treating spastic NBD for long time. This injection can be performed either on the detrusor (which needs an intermittent catheterization program and a greater decrease in intravesicle pressure) or on the external sphincter (which may cause urinary incontinence and a smaller decrease in intravesicle pressure). Here we present a SCI patient receiving a new injection method involving BoNT-A injection simultaneously to the detrusor and external sphincter. Video urodynamics (VUD) revealed elevated urethral pressure (max P urethral: 149 cmH_2O), detrusor overactivity, increased intravesicle pressure, and obvious DESD before injection. The patient was referred to the urology clinic for BoNT-A injection 2 years and 9 months after injury. We injected Botox (onabotulinumtoxinA) 200 U over the detrusor muscle and 100 U over the external sphincter. VUD after injection showed decreased intravesicle pressure and cystogram showed decreased bladder wall trabeculation. Sphincter EMG still showed DESD but the activity decreased with lower urethral pressure. After injection, this patient had increased bladder capacity and volume of self voiding with similar residual amount. The frequency of intermittent catheterization decreased in 3 months after injection. He was satisfied with this treatment with improved scores for the Overactive Bladder Symptom Score, the short-form Urogenital Distress Inventory-6, and the short-form Incontinence Impact Questionnaire-7.

並列關鍵字

botulinum toxin ； neurogenic bladder ； urodynamics ； voiding dysfunction

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