神經性膀胱功能障礙及上尿路併發症追蹤與治療：病例報告

Follow-up and Treatment of Neurogenic Bladder Dysfunction with Compromised Upper Urinary Tract: A Case Report

蔡素如(Su-Ju Tsai) ； 黃玉慧(Yu-Hui Huang) ； 簡郁佩(Yu-Pei Chien) ； 曾繁斐(Fan-Fei Tseng)

《台灣復健醫學雜誌》 34卷2期 (2006/06) Pp. 119-125

https://doi.org/10.6315/2006.34(2)08

摘要

脊髓損傷會導致神經性膀胱功能障礙(neurogenic bladder dysfunction，NBD)造成膀胱排尿異常，由於逼尿肌反射亢進(detrusor hyperreflexia)合併膀胱適應性降低，使得膀胱壓力上升造成尿路排泄受阻，引起上尿路併發症以及腎臟功能受損。對於慢性神經性膀胱功能障礙患者而言，定期接受泌尿系統功能的監測與追蹤，可以及時發現膀胱或上尿路功能之變化，再依據尿動力學檢查結果，調整膀胱照護策略或選擇合併藥物治療，以維護腎臟最佳機能與健康品質。
我們在此報告一名22歲女性患者，因為腰椎損傷導致雙下肢癱瘓與排尿困難，在受傷早期尿動力學檢查顯示逼尿肌與尿道括約肌無收縮反射，NBD歸類為下運動神經元類型(lower motor neuron NBD)，藉由腹壓解尿方式，可達低壓、低殘尿的平衡膀胱狀態，無需服用藥物。受傷時間日久，兩年之後逼尿肌反射轉而變成反射亢進，膀胱排尿壓力上升，且殘尿量增加，經常引起發燒及反覆性上尿路感染。兩年後患者再度接受追蹤評估，上尿路檢查發現水腎與腎功能降低，由錄影尿動力學檢查得知，逼尿肌反射亢進造成極高的排尿壓力(93 cm H2O)，膀胱適應性降低，尿道括約肌仍無收縮活動，所以此時NBD重新歸類為混合類型神經性膀胱功能障礙(mixed NBD)。因上述評估發現進而改變膀胱照護方式，每四到六小時進行定期間歇導尿以降低殘尿量，並且開始服用抗膽鹼藥物(anticholinergic agent)以降低逼尿肌收縮與膀胱壓力。治療三個月之後，泌尿系統功能追蹤發現膀胱壓力下降到正常壓力，殘尿量低於100毫升，水腎與尿路感染均緩解，腎臟排泄功能恢復至正常。繼續上述膀胱處置與治療，定期追蹤尿路功能，多年以來均能維持良好排尿狀態與尿路系統機能。希望藉此病例報告，供作臨床醫師診療及追蹤神經性膀胱功能障礙患者的參考。

關鍵字

神經性膀胱 ； 排尿障礙 ； 脊髓損傷 ； 抗膽鹼藥物治療

並列摘要

In spinal cod injury (SCI) patients with neurogenic bladder dysfunction (NBD), detrusor hyperreflexia and poor bladder compliance may lead to increased intravesical pressure and other adversities, including urinary tract infection, hydronephrosis, vesicoureteral reflux, and impairment of renal function. The primary objectives of urologic care after SCI are to provide an acceptable method for managing the lower urinary tract, to prevent urinary complications, and to preserve renal function. Because urologic status can change or deteriorate many years after the initial injury, sometimes without symptoms, lifelong urologic follow-up is fundamental for all SCI patients with NBD. Strategy of bladder management in individuals with SCI should be based on urodynamic findings.
We report a 22-year-old woman who was admitted with voiding dysfunction and paralysis of lower limbs secondary to complete SCI from a lumbar spine injury. The initial urodynamic study demonstrated a low intravesical pressure one month after injury, without contraction of detrusor or external urethral sphincter. The NBD was classified a lower motor neuron bladder type. Because Valsalva and Credé maneuvers worked well, she was able to establish a balanced bladder with a low voiding pressure and a low postvoid residual (PVR). Uninhibited detrusor contraction gradually developed two years later, which produced a high intravesical pressure and upper urinary tract damage. Renal sonography and renal scan revealed hydronephrosis and impairment of renal excretory function. The videourodynamic study demonstrated detrusor hyperreflexia with a voiding pressure of 93 cm H2O, low bladder compliance and concurrent urethral sphincter inactivity. The diagnosis of mixed type NBD was made two years postinjury. In order to achieve intravesical pressure less than 40 cm H2O and low PVR, utilization of anticholinergic therapy (tolterodine, 2 mg twice a day) and clean intermittent catheterization (CIC), every four to six hours, were performed. Three months later, the patient resumed a normal voiding pressure and a low PVR of less than 100 ml. Beyond our expectation, she had resolution of hydronephrosis and improvement of renal function after combing CIC with anticholinergic medication.

並列關鍵字

neurogenic bladder ； voiding dysfunction ； spinal cord injury ； anticholinergic therapy