骨盆底張力過高及其臨床評估

Clinical Assessment of Pelvic Floor Hypertonicity

郭漢崇(Hann-Chorng Kuo)

《中華民國泌尿科醫學會雜誌》 12卷1期 (2001/03) Pp. 1-8

https://doi.org/10.7024/JUAROC.200103.0001

摘要

骨盆底張力過高在神經學正常的人來說是在自行排尿時尿道外括約肌活力增強的一種現象。當尿道外括約肌放鬆不良時可以抑制逼尿肌的有力收縮，導致多種下尿路症狀，包括尿儲存的症狀（頻尿、急尿及尿失禁）以及尿排空的症狀，包括：小便細小、遲延、排尿困難及殘尿感。它也可能是造成婦女反覆性尿路感染的主要原因。骨盆底肌肉或尿道外括約肌放鬆不良的情形男性病人是相當常見的，很多研究也都指出排尿功能不良（dysfunctional voiding）是造成婦女排尿不正常之最常見原因。而使用terazosin及baclofen共同治療具有尿道外括約肌痙攣症候群的病人則可以在男性得到67.2%及女性68.5%的成功率。兒童的排尿功能不良可能會導致尿失禁，膀胱輸尿管逆流手術的必須性，而膀胱輸尿管逆流自動消失的比例也相當的高（35%），需要進行抗逆流手術的機會也降低。對於骨盆底張力過高的病人，我們第一步檢查應該進行尿流速及使用腹部超音波做殘尿量之測定。使用尿流速及骨盆底肌電圖是一種非侵襲性檢查且可以被重複使用來檢查病人的排尿功能不良。如果在排尿時有尿道外括約肌活力的增強時，排尿功能不良的診斷就可確立。使用影像尿路動力學檢查來偵測其排尿膀胱尿道攝影圖時具有一擴張的後段尿道以及一尖嘴形的遠端尿道可在許多排尿功能不良的病人被發現，此種現象即表示病人的骨盆底肌肉放鬆不良。對於排尿功能不良及急迫性尿失禁的病人，使用骨盆底肌肉運動訓練同時配合其飲食的調節以及排尿姿勢的改變可以有效治療大部份的此類患者。

關鍵字

骨盆底張力過高 ； 排尿功能不良 ； 尿道外括約肌

並列摘要

Pelvic floor hypertonicity is a condition that increases urethral sphincter activity or that shows a lack of relaxation during micturition in neurologically intact patients. Poor relaxation of the urethral sphincter can inhibit forceful contraction of the detrusor. Several lower urinary tract symptoms can develop, including urinary storage symptoms(frequency, urgency, and incontinence)and empty symptoms(small caliber of urine, hesitancy, dysuria, and residual urine sensation).This condition can also result in recurrent urinary tract infection in women. Poor relaxation of the pelvic floor or urethral sphincter is frequently found in men and women. Several studies have revealed that dysfunctional voiding is the most common condition causing dysuria in women. Treatment of a spastic urethral sphincter by terazosin and baclofen can achieve success rates of 67.2% in men and 68.5% in women. Dysfunctional voiding in children can result in urinary incontinence, vesicoureteral reflux, and recurrent urinary tract infection. Chronic spastic pelvic floor might also result in detrusor instability. Through active pelvic floor re-training, 35% of cases of vesicoureteral refiux may be resolved, and the need for anti-incontinence surgery can be decreased. Uroflowmetry and residual urine volume determination are the first steps in assessment of patients suspected to have pelvic floor hypertonicity. Combined uroflowmetry and sphincter electromyography are a reproducible and non-invasive investigation for assessing patients with dysfunctional voiding. A diagnosis of dysfunctional voiding can be established when increased sphincter activity is noted during micturition with a low flow rate. During videourodynamic study, a dilated posterior urethra and a spinning-top distal urethra can be found in patients with pelvic floor hypertonicity, indicating poor relaxtaion of the pelvic floor and urethral sphincter causing functional bladder outlet obstruction. Proper pelvic floor retraining either by pelvic floor muscle exercise or biofeedback, diet adjustment, and change of voiding posture can effectively treat most of patients with this condition.

並列關鍵字

pelvic floor hypertonicity ； dysfunctional voiding ； urethral sphincter