慢性脊髓損傷病人排尿障礙之泌尿科處置

The Urological Management of Voiding Dysfunction in Chronic Spinal Cord Injury

郭漢崇(Hann-Chorng Kuo)

《中華民國復健醫學會雜誌》 28卷4期 (2000/12) Pp. 195-211

摘要

慢性脊髓損傷會造成各種不同的的膀胱及尿道功能失常，這些脊髓損傷後的神經學變化，會導致病人產生各種不同的泌尿系統症狀及併發症。上尿路功能惡化與尿道漏尿壓力及膀胱內狀況有相當密切的關係。持續性的高膀胱內壓(超過40-50cmH2O)對於脊髓損傷病人的尿液逆流是一危險的跡象，使得脊髓損傷病人產生反覆性尿路感染、上尿路擴張，及最後造成末期腎衰竭。過去的研究顯示，積極的泌尿科處置可以減少脊髓損傷病人因為尿路感染所造成的死亡率，並且可以提供他們較好的生活品質。當我們在處理脊髓損傷病人的泌尿系統後遺症時，應該要考慮以下幾個重要因素，包括：維持或保護正常的腎功能、使病人免於尿路感染、免於長期留置導尿管、及盡可能維持尿不失禁。此外，病人能夠自我處理排尿的方便性以及其家庭照顧的方便與否，都是列入考慮的因素。對於脊髓損傷病人來說，膀胱處置的最終目標是在於達成一個能夠充分排空膀胱、維持一個低壓力之尿儲存、及排尿時較低膀胱內壓的狀況。這些情況可以避免病人尿路感染、膀胱壁受損、膀胱過度漲尿、膀胱輸尿管尿液逆流及形成尿路結石等問題。如果病人手部功能正常，可以教導他間歇性自行導尿。如果病人仍有腎臟水腫或反覆的尿路感染，則可以考慮使用手術的介入性治療，來增加病人的膀胱容量、減少膀胱內壓、或降低膀胱出口阻力。手術的處置包括膀胱擴大術、禁尿性尿改流，禁尿性膀胱造廔，及尿道外括約肌切開術等，也可以使用尿道周圍注射法來治療尿道括約肌缺損的病人，或對女性病人給予恥骨陰道吊帶來治療其無功能性尿道，也可考慮植入人工尿道括約肌以解決其尿失禁的問題。給予病人積極的泌尿系統處置來解決其排尿症狀，同時要充分考慮到所提高的生活品質與病人自我處理能力及家庭支持方便性的平衡。

關鍵字

脊髓損傷 ； 泌尿系統處置 ； 手術

並列摘要

Chronic spinal cord injury (SCI) results in various dysfunctions of the urinary bladder and urethra. These neurological deteriorations after SCI cause varying urological symptoms and complications. Early detection of high risk SCI patients is important. Regular determination of intravesical pressure, residual urine and leak point pressure can provide information to avoid upper tract deterioration. Agg-ressive urological management can reduce the mortality rate from urinary tract infection (UTI) and a better quality of life can thus ensue. In the management of urological sequalae of SCI, preservation of renal function, freedom from UTI, freedom from indwelling catheter, and continence should be the aims. The primary goal of bladder management in the patient with SCI is to achieve adequate bladder drainage, low-pressure urine storage, and low-pressure voiding. This will help prevent UTI, bladder wall damage, bladder overdistention, vesicoureteral reflux, and stone disease. An intravesical pressure of less than 40 cmH2O is essential for this goal. If hydronephrosis or recurrent UTI persists, surgical int-ervention is indicated in order to increase bladder capacity, decrease intravesical pressure, or decr-ease bladder outlet resistance. The surgical procedures include cystostomy, bladder augmentation, continent urinary diversion (Kock pouch or hemi-Kock with continent cystostomy), ureteral reimplan-tation, and external sphincterotomy. External sphincterotomy has proven to be successfully in treating recurrent UTI and intractable autonomic dysreflexia or detrusor external sphincter dyssynergia in most patients. Enterocystoplasty and continent urinary diversion have been documented to have several advantages: (1) increasing in bladder capacity; (2) decreasing in intravesical pressure; (3) regaining urinary continence, and (4) regaining bladder full sensation. Study shows that more than 80% of the patients with SCI were satisfied with active urological management. Since urinary dysfunction remains the most important issue in the quality of life of chronic SCI patients apart from physical movement, a more aggressive attitude in urinary management following SCI is necessary in order to improve their quality of life.

並列關鍵字

spinal cord injury ； urological management ； surgery