神经源性膀胱ppt课件.ppt

Neurogenic bladder Preface Neurogenic voiding dysfunction (neurogenic bladder), neuropathic bladder/neuropathic urethra Innervation Autonomic: Para.(S2~4)-pelvic n.-bladder(detrusor contracture) Sym.(T11~L2)-paravertebral chain-hypogastric n.-bladder/urethra(detrusor relaxation) Somatic: cortex-(S2~4)-pudendal n.-external sphincter Physiology 排尿：pelvic floor musculacture, external sphincter relax? urethral?Detrusor contracture?Trigone(防止VUR)?bladder pressure ?neck open? 解畢：Detrusor relax, bladder neck close, external sphincter tone 排尿途中：external sphincter contracture?detrusor relax Cause intracranial lesion：腦血管病變、巴金森氏症、老年痴呆症以及大腦退化等 spinal cord lesions：外傷性脊髓損傷(spinal cord injury)，多發性硬化症(multiple sclerosis)以及脊髓束緊症(tethered cord)等等 peripheral neuropathy：cauda equina syndrome以及骨盆手術術後造成之骨盆神經叢受傷 metabolic disease：最常見的是糖尿病所引發之周邊神經病變 Suprasacral cord lesion：detrusor hyperreflexia, detrusor-external sphincter dyssynergia (DESD) Supra-T6：autonomic dysreflexia (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 Siroky classification Stroke Initially urinary retention?detrusor hyperreflexia and inadequate contractility (DHIC)?incontinence, dysuria Frontal, parietal lobe, internal capsule?external sphincter dysfunction?dysuria Stroke Cerebral hemorrhage-85% detrusor areflexia / Cerebral infarction-10%?detrusor hyperreflexia, may combine with obstruction (pseudo-dyssynergia, BPH) Other intracranial diseases 巴金森氏症：detrusor hyperreflexia, pseudo-synnergia, DHIC 小腦病變（cerebellar ataxia)： hyperreflexia, DESD Cerebral palsy：normal or hyperreflexia Senile dementia：hyperreflexia, DHIC, areflexia ?d/d with BPH Others Multiple sclerosis 好發30~50 y/o female (80~96%) 60~70% detrusor hyperreflexia 20~40% DESD 15~40% hypocontractility DM 55~60% detrusor hyperreflexia 35% detrusor hyporeflexia, areflexia Sym. tone ??bladder neck tone ?d/d with hypocontractility Diagnosis Hx, PE, NE X-rays of skull and spine KUB EEG CMG Management Step by step 初期foley 3~7