外傷性脊髄損傷患者の泌尿器科学的研究 第5報: 下部尿路のレ線学的研究並びに薬物の影響について

Abstract

Cystouretherography was performed in 31 patients with truamatic spinal cord injury to examine and measure the bladder neck and posterior urethra. Based on the results of the measurements, morphological change of the lower urinary tracts was studied, as well as roentgenological findings in patients with vesicoureteral reflux and effect of drugs on the urinary bladder, bladder neck and posterior urethra. 1) The figures of the bladder neck observed in 31 patients were devided into 2 different types. The I-type was seen in 7 cases (included complete injuries only) and the IItype was demonstrated in 24 cases (included 12 complete and 12 incomplete injuries). 2) Local morphological changes : The dilatation of the bladder neck and descendance of the bladder basis were observed in 61.3 % and 74.2 % respectively, and the both changes were frequently seen in cases of injury of the lower spinal cord. The dilatation of the internal urethral orifice was demonstrated in 58.5 % of the patients frequently with lower spinal cord injury. In patients showing the II-type, however, 41.9 % of them showed values within Yanase's normal ranges and many of them had upper spinal cord injuries. Other partial morphological abnormalities were less frequently and less severely demonstrated. Concerning time elapsed from injury, morphological abnormalities were found to appear in relatively early stages. 3) Values of measureme n t at each part (excluding cases with I-type due to obscure internal urethral orifice) : The average values of measurement were recorded as 0.41 cm for width of the internal urethral orifice, 0.38 cm for width of the upper colliculus, 0.48 cm for width of the colliculus, 0.86 cm for width of transit between the internal urethral orifice and bladder basis, 0.51 cm for distance between the above two parts and 0.17 cm for width of the external sphincter muscles, which showed decreased dilatation. The distance of transit between the internal urethral orifice and bladder basis was longer in patients with upper cord injury, but the other measurements showed the largest value in patients with complete lower cord injury. 4) Effec t s of various drugs on the bladder, bladder neck, and posterior urethra. (I) Following a subcutaneous injection of 2.5 mg of Besacolin, reduction in inner surface area of the bladder, changes in shape of the bladder, increasing dilatation of the bladder neck and posterior urethra, as well as a trend to increase in abnormal figures of the shape of each part were demonstrated. (II) Following a sub c utaneous injection of 0.5 ml of 0.1 % Atropin, dilatations of the bladder neck and posterior urethra were either decreased or increased. (III) Following a subcutaneous injection of 0.5 ml of 0.1 % Epirenamin, dilatations of the bladder neck and posterior urethra were disappeared or decreased. (IV) No noticeable change was observed following a s u bcutaneous injection of 5 ml of 0.5 % Wintermin. (V) B efore and after the injection of such drugs, width of the internal urethral orifice and width and distance of the transit between the internal urethral orifice and bladder basis were measured. The values of the internal urethral orifice increased with Besacolin and Atropin and decreased with Epirenamin. The width of the transit between the internal urethral orifice and bladder basis increased with Besacolin and Wintermin, but decreased with Epirenamin. No drug effect was observed on the distance of the transit between the above two parts. 5) Refl u x was observed in 22.6 % of the cases without any difference in frequency regarding side and part of the cord affected. Concerning the relationship between reflux and bladder volume, reflux was most frequently demonstrated on cystogram when the bladder volume was found to be around 100 ml. A half of the cases showed increased reflux on miction effort, urination or photography. 6) Reflux in patients with spinal cord injury disappeared on cystogram following a subcutaneous injection of 2.5 mg Basacolin up to certain bladder volume. However, many such cases showed reappearance of reflux on increased bladder volume, miction effort or motion of urination. 7) On cystogram, reflux disappeared following a subcutaneous injection of 0.5 ml 0.5 % Atropin, but it reappeared with increased bladder volume. Conversely, some cases demonstrated reflux at small bladder volume, in which situation no reflux is usually seen before injection or after Besacolin injection.