神経因性膀胱における排尿効率改善に関する診断と治療

Abstract

In making the diagnosis of neurogenic bladder it is important to know the state of neurologic disease affecting the urinary bladder, and to perform routine neurological examinations. By using EMG of perineal muscle and cystometry, which are very useful examinations, we could predict the nerve damage of neurogenic bladder. We categorized the condition of both detrusor and sphincter by cystometory and EMG of perineal muscle into normal, hyperactive and hypoactive pattern, and in combination with the pattern of the detrusorsphincter, we established a simple diagnostic criteria for the neurogenic bladder closely related to clinical management. Most of the neurogenic bladders treated in our clinic, could be classified into 3 major patterns: hypoactive detrusor-hypoactive sphincter, hypoactive detrusor-hyperactive sphincter, and hyperactive detrusor-hyperactive sphincter. We examined EMG of perineal muscle and 2nd/4th sacral nerve activity percutaneously, and demonstrated that the 2nd and 3rd sacral nerves innervate the sphincter, and the 3rd and 4th sacral nerves innervate the detrusor. In the management of neurogenic bladder patient, because excess hyperactivity of detrusor and/or sphincter seems to be harmful in the preservation of renal function, excess activity should be lowered to an adequate level. In order to control the hyperactivity of the destusor and the sphincter, we employed pharmacotherapy first and thereafter performed TUR[BN] & TUR[P] and nerve block (sacral nerve block, pudendal nerve block and obturator nerve block). In case of hypoactive detrusor, we employed TUR[BN] & TUR[P] and voiding training. In 56 cases, we demonstrated good results with open ileal flap fixation to the bladder in order to improve voiding efficiency and reconstruction of urinary sensation. This paper, describes our method of practical diagnostic examination for neurogenic bladder and management of neurogenic bladder patients in our Hospital.