盆底肌训练对神经源性逼尿肌过度活动的效果

doi:10.3969/j.issn.1006-9771.2021.09.015

摘要/Abstract

摘要：

目的观察盆底肌训练对脊髓损伤患者逼尿肌过度活动的影响。方法 2019年8月至2020年8月,本院不完全性脊髓损伤患者17例随机分为对照组(n = 8)和试验组(n = 9)。两组均口服酒石酸托特罗定片4 mg/d,共12周,试验组行盆底肌训练。治疗前后行尿动力检查,采用神经源性膀胱症状评分量表、膀胱状况感知评分量表的差异,并分析治疗效果。结果治疗后,两组各项尿动力指标和量表评分均较治疗前改善(t > 3.674, |Z| > 2.646, P < 0.05)。试验组最大膀胱容量、逼尿肌首次收缩压力容积、逼尿肌漏尿点压力、逼尿肌最大收缩压力和神经源性膀胱症状评分较对照组有改善(|t| > 2.194, P < 0.05)。结论在药物治疗的基础上行盆底肌训练可以进一步改善脊髓损伤患者逼尿肌过度活动。

关键词: 脊髓损伤, 神经源性膀胱, 逼尿肌过度活动, 盆底肌训练, 康复

Abstract:

Objective To investigate the effect of pelvic floor muscle training on detrusor overactivity in patients with spinal cord injury.Methods From August, 2019 to August, 2020, 17 patients with incomplete spinal cord injury were randomly divided into control group (n = 8) and experimental group (n = 9). Both groups accepted tolterodine tartrate 4 mg a day orally for twelve weeks, while the experimental group accepted pelvic floor muscle training. They were measured urodynamic indexes, and assessed with Neurogenic Bladder Symptom Scale and Patient Perception of Bladder Condition before and after treatment.Results All the urodynamic indexes and scores of the scales improved in both groups after treatment (t > 3.674, |Z| > 2.646, P < 0.05), while the indexes of maximum bladder volume, first contraction pressure volume of detrusor, leakage point pressure of detrusor, maximum contraction pressure of detrusor and neurogenic bladder symptom score improved more in the experimental group than in the control group (|t| > 2.194, P < 0.05).Conclusion Pelvic floor muscle training based on medicine can release the detrusor overactivity in patients with spinal cord injury.

Key words: spinal cord injury, neurogenic bladder, detrusor overactivity, pelvic floor muscle training, rehabilitation

栗亮,廖利民,吴娟,靖华芳,高轶,王越. 盆底肌训练对神经源性逼尿肌过度活动的效果[J]. 《中国康复理论与实践》, 2021, 27(9): 1093-1097.

LI Liang,LIAO Li-min,WU Juan,JING Hua-fang,GAO Yi,WANG Yue. Effect of Pelvic Floor Muscle Training on Neurogenic Detrusor Overactivity[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2021, 27(9): 1093-1097.

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参考文献 37

[1]	中国残疾人康复协会脊髓损伤康复专业委员会, 国际脊髓学会中国脊髓损伤学会, 中华医学会泌尿外科学分会尿控学组. 脊髓损伤患者泌尿系管理与临床康复指南[J]. 中国康复理论与实践, 2013, 19(4):301-317.
	Society of Spinal Cord Injury of China Association of Rehabilitation of Disabled Persons, Chinese Society of Spinal Cord Injury of International Society of Spinal Cord, Chinese Continence Society of Chinese Medical Association. Guideline of Clinical Rehabilitation and Urologic Management for Patients with Spinal Cord Injury[J]. Chin J Rehabil Theory Pract, 2013, 19(4):301-317.
[2]	MOUSSA M, PAPATSORIS A, CHAKRA M A, et al. Lower urinary tract dysfunction in common neurological diseases[J]. Turk J Urol, 2020, 46(1):70-78.
[3]	索吕, 王红星. 中枢神经损伤后膀胱逼尿肌过度活动的治疗进展[J]. 中国康复医学杂志, 2020, 35(8):1004-1008.
	SUO L, WANG H X. Chin J Rehabil Med, 2020, 35(8):1004-1008.
[4]	廖利民. 神经源性膀胱的治疗现状和进展[J]. 中国康复医学杂志, 2011, 26(3):201-205.
	LIAO L M. Chin J Rehabil Med, 2011, 26(3):201-205.
[5]	GAO Y, LIAO L. Regional activity and functional connectivity in brain networks associated with urinary bladder filling in patients with tethered cord syndrome[J]. Int Urol Nephrol, 2021, 53(9):1805-1812. doi: 10.1007/s11255-021-02880-0
[6]	SEKIDO N, IGAWA Y, KAKIZAKI H, et al. Clinical Guidelines for the Diagnosis and Treatment of Lower Urinary Tract Dysfunction in Patients with Spinal Cord Injury[J]. Int J Urol, 2020, 27(4):276-288. doi: 10.1111/iju.v27.4
[7]	丛惠伶, 廖利民. 加倍剂量酒石酸托特罗定治疗脊髓损伤致逼尿肌过度活动的效果观察[J]. 中国康复理论与实践, 2010, 16(12):1108-1110.
	CONG H L, LIAO L M. Effect of double dosage tolterodine on detrusor overactivity after spinal cord injury[J]. Chin J Rehabil Theory Pract, 2010, 16(12):1108-1110.
[8]	FITZ F, SARTORI M, GIRÃO M J, et al. Pelvic floor muscle training for overactive bladder symptoms: a prospective study[J]. Rev Assoc Med Bras, 2017, 63(12):1032-1038. doi: 10.1590/1806-9282.63.12.1032
[9]	BYKOVIENE L, KUBILIUS R, ANIULIENE R, et al. Pelvic floor muscle training with or without tibial nerve stimulation and lifestyle changes have comparable effects on the overactive bladder. A randomized clinical trial[J]. Urol J, 2018, 15(4):186-192.
[10]	康海琼, 周红俊, 刘根林, 等. 脊髓损伤神经学分类国际标准检查表2019版最新修订及解读[J]. 中国康复理论与实践, 2019, 25(8):983-985.
	KANG H Q, ZHOU H J, LIU G L, et al. Modification and interpretation of the 2019 International Standards for Neurological Classification of Spinal Cord Injury Worksheet[J]. Chin J Rehabil Theory Pract, 2019, 25(8):983-985.
[11]	KIRSHBLUM S, SNIDER B, RUPP R, et al. Updates of the International Standards for Neurologic Classification of Spinal Cord Injury: 2015 and 2019[J]. Phys Med Rehabil Clin N Am, 2020, 31(3):319-330. doi: 10.1016/j.pmr.2020.03.005
[12]	SCHACHAR J S, DEVAKUMAR H, MARTIN L, et al. Pelvic floor muscle weakness: a risk factor for anterior vaginal wall prolapse recurrence[J]. Int Urogynecol J, 2018, 29(11):1661-1667. doi: 10.1007/s00192-018-3626-2
[13]	陈娟, 任远, 朱兰. 改良牛津肌力分级和盆底表面肌电评估女性压力性尿失禁患者盆底肌功能的相关性[J]. 中华医学杂志, 2020, 100(37):2908-2912.
	CHEN J, REN Y, ZHU L. Correlation between modified Oxford Grading Scale and pelvic floor surface electromyography in assessment of pelvic floor muscle function in female patients with stress urinary incontinence[J]. Natl Med J Chin, 2020, 100(37):2908-2912.
[14]	NILSEN I, REBOLLEDO G, ACHARYA G, et al. Mechanical oscillations superimposed on the pelvic floor muscles during Kegel exercises reduce urine leakage in women suffering from stress urinary incontinence: a prospective cohort study with a 2-year follow up[J]. Acta Obstet Gynecol Scand, 2018, 97(10):1185-1191. doi: 10.1111/aogs.2018.97.issue-10
[15]	WELK B, MORROW S A, MADARASZ W, et al. The conceptualization and development of a patient-reported neurogenic bladder symptom score[J]. Res Rep Urol, 2013, 5:129-137.
[16]	WELK B, LENHERR S, ELLIOTT S, et al. The Neurogenic Bladder Symptom Score (NBSS): a secondary assessment of its validity, reliability among people with a spinal cord injury[J]. Spinal Cord, 2018, 56(3):259-264. doi: 10.1038/s41393-017-0028-0
[17]	WELK B, MCKIBBON M. A randomized, controlled trial of transcutaneous tibial nerve stimulation to treat overactive bladder and neurogenic bladder patients[J]. Can Urol Assoc J, 2020, 14(7):297-303.
[18]	GRIFFITHS D. Neural control of micturition in humans: a working model[J]. Nat Rev Urol, 2015, 12(12):695-705.
[19]	FOWLER C J, GRIFFITHS D, DE GROAT W C. The neural control of micturition[J]. Nat Rev Neurosci, 2008, 9(6):453-466.
[20]	SAKAKIBARA R, KISHI M, TSUYUSAKI Y, et al. Neurology and the bladder: how to assess and manage neurogenic bladder dysfunction, with particular references to the neural control of micturition[J]. Brain Nerve, 2014, 53(3):527-537.
[21]	AMARENCO G, SHEIKH ISMAËL S, CHESNEL C, et al. Diagnosis and clinical evaluation of neurogenic bladder[J]. Eur J Phys Rehabil Med, 2017, 53(6):975-980.
[22]	AZURI J, KAFRI R, ZIV-BARAN T, et al. Outcomes of different protocols of pelvic floor physical therapy and anti-cholinergics in women with wet over-active bladder: a 4-year follow-up[J]. Neurourol Urodyn, 2017, 36(3):755-758. doi: 10.1002/nau.23016
[23]	BURGIO K L. Update on behavioral and physical therapies for incontinence and overactive bladder: the role of pelvic floor muscle training[J]. Curr Urol Rep, 2013, 14(5):457-464. doi: 10.1007/s11934-013-0358-1
[24]	BURGIO K L, KRAUS S R, JOHNSON T M, et al. Effectiveness of combined behavioral and drug therapy for overactive bladder symptoms in men: a randomized clinical trial[J]. JAMA Intern Med, 2020, 180(3):411-419. doi: 10.1001/jamainternmed.2019.6398
[25]	JHANG J F, KUO H C. Botulinum Toxin A and lower urinary tract dysfunction: pathophysiology and mechanisms of action[J]. Toxins (Basel), 2016, 8(4):120. doi: 10.3390/toxins8040120
[26]	KATO T, MIZUNO K, NISHIO H, et al. Urodynamic effectiveness of a beta-3 adrenoreceptor agonist (vibegron) for a pediatric patient with anticholinergic-resistant neurogenic detrusor overactivity: a case report[J]. J Med Case Rep, 2021, 15(1):86. doi: 10.1186/s13256-020-02564-w
[27]	KAGA K, YAMANISHI T, KAGA M, et al. Urodynamic efficacy of fesoterodine for the treatment of neurogenic detrusor overactivity and/or low compliance bladder[J]. Int J Urol, 2020, 27(10):899-904. doi: 10.1111/iju.v27.10
[28]	ORGEN S, DELIKTAS H, SAHIN H, et al. Histopathologic and urodynamic effects of the anticholinergic drugs oxybutynin, tolterodine, and trospium on the bladder[J]. Low Urin Tract Symptoms, 2017, 9(1):52-56.
[29]	VAN OPHOVEN A, ENGELBERG S, LILLEY H, et al. Systematic literature review and meta-analysis of sacral neuromodulation (SNM) in patients with neurogenic lower urinary tract dysfunction (nLUTD): over 20 years' experience and future directions[J]. Adv Ther, 2021, 38(4):1987-2006. doi: 10.1007/s12325-021-01650-9
[30]	STAMPAS A, KHAVARI R, FRONTERA J E, et al. Feasibility of self-administered neuromodulation for neurogenic bladder in spinal cord injury[J]. Int Neurourol J, 2019, 23(3):249-256. doi: 10.5213/inj.1938120.060
[31]	KNIGHT S L, EDIRISINGHE N, LEAKER B, et al. Conditional neuromodulation of neurogenic detrusor overactivity using transrectal stimulation in patients with spinal cord injury: a proof of principle study[J]. Neurourol Urodyn, 2018, 37(1):385-393. doi: 10.1002/nau.v37.1
[32]	BOURBEAU D J, GUSTAFSON K J, BROSE S W. At-home genital nerve stimulation for individuals with SCI and neurogenic detrusor overactivity: a pilot feasibility study[J]. J Spinal Cord Med, 2019, 42(3):360-370. doi: 10.1080/10790268.2017.1422881
[33]	ÇETINEL B, KOCJANCIC E, DEMIRDAĞ Ç. Augmentation cystoplasty in neurogenic bladder[J]. Investig Clin Urol, 2016, 57(5):316-323. doi: 10.4111/icu.2016.57.5.316
[34]	HOEN L', ECCLESTONE H, BLOK B F M, et al. Long-term effectiveness and complication rates of bladder augmentation in patients with neurogenic bladder dysfunction: a systematic review[J]. Neurourol Urodyn, 2017, 36(7):1685-1702. doi: 10.1002/nau.23205
[35]	LÚCIO A, LOURENÇO C B, DAMASCENO B P, et al. The effect of pelvic floor muscle contraction on detrusor overactivity pressure in neurogenic and nonneurogenic women during urodynamic study: a cross-sectional study[J]. Am J Phys Med Rehabil, 2019, 98(4):275-279. doi: 10.1097/PHM.0000000000001065
[36]	ANGELINI K. Pelvic floor muscle training to manage overactive bladder and urinary incontinence[J]. Nurs Womens Health, 2017, 21(1):51-57. doi: 10.1016/j.nwh.2016.12.004
[37]	VÁSQUEZ N, KNIGHT S L, SUSSER J, et al. Pelvic floor muscle training in spinal cord injury and its impact on neurogenic detrusor over-activity and incontinence[J]. Spinal Cord, 2015, 53(12):887-889. doi: 10.1038/sc.2015.121

项目	对照组 (n = 8)	试验组 (n = 9)	χ²/F值	P值
性别(男/女, n)	6/2	6/3	0.142	0.707
年龄(岁)	44.25±12.40	42.22±13.74	0.035	0.754
病程(月)	13.75±6.43	13.66±4.63	0.673	0.976
损伤分级(C/D, n)	7/1	6/3	1.022	0.312
肌力分级(3/4, n)	7/1	7/2	0.275	0.599

组别	n	治疗前	治疗后	t值	P值
对照组	8	120.87±47.40	163.87±46.73	-7.243	< 0.001
试验组	9	121.77±42.42	205.00±29.63	-11.566	< 0.001
t值		0.041	2.194
P值		0.968	0.044

组别	n	治疗前	治疗后	t值	P值
对照组	8	104.12±45.62	130.62±38.77	-5.539	< 0.001
试验组	9	96.44±41.84	176.00±30.40	-8.021	< 0.001
t值		-0.360	2.702
P值		0.724	0.016

组别	n	治疗前	治疗后	t值	P值
对照组	8	61.87±12.04	50.50±9.97	10.651	< 0.001
试验组	9	61.22±26.12	38.33±12.25	4.443	0.002
t值		-0.065	-2.226
P值		0.949	0.042

组别	n	治疗前	治疗后	t'值	P值
对照组	8	65.37±10.28	54.37±10.13	12.702	< 0.001
试验组	9	68.33±27.20	41.22±7.04	3.674	0.006
t'值		0.303	-3.139
P值		0.768	0.007