Structural and functional impairment of the upper urinary tract
Introduction
Introduction Normal urination activity is caused by the spinal reflex center and sympathetic, parasympathetic, and body nerves. The bladder urethral dysfunction caused by damage to the central nervous system or peripheral nerves that control urinary function is called neurogenic bladder. According to the detrusor function, it is divided into two categories: 1 detrusor hyperreflexia; 2 detrusor no reflection. Neurogenic bladder urethral dysfunction is a type of dysfunction of the bladder and/or urethra caused by neuropathy or damage, often accompanied by a coordinated disorder of bladder and urethral function. Neurogenic bladder and urethral dysfunction produces complex urination symptoms, and poor urination or urinary retention is one of the most common symptoms. The resulting urinary tract complications are the leading cause of death in patients.
Cause
Cause
Brain disease
(1) cerebrovascular disease: common with hypertensive intracranial hemorrhage, atherosclerotic cerebral infarction, cerebral embolism, intracranial arteritis, subarachnoid hemorrhage, cerebral vascular malformation and rupture of basilar aneurysm, etc. Internal bleeding is the most common. Studies have shown that nerve conduction bundles that control the detrusor and extra-urethral sphincters are almost identical to the nerve-walking pathways that govern somatosensory and motor movements, and are therefore often compromised at the same time. There are many nucleus involved in urinary control in the brain, such as basal ganglia, cerebellum, globus pallidus, striatum, thalamus, etc. When the above nerve pathway or nuclei are damaged, the patient has special consciousness and sensorimotor dysfunction. In addition to the clinical manifestations of the primary disease, there is often urinary dysfunction. The type of urinary dysfunction varies depending on the location of the lesion.
(2) Parkinson's disease: It is a chronic progressive central nervous system dysfunction, manifested as limb tremor, slow physical activity, unstable gait, and a gear-like rigidity during examination. 25% to 75% of patients have abnormal bladder function, mainly characterized by difficulty in urinary dysfunction, urgency or urgent urinary incontinence.
(3) Brain tumors: When the tumor affects the frontal lobe, basal ganglia or midbrain damage, urinary dysfunction may occur. Therefore, this symptom may indicate the significance of localization diagnosis to some extent. The main symptoms are frequent urination, urgency, and urge incontinence. In a few cases, dysuria and urinary retention occur.
(4) Multiple sclerosis: a chronic progressive central nervous system characterized by the presence of scattered demyelinated plaques in the brain and spinal cord resulting in a variety of different neurological symptoms or signs. About 5% of patients in the early stage may have bladder dysfunction, up to 90% in the advanced stage. It can be expressed as frequent urination, urgency, urge incontinence, and occasional urinary retention.
(5) Alzheimer's disease: Urinary incontinence is the most common symptom of the urinary system, mostly urge incontinence and loss of consciousness to control urination. The mechanism of its occurrence is mainly that the cerebral cortex loses control of the detrusor center of the spinal cord.
2. Spinal cord lesions
(1) Trauma: Spinal cord injury is divided into direct injury, indirect injury and high-speed projectile injury, among which indirect injury is most common such as spinal fracture, dislocation or subluxation. The early stage of spinal cord injury is the period of spinal cord shock, during which the spinal cord below the injury plane loses control of all tissues and organs that it dictates. Spinal cord shock generally lasts for 2 to 3 weeks, and some last for more than 2 years. In the later stage of the injury, fibrotic scar formation occurs at the injury site, and spinal adhesions can occur. The neurons at the injury site are replaced by stellate cells, and the spinal cord is gelatinized.
(2) Spinal cord diseases: such as spinal tuberculosis, disc herniation, metastatic tumors, cervical spondylosis, etc.
(3) vascular disease: spinal artery embolization can cause damage to the spinal cord at the corresponding site.
(4) neural tube insufficiency: the most common in the lumbosacral region. Large defects can cause spinal meningocele and more often have spinal dysplasia.
(5) Others: syringomyelia, polio, transverse myelitis and multiple sclerosis can cause bladder urethral dysfunction.
3. Peripheral neuropathy
(1) Diabetes: Due to the disorder of glucose metabolism, long-term diabetic patients increase the vascular resistance of the endometrium, causing ischemia and hypoxia, causing neuronal cells, axonal mutation, and demyelination of nerve fibers. The density of neurons in the bladder wall becomes thinner, the axons have degenerative lesions and nerve fragments, and the afferent and efferent fiber conduction impulses of the bladder lead to dysfunction of the bladder and urethra. Bladder dysfunction is one of the common complications of diabetic patients, and the incidence rate in patients with type 1 diabetes is as high as 43% to 87%.
(2) After pelvic organ resection: such as radical resection of rectal cancer, radical resection of uterine cancer, etc., urinary abnormalities often occur after surgery, the incidence rate is as high as 7.7% ~ 68%. It has been confirmed that the operation is caused by parasympathetic nerves, sympathetic nerves, pelvic ganglia and pudendal nerve damage in the pelvis.
(3) Herpes zoster: Herpes zoster virus is lurking in the cells of the posterior horn of the spinal cord and spreads along the nerve sheath, destroying the nerves. When the lumbar nerve or the sacral nerve is involved, urinary frequency and urinary retention may occur.
There are many methods for classification of neurogenic bladder. The commonly used classification method in the past is the Bors classification method, which classifies the following five categories:
1. Upper motor neuron lesions: lesions above the spinal cord center (S2 ~ S4), including sensory branches and motor branches.
2. Lower motor neuron lesions: The lesions are located in the spinal nerve center (S2 ~ S4) or peripheral nerves below the center, including the sensory branch and the motor branch.
3. Primary motor neuron lesions: lesions are limited to the motor branch, and the sensory branch has no lesions, such as polio.
4. Primary sensory neuron lesions: lesions are limited to sensory branches. Motor neuron lesions, such as the neurogenic bladder caused by diabetes and spinal cord spasm.
5. "Mixed" lesions: Autonomous motor neuron lesions (parasympathetic nerves) related to urination are not at the same level as body motor neuron lesions, one in the upper motor neuron, the other in the lower motor neuron, or one in the lesion and the other No lesions.
Although this classification method is more detailed, it is too complicated and has no guiding significance for the choice of treatment methods. In recent years, according to the international filling of the bladder, there is no inhibition contraction of the detrusor into two categories:
1. Detrusor hyperreflex: The reaction of the detrusor to the stimulus is hyperreflexive, and there is no inhibition of contraction when measuring intravesical pressure. Dysfunction with or without the urethral sphincter.
2. Detrusor-free reflex: The detrusor of this type of neurogenic bladder has no reflection or loss of reflexes. No inhibition of contraction occurs when measuring intravesical pressure. Dysfunction with or without the urethral sphincter.
Examine
an examination
Related inspection
Blood routine urine urinary plain film
History
1 urinary dysfunction with defecation dysfunction (such as constipation, fecal incontinence, etc.), the possibility of neuropathy through the original bladder.
2 pay attention to whether there is history of trauma, surgery, diabetes, polio, or history of drug application.
3 pay attention to the presence or absence of urinary sensation, bladder swelling and other feelings of decline or loss, such as the bladder's sensation is significantly reduced or increased, you can diagnose the neurogenic bladder.
2. Check
1 When there is a perineal sensation diminished, the anal sphincter tension is reduced or enhanced, the neurogenic bladder can be diagnosed, but the lack of these signs can not rule out the possibility of neurogenic bladder.
2 pay attention to the presence or absence of spina bifida, meningocele, tibia dysplasia and other deformities.
3 There is residual urine, but there is no mechanical obstruction of the lower urinary tract.
4 Electrical stimulation of spinal cord reflex test, this method mainly tests whether the spinal reflex nerves of the bladder and urethra are intact (ie, whether there are lesions in the lower motor neurons) and whether the neurons from the cerebral cortex to the pudendal nucleus (the spinal cord center) have lesions ( Upper motor neurons have no lesions). Therefore, this test can be diagnosed as a neurogenic bladder, and can distinguish between lower motor neuron lesions (detrusor non-reflection) and upper motor neuron lesions (detrusor hyperreflexia).
Diagnosis
Differential diagnosis
Differential diagnosis of structural and functional impairment of the upper urinary tract:
1. Benign prostatic hyperplasia: occurs in men over 50 years old, has dysuria, urinary retention, severe cases of kidney, ureteral expansion and accumulation of water. Rectal examination, cystoscopy, and cystography can confirm the diagnosis.
2. Bladder neck obstruction: Women have dysuria and urinary retention, normal skin around the anus and perineal sensation, cystoscopy or urodynamic examination can be identified.
3. Congenital urethral valve: more common in children, dysuria, urinary retention. Urethroscopy or urethrography can be identified.
4. Female stress urinary incontinence: normal detrusor function, decreased urethral resistance, positive bladder neck elevation test, bladder urethra angiography disappeared posterior urethral urethra, bladder neck position decreased.
5. Urethral stricture: can be congenital or acquired, with dysuria as the main performance. The urethral probe has a strict stenosis, and urethrography can confirm the diagnosis.
6. Bladder neck obstruction: dysuria is often accompanied by urination pain, sudden interruption of urinary flow during urination. Ultrasound examination showed a strong echo. The opaque shadow of the plain area of the bladder area. Cystoscopy can determine the size and number of stones.
7. Bladder cancer: A pedicled tumor located near the neck and triangle of the bladder can cause dysuria, urinary retention and other symptoms due to blockage of the urethral opening. However, patients usually have intermittent painless hematuria, and urine exfoliated cells can detect cancer cells. IVU can be seen in the filling area of the bladder. The cystoscopy can directly identify the location, size and number of the tumor, and can also take biopsy at the same time.
History
1 urinary dysfunction with defecation dysfunction (such as constipation, fecal incontinence, etc.), the possibility of neuropathy through the original bladder.
2 pay attention to whether there is history of trauma, surgery, diabetes, polio, or history of drug application.
3 pay attention to the presence or absence of urinary sensation, bladder swelling and other feelings of decline or loss, such as the bladder's sensation is significantly reduced or increased, you can diagnose the neurogenic bladder.
2. Check
1 When there is a perineal sensation diminished, the anal sphincter tension is reduced or enhanced, the neurogenic bladder can be diagnosed, but the lack of these signs can not rule out the possibility of neurogenic bladder.
2 pay attention to the presence or absence of spina bifida, meningocele, tibia dysplasia and other deformities.
3 There is residual urine, but there is no mechanical obstruction of the lower urinary tract.
4 Electrical stimulation of spinal cord reflex test, this method mainly tests whether the spinal reflex nerves of the bladder and urethra are intact (ie, whether there are lesions in the lower motor neurons) and whether the neurons from the cerebral cortex to the pudendal nucleus (the spinal cord center) have lesions ( Upper motor neurons have no lesions). Therefore, this test can be diagnosed as a neurogenic bladder, and can distinguish between lower motor neuron lesions (detrusor non-reflection) and upper motor neuron lesions (detrusor hyperreflexia).
