Abstract
目的
介绍男性膀胱过度活动症(overactive bladder,OAB)的尿动学分型并探究其临床疗效的差异。
方法
收集2015年1月至2017年1月北京大学人民医院泌尿外科诊断为OAB并且接受尿动力学检查的男性患者共126例,根据患者的主诉(是否可感知尿急)及尿动力学检查结果(是否有逼尿肌过度活动和终止不自主收缩的能力)将膀胱过度活动症分为四型,分析患者的基本信息、伴随疾病情况、治疗前后的OAB症状评分表(OAB symptom score,OABSS)以及国际前列腺症状评分(international prostate symptom score,IPSS)是否存在差异。
结果
根据分型方法,Ⅰ型32例(25.40%),Ⅱ型27例(21.43%),Ⅲ型59例(46.83%),Ⅳ型8例(6.35%),四型患者的身高差异无统计学意义(P>0.05),Ⅳ型患者的年龄、体质量、伴随疾病数目显著大于其余三型,差异有统计学意义(P<0.05),Ⅰ、Ⅱ、Ⅲ型患者的年龄、体质量、伴随疾病数目的差异无统计学意义(P>0.05),Ⅳ型患者治疗前后OABSS和IPSS量表差值显著小于其余三型,差异有统计学意义(P<0.05),Ⅲ型患者治疗前后OABSS和IPSS量表差值显著大于其余三型,差异有统计学意义(P<0.05),Ⅰ型和Ⅱ型患者治疗前后OABSS和IPSS量表差值的差异无统计学意义(P>0.05)。
结论
在四型男性OAB患者中,Ⅲ型治疗效果最好,Ⅳ型治疗效果最差,此分型方法对男性OAB的个体化诊疗以及指导预后具有重要意义。
Keywords: 男性, 膀胱过度活动症, 排尿障碍, 尿动力学
Abstract
Objective
To introduce a urodynamic classification of male patients with symptoms of overactive bladder (OAB) and discuss its clinical significance in practice.
Methods
From January 2015 to January 2017, there were 181 male patients from Peking University People’s Hospital who were diagnosed clinically with OAB and underwent preoperative urodynamic test. Finally 126 male patients were enrolled in the research. Male OAB patients could be stratified into four groups based on the chief complaints (whether or not presenting urgency) and the results of urodynamic test (whether or not presenting detrusor overactivity and the ability to stop the involuntary contraction). The contents of this follow-up study included the basic information, the preoperative and postoperative scores of the OAB symptom score (OABSS), the preoperative and postoperative scores of the international prostate symptom score (IPSS), and the amount of the concomitant diseases.
Results
According to the classification, the amounts of the four types of OAB patients were 32 (25.40%) for type Ⅰ, 27 (21.43%) for type Ⅱ, 59 (46.83%) for type Ⅲ, and 8 (6.35%) for type Ⅳ, respectively. The data of their heights showed no statistical significance (P>0.05). The ages, weights and the amount of the concomitant diseases of type Ⅳ were obviously higher than those of the other three types (P<0.05). And the ages, weights and the amount of the concomitant diseases of the other three types had shown no statistical significance (P>0.05). The improvement of the OABSS and IPSS scores of the type Ⅳ were obviously inferior to the other three types (P<0.05). The improvements of the OABSS and IPSS scores of type Ⅲ were obviously higher than those of the other three (P<0.05). The discrepancy of the OABSS and IPSS scores of type Ⅰ and type Ⅱ had shown no statistical significance (P>0.05).
Conclusion
Type Ⅳ has the worst outcome and type Ⅲ has the best among the four types of OAB. And this classification system will certainly have a profound significance in guiding and directing our clinical diagnosis and treatments, and evaluating the prognosis of the patients with OAB.
Keywords: Male, Overactive bladder, Urination disorders, Urodynamics
依据国际尿控协会(international continence society,ICS)的定义,膀胱过度活动症(overactive bladder,OAB)是一种以尿急症状为特征的症候群,常伴有尿频和夜尿症状,可伴或不伴急迫性尿失禁,且排除尿路感染或者其他明确的病理改变[1]。OAB的核心症状均较主观,难以量化。目前临床中常用的评估方法一般根据患者的主诉或症状评估量表,如OAB问卷调查(OAB questionaire,OAB-q)、OAB症状评分表(OAB symptom score,OABSS)等[2],仅达到对于OAB进行初步诊断的目的,并未对OAB患者进一步分类,这无疑会影响对OAB的精确诊断及后续治疗。尿动力学检查是一项侵入性检查,临床中并未将尿动学检查作为OAB的常规诊断方法[3,4]。本研究通过对治疗前完成尿动学检查的男性OAB患者进行分型并随访,比较各型治疗效果的差异,为OAB的分型诊疗以及预后评价提供依据。
1. 资料与方法
1.1. 入组病例
排除标准:(1)尿路感染及其他明确的病理改变者,(2)既往泌尿系统、盆腔(包括直肠)手术史者,(3)尿动力学报告不完整者,(4)未接受任何治疗者及未按医嘱治疗者。
2015年1月至2017年1月就诊于北京大学人民医院诊断为OAB且接受尿动力学检查的男性患者共181例,排除26例[接受过直肠手术者4例,尿动力学数据不完整者4例,经尿道前列腺电切术(transurethal resection of the prostate,TURP)术后6例,经尿道膀胱肿瘤切除术(trasnurethral resection of bladder tumor,TURBT)术后2例,肾脏术后1例,合并尿路感染3例,未治疗或者治疗期限不达标者6例],失访29例(包括死亡3例),失访率为18.71%(<20%), 最终纳入126例。
1.2. OAB分型方法
OAB分型方法是由Flisser等[5]于2003年提出(表1),根据是否有逼尿肌过度活动(detrusor overactivity,DO)、患者感知能力和是否能终止不自主收缩三方面进行分型,其中,Ⅰ型有OAB症状,尿动力学检查时无DO;Ⅱ型有OAB症状,尿动力学检查时有DO,患者能够感觉到并能够抑制不自主收缩;Ⅲ型有OAB症状,尿动力学检查时有DO,患者能够感觉到但不能够抑制不自主收缩,仅能暂时通过括约肌的收缩保持控尿;Ⅳ型有尿失禁症状,尿动力学检查有DO,患者不能够感觉到,也不能够抑制不自主收缩[5,6]。DO的诊断标准为:尿动力学检查时,膀胱储尿期出现的逼尿肌不自主收缩[7]。
1.
OAB的四类分型
Four types of OAB
| Types | Symptoms | Urodynamic test |
| Incontinence refer to the urge urinary incontinence. OAB, overactive bladder; DO, detrusor overactive. | ||
| Type Ⅰ | Urgency, no incontinence | No DO, no incontinence |
| Type Ⅱ | Urgency, no incontinence | DO, no incontinence |
| Type Ⅲ | Urgency, incontinence | DO, incontinence |
| Type Ⅳ | No urgency, incontinence | DO, incontinence |
1.3. 研究内容
对入组的126例患者于2017年12月集中进行电话随访,内容包括患者的身高、体质量、年龄、患者接受治疗前和接受治疗后的OABSS量表评分、患者治疗前和治疗后的国际前列腺症状评分(international prostate symptom score,IPSS)、伴随疾病情况[有无高血压、糖尿病、脑血管疾病、脑梗死/萎缩、阿尔茨海默病(Alzheimer disease,AD)、帕金森病(Parkinson’s disease,PD)、风湿病等],其中,伴随疾病情况要求患某疾病的时限大于1年,量化方法为:有一种伴随疾病记为1,有两种伴随疾病记为2,以此类推。进行量表调查时若患者给出一个得分范围,则统一取高值。
1.4. 统计学分析
所有数据均采用SPSS 20.0软件进行统计分析。各组数据通过软件计算出平均值±标准差,对于符合正态分布的数据,运用单因素方差分析(SNK检验)进行数据处理,对于不符合正态分布的数据采用非参数秩和检验(独立样本Kruskal-Walls检验)的方法,为校正混杂因素,采用多元Logistic回归分析进一步对数据进行处理,P<0.5为差异有统计学意义。
1.5. 偏倚控制
考虑随访过程中可能出现的各类偏倚,针对尿动力学历史数据,采取主任医师再审查的方法确保尿动学结果准确可靠。电话随访过程中尽量采取无诱导性提问,合理设计提问顺序,充分考虑提问时间与患者接受随访时的精神状态,尽量减少各类偏倚。
2. 结果
2.1. 患者一般资料
根据上述方法进行分型,Ⅰ型32例(25.40%),Ⅱ型27例(21.43%),Ⅲ型59例(46.83%),Ⅳ型8例(6.35%),见图1。
1.
四型OAB占比图
The four types of OAB
126例患者中单纯OAB患者47例(37.30%),这部分患者单纯接受药物治疗,治疗药物包括托特罗定(15例,1次2 mg,2次/d)、索利那新(32例,1次5 mg,1次/d),药物治疗的平均时间为3.2个月(0.5~20.0个月)。
OAB合并良性前列腺增生者79例(62.70%),这部分患者接受TURP手术治疗。
四型OAB患者身高的差异无统计学意义(P>0.05),Ⅰ、Ⅱ、Ⅲ型患者年龄、体质量、伴随疾病数目的差异无统计学意义(P>0.05),Ⅳ型患者的年龄、体质量、伴随疾病数目高于其他三型,差异有统计学意义(P<0.05),具体见表2、3。
2.
四型膀胱过度活动症男性患者相关信息的单因素分析
Univeriate analysis of information about the four types of male OAB patients
| Variables | Type Ⅰ | Type Ⅱ | Type Ⅲ | Type Ⅳ | Univariate analysis (P values) |
| *, the score difference before and after treatment. OAB, overactive bladder; OABSS, overactive bladder symptom score; IPSS, international prostate symptom score. | |||||
| Age/years, x±s | 69.50±13.92 | 69.51±8.05 | 68.75±9.29 | 78.50±9.20 | 0.033 |
| Height/cm, x±s | 171.38±5.98 | 171.70±6.00 | 171.22±5.54 | 173.63±4.94 | 0.125 |
| Weight/kg, x±s | 69.30±6.19 | 68.43±5.68 | 68.93±8.83 | 73.50±7.52 | 0.030 |
| OABSS*, x±s | 4.62±2.23 | 4.18±2.45 | 6.07±3.33 | 2.75±1.77 | <0.001 |
| IPSS*, x±s | 14.72±6.71 | 14.26±8.00 | 16.13±8.25 | 7.45±4.70 | 0.036 |
| Concomitant disease, x±s | 2.25±1.11 | 2.22±1.09 | 2.16±1.15 | 4.25±2.60 | <0.001 |
3.
四型膀胱过度活动症男性患者相关信息的多因素分析
Multivariate analysis of information about the four types of male OAB patients
| Variables | OR | 95%CI | P values |
| *, the score difference before and after treatment. OR, odds ratio; CI, confidence interval. Other abbreviations as in Table 2. | |||
| Age | 1.76 | 1.10-4.21 | 0.036 |
| Weight | 1.99 | 1.21-3.09 | 0.039 |
| OABSS* | 3.55 | 1.57-8.23 | 0.014 |
| IPSS* | 1.37 | 1.04-4.25 | 0.045 |
| Concomitant disease | 2.98 | 2.01-7.36 | 0.016 |
2.2. OABSS量表治疗前后得分差值
Ⅰ、Ⅱ、Ⅲ、Ⅳ型治疗前后OABSS量表得分差值分别为4.62±2.23、4.18±2.45、6.07±3.33、2.75±1.77,其中Ⅲ型患者OABSS量表得分差值明显高于其他三型,差异有统计学意义(P<0.05),Ⅳ型患者OABSS量表得分差值明显低于其他三型,差异有统计学意义(P<0.05),Ⅰ型和Ⅱ型患者OABSS量表得分差异无统计学意义(P>0.05),见表2、3。
2.3. IPSS量表治疗前后得分差值
Ⅰ、Ⅱ、Ⅲ、Ⅳ型治疗前后IPSS量表得分差值分别为14.72±6.71、14.26±8.00、16.13±8.25、7.45±4.70,其中Ⅲ型患者IPSS量表得分差值明显高于其他三型,差异有统计学意义(P<0.05),Ⅳ型患者IPSS量表得分差值明显低于其他三型,差异有统计学意义(P<0.05),Ⅰ型和Ⅱ型患者IPSS量表得分差异无统计学意义(P>0.05),见表2、3。
3. 讨论
目前,关于OAB发病机制的研究有了一些新的进展[8,9],首先是膀胱微动学说。“膀胱微动”表示膀胱组织沿着非运动区域存在局部微小收缩和微小伸展。OAB患者有强烈的尿急而膀胱内压力并没有明显改变,这表明单纯的膀胱内压力并不是传入活动的主要决定因素,这种“不受限制的自主性”可能导致尿急和DO[10]。Ⅰ型OAB患者尿动学检查提示无DO,但患者仍有尿急,考虑膀胱微动学说符合其发病机制。
还有一种理论考虑OAB与大脑对传入信号的处理能力下降有关[11,12]。脑白质病(white matter damage,WMD)的发病率随年龄增加而显著提高,最先影响前额皮质高级排尿中枢所在地深层的白质。多项基础研究表明,WMD可能是OAB脑部病因学的解剖基础[13]。WMD可发展成三种不同的老年综合征:(1)阿尔茨海默病,(2)帕金森病,(3)OAB,其中OAB可能先于其他两类症状出现。Ⅳ型OAB患者无法感知尿急,我们考虑WMD可能为Ⅳ型OAB的病理生理机制,因此在对待老年OAB患者时,应该考虑到脑部的疾病,必要时行神经系统检查[14]。
本研究中,四型OAB患者显示出不同的临床疗效,Ⅳ型OAB的临床疗效最差,Ⅲ型OAB的临床疗效最好。Ⅲ型患者存在逼尿肌不稳定收缩,患者可以感觉到并且可以收缩括约肌,但是不能终止逼尿肌不稳定收缩;而Ⅳ型患者存在逼尿肌不稳定收缩,但是膀胱感知功能下降,患者无法感觉到并且不能收缩括约肌,也无法终止逼尿肌不稳定收缩,患者没有尿急的感觉而直接出现尿失禁,故应注意与压力性尿失禁进行鉴别,尤其是前列腺术后的患者[15]。Ⅳ型的患者多为高龄老年人,伴随疾病较多,病情较重,治疗效果较差,应适当降低患者对于治疗效果的心理预期,复查频率也应适当提高。Ⅲ型患者虽然OABSS与IPSS的基础得分较高,对患者生活质量影响最大,但是随访表明该型更容易取得明显的症状改善,患者治疗后满意度较高,复查频率可开始较高,随着时间的推移可逐渐降低。
男性和女性OAB无论是在病因还是治疗方式上均有显著差异,男性OAB很大一部分为继发性OAB,即先有梗阻症状,后继发产生逼尿肌不稳定收缩,其治疗方式很大一部分以解除梗阻为主,而不是单纯治疗OAB症状;而女性OAB不容易受其他因素干扰,故目前对OAB的研究多以女性为主,专门针对男性OAB患者的研究较少。本研究纳入126例男性OAB患者,属于较大样本,且国内外尚未见类似的研究,这是本研究的优势,不足之处主要在于各组间例数不均衡,尤其是Ⅳ型仅有8例,虽然其临床识别度较高、代表性较好,但仍容易影响相关结论的准确性,另外,四型间治疗方式不尽相同、回忆偏倚等也会影响结果的可靠性。
本研究阐述了男性OAB的分型并对四种类型的治疗效果做出了评价,为OAB的分型诊疗以及预后评价提供了理论基础,关于此分型的临床意义还需在今后的临床实践中进一步证实。
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