電針神經(jīng)刺激療法治療慢性排尿障礙課件

Electroacupunctureneurostimulationfortreatmentofchronicvoidingdysfunction

電針神經(jīng)刺激療法治療慢性

排尿障礙Prof.WangSiyouShanghaiResearchInstituteofAcupunctureandMeridianStressUrinaryIncontinence

壓力性尿失禁

Urinaryincontinencecanbeclassifiedunder7typesinWesternmedicine尿失禁在西醫(yī)可分為7種類型。Nocturnalenuresis夜間遺尿Postvoiddribble排尿后滴尿Overflowurinaryincontinence充盈性尿失禁Stressurinaryincontinence(SUI)isdefinedasaninvoluntaryleakageofurinefromtheurethralmeatusatasuddenincreaseinintra-abdominalpressure(egcoughing,sneezing,laughing,runningorstrenuousactivities)withoutsimultaneousdetrusorcontraction.壓力性尿失禁是指平時無尿失禁狀態(tài)下，當(dāng)腹壓驟增時（如咳嗽、打噴嚏、大笑、奔跑、劇烈活動）尿液不自主從尿道口流出，同時不伴有膀胱逼尿肌收縮。Itoftenhappensinmultiparousandpostmenopausalwomen.ItcomesunderthecategoryofenuresisinTCM.臨床多見于中年已生育的婦女。屬中醫(yī)學(xué)遺尿范疇。Overactivebladder&

Urgeincontinence

Etiology(3)historyofvaginal,urethralorprostaticsurgery;(4)perinealorurethralinjury;(5)pelvictumescenceresultinginahighintra-abdominalpressureandalowerpositionofbladderneck.Morethanonecausemaycoexist.（3）陰道、尿道及前列腺手術(shù)史；（4）會陰部及尿道損傷；（5）盆腔內(nèi)腫物致腹壓增高，膀胱頸位置降低。一個或多個病因可同時存在。PathogenesisTheaboveetiologiesproducetheabnormalitiesof(vesicalneckandurethra)sphincters,thatis,urethralhypermobilityor/andintrinsicsphincterdeficiency(intrinsicmalfunctionoftheurethralsphincteritself)toresultinSUI.二.發(fā)病機理上述原因可引起（膀胱頸和尿道）括約肌異常：尿道活動度增大或/和括約肌內(nèi)在缺陷（尿道括約肌本身的內(nèi)在機能異常，近端尿道失去括約肌作用），導(dǎo)致壓力性尿失禁。Subtypesofstressincontinence

壓力性尿失禁的亞分類Thereare2possiblereasonsforurodynamicstressincontinence:

尿流動力學(xué)壓力性尿失禁的2個可能原因“Hypermobility”

“過度移動癥”(weaknessofbladdersupport)

（薄弱的膀胱支持力）“Intrinsicsphincterdeficiency”“固有括約肌功能障礙”

(“ISD”-weaknessofurethralsphincter)

(“ISD”－尿道括約肌力弱)Videoorextratests(UPP,VLPP)helptomakethisdistinction

影像技術(shù)及其他輔助檢查（尿道壓力描計UPP，屏氣時漏尿點壓力VLPP）有助于區(qū)分腹壓升高漏尿尿道無力StressUrinaryIncontinenceStressIncontinence:VLPP

Rest&StrainingClinicalmanifestations1.

SymptomInvoluntarylossofurineduringcoughing,sneezing,laughing,runningorphysicalexertionsuchassportactivitiesandsuddenchangesofposition.三.

臨床表現(xiàn)1.

癥狀咳嗽、打噴嚏、大笑、奔跑或體育活動、突然改變體位等身體用力時尿液不自主從尿道口流出。Clinicalmanifestations2.

SignsTheobservationoflossofurinefromtheurethraduringcoughing,sneezing,orphysicalexertion.PositiveMarshell(bladderbaseelevation)test.Positivepadtest.Avaginalexaminationshowscystocele,enteroceleorrectocele.2.

體征咳嗽、打噴嚏或身體用力時觀察到尿液從尿道口流出。指壓（尿道抬舉）試驗陽性。護墊試驗陽性。陰道檢查可見膀胱、腸、直腸膨出。

Video-urodynamics2.

Intrinsicsphincterdeficiency

Thevesicalneckandproximalurethraareopenatrestintheabsenceofdetrusorcontraction.2.

括約肌內(nèi)在缺陷靜止、無逼尿肌收縮時，膀胱頸（和近端尿道）開放。Hypermobility(typeIIincontinence)

過度移動癥（II型尿失禁）Easilydefinedonvideourodynamics

通過影像尿流動力學(xué)很容易確定butQ-tiptestorsimpleobservationwillhelp

但Q-tip試驗及簡單的觀察有助于診斷Hypermobility

過度移動癥(oncoughorValsalva,orpermanentdescent)

（咳嗽，Valsalva，或者持續(xù)下降）正常LPPmeasurement

漏尿點壓力測量Strain:leaksat165cmH2O

用力屏氣:在165cmH2O時漏尿（活動過度）

(hypermobility)Hyper-mobilitywithleakage(oncough)

活動過度伴漏尿（在咳嗽時）Startfilling

開始充盈Stopfillat200ml

在200ml時停止充盈Strain:leaksat45cmH2O

用力屏氣:在45cmH2O時漏尿LPPmeasurement

漏尿點壓力測量Initialpves

初始膀胱壓(nohypermobility,ISD)

（無過度移動癥，固有括約肌功能障礙）DagnosisBasedonThesymptom(history)ofstressincotinencePositivestresstest(lossofurineduringcoughingorphysicalexertion)andMarshelltestorpadtest.五.診斷根據(jù)：1.壓力性尿失禁癥狀（病史）。2.應(yīng)力試驗陽性（咳嗽或用力腹壓增高時有漏尿）和指壓試驗陽性或護墊試驗陽性。DagnosisBasedonTheresultsofimagingurodynamicexamination:urethralhypermobilityor/andintrinsicsphincterdeficiency

;noinvoluntarydetrusorcontraction.

3.影象尿動力檢查結(jié)果：尿道活動度增大或/和括約肌內(nèi)在缺陷；無逼尿肌無抑制性收縮。Treatment1.WesternconservativetreatmentConservativetreatmentcanbeappliedtomildandmoderateSUI.Itsadvantagesaresafety,microinvasion,andmuchlowerincidenceandlessseverityofcomplicationscomparedwithsurgicaltreatment.六.

治療方法1.西醫(yī)保守治療對于輕、中度壓力性尿失禁可采用保守治療，其優(yōu)點是安全微創(chuàng)，并發(fā)癥的發(fā)生率和嚴(yán)重程度遠(yuǎn)低于手術(shù)治療。1.WesternconservativetreatmentConservativetreatmentmainlyincludespelvicfloormuscleexercises(PFME),electricalstimulation(ES),variousvaginalandurethraldevicesandmedication.PFMEandtransvaginalortrans-analES(TES)arethetwomostcommonlyusedformsofconservativetreatmentforSUI.保守治療主要包括盆底肌鍛煉、電刺激、各種陰道和尿道裝置及藥物治療。其中盆底肌鍛煉和經(jīng)陰道或肛門電刺激（被動的盆底肌鍛煉）是最常用的二種治療方法。1.WesternconservativetreatmentPFMEcanbuildupthestructuralsupportofthepelvis,improveneuromuscularfunction,preventtheproximalurethraandbladderbasefromdescendingduringariseinabdominalpressureandincreaseurethralpressure.盆底肌鍛煉具有增強盆底肌肉支持力量，改善神經(jīng)肌肉功能，阻止腹內(nèi)壓增高時近端尿道和膀胱底部下降及增加尿道壓的作用。1.WesternconservativetreatmentItsshortcomingsaremanypatients’difficultyidentifyingandisolatingtheirPFMandinabilitytoperformPFMEeffectively;lackoflong-termpatientcompliance.缺點是：許多患者不能正確收縮盆底??；依從性差。1.WesternconservativetreatmentTESispassivePFMEthatproducesPFMcontractionsandhasgoodpatientcompliance.ItsshortcomingisthatitappliesvaginaloranalsurfaceelectrodeandinducesPFMcontractionsbyindirectnervestimulation,soitseffectisnotasgoodasthatofPFMEwhichisdonecorrectly.經(jīng)陰道或肛門電刺激是被動的盆底肌鍛煉，有很好的依從性。缺點是：因使用表面電極，作用是間接的，效果不及正確的盆底肌鍛煉

。2.AcupuncturetreatmentAcupunctureoftraditionalChinesemedicinecanalsobeappliedtomildandmoderatestressincontinence.Itsadvantagesaresafety,convenience,andnosideeffectsandcomplications.2.中醫(yī)針刺治療對于輕、中度壓力性尿失禁也可采用中醫(yī)針刺治療，其優(yōu)點是安全、方便、無副作用和并發(fā)癥。2.Acupuncturetreatment1)TherapeuticprincipleAccordingtoTCMtheory,itiscausedbydeficiencyofkidneyqiandfailureofthebladderinrestrainingtheurinedischarge,sothetherapeuticprincipleisreinforcingkidneyqiandimprovingvesicalrestrainingfunction.1)治療原則中醫(yī)認(rèn)為，尿失禁是由于腎氣不足，膀胱不固引起，因此治療原則是補益腎氣，固脬止遺。2)PointselectionTheBack-ShuandFront-Mupointsofthekidneyandbladderareselectedasthemainacupoints.TheacupointsoftenselectedareShenshu(B23),Pangguangshu(B28),Zhongji(Ren3),Guanyuan(Ren4),Mingmen(Du4),Huiyang(B35),Sanyinjiao(Sp6)andZusanli(S36).2)穴位選擇主穴是腎和膀胱的背俞穴和募穴。常用穴位有：腎俞，膀胱俞，中極，關(guān)元，命門，會陽，三陰交，足三里。2)PointselectionThekidneyisexteriorly-interiorlyrelatedtothebladder,sotheBack-Shupointsofthekidneyandbladderareapplied.Zhongji(Ren3)istheFront-Mupointsofthebladder.Thecombineduseoftheabovethreeacupointscontributestoreinforcekidneyqiandimprovevesicalrestrainingfunction.腎和膀胱相表里，故選腎和膀胱的背俞穴。中極是膀胱的募穴。三穴合用有助于補益腎氣，固脬止遺。2)PointselectionGuanyuan(Ren4)andMingmen(Du4)arethesourcesofprimordialqiandacupunctureofthemcantonifyprimordialyang(kidney-yang).Huiyang(B35)istheacupointofthefoot-taiyangmeridianandacupuinctureofitcaninvigoratethemeridionalqiofthebladder.關(guān)元、命門是元氣之源，針之能補腎益元。會陽是足太陽經(jīng)穴位，針之能振奮膀胱之經(jīng)氣。2)PointselectionSanyinjiao(Sp6)isthecrossingpointofthethreefoot-yinmeridiansandacupunctureofitcanregulatetheqiofthethreefoot-yinmeridians.Zusanli(S36)belongstotheyangmingmeridian,whichisfullofqiandblood,andacupunctureofitcantonifyqitostopincontinence.三陰交是足三陰經(jīng)交會穴，針之能調(diào)節(jié)足三陰經(jīng)氣。足三里屬陽明經(jīng)，陽明經(jīng)多氣多血，針之能補氣止遺。3)ShortcomingBecauseitusesageneralmethodofacupuncture,itisdifficultforconventionalacupuncture,likeelectricalnervestimulation,toimprovetheabilityincontrollingurinationbyexcitingthepudendalnerve,inducingtherhythmiccontractionofthepelvicfloormusclesandincreasingtheirstrength.3)不足之處因采用一般針刺方法，故難以象神經(jīng)電刺激療法那樣通過興奮陰部神經(jīng)誘發(fā)盆底肌節(jié)律性收縮，增強盆底肌肉力量來改善控尿能力。3.ElectroacupuncturepudendalnervestimulationBycombiningtheadvantagesofPFMEandTESandincorporatingthetechniqueofdeepinsertionoflongneedles,wedevelopedelectracupuncturepudendalnervestimulation(“Foursacralpoints”electracupuncturetherapy),whichisacombinationoftraditionalChineseandWesternmedicine.3.電針陰部神經(jīng)刺激療法綜合PFME和TES二種療法優(yōu)點，融入針灸長針深刺技術(shù)，我們發(fā)展成了(中西醫(yī)結(jié)合的)電針陰部神經(jīng)刺激療法（電針“骶四穴”療法）。3.ElectricalpudendalnervestimulationInthistherapy,foursacralspecificpointsareacupuncturedbyaspecialneedlingmethod(theneedletipinaspecificdirection)andelectrified3.電針陰部神經(jīng)刺激療法該療法對骶部四個特定穴位采用特殊針刺方法（針尖向特定方向）并加以電刺激3.Electricalpudendalnervestimulationtoimprovetheabilityincontrollingurinationbyexcitingthepudendalnerveandinducingtherhythmiccontractionofthepelvicfloormuscles(includingtheurethralsphincter)tostrengththemuscles,restorethenormalpositionsofbladderneckandproximalurethraandincreaseurethralclosurepressure.能直接興奮陰部神經(jīng)誘發(fā)盆底?。ò虻览s?。┕?jié)律性收縮，從而增強盆底肌肉力量，恢復(fù)膀胱頸部和近端尿道的正常位置，提高尿道關(guān)閉壓來改善控尿能力。Foursacralpoints

骶四穴Locationoffoursacralpointsandacupuncturemethods1)Thetwoupperpoints:locatedbythetwoedgesofthesacrumonalevelwiththefourthsacralforamina;定位和針刺方法1）上兩針刺點：骶骨邊緣旁，平第4骶后孔水平處（雙側(cè)）。Foursacralpoints

骶四穴Locationoffoursacralpointsandacupuncturemethods1)Thetwoupperpoints:usealongneedleof4cun(100mm);punctureperpendicularly3~3.5cunindepth;maketheneedlingsensationreachtheurethraoranus.使用4寸長針直刺，針刺深度為3-3.5寸，使針感達尿道或肛門。Foursacralpoints

骶四穴Locationoffoursacralpointsandacupuncturemethods2)Thetwolowerpoints:0.5cunbilateraltothetipofthecoccyx;usealongneedleof4or5cun(100or125mm);2）下兩針刺點：尾骨旁開0.5寸（雙側(cè)），使用4寸或5寸長針，F(xiàn)oursacralpoints

骶四穴Locationoffoursacralpointsandacupuncturemethods2)Thetwolowerpoints:punctureobliquely(laterally)towardstheischiorectalfossa,3~4.5cunindepth;maketheneedlingsensationreachtheurethra.向外側(cè)（坐骨直腸窩）斜刺，3-4.5寸深，使針感達尿道。ElectricalpudendalnervestimulationAftertheneedlingsensationreferredtotheabove