Wall L L
Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27710.
Clin Obstet Gynecol. 1990 Jun;33(2):367-77. doi: 10.1097/00003081-199006000-00021.
Detrusor instability is a urodynamic diagnosis made when the detrusor is shown objectively to contract, spontaneously or on provocation, during the filling phase of a cystometrogram while the patient is attempting to inhibit micturition. It often is responsible for symptoms of urgency, frequency, nocturia, urge incontinence, and nocturnal enuresis, but is not synonymous with any of them. Furthermore, it may be responsible for urinary incontinence which appears to be simple stress incontinence, and should be excluded before an operation for genuine stress incontinence is undertaken. Patients with mixed incontinence should have their detrusor instability treated before an attempt at surgical correction of stress incontinence is made. A number of therapeutic options exist for the unstable bladder. The simplest is bladder drill. My own preference is to start patients on bladder drill in conjunction with oxybutynin chloride 5 mg orally three times daily, with the plan of weaning them off the medication if possible in 3-6 months. Propantheline bromide in dosages of 15-30 mg orally four times daily also appears to be effective. Imipramine, in dosages of 25-50 mg orally twice daily, or up to 75 or 100 mg orally at night also may be helpful, especially if the patient suffers from nocturia or nocturnal enuresis. The effects of imipramine appear to be additive to those of other drugs, and this makes it a useful adjunct in therapy. Emepronium bromide and flavoxate hydrochloride appear to be less useful pharmacologic agents. The expected addition within the next few years of terodiline hydrochloride to the drugs available in the United States is likely to improve significantly our ability to treat detrusor instability. The use of prostaglandin synthetase inhibitors in women with perimenstrual exacerbations of their symptoms may be useful on a case-by-case basis. Patients who do not experience improvement with behavioral intervention and pharmacologic treatment may be candidates for electric stimulation therapy or surgery. The efficacy of electric stimulation therapy is diminished in many cases by poor patient acceptance. The most effective surgical treatment for refractory detrusor instability appears to be augmentation cystoplasty, which should be attempted only by a trained reconstructive urologist, and which should be reserved for the most refractory and difficult cases.
逼尿肌不稳定是一种尿动力学诊断，指在膀胱压力容积测定的充盈期，当患者试图抑制排尿时，逼尿肌被客观地显示出自发性收缩或激发性收缩。它常导致尿急、尿频、夜尿、急迫性尿失禁和夜间遗尿等症状，但与其中任何一种症状都不是同义词。此外，它可能是看似单纯压力性尿失禁的尿失禁的原因，在进行真性压力性尿失禁手术之前应排除这种情况。混合性尿失禁患者在尝试手术矫正压力性尿失禁之前，应先治疗其逼尿肌不稳定。对于不稳定膀胱有多种治疗选择。最简单的是膀胱训练。我个人的偏好是让患者开始进行膀胱训练，并同时口服氯化奥昔布宁5毫克，每日三次，如果可能的话，计划在3至6个月内逐渐停用该药物。溴丙胺太林口服剂量为15至30毫克，每日四次，似乎也有效。丙咪嗪口服剂量为25至50毫克，每日两次，或晚上口服高达75或100毫克，也可能有帮助，特别是如果患者患有夜尿或夜间遗尿。丙咪嗪的作用似乎与其他药物的作用有相加性，这使其成为治疗中的一种有用辅助药物。溴化依米普明和盐酸黄酮哌酯似乎是效果较差的药物。预计在未来几年内，盐酸替地那林在美国上市后，将显著提高我们治疗逼尿肌不稳定的能力。对于症状在月经周期加重的女性，使用前列腺素合成酶抑制剂可能在个别情况下有用。经行为干预和药物治疗后无改善的患者可能适合电刺激治疗或手术。在许多情况下，患者接受度差会降低电刺激治疗的疗效。对于难治性逼尿肌不稳定，最有效的手术治疗似乎是膀胱扩大成形术，这只应由训练有素的重建泌尿外科医生尝试，并且应仅用于最难治和最复杂的病例。
