Kuo Hann-Chorng
Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan.
Tzu Chi Med J. 2024 May 24;36(3):260-270. doi: 10.4103/tcmj.tcmj_29_24. eCollection 2024 Jul-Sep.
Neurogenic lower urinary tract dysfunction (NLUTD) is common in patients with central nervous system (CNS) lesions. Cases of cerebrovascular accidents (CVA), Parkinson's disease, dementia, and other intracranial lesions develop poor bladder control with or without urinary difficulty due to loss of cortical perception of bladder filling sensation and poor coordination of urethral sphincter relaxation during reflex micturition. Patients with CNS lesions usually have overactive bladder (OAB) symptoms, including urgency, frequency, incontinence, voiding symptoms of dysuria, large postvoid residual volume, and retention. In elderly patients with severe CNS disease the OAB symptoms are usually difficult to adequately relieve by medical treatment, and thus, their quality of life is greatly. Botulinum toxin A (BoNT-A) is currently licensed and has been applied in patients with idiopathic and neurogenic OAB due to spinal cord injury or multiple sclerosis. However, the application of BoNT-A in the treatment of urinary incontinence due to NLUTD in chronic CNS lesions has not been well-documented. Although cohort studies and case series support BoNT-A treatment for neurogenic OAB, chronic urine retention after intravesical BoNT-A injection for OAB and exacerbated urinary incontinence after urethral BoNT-A injection for voiding dysfunction have greatly limited its application among patients with NLUTD due to CNS lesions. This article reviews the pathophysiology and clinical characteristics of NLUTD in patients with CNS lesions and the clinical effects and adverse events of BoNT-A injection for patients with NLUTD. A flowchart was created to outline the patient selection and treatment strategy for neurogenic OAB.
神经源性下尿路功能障碍（NLUTD）在中枢神经系统（CNS）病变患者中很常见。脑血管意外（CVA）、帕金森病、痴呆和其他颅内病变的患者，由于膀胱充盈感觉的皮质感知丧失以及反射性排尿期间尿道括约肌松弛的协调性差，无论有无排尿困难，都会出现膀胱控制不佳的情况。CNS病变患者通常有膀胱过度活动症（OAB）症状，包括尿急、尿频、尿失禁、排尿困难的排尿症状、大量排尿后残余尿量和尿潴留。在患有严重CNS疾病的老年患者中，OAB症状通常难以通过药物治疗得到充分缓解，因此，他们的生活质量受到很大影响。肉毒杆菌毒素A（BoNT-A）目前已获许可，并已应用于因脊髓损伤或多发性硬化症导致的特发性和神经源性OAB患者。然而，BoNT-A在慢性CNS病变导致的NLUTD所致尿失禁治疗中的应用尚未得到充分记录。尽管队列研究和病例系列支持BoNT-A治疗神经源性OAB，但膀胱内注射BoNT-A治疗OAB后出现的慢性尿潴留以及尿道注射BoNT-A治疗排尿功能障碍后尿失禁加重，极大地限制了其在CNS病变导致的NLUTD患者中的应用。本文综述了CNS病变患者NLUTD的病理生理学和临床特征，以及BoNT-A注射治疗NLUTD患者的临床效果和不良事件。绘制了一个流程图来概述神经源性OAB的患者选择和治疗策略。
