Pathophysiology and Management of Sphincter Dyssynergia

(1)肌电研究：对73例患者同时记录外括约肌肌电和膀胱压力。患者存在Shincter协同障碍(SD)。通过检查整个排尿过程中SD的模式，有可能像Blaivas所做的那样将其分类为三种不同的类型。1型7例，2型10例，3型47例。9例患者有协同的尿道括约肌活动(0型)。以残余尿率评价的排尿功能障碍随着类型从1增加到3有增加的趋势。运动单位分析显示，膀胱可控期记录的单位消失(AO)、减少(AI)，并在有(B1)或不(BO)招募新单位的排尿尝试中保留或增加其活动(A2)。A0B1型3例，A1B1型7例，A2B1型32例，A2B0型4例，A1B0型2例随着运动单位亚型从A0变为A1和A2，更多的功能会恶化。对这些运动单位活动的分析表明，可控性反射的异常(即通过膀胱和尿路的松弛反射失效和通过尿路的收缩反射使尿路过度)可能与SD的发生有关。根治性TUR-P后，SD型或其亚型均有改善，并伴有残余尿率下降。EUS对α-肾上腺素能刺激的反应是增加预先存在的运动单位的频率和招募新的运动单位。在根治性TUR-P后，EUS在α-肾上腺素刺激下也同样被激活。提示根治性TUR-P通过抑制或消除异常的可控性反射而有效地缓解SD。此外，EUS的α-肾上腺素能激活似乎也可能在SD的发生中起交感神经作用，但其参与EUS的躯体运动神经支配的确切方式仍有待确定。(2)人前列腺中的α_1-肾上腺素能受体：用配备测微尺的光学显微镜进行颗粒计数，对α_1-肾上腺素能受体的放射自显影分布进行定量。特异性结合主要见于周围带(PZ)的纤维肌间质、中央区(CZ)的纤维肌间质和前列前括约肌。PZ的腺上皮和尿道腺未见特异性结合。CZ的腺上皮有少量的特异性结合。在纤维肌部中，CZ和前列前括约肌的特异性结合均显著高于PZ。CZ腺体上皮细胞的特异性结合明显低于PZ的纤维肌肉间质。这些结果表明，人前列腺的α_1-肾上腺素能受体的分布具有地带性差异，可能反映了这些区域的某些功能差异。较少

(1) Electromyographic study :Simultaneous recordings of electromyography of the external urethral sphincter (EUS) and bladder pressure were performed in 73 patients. Shincter dyssynergia (SD) was noted in 64 patients. By examining the patterns of SD throughout the voiding, it was possible to calssify them into three distinct types as done by Blaivas. Type 1 was found in 7 patients, Type 2 in 10 patients, and Type 3 in 47 patients. Synergic urethral sphincter activity (Type 0) was found in other 9 patients. Voiding dysfunction as evaluable by residual urine rate tended to increase as the type deteriorated from 1 to 3. Analysis of motor units revealed that the units noted during continent phase of the bladder disappeared (AO), decreased (AI), and retained or rather increased their activity (A2) during voiding attempt with (Bl) or without (BO) recruitment of new units. A0B1 was found in 3 patients, A1B1 in 7, A2B1 in 32, A2B0 in 4, and A1B0 in 2. Again there was a tendency for voiding fun … More ction to deteriorate as motor units sub-type changed from A0 to A1 and A2. The analysis of these motor units activities suggested that abnormal continence reflex (i. e. failure of vesicourethral and urethrourethral relaxation reflex and exaggeration of urethrourethral contraction reflex) might be contributing to the genesis of SD. After radical TUR-P, there was an improvement in the type of SD or in its sub-types associated with decrease in residual urine rate. EUS responded to alpha-adrenergic stimulation with an increase in the frequency of pre-existing motor units and recruitment of new motor units. After radical TUR-P, EUS was similarly activated when stimulated with alpha-adrenergics. These data indicated that radical TUR-P was effective in relieving SD by suppressing or abolishing abnormal continence reflex. Moreover, alpha-adrenergic activation of EUS also seemed to suggest a possible sympathetic role in the genesis of SD, although exact mode of its involvement in the somatomotor innervation of the EUS remains to be settled.(2) alpha_1-adrenoceptors in human prostate :Autoradiographic distribution of alpha_1-adrenoceptor was quantitated by grain counting using a light microscope equipped with a micrometer. Specific binding was demonstrated predominantly in fibromuscular stroma of peripheral zone (PZ), fibromuscular stroma of central zone (CZ) and preprostatic sphincter. No specific binding was demonstrated in glandular epithelium of PZ and periurethral gland. Glandular epithelium of CZ showed a few specific bindings. Among fibromuscular portion, specific bindings in both CZ and preprostatic sphincter were significantly higher than in PZ. Specific binding in glandular epithelium of CZ was significantly less than in fibromuscular stroma of PZ. These results show that the human prostate has a zonal difference in the distribution of alpha_1-adrenoceptors, probably reflecting some functional difference in these regions. Less