Pathophysiology and Management of Sphincter Dyssynergia

(1)肌电图研究：同时记录73例患者尿道外括约肌（EUS）肌电图和膀胱压力。64例患者出现筋膜协同功能障碍。通过检查整个排尿过程中的SD模式，可以将其分为Blaivas所做的三种不同类型。1型7例，2型10例，3型47例。另外9例出现协同性尿道括约肌活动（0型）。以残尿率评价的排尿功能障碍随着类型从1到3的恶化而增加。运动单位的分析显示，在排尿过程中，无论是否有（Bl）或（BO）新单位的招募，膀胱禁尿期注意到的单位消失（AO），减少（AI），保留或更确切地说增加了它们的活动（A2）。A0B1 3例，A1B1 7例，A2B1 32例，A2B0 4例，A1B0 2例。当运动单元亚类型从A0变为A1和A2时，更多的动作退化。运动单元活动分析提示尿失禁反射异常（膀胱尿道和尿道尿道松弛反射失败，尿道尿道收缩反射过度）可能与SD的发生有关。根治性turp治疗后，SD类型或其亚型的改善与残尿率的降低有关。EUS对α -肾上腺素能刺激的反应是原有运动单元的频率增加和新运动单元的增加。在根治性turp后，EUS同样在α -肾上腺素能刺激下被激活。这些数据表明根治性turp通过抑制或消除异常的失禁反射来有效缓解SD。此外，EUS的α -肾上腺素能激活似乎也表明在SD的发生中可能有交感作用，尽管其参与EUS的体运动神经支配的确切模式仍有待解决。(2)人前列腺α _1-肾上腺素能受体：利用配备千分尺的光学显微镜，采用颗粒计数法定量测定α _1-肾上腺素能受体的放射自显像分布。特异性结合主要表现在外周区纤维肌间质（PZ）、中心区纤维肌间质（CZ）和前列腺前括约肌。PZ和尿道周围腺的腺上皮未见特异性结合。CZ腺上皮显示少量特异性结合。在纤维肌肉部分，CZ和前列腺前括约肌的特异性结合明显高于PZ。CZ的腺上皮特异性结合明显少于PZ的纤维肌基质。这些结果表明，人类前列腺中α _1-肾上腺素受体的分布具有地域性差异，可能反映了这些区域的功能差异。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