| Nonnal micturition requires a coordinated event of the neuronal circuits from the brain and spinal cord to the smooth muscle in the bladder and urethra.The sympathetic,parasympathetic and peripheral nerve together participate in the reflex.Any damage to nerve associated xwith urination can cause voiding dysfunction,which is called neurogenic bladder(neurogenic bladder,NB).NB is the function disorder of the bladder and/or urethra caused by neuropathy or damage to nerv e,often go with uncoordinate of bladder and urethra.The most common urinary symptooms such as voiding difficulty or urinary retention can be complex.NB is the common complication and clinical problems after spinal cord injury(spinal cord injury,SCI).The symptoms of SCI patients can be divided into different types according to the different section of the injuried spinal cord,usually as follows:1)Detrusor hyperreflexia;2)Detrusor areflexia.And then the complications such as renal failure,kidney and bladder stones,bladder cancer,urinary tract infection(UTI)and ureteral reflux(VUR)will increase the risk of death.Therefore,for the paralysed SCI patients,restore bladder function even more important than restore movement function.Recent research on NB after SCI expounded the lack of safety and effective treatment and that electropuncture can prevent or reduce the secondary damage after SCI and promote the repair and regeneration of the injuried spinal cord.But the mechanism of the treatment with electropuncture for SCI has not been completely uncovered and the stimulation intensity hasn't been finalized as a standard.It's neither the recovery of the up and down neurons electrophysiological function nor the reconstruction of the tracts,so can not be the functional replacement of the damage parts and also can not completely rebuild the bladder function.NB after SCI belongs to the category of dysuria in traditional Chinese medicine.The basic research has proved that Jisheng Shenqi wan have effect in adjusting the bladder pressure and regulating the metabolism,nervous and immune function.So we treat NB after SCI with sacral electropuncture combining with the advantages of Chinese medicine.Under the guidance of TCM syndrome differentiation we chose.Jisheng Shenqi wan to treat NB after SCI,aiming at reducing bladder infection and protecting the function of bladder and kidney,promoting the reconstruction of bladder function.The study comprises three sections:literature review about NB after SCI,animal experiment and clinical urine dynamics analysis.To discussed and evaluated the animal model,the effect of the treatment combining sacral electropuncture with Jisheng Shenqi wan on NB after SCI and preliminary discuss on the molecular mechanism of the bladder functional improvement in the NB rat after SCI.To provide new method and train of thought on clinical treatment for NB after SCI.Part 1 Literature reviewThis paper formulates the epidemiology,pathology,physiology,classification,diagnosis and treatment and the theoretical basis of TCM,Chinese medicine therapy,acupuncture and other treatments of TCM fr-om western medicine and TCM on NB after SCI,and expounds the progress of and summarize the advantages and disadvantages of' the traditional Chinese and western medicine treatment on NB after SCI.Part 2 Animal experiment 1Objective To establish the ideal animal model of neurogenic bladder after spinal cord injury and evaluate the state of the bladder.Methods Sixteen female SD rats were grouped linto control group and the experimental group(T9 spinal cord transection injury model),according the record of the daily artificial urine output to evaluate the neurogenic bladder recovery after spinal cord injury.After two weeks the simultaneous recording of the intravesical pressure were used to detect,compare and assess the state of bladders of the two groups.Results In a week postoperatively,the daily artificial urine output increased and reached maximum.A week later postoperatively,the daily artificial urine output was on the gradually decrease and stable during the two weeks.The values of the parameters of the maximum bladder pressure,the basis bladder pressure,voiding threshold,bladder capacity,voiding efficiency in the control group and experimental group respectively were(26.60±4.31)mmH2O and(21.66±2.56)mmH2O,(11.66±2.33)mmH2O and(14.72±2.56)mmH2O,(20.46±0.52)mmH2O and(16.99±0.81)mmH2O,(1.36±1.58)min and(2.02±0.36)min,(0.82±0.15)ml and(2.20±0.24)ml,(92.67± 1.97)%and(25.33±4.46)%.The differences were statistically significant(P<0.05).Conclusion The neurogenic bladder rat model of T9 level spinal cord transection injury with a strong maneuverability and easy to quantify,repeatable.With the correct postoperative nursing care,there were fewer complications and low mortality.The recording of daily artificial urine output and the intravesical pressure can be good ways to detect the spinal cord recovery and evaluate the status of the bladder.Part 3 Animal experiment 2Objective To study the interventional effect of treatment by electropuncture combined with Jisheng Shenqi wan on the NB after SCI rats' bladder and renal function and preliminary discuss the molecular mechanisms of injury repair.Methods Randomly selected 8 rats in 50 female SD rats as A group(sham group),modling the other 42 rats with T9 spinal cord transection injury.2 weeks later randomly selected 8 rats in the survival of 39 NB modle rats as group B(control group).Divided the rest 31 rats in accordance with the random number table into 3 groups:11 rats in group C(TCM group)and 10 rats in group D(electric acupuncture group,EA group)and 10 rats in group E(TCM and EA group).Group A hadn't been any intervention.After modling the group B hadn't been any intervention.Rats in the Group C were intragastrically administered the self-manufactured Jisheng Shenqi wan decoction and shame EA.Rats in the Group D were intragastrically administered distilled water and sacral 2 nerve EA.Rats in the Group E were intragastrically administered the self-manufactured Jisheng Shenqi wan decoction and sacral 2 nerve EA.Observate and record the deaths of rats during the experiment.Weight the rats respectively in pre-experiment,4 days,2 weeks and 4 weeks after intervention.After the experimental rats were killed,weigh the bladder.Whole blood was collected 2 weeks after intervention the orbit of rats to determinate blood serum creatinine,blood urea nitrogen,urine trace albumin.Take T8-T10 and S2 nerve root on both sides of the spinal cord for detecting Western blot.Results There were 9 rats died during the experiment,including 3 rats died in the procession of modling and the other 6 rats died in the procession of intervention and sampling.They were 3 rats in group C,1 rat in group D and 2 rats in group E.(1)General situation:group E can improve weight loss of rats after SCI obviously(P<0.05).There was no statistical difference in the bladder weight and final artificial urine output between the control group and treatment groups(P>0.05).(2)There was no statistical difference in serum creatinine between the control group and treatment groups(P>0.05).2 weeks after the intervention,group E can significantly reduce the level of urea nitrogen in rats after SCI,compared with the control group(P<0.05).The urine trace albumin in group C,D,E was significantly detected than that of the control group(P<0.05).(3)The bladder HE staining:group C,D,E group can significantly improve bladder structure of the NB rats after SCI.Specific performance in alleviating bladder wall muscle layer and mucosa edema,congestion and inflammatory cell infiltration,reducing the degree of hyperplasia of muscular layer.And group E performed the best.(4)The simultaneous recording of the intravesical pressure measurement:group D and E can significantly reduce the bladder capacity of NB rats after SCI,compared with the control group(P<0.05).(5)Detecting the expression of related factor protein by Western Blot:group C and group E can significantly improve the expression of NGF and its receptor TrkA in the spinal cord tissue of NB rats after SCI and reduce that in the nerve root tissue.Group D can significantly improve expression of TrkA in spinal cord tissue of NB rats after SCI at the same time reduce that in the nerve root tissue(P<0.05).Conclusion(1)Electrouncture combined with Jisheng Shenqi won can improve the weight,renal function,bladder histopathological changes and bladder capacity of the NB rats after SCI.(2)Electrouncture combined with Jisheng Shenqi wan can improve the expression of NGF and its receptor TrkA in the spinal cord tissue of NB rats after SCI and reduce that in the nerve root tissue.It may be one of the mechanism of improving the bladder function of NB rats after SCI.Part 4 Clinical analysisObjective To analyse the characteristics of urine dynamics study in different NB after SCI patients according to the different damaged section of spinal cord.Methods 113 outpatient or ward cases were collected from October 2014 to December 2016 in image urine dynamics test center of China rehabilitation research center Beijing charity hospital.They were divided into two groups:damage above sacral vertebral group and sacral vertebral injury group according to the injuried section of patients.The urine dynamics study index maximum bladder capacity,residual urine volume were compared and detrusor areflexia,detrusor hyperactivity,increased compliance,reduced compliance,bladder paresthesia,vesicoureteral reflux in the image urine dynamics study were observed in the two groups of patients.Results There was no statistical difference in two groups of patients' urine dynamics study index maximum bladder capacity,residual urine volume(P>0.05).The incidence of detrusor areflexia,detrusor hyperactivity,increased compliance,reduced compliance,bladder paresthesia and vesicoureteral reflux in patients with damage above the sacral vertebral respectively were 34.7%,36.8%,9.5%,44.2%,55.8%,63.2%,while that of patients with sacral vertebra injuried respectively were 85.7%,21.4%,21.4%,21.4%,28.6%,71.4%.Detrusor areflexia was more obvious in sacral vertebra injuried patients than in patients with damage above sacral vertebral.And so as the incidence of vesicoureteral reflux.But the incidence of bladder paresthesia was significantly lower than the patients with damage above sacral vertebral(P<0.05).Conclusion Patients with damage above sacral vertebral mainly manifest as bladder paresthesia,detrusor areflexia and vesicoureteral reflux were the main manifestations of patients with sacral vertebra injuried. |
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