Urinary incontinence is due to fear of bladder sphincter damage or neurological dysfunction and loss of urinary self-control Shanghai ability to urinate involuntarily out. The causes of urinary incontinence patients can be divided into the following: ① congenital disorders such as urethral cleft ② trauma such as women’s birth trauma pelvic fractures, etc. ③ extraordinary surgery in adults for prostate surgery know urethral stricture repair, etc.; chronic children for posterior urethral valve surgery more said, etc. ④ various links caused by neurogenic bladder and due to the control of the central or peripheral nerves of the bladder caused by urinary dysfunction, called neurogenic voiding disorder, also known as neurogenic bladder. In this article, we will only discuss the typology of neurogenic voiding disorder and the combination of Chinese and Western medicine rehabilitation treatment.
A. Innervation of the bladder and urethra.
The bladder is a muscular organ for urine storage, the bladder wall is composed of smooth or forced urinary muscle, in the bladder and urethra connection, that is, around the urethral orifice, there is smooth muscle composition of the urethral sphincter; in the urethral membrane, that is, the urethra through the urethral genital diaphragm, there is the external urethral sphincter, this is the transverse muscle. The nerves distributed to the bladder include four parts: sympathetic, parasympathetic, somatic motor and visceral sensory nerves.
1, sympathetic nerve preganglionic neurons located in the thoracic 11 to lumbar 3 lateral angle, through the nerve before the heel, white traffic and sensory ganglion, to the abdominal aortic plexus, infra-abdominal plexus, infra-abdominal nerve and infra-abdominal plexus, forming synapses in the plexus, its postganglionic fibers hit the bladder, so that the detrusor muscle is retarded, the internal urethral sphincter contraction, the urine stored in the bladder.
2.Parasympathetic nerve The preganglionic neurons are located in the lateral angles of the second to fourth sacral nerve roots and the pelvic visceral nerve through the pelvic plexus into the bladder wall, after forming a protrusion in the ganglion of the bladder, the postganglionic fibers are directly distributed with the forceps and the internal urethral sphincter, causing the forceps to contract and the sphincter to open when excited, resulting in urination.
3.Pubic nerve is a somatic motor nerve that originates from the motor cells of the anterior horn of sacral 2 to sacral 4, and is distributed to the external sphincter of the urethra, which can control the contraction of the external sphincter at will.
4.Sensory nerve The visceral sensory nerve fibers originating from the bladder, part of the age of the pelvic visceral nerve into the sacral medulla, the posterior horn of the corresponding segment, mainly conduct the sense of bladder distension and part of the pain; the other part of the fibers with the sympathetic nerve into the lumbar medulla, mainly conduct the pain. It can be seen that the sensation of conduction of urination is mainly via the pelvic visceral nerve.
Two, bladder reflex
The bladder reflex is a complex reflex activity. The bladder muscle has a certain stretch, so when the volume of urine in the bladder reaches 100~150ml, there can be a sense of urination, and when 300~400ml, there is a feeling of urination. The urinary activity of the bladder is controlled by the higher cortical centers of the brain and when the lesion involves these peripheral or central nerves, it causes neurogenic bladder.
Third, the subtype of neurogenic bladder
1, no inhibitory bladder lesions are located in the paracentral lobule of both cerebral hemispheres or their inferior cone bundle. Commonly seen in cerebral hemorrhage, cerebral infarction, superior sagittal sinus thrombosis, meningioma near the superior sagittal sinus, multiple sclerosis, etc. Clinical manifestations: urinary urgency, inability to control urination at will, and immediate urination once the urge to urinate arises. The incontinence of urination is sudden, and the volume of urine is small but frequent each time, but the force of bladder sensation and sending urine and urine line are normal, and there is no residual urine.
2, sensory loss bladder lesions located in the posterior root and posterior cord, seen in multiple sclerosis, spinal cord cavitation, and spinal consumption. Clinical manifestations: loss of bladder sensation, extreme weakness in urination, only slow overflow, increased bladder capacity up to 1000 ml, and large amount of residual urine.
3, motor paralysis type bladder lesions located in the efferent pathway of the urinary reflex, seen in poliomyelitis and polyradiculoneuritis, etc.. The symptoms of these patients are basically the same as those of sensory bladder dysfunction, except for normal bladder sensation and a sense of distension, i.e., urinary retention and overflow incontinence, large bladder volume, large residual urine, and weakness in urination.
4.Reflex bladder dysfunction The lesion is located above the sacral medulla, such as transverse trauma, infection or tumor of the cervical, thoracic and lumbar segments of the spinal cord. It is manifested in the shock period, where the urinary reflex disappears and urinary retention occurs. After the shock period, periodic urination occurs, that is, when the urine volume accumulates to a certain amount, it causes a reflex urination, and urination is sudden and uncontrollable.
5.Automatic bladder dysfunction Lesions are located in the sacral medulla or cauda equina, commonly due to trauma, infection, tumor and spinal cord membrane bulge and cauda equina tumor in the conus of the spinal cord. The bladder does not have any sensation and is controlled by the bladder nerves around the bladder or by the postganglionic neurons in the bladder wall to make the contraction of the detrusor muscle to complete the urination action. However, the contraction force of the detrusor muscle is still very insufficient, and urination is weak, so it is necessary to use the abdominal muscle or press the abdomen by hand to help send urine.
IV. Bladder function training
Good bladder care can not only improve the function of urination, but also understand the patient’s psychological stress and prevent the occurrence of bed sores, which is beneficial to the overall recovery. The purpose of bladder hopping training is to maintain normal bladder contraction and diastolic function, retrain reflex bladder, no serious ureteral bladder reflux and urinary tract infection is controlled only when
1. indwelling catheter method. Use the method of opening the catheter regularly to allow proper filling and emptying of the bladder to promote the recovery of the muscle capacity of the bladder wall. Steps: ① Open the catheter regularly, depending on the amount of water drunk during the day, open the catheter once every 2 to 3 hours. When opening the catheter, ask the patient to make urinary movements, actively increase abdominal pressure or press the lower abdomen with your hand to make urine discharge, and keep the catheter open after sleep. ②Tell the patient and family members about urinary premonitions or signals, such as flushing, chills, goose bumps or cold sweat, etc. If this sign is present, urine should be released once. ③The extubation test is performed by instilling sterile saline at 37°C after first draining the urine. Until it cannot be instilled (< 400ml), then drain the saline to test its bladder capacity; then perform the ice water test by instilling sterile physiological saline at 5 to 8 degrees for 50 to 100rnl and then withdraw the catheter, if the saline can be immediately relieved, it means that the pelvic nerve conduction function is good and there is coordination between the forced urinary muscle and external sphincter. When the bladder has a certain volume (> 150ml) and the ice water test (+), the catheter can be withdrawn and the patient can urinate on his own.
2. Intermittent clean catheterization method. This technique is applied to produce coordination between the training forceps and external sphincter muscles to help patients reduce involuntary urination or monitor residual urine volume to solve long-term urinary incontinence problems and maintain the health of the urinary tract. ① wash hands with soap (especially the ends of the fingers should be cleaned and no nails should be left), and after three cleanings, the patient is placed in a semi-recumbent or sitting position and the external urethral opening is scrubbed from the inside out with a hand-held saline cotton ball; ② hold the catheter (catheter is usually chosen to be thinner 10 to 12 gauge) through the fresh bag in your hand, apply lubricant to the front of the catheter and insert the catheter slowly into the urethra (female patients can be placed between their legs A mirror); ③ insert the catheter into the bladder, the urine will flow into the fresh bag, and the catheter will be removed after the bladder is emptied; ④ the number of catheterization depends on the situation, generally when training, 4-6 hours / time, before sex and sports, should be temporarily catheterized once. Patients should try active urination before each catheterization, and if self-catheterization is resumed or reflex bladder has been established and its residual urine volume is <50 ml, catheterization can be stopped.
3. Urinary retention. Regular pressure on the abdomen and intermittent pressure with the hand downward and backward can be tried to make urine discharge from the bladder, and also try to listen to the sound of running water, acupuncture, etc. If it is ineffective, one-time catheterization is feasible; for those with cloudy urine, consider urine to drain the retained sediment, urinary tract infection, and catheter incompetence, etc. A urinary catheter should be left in place and the bladder flushed twice a day, or a small dose of medication bladder retention.
V. Acupuncture therapy
1, milli-needle therapy
A Treatment of urinary incontinence: Kidney Yu, Huiyang, Baihui, Si Shenchong, Hegu.
Operation: kidney Yu, Huiyang acupuncture sensation transmission want to Huiyin, once a day, each time to keep the needle 30 minutes
B Treatment of urinary retention: secondary liao, middle liao
Operation: secondary liao, zhong liao needle sensation transmitted to the vulva, once a day, each time retaining the needle for 30 minutes
VI. Chinese medicine treatment
Urinary incontinence.
1, bladder deficiency cold – shrink spring soup
Wu yao 20 g, ginseng 30g
2, heart and spleen deficiency – mulberry cuttlebone san
Mulberry cuttlebone 18 g Farmer’s mantle 12 g Calamus 12 g Dragon bone 30 g Radix et Rhizoma ginseng 18 g Poria 12 g Radix Angelicae Sinensis 18 g Turtle shell 30 g
3, deficiency of middle energy – tonifying the middle and benefiting the qi Tang
Astragalus membranaceus 40 g Glycyrrhiza glabra 20 g Radix Codonopsis pilosulae 20 g Radix Angelicae Sinensis 15 g Radix Angelicae Sinensis 12 g Radix et Rhizoma Polygonati 12 g Radix bupleurum 12 g Atractylodes macrocephala 12 g
Urinary retention: 1 Dampness and heat in the bladder-Bazheng San
Slippery Rock 30 g Moutong, Plantago ovata 10 g each, Gao Cao, Qu Mai 15 g each, Zhi Mu, Huang Bai, Gardenia, Rhubarb 12 g each
2.Heat in the lung-clearing lung drink
Scutellaria baicalensis, Morinda citrifolia, Gardenia jasminoides, Mai Dong, Poria cocos, North almond 12g each, Mouton 10g, Plantago ovata 18g
3.Urinary tract obstruction – Dai Dai Dang Wan
Radix Angelicae Sinensis, peach kernel, safflower, poria, psyllium, zedoary 15g each Rhubarb 12g Andrographis paniculata 20g
4, deficiency in the middle energy – tonifying the middle energy soup
Astragalus Membranaceus 40g Glycyrrhiza Glabra 20g Radix Codonopsis Pilosulae 20g Radix Angelicae Sinensis 15g Radix Angelicae Sinensis 12g Radix et Rhizoma Atractylodes Macrocephala 12g
5. Kidney Yang Qi deficiency-Jisheng Kidney Qi Pill
Radix Rehmanniae Praeparata, Rhizoma Dioscoreae, Rhizoma Zedoariae, Radix Bacopa Monnierae, Poria 15g each Cinnamon 6g Cornu Cervi Pantotrichum, Radix Rehmanniae 12g each Plantago Asiatica, Radix Achyranthes Bidentatae 12g each Mudanpi 10g