前列冲剂治疗前列腺增生症膀胱逼尿肌收缩功能受损的临床研究

【作者】 张春和；

【导师】 李曰庆；

【作者基本信息】 北京中医药大学 ， 中医外科学， 2002， 博士

【摘要】 良性前列腺增生症（BPH）是常见的老年疾病，是一种复杂的，由多种因素造成的影响绝大多数老年男性生活质量的疾病。进入21世纪后，随着人类预期寿命的延长，患有BPH的男性将继续增多。患BPH之后，可引起膀胱颈梗阻，从而影响泌尿系统的正常功能，产生不同程度的排尿症状，最终引起膀胱及肾脏病变，导致肾功能损害，有的甚至发展为尿毒症而危及生命，严重影响老年人的生活质量。因此，研究与诊治前列腺增生症，选择最有效、最合理、痛苦又小的治疗方案，是每个泌尿科医生所追求的目标。良性前列腺增生症属于中医“癃闭”的范畴，其病位在精室和膀胱，与肾的关系最为密切。年老肾虚为发病之本，瘀阻水道为发病之标，本虚标实是本病的病机特点。BPH发病的基本因素是老龄和功能性睾丸，其引起排尿障碍的病理机制是由增生的前列腺压迫尿道引起尿道前列腺部梗阻（静力因素）、尿道平滑肌肌肉张力增加导致的张力因素（动力因素）以及膀胱逼尿肌功能异常等多种因素引起的。BPH症候群包括膀胱出口梗阻、逼尿肌不稳定及逼尿肌收缩力受损三组症状，其中逼尿肌收缩力受损的程度直接影响到临床诊断、治疗方法选择、疗效评价及预后等问题。因此，从BPH症候群中区别出逼尿肌收缩力受损所致的症状，并通过尿动力学检查对逼尿肌收缩力进行定量分级，根据分级结果对那些西医药治疗效果欠佳的患者采用中医药治疗具有重要的临床意义。目前中医学在治疗良性前列腺增生症方面，形成了自己独特的理论认识，积累了丰富的临床经验，中医药以其可靠的疗效和低毒无毒的优越性，已引起了世人的瞩目。在全世界崇尚自然疗法的今天，积极挖掘传统医药学宝贵遗产，研究开发出针对性强、疗效确切、副作用小的中成药是有广阔前景的。1. 临床调研近年来，对本病的研究论述颇多，然各家临床辨证各执己见，未能对BPH的症候学及辨证规律形成统一认识。由此为了探讨BPH的证候学特点及辨证规律，考察相关因素对BPH的影响，我对152例BPH进行了临床调研。通过对152例前列腺增生症中医辨证分型与B超、尿动力学之间关系的分析，结果发现肾阳虚弱型71例，其BPH多为Ⅱ°增生（46.5%），平均体积为36.8 cm3，残余尿量(RUV)平均小于100ml，膀胱出口梗阻（BOO）有58例为Ⅲ~Ⅵ度梗阻；瘀阻水道型40例，其BPH多为Ⅲ°、Ⅳ°增生（62.5%），平均体积为57.5cm3，RUV明显增多，平均大于100ml，BOO有12例为Ⅲ~Ⅵ度梗阻，严重梗阻(Ⅴ~Ⅵ)26例；而肾阴不足型14例，其BPH多为Ⅰ°增生（50.0%），平均体积为28.3 cm3，RUV也较少，平均为41.4ml，BOO多为0~Ⅱ梗阻(13例)。膀胱收缩功能减弱者以肾阳虚弱和瘀阻水道为主。通过对发病年龄、病程、临床症状、体征和舌脉的调查，结果显示BPH的发病特点是随年龄增大发病率逐渐增高，临床表现特征以排尿困难、尿频、老年退行性症状为主，病理特征以前列腺腺体病理性增生为主，从而证实肾虚血瘀水阻，膀胱气化失司是BPH发病的主要病理机制。通过对BPH内在规律性的探讨，既可以充实中医的辨证论治内容，又可为中医药治疗BPH提供可靠的理论依据，同时还可为中医药治疗该病提供科学的疗效判定标准。2. 临床疗效观察目前治疗BPH有手术、微创和药物等多种手段，但仍无公认的高效药物和成功治疗模式。<WP=4>多数学者认为经尿道前列腺电切术（TURP）是治疗BPH的金标准，但该术式旨在减小前列腺体积，主要消除其静力性因素的影响，而对前列腺体积不大者效果不佳，并给病人带来不同程度的损害，有20～25％的患者需再次手术，其逆向射精发生率达70～75％。临床上发现在BPH患者中，25～30％无BOO，其排尿异常仅反映膀胱功能的异常，如逼尿肌不稳定、逼尿肌收缩功能损害，对这部分患者施行解除BOO的前列腺手术显然是不合理的。因此，对于膀胱逼尿肌功能异常的治疗就显得非常重要。目前的药物治疗主要是针对BPH动力因素和静力因素的，还没有明确针对膀胱逼尿肌功能受损的药物，因此寻求针对性强、疗效确切、副作用小的治疗膀胱逼尿肌收缩功能受损的药物无疑是一项有意义的课题。李曰庆教授长期使用经验方“前列冲剂”治疗BPH临床疗效较好，籍此通过观察其治疗前后尿动力学的变化来探索该方对膀胱逼尿肌的影响，以进一步确定该方治疗的具体环节和临床疗效。结合具体临床实际，采用随机对照的方法，以逼尿肌收缩力分级为极弱（VW）和弱减(W—)、弱加(W+)的前列腺增生症患者为主要观察对象，以通尿灵作对照药，对前列冲剂和通尿灵的疗效和不良反应进行了对比观察。结果共收集60例样本，其中有效样本55例，治疗组36例，对照组19例。两组在年龄、职业、病程等临床一般性资料方面无显著性差异。经过8周（1个疗程）的治疗，临床疗效显示，治疗组临床显效率为33.3%，总有效率为75.0%；对照组临床显效率为15.8%，总有效率为68.4%，两组相比有显著性差异。对疗效进行具体分析，发现治疗组主要在改善逼尿肌收缩力和减少膀胱残余尿量方面优于对照组，经治疗使I-PSS明显降低（与治疗前相比P＜0.001）。未观察到明显的不良反应。通过以上研究表明，BPH的发生发展是多种因素相互作用的结果，在确定本病的治疗方案时应充分考虑逼尿肌更多还原

【Abstract】 Benign prostatic hyperplasia (BPH) is one kind of usual and complicated disease caused by many reasons in the aged. And this disease can influence many old men’s qualities of life. In the 21st century, with the extending of people’s life expectancy, the number of people who get the BPH is on the increase. BPH can result in bladder neck obstruction, which can affect the normal functions of the urinary system, and brings about many urinating symptoms. At last, BPH can lead to the pathological changes of bladder and kidney and the damages of renal functions. Some people’s BPH can even change to the uremia, and affects their qualities of life, critically. So, at present, it is the object of every doctor who has learned something about urology to study and research BPH, and to find the most effective, reasonable and little anguished curing scheme. BPH is belonged to the category of traditional Chinese medicine’s "difficulty in urination". The position of BPH is at the jingshi and the bladder, and, there is a close relation between the BPH and the kidney. The origin of BPH is the deficiency of the old man’s kidney. And the outcome of BPH is the stagnancy of the aqueducts. So, the pathogenesis of BPH is vacuity in origin and excess in superficiality. The basic causes of BPH are the old age and the functional testes. The pathogeneses of BPH why BPH can result in obstacle of urinating are caused by the urethra oppressed by the increasing prostate which can lead to prostatic portion of urethra (static factor), and, tension factor which is caused by increasing muscle tonus of urethra smooth (dynamic factor), and, the disfunction of detrusor urinae of bladder, and etc. The symptom group of BPH includes bladder outflow obstruction, and detrusor instability, and detrusor underactivity. In all these three symptom groups, the degree of detrusor underactivity can make a direct impact on the clinical diagnosis, treatment choosing, curative effect evaluating. So, we can distinguish symptoms of detrusor underactivity from BPH symptom group, and make a quantificational classification, through urodynamic study examination, then, we can find that it is important to treat those patients, whose therapeutic efficacy by modern medicine are below the mark, by TCM, on the basis of classification. At present, TCM has already formed its own theory, and has accumulated abundant experience. And, people have focused attention upon TCM, because of its credibly curative effect and low or no toxin. It has great foreground to energetically search more and more precious TCM heritage, and excogitate some Chinese patent medicine, which has high pertinence, reliably curative effect, and low side-effect.1. The clinical investigationLately, there are many research about BPH, but everyone has his/her own aside, and, until recently, there can not find any unitive comprehension about characteristics of clinical TCM syndromes of BPH and its law of the differentiation of symptoms and signs. So, I studied 152 BPH patients in order to probe into the characteristics of clinical TCM syndromes and the law of the differentiation of symptoms and signs, and, at the same time, I studied other factors that can influence BPH. After analyze 152 patients who have got the hyperplasis of prostate relation of TCM symptoms, the result of brightness mode ultrasonic examination, and the result of Urodynamic study, we can find there are <WP=6>mainly three kinds of TCM symptoms. The first kind of TCM symptoms is the kidney yang vacuity, and there are 71 patients who got this kind of TCM symptoms. And, the degree of the proliferations of the prostates of this kind of patients is often Ⅱ° (46.5%), and the average volume of the prostate of this kind of patients is 36.8 cm3, and the average residual urine volume (RUV) of this kind of patients is below 100ml, and, in all these 71 patients, there are 58 patients whose degree of bladder outflow obstruction (BOO) are Ⅲ~Ⅳ°. The second kind of TCM symptoms is the stagnancy of the aqueducts, and there are 40 patients who got this kin更多还原