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ELEKTRODIAGNOSTIKA MOTENJ MIKCIJE
SACRAL ELECTRODIAGNOSTICS IN PATIENTS WITH LOWER URINARY DYSFUNCTION
Simon Podnar
Inštitut za klinično nevrofiziologijo, Nevrološka klinika, Klinični center, Zaloška 1, 1525 Ljubljana
Ključne besede: elektrodiagnoza; indikacije; motnje mikci-
je; križno živčevje; napotitve
Izvleček – Izhodišča. Elektrodiagnostična preiskava velja za
nadaljevanje klinične nevrološke preiskave (1). Elektrodiagno-
stika križnega živčevja je smiselna le pri bolnikih z motnjami
mikcije, iztrebljanja in spolnimi dejavnostmi, pri katerih su-
mimo, da je vzrok njihovih težav okvara živčevja (2). Razen
tega, da elektrodiagnostična preiskava okvaro dokaže, jo po-
maga tudi natančneje umestiti in določiti njeno težo. Namen
naše raziskave je bil proučiti vzorec napotitev na elektrodi-
agnostično preiskavo križnega živčevja in najdbe preiskave
pri bolnikih z motnjami mikcije.
Metode. Iz arhiva Inštituta za klinično nevrofiziologijo v Ljub-
ljani smo izbrali vse preiskovance, pri katerih je avtor v času
med majem 1997 in decembrom 2002 opravil elektrodiagno-
stično preiskavo križnega živčevja. Vključili pa smo le bolni-
ke z motnjami mikcije (uhajanje ali zastanek seča), pri kate-
rih smo opravili kvantitativno elektromiografijo (EMG) zu-
nanje zapiralke zadnjika. Izmerjene vrednosti parametrov
potencialov motoričnih enot (PME) pri bolnikih smo primer-
jali z našimi normativnimi vrednostmi, izmerjenimi pri 64
kontrolnih preiskovancih (3). Z uporabo opisne statistike smo
proučili podatke o preiskovancih, specializiranosti napotnih
zdravnikov, diagnozah, nevroloških simptomih in znakih ter
elektrodiagnostičnih najdbah.
Rezultati. V opisanem obdobju je avtor opravil kvantitativni
EMG zunanje zapiralke zadnjika pri 203 preiskovancih, od
katerih jih je imelo motnje mikcije 127 (44% moških, starost
13–84 let). Uhajanje seča je bil edini simptom pri 63 bolni-
kih, zastanek seča je bil edini simptom pri 31, oboje, tako uha-
janje kot tudi zastanek, pa je navajalo 35 bolnikov. Urologi
so napotili na elektrodiagnostično preiskavo križnega živčevja
31 bolnikov z motnjami mikcije, družinski zdravniki 30, nev-
rologi 24, proktologi 14, ortopedi in travmatologi 13, gineko-
logi 8, preostalih 7 bolnikov z motnjami mikcije pa so napoti-
li zdravniki ostalih specialnosti. Ob motnjah mikcije je 47 bol-
nikov navajalo uhajanje blata, 40 zaprtje, med 56 s podatki o
spolnih dejavnostih jih je imelo motnje 36 (29 moških). Ob
kliničnem pregledu smo pri 37 bolnikih našli senzibilitetne
motnje perinealno. Kvantitativni EMG zunanje zapiralke zad-
njika je bil patološki pri 39 bolnikih (31%). Od teh je imelo 26
bolnikov ob motnji mokrenja tudi moteno iztrebljanje ali mot-
nje spolne dejavnosti, pri 16 od njih pa smo pri nevrološkem
pregledu našli motnje senzibilitete perinealno. Le 1 bolnik (z
operacijo medvretenčne ploščice v anamnezi) je imel ob izoli-
rani motnji mikcije in povsem ohranjeni perinealni senzibi-
liteti patološki kvantitativni EMG zunanje zapiralke zadnji-
ka. Med 87 bolniki, ki so imeli ob motnji mikcije bodisi dodat-
no križno motnjo (moteno iztrebljanje ali spolne motnje) ali
pa moteno perinealno senzibiliteto pri kliničnem pregledu,
smo pri 38 bolnikih (44%) našli patološki kvantitativni EMG.
Med bolniki z abnormnim rezultatom elektrodiagnostične pre-
POSTERJI
Key words: electrodiagnosis; indications; micturition dis-
orders; sacral nervous system; referrals; urinary dysfunction
Abstract – Background. Electrodiagnostic studies are regar-
ded as a continuation of clinical neurological examination
(1). They are thought to be useful in patients with urinary,
bowel or sexual dysfunction in whom peripheral sacral ner-
vous system lesion is suspected (2). In addition to demonstra-
ting the lesion, these tests can help localise it and assess its
severity. The aim of the present study was to analyse the refer-
ral pattern and findings in the patients with lower urinary
dysfunction referred for electrodiagnostic evaluation.
Methods. From the database of our tertiary referral centre,
all examinees from May 1997 to December 2002 in whom the
author performed sacral electrodiagnostic studies for routi-
ne diagnostic purposes, were identified. Patients with lower
urinary dysfunction (incontinence or retention) in whom qu-
antitative electromyography (EMG) of the external anal
sphincter (EAS) muscle was performed, were included. The
values of motor unit potential (MUP) parameters obtained
in patients were compared with published normative data
(3). Data on examinees, specialities of referring doctors, dia-
gnoses, symptoms and signs on neurological examination,
and electrodiagnostic findings were evaluated using descrip-
tive statistics.
Results. During the defined period, sacral electrodiagnostic
studies – including valid quantitative EMG of the EAS – were
performed in 201 patients. Of them, 127 had lower urinary
dysfunction (44% men, 13–84 years of age) and were thus
eligible for the study. Urinary incontinence was the only com-
plaint in 63 patients, urinary retention in 31, while both, in-
continence and retention, was reported by 35. Thirtyone pa-
tients were referred by urologists, 30 by family doctors, 24 by
neurologists, 14 by proctologists, 13 by orthopaedic or trau-
ma surgeons, 8 by gynecologists, and remaining 7 by other
physicians. In addition to lower urinary dysfunction, 47 pa-
tients reported faecal incontinence, 40 constipation, and 36
(29 men) of 56 with data available reported sexual dysfun-
ction. On clinical examination, 37 patients had perianal sen-
sory loss. Pathological quantitative EMG of the EAS was
found in 39 patients (31%), of whom 26 also had additional
non-urinary sacral dysfunction, and 16 patients also had pe-
rianal sensory loss on neurological examination. Only 1 pa-
tient (with a history of lumbar disc surgery) with both, isola-
ted lower urinary dysfunction and normal perianal sensa-
tion, had abnormal electrophysiological findings. In a group
of 87 patients with either additional non-urinary sacral dys-
function or perianal sensory loss, abnormal electrophysiolo-
gical findings were demonstrated in 38 patients (44%).
Among those with abnormal sacral electrodiagnostic findings,
cauda equina lesion was diagnosed in 12, multi system atro-
phy in 7, polineuropathy in 3, old obstetric injury in 2, and
lesion due to (surgery for) anal prolapse in 1. In the remain-
II-186 ZDRAV VESTN 2003; 72: SUPPL II
iskave smo postavili diagnozo okvare kavde ekvine pri 12,
multi-sistemske atrofije pri 7, polinevropatije pri 3, obporo-
dne okvare pri 2 in okvare (po operaciji) prolapsa zadnjika
pri 1. Pri preostalih 13 bolnikih nismo našli vzroka nevro-
patskim spremembam zunanje zapiralke zadnjika. Pri 3 od
teh pa smo našli znake okvare osrednjega živčevja, 2 sta ime-
la v preteklosti operacijo medvretenčne ploščice ledveno, ena
bolnica je imela v preteklosti totalno histerektomijo, en bolnik
je navajal bolečino v križu, eden pa je imel diagnozo Crohno-
va bolezen.
Zaključki. Naša študija je razkrila, da so motnje mikcije po-
gost razlog za napotitev na elektrodiagnostično preiskavo
križnega živčevja v naš inštitut. Pri bolnikih z motnjami mik-
cije smo našli elektrodiagnostične abnormnosti praktično iz-
ključno, kadar so imeli še bodisi dodatne motnje iztrebljanja
ali spolnih dejavnosti, ali pa smo ob kliničnem pregledu našli
motnje senzibilitete perinealno. Prisotnost bodisi dodatne križ-
ne motnje ob motnji mikcije ali pa motene perinealne senzi-
bilitete je občutljivo (senzitivno), vendar neznačilno (nespe-
cifično) pri odkrivanju nevrogene križne motnje. Na osnovi
naših najdb priporočamo, da vse bolnike z moteno mikcijo
zdravniki vprašajo tudi po morebitnih motnjah iztrebljanja
ali moteni spolnosti ter pri kliničnem pregledu preverijo za-
znavo dotika perinealno. Elektrodiagnostične preiskave križ-
nega živčevja so torej indicirane pri bolnikih bodisi s kombi-
nacijo več križnih motenj ali pa z moteno perinealno obču-
tljivostjo.
ing 13 patients no aetiology of neurogenic lesion was identi-
fied, but in 3 of them concomitant upper motor neurone signs
were found, 2 patients had previous lumbar disc surgery, 1
had previous hysterectomy, 1 complained of lumbalgia, and
in 1 Crohn’s disease was diagnosed.
Conclusions. Lower urinary dysfunction was found to be a
common reason for referral for sacral electrodiagnostic stu-
dies in our clinical setting. In patients with lower urinary
dysfunction our study demonstrated electrodiagnostic abnor-
malities almost exclusively when either additional non-uri-
nary sacral dysfunction was reported or perianal sensory loss
was demonstrated on neurological examination. We propose
that all patients with lower urinary dysfunction shall be asked
about bowel and sexual dysfunction, and have perianal sen-
sation tested. Non-urinary sacral dysfunction and abnormal
sensation are sensitive but non-specific for the detection of a
neurogenic sacral lesion. Hence, in patients who suffer from
several sacral dysfunctions or have parianal sensory loss, elec-
trodiagnostic studies are indicated.