阻塞性睡眠呼吸暂停低通气综合征合并夜间多尿患者尿动力学改变情况分析

Urodynamic changes in patients with obstructive sleep apnea-hypopnea syndrome and nocturnal polyuria

目的观察存在夜间多尿的OSAHS患者的尿动力学变化。方法前瞻性纳人武汉大学人民医院2002年9月至2008年6月存在夜间多尿、并经多导睡眠监测（PSG）诊断的OSAHS患者，共入选患者23例，其中男19例，女4例，年龄46—81岁，中位年龄68岁。记录患者夜晚及持续气道正压（CPAP）压力滴定夜晚的夜尿次数、夜尿量、夜尿渗透压和尿钠浓度，于研究当夜11时和次晨7时留取静脉血测定脑钠肽及心房利钠肽（ANP）水平。同时对每位患者进行尿动力学检查，包括尿流率，充盈期膀胱压，压力一流率及尿道压测定，并在使用CPAP治疗3个月后再次进行尿动力学检查。结果PSG检查结果显示，本组患者均存在中重度OSAHS，平均睡眠呼吸暂停低通气指数（AHI）为（48±15）次／h。OSAHS患者夜间尿量明显增多，尿钠浓度增加，尿渗透压降低，次晨7时ANP水平升高，CPAP治疗3个月后可恢复正常。患者行CPAP压力滴定当夜排尿次数明显少于PSG监测当夜排尿次数。尿动力学检查显示本组患者尿动力学主要特征是逼尿肌收缩无力、膀胱感觉迟钝、低顺应性膀胱、逼尿肌尿道外括约肌协同失调。CPAP治疗后，逼尿肌收缩力增强，并恢复膀胱顺应性。结论CPAP可有效减少OSAHS患者的夜间多尿症状，OSAHS患者夜尿量增多、尿渗透压下降及尿钠浓度增高症状可能与ANP升高有关，OSAHS病程可能损害膀胱逼尿肌功能。CPAP治疗可减少ANP分泌，同时改善膀胱逼尿肌收缩力。

Objective To investigate the urodynamic changes in patients with obstructive sleep apnea-hypopnea syndrome （OSAHS） and nocturnal polyuria. Methods From Sept. 2002 to Jun. 2008, 23 patients with nocturnal polyuria were diagnosed as having OSAHS by polysomnography（PSG）. The number and output of noeturia, the osmotic pressure and the excretion of Na ＋ were recorded during both the PSG night and CPAP titrating night. Plasma levels of brain natriuretic peptide （ BNP ） and atrial natriuretic peptides （ANP） were also measured at llPM in the 2 nights and 7AM in the next mornings. Urodynamic studies including urine flow, bladder pressure during filling, pressure-flow study during voiding and urethral pressure were carried out in these patients. Urodynamic studies were performed again after treatment with CPAP for 3 months. Results PSG showed that the patients with nocturnal polyuria had moderate to severe OSAHS, in which the apnea-hypopnea index （AHI） being 48 ± 15 events per hour. The number of nocturnal voiding during the PSG night was more than that during the CPAP titrating night. During the PSG night, the output of nocturia, the nocturia excretion of Na^＋ , ANP levels （at 7am in the next morning after PSG night） increased and the osmotic pressure of nocturia decreased. CPAP therapy could reverse these abnormalities. The main characteristics of urodynamics in these patients included weak detrusor contraction, hypoesthesia in filling cystometry, and decreased bladder compliance, and detrusor ex-ternal sphincter dyssynergia. After 3 months of CPAP treatment, both the myotility of the detrusor of bladder and the bladder compliance improved. Conclusions CPAP therapy can effectively reverse the nocturnal polyuria in OSAHS patients. InOSAHS patients, the features of nocturia, including the changes of output, osmotic pressure and the excretion of Na^＋ , may be related to the secretion of high-level of ANP. During the course of chronic progressively OSAHS pathophysiology, detrusor function of bladder may be damaged. CPAP therapy could decrease the nocturnal excretion of ANP, and improve the myotility of the detrusor of bladder.