尿动力学在伴下尿路症状的帕金森型多系统萎缩和帕金森病患者诊断中的价值

The value of urodynamic study in the differential diagnosis of patients with parkinsonian-type multiple system atrophy and Parkinson′s disease with lower urinary tract symptoms

目的:探讨伴下尿路症状(LUTS)的帕金森型多系统萎缩(MSA-P)患者和帕金森病患者的尿动力学表现差异,并确定尿动力学参数的鉴别诊断价值。方法:连续收集2017年2月至2020年12月就诊于郑州大学第一附属医院,并行尿动力检查的伴LUTS的MSA-P型患者68例和帕金森病患者85例。采用受试者工作特征(ROC)曲线来评价尿动力学参数帮助诊断的效能。结果:与帕金森病患者相比,MSA-P型患者的病程更短[分别为2.70(2.05,3.00)年和5.00(4.00,6.00)年, Z=-7.44, P<0.001],在自由尿流率(UFM)和压力-流率中的最大尿流率(Qmax)降低[UFM-Qmax分别为6.00(3.00,8.75)ml/s和9.00(6.00,14.00)ml/s, Z=-4.31, P<0.001;压力-流率-Qmax分别为6.00(3.00,8.75)ml/s和9.00(6.00,14.00)ml/s, Z=-4.03, P<0.001],残余尿量增多[UFM-残余尿量分别为207.50(113.75,280.00)ml和45.00(10.00,117.50)ml, Z=-6.03, P<0.001;压力-流率-残余尿量分别为269.00(148.75,337.50)ml和75.00(20.00,167.50)ml, Z=-6.55, P<0.001],膀胱顺应性降低者增加[分别为42.65%(29/68)和14.12%(12/85),χ^(2)=15.68, P<0.001],Qmax时的逼尿肌收缩压(PdetQmax)[分别为13.00(6.00,27.75)cmH_(2)O和 27.00(15.00,39.50)cmH_(2)O, Z=-4.65, P<0.001;1 cmH_(2)O=0.098 kPa]和膀胱收缩指数(BCI)降低[分别为43.00(34.00,59.25)和79.00(46.50,100.00), Z=-5.44, P<0.001]。与MSA-P患者相比,逼尿肌过度活动(DO)在帕金森病患者中更显著[分别为54.41%(37/68)和78.82%(67/85),χ^(2)=10.34, P=0.001]。ROC曲线示,压力-流率-残余尿量的曲线下面积(AUC)最高为0.81(95% CI 0.74~0.88, P<0.001),其次为UFM-残余尿量、BCI和PdetQmax(分别为0.78、0.76和0.72)。 结论:MSA-P患者Qmax降低、残余尿量增加、同时伴有膀胱顺应性下降和收缩力受损。而DO在帕金森病中更多见。ROC曲线分析压力-流率-残余尿量对MSA-P和帕金森病的鉴别诊断具有最高的AUC和特异度。尿动力学检查是帮助鉴别伴LUTS的MSA-P和帕金森病的有效方法。

Objective To investigate the urodynamic characteristics in parkinsonian-type multiple system atrophy(MSA-P)and Parkinson′s disease(PD)patients with lower urinary tract symptoms(LUTS)and to identify the differential diagnostic ability of urodynamic study.Methods Sixty-eight MSA-P patients and 85 PD patients with LUTS who underwent urodynamic studies and were hospitalized in the First Affiliated Hospital of Zhengzhou University from February 2017 to December 2020 were reviewed.The receiver operating characteristic(ROC)curve was used to evaluate the discriminatory power of urodynamic parameters.Results Compared with PD,patients with MSA-P had shorter disease duration[2.70(2.05,3.00)years vs 5.00(4.00,6.00)years,Z=-7.44,P<0.001].In free uroflowmetry(UFM)and pressure-flow study(PFS),patients with MSA-P showed lower maximal flow rate[Qmax;UFM-Qmax 6.00(3.00,8.75)ml/s vs 9.00(6.00,14.00)ml/s,Z=-4.31,P<0.001;PFS-Qmax[6.00(3.00,8.75)ml/s vs 9.00(6.00,14.00)ml/s,Z=-4.03,P<0.001]and larger postvoid residual[PVR;UFM-PVR 207.50(113.75,280.00)ml vs 45.00(10.00,117.50)ml,Z=-6.03,P<0.001;PFS-PVR 269.00(148.75,337.50)ml vs 75.00(20.00,167.50)ml,Z=-6.55,P<0.001)]with decreased compliance[42.65%(29/68)vs 14.12%(12/85),χ^(2)=15.68,P<0.001],decreased detrusor pressure at maximun flow rate[PdetQmax;13.00(6.00,27.75)cmH_(2)O vs 27.00(15.00,39.50)cmH_(2)O,Z=-4.65,P<0.001;1 cmH_(2)O=0.098 kPa]and impaired contractility[43.00(34.00,59.25)vs 79.00(46.50,100.00),Z=-5.44,P<0.001].Compared with the MSA-P patients,detrusor overactivity(DO)was prominent in PD[54.41%(37/68)vs 78.82%(67/85),χ^(2)=10.34,P=0.001].The ROC curve results showed that PFS-PVR had highest area under the curve(AUC),which was 0.81(95%CI 0.74-0.88,P<0.001),followed by UFM-PVR,bladder contractility index and PdetQmax(0.78,0.76 and 0.72,respectively).Conclusions Patients with MSA-P showed lower Qmax and larger PVR with decreased bladder compliance and impaired contractility,while patients with PD had higher incidence of DO.The ROC results showed that PFS-PVR had the highest AUC and specificity in the differential diagnosis of MSA-P and PD,indicating that urodynamic study is a useful tool in differential diagnosis of patients with MSA-P and PD with lower urinary tract symptoms.