原发性单症状性夜遗尿症患儿静息态磁共振脑功能成像和动态尿动力学研究

摘要

Objective To investigate the significance of blood oxygenation level dependent functional magnetic resonance imaging (BOLD-fMRI) and ambulatory urodynamics monitoring (AUM) to find the cause of primary monosymptomatic nocturnal enuresis (PMNE) in children.Methods Thirty-seven children with PMNE (20 males and 17 females) were selected,with a mean age of (11.3 ±4.1) years old.A clinical management tool,3-day urination record,daytime BOLD-fMRI scan,conventional urodynamics (CUD) and AUM were performed respectively.Thirty-seven gender-age matched children(19 males,18 females) who would receive surgery treatment because of upper urinary tract disease and were confirmed to have no lower urinary tract dysfunction by CUD were enrolled as controls,with a mean age of (11.1 ± 2.9) years old,and 13 cases underwent BOLD-fMRI scanning.Results It was found that the ALFF value of the left middle frontal gyrus of PMNE was decreased and the ReHo value of the left superior occipital gyrus was increased compared with the control group by the resting BOLD-fMRI.The maximum voiding volume of PNME children was (303.11 ± 87.48) mL,the total urine volume at night was (568.65 ± 208.48) mL,and the nighttime bladder volume was (217.43 ± 81.53) mL.The incidence of maximum voiding volume reduction,nocturnal polyuria and decreased nocturnal bladder volume were 24.32％ and 56.76％,and 64.86％,respectively.However,AUM results showed that maximum detrusor pressure in the PMNE group was (39.22 ± 7.78) cmH2O (1 cmH2O =0.098 kPa),which was statistically significantly higher than that in CUD (32.22 ±9.00) cmH2O,and the difference was statistically significant (P ＜0.05).In PMNE group,29 cases (78.37％) had detrusor overactivity (DO),which was significantly higher than that in CUD group [16 cases (43.24％)],and the difference was statistically significant(t =-3.047,P =0.004).CUD and AUM were all detected in children with DO,the frequency of DO detected by AUM was significantly higher than that detected by CUD[(2.00 ±0.55 times/h) vs.(1.38 ±0.50) times/h,P ＜0.05],and the maximum amplitude of detrusor pressure when DO occurring was significantly higher in AUM than in CUD [(19.56 ± 6.01) cmH2O vs.(14.38 ± 3.07) cmH2O],and the differences were statistically significant (all P ＜ 0.05);however,there was no significant difference in bladder compliance detected by AUM or CUD (P ＞ 0.05).Conclusions The abnormal functions of the left middle frontal gyrus and left superior occipital gyrus,nighttime DO and the decrease of bladder capacity at night are considered to be key causes of enuresis in children with PMNE.AUM and resting state BOLD-fMRI evaluations are helpful in differentiating the pathogenesis of PMNE.%目的 探讨静息态血氧水平依赖性功能磁共振成像(BOLD-fMRI)和动态尿动力学检查(AUM)对发现原发性单症状性夜遗尿症(PMNE)病因的意义.方法 选取PMNE患儿37例(男20例,女17例),年龄(11.3±4.1)岁.完成病史采集表,3d排尿日记,白天静息态BOLD-fMRI扫描和常规尿动力学检查(CUD)及AUM.选取因上尿路疾病需手术,且CUD证实下尿路功能正常的37例患儿(男19例,女18例)为对照组,年龄(11.1±2.9)岁,其中13例完成BOLD-fMRI扫描.结果 静息态BOLD-fMRI发现,与对照组相比,PMNE组左侧眶部额中回ALFF值降低,左侧枕上回ReHo值增高.PMNE患儿最大排尿量(303.11±87.48) mL,夜间总尿量(568.65±208.48) mL,夜间最大膀胱容量(217.43 ±81.53) mL;最大排尿量减小、夜间多尿和夜间最大膀胱容量降低的发生率分别为24.32％、56.76％和64.86％.PMNE组夜间最大逼尿肌压显著高于白天[(39.22±7.78) cmH2O比(32.22 ±9.00) cmH2O,1 cmH2O=0.098 kPa],差异有统计学意义(P＜0.05).PMNE组患儿AUM检出29例(78.37％)存在逼尿肌过度活动(DO),显著高于CUD[16例(43.24％)],差异有统计学意义(t=-3.047,P=0.004);且CUD和AUM均检出DO的患儿,AUM中夜间DO发生频率更高[(2.00±0.55)次/h比(1.38 ±0.50)次/h],逼尿肌压力最大幅度显著增高[(19.56 ±6.01)cmH2O比(14.38 ±3.07) cmH2O],差异均有统计学意义(均P＜0.05);而膀胱顺应性差异无统计学意义(P＞0.05).结论 左侧眶部额中回和枕上回脑功能异常、夜间膀胱功能障碍和夜间多尿是PMNE患儿发生遗尿的重要原因,AUM和静息态BOLD-fMRI评估有助于鉴别PMNE患儿发病原因.