摘要
膀胱出口阻塞是老年男性最常見的泌尿道問題，而良性前列腺肥大是造成膀胱出口阻塞最常見的原因。大部份病患表現的症狀為：頻尿、急尿、解尿困難、夜尿、尿流柱變細或排尿後仍據餘尿感等等。 產生嚴重困擾的臨床症狀時，約只有四分之一的病人會因良性前列腺肥大而尋求治療。標準診斷膀胱出口阻塞的方法為壓力尿流檢查，但是此項檢查較俱侵略性、檢查費時與產生精神上的壓力等缺點。在診斷膀胱出口阻塞方法上，使用超音波測量膀胱壁厚度與重量提供臨床上兩個新的參數指標，同時據有無侵略性、快速、可重覆使用與費用較低等優點。
我們共計收集137位男性病患，依病患的膀胱功能狀態，將病患分為四組，A組為膀胱失去排尿功能病患常期置放導尿管，B-1組為診斷為膀胱出口阻塞病患常期接受藥物治療，B-2組為診斷為膀胱出口阻塞新病患未接受任何藥物治療，C組為健康成年男性。我們將實驗分兩部份進行，使用3或4MHz扇形探頭於恥骨連合上兩指幅寬處行橫向與縱向掃瞄，對於長期置放導尿管的A組病患，經由尿管灌注生理食鹽水，進行超音波測量膀胱容積與實際灌注量的直線迴歸分析，並且使用超音波測量膀胱壁厚度，計算膀胱重量。另三組病患則請病患喝水後據尿意時，進行漲尿時膀胱壁厚度與重量測量，並將四組病患膀胱容積、壁厚度與重量進行多變異分析，評估臨床所代表意義。
實驗結果A組病患線性迴歸分析顯示超音波測量膀胱容積與實際灌注容積判定係數(r2)0.806，相關係數(r)0.900，即在實際灌注容積(X)50毫升至180毫升下，超音波測量膀胱容積(Y)有80.6%可用Y=0.99X+7.9來解釋，兩者據有相當強的正相關性。四組病患膀胱容
積、膀胱壁厚度與重量進行多變異數分析可得以下結論：就膀胱容積
而言，去代償性的膀胱A組與膀胱出口阻塞未用藥B-2組病患，因出口阻塞而造成膀胱纖維化性病變，較健康成年男性C組膀胱容積明顯減少，平均容積從124.4毫升與141.6毫對比187.4毫升。就膀胱壁厚度而言，我們認為大於5.7公釐即表示逼尿肌已進入去代償期，排尿功能無法恢復，若厚度大於3.0公釐即表示膀胱出口已發生阻塞，但尚在代償期，經藥物治療後厚度減少，但仍無法恢復成健康成人1.3公釐之厚度,若以1.3公釐為診斷標準，診斷膀胱出口阻塞正預測值為95.2%，負預測值為59.3%。至於超音波測量膀胱重量，我們得到以下的結果，若膀胱重量大於82.8公克，表示逼尿肌已進入去代償期，排尿功能無法恢復，膀胱重量大於39.7公克，膀胱已發生阻塞性病變，接受藥物治療後重量將減少，但也無法恢復到健康成人的膀胱重量18.7公克，若以18.7公克為診斷標準，則正預測值為92.4%，負預測值為56.3%。
超音波測量膀胱壁厚度與重量，用來評估膀胱出口阻塞，是2個新的臨床參數指標，我們結果認為膀胱壁厚度大於5.7公釐與膀胱重量大於82.8公克表逼尿肌已入去代償期，排尿功能永遠無法恢復，任何侵入性治療不應該使用。當膀胱壁厚度大於3公釐與重量大於39.7公克時，逼尿肌已進入代償期，病患需要治療，治療後膀胱壁厚度與重量將減少，但無法完全恢復至健康狀態。然而更多的臨床資料必需收集、分析與比較，以評估用超音波測量膀胱壁厚度與重量，來診斷膀胱出口阻塞的可行性與建立精確的診斷標準值，同時評估依據膀胱壁厚度與重量的變化建立各種臨床治療路徑的可行性。
目前使用傳統超音波儀器測量膀胱壁厚度與重量仍須人工計算，因此結合膀胱超音波影像分析與設計電腦化運算程式，分析膀胱壁
厚度與計算膀胱容積和重量，亦為本研究之另一目標。
關鍵詞：超音波﹐膀胱壁厚度﹐膀胱重量﹐膀胱出口阻塞

Bladder out obstruction (BOO) is the most common urologic problem in elder men. Benign prostatic enlargement (BPE) is the most common cause of BOO in men. Majority of patients present with frequency,urgency, nocturia, hesitancy, weak stream or sensation of incomplete bladder emptying. One-fourth men will seek treatment for BPE due to troublesome symptoms. The gold standard for diagnosing of BOO is pressure flow urodynamic studies but patients will suffer from invasive procedure, time consuming and psychological stress. Ultrasonic measurement of bladder wall thickness (BWT) and bladder weight (UEBW) may provide rapid, reproducible and inexpensive diagnostic tool for evaluation of BOO.
We collected one hundred and thirty-seven patients and classified four groups according to different bladder function of patients. Group A was failure of spontaneously voiding with permanent Foley catheterization, group B-1 was BOO with regular oral medication for long time, group B-2 was fresh cases of BOO without any medication and group C was normal subjects. We divided our study into two parts. Part I was group A, normal saline was instillation via patient’s Foley catheter into urinary bladder and then measured the bladder capacity, BWT and UEBW. The linear regression between real instillation bladder volume and ultrasonic estimation of bladder volume was carried out. Three other groups, the ultrasonic estimation of bladder capacity, BWT and UEBW was done. The multiple variant comparison (ANOVA) was used to analyze the results of bladder capacity, BWT and UEBW of four groups. The linear
regression of group A showed the square of correlation coefficient and correlation coefficient was 0.806 and 0.900. The real volume(X) and ultrasonic estimation of bladder volume(Y) explained as following formula Y=0.99X+7.9 which had strong positive correlation between the real volume and ultrasonic estimation of bladder volume. Comparison of BWT and BW of four groups with multiple variant analysis has shown that if the BWT is more than 5.7mm the detrusor will go into decompensated stage, the bladder function is not recovery. If the BTW is more than 3mm, the BOO will occur and the detrusor will be in the compensatory stage, the thickness will be progressively decreased after medication but it cannot recover to normal thickness. If the UEBW is more than 82.8g, the detrusor function will be in fatigue stage without possibility of recovery from spontaneously voiding. When the bladder weight is more than 39.7gm, the BOO occurs, the bladder weight will progressively decrease after medication but no chance retrieves normal weight. When the BWT more than 1.3mm and UEBW more than 18.7g were the cutoff value of diagnosis of BOO, the positive predictive value was 95.2% and 92.4% and negative predictive value was 59.3% and
56.3%.
Ultrasonic estimation of BWT and UEBW are two new parameters of diagnosis of BOO. We consider that the BWT more than 5.7mm and UEBW more than 82.8g are detected, the detrusor is fatigue without possibility of recovery of spontaneously voiding, and any interventional treatment should be given up. When the BWT more than 3.0 mm and UEBW more than 39.7g are noticed, the compensatory stage of detrusor occurs and the BWT and UEBW will de decreased after medication but they cannot retrieve normal thickness and weight. However, more detail data should be collected, analyzed and compared to evaluate of BOO and establish the guideline of treatment by BWT and UEBW.
Ultrasonic measurement of BWT and UEBW are does by manual operation at this study. An efficient and automatic image processing for the measurement of BWT, BW and bladder volume are needful for clinical applications.
Key words: Ultrasound, bladder wall thickness, bladder
weight, bladder outlet obstruction

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