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Neurourologische Funktionsstörungen des unteren Harntraktes bei Erkrankungen des ZNS

Pathophysiologie, Epidemiologie und Therapieoptionen

Neuro-urological dysfunction of the lower urinary tract in CNS diseases

Pathophysiology, epidemiology, and treatment options

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Zusammenfassung

Der untere Harntrakt (UHT) wird durch ein komplexes neuronales Netzwerk gesteuert, das unter supraspinaler Kontrolle steht. Neurologische Erkrankungen, insbesondere des zentralen Nervensystems, können rasch zu einer Störung dieser Kontrolle führen. Multiple Sklerose, Morbus Parkinson, Multisystematrophie und Schlaganfall sind neurologische Erkrankungen, die sehr häufig eine Funktionsstörung des UHT verursachen. Bezogen auf die Pathophysiologie der Blasenfunktionsstörung bei Erkrankungen des zentralen Nervensystems (ZNS) gibt es für einzelne Erkrankungen unterschiedliche Hypothesen, wobei Störungen der neuronalen Kommunikation zwischen frontalem Kortex und pontinem Miktionszentrum, zwischen pontinem Miktionszentrum und lumbosakralen Rückenmarkanteilen sowie zwischen Basalganglien, Thalamus und der Pars anterior des Gyrus cinguli eine zentrale Rolle bei der Entwicklung von Harnblasenfunktionsstörungen einzunehmen scheinen. Die Symptomatik und urodynamische Präsentation der Funktionsstörung des UHT können je nach Erkrankung und Erkrankungsfortschritt sehr unterschiedlich sein und im Verlauf variieren. Die Inzidenz und Prävalenz von Funktionsstörungen des unteren Harntraktes steigt mit zunehmendem Progress der neurologischen Grunderkrankung.

Um gesundheitliche Folgeschäden zu verhindern und um die Lebensqualität dieser Patienten zu verbessern stehen verschieden konservative, minimal-invasive und offen chirurgische Verfahren zur Verfügung. Allerdings gibt es zu den meisten Therapieoptionen bei oben genannten ZNS-Erkrankungen noch wenig Daten. Zu den wichtigsten konservativen Therapieoptionen zählen der intermittierende Selbstkatheterismus und antimuskarinerge Medikamente. Zu den wichtigsten minimal-invasiven Therapieoptionen zählen Botulinumneurotoxin-Typ-A-Injektionen in den Detrusor, sowie zunehmend die sakrale und/oder pudendale Neuromodulation. Die chirurgischen Methoden umfassen die rekonstruktive kontinente oder inkontinente Harnableitung.

Bei der Therapieplanung müssen aktuelle Patientenbedürfnisse und neurologische Einschränkungen sowie ein möglicher Krankheitsprogress berücksichtigt werden. Häufig empfiehlt sich bei Therapieplanung die Rücksprache und Kooperation mit dem betreuenden Neurologen.

Abstract

The lower urinary tract (LUT) is regulated by a complex neural network that is subject to supraspinal control. Neurological disorders, especially of the central nervous system (CNS), can rapidly lead to disruption of this control. Multiple sclerosis, Parkinson’s disease, multiple system atrophy, and stroke are neurological disorders which quite frequently cause dysfunction of the LUT. With respect to the pathophysiology of bladder dysfunction in CNS diseases there are various hypotheses regarding the individual disorders: disturbances of neural communication between the frontal cortex and pontine micturition center, between the pontine micturition center and the lumbosacral parts of the spinal cord, and between the basal ganglia, thalamus, and anterior cingulate gyrus appear to play a pivotal role in the development of bladder dysfunction. The symptoms and urodynamic presentation of LUT dysfunction can vary considerably depending on the disease and disease progression and can change in the course of the disease. The incidence and prevalence of LUT dysfunctions rise with increasing progression of the underlying neurological disease.

Various conservative, minimally invasive, and open surgical procedures are available to prevent harmful sequelae and to improve the quality of life of these patients. As yet, however, few data exist on most of the treatment options in cases of the above-mentioned CNS diseases. Intermittent self-catheterization and antimuscarinic medications are among the most important conservative treatment options. Injection of botulinum neurotoxin type A into the detrusor muscle and increasingly sacral or pudendal neuromodulation are among the most important minimally invasive treatment options. Surgical methods include reconstructive continent or incontinent urinary diversion.

When planning therapy the patient’s current needs and neurological limitations as well as possible disease progression must be taken into consideration. It is often advisable to consult with and enlist the cooperation of the attending neurologist when planning treament.

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Der korrespondierende Autor weist auf folgende Beziehungen hin: Beratungs- und Referententätigkeit für Allergan und Astellas.

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  1. Urologische Klinik, Marienhospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Widumer Straße 8, 44627, Herne, Deutschland

    U. Mehnert

  2. Schwerpunkt Neuro-Urologie, Marienhospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Deutschland

    M. Nehiba

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Mehnert, U., Nehiba, M. Neurourologische Funktionsstörungen des unteren Harntraktes bei Erkrankungen des ZNS. Urologe 51, 189–197 (2012). https://doi.org/10.1007/s00120-011-2796-z

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