摘要：男性膀胱出口梗阻(bladder outlet obstruction, BOO)常因良性前列腺增生(benign prostatic hyperplasia, BPH)引起的前列腺阻塞(benign prostatic obstruction,BPO)所致，有些患者由于长时间尿潴留，会出现上尿路积水，进而影响肾脏功能，且在此过程中，还会对膀胱的组织结构、功能产生不可逆的损伤。故BOO及时诊断对于保护肾脏及膀胱的功能十分必要。现有的尿动力学检查(urodynamics,UDS)是诊断BOO的金标准，但其具有有创、不适性，于是超声、近红外光谱(near-infrared spectroscopy,NIRS)和阴茎袖套等非侵入技术逐渐发展，但很少有研究报道这些技术的截断值，故仍需大量研究对测量方法进行标准化。本文对目前诊断男性BOO的辅助检查方法进行综述，探讨其国内外研究现况及临床上的应用价值。
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下尿路症状(lower urinary tract symptoms, LUTS)是指>50岁的中老年男性出现储尿期、排尿期和排尿后期的问题，患病率高达50%~75%，并随着年龄的增长呈上升趋势。LUTS患者的身心健康及生活质量受到严重影响。这些症状并非器官特异性，可能与潜在的病理生理机制有关，如膀胱出口梗阻(bladder outlet obstruction,BOO)。有研究表明，引起男性BOO最常见的病因是良性前列腺增生(benign prostatic hyperplasia,BPH)引起的前列腺阻塞(benign prostatic obstruction,BPO)。前列腺良性生长是无害的，但其体积长到一定程度压迫尿道，会导致患者出现一系列的LUTS，有些患者因长时间尿潴留，会出现上尿路积水进而影响肾脏功能，且在此过程中，还会对膀胱的组织结构、 功能产生不可逆的损伤。故早诊断、早治疗、保护膀胱功能是诊治BOO的重要原则。近期有研究鼓励采用无创性检查来诊断BOO，如超声、近红外光 谱(near-infrared spectroscopy,NIRS)和阴茎袖套等，但均没有标准化其诊断方法。故本文对目前诊断男性BOO的评估方法进行系统回顾，探讨其国内外研究现况及临床上的应用价值。
1 尿动力学检查
2 影像尿动力学检查
3 超声测量膀胱壁厚度和逼尿肌厚度
4 超声估测膀胱重量
5 前列腺突入膀胱程度
6 逼尿肌动脉阻力指数
7 前列腺动脉RI
8 前列腺尿道角度
9 膀胱颈角度
10 NIRS
11 阴茎套囊试验与阴茎尿道压缩-释放试验
12 超声膀胱应变成像
13 总结
综上所述，目前诊断BOO的金标准仍是UDS, 但其具有一定侵入性且价格较为昂贵。
而VUDS在UDS基础上结合影像学，不仅显示功能学的数据，还同步显示解剖学的情况，但VUDS并未改变UDS的缺陷，且可能增加病人受到辐射暴露的危险，故是否在UDS基础上增加影像学(特别是X线)需具有一定的适应证：①神经系统异常或有相关神经系统疾病史；②先天性泌尿生殖系统异常(如异位输尿管、后尿道瓣膜、膀胱输 尿管反流、皱梅腹综合征等)；③有复杂病史的BOO或尿潴留；④盆腔放疗史或盆腔内手术史；⑤盆腔重建手术史、压力性尿失禁手术史、尿道狭窄修复术、盆腔脏器脱垂重建史、尿道憩室切除史；⑥怀疑有膀胱阴道瘘或尿道阴道瘘；⑦怀疑有尿道憩室；⑧肾移植术前后。超声下测量BWT和DWT, 操作较简便，但BWT与DWT相对较薄，受膀胱充盈程度、探头类型、频率、测量期间应用的缩放比例等影响，故目前诊断BOO的截断值说法不一，尚未标准化，仅能作为临床上诊断BOO的辅助测量值之一，若BWT或DWT相对较厚提示可能存在BOO, 特别是70岁以上的男性。UEBW虽然有研究表明其与BOO呈正相关，但其受BWT的测量影响较大，而膀胱壁本身较薄难以保证测量的精准，且其原理是把膀胱想象为一个球体，但事实上膀胱是随着尿液增减形状变化不一的器官，故UEBW诊断BOO的准确率并不高。IPP目前已被证实是对BOO进行分级的有效预测指标，由于其简便、无创性，临床上可根据2019年ACR诊断标准对BOO进行初步分级。逼尿肌动脉RI的实践尤为困难，本身逼尿肌较薄，其血流频谱难以获取，故暂不推荐使用。而前列腺动脉RI受其他因素干扰严重，如炎症、肿瘤均可能增加前列腺动脉RI，故同样暂不推荐使用。 PUA及BNA均在TRUS下进行，而TRUS与UDS 一样具有侵入性，无法避免同样的缺陷，且PUA仅仅反映的是静息状态下的尿道角度，而非排尿过程，若患者有行TRUS的需要可以同时测量PUA及BNA辅助诊断BOO。NIRS是可实时检测与BOO相关的血流动力学变化的非侵入性新技术，但目前其相关研究说法不一，仍需更多高质量研究进行考量。PCR与PCT是为了避免UDS的缺点而开发的，但目前存在套囊泄漏、抑制排尿、袖带释放、无腹压监测、储尿期评估等问题，需要进一步完善其技术再广泛应用。超声膀胱应变成像可无创评估排尿过程中的BWT动态变化，监测膀胱储尿、排尿，但其过程中存在漏尿问题，且相关研究数量少，有待更多高质量研究验证其诊断BOO的效能。
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