梨花醫大誌 : 第 32 卷第 1 號 2009 Ewha Med J Vol. 32, No. 1, 2009 online ML Comm 여성하부요로증상과외음부진동감각역치의상관관계 이화여자대학교의학전문대학원비뇨기과학교실 유재영 윤현석 전계민 윤하나 = Abstract = Correlation Between Female Lower Urinary Tract Symptoms and Genital Vibratory Thresholds Jae-Yeong Yoo Hyun-Suk Yoon Kye-Min Chun Hana Yoon Department of Urology, Ewha Womans University School of Medicine Purpose:Biothesiometer is a device for quantitatively measuring vibratory thresholds in a noninvasive manner. It has been utilized for evaluating variety of neurological diseases for decades. We aimed to investigate difference of vibratory thresholds according to presence of specific lower urinary tract symptoms(luts). Materials and Methods:173 female patients were included in this study. We investigated medical history, and performed physical examination, cystoscopy, and biothesiometry. Biothesiometry were recorded on clitoris, vestibules, and both labia minora. Relationship between age, LUTS, serum triglyceride(tg) and cholesterol(chol) level, and vibratory thresholds were also analyzed. Results:Mean age of patients was 51.8±9.4 years. LUTS consisted of stress urinary incontinence(sui)(87.4%), urgency or urge incontinence(uui)(77.1%), and frequency(66%). Age was closely related with vibratory thresholds. Correlation coefficient was 0.394, 0.343, 0.332, 0.294, 0.279 for clitoris, both labia, and anterior and posterior vestibules, respectively(p<0.001). Patients with SUI and UUI showed significantly increased vibratory thresholds on clitoris and right labium compared to those who do not have any of SUI or UUI(p<0.05). TG and Chol levels were not related with vibratory thresholds. Conclusion:Vibratory thresholds of external genitalia area were increased in proportion to age. Patients had different vibratory thresholds according to their LUTS. This finding suggests that LUTS is associated with insufficiency of pudendal nerve. KEY WORDS:Genital sensation Biothesiometry LUTS. 서 복압성요실금및과민성방광, 그리고복합성요실금 론 - 15 - 의병인으로서음부신경의손상은중요한역할을하는것으로보인다. 분만에의한음부신경의손상은음부신경의지배영역인골반저근및외요도괄약근의약화를가져오고, 자연분만을경험한여성의 30% 에서첫분만 교신저자 : 윤하나, 158-710 서울양천구목동 911-1 이화여자대학교의학전문대학원비뇨기과학교실전화 :(02) 2650-5046 전송 :(02) 2654-3682 E-mail:wowhana@ewha.ac.kr
후요실금이발생한다 1). 또한일부의연구에서는음부신경이 Alcock s canal 또는 ischial spine에서압박되는 pudendal nerve entrapment 환자역시복압성요실금및복합성요실금을경험하였다 2)3). 임상적으로음부신경손상을측정할수있는방법으로 somato-sensory evoked potential 측정등의근전도검사가있지만이는별도의검사장비와숙련된검사자가필요하다. 한편, 음부신경가지가분포하는피부영역의진동감각의변화는부분적신경손상을검사할수있는간접적지표가될수있을것이다. 정량적감각검사 (Quantitative sensory testing;qst) 는당뇨병성신경병증, 신경독소노출, 화학요법에의한말초신경기능장애평가에유용성이입증된검사법이며, 감각신경진동각측정기는여성외음부의진동에대한피부감각측정에유용한검사법으로서, 정량화된감각기능의평가가가능하다 4-6). Vardi 등에의하면음부신경분포영역인질과음핵의감각신경진동각측정은신경학적기능평가에있어정확도가다른감각측정법에비해높았다 7). 본연구에서는복압성요실금및과민성방광여자환자에서외음부의진동감각역치를측정함으로써, 배뇨증상과외음부감각기능사이의상관관계를알아보고, 하부요로증상의발생에신경손상이차지하는의미에대해연구하여보고자하였다. 대상및방법 2004 년 3월부터 2007 년 6월까지하부요로증상을주소로본원방광및골반재활클리닉에내원한여성환자를대상으로하였으며, 후향적의무기록분석을통하여연구를진행하였다. 기본병력, 신체검사, 소변검사및소변배양검사, 그리고혈중중성지방과콜레스테롤수치검사에대한자료를수집하였다. 요역동학검사, 배뇨후잔뇨량측정및방광내시경검사시행후감각신경진동각측정기 (Biothesiometer, Biomedical Instrument Company, OH, USA)(Fig. 1) 를이용하여외음부의진동감각에대한역치를측정하였다. 진동감각역치의측정은쇄석위상태에서이루어졌으며, 오른쪽집게손가락, 음핵의귀두부, 해면체부인질전정부, 그리고좌우소음순에서각각 3회측정후그평균값을사용하였다. 환자들의나이와, 혈중중성지방및콜레스테롤수치 Fig. 1. Biothesiometer(Biomedical Instrument Company, OH, USA). 와진동감각역치측정값사이의상관관계를관찰하였으며, 각각의하부요로증상의유무에따른각부위의진동감각역치비교및복압성요실금과절박뇨및절박성요실금을동반한환자군과두증상이모두없는환자군의진동감각역치를비교하여보았다. 각부위에서의진동감각역치측정값과기타측정값과의상관관계는 simple correlation test 로조사하였으며, 하부요로증상여부에따른진동감각역치측정값은 paired t-test 를이용하여비교하였다. p-value<0.05 일때통계학적의미가있는것으로판정하였다. 결 총 173 명의환자가연구에포함되었으며, 평균나이는 51.8±9.4(25~73) 세였다. 환자들의주증상중복압성요실금은 87.4%, 절박뇨및절박성요실금은 77.1%, 그리고빈뇨는 66% 에서나타났다 (Table 1). 내원시수술로인해, 또는자연적으로폐경이라고대답하였던환자들중검사당시국소적또는전신적으로호르몬보충요법을시행하고있는환자는없었다. 과 - 16 -
진동감각역치와나이, 혈중콜레스테롤및중성지방치와의상관관계에있어서는음핵귀두부, 질전정부, 그리고좌우소음순에서모두나이가증가할수록진동감각역치가증가하는것으로조사되었다 (p<0.001). 그러나혈중콜레스테롤및중성지방수치와진동감각역치사이에는유의한상관관계가보이지않았다 (Table 2). 복압성요실금, 절박뇨및절박성요실금, 빈뇨의유무에따른각부위별진동감각역치는모든측정부위에서하부요로증상이있는군이없는군에비해증가되어있었다. 각각의증상여부에따른진동감각역치측정값중오른쪽집게손가락에서복압성요실금의유무에따른측정값만이통계적으로유의한차이를보였으나, 다른측정부위에서는배뇨증상에따른진동감각역치의유의한차이가발견되지않았다 (Table 3). 복압성요실금과절박뇨및절박성요실금을모두가진환자와두증상이모두없는환자군의평균나이는각 Table 1. Patient characteristics for women with LUTS Number of patients 173 Mean age of 51.8±9.4(25-73) patients(years) Chief complaint SUI 151(87.4%) Mean number of parity UUI 133(77.1%) Frequency 114(066%) Vaginal delivery(88) 02.4±1.0 Cesarian section(25) 01.3±0.8 Biothesiometry IF 06.2±1.9 C 06.9±3.9 LR 08.7±4.1 LL 09.6±4.5 AV 10.5±4.5 PV 10.6±4.7 SUI:stress urinary incontinence, UUI:urgency or urge incontinence, IF:index finger, C:clitoris, LR:labium, right, LL:labium, left, AV:anterior vagina, PV:posterior vagina Table 2. Association between vibratory thresholds and age, serum triglyceride, and cholesterol level IF C LL LR AV PV Age -0.394* -0.357* -0.343* -0.332* -0.294* -0.279* TG -0.108* -0.049* -0.015* -0.038* -0.083* -0.086* Chol -0.011* -0.044* -0.062* -0.087* -0.035* -0.013* Each value means Pearson correlation coefficient. *: p value<0.001, IF:index finger, C:Clitoris, LR:Labium, right, LL:Labium, left, AV:Anterior vagina, PV:Posterior vagina, TG:serum triglyceride level, Chol:serum total cholesterol level 각 52.2 세 (25~73), 48.1 세 (32~71) 로유의한차이를보이지않았다. 진동감각역치를비교하여보았을때는오른쪽집게손가락, 음핵의귀두부, 우측소음순에서두증상을모두가진군이두증상이없는군에비해높은진동감각역치를보였다 (p<0.05). 좌측소음순, 앞측질전정부에서는두군의진동감각역치사이의확실한통 Table 3. Vibratory thresholds according to presence of specific urinary symptoms SUI UUI Frequency IF Yes 06.33 06.43 06.43 No 05.89 06.09 06.17 p-value 00.001* 00.054** 00.23 C Yes 07.09 07.00 07.16 No 06.05 06.89 06.82 p-value 00.130 00.779 00.205 LL Yes 08.84 09.00 09.98 No 08.21 08.61 08.62 p-value 00.327 00.237 00.204 LR Yes 09.70 09.89 09.70 No 08.63 09.33 09.48 p-value 00.119 00.530 00.191 AV Yes 10.67 10.77 11.01 No 09.33 10.37 10.17 p-value 00.257 00.753 00.082** PV Yes 10.87 10.85 11.33 No 09.16 09.59 10.22 p-vlaue 00.347 00.45 00.067** *:p value<0.05, **:0.05<p value<0.1, SUI:stress urinary incontinence, UUI:urgency or urge urinary incontinence, IF:index finger, C:Clitoris, LR:labium, right, LL:labium, left, AV:anterior vagina, PV:posterior vagina Table 4. Vibratory thresholds according to presence of both SUI and UI SUI with UUI p value Yes(n=130) No(n=17) Mean age 52.2±9.5 (25-73) 48.1±10.0 (32-71) 0.143** IF 06.48 5.83 0.003** C 07.10 6.25 0.043** LL 09.07 8.50 0.082** LR 09.91 8.42 0.037** AV 10.89 9.45 0.051** PV 11.04 9.55 0.163** *:p value<0.05, **:0.05<p value<0.1, SUI:stress urinary incontinence, UUI:urgency or urge urinary incontinence, IF:index finger, C:clitoris, LR:labium, right, LL:labium, left, AV:anterior vagina, PV:posterior vagina - 17 -
계적인유의성은발견하지못하였으나, 경계선적인유의성을나타내었다 (p=0.082, 0.051)(Table 4). 고찰 정량적감각검사는말초신경및중추신경계질환으로인한신경기능부전환자의감각기능평가에빈번히사용된방법이다. 이검사법은주로압력, 진동, 그리고온도등의자극을정량화된방법으로주고, 검사대상자는인지된자극을말로표현하거나버튼을누름으로써감각역치를표현하게된다 7). 말초신경에서접촉감, 가벼운압력, 그리고진동감각은유수신경 (myelinated fiber, A β, A δ) 을거쳐, 등쪽척수로를통하여전달된다 6). Belemans 등 8) 은발기부전남성에서귀두부의진동감각역치측정이신경생리학적인검사를대체할수없다고보고한바있으나, Connell 등 9) 은여성의외음부진동감각역치와성기능부전이상관관계를보인다고하고, 여성의성기능부전은자율신경계및음부신경의기능부전과관련이있을것으로보았다. 본연구에서측정한외음부의진동감각역치는음부신경기능평가의간단하고비침습적인방법이며, 저자들은증가된진동감각역치는음부신경손상을간접적으로시사하므로복압성요실금, 과민성방광등의하부요로증상과연관이있을것으로예측하였다. 복압성요실금을가진여성의 1/3에서절박성요실금을동반하는한편, 절박뇨와복압성요실금은상호증상의발현이나악화에상호영향을주는밀접한관련을보인다 8)10). 잘알려져있듯이질식분만은노화, 비만과함께복압성요실금의가장큰위험요인이며, 이는분만으로인한골반저근, 결합조직, 그리고음부신경을포함한신경손상때문으로보고있다 1)9). Furuta 등 11) 의연구에서는음부신경을손상시킨흰쥐에서복압성요실금뿐만아니라절박성요실금이유발되었으며, 이는음부신경손상에의해방광구심성신경전달로의감작이일어나기때문으로보았다. Pudendal nerve entrapment 역시복압성요실금및과민성방광의증상을동시에유발할수있다는점으로미루어음부신경의손상은복압성요실금및과민성방광의중요한병인으로생각할수있다 2)3). 본연구에서는복압성요실금, 과민성방광증상을가진여성의외음부의진동감각역치를측정하여앞에서언급한여성하부요로증상과의상관관계를설명해보고 자하였다. 복압성요실금, 절박뇨및절박성요실금, 그리고빈뇨각각의하부요로증상이있는군과없는군의외음부진동감각역치는대부분통계적으로의미있는차이를보이지않았으나, 복압성요실금및절박뇨및절박성요실금을동반한환자군과두증상모두를동반하지않은환자군을비교하였을때는대부분의외음부영역에서진동감각역치가유의하게차이가있거나경계선적인유의성을보였다. 이는앞서언급한음부신경의손상에의한하부요로증상의발현과관련이있다는것을시사하는결과이다. 또한집게손가락의진동감각역치가배뇨증상이있는군에서없는군에비해유의하게높게나왔다. 음핵같이신경분포가풍부한부위의진동감각역치보다손가락, 발가락의진동감각역치는나이에영향을많이받는다고알려져있으며 7), 이는나이에따른말초신경기능부전에의한것으로여겨진다. 본연구에서환자들의말초신경기능에대한검사를시행하지는않았지만집게손가락의진동감각차이역시말초신경기능부전에의한것으로생각되며, 여성의배뇨장애가전반적인말초신경기능부전의한증상이라고유추할수있겠다. 한편, 본연구에서외음부의진동감각역치는나이에따라유의한증가를보였는데, 외음부가에스트로겐수용체밀집지역이며, 혈중에스트로겐농도또는폐경여부와관련된감각수용체의변화및신경감각의둔화는이미잘알려져있는사실로, 나이에따른진동감각의둔화는에스트로겐농도의감소와도관련이있을것으로여겨진다. Connell 등 4) 은진동감각측정을통하여나이, 폐경이외음부의진동감각역치에유의한영향을미치는인자라고하였는데, 나이는전반적인신경계기능부전과연관이있으나, 폐경은오직외음부의감각기능부전과연관이있다고하였으며, 이는외음부에에스트로겐수용체가밀집되어있기때문이라고하였다. 본연구에서는환자들의에스트로겐수치를측정하지는않았으나, 환자들의평균나이가 51.8 세이고, 호르몬보충치료를하지않고있었던점으로미루어나이및혈중에스트로겐수치가외음부진동감각역치에영향을미쳤을것으로본다. 최근대사증후군이내피기능부전, 신경전달체감소등에미치는영향에대한관심이증가하고있고, 일부연구에서는전립선비대와관련된하부요로증상과대사증후군이상관관계가있다고보고되고있는바 12)13), 본연 - 18 -
구에서도부분적이지만혈중중성지방및콜레스테롤수치와진동감각역치와의상관관계를조사하여보았다. 그러나, 여기에서는혈중중성지방및콜레스테롤수치와진동감각역치는의미있는상관관계를볼수없었다. 요약 목적감각신경진동각측정기는인체에서진동에대한감각역치를간편하고도정확하게측정하기위해고안된장치로서, 현재다양한신경학적질환의연구에서사용되고있다. 본연구에서는복압성요실금과과민성방광, 복합성요실금환자에서음부신경이지배하는외음부의여러부위별진동감각역치의차이와그의미에대하여알아보고자하였다. 방법 2004 년 3월부터 2007 년 6월까지방광클리닉에내원한 173 명의여성환자를대상으로현병력을조사하고, 신체검사와방광내시경을시행하였으며감각신경진동각측정기 (biothersiometer, Bio-medical instrument company, USA) 를이용하여진동감각에대한역치검사를하였다. 쇄석위상태에서음핵의귀두부와해면체부인질전정부, 좌우소음순에서진동감각역치를측정하였으며, 각부위에서연속 3회측정의평균치를기록하였다. 환자들의연령및질환의종류, 방광용적, 최대요속과배뇨후잔뇨량, 혈중중성지방과콜레스테롤수치와감각신경역치와의연관성을분석하였다. 결과대상환자들의평균나이는 51.8±9.4 세였으며, 환자들의주증상중복압성요실금은 87.4%, 요급과급박성요실금은 77.1%, 빈뇨는 66% 에서나타났다. 환자의나이와진동각측정치간의상관관계를보았을때, 음핵귀두부 (r=0.394, p<0.001), 좌우질전정부 (r=0.343, p< 0.001, r=0.332, p<0.001), 좌우소음순 (r=0.294, p< 0.001, r=0.279, p<0.001) 에서모두나이가증가할수록감각신경역치가증가하는것으로나타났다. 주증상이복압성요실금인환자들과요급및급박성요실금인환자들의진동감각역치평균을각각해당증상이없는환자들과비교했을때증상이있는환자들에서진동감각역치의평균이모든측정위치에서증가되어있었으나기준 치인검지에서의측정치이외에는통계적으로유의하지않았다. 복압성요실금과요급및급박성요실금을모두가지고있는환자들의진동감각역치평균을두증상이모두없는환자들과비교하였을때, 음핵귀두부 (7.01 vs 6.25, p=0.043) 와우측소음순 (9.91 vs 8.41, p=0.037) 에서증상이있는환자들에서의역치가높게나타났다. 혈중중성지방과콜레스테롤수치와감각신경역치사이에는유의한관계가나타나지않았으며, 연령과혈중중성지방간에는양의상관관계가나타났다.(r=0.192, p<0.001) 결론감각신경진동각측정기를사용하여진동자극역치를측정한결과환자들의외음부의진동자극인지기능이연령이증가할수록모든부위에서둔화됨을알수있었고, 환자들의주증상여부에따라진동감각역치가차이가있음을알수있었다. 중심단어 : 외음부감각 감각신경진동각검사 하부요로증상. References 1) Meyer S, Schreyer A, De Grandi P, Hohlfeld P. The effects of birth on urinary continence mechanisms and other pelvic-floor characteristics. Obstet Gynecol 1998; 92:613-618 2) Beco J, Climov D, Bex M. Pudendal nerve decompression in perineology:a case series. BMC surg 2004; 4:15 3) Popeney C, Ansell V, Renney K. Pudendal entrapment as an etiology of chronic perineal pain:diagnosis and treatment. Neurourol Urodyn 2007;26:820-827 4) Connell K, Guess MK, Bleustein CB, Powers K, Lazarou G, Mikhail M, et al. Effects of age, menopause, and comorbidities on neurological function of the female genitalia. Int J Impot Res 2005;17:63-70 5) Gelber DA, Pfeifer MA, Broadstone VL, Munster EW, Peterson M, Arezzo JC, et al. Components of variance for vibratory and thermal threshold testing in normal and diabetic subjects. J Diabetes Complications 1995; 9:170-176 6) Zalansky R, Yarnitsky D. Clinical applications of quantitative sensory testing(qst). J Neurol Sci 1998;153: 215-238 7) Vardi Y, Gruenwald I, Sprecher E, Gertman I, Yartnitsky - 19 -
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