慢性间质性膀胱炎的中医治疗-ppt课件.ppt

1、间质性膀胱炎的中医治疗间质性膀胱炎的中医治疗v以尿频、尿急、尿痛和尿意不尽等尿路刺激症状为临床表现v多见于西医学某些泌尿系统的疾病，如泌尿系统感染、泌尿系统结石、泌尿系统肿瘤以及乳糜尿等疾病v在临床表现为尿路刺激症状为主者西方医学观点西方医学观点引起间质性膀胱炎的原因v至今仍不明IC可能的致病机转v发炎后之自体免疫反应过程：曾有的膀胱发炎导致膀胱璧受损，并产生自体免疫反应。此自体免疫反应导致膀胱黏膜下及肌肉层后续之发炎及纤维化。(Sant, 1999)IC可能的致病机转v膀胱表皮功能异常v膀胱的黏膜内皮是由类似肝素的黏蛋白类组成（glycosaminoglycan, GAG），可防止细菌粘住膀

2、胱壁。vParsons,1994，认为IC是由于各种毒性或酸碱度改变、或膀胱过胀导致膀胱表皮渗漏性增加（缺乏GAG层所导致），使尿液里的有毒物质及钾离子进入膀胱黏膜下之感觉神经，导致膀胱疼痛及炎性反应。间质性发炎v病毒感染v过敏性免疫反应/auto-immune reactionv立克次菌中医观点中医观点中医观点v依照临床症状表现，间质性膀胱炎隶属于中医“淋证”的范畴。v最早在秦汉时代的皇帝内经一书中即有关于淋证的记载。v淋证的症状描述： -小便频数、短涩，淋沥不畅，小腹拘急引痛中医观点v血证论 第四卷血下泄证治六条- 尿血 第六卷失血兼见诸证- 遗精、淋浊v尿血v内容：膀胱与血室。并域而居。

3、热入血室。则蓄血。热结膀膀胱与血室。并域而居。热入血室。则蓄血。热结膀胱。则尿血。尿乃水分之病。而亦干动血分者。以与血室胱。则尿血。尿乃水分之病。而亦干动血分者。以与血室 并居。故相连累也。其致病之由。则有内外二因。并居。故相连累也。其致病之由。则有内外二因。 v一外因。乃太阳阳明传经之热。结于下焦。其証。身有寒热。口渴腹满。小便不利。溺血疼痛溺血疼痛。宜仲景桃仁承 气汤治之。小柴胡汤。加桃仁丹皮牛膝。亦治之。 v一内因。乃心经遗热于小肠。肝经遗热于血室。其証。淋秘淋秘割痛。小便点滴不通者。呼赤淋。割痛。小便点滴不通者。呼赤淋。治宜清热。治心经遗热。虚烦不眠。或昏睡不醒。或舌咽作痛。或怔忡懊

4、。宜导赤饮。加炒栀连翘丹皮牛膝。治肝经遗热。其証少腹满。胁肋刺痛。口苦耳聋。或则寒热往来。宜龙胆泻肝汤。加桃仁丹皮牛膝郁金。尿血治心与肝而不愈者。当兼治其肺。肺为水尿血治心与肝而不愈者。当兼治其肺。肺为水之上源。金清则水清。水宁则血宁。盖此証原是水病累血。之上源。金清则水清。水宁则血宁。盖此証原是水病累血。故治水即是治血。故治水即是治血。人参泻肺汤。去大黄 v遗精v内容：世谓上吐血。下遗精。其病不治。谓其上逆世谓上吐血。下遗精。其病不治。谓其上逆下竭。立见消耗也。然病此者。但未沉久。犹可图下竭。立见消耗也。然病此者。但未沉久。犹可图治。盖遗精失血。治。盖遗精失血。 v虽是两病。其实一而已矣。精

5、者肾中阳气所化。精者肾中阳气所化。乃天一所生之癸水也。女子十四。则癸水至于胞中。女子十四。则癸水至于胞中。而冲任两脉即通。将心火所化之血。转输入胞。与癸水交合。水从血化。是为月信。男子十六。则癸水从血化。是为月信。男子十六。则癸水亦至于胞中。水亦至于胞中。而冲任两脉。亦输血入胞。与癸水合。血从水化。是谓之精。胞者精之舍。即血之室血从水化。是谓之精。胞者精之舍。即血之室也。吐衄者。是胞中血分之病。遗精者。是胞中水也。吐衄者。是胞中血分之病。遗精者。是胞中水分之病。血与水。上下内外。皆相济而行。吾已言分之病。血与水。上下内外。皆相济而行。吾已言之屡矣。故病血者。未尝不病水。之屡矣。故病血者。未尝不

6、病水。 v淋浊v内容：淋者小便短数。淋沥不通之谓也。单淋者小便短数。淋沥不通之谓也。单病此者。自有诸书可考。血家病此。病此者。自有诸书可考。血家病此。特其兼见者耳。然二便为消息之门户。若一闭塞。则上中焦不得消息。故伤寒论。有言急下者。有言当利其小便者。有言有小便则生。无小有言有小便则生。无小便死者。无一不吃紧于此。此水病也。水与便死者。无一不吃紧于此。此水病也。水与血相为倚伏。吾已言之屡屡。单病血。不病血相为倚伏。吾已言之屡屡。单病血。不病水者易愈。以水调。则其血虽病。犹有水以水者易愈。以水调。则其血虽病。犹有水以濡之也。若病血。而又累及于水。则上而喘濡之也。若病血。而又累及于水。则上而喘咳。

7、外而肿热。下而淋浊。均不能免。水病咳。外而肿热。下而淋浊。均不能免。水病则无以濡血。而血証亦因以难愈矣。则无以濡血。而血証亦因以难愈矣。 中医观点v依其他兼症表现，淋证又可再细分成六类： 1. 热淋（小便灼热刺痛） 2. 血淋（血便） 3. 膏淋（小便浑浊） 4. 石淋（尿路结石） 5. 气淋（膀胱功能失司） 6. 劳淋（久病正气虚衰）1.热淋v症状：小便短数，灼热刺痛，溺色黄赤。v兼症：腰痛拒按、寒热起伏、口苦、呕恶、便秘，苔黄腻，脉濡数。v病机：湿热蕴结下焦，膀胱气化失司。v治法：清热利湿，通淋。v主方：八正散。2.血淋：v实证v症状：小腹涩痛，尿中有血或尿时夹有血块，疼痛满急加剧。v兼症

8、：心烦、舌尖红，苔黄、脉数。v病机：湿热下注膀胱，热盛灼络，迫血妄行。v治法：清热通淋，凉血止血。v主方：小蓟饮子合导赤散。2.血淋：v虚证v症状：尿色淡红，疼痛涩滞不甚显著。v兼症：腰酸膝软，神疲乏力，舌淡红，脉细数。v病机：肾阴不足，虚火扰动阴血。v治法：滋阴清热，补虚止血。v主方：知柏地黄丸。3.膏淋：v实证v症状：小便混浊如米泔水，尿道热涩疼痛。v兼症：舌红，苔黄腻，脉濡数。v病机：湿热下注,阻滞络脉，脂液不循常道。v治法：清热利湿，分清泄浊。v主方：程氏萆薢分清饮。3.膏淋：v虚证v症状：淋出如脂，涩痛反见减轻。v兼症：形瘦、头昏、乏力，腰疲膝软。舌淡苔腻，脉细弱无力。v病机：肾虚下

9、元不固，不能制约脂液。v治法：补虚固涩。v主方：膏淋汤。( (生山药生山药 生芡实生芡实 生牡蛎生牡蛎 大生地大生地 党参党参 芍药芍药) )4.石淋v症状：尿中时夹砂石，小便艰涩，尿时疼痛或突然中断。v兼症：腰腹绞痛难忍，尿中带血。舌质红，苔薄黄，脉弦或带数。v病机：湿热煎熬尿液，结为砂石。v治法：清热利湿，通淋排石。v主方：石苇散。 ( (通草通草 王不留行王不留行 滑石滑石 当归当归)5.气淋v实证v症状：小便涩滞，淋沥不宣。v兼症：少腹满痛，脉沈弦。v病机：气机郁结，膀胱气化不利。v治法：利气疏导。v主方：沈香散。( (沉香沉香 木香木香 枳壳枳壳) ) 5.气淋v虚证v症状：少腹坠胀

10、，尿有余沥。v兼症：面色晄白，舌质淡，脉虚细无力。v病机：气虚下陷。v治法：益气升提。v主方：补中益气汤。 6.劳淋v症状：小便不甚赤涩，但淋沥不已，时作时止，遇劳即发。v兼症：腰痠膝软神疲乏力，舌淡，脉弱。v病机：脾肾两虚，湿浊留恋不去。v治法：健脾益肾。v主方：无比山药丸。(薯蓣薯蓣 肉苁蓉肉苁蓉 五味子五味子 菟丝子菟丝子 杜仲杜仲 牛膝牛膝 泽泻泽泻 干地黄干地黄 山茱萸山茱萸 茯苓茯苓 巴戟天巴戟天 赤石脂赤石脂)病因中医观点v虚 乱 郁 结1.气血不足2.脾肾不足邪气血瘀滞、痰浊结聚、邪毒蕴结七情内伤外感六淫喜怒忧思悲恐惊风寒暑湿燥火中医观点v致病机转： 邪 病位 致病 湿热，痰瘀

11、 膀胱（肾） 淋证 1. 外邪致病 病因 2. 素体脏腑功能不协调 3. 情志不调 间质性膀胱炎的中医证型分类v脾肺气虚，下焦湿阻v脾肾阳虚，膀胱气化不利v肝气郁滞，肝经气滞血瘀针灸对骨盆腔疼痛的疗效v西方医学许多相关研究都证实有效Effects of acupuncture for chronic pelvic pain syndrome with intrapelvic venous congestion: preliminary results.v出处- Int J Urol. 2004 Aug;11(8):607-12.vAbstractvBACKGROUND: The present

12、 study was designed to reveal the usefulness of acupuncture for chronic pelvic pain syndrome with intrapelvic venous congestion as evaluated by symptom scores, transrectal ultrasonography (TRUS) and magnetic resonance (MR) venography.vMETHODS: Ten male patients suffering from non-inflammatory chroni

13、c pelvic pain syndrome (NIH category IIIB) with intrapelvic venous congestion were treated using acupuncture. Eight patients had previously received pharmacotherapy, which was unsuccessful. Acupuncture was performed using disposable stainless steel needles, which were inserted into the bilateral BL-

14、33 points and rotated manually for 10 min. The treatment was repeated every week for 5 weeks without other therapeutic maneuvers. Results from TRUS and MR venography, as well as clinical symptoms based on the NIH chronic prostatitis symptom index (NIH-CPSI) and the international prostate symptom sco

15、re (IPSS), were compared before and after the treatment.vRESULTS: No side-effects were recognized throughout the treatment period. The average pain and QOL scores of the NIH-CPSI 1 week after the 5th acupuncture treatment decreased significantly (P 0.05 and P 0.01, respectively) compared with the ba

16、seline. The maximum width of the sonolucent zone 1 week after the 5th treatment also decreased significantly (P or = 20 years old, and had a total score or = 15 on the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) and symptoms for at least 3 of the preceding 6 months. They were randomized 1:1 to

17、acupuncture or sham acupuncture. Treatment consisted of twice-weekly 30-minute sessions for 10 weeks (20 sessions total) without needle stimulation, herbs, or adjuvants. The primary response criterion was a 6-point decrease from baseline to week 10 in NIH-CPSI total score (range 0-43).vRESULTS: Thir

18、ty-two (73%) of 44 participants responded in the acupuncture group compared with 21 (47%) of 45 sham group participants (relative risk 1.81, 95% confidence interval, 1.3-3.1, P = .02). Long-term responses 24 weeks after completing therapy without additional treatment occurred in 14 (32%) of 44 acupu

19、ncture group participants and in 6 (13%) of 45 sham group participants (relative risk 2.39, 95% confidence interval, 1.0-5.6, P = .04).vCONCLUSIONS: After 10 weeks of treatment, acupuncture proved almost twice as likely as sham treatment to improve CP/CPPS symptoms. Participants receiving acupunctur

20、e were 2.4-fold more likely to experience long-term benefit than were participants receiving sham acupuncture.Success of acupuncture in the treatment of painful bladder syndrome (interstitial cystitis)v出处- The Journal Of Urology Vol. 181, No. 4, Supplement, Saturday, April 25, 2009 vPainful Bladder

21、Syndrome (Interstitial Cystitis) (PBS/IC). Is an important clinical condition of unknown aetiology and affects between 0.01% and 0.5% of the female population. The goal of management is to ameliorate the associated pain and storage symptoms and improve quality of life. Available evidence on conserva

22、tive and supportive therapy suggests limited efficacy for most therapies. Our objective was to determine how effective acupuncture is at reducing symptoms and improving quality of life in a group of individuals who had failed to respond to conventional conservative therapy.Effectiveness of acupunctu

23、re in patients with category IIIB chronic pelvic pain syndrome: a report of 97 patients.v出处- Pain Med. 2010 Apr;11(4):518-23. Epub 2010 Jan 22.vAbstractvOBJECTIVE: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is of significant interest in urology and unfortunately, the therapy modaliti

24、es recommended are not fully effective. Therefore, we undertook a pilot study to determine whether acupuncture improves the pain, voiding symptoms, and quality of life in men with category IIIB CP/CPPS.vDESIGN: Prospective, one-group trial, cohort study.vSETTING: Outpatient urology clinic.vPATIENTS

25、AND INTERVENTIONS: Ninety-seven CP/CPPS patients received six sessions of acupuncture to the BL-33 acupoints once a week. The National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI) was completed by each patient before and after the treatment and on 12th and 24th weeks following th

26、e treatment.vOUTCOME MEASURES: Mean values of total CPSI score, pain subscore, urinary subscore, and quality of life subscore after the treatment and on follow-up after the treatment were compared with the baseline values.vRESULTS: There was a statistically significant decrease in all of the subscor

27、es evaluated at all periods compared with the baseline. Eighty-six patients out of 93 (92.47%) were NIH-CPSI responders (more than 50% decrease in total NIH-CPSI score from baseline) at the end of the treatment.vCONCLUSIONS: The results of this study suggest that acupuncture appears to be a safe and

28、 potentially effective treatment in improving the symptoms and quality of life of men clinically diagnosed with CP/CPPS.常用穴位阴陵泉v在小腿内侧，胫骨内侧髁下缘凹陷处。 v脾经合穴v运中焦、化湿滞、调膀胱、袪风冷常用穴位三阴交v内踝尖直上四横指，胫骨后缘。 v肝、脾、肾v补脾土、助运化、通气滞、疏下焦、调血室精宫、袪经络风湿常用穴位阳陵泉v屈膝90度，在膝盖外侧可见到两个突起，前上方为胫骨小头，后方偏下的是腓骨小头，两点连线作一正三角形，第三点即为该穴。v胆经合穴v疏泄肝胆

29、、清利湿热、疏筋健膝 常用穴位关元v在任脉上，肚脐至耻骨的距离是五吋 ，关元穴约在肚脐下3吋v交会穴（墓穴）v男子藏精、女子蓄血之处v益肾气、利下焦、回阳救逆常用穴位太冲v太冲穴位于足背侧，第一、二趾跖骨连接处。以手指沿拇趾、次趾夹缝向上移压，压至能感觉到动脉应手，即是此穴 。v肝经原穴v平肝熄风、清热利胆、明目临床观察小结（中医观点）v患者除IC之外，均有其他免疫系统失调疾病，例如，上呼吸道过敏、皮肤过敏v肠胃功能障碍亦见于80以上病患。v少数病患还有患有不同程度的风湿性病变。v不同程度情绪障碍同时伴随出现。v女性病患病情会随月经周期而波动。临床观察小结（中医观点）v膀胱是身体的一部份，不是

30、独立存在的脏器。v间质性膀胱炎是全身性的疾病在膀胱的表现。而全身性的疾病偏表现于呼吸道及消化道的失调，以中医的眼光看来，这些部位与膀胱有着内在的联系。v间质性膀胱炎似乎与免疫系统失调强烈相关。v治疗间质性膀胱炎的同时，应治疗全身性免疫系统的不协调 治疗全身脏腑关系的失衡治疗经验总结v间质性膀胱炎的表现，在许多方面来看，与过敏疾病有很多相似的表现。v过敏体质是不容易改变的，只有在青春期、怀孕时或更年期时有机会转变。v过敏反应多由特定的刺激所引发。而引发间质性膀胱炎急性发作的刺激原现今并不清楚，我们只知可能与压力、憋尿、月经周期（排卵期、月经期）、感冒或肠胃功能不稳定有关。治疗经验总结v经过长期观察，中药药物介入治疗可以减少发病频率，缩短发病时间，减少病情严重程度。v针灸可有效缓解骨盆腔疼痛，效果持续时间较短暂，每周宜施针2-3回。中西医整合治疗间质性膀胱炎v自民国101年5月开始至今v在每周二下午，以整合门诊讨论方式进行个案研讨v各科相关专题报告v营养科、精神科、中医科、泌尿科、麻醉科、免疫风湿科、妇科治疗模式v 初诊v 询问病史 建立病患体质模式v 复诊 现在症状表现v 分析病情 辨邪正，病位，病势v 决定治疗方向 v 处方治疗模式v以教学及研究为目的v以内服药物（汤药）为主v未来考虑建立“针灸治疗间质性膀胱炎”计划。谢谢大家热情参予敬请指教敬祝大家 身体健康 事事如意