今日の臨床サポート

骨盤臓器脱

著者: 古山将康 大阪市立大学大学院医学研究科 女性生涯医学

監修: 小林裕明 鹿児島大学大学院医歯学総合研究科生殖病態生理学

著者校正/監修レビュー済:2018/12/06
患者向け説明資料

概要・推奨   

疾患のポイント:
  1. 性器脱は腟壁の弛緩によって骨盤底臓器が下垂・脱出するヘルニアの状態を指す。肛門から直腸壁が重積のような形で脱出する直腸脱を合わせて、骨盤臓器脱(pelvic organ prolapse、POP)と呼ばれる。
  1. 性器脱(骨盤臓器脱)の進展は骨盤底臓器の支持機構の破綻による。発症には素因(人種や遺伝的要素)、誘発因子(妊娠・分娩、手術既往)、助長因子(肥満、便秘、慢性の咳、職業など)、非代償性因子(加齢、エストロゲン低下、組織の萎縮)が関わる。
  1. 性器脱(骨盤臓器脱)は陰部からの腟の脱出に伴う違和感として気づかれることが多い。無症状の患者が多く、20~80歳の女性で有症状の骨盤臓器脱の頻度は約3%とされる。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
古山将康 : 特に申告事項無し[2021年]
監修:小林裕明 : 講演料(中外製薬株式会社,アストラゼネカ株式会社),奨学(奨励)寄付など(中外製薬株式会社)[2021年]

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 性器脱は骨盤底臓器が腟壁を押す形で下垂・脱出するヘルニアの状態を指し、肛門から直腸壁が重積のような形で脱出する直腸脱を合わせて、骨盤臓器脱(pelvic organ prolapse、 POP)と呼ばれる。
  1. 骨盤臓器脱の進展は骨盤底臓器の支持機構の破綻による。発症には素因(人種や遺伝的要素)、誘発因子(妊娠・分娩、手術既往)、助長因子(肥満、便秘、慢性の咳、職業など)、非代償性因子(加齢、エストロゲン低下、組織の萎縮)が関わる。
  1. 骨盤臓器脱は無症状の患者が多く医療機関の受診率が一定でないため正確な有病率は不明であるが、20~80歳の女性で有症状の骨盤臓器脱の頻度は約3%とされる[1]
  1. 米国の20~80歳までに骨盤臓器脱もしくは尿失禁で手術を受ける生涯リスクは11.1%であった。手術後の再手術は29.2%に施行されていた[2]
  1. Women’s Health Initiative Study(WHI研究)によると一般女性の診察結果では子宮脱が14%、膀胱瘤は34%、直腸瘤が19%の有病率であった。人種間の差としては黒人は骨盤臓器脱の発症頻度は少なく、ヒスパニックは子宮脱、アジア系は膀胱瘤の発症が高い[3]
  1. 20~59歳までの女性の約30%、50歳代の女性の約55%、出産経験者の女性の44%が何らかの骨盤臓器脱症状を有する[4]
  1. 子宮脱矯正リングペッサリーが保存的治療で用いられる。わが国のペッサリーのメーカーでは月約6,000個の受注があり、骨盤臓器脱患者の約50%にリングが使用されていると仮定すると、骨盤臓器脱のために受診する新規患者は毎年14万人程度いると推定される。
  1. 分娩は大きな誘発因子であるが、この調査では分娩回数とは相関していなかった。他の研究では1回の分娩で4倍、2回の分娩で8倍、3回では9倍、4回では10倍のリスクがあるとの報告もある[5]
問診・診察のポイント  
問診:
  1. 外陰部の下垂感を自覚した状況(場所、時間、視認か触知か、腹圧の有無)

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文献 

著者: Ingrid Nygaard, Matthew D Barber, Kathryn L Burgio, Kimberly Kenton, Susan Meikle, Joseph Schaffer, Cathie Spino, William E Whitehead, Jennifer Wu, Debra J Brody, Pelvic Floor Disorders Network
雑誌名: JAMA. 2008 Sep 17;300(11):1311-6. doi: 10.1001/jama.300.11.1311.
Abstract/Text CONTEXT: Pelvic floor disorders (urinary incontinence, fecal incontinence, and pelvic organ prolapse) affect many women. No national prevalence estimates derived from the same population-based sample exists for multiple pelvic floor disorders in women in the United States.
OBJECTIVE: To provide national prevalence estimates of symptomatic pelvic floor disorders in US women.
DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional analysis of 1961 nonpregnant women (>or=20 years) who participated in the 2005-2006 National Health and Nutrition Examination Survey, a nationally representative survey of the US noninstitutionalized population. Women were interviewed in their homes and then underwent standardized physical examinations in a mobile examination center. Urinary incontinence (score of >or=3 on a validated incontinence severity index, constituting moderate to severe leakage), fecal incontinence (at least monthly leakage of solid, liquid, or mucous stool), and pelvic organ prolapse (seeing/feeling a bulge in or outside the vagina) symptoms were assessed.
MAIN OUTCOME MEASURES: Weighted prevalence estimates of urinary incontinence, fecal incontinence, and pelvic organ prolapse symptoms.
RESULTS: The weighted prevalence of at least 1 pelvic floor disorder was 23.7% (95% confidence interval [CI], 21.2%-26.2%), with 15.7% of women (95% CI, 13.2%-18.2%) experiencing urinary incontinence, 9.0% of women (95% CI, 7.3%-10.7%) experiencing fecal incontinence, and 2.9% of women (95% CI, 2.1%-3.7%) experiencing pelvic organ prolapse. The proportion of women reporting at least 1 disorder increased incrementally with age, ranging from 9.7% (95% CI, 7.8%-11.7%) in women between ages 20 and 39 years to 49.7% (95% CI, 40.3%-59.1%) in those aged 80 years or older (P < .001), and parity (12.8% [95% CI, 9.0%-16.6%], 18.4% [95% CI, 12.9%-23.9%], 24.6% [95% CI, 19.5%-29.8%], and 32.4% [95% CI, 27.8%-37.1%] for 0, 1, 2, and 3 or more deliveries, respectively; P < .001). Overweight and obese women were more likely to report at least 1 pelvic floor disorder than normal weight women (26.3% [95% CI, 21.7%-30.9%], 30.4% [95% CI, 25.8%-35.0%], and 15.1% [95% CI, 11.6%-18.7%], respectively; P < .001). We detected no differences in prevalence by racial/ethnic group.
CONCLUSION: Pelvic floor disorders affect a substantial proportion of women and increase with age.

PMID 18799443  JAMA. 2008 Sep 17;300(11):1311-6. doi: 10.1001/jama.300・・・
著者: A L Olsen, V J Smith, J O Bergstrom, J C Colling, A L Clark
雑誌名: Obstet Gynecol. 1997 Apr;89(4):501-6. doi: 10.1016/S0029-7844(97)00058-6.
Abstract/Text OBJECTIVE: To determine the incidence of surgically managed pelvic organ prolapse and urinary incontinence in a population-based cohort, and to describe their clinical characteristics.
METHODS: Our retrospective cohort study included all patients undergoing surgical treatment for prolapse and incontinence during 1995; all were members of Kaiser Permanente Northwest, which included 149,554 women age 20 or older. A standardized data-collection form was used to review all inpatient and outpatient charts of the 395 women identified. Variables examined included age, ethnicity, height, weight, vaginal parity, smoking history, medical history, and surgical history, including the preoperative evaluation, procedure performed, and details of all prior procedures. Analysis included calculation of age-specific and cumulative incidences and determination of the number of primary operations compared with repeat operations performed for prolapse or incontinence.
RESULTS: The age-specific incidence increased with advancing age. The lifetime risk of undergoing a single operation for prolapse or incontinence by age 80 was 11.1%. Most patients were older, postmenopausal, parous, and overweight. Nearly half were current or former smokers and one-fifth had chronic lung disease. Reoperation was common (29.2% of cases), and the time intervals between repeat procedures decreased with each successive repair.
CONCLUSION: Pelvic floor dysfunction is a major health issue for older women, as shown by the 11.1% lifetime risk of undergoing a single operation for pelvic organ prolapse and urinary incontinence, as well as the large proportion of reoperations. Our results warrant further epidemiologic research in order to determine the etiology, natural history, and long-term treatment outcomes of these conditions.

PMID 9083302  Obstet Gynecol. 1997 Apr;89(4):501-6. doi: 10.1016/S002・・・
著者: Susan L Hendrix, Amanda Clark, Ingrid Nygaard, Aaron Aragaki, Vanessa Barnabei, Anne McTiernan
雑誌名: Am J Obstet Gynecol. 2002 Jun;186(6):1160-6.
Abstract/Text OBJECTIVE: The purpose of this study was to describe the prevalence of and correlates for pelvic organ prolapse.
STUDY DESIGN: This was a cross-sectional analysis of women who enrolled in the Women's Health Initiative Hormone Replacement Therapy Clinical Trial (n = 27,342 women). Baseline questionnaires ascertained demographics and personal habits. A baseline pelvic examination assessed uterine prolapse, cystocele, and rectocele. Descriptive statistics and logistic regression models were used to investigate factors that were associated with pelvic organ prolapse.
RESULTS: In the 16,616 women with a uterus, the rate of uterine prolapse was 14.2%; the rate of cystocele was 34.3%; and the rate of rectocele was 18.6%. For the 10,727 women who had undergone hysterectomy, the prevalence of cystocele was 32.9% and of rectocele was 18.3%. After controlling for age, body mass index, and other health/physical variables, African American women demonstrated the lowest risk for prolapse. Hispanic women had the highest risk for uterine prolapse. Parity and obesity were strongly associated with increased risk for uterine prolapse, cystocele, and rectocele.
CONCLUSION: Pelvic organ prolapse is a common condition in older women. The risk for prolapse differs between ethnic groups, which suggests that the approaches to risk-factor modification and prevention may also differ. These data will help address the gynecologic needs of diverse populations.

PMID 12066091  Am J Obstet Gynecol. 2002 Jun;186(6):1160-6.
著者: E C Samuelsson, F T Victor, G Tibblin, K F Svärdsudd
雑誌名: Am J Obstet Gynecol. 1999 Feb;180(2 Pt 1):299-305.
Abstract/Text OBJECTIVE: Our objective was to study the prevalence of genital prolapse and possible related factors in a general population of women 20 to 59 years of age.
STUDY DESIGN: Of 641 eligible women in a primary health care district, 487 (76%) answered a questionnaire and accepted an invitation to a gynecologic health examination.
RESULTS: The prevalence of any degree of prolapse was 30.8%. Only 2% of all women had a prolapse that reached the introitus. In a set of multivariate analyses, age (P <.0001), parity (P <.0001), and pelvic floor muscle strength (P <.01)-and among parous women, the maximum birth weight (P <.01)-were significantly and independently associated with presence of prolapse, whereas the woman's weight and sustained hysterectomy were not.
CONCLUSIONS: Signs of genital prolapse are frequently found in the female general population but are seldom symptomatic. Of factors associated with genital prolapse found in this study, pelvic floor muscle strength appears to be the only one that could be affected.

PMID 9988790  Am J Obstet Gynecol. 1999 Feb;180(2 Pt 1):299-305.
著者: J Mant, R Painter, M Vessey
雑誌名: Br J Obstet Gynaecol. 1997 May;104(5):579-85.
Abstract/Text OBJECTIVE: To explore the epidemiology of uterovaginal and post-hysterectomy prolapse.
DESIGN: Cohort study.
SETTING: Seventeen large family planning clinics in England and Scotland.
POPULATION: 17,032 women who attended family planning clinics between 1968 and 1974, aged between 25 and 39 years at study entry.
METHODS: Annual follow up by interview, postal or telephone questionnaire until July 1994. Further details on all hospital admissions were obtained from the hospital discharge summaries. All women were flagged at time of recruitment in the NHS central registers.
MAIN OUTCOME MEASURE: In-patient admission with diagnosis of prolapse (ICD codes 8th Revision 623.0-623-9).
RESULTS: The incidence of hospital admission with prolapse is 2.04 per 1000 person-years of risk. Age, parity, calendar period and weight were significantly associated with risk of an inpatient admission with prolapse after adjustment for principal confounding factors. Significant trends were observed with regard to smoking status and obesity (Quetelet Index) at entry to the study and risk of prolapse. Social class, oral contraceptive use and height were not significantly associated with risk of prolapse. The incidence of prolapse which required surgical correction following hysterectomy was 3.6 per 1000 person-years of risk. The cumulative risk rises from 1% three years after a hysterectomy to 5% 15 years after hysterectomy. The risk of prolapse following hysterectomy is 5.5 times higher (95% CI 3.1-9.7) in women whose initial hysterectomy was for genital prolapse as opposed to other reasons.
CONCLUSION: Among the potential risk factors that were investigated, parity shows much the strongest relation to prolapse.

PMID 9166201  Br J Obstet Gynaecol. 1997 May;104(5):579-85.
著者: G M Ghoniem, F Walters, V Lewis
雑誌名: J Urol. 1994 Sep;152(3):931-4.
Abstract/Text To detect possible stress urinary incontinence associated with but masked by large cystoceles protruding through the vaginal orifice, a vaginal pack test was done in conjunction with video fluoro-urodynamic studies. Sixteen female patients with large cystoceles did not demonstrate stress urinary incontinence on clinical examination and were included in this study. Additionally, 10 healthy female volunteers underwent the same test to study the effect of a vaginal pack on urethral dynamics. The vaginal pack revealed the presence of stress urinary incontinence in 11 patients (69%): 3 (19%) with type II (vesicourethral hypermobility) and 8 (50%) with type III (internal sphincteric deficiency). After insertion of the vaginal pack, urodynamic studies showed that the closing proximal urethral pressure in patients with stress urinary incontinence was significantly lower than in continent patients (p < 0.05). No significant change in urethral pressures was noted in volunteer subjects after vaginal pack insertion. Fluoroscopy showed kinking of the posterior urethra and enlargement of the most dependent portion of the cystocele, that is the lower half of the hourglass image. Our study suggests that the mechanisms of continence in these patients are multifactorial, including urethral kinking, urethral compression and pressure dissipation. The vaginal pack test is easy to perform, increases visualization of the vesicourethral unit when used with fluoroscopy, and can aid in the selection of patients who would benefit from anti-incontinence surgery and/or cystocele repair.

PMID 8051758  J Urol. 1994 Sep;152(3):931-4.
著者: R C Bump, A Mattiasson, K Bø, L P Brubaker, J O DeLancey, P Klarskov, B L Shull, A R Smith
雑誌名: Am J Obstet Gynecol. 1996 Jul;175(1):10-7.
Abstract/Text This article presents a standard system of terminology recently approved by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons for the description of female pelvic organ prolapse and pelvic floor dysfunction. An objective site-specific system for describing, quantitating, and staging pelvic support in women is included. It has been developed to enhance both clinical and academic communication regarding individual patients and populations of patients. Clinicians and researchers caring for women with pelvic organ prolapse and pelvic floor dysfunction are encouraged to learn and use the system.

PMID 8694033  Am J Obstet Gynecol. 1996 Jul;175(1):10-7.
著者: V Wu, S A Farrell, T F Baskett, G Flowerdew
雑誌名: Obstet Gynecol. 1997 Dec;90(6):990-4.
Abstract/Text OBJECTIVE: To evaluate a simplified protocol for pessary management.
METHODS: Women with symptomatic pelvic organ prolapse who opted for pessaries were enrolled in a prospective simplified protocol for pessary management. After the initial pessary fitting, they were seen at 2 weeks for reexamination and thereafter at 3- to 6-month intervals.
RESULTS: One hundred ten women (mean age 65 years) were enrolled, and 81 (74%) of them were fitted successfully with a pessary. Life-table analysis showed that 66% of those who used a pessary for more than 1 month were still users after 12 months and 53% were still users after 36 months. The severity of pelvic prolapse did not predict the likelihood of pessary failure except in cases of complete vaginal eversion. Patients complaining of stress incontinence were less likely to have a successful pessary fitting and more likely to opt for surgery. Current hormone use and substantial perineal support do not predict greater likelihood of pessary fitting success. No serious complications from using the pessary were observed in the study sample.
CONCLUSION: Stringent guidelines calling for frequent pelvic examinations during pessary use can be relaxed safely. Pessaries can be offered as a safe long-term option for the management of pelvic prolapse.

PMID 9397117  Obstet Gynecol. 1997 Dec;90(6):990-4.

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