今日の臨床サポート

尿失禁・頻尿(産婦人科)

著者: 角俊幸 大阪市立大学 産科婦人科学

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

著者校正済:2022/11/09
現在監修レビュー中
患者向け説明資料

概要・推奨   

  1. 尿失禁の患者には問診により尿失禁の病態を分類することが勧められる(推奨度2)
  1. 頻尿の患者には過活動膀胱症状質問票により診断することが勧められる(推奨度1)
  1. 腹圧性尿失禁の行動療法として骨盤底筋訓練を行うことが勧められる(推奨度1)
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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。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※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、実際の保険適応の査定において保険適応及び保険適応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応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:
角俊幸 : 特に申告事項無し[2022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),研究費・助成金など(シスメックス株式会社),奨学(奨励)寄付など(中外製薬株式会社)[2022年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 尿失禁・頻尿は、正式には下部尿路症状(lower urinary tract symptoms、LUTS)といわれる。
  1. LUTSは、蓄尿症状、排尿症状、排尿後症状の3つに大別されるが、尿失禁・頻尿は蓄尿症状の1つである。
  1. 1日8~10回以上の排尿回数を頻尿という。
  1. 尿の無意識あるいは不随意な漏れが衛生的または社会的に問題となったものを尿失禁という。
  1. 頻尿を呈する代表的な疾患は過活動膀胱(overactive bladder、OAB)である。
  1. OABは、「尿意切迫感を必須とした症状症候群で、通常は頻尿と夜間頻尿を伴う。切迫性尿失禁は必須ではない。」と定義されている。
  1. わが国の40歳以上の女性のLUTSの頻度は、昼間頻尿48.7%、夜間頻尿66.9%、尿失禁43.9%、過活動膀胱10.9%と報告されている[1]
  1. 女性のLUTSの病因として、経腟分娩・加齢・高度な肥満などによる骨盤臓器支持組織の破綻や骨盤底筋群の脆弱化が考えられている。加齢に関しては、閉経による女性ホルモン欠落状態が骨盤臓器支持組織脆弱化を惹き起こす原因の1つと考えられている。
問診・診察のポイント  
 
 
  1. 尿失禁の病態を分類するには詳細な問診が必要であるが、これには問診票などを使うと簡便にできる[2][3]
 
 
  1. 過活動膀胱の診断には、過活動膀胱症状質問票(overactive bladder symptom score、OABSS)が有用である[4]
 
 
  1. 明らかに神経疾患(脳血管障害、脊髄障害など)の既往、あるいは治療中である場合は、ウロダイナミクス検査などの検査により病態診断が必要となる。

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文献 

O Ishiko, T Sumi, K Hirai, S Ogita
Classification of female urinary incontinence by the scored incontinence questionnaire.
Int J Gynaecol Obstet. 2000 Jun;69(3):255-60.
Abstract/Text OBJECTIVES: Our purpose was to investigate whether urinary incontinence (UI) severity could be graded by UI scores.
METHODS: The study included 168 UI patients diagnosed by conventional procedures as stress incontinence (SI, n=108) or urge incontinence (URI, n=60). A questionnaire containing 15 items scored for stress-score (s-s) and urge-score (u-s) was administered to patients to assess the correlation between pad test values (PTVs) and s-s in SI and u-s in URI.
RESULTS: Significant correlations were found between log[PTVs] and both s-s and u-s: log[PTV(SI)]=0.051s-s-0.207 (r=0.830, P<0.0001) and log[PTV(URI)]=0.064u-s-0.459 (r=0.827, P<0. 0001). Based on theoretical PTVs obtained using these equations, s-s of 26-24, 23-18, and 17-10 in SI were equivalent to severe, moderate, and mild, respectively, and u-s of 22-19 and 18-12 in URI were equivalent to moderate and mild, respectively, according to the classification of the International Continence Society.
CONCLUSION: The UI score should be a simple and useful procedure for use by general gynecologists to grade UI severity clinically.

PMID 10854868
O Ishiko, K Hirai, T Sumi, S Nishimura, S Ogita
The urinary incontinence score in the diagnosis of female urinary incontinence.
Int J Gynaecol Obstet. 2000 Feb;68(2):131-7.
Abstract/Text OBJECTIVE: Our purpose was to determine whether the urinary incontinence (UI) score is significantly useful in evaluating the clinical status of UI.
METHOD: The questionnaire was administered to 198 UI patients (27-73 years of age) diagnosed by conventional procedures. It consisted of 15 questions, and the answers were assigned points divided into a stress score (s-s) and urge score (u-s) according to severity.
RESULTS: The patients were classified into a stress incontinence group (SI; 125 cases), urge incontinence group (URI; 29 cases), mixed incontinence group (MI; 41 cases), and overflow incontinence group (3 cases). Classification by questionnaire yielded 110 SI cases, 31 URI cases, and 46 MI cases, accuracy of 83.2%, 86.2%, and 61.0%, respectively. A significant correlation was observed with s-s of SI (r = 0.669, P < 0.001) and u-s of URI (r = 0.583, P < 0.005).
CONCLUSION: The UI score will be a simple, clinically effective diagnostic procedure for UI for use by general gynecologists.

PMID 10717817
E Jean C Hay-Smith, Roselien Herderschee, Chantale Dumoulin, G Peter Herbison
Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women.
Cochrane Database Syst Rev. 2011 Dec 7;(12):CD009508. doi: 10.1002/14651858.CD009508. Epub 2011 Dec 7.
Abstract/Text BACKGROUND: Pelvic floor muscle training is the most commonly recommended physical therapy treatment for women with stress urinary incontinence. It is also sometimes recommended for mixed and, less commonly, urge urinary incontinence. The supervision and content of pelvic floor muscle training programmes are highly variable, and some programmes use additional strategies in an effort to increase adherence or training effects.
OBJECTIVES: To compare the effects of different approaches to pelvic floor muscle training for women with urinary incontinence.
SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings (searched 17 May 2011), and the reference lists of relevant articles.
SELECTION CRITERIA: Randomised trials or quasi-randomised trials in women with stress, urge or mixed urinary incontinence (based on symptoms, signs or urodynamics). One arm of the study included pelvic floor muscle training. Another arm was an alternative approach to pelvic floor muscle training, such as a different way of teaching, supervising or performing pelvic floor muscle training.
DATA COLLECTION AND ANALYSIS: We independently assessed trials for eligibility and methodological quality. We extracted then cross-checked data. We resolved disagreements by discussion. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions (version 5.2.2). We subgrouped trials by intervention.
MAIN RESULTS: We screened 574 records for eligibility and included 21 trials in the review. The 21 trials randomised 1490 women and addressed 11 comparisons. These were: differences in training supervision (amount, individual versus group), in approach (one versus another, the effect of an additional component) and the exercise training (type of contraction, frequency of training). In women with stress urinary incontinence, 10% of those who received weekly or twice-weekly group supervision in addition to individual appointments with the therapist did not report improvement post-treatment compared to 43% of the group who had individual appointments only (risk ratio (RR) for no improvement 0.29, 95% confidence interval (CI) 0.15 to 0.55, four trials). Looking at this another way, 90% of those who had combined group and individual supervision reported improvement versus 57% of women receiving individual supervision only. While women receiving the combination of frequent group supervision and individual supervision of pelvic floor muscle training were more likely to report improvement, the confidence interval was wide, and more than half of the 'control' group (the women who did not get the additional weekly or twice-weekly group supervision) reported improvement. This finding, of subjective improvement in both active treatment groups, with more improvement reported by those receiving more health professional contact, was consistent throughout the review.We feel there are several reasons why caution is needed when interpreting the results of the review: there were few data in any comparison; a number of trials were confounded by comparing two arms with multiple differences in the approaches to pelvic floor muscle training; there was a likelihood of a relationship between attention and reporting of more improvement in women who were not blind to treatment allocation; some trials chose interventions that were unlikely to have a muscle training effect; and some trials did not adequately describe their intervention.
AUTHORS' CONCLUSIONS: This review found that the existing evidence was insufficient to make any strong recommendations about the best approach to pelvic floor muscle training. We suggest that women are offered reasonably frequent appointments during the training period, because the few data consistently showed that women receiving regular (e.g. weekly) supervision were more likely to report improvement than women doing pelvic floor muscle training with little or no supervision.

PMID 22161451
June D Cody, Karen Richardson, Birgit Moehrer, Andrew Hextall, Cathryn Ma Glazener
Oestrogen therapy for urinary incontinence in post-menopausal women.
Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001405. doi: 10.1002/14651858.CD001405.pub2. Epub 2009 Oct 7.
Abstract/Text BACKGROUND: It is possible that oestrogen deficiency may be an aetiological factor in the development of urinary incontinence in women.
OBJECTIVES: To assess the effects of local and systemic oestrogens used for the treatment of urinary incontinence.
SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Register of trials (2 April 2009) and the reference lists of relevant articles.
SELECTION CRITERIA: Randomised or quasi-randomised controlled trials that included oestrogens in at least one arm, in women with symptomatic or urodynamic diagnoses of stress, urgency or mixed urinary incontinence or other urinary symptoms post-menopause.
DATA COLLECTION AND ANALYSIS: Trials were evaluated for methodological quality and appropriateness for inclusion by the review authors. Data were extracted by at least two authors and cross checked. Subgroup analyses were performed grouping participants under local or systemic administration. Where appropriate, meta-analysis was undertaken.
MAIN RESULTS: Thirty- three trials were identified which included 19,313 (1,262 involved in trials of local administration) incontinent women of whom 9417 received oestrogen therapy. Sample sizes ranged from 16 to 16,117. The trials used varying combinations of type of oestrogen, dose, duration of treatment and length of follow up. Outcome data were not reported consistently and were available for only a minority of outcomes.Systemic administration (of oral oestrogens) resulted in worse incontinence than on placebo (RR 1.32, 95% CI 1.17 to 1.48). This result is heavily weighted by a subgroup of women from the Hendrix trial, which had large numbers of participants and a longer follow up of one year; all the women had had a hysterectomy and the treatment used was conjugated equine oestrogen. The result for women with an intact uterus where oestrogen and progestogen combined were used also showed a statistically significant worsening of incontinence (RR 1.11, 95% CI 1.04 to 1.18).There was some evidence that oestrogens used locally (for example vaginal creams or tablets) may improve incontinence (RR 0.74, 95% CI 0.64 to 0.86). Overall, there were around one to two fewer voids in 24 hours and nocturnal voids amongst women treated with local oestrogen, and there was less frequency and urgency. No serious adverse events were reported although some women experienced vaginal spotting, breast tenderness or nausea.Women who were continent and received systemic oestrogen replacement, with or without progestogens, for reasons other than urinary incontinence were more likely to report the development of new urinary incontinence in one large study.The data were too few to address questions about oestrogens compared with or in combination with other treatments, different types of oestrogen or different modes of delivery.
AUTHORS' CONCLUSIONS: Local oestrogen treatment for incontinence may improve or cure it, but there was little evidence from the trials on the period after oestrogen treatment had finished and none about long-term effects. However, systemic hormone replacement therapy, using conjugated equine oestrogen, may make incontinence worse. There were too few data to reliably address other aspects of oestrogen therapy, such as oestrogen type and dose, and no direct evidence on route of administration. The risk of endometrial and breast cancer after long-term use suggests that oestrogen treatment should be for limited periods, especially in those women with an intact uterus.

PMID 19821277

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