今日の臨床サポート

尿閉

著者: 田中博 市立札幌病院 泌尿器科

監修: 力石辰也 聖マリアンナ医科大学

著者校正/監修レビュー済:2018/04/05
患者向け説明資料

概要・推奨   

所見のポイント:
  1. 尿閉とは、排尿ができないか、あるいは排尿後にも多量の残尿を有する状態である。尿閉の原因には下部尿路閉塞、排尿筋収縮不全、薬剤による影響、下部尿路や性器の感染や炎症、神経因性の排尿障害などがあり、さらにいくつかの原因が複合している例もある。
  1. まず尿閉なのか無尿なのかを判断することが大事である。
 
緊急対応:
  1. 基本的に、尿閉が疑われる場合には、早急に泌尿器科へコンサルトする必要がある。膀胱痛などの苦痛が強い場合には、まず導尿して苦痛を緩和する。その際には、排出された尿量を記録しておく必要がある。
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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:
田中博 : 未申告[2021年]
監修:力石辰也 : 未申告[2021年]

編集部編集コンテンツ:
 
関連する医療事故:
  1. 尿道ステント留置中患者に経尿道膀胱留置カテーテルを挿入しない:
  1. 事例:尿管ステントの禁止事項を知らずさらに尿道膀胱カテーテル留置したためステントがずれてしまった。(詳細情報ページ:医療事故情報 詳細表示

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 尿閉とは膀胱内の尿を全く排出できないか、排出するのがきわめて困難な状態で、多量の残尿(300mL以上が目安)が常時ある状態である[1]。尿閉の原因には下部尿路閉塞、排尿筋収縮不全、薬剤による影響、下部尿路や性器の感染や炎症、神経因性の排尿障害などがあり、さらにいくつかの原因が複合している例もある。
  1. 尿閉は、急激に発症し膀胱痛や強い残尿感などを伴う急性尿閉と、慢性に経過し膀胱痛などの症状を伴わない慢性尿閉に区別される。急性尿閉では、導尿により尿を排出しない限り患者の苦痛は改善しない。慢性尿閉は自覚症状に乏しいが、腎後性腎不全などの合併症が存在する可能性がある。
  1. 地域住民を対象とした研究では、中高年男性が急性尿閉を発症する頻度は年間1,000人当たり3.06件から6.8件と報告されている[2][3]。加齢に伴って高率となり、70歳代の男性の10%、80歳代男性の30%が急性尿閉を経験する[3]。女性に急性尿閉が発生する頻度は男性よりも低いと考えられるが、十分な調査がなく実際の頻度は不明である。
問診・診察のポイント  
診察:
  1. 急性尿閉では、通常の膀胱容量を超える尿により過度に拡張した膀胱を体表から触知する。しかしながら、患者の体型や触診の技術により、緊満した膀胱を確認できないこともある。

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文献 

著者: Paul Cathcart, Jan van der Meulen, Jim Armitage, Mark Emberton
雑誌名: J Urol. 2006 Jul;176(1):200-4; discussion 204. doi: 10.1016/S0022-5347(06)00509-X.
Abstract/Text PURPOSE: We report how the incidence of primary and recurrent acute urinary retention changed in England between 1998 and 2003. In addition, we present data on changes with time in the use of prostatectomy after acute urinary retention and recurrent acute urinary retention.
MATERIALS AND METHODS: Data were extracted from the Hospital Episode Statistics database of the Department of Health in England. Patients were included in the study if an International Classification of Diseases, Tenth Revision code for acute urinary retention or an operative procedure code for transurethral prostate resection was present in any diagnosis or procedure fields of the Hospital Episode Statistics database. A total of 165,527 men were identified to have been hospitalized with acute urinary retention in the study period.
RESULTS: The incidence of primary acute urinary retention was 3.06/1,000 men yearly. Acute urinary retention was spontaneous in 65.3% of cases. The incidence of acute urinary retention decreased from 3.17/1,000 men yearly in 1998 to 2.96/1,000 yearly in 2003. Surgical treatment following spontaneous acute urinary retention decreased 20% from 32% in 1998 to 26% in 2003. This trend coincided with a 20% increase in the rate of recurrent acute urinary retention.
CONCLUSIONS: The slight decrease in the incidence of primary acute urinary retention suggests that the shift away from surgical treatment for benign prostatic hyperplasia has not resulted in an increase in acute urinary retention. The increase in recurrent acute urinary retention suggests that the observed decrease in surgery after acute urinary retention may have put more men at risk for acute urinary retention recurrence.

PMID 16753401  J Urol. 2006 Jul;176(1):200-4; discussion 204. doi: 10.・・・
著者: S J Jacobsen, D J Jacobson, C J Girman, R O Roberts, T Rhodes, H A Guess, M M Lieber
雑誌名: J Urol. 1997 Aug;158(2):481-7.
Abstract/Text PURPOSE: We determined the occurrence of and risk factors for acute urinary retention in the community setting.
MATERIALS AND METHODS: A cohort of 2,115 men 40 to 79 years old was randomly selected from an enumeration of the Olmsted County, Minnesota population (55% response rate). Participants completed a previously validated baseline questionnaire that assessed symptom severity, and voided into a portable urometer to measure peak urinary flow rates. A 25% random subsample underwent transrectal sonographic imaging of the prostate to determine prostate volume. Followup was performed through a retrospective review of community medical records to determine the occurrence of acute urinary retention in the subsequent 4 years.
RESULTS: During the 8,344 person-years of followup 57 men had a first episode of acute urinary retention (incidence 6.8/1,000 person-years, 95% confidence interval [CI] 5.2, 8.9). Among men with no to mild symptoms (American Urological Association symptom index score 7 or less) the incidence of acute urinary retention increased from 2.6/1,000 person-years among men 40 to 49 years old to 9.3/1,000 person-years among men 70 to 79 years old. By contrast, rates increased from 3.0/1,000 person-years for men 40 to 49 years old to 34.7/1,000 person-years among men 70 to 79 years old among men with moderate to severe symptoms (American Urological Association symptom index score greater than 7). Men with depressed peak urinary flow rate (less than 12 ml. per second) were at 4 times the risk of acute urinary retention compared with men with urinary flow rates greater than 12 ml. per second (95% CI 2.3, 6.6). Men with an enlarged prostate (greater than 30 ml.) experienced a 3-fold increase in risk (95% CI 1.0, 9.0, p = 0.04).
CONCLUSIONS: Lower urinary tract symptoms, depressed peak urinary flow rates, enlarged prostates and older age are associated with an increased risk of acute urinary retention in community dwelling men. These findings may help to identify men at increased risk of acute urinary retention in whom closer evaluation may be warranted.

PMID 9224329  J Urol. 1997 Aug;158(2):481-7.
著者: S Choong, M Emberton
雑誌名: BJU Int. 2000 Jan;85(2):186-201.
Abstract/Text
PMID 10671867  BJU Int. 2000 Jan;85(2):186-201.
著者: Steven A Kaplan, Alan J Wein, David R Staskin, Claus G Roehrborn, William D Steers
雑誌名: J Urol. 2008 Jul;180(1):47-54. doi: 10.1016/j.juro.2008.03.027. Epub 2008 May 15.
Abstract/Text PURPOSE: The definitions of acute and chronic urinary retention remain empirical and subject to wide interpretation. Standardized criteria have not been established and many questions remain unanswered. Moreover, the definition of significant post-void residual urine is unclear. We reviewed several aspects of urinary retention that require clarification with the objective of stimulating discussion among urologists to establish an accurate and coherent definition of urinary retention and significant post-void residual urine, and clarify risk factors.
MATERIALS AND METHODS: A MEDLINE search for articles written in English and published before April 2007 was done using a list of terms related to urinary retention. Articles not directly relevant to urinary retention or post-void residual urine were excluded.
RESULTS: The term urinary retention lacks precise clinical or urodynamic meaning. Use of this term to describe a symptom, a sign, and a condition further complicates the issue. Many factors can contribute to the development of retention, including bladder outlet obstruction, detrusor underactivity, and neurogenic bladder conditions. Community based studies and clinical trials in patients with benign prostatic enlargement and/or lower urinary tract symptoms yield different estimates of the incidence of retention and only provide information on the epidemiology of acute urinary retention. However, age, previous retention episodes, lower urinary tract symptoms, chronic inflammation, serum prostate specific antigen level, prostate size, and urodynamic variables appear to be predictors of acute urinary retention. Alpha-receptor antagonists and 5alpha-reductase inhibitors may be useful in preventing urinary retention episodes and progressive benign prostatic enlargement. Clinical trials on the short-term use of antimuscarinics have not provided evidence that these agents increase the risk of retention; data on longer term administration are needed.
CONCLUSIONS: Clinicians are adopting less invasive approaches (eg pharmacology or catheterization) to treating patients who present with the symptoms, sign, and condition of urinary retention. Faced with an abundance of new data on acute urinary retention, urologists need to reach a consensus about the risks of urinary retention; this may promote movement toward patient centered prevention strategies with tailored treatment options.

PMID 18485378  J Urol. 2008 Jul;180(1):47-54. doi: 10.1016/j.juro.2008・・・
著者: Rajesh B C Kavia, Soumendra N Datta, Ranan Dasgupta, Sohier Elneil, Clare J Fowler
雑誌名: BJU Int. 2006 Feb;97(2):281-7. doi: 10.1111/j.1464-410X.2006.06009.x.
Abstract/Text OBJECTIVE: To report the experience of the last 4 years from a centre to which women with voiding difficulties and urinary retention were referred nationally, describing what investigations were helpful in making a diagnosis and the management strategies used.
PATIENTS AND METHODS: Women with voiding difficulties and urinary retention remain a diagnostic and management challenge, and those with no anatomical or neurological basis for their symptoms may be dismissed, assuming that their retention has a psychogenic basis. The finding of an electromyographic (EMG) abnormality of the striated urethral sphincter explaining their disorder (Fowler's syndrome) has led to the referral of women for consideration of that diagnosis. Thus we audited the referrals to the centre over a 4-year period of such women.
RESULTS: In all, 247 women (mean age 35 years) with complete (42%) or partial retention (58%) were referred; 175 (71%) had urethral pressure profilometry, 141 (57%) had a transvaginal ultrasonographic measurement of the sphincter volume, and 95 (39%) had sphincter EMG. The mean maximum urethral closure pressure difference between patients with an EMG abnormality (101.5 cmH(2)O) and the patients with known other causes of voiding dysfunction (66.2 cmH(2)O) was 35.3 cmH(2)O (P < 0.05). In patients with complete retention there was a significant difference in sphincter volume between those who were EMG-positive (2.14 mL) or EMG-negative (1.64 mL) (P < 0.05).
CONCLUSION: These investigations helped to classify the cause of retention in two-thirds of cases. The commonest diagnosis was Fowler's syndrome, in which sacral nerve stimulation is the only intervention that restores voiding.

PMID 16430630  BJU Int. 2006 Feb;97(2):281-7. doi: 10.1111/j.1464-410X・・・
著者: John A Taylor, George A Kuchel
雑誌名: J Am Geriatr Soc. 2006 Dec;54(12):1920-32. doi: 10.1111/j.1532-5415.2006.00917.x.
Abstract/Text Urinary incontinence and other lower urinary tract symptoms exert a major influence on the health and independence of frail older people. Detrusor underactivity (DU) is defined as a contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span. DU may influence the clinical presentation and impede the therapy of disorders as common and as disparate as detrusor overactivity, urinary retention, and benign prostatic hyperplasia. Urodynamically, nearly two-thirds of incontinent nursing home residents exhibit DU. The clinical diagnosis of DU when present alone or in association with other bladder conditions such as detrusor overactivity (detrusor hyperactivity with impaired contractility (DHIC)) is challenging, because symptoms lack adequate precision. A catheterized and increasingly noninvasive ultrasound-based postvoid residual assessment allows a bedside diagnosis of retention and may suggest the presence of DU in individuals (mostly women) with a low likelihood of bladder outlet obstruction (BOO). Nevertheless, it cannot differentiate primary DU from retention secondary to BOO. The management of individuals with DHIC remains unsatisfactory, because antispasmodic anticholinergic medications may worsen retention, whereas bethanechol does not improve bladder emptying. Human detrusor biopsies reveal axonal degeneration, muscle loss, and fibrosis in DU. Animal studies suggest that multiple risk factors, including retention itself, lack of estrogen, infection, inflammation, and aging, may contribute to DU. Priority areas for future research include efforts to facilitate clinical nonurodynamic diagnosis of probable DU plus translational research designed to address the pathogenesis of this complex multifactorial geriatric syndrome.

PMID 17198500  J Am Geriatr Soc. 2006 Dec;54(12):1920-32. doi: 10.1111・・・
著者: Katia M C Verhamme, Miriam C J M Sturkenboom, Bruno H Ch Stricker, Ruud Bosch
雑誌名: Drug Saf. 2008;31(5):373-88.
Abstract/Text Urinary retention is a condition in which impaired emptying of the bladder results in postvoidal residual urine. It is generally classified into 'acute' or 'chronic' urinary retention. Because of the complex mechanism of micturition, many drugs can interact with the micturition pathway, all via different modes of action. Although the incidence of urinary retention, in particular acute urinary retention, has been well studied in observational studies and randomized controlled trials, data on the incidence of drug-induced urinary retention are scarce. Data from observational studies suggest that up to 10% of episodes might be attributable to the use of concomitant medication. Urinary retention has been described with the use of drugs with anticholinergic activity (e.g. antipsychotic drugs, antidepressant agents and anticholinergic respiratory agents), opioids and anaesthetics, alpha-adrenoceptor agonists, benzodiazepines, NSAIDs, detrusor relaxants and calcium channel antagonists. Elderly patients are at higher risk for developing drug-induced urinary retention, because of existing co-morbidities such as benign prostatic hyperplasia and the use of other concomitant medication that could reinforce the impairing effect on micturition. Drug-induced urinary retention is generally treated by urinary catheterization, especially if acute, in combination with discontinuation or a reduction in dose of the causal drug. Studies have been carried out examining the effects of preventive measures for anaesthesia-related urinary retention, both during and after surgery, particularly into the effect of using opioids in combination with non-opioid analgesic drugs on the incidence of postoperative urinary retention. Although combination therapy reduces the opioid-related adverse events, the effect on urinary retention yields contradictory results. This article reviews the literature on drug-induced urinary retention and focuses on its incidence, the different classes of drugs that have been associated with it, and options for its management and prevention.

PMID 18422378  Drug Saf. 2008;31(5):373-88.
著者: Brian A Selius, Rajesh Subedi
雑誌名: Am Fam Physician. 2008 Mar 1;77(5):643-50.
Abstract/Text Urinary retention is the inability to voluntarily void urine. This condition can be acute or chronic. Causes of urinary retention are numerous and can be classified as obstructive, infectious and inflammatory, pharmacologic, neurologic, or other. The most common cause of urinary retention is benign prostatic hyperplasia. Other common causes include prostatitis, cystitis, urethritis, and vulvovaginitis; receiving medications in the anticholinergic and alphaadrenergic agonist classes; and cortical, spinal, or peripheral nerve lesions. Obstructive causes in women often involve the pelvic organs. A thorough history, physical examination, and selected diagnostic testing should determine the cause of urinary retention in most cases. Initial management includes bladder catheterization with prompt and complete decompression. Men with acute urinary retention from benign prostatic hyperplasia have an increased chance of returning to normal voiding if alpha blockers are started at the time of catheter insertion. Suprapubic catheterization may be superior to urethral catheterization for short-term management and silver alloy-impregnated urethral catheters have been shown to reduce urinary tract infection. Patients with chronic urinary retention from neurogenic bladder should be able to manage their condition with clean, intermittent self-catheterization; low-friction catheters have shown benefit in these patients. Definitive management of urinary retention will depend on the etiology and may include surgical and medical treatments.

PMID 18350762  Am Fam Physician. 2008 Mar 1;77(5):643-50.

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