女性下部尿路症状診療ガイドライン

目次はじめに................................................................................................................................................................ iii

1

診療アルゴリズム................................................................................................................................ 2
初期診療のアルゴリズム ...................................................................................................................... 2
専門的診療のアルゴリズム ................................................................................................................. 42

女性下部尿路症状とは .................................................................................................................... 61 下部尿路症状 ............................................................................................................................................... 61）蓄尿症状 .................................................................................................................................................... 72）排尿症状 .................................................................................................................................................... 93）排尿後症状 ............................................................................................................................................ 10
2 女性下部尿路症状の臨床的意義 .................................................................................................... 101）成因........................................................................................................................................................... 102）自然史...................................................................................................................................................... 113）頻度........................................................................................................................................................... 114）医療機関への受診 ............................................................................................................................. 125）性機能との関連 .................................................................................................................................. 136）妊娠および分娩との関連 ............................................................................................................... 137）骨盤臓器脱との関連......................................................................................................................... 14
3 その他の症状 ............................................................................................................................................ 141）性交に伴う症状 .................................................................................................................................. 142）骨盤臓器脱に伴う症状.................................................................................................................... 143）生殖器痛・下部尿路痛.................................................................................................................... 144）生殖器・尿路痛症候群.................................................................................................................... 153

疫学と QOL ........................................................................................................................................... 19
1 女性下部尿路症状の疫学 ................................................................................................................... 19
2 女性下部尿路症状と QOL ................................................................................................................. 241）QOL に対する影響 ........................................................................................................................... 242）QOL の評価方法 ................................................................................................................................ 253）推奨される質問票 ............................................................................................................................. 26
Clinical Question ......................................................................................................................................... 34
女性下部尿路症状の診療において，QOL 評価は推奨されるか ?................ 34
CQ1viii

目次4

病態と疾患 .............................................................................................................................................. 35
1 蓄尿症状を呈するもの ........................................................................................................................ 351）膀胱の病態・疾患 ............................................................................................................................. 35
a．尿路感染症（膀胱炎，尿道炎）.............................................................................................. 35b．膀胱結石 ........................................................................................................................................... 35c．膀胱腫瘍 ........................................................................................................................................... 36
d．間質性膀胱炎 ................................................................................................................................. 36e．過活動膀胱 ...................................................................................................................................... 36
f．低コンプライアンス膀胱，萎縮膀胱................................................................................. 372）腹圧性尿失禁 ....................................................................................................................................... 373）骨盤臓器脱 ............................................................................................................................................ 38a．骨盤臓器脱と腹圧性尿失禁 .................................................................................................... 38b．骨盤臓器脱と過活動膀胱 ......................................................................................................... 384）子宮筋腫 ................................................................................................................................................. 395）神経系の疾患 ....................................................................................................................................... 39
a．脳血管障害 ...................................................................................................................................... 39
b．パーキンソン病 ............................................................................................................................ 40
c．多系統萎縮症 ................................................................................................................................. 40
d．脳腫瘍................................................................................................................................................ 40
e．認知症................................................................................................................................................ 40
f．脊髄損傷 ........................................................................................................................................... 40
g．多発性硬化症 ................................................................................................................................. 40
h．脊椎変性疾患 ................................................................................................................................. 41
i．脊髄血管障害 ................................................................................................................................. 41
j．二分脊椎 ........................................................................................................................................... 41k．末梢神経障害 ................................................................................................................................. 416）女性ホルモン（エストロゲン）欠乏 ......................................................................................... 42
7）心因性...................................................................................................................................................... 428）薬剤性...................................................................................................................................................... 429）その他...................................................................................................................................................... 42
a．多尿..................................................................................................................................................... 42b．睡眠障害 ........................................................................................................................................... 42
2 排尿症状を呈するもの ........................................................................................................................ 451）膀胱・尿道の病態・疾患 ............................................................................................................... 46a．膀胱頸部閉塞 ................................................................................................................................. 46
b．加齢に伴う排尿筋低活動 ......................................................................................................... 47c．膀胱憩室 ........................................................................................................................................... 47d．膀胱結石 ........................................................................................................................................... 47
e．尿道狭窄 ........................................................................................................................................... 47
f．尿道憩室 ........................................................................................................................................... 48
女性下部尿路症状診療ガイドラインix

女性下部尿路症状診療ガイドライン2）骨盤臓器脱・子宮筋腫.................................................................................................................... 483）神経系の疾患 ....................................................................................................................................... 484）心因性...................................................................................................................................................... 495）尿失禁手術後 ....................................................................................................................................... 496）薬剤性...................................................................................................................................................... 497）その他...................................................................................................................................................... 50

3 排尿後症状を呈するもの ................................................................................................................... 51
Clinical Question ......................................................................................................................................... 52
女性下部尿路症状のリスク因子は何か ? .................................................................. 52
CQ25診断 ............................................................................................................................................................... 54
1 症状，問診票 ............................................................................................................................................ 541）病歴の聴取 ............................................................................................................................................ 54
a．現病歴................................................................................................................................................ 54
b．既往歴・合併症 ............................................................................................................................ 542）症状・QOL 評価 ................................................................................................................................ 55
a．主要下部尿路症状スコア（CLSS）...................................................................................... 56
b．International Consultation on Incontinence Questionnaire-Short Form（ICIQ-SF）....................................................................................................................................... 56
c．キング健康質問票（KHQ）...................................................................................................... 56
d．過活動膀胱症状スコア（OABSS）....................................................................................... 59
e．Overactive Bladder-questionnaire（OAB-q）............................................................. 59
f．夜間頻尿特異的 QOL 質問票（N-QOL）.......................................................................... 59
g．間質性膀胱炎症状スコア・問題スコア（ICSI・ICPI）.............................................. 593）排尿記録 ................................................................................................................................................. 59
2 診察................................................................................................................................................................. 66
3 検査................................................................................................................................................................. 691）尿検査...................................................................................................................................................... 702）残尿測定 ................................................................................................................................................. 703）血清クレアチニン測定.................................................................................................................... 704）超音波検査 ............................................................................................................................................ 70a．経腹的超音波検査 ....................................................................................................................... 70
b．経会陰的超音波検査................................................................................................................... 71
c．経腟的超音波検査 ....................................................................................................................... 71
d．経直腸的超音波検査................................................................................................................... 715）パッドテスト ....................................................................................................................................... 726）尿流動態検査（urodynamic study: UDS）............................................................................ 72
a．尿流測定（uroflowmetry: UFM）.......................................................................................... 72b．膀胱内圧測定（cystometry）.................................................................................................. 73x目次

c．尿道内圧検査（urethral pressure profilometry: UPP）............................................ 73
d．腹圧下漏出時圧（abdominal leak point pressure: ALPP）................................... 74e．その他の尿流動態検査.............................................................................................................. 747）内視鏡検査（膀胱・尿道内視鏡検査）..................................................................................... 748）鎖膀胱尿道造影（chain cystourethrography: chain CUG）....................................... 759）その他の検査 ....................................................................................................................................... 7510）検査・診断の手順 ............................................................................................................................. 76

Clinical Questions ...................................................................................................................................... 78
女性下部尿路症状の診療において，排尿記録は推奨されるか ? .................. 78
CQ3
女性下部尿路症状の診断において，尿流動態検査は推奨されるか ? ........ 79
CQ4
女性下部尿路症状の診断・治療において，上部尿路の評価はCQ5
どのような場合に推奨されるか ? ................................................................................. 80

6治療 ............................................................................................................................................................... 82
1 行動療法....................................................................................................................................................... 821）生活指導（lifestyle interventions）............................................................................................ 822）理学療法（physical therapies）.................................................................................................. 85
a．骨盤底筋訓練（pelvic floor muscle training: PFMT）............................................... 85b．妊婦または産後に対する骨盤底筋訓練の尿失禁予防効果 ..................................... 87c．フィードバック訓練，バイオフィードバック訓練 ................................................... 87d．腟コーン ........................................................................................................................................... 893）膀胱訓練（bladder training），計画療法（scheduled voiding regimens）........ 924）電気・磁気刺激療法......................................................................................................................... 94a．電気刺激療法（electrical stimulation: ES）.................................................................... 94
b．磁気刺激療法（magnetic stimulation: MS）.................................................................. 96
c．仙髄神経電気刺激法（sacral nerve stimulation: SNS）........................................... 97
d．経皮的脛骨神経刺激（percutaneous tibial nerve stimulation: PTNS）.......... 975）その他の保存療法 .......................................................................................................................... 100
2 薬物療法.................................................................................................................................................... 1001）過活動膀胱の薬物療法................................................................................................................. 101
a．抗コリン薬 ................................................................................................................................... 101
b．β3 アドレナリン受容体作動薬（ミラベグロン mirabegron）............................ 112
c．フラボキサート（flavoxate）............................................................................................... 113
d．三環系抗うつ薬 ......................................................................................................................... 114
e．漢方薬（牛車腎気丸）.............................................................................................................. 114
f．エストロゲン（estrogen）.................................................................................................... 115
g．ボツリヌス毒素（botulinum toxin）................................................................................. 116
h．レジニフェラトキシン（resiniferatoxin），カプサイシン（capsaicin）....... 118
i．抗利尿ホルモン（デスモプレシン）................................................................................. 119
j．αアドレナリン受容体遮断薬 ............................................................................................. 120

女性下部尿路症状診療ガイドラインxi女性下部尿路症状診療ガイドライン2）腹圧性尿失禁の薬物療法 ............................................................................................................ 128
a．βアドレナリン受容体作動薬（クレンブテロール clenbuterol）...................... 128
b．漢方薬など（補中益気湯，植物抽出物）....................................................................... 129
c．三環系抗うつ薬 ......................................................................................................................... 129
d．エストロゲン（estrogen）.................................................................................................... 130
e．α アドレナリン受容体刺激薬............................................................................................. 130
f．デュロキセチン（duloxetine）............................................................................................ 1313）排出障害の薬物療法...................................................................................................................... 134
a．排尿筋の収縮力を増強させる薬剤 .................................................................................. 134b．尿道抵抗を減弱させる薬剤 ................................................................................................. 136

3 手術療法.................................................................................................................................................... 1371）腹圧性尿失禁に対する主な術式 ............................................................................................. 137
a．中部尿道スリング手術（mid-urethral sling: MUS）................................................ 138
b．筋膜スリング手術（fascial suburethral sling）......................................................... 147
c．経腹的恥骨後式膀胱頸部挙上術（open abdominal retropubic colposuspension）................................................. 148
d．腹腔鏡下恥骨後式膀胱頸部挙上術（laparoscopic retropubic colposuspension）......................................................... 148
e．前腟壁形成術（anterior colporrhaphy）....................................................................... 149
f．針式膀胱頸部挙上術（needle bladder neck suspension）............................... 150
g．尿道周囲注入術（periurethral injection of bulking agent）............................... 150
h．人工尿道括約筋（artificial urinary sphincter: AUS）............................................. 152
2）過活動膀胱・低コンプライアンス膀胱に対する膀胱拡大術（augmentation）.............................................................................................................................. 159
4 その他の治療法 .................................................................................................................................... 160
尿道留置カテーテル，間欠（自己）導尿 ............................................................................ 160
a．尿道留置カテーテル................................................................................................................ 160
b．間欠（自己）導尿〔intermittent（self）catheterization〕....................................... 160
Clinical Questions ................................................................................................................................... 161
女性下部尿路症状に対する行動療法統合プログラムはCQ6推奨されるか ? ..................................................................................................................... 161
過活動膀胱に対する行動療法と薬物療法の併用は推奨されるか ? .......... 163
CQ7
女性下部尿路症状に対してホルモン補充療法は推奨されるか ? ............... 164
CQ8
抗コリン薬が有用でない過活動膀胱に対するボツリヌス毒素のCQ9膀胱壁内注入療法は推奨されるか ? ......................................................................... 165
CQ10 混合性尿失禁に対して中部尿道スリング手術は推奨されるか ? ............... 168
CQ11 骨盤臓器脱手術後に起こる尿失禁に対し，予防的な腹圧性尿失禁手術は推奨されるか ? ......................................................................... 169
CQ12 腹圧性尿失禁手術後の排尿困難に対して，どう対処するか ?.................... 170

索引.................................................................................................................................................................. 172xii