女性下部尿路症状診療ガイドライン［第 2 版］

目次発刊に寄せて.......................................................................................................................................................... iii
序...................................................................................................................................................................................... iv
はじめに..................................................................................................................................................................... v
作成委員，評価委員........................................................................................................................................ ix

1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...................................................................................................................... 42Clinical Questions................................................................................................................................... 6CQ1CQ2CQ3CQ4CQ5CQ6CQ7CQ8CQ9CQ10CQ11CQ12CQ13CQ14CQ15CQ16CQ17CQ18CQ19x

女性下部尿路症状のリスク因子は何か ?.......................................................................... 6
女性下部尿路症状の評価に，排尿日誌は推奨されるか ?..................................... 10
女性下部尿路症状の基本評価として，残尿測定は推奨されるか ?.................. 11
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 ?............. 12
女性下部尿路症状の診断・治療において，上部尿路の評価はどのような場合に推奨されるか ?...................................................................................... 13
骨盤臓器脱に伴う下部尿路症状にはどのようなものがあるか ?....................... 14
間質性膀胱炎・膀胱痛症候群の診断のポイントは何か ?..................................... 15
女性下部尿路症状は，性機能へどのような影響を与えるか ?............................ 18
女性下部尿路症状に対して，どのような行動療法（生活指導・理学療法）が推奨されるか ?...................................................................... 21
女性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 ?........ 22
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 ?.................. 23
女性過活動膀胱に対して，抗コリン薬，β3 作動薬の種類による有効性，安全性に違いはあるか ?...................................................................................... 24
女性過活動膀胱に対して，抗コリン薬とβ3 作動薬の併用療法は推奨されるか ?............................................................................................................................. 26
過活動膀胱治療薬は，認知機能に影響を与えるか ?............................................... 29
女性難治性過活動膀胱に対する仙骨神経刺激療法と膀胱鏡下ボツリヌス毒素注入手術は推奨されるか ?.................................................................. 30
混合性尿失禁に対して，抗コリン薬，β3 作動薬は推奨されるか ?................. 33
女性下部尿路症状に対して，健康食品・サプリメントなどの代替療法は推奨されるか ?........................................................................................................................ 34
女性低活動膀胱の治療には何があるか ?....................................................................... 36
再発性細菌性膀胱炎にはどのように対処すべきか ?............................................... 40

目次

CQ20
CQ21
CQ22
CQ23
CQ24
CQ25
CQ263

女性下部尿路症状を訴える患者は，どのような場合に専門医への紹介を考慮すべきか ?.............................................................................................................. 43
女性下部尿路症状を訴える患者は，どのような場合に専門医から一般医への紹介を考慮すべきか ?...................................................................................... 44
FDA（アメリカ食品医薬品局）警告における中部尿道スリング手術の評価と影響はどのようなものか ?...................................................................................... 45
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 ?.................. 48
骨盤臓器脱手術後に起こる尿失禁に対して，予防的腹圧性尿失禁手術は推奨されるか ?........................................................................................................................ 49
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 ?............................ 50
女性下部尿路症状の保険診療上の留意点は何か ?.................................................... 51

女性下部尿路症状とは...................................................................................................................... 55
1 下部尿路症状................................................................................................................................................. 551）蓄尿症状...................................................................................................................................................... 572）排尿症状...................................................................................................................................................... 583）排尿後症状................................................................................................................................................. 58
その他の症状................................................................................................................................................. 594）性交に伴う症状....................................................................................................................................... 595）骨盤臓器脱に伴う症状......................................................................................................................... 596）生殖器痛・下部尿路痛......................................................................................................................... 597）生殖器・尿路痛症候群......................................................................................................................... 598）下部尿路機能障害（lower urinary tract dysfunction: LUTD）を示唆する症状症候群................................................................................................................................................. 60

2 女性下部尿路症状（female lower urinary tract symptom: FLUTS）............................ 60
3 下部尿路症状と類似・関連した用語............................................................................................... 6045

女性下部尿路症状の疫学................................................................................................................. 63
女性下部尿路症状と QOL.............................................................................................................. 71
1 QOL に対する影響..................................................................................................................................... 71
2 QOL の評価方法.......................................................................................................................................... 73
3 推奨される質問票....................................................................................................................................... 73

6

病態と疾患................................................................................................................................................... 79
1 蓄尿症状を呈するもの............................................................................................................................. 791）膀胱の病態・疾患.................................................................................................................................. 80
a．尿路感染症（膀胱炎，尿道炎）................................................................................................... 80b．膀胱結石................................................................................................................................................ 80c．膀胱腫瘍................................................................................................................................................ 80
d．間質性膀胱炎...................................................................................................................................... 80
e．過活動膀胱........................................................................................................................................... 80

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女性下部尿路症状診療ガイドライン［第 2 版］

f． 低コンプライアンス膀胱，萎縮膀胱..................................................................................... 812）腹圧性尿失禁............................................................................................................................................ 813）骨盤臓器脱................................................................................................................................................. 82
a．骨盤臓器脱と腹圧性尿失禁......................................................................................................... 82
b．骨盤臓器脱と過活動膀胱.............................................................................................................. 82
c．骨盤臓器脱修復による下部尿路症状の変化....................................................................... 834）子宮筋腫...................................................................................................................................................... 835）子宮内膜症................................................................................................................................................. 846）女性ホルモン（エストロゲン）欠乏.............................................................................................. 847）神経系の疾患............................................................................................................................................ 85
a．脳血管障害........................................................................................................................................... 85
b．パーキンソン病................................................................................................................................. 85
c．多系統萎縮症...................................................................................................................................... 86d．脳腫瘍..................................................................................................................................................... 86
e．認知症..................................................................................................................................................... 86f． 脊髄損傷................................................................................................................................................ 86
g．多発性硬化症...................................................................................................................................... 86
h．脊椎変性疾患...................................................................................................................................... 86i． 脊髄血管障害...................................................................................................................................... 87
j． 二分脊椎................................................................................................................................................ 87k．末梢神経障害...................................................................................................................................... 878）その他........................................................................................................................................................... 87
a．薬剤性..................................................................................................................................................... 87b．多尿......................................................................................................................................................... 87
c．睡眠障害................................................................................................................................................ 88d．心因性（蓄尿障害，排尿障害ともに関連する）................................................................. 88

2 排尿症状を呈するもの............................................................................................................................. 931）膀胱・尿道の病態・疾患.................................................................................................................... 93a．膀胱頸部閉塞...................................................................................................................................... 93
b．加齢に伴う排尿筋低活動.............................................................................................................. 94c．膀胱憩室................................................................................................................................................ 94
d．膀胱結石................................................................................................................................................ 94
e．尿道狭窄................................................................................................................................................ 94
f． 尿道憩室................................................................................................................................................ 952）骨盤臓器脱・子宮筋腫・子宮内膜症............................................................................................ 953）尿失禁手術後............................................................................................................................................ 964）神経系の疾患............................................................................................................................................ 965）その他........................................................................................................................................................... 96
a．薬剤性..................................................................................................................................................... 96
b．心因性..................................................................................................................................................... 97
3 排尿後症状を呈するもの........................................................................................................................ 98xii

目次7診断 .................................................................................................................................................................... 99
1 症状，問診票................................................................................................................................................. 991）病歴の聴取................................................................................................................................................. 99
a．現病歴..................................................................................................................................................... 99
b．既往歴・合併症................................................................................................................................. 992）症状・QOL 評価................................................................................................................................... 100
a．主要下部尿路症状スコア（CLSS）......................................................................................... 101
b．International Consultation on Incontinence Questionnaire-Short Form.......................................................................................................................................... 101（ICIQ-SF）
c．キング健康質問票（KHQ）......................................................................................................... 101
d．過活動膀胱症状スコア（OABSS）.......................................................................................... 101
e．Overactive Bladder-questionnaire（OAB-q）................................................................ 102
f． 夜間頻尿特異的 QOL 質問票（N-QOL）............................................................................. 102
g．間質性膀胱炎症状スコア・問題スコア（ICSI・ICPI）................................................. 1023）排尿記録.................................................................................................................................................... 102
2 診察.................................................................................................................................................................... 111
3 検査.................................................................................................................................................................... 1141）尿検査......................................................................................................................................................... 1142）残尿測定.................................................................................................................................................... 1143）血清クレアチニン測定....................................................................................................................... 1144）超音波検査............................................................................................................................................... 115
a．経腹的超音波検査.......................................................................................................................... 115
b．経会陰的超音波検査..................................................................................................................... 115
c．経腟的超音波検査.......................................................................................................................... 115
d．経直腸的超音波検査..................................................................................................................... 115
5）パッドテスト.......................................................................................................................................... 1166）尿流動態検査（urodynamic study: UDS）.............................................................................. 116
a．尿流測定（uroflowmetry: UFM）............................................................................................. 116
b．膀胱内圧測定（cystometry）..................................................................................................... 117
c．尿道内圧検査（urethral pressure profilometry: UPP）............................................... 117
d．腹圧下漏出時圧（abdominal leak point pressure: ALPP）...................................... 118
e．その他の尿流動態検査................................................................................................................. 1187）内視鏡検査（膀胱・尿道内視鏡検査）........................................................................................ 1188）鎖膀胱尿道造影（chain cystourethrography: chain CUG）.......................................... 118
9）その他の検査.......................................................................................................................................... 11910）検査・診断の手順................................................................................................................................ 1198

治療.................................................................................................................................................................. 122
1 行動療法......................................................................................................................................................... 1221）生活指導（lifestyle interventions）............................................................................................... 122
a．体重減少.............................................................................................................................................. 122

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女性下部尿路症状診療ガイドライン［第 2 版］

b．身体活動（physical activity）.................................................................................................... 124c．禁煙....................................................................................................................................................... 125
d．飲水制限（アルコール，炭酸飲料を含む）......................................................................... 125
e．便秘の改善......................................................................................................................................... 1262）骨盤底筋訓練（pelvic floor muscle training: PFMT）........................................................ 128
a．骨盤底筋訓練.................................................................................................................................... 128
b．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........................................ 131
c．フィードバックあるいはバイオフィードバック訓練.................................................. 131
3）膀胱訓練（bladder training），計画療法（scheduled voiding regimens）........... 134
a．膀胱訓練（bladder training）.................................................................................................... 135
b．定時排尿法（timed voiding）.................................................................................................... 136c．排尿促進法（prompted voiding）........................................................................................... 136
4）その他の保存療法................................................................................................................................ 137
a．腟コーン.............................................................................................................................................. 137
b．鍼治療（acupuncture）................................................................................................................ 137
c．蒸気温熱シート............................................................................................................................... 137
d．催眠療法（hypnotherapy）......................................................................................................... 138

2 薬物療法......................................................................................................................................................... 139
1）過活動膀胱の薬物療法....................................................................................................................... 139
a．抗コリン薬......................................................................................................................................... 139
b．β3 アドレナリン受容体作動薬................................................................................................. 154
c．フラボキサート（flavoxate）..................................................................................................... 159
d．三環系抗うつ薬............................................................................................................................... 160
e．漢方薬（牛車腎気丸）.................................................................................................................... 161
f． エストロゲン（estrogen）.......................................................................................................... 161
g．ボツリヌス毒素（botulinum toxin）....................................................................................... 163
h．抗利尿ホルモン（デスモプレシン）....................................................................................... 167
i． αアドレナリン受容体遮断薬................................................................................................... 1672）腹圧性尿失禁の薬物療法.................................................................................................................. 169
a．β2 アドレナリン受容体作動薬（クレンブテロール clenbuterol）......................... 169
b．漢方薬など（補中益気湯，植物抽出物）............................................................................. 169
c．三環系抗うつ薬............................................................................................................................... 170
d．エストロゲン（estrogen）.......................................................................................................... 170
e．αアドレナリン受容体刺激薬................................................................................................... 171
f． デュロキセチン（duloxetine）.................................................................................................. 172
3）排出障害の薬物療法........................................................................................................................... 175
a．排尿筋の収縮力を増強させる薬剤........................................................................................ 175b．尿道抵抗を減弱させる薬剤....................................................................................................... 176
c．低活動膀胱に対する新規薬剤の開発................................................................................... 178
3 神経変調療法............................................................................................................................................... 1791）電気刺激療法（electrical stimulation: ES）............................................................................. 179

xiv目次2）磁気刺激療法（magnetic stimulation: MS）........................................................................... 180
3）仙骨神経刺激療法（sacral nerve stimulation: SNS）または仙骨神経変調療法（sacral neuromodulation: SNM）....................................................... 181
4）後脛骨神経刺激療法（posterior tibial nerve stimulation: PTNS）.............................. 183
5）その他の電気刺激療法....................................................................................................................... 184

4 手術療法......................................................................................................................................................... 1861）腹圧性尿失禁に対する主な術式................................................................................................... 186
a．中部尿道スリング手術（mid-urethral sling: MUS）...................................................... 187
尿道括約筋不全症例における中部尿道スリング手術の治療成績..................... 191
混合性尿失禁症例に対する中部尿道スリング手術の治療成績.......................... 192
骨盤臓器脱修復手術と同時に施行した腹圧性尿失禁手術の治療成績............ 193
b．筋膜スリング手術（fascial suburethral sling）............................................................... 194
c．経腹的恥骨後式膀胱頸部挙上術（open abdominal retropubic
colposuspension）........................................................................................................................ 195
d．腹腔鏡下恥骨後式膀胱頸部挙上術（laparoscopic retropubic
colposuspension）........................................................................................................................ 196
e．前腟壁形成術（anterior colporrhaphy）............................................................................. 197
f．針式膀胱頸部挙上術（needle bladder neck suspension）..................................... 197
g．尿道周囲注入術（periurethral injection of bulking agent）..................................... 198
h．人工尿道括約筋（artificial urinary sphincter: AUS）................................................... 199
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）.... 207
5 その他の治療法.......................................................................................................................................... 208
尿道留置カテーテル，清潔間欠（自己）導尿................................................................................ 208
a．尿道留置カテーテル..................................................................................................................... 208
b．清潔間欠（自己）導尿〔clean intermittent（self）catheterization〕....................... 208

索引............................................................................................................................................................................ 210

女性下部尿路症状診療ガイドライン［第 2 版］

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