間質性膀胱炎・膀胱痛症候群診療ガイドライン

目次
発刊に寄せて..................................................................................................................................................... iii
序.................................................................................................................................................................................. iv
作成委員，評価委員..................................................................................................................................... v
図譜............................................................................................................................................................................. x膀胱鏡所見−ハンナ病変.......................................................................................................................x膀胱鏡所見−拡張後粘膜出血....................................................................................................... xiv
病理所見........................................................................................................................................................ xv

はじめに............................................................................................................................................................ xvii
背景と目的.................................................................................................................................................. xvii
対象患者・利用者................................................................................................................................. xvii
使用方法・適応範囲............................................................................................................................ xvii
作成方法..................................................................................................................................................... xvii
論文検索.................................................................................................................................................... xviii
レベルの表示.......................................................................................................................................... xviii
略記・略語................................................................................................................................................. xix
利益相反........................................................................................................................................................ xx
修正・改訂................................................................................................................................................. xxi

1

定義................................................................................................................................................................... 1「間質性膀胱炎・膀胱痛症候群」とその関連用語の解説.................................................... 11．
1）間質性膀胱炎........................................................................................................................................... 12）ハンナ型間質性膀胱炎と非ハンナ型間質性膀胱炎............................................................. 23）症候群.......................................................................................................................................................... 33-1）疼痛性膀胱症候群（Painful bladder syndrome: PBS）......................................... 33-2）骨盤痛症候群（Pelvic pain syndrome）......................................................................... 43-3）膀胱痛症候群（Bladder pain syndrome: BPS）........................................................ 44）過知覚膀胱................................................................................................................................................ 42．IC/BPS に関連する用語の対比.......................................................................................................... 43．2019 年版 GL で用いる用語................................................................................................................ 523vi

診療のアルゴリズム........................................................................................................................... 8疫学................................................................................................................................................................ 10目次4

病因・病態............................................................................................................................................... 121．尿路上皮機能不全................................................................................................................................... 121）グリコサミノグリカン層（Glycosaminoglycan: GAG layer）異常........................ 122）細胞間接着異常................................................................................................................................... 123）上皮代謝障害........................................................................................................................................ 134）尿路上皮に対する自己免疫........................................................................................................... 132．膀胱の炎症性変化................................................................................................................................... 131）肥満細胞の活性化.............................................................................................................................. 132）免疫性炎症............................................................................................................................................. 133）神経原性炎症........................................................................................................................................ 14
3．侵害刺激受容機構の異常亢進.......................................................................................................... 144．尿中毒性物質............................................................................................................................................. 145．微生物感染.................................................................................................................................................. 145病理................................................................................................................................................................ 181．HIC の病理組織像................................................................................................................................... 18
2．HIC 以外の IC/BPS の病理組織像................................................................................................ 19
3．IC/BPS における肥満細胞浸潤....................................................................................................... 206診断................................................................................................................................................................ 22

1．症状.................................................................................................................................................................. 221）下部尿路症状........................................................................................................................................ 222）その他の症状........................................................................................................................................ 223）症状の経過............................................................................................................................................. 234）症状に影響する因子......................................................................................................................... 235）症状の評価............................................................................................................................................. 23
2．QOL................................................................................................................................................................. 23
3．病歴.................................................................................................................................................................. 23
4．検査.................................................................................................................................................................. 231）身体所見.................................................................................................................................................. 232）排尿記録.................................................................................................................................................. 263）尿検査....................................................................................................................................................... 264）尿流動態検査........................................................................................................................................ 265）膀胱鏡検査............................................................................................................................................. 266）膀胱水圧拡張検査.............................................................................................................................. 287）膀胱生検.................................................................................................................................................. 288）カリウムテスト................................................................................................................................... 299）バイオマーカー................................................................................................................................... 29
5．除外診断....................................................................................................................................................... 29
6．診断の流れ.................................................................................................................................................. 29
間質性膀胱炎・膀胱痛症候群診療ガイドラインvii

間質性膀胱炎・膀胱痛症候群診療ガイドライン

7．難病指定....................................................................................................................................................... 307治療総論..................................................................................................................................................... 33

1．保存的治療.................................................................................................................................................. 332．薬物治療....................................................................................................................................................... 33
3．膀胱腔内・壁内注入療法.................................................................................................................... 34
4．手術療法....................................................................................................................................................... 34
5．その他の治療............................................................................................................................................. 35
6．HIC とそれ以外を分けた治療戦略................................................................................................ 35
治療の推奨グレード.............................................................................................................................. 36
治療法の一覧............................................................................................................................................. 37

8治療 -1 保存的治療......................................................................................................................... 38

1．緊張の緩和（Stress reduction）...................................................................................................... 38
2．理学療法（Physical therapy）........................................................................................................... 38
3．行動療法（Behavioral modification）........................................................................................... 39
4．食事療法（Dietary modification）................................................................................................... 39

9治療 -2 薬物治療............................................................................................................................... 42

1．中枢性感作（Central sensitization）............................................................................................. 421）アミトリプチリン（Amitriptyline）............................................................................................. 422）デュロキセチン（Duloxetine）..................................................................................................... 423）ガバペンチン，プレガバリン（Gabapentin, Pregabalin）.......................................... 434）トラマドール（Tramadol）............................................................................................................. 43
2．リンパ球・肥満細胞の活性化（Lymphocyte/Mast cell activation）.......................... 441）ヒドロキシジン（Hydroxyzine）................................................................................................. 442）シメチジン（Cimetidine）............................................................................................................... 443）スプラタスト（Suplatast）............................................................................................................. 454）モンテルカスト（Montelukast）.................................................................................................. 45
3．免疫反応・炎症（Immunological response, Inflammation）........................................ 451）シクロスポリン A，タクロリムス（Cyclosporine A, Tacrolimus）......................... 452）アセトアミノフェン，セレコキシブ（Acetaminophen, Celecoxib）.................... 463）ステロイド（Prednisolone）......................................................................................................... 464）アルギニン（L-arginine）................................................................................................................ 475）アダリムマブ，セルトリズマブ ペゴル（Adalimumab, Certolizumab pegol）.... 47
4．膀胱上皮障害（Dysfunctional bladder epithelium）........................................................... 48
1）ポリ硫酸ペントサンナトリウム（Pentosan polysulfate sodium）.......................... 48
5．尿アルカリ化（Urinary alkalinization）....................................................................................... 49
1）クエン酸（Citrate）............................................................................................................................. 49viii

目次6．感染（Infection）....................................................................................................................................... 491）抗菌薬....................................................................................................................................................... 49
7．漢方薬............................................................................................................................................................ 5010治療 -3 膀胱内注入療法............................................................................................................. 53

1．ジメチルスルホキシド（Dimethyl sulfoxide: DMSO）...................................................... 53
2．ヘパリン（Heparin）............................................................................................................................... 54
3．ヒアルロン酸（Hyaluronic acid）................................................................................................... 54
4．コンドロイチン硫酸（Chondroitin sulfate）............................................................................ 55
5．ポリ硫酸ペントサンナトリウム（Pentosan polysulfate sodium: PPS）.............. 55
6．カプサイシン，レジニフェラトキシン（Capsaicin, Resiniferatoxin）................... 56
7．Bacillus Calmette-Guérin（BCG）................................................................................................ 56
8．オキシブチニン（Oxybutynin）........................................................................................................ 57
9．リドカイン（Lidocaine）...................................................................................................................... 57
10．ステロイド（Steroid）............................................................................................................................ 58
11．ボツリヌス毒素（Botulinum toxin）.............................................................................................. 58
12．リポソーム（Liposome）..................................................................................................................... 59

11治療 -4 内視鏡的治療................................................................................................................... 65

1．膀胱水圧拡張術（Hydrodistension）............................................................................................. 652．経尿道的ハンナ病変切除・焼灼術（Transurethral resection/fulguration of the Hunner lesions），経尿道的レーザー治療...................................... 66

12治療 -5 その他の治療................................................................................................................... 71

1．経皮的電気刺激（Transcutaneous electric nerve stimulation: TENS）................. 71
2．仙骨神経刺激（Sacral neuromodulation: SNM）................................................................. 713．鍼（Acupuncture）................................................................................................................................... 72
4．膀胱拡大術（Augmentation）・膀胱摘出術，尿路変更術............................................... 73

13

治療効果の評価.................................................................................................................................... 78

1．対象患者の採用基準.............................................................................................................................. 78
2．有効性の判定基準................................................................................................................................... 781）有効性の評価方法.............................................................................................................................. 782）有効性の評価に影響を与える可能性のある事項............................................................... 80
3）特に薬剤治験において注意すべき点........................................................................................ 80

索引...................................................................................................................................................................... 81

間質性膀胱炎・膀胱痛症候群診療ガイドラインix