KEYWORDS: ..본인의 의사와 상관없이 소변이 요도 밖으로 흘러나오는 증상으로서 다양한 원인에 의하여 방광내부의 압력이 요도저항보다 높아지면 그 압력의 차이에 의해서 발생한다. ..Prevalence : 5~53% (국내 :전체 유병률 46.3%중 남성 26.7% 여성 50.2% - 일상 생활에 지장을 줄 정도의 심한 요실금 경험자는 남성 3.7%,여성 10.1%) Urinary Incontinence 기침, 폭소, 재채기, 운동과 같이 복압이 증가하는 상황에서 발생 : Typically urethral hypermobility caused by a failure of the normal anatomic supports of the urethrovesical junction. ▶ Loss of bladder neck support is often attributed to nerve, muscle and connective tissue injury occurring during vaginal delivery, however vaginal childbirth is certainly not the only contributing factor. ▶ Intrinsic urethral sphincter deficiency is another factor : Advanced age, Inadequate estrogen levels, Previous vaginal surgery, Certain neurologic lesions are associated with poor urethral sphincter junction. 방광에 소변이 차 있든 비어 있든지 간에 매우 급하게 요의를 느끼며 참을 수 없이 소변이 나옴 : ▶ Some cases of overactive bladder can be attributed to specific conditions, such as acute or chronic urinary tract infection, bladder cancer and bladder stones, but most cases result from an idiopathic inability to suppress detrusor contractions. Stress Incontinence와 Urge Incontinence의 증상이 모두 나타나는 경우 : ▶ For these patients, it is helpful to identify the most bothersome symptom and treat accordingly. 방광의 과다 팽창에 의한 요실금 현상이며, 환자는 자주 지속적으로 소변이 방울방울 떨어지거나 복 압성, 절박성 요실금의 증상이 생김 ▶ Caused by an underactive bladder(detrusor) muscle and/or outlet obstruction. ▶ The detrusor muscle may be underactive secondary to drug therapy (psychotropic agents) or conditions such as diabetic neuropathy, low spinal cord injury, radical pelvic surgery and muscle sclerosis. Outlet obstruction in women is almost always a result of urethral occlusion from pelvic organ prolapse or previous anti-incontinence surgery. 누관(fistula)이 가장 흔한 원인이며, 자궁 절제술이나 골반수술의 합병증으로 방광-질 누관, 요로-질 누관 또한 이소성 요도나 게실이 원인이 될 수 있다. Stress Incontinence Urge Incontinence (Overactive bladder) Mixed Incontinence Overflow Incontinence Lack of Continuity or Deformity 523 The Root of ambulatory care ..요실금의 진단은 병력과 신체진찰, 그리고 몇가지 간단한 검사로 내려지며, 만약 증상이 복잡하거나 초치료가 효과적이지 못할 때, 정확한 진단을 위한 특수 검사들이 요구된다. 1. Stress Incontinence? ..Do you leak urine when you cough, laugh, lift something or sneeze? 2. Urge Incontinence? ..Do you ever leak urine when you have a strong urge on the way to the bathroom? ..How frequently do you empty your bladder during the day? ..How many times do you get up to urinate after going to sleep? Is it the urge to urinate that wakes you? ..Do you ever leak urine during sex? 3. Outlet obstruction, interstitial cystitis, UTI? ..Dose it hurt when you urinate? ..Do you ever feel that you are unable to completely empty your bladder? 4. Severity ..Do you wear pads that protect you from leaking urine? How often do you have to change them? ..Do you ever find urine on your pads or clothes and were unaware of when the leakage occurred? 5. Contributing factors? ..Medical history : DM, stroke, lumbar disc disease, chronic lung disease, fecal impaction, cognitive impairment ..Obstetric and gynecologic history : gravity, parity, the number of vaginal, instrumentassisted and cesarean deliveries, the time interval between deliveries, previous hysterectomy and/or vaginal or bladder surgery, pelvic radiotherapy, trauma, estrogen status ..All prescription and nonprescription drugs (Table1) Key questions 만성적인 육체적 혹은 인지적 기능의 손상에 의해 발생 : ▶ Many functionally impaired persons can also have other types of urinary incontinence that may respond to specific treatments, pure functional incontinence should be a diagnosis of exclusion. Functional Incontinence Urinary Incontinence Table 1. Commonly used drugs that can influence bladder function i. Antidepressants, Antipsychotics, Sedatives/Hypnotics ii. Diuretics iii. Caffeine iv. Anticholinergics v. Alcohol vi. Narcotics vii. Alpha-adrenergic blockers viii. Alpha-adrenergic agonists ix. Beta-adrenergic agonists x. Calcium channel blockers xi. ACE inhibitors ..소변 일지는 요실금의 세부적인 진단을 위해 고려해 볼 수도 있다. 525 The Root of ambulatory care ..가정의학 외래에서 잔뇨량 측정이 유용한지에 대해선 논란이 있지만 overflow incontinence, chronic urinary tract infections, hematuria, diabetes, kidney disease, metabolic abnormalities 선별에 도관을 이용한 잔뇨량 검사는 유용할 수 있다. ..Stress incontinence 와 Urge incontinence인 경우 가정의학 외래에서 치료할 수 있다. Screening question to ask about urinary incontinence during office visit Give the patient a 24 hour bladder diary Review diary entries subsequent visit Consider initiation of local or systemic estrogen replacement therapy (ERT) Determine Post-Void Residual (PVR) volume Obtain urine culture and perform UA Stress Incontinence Pelvic muscle exercises Weighted vaginal cones Pelvic floor electrical stimulation Occlusive devices Alpha-adrenergic drugs Local ERT Urge Incontinence Behavioral therapy Pharmacologic agents Pelvic floor electrical stimulation Extracorporeal magnetic innervation Local ERT Neuromodulation Consider subspecialist consultation Mixed Incontinence Treatment based on predominant symptom If PVR volume > 100mL, treat underlying cause of retention or refer If UA positive for UTI, treat accordingly If glucose evident on UA, screen for DM If UA is positive for hematuria, treat for UTI : evaluate if subsequent UA is positive for hematuria Yes Normal Not improved Abnormal Fig 1. Algorithm for the evaluation urinary incontinence Key treatments of Stress Incontinence Key treatments of Urge Incontinence Urinary Incontinence 1. Kegel exercise - 10~20 contractions씩 하루에 3번 혹은 4번씩 수개월 지속 2. Pelvic floor electrical stimulation 3. Pharmacologic - Sudafed.. 60mg 1T tid-qid - Premarin Vag cream.. apply (매일밤 질내 도포 - 폐경기 여성에서 위축성 질염과 동반된 경우) 4. Retropubic urethropexies and suburethral slings/Suburethral sling ..Sudafed..-Pseudoephedrine 1. Behavioral therapy : bladder training and biofeedback-ignore uregency and void in response to cortical signals during waking hours 2. Pharmacologic - Detrusitol.. 2mg 1T, 1/2T bid start, dose up to 2~4mg bid - Ditropan.. 5mg 1T, 1/2T bid start, dose up 2.5mg every other day (Daily maximum : 20mg) - Estrogen replacement (topical or systemic) 3. Pelvic floor electrical stimulation 4. Neuromodulation 5. Extracorporeal magnetic innervation ..Detrusitol..-Tolterodine ..Ditropan..- Oxybutyrin HCL 참고 문헌 Patrick J. Culligan, M.D., Michael Heit, M.D. : Urinary Incontinence. A journal of the American Family Physicains 2000 ; 62(11) : 2433-2444, 2447, 2452 정유석 : 요실금, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1292-1299 Deborah Bartholomew, M.D. : Urinary Incontinence, in Conn's Current Therapy 2004, Robert E. Rakel(ed), Edward T. Bope(ed). Philadelphia, Saunders, 2004, P 721-725 오창석(ed) : 요실금, in Complete Guide To Practical Based Prescription Medicine. 서울, 한우리, 2005, P 302-303 527 The Root of ambulatory care