Urinary Incontinence (요실금, 오줌새기)

The Root of Ambulatory Care
- 저 자 : 이진우
- 출 판 : 군자출판사
- 페이지수: 543면
이진우 선생님, 군자출판사와 제휴를 통해 책 내용 및 그림을 제공합니다.
무단 복제/배포 금지.
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
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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.
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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
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