膀胱過動症 林正日 1 林鉅勝 2 李建儀 3 劉夷生 4 前言 (Overactive bladder, OAB) 流行病學 16.2% 16.9% (OAB wet)( ) ( 55%) (OAB dry)( ) ( 84%) [1] 1 臺中榮民總醫院家庭醫學科住院醫師 2 臺中榮民總醫院家庭醫學科主治醫師 3 臺中榮民總醫院泌尿外科主治醫師 4 臺中榮民總醫院家庭醫學科主任 overactive bladder, hyperactive bladder 16.9%(18.3% v.s. 16.0%) 60OAB 28.2% [2] 定義 a. (OAB) 2002 (International Continence Society, ICS) (urgency) (frequency) (nocturia) (urgency incontinence) ( ) ( ) ( / ) b. (Urgency) (sudden compelling desire) c. (Frequency) 32 家庭醫學與基層醫療 第二期
8 2 (voiding dairy) 3~4 6~7 ( ) ( ) d. (Nocturia) (Excessive nighttime urine production or nocturnal polyuria) () e. (Urgency urinary incontinence) 診斷 病史詢問 ( ) / (nocturnal polyuria) (Symptom questionnaires) (overactive bladder questionnaire, QAB-q) [3] ( ) 理學檢查 () (anti-muscarinics) 家庭醫學與基層醫療 第二期 33
表一膀胱過動症自我檢測表 您被以下症狀所困擾的程度 完全沒有 略微有些相當很大極大 1 白天頻尿? 0 1 2 3 4 5 2 令人不適的尿急感? 0 1 2 3 4 5 3 稍有預警或無預警的突然尿急感? 0 1 2 3 4 5 4 意外的少量尿失禁? 0 1 2 3 4 5 5 夜尿? 0 1 2 3 4 5 6 夜間因不得不排尿而醒來? 0 1 2 3 4 5 7 無法控制的尿急感? 0 1 2 3 4 5 8 與強烈排尿感相關的尿失禁? 0 1 2 3 4 5 您是男性嗎? 如果是男性, 在總分內加兩分 若總分等於或大於 8, 則可能患有膀胱過動症 實驗室及其它檢查 ( ) (leukocyte esterase)(nitrite) ( - Weak stream-intermittency -Straining to void -Emptying incompletely) ( ) (Post-void residual assessment) 治療 34 家庭醫學與基層醫療 第二期
衛教 ( ) 行為治療 (Kegel exercise) 8% [7] / [4~7] 25~30% 藥物治療 Immediate Release, IR Sustained Release, SR Extended Release, ER. 1. 家庭醫學與基層醫療 第二期 35
(antimuscarinic) ( Darifenacin, Fesoterodine, Oxybutynin, Solifenacin, Tolterodine or Trospium) M3 (Psyllium) (1)Oxybutynin Oxybutynin Immediate Release, IR 5mg Oxybutynin 60~80%50% [8] N- desethyloxybutynin Oxybutynin & TolterodineExtended Release, ER [9] ( ) (10mg ) (patch ) (gel) 17~26% [10] (2)Darifenacin 7.5~15 M3 [11,12] (3)Fesoterodine M3 4~8 (4)Solifenacin 5~10 36 家庭醫學與基層醫療 第二期
(5)Tolterodine Tolterodine Oxybutynin 1~2 2~4 (6)Trospium Trospium 表二 OAB 藥物總整理 藥物作用機轉建議劑量副作用 抗毒蕈鹼類 (anti-muscarinic) Darifenacin 抑制 muscarinic receptor, 減少膀 7.5-15 mg QD 口乾 (20-40%) 便秘 (17%) Fesoterodine 胱逼尿肌的收縮 4-8 mg QD 口乾 (20-40%) 便秘 (7-9%) Solifenacin 5-10mg QD 口乾 (20-40%) 便秘 (7-9%) Tolterodine IR 1-2 mg BID 口乾 (28.8%) 便秘 (4.9%) Tolterodine LA 2-4 mg QD 口乾 (7.3-18%) 便秘 (5.7%) Trospium IR 20 mg BID 口乾 (8.7-12.9%) Oxybutynin IR 混合作用 : 除了抑制 muscarinic receptor 外, 亦有直接放鬆平滑肌及局部麻醉的效果 2.5-5 mg TID 口乾 (68%) 便秘 (12.1%) Oxybutynin ER 5-10mg QD 口乾 (40%) 其它 : 散瞳 眼壓增高 心搏過速 乙三型交感神經刺激劑 (β3- adrenergic agents) Mirabegron 刺激迫尿肌的 β3 腎上腺素激導性接受器, 抑制膀胱逼尿肌收縮 25-50 mg QD 高血壓 鼻咽發炎及泌尿道感染 抗鬱劑 (Antidepressants) Imipramine 抗膽鹼激素性與腎上腺素激導性 (adrenergic), 可鬆弛膀胱與增加尿道阻力 亦可經由中樞神經系統影響排尿反射 10-25mg TID- QID 鎮靜 嗜睡 姿態性低血壓與心臟傳導障礙 平滑肌鬆弛劑 (smooth muscle relaxants) Flavoxate 直接放鬆平滑肌的效果, 亦有抗膽鹼效果 100-200 mg TID-QID 資料來源 : 參考資料 13, 14 家庭醫學與基層醫療 第二期 37
20 60 60~75% [8] (narrow angle glaucoma) (acetylcholinesterase inhibitors) ( ) (Start low, Go slow) 2. ( 3-adrenergic agents) Mirabegron 3 (FDA) 2012 7 2015 25~50 Mirabegron (nasopharyngitis) 對於行為治療及藥物治療反應不佳的病患 侵襲性治療 38 家庭醫學與基層醫療 第二期
1. / (SNS) (S3 sacral foramen) (pulse generator) 2. (Intradetrusor OnabotulinumtoxinA) 100 20 3. (PTNS) ( ) 其它治療 ( ) (urinary diversion) (augmentation cystoplasty) 追蹤 家庭醫學與基層醫療 第二期 39
圖一膀胱過動症的診斷及治療流程 ( 摘自 2014 美國泌尿科學會指引 ) (Practice Guidelines published in AFP) 結語 40 家庭醫學與基層醫療 第二期
(16-17%) ( ) 參考資料 1. Stewart W, Van Rooyen JB, Cundiff G et al: Prevalence and burden of overactive bladder in the united States. World J Urol 2003; 20: 327. 2. Yu HJ, Liu CY, Lee KL, Lee WC, Chen TH: Overactive bladder syndrome among communitydwelling adults in Taiwan: prevalence, correlates, perception, and treatment seeking. Urol Int 2006; 77:327-33. 3. Coyne K, Revicki D, Hunt T et al: Psychometric validation of an overactive bladder symptom and health-related quality of life questionnaire: TheOAB-q. Qual Life Res 2002 ; 11:563-74. 4. Burgio KL, Goode PS, Johnson TM et al: Behavioral versus drug treatment for overactive bladder in men: the Male Overactive Bladder Treatment in Veterans (MOTIVE) Trial. J Am Geriatr Soc 2011; 59: 2209. 5. Kaya S, Akbayrak T and Beksac S: Comparison of different treatment protocols in the treatment of idiopathic detrusor overactivity: a randomized controlled trial. Clin Rehabil 2011; 25: 327. 6. Arruda RM, Castro RA, Sousa GC et al: Prospective randomized comparison of oxybutynin, functional electrostimulation, and pelvic floor training for treatment of detrusor overactivity in women. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19: 1055. 7. Subak LL, Wing R, West DS et al: Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med 2009; 360: 481. 8. Ouslander JG: Management of overactive bladder. N Engl J med 2004; 350:786-99. 9. Le TH, Ostergard DR, Bhatia NN, et al: Newer pharmacologic option in management of overactive bladder syndrome. Curr Opin Obstet Gynecol 2005; 174:495-506. 10. Dmochowski RR, Davila GW, Zinner NR et al: Efficacy and safety of transdermal oxybutynin in patients with urge and mixed urinary incontinence. J Urol 2002; 168: 580. 11. Lipton RB, Kolodner K, Wesnes K: Assessment of cognitive function of the elderly population: effects of darifenacin. J Urol 2005; 173: 493. 12. Kay G, Crook T, Rekeda L et al: Differential effects of the antimuscarinic agents darifenacin and oxybutynin ER on memory in older subjects. Eur Urol 2006; 50: 317. 13. Gormley EA: Overactive Bladder: Diagnosis and Management. American Urological Association 2014. 14. 2005 21 100 家庭醫學與基層醫療 第二期 41