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首页 2011版泌尿外科指南10-女性压力性尿失禁诊断治疗指南-2010年版

2011版泌尿外科指南10-女性压力性尿失禁诊断治疗指南-2010年版.doc

2011版泌尿外科指南10-女性压力性尿失禁诊断治疗指南-20…

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2018-09-10 0人阅读 0 0 0 暂无简介 举报

简介:本文档为《2011版泌尿外科指南10-女性压力性尿失禁诊断治疗指南-2010年版doc》,可适用于医药卫生领域

女性压力性尿失禁诊断治疗指南主编李龙坤第三军医大学西南医院编委(按姓氏拼音排序)杜鹏首都医科大学附属北京朝阳医院鞠彦合中国康复研究中心附属北京博爱医院林涛四川大学华西医院肖云翔北京大学泌尿外科研究所北京大学第一医院审查委员会主审宋波第三军医大学西南医院副主审杨勇首都医科大学附属北京朝阳医院廖利民中国康复研究中心附属北京博爱医院王平中国医科大学附属第四医院杜广辉华中科技大学同济医学院附属同济医院卫中庆南京大学医学院附属鼓楼医院沈宏四川大学华西医院委员刘润明西安交通大学医学院第一附属医院吴士良北京大学泌尿外科研究所北京大学第一医院方祖军复旦大学附属华山医院许传亮第二军医大学附属长海医院赵耀瑞天津医科大学第二医院宋希双大连医科大学第一医院李振华中国医科大学第一医院郑少斌南方医科大学南方医院文建国郑州大学第一附属医院关志忱北京大学深圳医院黎玮河北医科大学第二附属医院目录前言一、概述二、诊断三、非手术治疗四、手术治疗五、合并疾病的处理六、随访七、预防前言女性尿失禁是女性常见病目前据全球统计患病率接近严重尿失禁约为其中约一半为压力性尿失禁。我国的患病率与此基本相当。如此庞大的患病人群对女性生活质量和健康状态构成严重影响。由于社会经济和文化教育等因素加之女性对排尿异常羞于启齿导致女性压力性尿失禁长期以来不为医患双方所重视。随着我国国民经济的快速增长及人民生活水平的迅速提高女性压力性尿失禁所带来的诸多健康和社会问题正逐渐受到重视。因此有必要对我国压力性尿失禁的诊治进行规范和指导。一、压力性尿失禁诊治指南的进展尿失禁是泌尿外科常见病和高发病一直受到国际尿控学会和各国泌尿外科学会的重视。国际尿控学会(InternationalContinenceSociety,ICS)先后于年年年召开了尿失禁咨询委员会(InternationalConsultationonIncontinence,ICI)最后一届会议于年月~日召开年正式出版诊治指南。美国泌尿外科学会(AmericanUrologicalAssociationAUA)和欧洲泌尿外科学会(EuropeanAssociationofUrologyEAU)分别于年和年发布了尿失禁诊治指南。加拿大日本等发达国家也都发布了自己的指南针对各自国家尿失禁的患病及诊治情况做出了规范。二、制订我国尿失禁诊治指南的目的和意义我国排尿功能障碍性疾病的诊治naryincontinence:amulticenterrandomizedtrialJAmJObstetGynecol,,():DietzHPAsystematicreviewoftensionfreeurethropexyforstressurinaryincontinence:intravaginalslingplastyandthetensionfreevaginaltapeprocedureJBJUInt,,:WeinAJAsystematicreviewoftensionfreeurethropexyforstressurinaryincontinence:intravaginalslingplastyandthetensionfreevaginaltapeproceduresJJUrol,,:MerlinT,ArnoldE,PetrosPAsystematicreviewoftensionfreeurethropexyforstressurinaryincontinence:intravaginalslingplastyandthetensionfreevaginaltapeproceduresJBJUInt,,:DietzHPTVTandSparcsuburethralslings:acasecontrolseriesJIntUrogynecol,,:LordHE,TaylorJDArandomizedcontrolledequivalencetrialofshorttermcomplicationsandefficacyoftensionfreevaginaltapeandsuprapubicurethralsupportslingfortreatingstressincontinenceJBJUInt,,:UlmstenU,JohnsonP,RezapourMAthreeyearfollowupoftensionfreevaginaltapeforsurgicaltreatmentoffemalestressurinaryincontinenceJBrJObstetGynaecol,,:NilssonCG,KuuvaNTheTVTproceduresuccessfulinthemajorityofwomenwithindicationforsurgicaltreatmentofurinarystressincontinenceJBrJofObstetandGynecol,,:NilssonCG,RezapourMandFalconerCyearfollowupofthetensionfreevaginaltapeprocedureJInternationalUrogynecologyJournal,,(supplement):NilssonCG,FalconerC,RezapourMSevenyearfollowupofthetensionfreevaginaltapeprocedurefortreatmentofurinaryincontinenceJObstetGynecol,,:RardinCR,KohliNTVT:outcomesamongwomenwithprimaryversusrecurrentstressurinaryincontinenceJObstetGynecol,,:RezapourM,UlmstenUTensionfreevaginaltape(TVT)inwomenwithrecurrentstressurinaryincontinencealongtermfollowupJIntUrogynecolJPelvicFloorDysfunct,,(Suppl):S–SRezapourM,UlmstenUTensionfreevaginaltape(TVT)inwomenwithmixedurinaryincontinencealongtermfollowupJIntUrogynecolJPelvicFloorDysfunct,,(Suppl):S–SLiapisA,BakasP,CreatsasGBurchcolposuspensionandtentionfreevaginaltapeinthemanagementofstressurinaryincontinenceinwomenJEurUrol,,:KlutkeC,SiegelS,CarlinB,etalUrinaryretentionaftertensionfreevaginaltapeprocedure:incidenceandtreatmentJUrology,,:AbouassalyR,SteinbergJRComplicationsoftensionfreevaginaltapesurgery:amultiinstitutionalreviewJBJUInt,,:HuangKH,KungFT,LiangHM,etalManagementofpolypropylenemesherosionafterintravaginalmidurethralslingoperationforfemalestressurinaryincontinenceJIntUrogynecolJPelvicFloorDysfunct,,():SchraffordtKoopsSE,BisselingTM,HeintzAP,etalProspectiveanalysisofcomplicationsoftensionfreevaginaltapefromTheNetherlandsTensionfreeVaginalTapestudyJAmJObstetGynecol,,():BezerraCA,BruschiniH,CodyDJTraditionalsuburethralslingoperationsforurinaryincontinenceinwomenJCochraneDatabaseSystRev,,:CDLeeKS,HanDH,ChoiYS,etalAprospectivetrialcomparingtensionfreevaginaltapeandtransobturatorvaginaltapeinsideoutforthesurgicaltreatmentoffemalestressurinaryincontinence:yearfollowupJJUrol,,:deLevalJNovelsurgicaltechniqueforthetreatmentoffemalestressurinaryincontinence:transobturatorvaginaltapeinsideoutJEurUrol,,:KrauthJS,RasoamiaramananaH,BarlettaH,etalSuburethraltapetreatmentoffemaleurinaryincontinencemorbidityassessmentofthetransobturatorrouteandanewtape(ISTOP):amulticentreexperimentinvolvingcasesJEurUrol,,:,discussionNeumanMTVTandTVTObturator:ComparisonoftwooperativeproceduresJEurJObstetGynecolReprodBiol,AprinpressDavidMontefioreE,FrobertJL,GrisardAnafM,etalPerioperativecomplicationsandpainafterthesuburethralslingprocedureforurinarystressincontinence:aFrenchprospectiverandomisedmulticentrestudycomparingtheretropubicandtransobturatorroutesJEurUrol,,:UlmstenUThebasicunderstandingandclinicalresultsoftensionfreevaginaltapeforstressurinaryincontinenceJUrologeA,,:SunMJ,ChenGD,LinKCObturatorhematomaafterthetransobturatorsuburethraltapeprocedureJObstetGynecol,,:RobertM,MurphyM,BirchC,etalFivecasesoftapeerosionaftertransobturatorsurgeryforurinaryincontinenceJObstetGynecol,,:LapitanMC,CodyDJ,GrantAMOpenretropubiccolposuspensionforurinaryincontinenceinwomenJCochraneDatabaseSystRev,,CDBurchJCCooper’sligamenturethrovesicalsuspensionforstressurinaryincontinence:nineyears’experience:results,complication,techniqueJAmJObstetGynecol,,:–DigesuGA,BombieriL,HutchingsA,etalEffectsofBurchcolposuspensionontherelativepositionsofthebladdernecktothelevatoranismuscle:anobservationalstudythatusedmagneticresonanceimagingJAmJObstetGynecol,,:–LiapisAE,AshimidisV,LoghisCD,etalArandomizedprospectivestudyofthreeoperativemethodsforgenuinestressincontinenceJJGynecolSurg,,:–CulliganPJ,GoldbergRP,SandPKArandomizedcontrolledtrialcomparingamodifiedBurchprocedureandasuburethralsling:longtermfollowupJIntUrogynecolJPelvicFloorDysfunct,,:ThakarR,StantonS,ProdigalidadL,etalSecondarycolposuspension:resultsofaprospectivestudyfromatertiaryreferralcentreJBJOG,,:BidmeadJ,CardozoLAcomparisonoftheobjectiveandsubjectiveoutcomesofcolposuspensionforstressincontinenceinwomenJBJOG,,:DigesuGAEffectsofBurchcolposuspensionontherelativepositionofthebladdernecktothelevatoranimuscle:anobservationalstudythatusedmagneticresonanceimagingJAmJObstetGynecol,,:LongerRLongtermfollowupafterBurchcolposuspensionforurinarystressincontinenceJIntUrogynecolJPelvicFloorDysfunct,,:AlcalayM,MongaAStantonSBurchColposuspension:ayearfollowupJBritishJObstetandGynaecol,,:BaiSW,KimBJ,KimSK,etalComparisonofoutcomesbetweenBurchcolposuspensionwithandwithoutconcomitantabdominalhysterectomyJYonseiMedJ,,:–BergmanA,EliaGThreeSurgicalproceduresforgenuinestressincontinence:FiveyearfollowupofaprospectiverandomisedstudyJAmJobstetGynecol,,:MoehrerB,CareyM,WilsonDLaparoscopiccolposuspension:asystematicreviewJBJOG,,:FatthyHModifiedBurchcolposuspension:laparoscopyversuslaparotomyJJAmAssocGynecollaparosc,,:KitchenerHC,DunnG,SmithAR,etalLaparoscopicversusopencolposuspensionresultsofaprospectiverandomisedcontrolledtrialJBJOG,,:AnkardalMArandomisedtrialcomparingopenBurchcolposuspensiousingsutureswithlaparoscopiccolposuspensionusingmeshandstaplesinwomenwithstressurinaryincontinenceJBJOG,,:MoehrerB,EllisG,CareyM,etalLaparoscopiccolposuspensionforurinaryincontinenceinwomenJCochraneDatabaseSystRev,,:CDHuangWC,YangJMAnatomiccomparisonbetweenlaparoscopicandopenBurchcolposuspensionforprimarystressincontinenceJUrology,,:–WardKL,HiltonPAprospectivemulticenterrandomizedtrialoftensionfreevaginaltapeandcolposuspensionforprimaryurodynamicstressincontinence:twoyearfollowupAmJObstetGynecol,,:LiapisA,BakasPCreatsasGBurchcolposuspensionandTVTinthemanagementofstressurinaryincontinenceinwomenJEuropeanUrology,,:WangAC,ChenMCComparisionoftensionfreevaginaltapingversusmodifiedBurchcolposuspensiononurethralobstruction:arandomizedcontrolledtrialJNeurourolUrodyn,,:BryansFEMarlexgauzehammockslingoperationwithCooper'sligamentattachmentinthemanagementofrecurrentstressurinaryincontinenceJAmJObstetGynecol,l,:UstunYTensionfreevaginaltapecomparedwithlaparoscopicBurchurethropexyJJAmAssocGynecolLaparosc,,:ParaisoMF,WaltersMD,KarramMM,etalLaparoscopicBurchcolposuspensionversusthetensionfreevaginaltapeprocedure:arandomizedclinicaltrialJObstetGynecol,,:ParaisoMFLaparoscopicBurchcolposuspensionandthetensionfreevaginaltapeprocedureJCurrOpinObstetGynecol,,:LiangC,SoongYTensionfreevaginaltapeversuslaparoscopicbladdernecksuspensionforstressurinaryincontinenceJChangGungMedJ,,:DeanN,HerbisonP,EllisG,etalLaparoscopiccolposuspensionandtensionfreevaginaltape:asystematicreviewJBJOG,,:JarvisGJSurgeryforgenuinestressincontinenceJBrJObstetGynaecol,,:BezerraCA,BruschiniHSuburethralslingoperationsforurinaryincontinenceinwomenJCochraneDatabaseSystRev,,:CDChaikinDC,RosenthalJ,BlaivasJGPubovaginalfascialslingforalltypesofstressurinaryincontinence:long–termanalysisJJUrol,,:Blaivas,JGandJacobs,BZPubovaginalfasciaslingforthetreatmentofcomplicatedstressurinaryincontinenceJJUrol,,:McGuireEJ,ConnellHEsurgicaltreatmentofintrinsicurethraldysfunctionJUrolClinNAmer,,:CespedesRD,CrossCA,McguireEJPubovaginalfascialslingsJTechUrol,,:McguireEJ,LyttonBPubovaginalslingprocedureforstressincontinenceJJUrol,,:ZaragozaMRExpandedindicationsforthepubovaginalslings:treatmentoftypeorstressincontinenceJJUrol,,:GroutzA,BlaivasJGPubovaginalfascialslingsurgeryforsimplestressurinaryincontinence:analysisbyanoutcomescoreJJUrol,,:MorganTo,WestneyOLMcguireEJPubovaginalsling:yearoutcomeanalysisandqualityoflifeassementJJUrology,,:JarvisGJSurgeryforgenuinestressincontinenceJBrJObstetGynaecol,,:GhonheimG,ShaabanASuburethralslingsforthetreatmentofstressurinaryincontinenceJIntUrogynecolJ,,:LeachGE,DmochowskiRR,AppellRAFemalestressurinaryincontinenceclinicalguidelinesJJUrol,,:WeinbergerM,OstergardDLongtermclinicalandurodynamicevaluationofthepolyteraflouroethylenesuburethralslingfortreatmentofgenuinestressincontinenceJObstetGynecol,,:VancaillieTG,SchuesslerWLaparoscopicbladdernecksuspensionJJLaparoendoscSurg,,:–ColomboM,ScalambrinoS,MaggioniA,etalBurchcolposuspensionversusmodifiedMarshallMarchettiKrantzurethropexyforprimarygenuinestressurinaryincontinence:aprospective,randomizedclinicaltrialJAmJObstetGynecol,,:BlackNAandDownsSHTheeffectivenessofsurgeryforstressincontinenceinwomen:asystematicreviewJBrJUrol,,:MainprizeTC,DrutzHPTheMarshallMarchettiKrantzprocedure:acriticalreviewJObstetGynecolSurv,,:GlazenerCM,CooperKBladderneckneedlesuspensionforurinaryincontinenceinwomenJCochraneDatabaseSystRev,,CDTebyaniMLPercutaneousneedlebladdernecksuspensionforthetreatmentofstressurinaryincontinenceinwomen:longtermresultsJJunroll,,:GrahamCW,DmochowskiRRPubicosteomyelitisfollowingbladdernecksurgeryusingboneanchors:areportofcasesJJUrol,,:CulliganPJ,GoldbergRP,SandPKArandomizedcontrolledtrialcomparingamodifiedBurchprocedureandasuburethralsling:longtermfollowupJIntUrogynecolJPelvicFloorDysfunct,,:DmochowskiRR,AppellRAInjectableagentsinthetreatmentofstressurinaryincontinenceinwomen:wherearewenowJUrology,,(Suppl):PELee,RCKung,HPDrutzPeriurethralautologousfatinjectionastreatmentforfemalestressurinaryincontinence:arandomizeddoubleblindcontrolledtrialJJUrol,,:–CACrossAfollowupontransurethralcollageninjectiontherapyforurinaryincontinenceJJUrol,,:–GroutzAOutcomeresultsoftransurethralcollageninjectionforfemalestressincontinence:assessmentbyurinaryincontinencescoreJJUrol,,:–BentCollagenimplantfortreatingstressurinaryincontinenceinwomenwithurethralhypermobilityJJUrol,,:Corcos,JFournier,CPeriurethralcollageninjectionforthetreatmentoffemalestressurinaryincontinence:yearfollowupresultsJUrology,,:TamaniniJTMacroplastiqueimplantationsystemforthetreatmentoffemalestressurinaryincontinenceJJUrol,,:–BarrangerEResultsoftransurethralinjectionofsiliconemicroimplantsforfemaleswithintrinsicsphincterdeficiencyJJUrol,,:LightnerD,CalvosaC,AndersenR,etalAnewinjectablebulkingagentfortreatmentofstressurinaryincontinence:resultsofamulticenter,randomised,controlled,doubleblindstudyofDurasphereJUrology,,:–PickardRPeriurethralinjectiontherapyforurinaryincontinenceinwomenJChchraneDatabaseSystRev,,:CDooWebsterSD,KhouryJMManagementofstressurinaryincontinenceusingartificialurinarysphincterJUrology,,:PierreC,NicolasM,BertrandR,etalTheuseofanartificialurinarysphincterinwomenwithtypeIIIincontinenceandanegativemarshalltestJJUrol,,:BorirakchanyavatS,AboseifS,CarrollP,etalContinencemechanismoftheisolatedfemaleurethra:ananatomicalstudyoftheintrapelvicsomaticnervesJJUrol,,:WebsterSD,KhouryJMManagementofstressurinaryincontinenceusingartificialurinarysphincterJUrology,,:PierreC,NicolasM,BertrandR,etalTheuseofanartificialurinarysphincterinwomenwithtypeIIIincontinenceandanegativeMarshalltestJJUrol,,:KowalczykJJ,MulcahyJJUseoftheartificialurinarysphincterinwomenJIntUrogynecolJPelvicFloorDysfunct,,:–CostaPTheuseofanartificialurinarysphincterinwomenwithtypeIIIincontinenceandanegativeMarshalltestJJUrol,,:DuncanHJ,MundyARRoleoftheartificialurinarysphincterinthetreatmentofstressincontinenceinwomenJBrJUrol,,:DemirciFTenyearresultsofMarshallMarchettiKrantzandanteriorcolporraphyproceduresJAustNZJObstetGynaecol,,:BallT,TeichmanJ,SharkeyF,etalTerminalnervedistributiontotheurethraandbladderneckconsiderationsinthemanagementofstressincontinenceJJUrol,,:五、合并疾病的处理(一)合并膀胱过度活动症年ICI指南建议:对混合性尿失禁患者应首先采取膀胱行为治疗、盆底肌训练和抗胆碱能制剂等相应措施控制急迫性尿失禁症状。待急迫性尿失禁控制满意后再对压力性尿失禁诊断、尿失禁严重程度以及对患者生活质量的影响进行重新评判并据此采取相应处理。年中华医学会泌尿外科学分会(CUA)发布的OAB诊治指南观点与此基本相同即先处理急迫性尿失禁待稳定后再行压力性尿失禁处理。(二)合并盆腔脏器脱垂盆腔脏器脱垂的诊治涉及泌尿、妇产及肛肠。单纯的子宫脱垂或阴道后壁膨出常无排尿症状而阴道前壁膨出时即可能出现压力性尿失禁症状。在严重的阴道前壁膨出时因下垂的膀胱尿道与相对固定于耻骨后的尿道形成成角畸形从而还可产生排尿困难。阴道前壁膨出常与其他盆腔脏器脱垂同时存在建议的处理原则如下:.有压力性尿失禁症状但盆腔脏器脱垂无需手术治疗者压力性尿失禁部分可按压力性尿失禁处理建议向患者说明有进一步手术处理之可能。.有压力性尿失禁症状且盆腔脏器脱垂部分需要手术治疗者在修补盆腔脏器脱垂的同时行抗压力性尿失禁手术治疗治愈率可达~,。.无尿失禁症状而仅有盆腔脏器脱垂者治疗尚存在争议。因盆腔脏器脱垂有可能合并隐性压力性尿失禁脱垂校正后出现尿失禁症状因而许多作者推荐盆腔重建时同时进行抗尿失禁手术以预防术后压力性尿失禁的发生但采取何种术式预防潜在的压力性尿失禁尚无一致意见。(三)合并逼尿肌收缩力受损尿流率较低(<cmHO)考虑逼尿肌收缩力受损时如受损较轻最大逼尿肌收缩压>cmHO、无明显剩余尿量、平时无明显腹压排尿状态时可先行保守治疗和药物治疗处理压力性尿失禁无效时考虑行抗压力性尿失禁手术但术前应告知自家间歇导尿的可能性。逼尿肌受损严重最大逼尿肌收缩压≤cmHO或有大量剩余尿量或平时为明显腹压排尿应注意有无其他尿失禁的可能此类患者不建议抗尿失禁手术可试用抗尿失禁药物治疗如出现排尿困难加重应及时停药。(四)合并膀胱出口梗阻(bladderolowobstruction,BOO)应先解除BOO待稳定后再评估和处理压力性尿失禁。对于冰冻尿道及尿道狭窄等患者可同期行解除BOO和尿失禁治疗。如尿道松解同期行尿道中段悬吊术。参考文献MilaniRMMKprocedureandBurchcolposuspensioninthesurgicaltreatmentoffemaleurinaryincontinenceJBrJObstetGynecol,,:ColomboMRandomisedcomparisonofBurchcolposuspensionversusanteriorcolporrhaphyinwomenwithstressurinaryincontinenceandanteriorvaginalwallprolapseJBJOG,,:HuangHConcomitantsurgerywithtensionfreevaginaltapeJActaObstetGynecolScand,,:BarberMPredictionandpreventionofpostoperativestressurinaryincontinenceinwomenundergoingsurgeryforprolapse:asystemicreviewAmericanUrogynecologicSocietymeeting,GordonDCombinedgenitourinaryprolapserepairandprophylactictensionfreevaginaltapeinwomenwithsevereprolapseandoccultstressurinaryincontinence:preliminaryresultsJUrology,,:ChaikinDC,GroutzA,BlaivasJGPredictingtheneedforantiincontinencesurgeryincontinentwomenundergoingrepairofsevereurogenitalprolapseJJUrol,,:KlutkeJJ,RamosSUrodynamicoutcomeaftersurgeryforsevereprolapseandpotentialstressincontinenceJAmJObstetGynecol,,:六、随访(一)盆底肌肉训练(PFMT)的随访.时间训练后~个月内。.内容和指标主要随访PFMT治疗后的疗效包括主观评价和客观证据。主观自我评价:推荐使用国际上公认的问卷如ICIQ评估尿失禁次数和量对生活质量的影响。客观证据:高度推荐使用排尿日记和尿垫试验可选尿动力学检查或盆底肌收缩强度测试,。.疗效判定完全干燥为治愈尿失禁减轻为改善两者合称有效。尿失禁不减轻甚至加重为无效。(二)药物治疗的随访.时间多为~个月,。.内容和指标()主观疗效:使用问卷进行自我评价指标包括尿失禁次数和量、生活质量评分等。()客观疗效:高度推荐排尿日记、尿垫试验可选尿动力学检查。()不良反应:如α受体激动剂常见时的血压升高、头痛、睡眠障碍、震颤和心悸、肢端发凉和立毛等副作用雌激素有可能增加乳腺癌、子宫内膜癌和心血管疾患的危险Duloxetine有恶心等副作用。(三)手术治疗的随访.时间推荐术后周内至少进行次随访主要了解近期并发症。周以后主要了解远期并发症及手术疗效。.内容和指标手术疗效评价与随访:()主观指标:即患者使用问卷进行的自我评价指标包括尿失禁次数、量和生活质量评分等。()客观指标:高度推荐排尿日记及尿垫试验可选尿动力学尤其是无创检查如尿流率及B超测定剩余尿量。()并发症随访:对压力性尿失禁的术后随访中必须观察和记录近期和远期并发症。压力性尿失禁术后近期并发症常见有:出血、血肿形成、感染、膀胱尿道损伤、尿生殖道瘘、神经损伤和排空障碍等。远期并发症有:新发尿急、继发泌尿生殖器官脱垂、耻骨上疼痛、性交痛、尿失禁复发、慢性尿潴留及吊带的侵蚀等。参考文献WilsonPDConservativetreatmentinwomenInIncontinence(EdAbrams,KhouryandWein),WellsTJ,BrinkDAPelvicmuscleexerciseforstressurinaryincontinenceinelderlywomenJJournaloftheAmericanGeriatricsSociety,,:BoK,HagenRHPelvicfloormuscleexercisefortreatmentoffemalestressurinaryincontinenceJNeurourolUrodyn,,:HenallaSM,HutchinsCJNonoperativemethodsinthetreatmentoffemalegenuinestressincontinenceofurineJJournalofObstetricsandGynaecology,,:DmochowskiRR,NortonPA,ZinnerNRDuloxetineversusplaceboforthetreatmentofNorthAmericanwomenwithstressurinaryincontinenceJJUrol,,:JacksonS,AbramsPTheeffectofoestradiolonobjectiveurinaryleakageinpostmenopausalstressincontinence:adoubleblindplacebocontrolledtrialJNeurourolUrodyn,,:WeinAJPharmacologyofincontinenceJUrolClinNAm,,:RadleySC,ChappleCREffectsofMethoxamineonmaximumurethralpressureinwomenwithgenuinestressincontinence:aplacebocontrolled,doubleblindcrossoverstudyJNeurourolUrodyn,,:ChahlihaC,StantonSLComplicationsofsurgeryforgenuinestressincontinenceJBrJObstetGynecol,,:七、预防(一)普及教育压力性尿失禁是女性高发病首先应提高公众意识增加该病的了解和认识早期发现早期处理将其对患者生活质量的影响降到最低限度。医务人员则应进一步提高对该病的认识广泛宣传并提高诊治水平。对于压力性尿失禁患者还应注意心理辅导向患者及家属说明本病的发病情况及主要危害解除其心理压力。(二)避免危险因素根据尿失禁的常见危险因素采取相应的预防措施。对于家族中有尿失禁发生史、肥胖、吸烟、高强度体力运动以及多次生育史者如出现尿失禁应评估生活习惯与尿失禁发生的可能相关关系并据此减少对易感因素的接触机会。产后及妊娠期间的盆底肌训练(PFMT)意义:产后及妊娠期间行盆底肌训练可有效降低压力性尿失禁的发生率和严重程度。时机:妊娠周起至产后个月间。方法:每天进行大于或等于次盆底肌收缩训练最好在医生的督促指导下进行。每次包括~秒收缩~秒舒张×~次。(三)选择性剖宫产选择性剖宫产可作为预防尿失禁方法之一可一定程度上预防和减少压力性尿失禁的发生。但选择性剖宫产时还应考虑到社会、心理及经济等诸多因素。参考文献MorkvedS,BoK,ScheiB,etalPelvicfloormuscletrainingduringpregnancytopreventurinaryincontinence:asingleblindrandomizedcontroltrialJObstetGynecol,,:ChiarelliPandCockburnJPromotingurinarycontinenceinwomenafterdelivery:randomizedcontrolledtrialJBrMedJ,,:RortveitG,DaltveitAK,HannestadYS,etalUrinaryincontinenceaftervaginaldeliveryorcesareansectionJNewEngJMed,,:SampselleCM,MillerJM,MimsBM,etalEffectofpelvicmuscleexerciseontransientincontinenceduringpregnancyandafterbirthJObstetGynecol,,:ReillyETC,FreemanRM,WaterfieldMR,etalPreventionofpostpartumstressincontinenceinprimigravidaewithincreasedbladderneckmobility:arandomizedcontrolledtrailofantenatalpelvicfloorexerciseJBrJObstetGynecol,,:附录一常用压力性尿失禁辅助检查方法:.ICS小时尿垫试验方法:①病人无排尿②安放好已经称重的收集装置试验开始③分钟内喝ml无钠液体然后坐下或躺下④步行半小时包括上下一层楼梯⑤起立和坐下次⑥剧烈咳嗽次⑦原地跑分钟⑧弯腰拾小物体次⑨流动水中洗手分钟⑩小时终末去除收集装置并称重。结果判断:①尿垫增重﹥g为阳性②尿垫增重﹥g时注意有无称重误差、出汗和阴道分泌物③尿垫增重﹤g提示基本干燥或实验误差。.压力诱发试验患者仰卧双腿屈曲外展观察尿道口咳嗽或用力增加腹压同时尿液漏出腹压消失后漏尿也同时消失则为阳性。阴性者站立位再行检查。检查时应同时询问漏尿时或之前是否有尿急和排尿感若有则可能为急迫性尿失禁或合并有急迫性尿失禁。.膀胱颈抬举试验患者截石位先行压力诱发试验若为阳性则将中指及食指阴道插入患者阴道分别放在膀胱颈水平尿道两侧的阴道壁上嘱患者咳嗽或Valsalva动作增加腹压有尿液漏出时用手指向头腹侧抬举膀胱颈如漏尿停止则为阳性。提示:压力性尿失禁的发病机制与膀胱颈和近端尿道明显下移有关。注意:试验时不要压迫尿道否则会出现假阳性。.棉签试验截石位消毒后于尿道插入无菌棉签棉签前端应插过膀胱颈。无应力状态下和应力状态下棉签活动的角度超过°则提示膀胱颈过度活动。附录二排尿时间尿量尿急?漏尿?备注?饮水时间、类型和量早:中午:下午:午夜:排尿日记姓名:日期:附录三国际尿失禁咨询委员会尿失禁问卷表简表(ICIQSF)许多患者时常漏尿该表将用于调查尿失禁的发生率和尿失禁对患者的影响程度。仔细回想你近周来的症状尽可能回答以下问题。.您的出生日期:年月日.性别(在空格处打()男女.您漏尿的次数?(在一空格内打()从来不漏尿星期大约漏尿次或经常不到次一星期漏尿次或次每天大约漏尿次天漏尿数次一直漏尿.我们想知道您认为自己漏尿的量是多少?在通常情况下您的漏尿量是多少(不管您是否使用了防护用品)(在一空格内打()不漏尿少量漏尿中等量漏尿大量漏尿.总体上看漏尿对您日常生活影响程度如何?请在(表示没有影响)~(表示有很大影响)之间的某个数字上画圈没有影响有很大影响ICIQSF评分(把第、、个问题的分数相加):.什么时候发生漏尿?(请在与您情况相符合的那些空格打()从不漏尿未能到达厕所就会有尿液漏出在咳嗽或打喷嚏时漏尿在睡着时漏尿在活动或体育运动时漏尿在小便完和穿好衣服时漏尿在没有明显理由的情况下漏尿在所有时间内漏尿非常感谢您回答以上的问题!附录四常用压力性尿失禁的分型方法型(type)压力性尿失禁:典型压力性尿失禁病史但临床和尿动力学检查未能显示压力性尿失禁影像尿动力学示膀胱颈近端尿道位于耻骨联合下缘上方应力状态下膀胱颈近端尿道开放并有所下降。Ⅰ型:在应力状态下出现漏尿膀胱底部下移<cm。Ⅱ型:在应力状态下出现漏尿膀胱底部下移>cm。ⅡA型:膀胱底部下移在应力状态下出现者。ⅡB型:膀胱底部下移在静息状态下就出现者。Ⅲ型:在静息期膀胱充满时膀胱颈和近段尿道就已经处于开放状态可伴有或不伴有下移。Ⅱ型GSI与尿道过度移动有明显的关系。Ⅰ型和Ⅲ型GSI意味着不同程度的ISD。附录五盆腔脏器脱垂的顺序分期系统ICS分期分期脱垂脏器最远端:阴道前壁或后壁的最远点位置(Aa,Ap,Ba,Bp等部位标记点)脱垂脏器最远端:阴道顶端或是子宫颈(C点或D点)无脱垂:所有点在处女膜以上cm(=cm)无脱垂:阴道顶端或是子宫颈在处女膜上方等于tvl全长或者是在cm内Ⅰ所有点均距离处女膜cm以上(<cm)Ⅱ脱垂最远端在处女膜近端或远端cm内(>至<)Ⅲ脱垂最远端超出处女膜外cm小于cm(>但是<{tv–})Ⅳ脱垂最远端超出处女膜外cm阴道+宫颈完全外翻(≥{tv–})tvl=阴道总长度。版权许可。来源:盆腔脏器脱垂标准化术语StrohbehnKStandardizedterminologyofpelvicorganprolapseAUGSBull,,:–附录六常用压力性尿失禁手术并发症()TVTTOTTVTOBurchSlings术中并发症膀胱穿孔失血(ml)尿道损伤髂血管损伤其他术后并发症血肿吊带排斥吊带调整尿路感染发烧(>℃)尿潴留需留尿管>天排尿困难新发尿急附录七常用压力性尿失禁手术推荐程度表高度推荐推荐可选轻度盆底肌训练减肥米多君饮食调整其他药物中度盆底肌训练中段尿道吊带膀胱颈吊带术米多君Burch阴道壁悬吊术注射疗法阴道前壁修补MMK针刺悬吊重度中段尿道吊带膀胱颈吊带术Burch阴道壁悬吊术注射疗法人工尿道括约肌高度推荐推荐可选解剖型中段尿道吊带Burch阴道壁悬吊术膀胱颈吊带术针刺悬吊术MMK阴道前壁修补ISD型中段尿道吊带注射疗法膀胱颈吊带术人工尿道括约肌附录八压力性尿失禁诊治策略图附录九中英文词汇对照表ICSInternationalContinenceSociety国际尿控学会ICIInternationalconsultationonIncontinence国际尿控咨询委员会AUAAmericanUrologicalAssociation美国泌尿外科学会EAUEuropeanAssociationofUrology欧洲泌尿外科学会SUIStressUrinaryIncontinence压力性尿失禁POPpelvicorganprolapse盆腔脏器脱垂MUCPmaximumurethralclosepressure最大尿道闭合压ALPPabdominalleakpointpressure腹压漏尿点压PFMTpelvicfloormuscletraining盆底肌训练RCTsRandomizedcontrolledtrials随机对照研究TVTtensionfreevaginaltape无张力尿道中段吊带术BOObladderolowobstruction膀胱出口梗阻ISDintrinsicsphincterdeficiency尿道固有括约肌功能缺陷尿失禁病史体格检查确定诊断ICIQSF尿动力学程度诊断合并疾病诊断OAB逼尿肌受损POP可疑诊断先处理OAB药物治疗尿失禁同期手术抗尿失禁轻度中度重度分型诊断BOO先解除BOO手术治疗尿失禁重度受损轻度受损POP需手术POP无需手术非手术治疗手术治疗治疗有
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