女性排尿障礙之探討

Dysfuntional Voiding and Bladder Outlet Obstruction in Women

許多研究顯示膀脫、尿道的疾病會導致心理、社會及生理的問題;而有趣的是這些問題也會影響疾病的嚴重度及疾病治療的進展(Van kerrebroeck et al,2003)。大約有二萬至二百萬的美國婦女因為持續性的慢性膀胱衰弱問題感到挫折和沮喪，但是這些問題卻經常干擾婦女們正常的生活如個人的衛生，減少社交機會和性生活等等（Blavivas et al 1997）。但式在泌尿科門診卻很少聽見婦女提出此常見的疾病，究其原因是婦女病患把這問題視為是一種自然老化的現象或是羞于啟口的問題。而此錯誤的觀念將造成她們的疾病情形越來越嚴重，甚至於有一些患者不敢在出遠門或者從事戶外活動，嚴重影響其身心的健康。

About 20,000 to 2 million American women suffered from chronic voiding dysfunction. Female voiding dysfunction involves bladder pain syndrome, chronic and unremitting bladder problems, major reconstruction and female geriatric problems.Urinary incontinence, impaired detrusor contractility, cystitis and bladder outlet obstruction remain the major modules of female voiding dysfunction. The evaluation of female voiding dysfunction includes complete history and physical examination, past medical history, urinalysis, voiding diary, pad test, post void residual urine, uroflowmetry, cystoscopy, and urodynamic studies.Urinary incontinence is a devastating medical and social problem and the incidence is increasing in the United States. Urethral hypermobility and intrinsic sphincter deficiency are the causes of urinary incontinence. Although intrinsic sphincter muscle deficiency can result in stress urinary incontinence, impaired detrusor contractility is the common causes of overflow and urge type of urinary incontinence.The treatment for urinary incontinence consists of: (1) behavioral management including bladder training, pelvic floor muscle exercise, biofeedback, electrical stimulation and pessaries, (2) medical management using anticholinergic medication, tricyclic drugs, αadrenergic agonist and estrogen. (3) Surgical management such as bladder neck suspension, pubovaginal sling procedure, vaginal approach (Raz, Peyrera, Gittes and Stamey procedures), laparoscopic surgery, periurethral injectable agents, and artificial urinary sphincter.Impaired detrusor contractility is an increasingly condition in the geriatric people and in patients with neurological diseases, and diabetes mellitus. Clinically, effective treatment for impaired detrusor contractility is limited. Intermittent or indwelling catheterization is the most common treatment but is not convenient for the patients and is just circumvention of the problem. Bladder reconstitution using intestine or biomaterials may be helpful for the management of impaired detrusor contractility. Bladder outlet obstruction is classified as (1) structural obstruction including urethral stricture, pelvic organ prolapse, tumor compression, urethral diverticulum, and postoperative scaring or contracture, (2) functional obstruction with difficulty in the relaxation of bladder neck or urethral sphincter during voiding. The management for bladder outlet obstruction consists of surgery for structural obstruction, and sympathetic blocking, bladder neck surgery, electrical stimulation, biofeedback, and medical treatment for functional obstruction. We believe that treatment of the underlying pathophysiology facilitates better treatment of symptoms. In the future, we hope the combination of basic research and clinical medicine should be able to resolve most of the voiding dysfunction problems in women.