尿失禁保守治疗之种类及选择课件

尿失禁保守治療之種類及選擇 蔡娟秀 慈濟技術學院 護理系 慈濟醫院排尿障礙治療中心 中華民國 九十二 年 八 月 十 日 尿失禁的保守療法 n以非藥物及手術的方式，改善尿失禁 n又稱為行為治療 n常見的治療方式包含 生活型態改變及行為重建 骨盆底肌肉運動 排尿訓練 電刺激 輔助控尿的醫材使用 選擇保守治療影響因素 n尿失禁與骨盆底鬆弛之嚴重度 n病人之認知狀態及動機 n骨盆底肌肉之功能及隨意收縮之能力 n活動及日常生活自理能力 病患評估 神經肌肉功能認知功能 環境及輔助用物 泌尿系統功能 History Onset and clinical course Frequency and volume of accidents Circumstance of causing urine loss Bladder habits Daily fluid intake Self-management technique Urinary symptoms and bowel habits Related medical diagnosis and medication Pelvic examination nAtrophic changes nVaginitis nCystocele nRectocele nUterine prolapse nLaxity and Levator ani structure Functional assessment ADL function. Mobility and toileting ability Mental and cognitive status Environmental Assessment nThe distance to reach the toilet nAny barrier between the clients usual location and the toilet: poor lighting, furniture or other objects, steps nThe size of the bathroom nThe toilet height nThe presence or absence of grab bars nThe availability of caregiver or nursing staff assistance nThe availability of emergency call Lifestyle Modification 生活型態改變及行為重建 nPosture correction nSmoke cessation nWeight reduction nGood bowel habits nCaffeine reduction nDietary and fluid modification 骨盆底肌肉訓練 n個別指導 n團體指導 n居家訓練 n生理回饋輔助訓練 n陰道錐重力訓練 n運動器材輔助訓練 骨盆底肌肉運動訓練之選擇 骨盆底肌肉力量 23 displacenoneFinger- tip Whole finger Pulled in Digital Examination nWorth(1986) methods: one finger 123 pressureslightmoderatefirm durationnone 34 + ribbingsoftNot very rib ribbing The P.E.R.F.E.C.T. Scheme nP/E/R/F n2/3/4/6 P=Power E=Endurance R=Repetitions F=Fast ECT=Every Contraction timed Power Description 0Nil 1Flicker 2Weak 3Moderate 4Good 5Strong Laycock, J., & Jerwood, D., 2001 單純骨盆底肌肉訓練 nUsed of stress, urge, and mixed UI, cognitively intact and highly motivated nAble to perform isolated PFM contraction nRegular exercise with stress strategy (knack) and urge strategy 椅子及啞鈴輔助訓練 PFM Exercise 治療球輔助訓練 PFM Exercise Biofeedback nUse electronic or mechanical instruments to display visual or auditory information about neuromuscular or bladder activity nUI patients, able to interpret analog or digital signals, motivated, with very weak PFM or unable to preformed isolated contraction 生理回饋輔助骨盆底肌肉訓練 Electrical Stimulation nApplication of electrical current to sacral and pudendal afferent fibers through vaginal, anal, or surface electrodes nUI patients who are highly motivated, useful in weak PFM nContraindication: diminished sensory perception, urinary retention, moderate to severe prolapse, cardiac arrhythmia, pacemaker user 骨盆底肌肉電刺激 最佳雙部位雙頻肌肉電刺激儀 Two channels : Channel 1 vaginal / penile Channel 2 anal / IVES Vaginal Weight Training nActive retention of increasing weights, typically twice a day nUI patient, cognitively intact, able to stand, have sufficient vaginal vault and introitous to retain cone, highly motivated nContraindicated in women with moderate-to severe prolapse 排尿訓練 nBladder retraining nHabit training nTimed voiding nPrompted voiding 病患評估 神經肌肉功能認知功能 環境及輔助用物 泌尿系統功能 時 間喝水量及 種類 解尿量 漏尿漏尿時情況 小中大活動尿急感 Bladder Diary範例 膀胱訓練之選擇 病患是否能感覺到尿急 或是來不及上廁所 是 PME及 膀胱訓練 否 Immobility 三天 Prompted voiding 認知缺損 50%以上時間 仍失禁 Time voiding 60%以上時間仍失禁 使用尿布或其他器具 60%反應正確 否 Bladder Retraining nStress, urge, mixed UI who are cognitively intact, able to toilet, motivated nScheduled toileting with progressive voiding intervals Teaching of urge control strategies Self-monitoring Reinforcement techniques Timed Voiding nStress, urge or mixed UI and physical impairment, or patient with infrequent or irregular voiding pattern nToileting on a fixed schedule, typically every two hours during waking hours Habit training nStress, mixed, urge UI with cognitive or physical impairment nScheduled toileting, voiding intervals adjusted based on the individuals voiding pattern Prompted Voiding nUsed for UI in patients who are functionally able to use a toilet or commode, needed assistance with primary caregiver nUsed operant learning theory Devices and absorbent Products nIntravaginal support device nExternal occlusive devices nIntraurethral occlusive devices nExternal collection devices nUrethral catheters nCommode and urinals nPads and pants Pessary Device and Pads 保守治療之施行 n所有的治療都須先排除急性泌尿道方面的疾 病方可執行 n保守治療是依循行為治療之原則，所以衛教 良好的排尿、飲水習慣及姿勢矯正為首務 n如果是單純因為骨盆底肌肉鬆弛而造成漏尿 或脫垂之情形，則以骨盆底肌肉運動為主 n如果已經造成頻尿或急尿而漏尿之現象，則 需加上膀胱訓練及喝水方面的衛教 Conclusions nFirst line management option nWho will benefit from behavioral therapy and who wont? nResearch to answer this question is lacking Sampselle, C. M. AJN, March 2003 Supplement, 9-19. 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