Virtsankarkailu (naiset)

Käypä hoito
16.12.2011
Suomalaisen Lääkäriseuran Duodecimin ja Suomen Gynekologiyhdistyksen asettama työryhmä

Koosteet

Potilaalle

Keskeinen sisältö

  • Naisten virtsankarkailun esiintyvyys vaihtelee 5–58 %:n välillä (mediaani 28 %).
  • Virtsankarkailu jaotellaan ponnistus-, pakko- ja sekamuotoiseen karkailuun. Lisäksi virtsaummen yhteydessä voi esiintyä ylivuotokarkailua.
  • Virtsankarkailun perustutkimukset ja konservatiivinen hoito voidaan toteuttaa perusterveydenhuollossa.
  • Anamneesin apuvälineinä käytetään oireiden pisteytys- ja haitta-astelomakkeita.
  • Painonhallinta, lantionpohjan lihaskunnon ylläpito, tupakoinnin lopettaminen, ummetuksen hoito ja erityisesti 65 vuotta täyttäneillä fyysinen aktiivisuus ehkäisevät virtsankarkailua.
  • Lantionpohjan ohjattu lihasharjoittelu on vaikuttava hoito kaikissa virtsankarkailun muodoissa
  • Ponnistus- ja sekamuotoista virtsankarkailua voidaan hoitaa vähän kajoavilla nauhaleikkauksilla (TVT, TVT-O, TOT), ellei konservatiivinen hoito ole auttanut.

Tavoite

  • Tavoitteena on yhtenäistää naisten virtsankarkailun eli virtsainkontinenssin tutkimus- ja hoitokäytäntöjä avoterveydenhuollossa ja erikoissairaanhoidossa.

Kohderyhmä

  • Suosituksen kohderyhminä ovat avoterveydenhuollon ja erikoissairaanhoidon lääkärit ja muu hoitohenkilökunta, vanhusten hoitolaitosten henkilöstö ja terveydenhuollon päätöksentekijät.

Määritelmä ja aiheen rajaus

Taulukko 1. Naisen virtsankarkailun tyypit ja syntymekanismit «Hilton P, Dolan LM. Pathophysiology of urinary incontinence and pelvic organ prolapse. BJOG 2004;111 Suppl 1:5-9 »3, «Mostwin J, Bourcier A, Haab F ym. Pathophysiology of urinary incontinence, fecal incontinence and pelvic organ prolapse. Kirjassa: Abrams P, Cardozo L, Khoury S, Wein A (toim.). Incontinence. Health »4.
Virtsankarkailun tyyppiSyntymekanismiMahdollisia aiheuttajia
Ponnistusvirtsankarkailu
eli virtsan karkaaminen fyysisen rasituksen tai ponnistuksen (esim. yskäisy tai aivastus) yhteydessä
Virtsaputkea ympäröivien tukirakenteiden tai virtsaputken sulkijamekanismin heikkousLantionpohjan lihasten hermotushäiriö tai vamma: synnynnäinen tai ikääntymisen, synnytyksen, leikkauksen tai tapaturman aiheuttama
Sidekudosten heikkous: rotu, ikääntyminen, raskaudet tai hormonaaliset syyt
Elintavat: lihavuus, tupakointi
Pakkovirtsankarkailu
eli virtsan karkaaminen äkillisen virtsaamispakon yhteydessä samanaikaisesti virtsaamispakko-oireen kanssa tai heti sen jälkeen
Rakkolihaksen supistelu:
– neurogeeninen
Keskushermoston sairaus tai vamma, neuropatia, diabetes, psykosomaattiset tekijät
– ei-neurogeeninenInfektio (akuutti virtsatieinfektio tai toistuvat virtsatieinfektiot), kasvain, rakon seinämän sairaus, rakkokivi, atrofia, rakon nopea täyttyminen, elintavat
– idiopaattinen
Sekatyyppinen virtsankarkailu
eli yhtäaikainen ponnistus- ja pakkovirtsankarkailu
Ponnistus- ja pakkoinkontinenssin mekanismit yhdessäMainittujen aiheuttajien yhdistelmät
Ylivuotovirtsankarkailu
eli virtsan karkaaminen, johon liittyy virtsarakon akuutti tai krooninen tyhjenemishäiriö eli virtsaretentio
Heikentynyt virtsaamisheijasteHermoston sairaus tai vamma, leikkauksen jälkitila, lääkehoito
Mekaaninen esteKasvain, laskeuma, leikkauskomplikaatio (esim. tiukka nauhaleikkaus)
Fistelit ja anomaliatSynnynnäinen, toimenpiteestä johtuva tai anoksinen vaurioLeikkaus, sädehoito tai synnytykseen liittyvä vamma

Esiintyvyys ja ilmaantuvuus

Esiintyvyys neurologisten sairauksien yhteydessä

Taulukko 2. Virtsankarkailun esiintyvyys eräiden neurologisten sairauksien yhteydessä.
Neurologinen sairausVirtsankarkailua (%)Kirjallisuusviitteet
Akuutti tulehduksellinen demyelinoiva polyneuropatia (AIDP), Guillain–Barrén oireyhtymä (akuutti vaihe)Harvoin «Sakakibara R, Hattori T, Kuwabara S ym. Micturitional disturbance in patients with Guillain-Barré syndrome. J Neurol Neurosurg Psychiatry 1997;63:649-53 »35, «Zochodne DW. Autonomic involvement in Guillain-Barré syndrome: a review. Muscle Nerve 1994;17:1145-55 »36
Aivohalvaus
– akuutti vaihe40–60 « Thomas LH, Cross S, Barrett J ym. Treatment of urinary incontinence after stroke in adults. Cochrane Database Syst Rev 2008;1:CD004462 »25
– kotiutuminen sairaalasta25 « Thomas LH, Cross S, Barrett J ym. Treatment of urinary incontinence after stroke in adults. Cochrane Database Syst Rev 2008;1:CD004462 »25
– 12 kk sairastumisesta15 « Thomas LH, Cross S, Barrett J ym. Treatment of urinary incontinence after stroke in adults. Cochrane Database Syst Rev 2008;1:CD004462 »25
Dementia
– kotona asuvatMiehet 35
Naiset 37
«Ouslander JG, Zarit SH, Orr NK ym. Incontinence among elderly community-dwelling dementia patients. Characteristics, management, and impact on caregivers. J Am Geriatr Soc 1990;38:440-5 »26
– pitkäaikaishoidossa olevat78 «Hägglund D. A systematic literature review of incontinence care for persons with dementia: the research evidence. J Clin Nurs 2010;19:303-12 »27
Lannerangan välilevytyräHarvoin «Fraser S, Roberts L, Murphy E. Cauda equina syndrome: a literature review of its definition and clinical presentation. Arch Phys Med Rehabil 2009;90:1964-8 »33, «Fernández O. Mechanisms and current treatments of urogenital dysfunction in multiple sclerosis. J Neurol 2002;249:1-8 »34
Multippeliskleroosi19–72 «de Sèze M, Ruffion A, Denys P ym. The neurogenic bladder in multiple sclerosis: review of the literature and proposal of management guidelines. Mult Scler 2007;13:915-28 »28
Parkinsonin tautiMiehet 26
Naiset 28
«Sakakibara R, Uchiyama T, Yamanishi T ym. Genitourinary dysfunction in Parkinson's disease. Mov Disord 2010;25:2-12 »29

Riskitekijät

Taulukko 3. Virtsainkontinenssin riski- ja taustatekijöitä naisilla1).
TekijäRiskisuhde (95 %:n luottamusväli)Kirjallisuusviite
Ikä1.3 viittä ikävuotta kohti (1.2–1.5) «Brown JS, Seeley DG, Fong J ym. Urinary incontinence in older women: who is at risk? Study of Osteoporotic Fractures Research Group. Obstet Gynecol 1996;87:715-21 »37, «Zhu L, Lang J, Liu C ym. The epidemiological study of women with urinary incontinence and risk factors for stress urinary incontinence in China. Menopause 2009;16:831-6 »38
Ylipaino
– BMI vähintään 30 kg/m23.7 (2.0–6.7) «Uustal Fornell E, Wingren G, Kjølhede P. Factors associated with pelvic floor dysfunction with emphasis on urinary and fecal incontinence and genital prolapse: an epidemiological study. Acta Obstet Gy»39
– BMI vähintään 40 kg/m25.0 (3.4–7.3) «Hannestad YS, Rortveit G, Daltveit AK ym. Are smoking and other lifestyle factors associated with female urinary incontinence? The Norwegian EPINCONT Study. BJOG 2003;110:247-54 »40
Raskaus ja synnyttäneisyys2)Ikävakioimaton20–34-vuotiaat           «Rortveit G, Hannestad YS, Daltveit AK ym. Age- and type-dependent effects of parity on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynecol 2001;98:1004-10 »41, «Wesnes SL, Rortveit G, Bø K ym. Urinary incontinence during pregnancy. Obstet Gynecol 2007;109:922-8 »42
– 1 synnytys1.6 (1.5–1.8)2.2 (1.8–2.6)
– 2 synnytystä1.8 (1.6–1.9)2.4 (2.0–2.8)
– 3 synnytystä2.0 (1.8–2.2)2.4 (2.0–3.0)
– 4 synnytystä tai enemmän2.3 (2.1–2.5)3.3 (2.4.–4.4)
– keisarileikkaus verrattuna synnyttämättömiin1.5 (1.2–1.9) «Rortveit G, Daltveit AK, Hannestad YS ym. Urinary incontinence after vaginal delivery or cesarean section. N Engl J Med 2003;348:900-7 »43
– alatiesynnytys verrattuna keisarileikkaukseen1.7 (1.3–2.1)
Muut synnytykseen liittyvät tekijät
– syntymäpaino yli 4 000 g1.3 (1.2–1.5) «Rortveit G, Daltveit AK, Hannestad YS ym. Vaginal delivery parameters and urinary incontinence: the Norwegian EPINCONT study. Am J Obstet Gynecol 2003;189:1268-74 »44
– perätilasynnytys1.4 (1.1–1.7) «Rortveit G, Daltveit AK, Hannestad YS ym. Vaginal delivery parameters and urinary incontinence: the Norwegian EPINCONT study. Am J Obstet Gynecol 2003;189:1268-74 »44
– pihti- vs spontaani synnytys3.5 (1.1–11.4) «Arya LA, Jackson ND, Myers DL ym. Risk of new-onset urinary incontinence after forceps and vacuum delivery in primiparous women. Am J Obstet Gynecol 2001;185:1318-23; discussion 1323-4 »45
– pihti- vs imukuppisynnytys3.5 (0.7–16.1) «Arya LA, Jackson ND, Myers DL ym. Risk of new-onset urinary incontinence after forceps and vacuum delivery in primiparous women. Am J Obstet Gynecol 2001;185:1318-23; discussion 1323-4 »45
– hartiadystokia2.9 (1.1–7.7) «Hatem M, Pasquier JC, Fraser W ym. Factors associated with postpartum urinary/anal incontinence in primiparous women in Quebec. J Obstet Gynaecol Can 2007;29:232-9 »46
– pitkittynyt ponnistusvaihe1.7 (1.1–2.5) «Hatem M, Pasquier JC, Fraser W ym. Factors associated with postpartum urinary/anal incontinence in primiparous women in Quebec. J Obstet Gynaecol Can 2007;29:232-9 »46
– 3.–4. asteen repeämä4.0 (2.3–6.9) «Hatem M, Pasquier JC, Fraser W ym. Factors associated with postpartum urinary/anal incontinence in primiparous women in Quebec. J Obstet Gynaecol Can 2007;29:232-9 »46
Välilihan leikkaus vs ei leikkausta
– pakkovirtsankarkailu1.9 (1.2–2.9) «Baydock SA, Flood C, Schulz JA ym. Prevalence and risk factors for urinary and fecal incontinence four months after vaginal delivery. J Obstet Gynaecol Can 2009;31:36-41 »47
– välilihan leikkaus rutiinisti vs harkitusti0.9 (0.8–1.2) «Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2009;1:CD000081 »48
Kohdunpoisto «Brown JS, Sawaya G, Thom DH ym. Hysterectomy and urinary incontinence: a systematic review. Lancet 2000;356:535-9 »49
– ikävakioimaton1.4 (1.2–1.7)
– yli 60-vuotiaat1.6 (1.4–1.8)
– pakkovirtsankarkailu1.9 (1.4–2.6) «Holroyd-Leduc JM, Straus SE. Management of urinary incontinence in women: scientific review. JAMA 2004;291:986-95 »50
– riski joutua karkailun vuoksi leikkaushoitoon2.4 (2.3–2.5) «Altman D, Granath F, Cnattingius S ym. Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study. Lancet 2007;370:1494-9 »51
Perussairaudet, vähintään kaksi4.4 (2.5–7.7) «Holroyd-Leduc JM, Straus SE. Management of urinary incontinence in women: scientific review. JAMA 2004;291:986-95 »50
Diabetes «Ebbesen MH, Hannestad YS, Midthjell K ym. Diabetes and urinary incontinence - prevalence data from Norway. Acta Obstet Gynecol Scand 2007;86:1256-62 »52
– pakkokarkailu1.5 (1.0–2.2)
– sekamuotoinen karkailu1.3 (1.1–1.7)
– vaikea-asteinen karkailu1.5 (1.2–2.0)
Rotu ja perimä
musta vs valkoinen rotu
– ponnistuskarkailu0.4 (0.2–0.6) «Thom DH, van den Eeden SK, Ragins AI ym. Differences in prevalence of urinary incontinence by race/ethnicity. J Urol 2006;175:259-64 »53
– vaikea-asteinen karkailu0.5 (0.4–0.6) «Danforth KN, Townsend MK, Lifford K ym. Risk factors for urinary incontinence among middle-aged women. Am J Obstet Gynecol 2006;194:339-45 »54
aasialainen vs valkoinen rotu
– ponnistuskarkailu0.5 (0.3–0.9) «Thom DH, van den Eeden SK, Ragins AI ym. Differences in prevalence of urinary incontinence by race/ethnicity. J Urol 2006;175:259-64 »53
– vaikea-asteinen karkailu0.6 (0.5–0.7) «Danforth KN, Townsend MK, Lifford K ym. Risk factors for urinary incontinence among middle-aged women. Am J Obstet Gynecol 2006;194:339-45 »54
Äidin virtsankarkailuponnistusvirtsankarkailu 1.5 (1.3–1.8) «Hannestad YS, Lie RT, Rortveit G ym. Familial risk of urinary incontinence in women: population based cross sectional study. BMJ 2004;329:889-91 »55
sekamuotoinen virtsankarkailu 1.6 (1.2–2.0)
pakkovirtsankarkailu 1.8 (0.8–3.9)
Nuoremmilla sisarilla virtsankarkailuponnistusvirtsankarkailu 1.8 (1.3–2.3) «Hannestad YS, Lie RT, Rortveit G ym. Familial risk of urinary incontinence in women: population based cross sectional study. BMJ 2004;329:889-91 »55
sekamuotoinen virtsankarkailu 1.7 (1.1–2.8)
Virtsarakon laskeuma2.5 (1.5–4.2) «Holroyd-Leduc JM, Straus SE. Management of urinary incontinence in women: scientific review. JAMA 2004;291:986-95 »50
Kohdunlaskeuma4.1 (2.2–7.9) «Holroyd-Leduc JM, Straus SE. Management of urinary incontinence in women: scientific review. JAMA 2004;291:986-95 »50
Lantionpohjan lihasten heikkous3.4 (0.51–23) «Samuelsson E, Victor A, Svärdsudd K. Determinants of urinary incontinence in a population of young and middle-aged women. Acta Obstet Gynecol Scand 2000;79:208-15 »56
Toistuvat virtsatietulehdukset «Brown JS, Grady D, Ouslander JG ym. Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Heart & Estrogen/Progestin Replacement Study (HERS) Research Group. Obstet G»57
– sekamuotoinen virtsankarkailu2.4 (1.5–3.9)
– pakkovirtsankarkailu2.0 (1.1–3.6)
– ponnistus-
virtsankarkailu
1.5 (0.8–3.0)
Suolen toiminnan häiriöt
– ummetus tai ripuli2.0 (1.3–3.0) «van Beurden M, van Der Vange N, ten Kate FJ ym. Restricted surgical management of vulvar intraepithelial neoplasia 3: Focus on exclusion of invasion and on relief of symptoms. Int J Gynecol Cancer 199»58
– ulosteen karkailu5.8 (1.8–18.2) «Slieker-ten Hove MC, Pool-Goudzwaard AL, Eijkemans MJ ym. Prevalence of double incontinence, risks and influence on quality of life in a general female population. Neurourol Urodyn 2010;29:545-50 »59
Teen juonti yli 3 kuppia päivässä
– ponnistus-
virtsankarkailu
1.3 (1.1–1.5) «Hannestad YS, Rortveit G, Daltveit AK ym. Are smoking and other lifestyle factors associated with female urinary incontinence? The Norwegian EPINCONT Study. BJOG 2003;110:247-54 »40
– sekamuotoinen virtsankarkailu1.5 (1.3–1.8)
Kahvin juonti yli 3 kuppia päivässä
– ponnistus-
virtsankarkailu
1.2 (1.1–1.5) «Tomlinson BU, Dougherty MC, Pendergast JF ym. Dietary caffeine, fluid intake and urinary incontinence in older rural women. Int Urogynecol J Pelvic Floor Dysfunct 1999;10:22-8 »60
– sekamuotoinen virtsankarkailu0.7 (0.5–0.9)
Tupakointi yli 20 savuketta päivässä1.3 (1.1–1.6) «Hannestad YS, Rortveit G, Daltveit AK ym. Are smoking and other lifestyle factors associated with female urinary incontinence? The Norwegian EPINCONT Study. BJOG 2003;110:247-54 »40
yli 10 savuketta päivässäpakkovirtsankarkailu 1.7 (0.3-8.5)
ponnistuskarkailu 1.3 (0.6-2.8)
«Tähtinen RM, Auvinen A, Cartwright R ym. Smoking and bladder symptoms in women. Obstet Gynecol 2011;118:643-8 »61
Heikentynyt toimintakyky
– päivittäistoiminnot (ADL)2.3 (1.2–4.3) «Maggi S, Minicuci N, Langlois J ym. Prevalence rate of urinary incontinence in community-dwelling elderly individuals: the Veneto study. J Gerontol A Biol Sci Med Sci 2001;56:M14-8 »62
– pakko- tai sekamuotoinen virtsankarkailu3.6 (1.7–7.3) «Nuotio M, Jylhä M, Luukkaala T ym. Urinary incontinence in a Finnish population aged 70 and over. Prevalence of types, associated factors and self-reported treatments. Scand J Prim Health Care 2003;21»16
– ponnistus-
virtsankarkailu
0.8 (0.3–2.0)
Heikentynyt liikuntakyky
– poikkileikkausaineisto2.1 (1.2–3.9) «Maggi S, Minicuci N, Langlois J ym. Prevalence rate of urinary incontinence in community-dwelling elderly individuals: the Veneto study. J Gerontol A Biol Sci Med Sci 2001;56:M14-8 »62
– pitkittäisaineisto; lievä virtsankarkailu1.6 (1.1–2.2) «Jenkins KR, Fultz NH. Functional impairment as a risk factor for urinary incontinence among older Americans. Neurourol Urodyn 2005;24:51-5 »63
– pitkittäisaineisto; vaikea virtsankarkailu2.0 (1.1–3.5)
1) Suurin osa riski- ja taustatekijöitä koskevista tiedoista on saatu poikkileikkaustutkimuksista. Toistaiseksi on tehty hyvin vähän kontrolloituja tutkimuksia, jotka osoittaisivat, että riskitekijään kohdistuva interventio vähentäisi virtsankarkailun ilmaantuvuutta tai vaikeusastetta.
2) Synnytystä ja keisarileikkausta on verrattu synnyttämättömyyteen.
3) Vaikeusaste vaihtelee artikkeleittain.

Elintavat

Muut riskitekijät

Taulukko 4. Virtsankarkailua mahdollisesti aiheuttavia tai pahentavia lääkeaineita, jotka on syytä huomioida erityisesti iäkkäillä. Lääkeaineryhmät on lueteltu aakkosjärjestyksessä.
LääkeaineVaikutustapa
ACE-estäjätYskä, ponnistusvirtsankarkailu
Alfa-adrenergiset antagonistit
(esim. pratsosiini)
Vähentävät sileän lihaksen tonusta virtsaputkessa, ponnistusvirtsankarkailu
AntihistamiinitSekavuus
AntikolinergitTyhjenemisvaikeudet, virtsaumpi, ummetus, ylivuotovirtsankarkailu
Kognitiiviset häiriöt, WC:ssä käyntitaitojen heikentyminen
Asetyylikolinesteraasin estäjät
(Alzheimerin taudissa käytettävät)
Virtsarakon supistumisherkkyyden lisääntyminen, pakkovirtsankarkailu
BentsodiatsepiinitSekavuus, liikuntakyvyn heikentyminen
DiureetitVirtsanerityksen ja virtsamäärien lisääntyminen, pakkovirtsankarkailu
GabapentiiniTurvotukset, yöllinen polyuria
Sekavuus
KalsiumsalpaajatTyhjenemisvaikeudet, virtsaumpi, ummetus
LitiumPolyuria
OpiaatitTyhjenemisvaikeudet, virtsaumpi, ummetus, sekavuus, liikuntakyvyn heikentyminen
PsykoosilääkkeetAntikolinergivaikutukset
SSRI-lääkkeetKolinerginen, rakkosupistuksia lisäävä vaikutus
TulehduskipulääkkeetTurvotukset, yöllinen polyuria

Diagnostiikka

Perustutkimukset

Perustutkimukset haurailla tai monisairailla

Laboratoriotutkimukset

Täydentävät tutkimukset ja erotusdiagnostiikka

  • Täydentäviä tutkimuksia ovat kystoskopia, urodynaamiset mittaukset ja kuvantamistutkimukset.
  • Täydentäviä tutkimuksia tarvitaan (ks. Hoitokaavio «»1), kun
    • esiintyy epätyypillisiä oireita (esim. virtsarakon tyhjenemisvaikeuksia, ylivuotovirtsankarkailua, rakon ärsytysoireita) tai oireet ovat alkaneet äkillisesti
    • virtsankarkailun tyypin määrittäminen on kliinisesti hankalaa
    • todetaan oireileva kohdun tai emättimen laskeuma
    • vaste hoitoon on huono (lääkehoidon tehottomuus, leikkaushoidon jälkeen uusiutunut virtsankarkailu)
    • epäillään neurologista sairautta
    • epäillään virtsarakon sairautta (esim. interstitiaalinen kystiitti, rakkokivi tai -syöpä), alavatsan kasvainta (esim. munasarjakasvain, kookas myooma) tai fisteliä.
  • Ponnistusvirtsankarkailun leikkaushoitoon voidaan päätyä ilman täydentäviä tutkimuksia «Weber AM, Taylor RJ, Wei JT ym. The cost-effectiveness of preoperative testing (basic office assessment vs. urodynamics) for stress urinary incontinence in women. BJU Int 2002;89:356-63 »96, kun
    • potilas on alle 70-vuotias
    • potilaalle ei ole aikaisemmin tehty virtsankarkailuleikkausta
    • potilaalla ei ole todettu rakon toimintaan vaikuttavia perussairauksia eikä hän käytä rakon toimintaan vaikuttavia lääkkeitä
    • riskipisteet erottelupistelomakkeessa ovat alle 7
    • haitta-aste on yli 50 %
    • yskäisytestin tulos on positiivinen
    • virtsaamislistan mukainen rakon toiminnallinen tilavuus on yli 300 ml eikä todeta viitteitä rakon tyhjenemishäiriöstä.

Kystoskopia

Urodynaamiset mittaukset

Kuvantamistutkimukset

Ehkäisy

Hoito

Elintapamuutokset

Lantionpohjan lihasharjoittelu ja fysioterapia

Lääkehoito

  • Ks. Hoitokaavio «»1.
  • Virtsankarkailun lääkehoito riippuu karkailun tyypistä (taulukko « Virtsankarkailun lääkehoito.»5).
  • Uutena alkaneen virtsankarkailun taustalla voi olla äkillinen virtsatietulehdus.
    • Oireetonta bakteerivirtsaisuutta ei tarvitse hoitaa.

Pakkovirtsankarkailun lääkehoito

Taulukko 5. Virtsankarkailun lääkehoito.
PakkovirtsankarkailuValmistemuotoAnnostusKommentteja
OksibutyniiniLyhytvaikutteinen tabletti3 mg x 2–3
5 mg x 2–3
Enemmän haittavaikutuksia (lähinnä suun kuivuminen) kuin muilla valmistemuodoilla «Hay-Smith J, Herbison P, Ellis G ym. Which anticholinergic drug for overactive bladder symptoms in adults. Cochrane Database Syst Rev 2005;3:CD005429 »123
Pitkävaikutteinen tabletti (tyhjään mahaan)10 mg x 1Paremmin siedetty kuin lyhytvaikutteinen «Hay-Smith J, Herbison P, Ellis G ym. Which anticholinergic drug for overactive bladder symptoms in adults. Cochrane Database Syst Rev 2005;3:CD005429 »123
Laastari, vaihto kahdesti viikossa3.9 mg/vrkIhon kautta annosteltava oksibutyniini aiheuttaa vähiten suun kuivumista; ihoärsytystä ilmenee 10–16 %:lla käyttäjistä «Dmochowski RR, Davila GW, Zinner NR ym. Efficacy and safety of transdermal oxybutynin in patients with urge and mixed urinary incontinence. J Urol 2002;168:580-6 »136, «Dmochowski RR, Sand PK, Zinner NR ym. Comparative efficacy and safety of transdermal oxybutynin and oral tolterodine versus placebo in previously treated patients with urge and mixed urinary incontine»137
TolterodiiniLyhytvaikutteinen tabletti
Pitkävaikutteinen tabletti
2 mg x 2
4 mg x 1
Pitkävaikutteisella jonkin verran vähemmän haittavaikutuksia kuin lyhyt- tai pitkävaikutteisella oksibutyniinilla; ei eroa oksibutyniinin transdermaaliseen käyttöön «Hay-Smith J, Herbison P, Ellis G ym. Which anticholinergic drug for overactive bladder symptoms in adults. Cochrane Database Syst Rev 2005;3:CD005429 »123
TrospiumkloridiTabletti20 mg x 2Vähemmän keskushermostovaikutuksia kuin oksibutyniinilla ja tolterodiinilla «Diefenbach K, Arold G, Wollny A ym. Effects on sleep of anticholinergics used for overactive bladder treatment in healthy volunteers aged > or = 50 years. BJU Int 2005;95:346-9 »138, «Staskin DR, Harnett MD. Effect of trospium chloride on somnolence and sleepiness in patients with overactive bladder. Curr Urol Rep 2004;5:423-6 »139
Pitkävaikutteinen tabletti60 mg x 1
SolifenasiiniTablettiAloitusannos 5 mg x 1; suurennetaan tarvittaessa määrään 10 mg x 1
DarifenasiiniTablettiAloitusannos 7.5 mg x 1; suurennetaan tarvittaessa määrään 15 mg x 1
FesoterodiiniTablettiAloitusannos 4 mg x 1; suurennetaan tarvittaessa määrään 8 mg x 1Sama vaikuttava metaboliitti, 5-hydroksimetyyli tolterodiini (5-HMT), kuin tolterodiinilla.
Fesoterodiini 8 mg tehokkaampi pakkovirtsankarkailussa kuin tolterodiini 4 mg «Nabi G, Cody JD, Ellis G ym. Anticholinergic drugs versus placebo for overactive bladder syndrome in adults. Cochrane Database Syst Rev 2006;4:CD003781 »140, «Herschorn S, Swift S, Guan Z ym. Comparison of fesoterodine and tolterodine extended release for the treatment of overactive bladder: a head-to-head placebo-controlled trial. BJU Int 2010;105:58-66 »141
EstrogeenipaikallishoitovalmisteetPaikallinen ärsytys, kutina ja kirvely lähinnä hoidon aloitusvaiheessa; ei systeemisiä haittavaikutuksia «Emättimeen annosteltava paikallinen estrogeenihoito ilmeisesti lievittää pakkovirtsankarkailun oireita vaihdevuosi-iän ylittäneillä naisilla.»B
EstradioliEmätintabletti10 µg kahdesti viikossa
3 kk:n välein vaihdettava rengas7.5 µg/vrk
EstroniVoide 0.1 mg/g,
asetin,
emätinpuikko 0.5 mg
Kahtena iltana viikossa
Ponnistusvirtsankarkailu
DuloksetiiniTablettiAloitusannos 20 mg x 2
(2 viikon ajan), hoitoannos 40 mg x 2
Haittavaikutuksina pahoinvointi varsinkin alussa, verenpaineen nousu ja serotoniinioireyhtymän riski; ei saa käyttää siprofloksasiinin, fluvoksamiinin ja enoksasiinin käytön yhteydessä

Hauraiden, monisairaiden ja muistihäiriöisten lääkehoito

Muut hoidot

Ponnistusvirtsankarkailun lääkehoito

Kirurginen hoito ponnistusvirtsankarkailussa

Retropubiset nauhaleikkaukset (TVT)

Obturator-kuopan kautta tehtävät nauhaleikkaukset (TOT, TVT-O)

Nauhaleikkauksen yhdistäminen laskeumaleikkauksiin

Mininauhat

Muut leikkaukset

Pakkovirtsankarkailun kirurginen hoito

Virtsankarkailun hoitojen taloudellinen arviointi

  • Virtsankarkailusta aiheutuu kustannuksia sekä potilaalle että yhteiskunnalle.
  • Taloudellinen arviointi tulisi tehdä yhteiskunnan näkökulmasta siten, että huomioidaan kaikki virtsankarkailuun liittyvät kustannukset ja resurssien käyttö:
    • lääkärissä käynnit
    • diagnostiset toimenpiteet
    • hoitotoimenpiteet
    • apuvälineet
    • lääkkeet ja muu konservatiivinen (kajoamaton) hoito, kuten fysioterapia
    • tuottavuuskustannukset (työstä poissaolosta aiheutuva tuotannon menetys).
  • Kustannus-utiliteettianalyysi (kustannukset/QALY, quality-adjusted life year) on suositeltavin vaihtoehto taloudellisen arvioinnin menetelmäksi, ja se sopii hyvin myös virtsankarkailun hoitomuotojen kustannusvaikuttavuuden vertailuun, sillä se huomioi hoidon vaikutuksen potilaan terveyteen liittyvään elämänlaatuun.
  • Kustannusvaikuttavuudelle ei ole Suomessa määritelty kynnysarvoa, mutta esimerkiksi Englannissa National Institute for Health and Clinical Excellence (NICE) on määritellyt, että yhteiskunta on valmis maksamaan yhdestä lisä-QALY:stä noin 30 000 puntaa (34 800 €).
  • Muissa maissa tehtyjen virtsankarkailun hoitojen kustannusarvioiden vertailu Suomen tilanteeseen on hankalaa, koska eri maiden terveydenhuoltojärjestelmät, hinnoittelutavat ja resurssien käyttö ovat erilaiset.
  • Pitkäaikaisessa laitoshoidossa olevien virtsankarkailu vie paljon henkilöresursseja ja aiheuttaa siten merkittävän osan laitoshoidon kokonaiskustannuksista.
  • Lisätietoa virtsankarkailun taloudellisten arviointien tulkinnasta on sähköisessä tausta-aineistossa «Taloudellinen arviointi ja virtsankarkailu»27.

Apuvälineet

Iäkkäiden hoidon erityispiirteet

Uusiutuneen ponnistusvirtsankarkailun leikkaushoito

Hoidon porrastus ja seuranta

Suomalaisen Lääkäriseuran Duodecimin ja Suomen Gynekologiyhdistyksen asettama työryhmä

Virtsankarkailu (naiset) -suosituksen historiatiedot «Virtsankarkailu (naiset), Käypä hoito -suosituksen historiatiedot»28

Puheenjohtaja:

Pentti Kiilholma, naistentautien ja synnytysopin dosentti, hallinnollinen osastonylilääkäri (eläkkeellä); Turun yliopisto ja TYKS:n naistenklinikka

Kokoava kirjoittaja:

Seija Ala-Nissilä, LT, naistentautien ja synnytysten sekä gynekologisen endoskopian erikoislääkäri; TYKS:n naistenklinikka

Jäsenet:

Olavi Airaksinen, fysiatrian dosentti, ylilääkäri, fysiatrian erikoislääkäri, kivunhoidon ja kuntoutuksen erityispätevyys; KYS:n fysiatrian klinikka

Heidi Alenius, LL, yleislääketieteen erikoislääkäri, lääkäri-toimittaja; Lempäälän terveyskeskus ja Kustannus Oy Duodecimin Lääkärin tietokannat

Pauliina Aukee, LT, osastonylilääkäri, synnytysten ja naistentautien erikoislääkäri; Keski-Suomen keskussairaalan synnytys- ja naistentautienyksikkö ja lantionpohjan tutkimus- ja hoitoyksikkö

Aarre Kivelä, LT, osastonylilääkäri (eläkkeellä); OYS:n naistenklinikka

Tomi Mikkola, dosentti, naistentautien erikoislääkäri; HYKS:n naistenklinikka

Maria Nuotio, LT, ylilääkäri, geriatrian erikoislääkäri; Seinäjoen keskussairaala

Ilkka Perttilä, LL, urologi, osastonlääkäri; HYKS:n urologian klinikka

Juhani Ruutiainen, neurologian dosentti, vastaava ylilääkäri, kuntoutuksen erityispätevyys; Suomen MS-liitto

Pirjo Räsänen, dosentti, FT, erikoissairaanhoitaja, uroterapeutti, erikoistutkija; HUS ja Terveyden ja hyvinvoinnin laitos, Finohta

Minna Törnävä, fysioterapeutti, seksuaaliterapeutti (NACS), TtK; TAYS:n fysiatrian yksikkö

Antti Valpas, LT, naistentautien erikoislääkäri, ylilääkäri; Etelä-Karjalan keskussairaala

Piia Vuorela, LT, dosentti, synnytys- ja naistentautiopin erikoislääkäri, tutkijalääkäri; Biomedicum Helsinki (Käypä hoito -toimittaja)

Sidonnaisuudet

Olavi Airaksinen: Koulutus-, tutkimus- ja konsultaatioyhteistyötä terveydenhuoltoalan yritysten ja yhteisöjen sekä lääkealan yritysten kanssa (mm. MSD, Leiras, Mundipharma, GSK, Novartis, Pfizer, Amgen, Abbott, Lilly, Orion, Meda Oy, Pierre Fabre Laboratories, Parexel, TFS trials, Smedrud, Secret Files, Mega Elektronics, Fysioline, St Jude Medical Finland, Respecta Oy, HLD Oy). Luentoja, asiantuntijalausuntoja, konsultaatiotehtäviä sekä kliinisten tutkimusten suunnittelua, koordinaatiota ja käytännön suorittamista. Osallistunut kansainvälisiin kongresseihin yllä mainittujen yritysten kutsumana.

Seija Ala-Nissilä: Osallistunut ulkomaiseen kongressiin (Astellas) ja koulutustilaisuuteen (Upviser). Toimii asiantuntijana lääkealan yritykselle (Pfizer).

Heidi Alenius: Ei sidonnaisuuksia.

Pauliina Aukee: Osallistunut lääkealan yrityksen kustantamana ulkomaiseen kongressiin (Orion) ja ulkomaiseen koulutukseen (Astellas). Toiminut asiantuntijana hoitotarvikevalmistajalle (SCA Oy).

Pentti Kiilholma: Toiminut asiantuntijana lääke- ja hoitotarvikealan yrityksille (SCA, Pfizer). Luennoinut lääkealan yritysten koulutuksissa (Pfizer, Astellas, Gynecare, Bard, Upviser). Osallistunut lääkealan yritysten koulutusten suunnitteluun (Pfizer, Astellas, Gynecare, Bard, Upviser). Osallistunut ulkomaisiin koulutustilaisuuksiin lääkealan yritysten rahoittamana (Pfizer, Astellas, Gynecare, Bard, Upviser).

Aarre Kivelä: Ulkomaan kongressimatka (Astellas Pharma).

Tomi Mikkola: Luennoisijana lääkealan yritysten kutsusta ja saanut palkkion (Astellas, Bayer, Johnson&Johnson, Novo Nordisk, Pfizer). Osallistunut kongressiin lääkealan yritysten rahoittamana (Astellas, Bayer, Novo Nordisk). Antanut asiantuntija-apua lääkealan yrityksille (Astellas, Bayer).

Maria Nuotio: Osallistunut lääkealan yrityksen järjestämän koulutustilaisuuden suunnitteluun (Astellas Pharma, Pfizer). Antanut asiantuntija-apua terveydenhuollon ja lääkealan yritykselle (Astellas Pharma, Pfizer).

Ilkka Perttilä: Toistuvia luentoja eri terveydenhuollon ja/tai lääkealan yrityksen koulutuksissa (Allergan Norden, Pfizer Oy). Osallistunut terveydenhuollon ja/tai lääkealan yrityksen koulutusten suunnitteluun (Allergan Norden, Astellas Pharma). Ulkomaan kongressimatka terveydenhuollon ja/tai lääkealan yritysten rahoittamana (Allergan Norden, Astellas Pharma, Pfizer Oy). Toiminut lääkealan yrityksen asiantuntijana (Allergan Norden, Astellas Pharma).

Juhani Ruutiainen: Kutsuttuna luennoitsijana ja asiantuntijana lääkealan yrityksen koulutuksessa (Allergen Norden).

Pirjo Räsänen: Ei sidonnaisuuksia.

Minna Törnävä: Ei sidonnaisuuksia.

Antti Valpas: Kutsuttuna luennoitsijana ja asiantuntijana koulutustilaisuuksien suunnittelussa (Pfizer, Astellas Pharma). Advisory Board (Pfizer, Astellas Pharma).

Piia Vuorela: Ei sidonnaisuuksia.

Vastuun rajaus

Käypä hoito -suositukset ovat parhaiden asiantuntijoiden laatimia yhteenvetoja yksittäisten sairauksien diagnostiikan ja hoidon vaikuttavuudesta. Ne eivät korvaa lääkärin tai muun terveydenhuollon ammattilaisen omaa arviota yksittäisen potilaan parhaasta mahdollisesta diagnostiikasta, hoidosta ja kuntoutuksesta hoitopäätöksiä tehtäessä.

Tiedonhakukäytäntö

Käypä hoito -suositukset tehdään näyttöön perustuvan lääketieteen (EBM) periaatteilla. Lue lisää artikkelista nix01853

Kirjallisuutta

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