대한배뇨장애요실금학회지 J Korean Continence Soc 2009;13:37-44 원저 과민성방광여성에서나이에따른배뇨형태의변화 전남대학교의과대학비뇨기과학교실 Age Related Changes of Voiding Patterns in Women with Overactive Bladder Ho Suck Chung, Jun Seok Kim, Sun-Ouck Kim, Hee Sun Kim, Dongdeuk Kwon, Kwangsung Park, Soo Bang Ryu Department of Urology, Chonnam National University Medical School, Gwangju, Korea Purpose: We tried to discover the voiding patterns, which was diurnal & nocturnal urinary volume and voiding frequencies in women with overactive bladder (OAB). Materials and Methods: All voided volumes, times and frequencies were recorded in 249 women with overactive bladder. The subjects age related changes in bladder capacity, urinary volume and frequency were evaluated. The causes of nocturnal urinary frequency and its increase with age in older women with OAB were evaluated using 3 days of voiding diaries. Nocturia was devided into three types: nocturnal polyuria, decreased nocturnal bladder capacity and mixed type. Results: Total voided volume, daytime urine volume, functional bladder capacity were decreased with the age. Nocturnal urine volume and nocturnal urinary frequency were increased with age. Nocturnal polyuria was the major cause for nocturia, and mixed type was increased with age. Conclusions: Voiding symptoms as well as storage symptoms were increased with age in OAB female. In most cases, nocturia was caused by nocturnal polyuria. (J Korean Continence Soc 2009;13:37-44) Key Words: Overactive bladder, Female, Aging 1) 서 여성의하부요로증상중에서과민성방광은요실금과더불어생활에불편을야기하는대표적인질환이다. 2002년 International Continence Society (ICS) 는과 접수일자 : 2009 년 4 월 9 일수정일자 : 2009 년 5 월 7 일채택일자 : 2009 년 5 월 19 일교신저자 : 김선옥, 전남대학교의과대학비뇨기과학교실광주시동구학동 8 번지우 501-757 Tel: 062-220-6703, Fax: 062-227-1643 E-mail: seinsena@hanmail.net 론 민성방광을절박성요실금 (urge incontinence) 유무에관계없이요절박 (urgency) 이있는증상군으로, 대게빈뇨와야간뇨를동반하는것으로정의하였다 (1). 과민성방광의유병률은보고자마다다양한데미국에서는 18세이상인구의약 16.5%, 유럽에서는 40세이상의약 16.6% 에해당하는높은유병률을보이고있다 (2,3). 과민성방광은남성에비하여여성에서더욱유병률이높으며연령이증가할수록과민성방광의발생위험율이높아진다고한다. Wagner 등 (4) 은 30 60세연령군에서남성은 5.7%, 여성은 24.5% 를나타냈고 60세이상에서는남성의 14.5%, 여성의 31.5% 가과민 Vol. 13, No. 1, 2009 37
Table 1. Definitions in the classification and etiology of nocturia NUV (Nocturnal urine volume) Nightly voided volume plus first morning voided volume FBC (Functional bladder capacity) Largest single recorded voided volume from 24hr diary Ni (Nocturia index) NUV/FBC ANV (Actual number of nightly voids) Recored from voiding diary PNV (Predicted number of nightly voids) Ni-1 NBCi (Nocturnal bladder capacity index) ANV-PNV NPi (Nocturnal polyuria index) NUV/24hr total voided volume 성방광증상을보여남녀모두나이가증가함에따라그유병률은증가하며여성에서더욱이환율이높음을보여주었다. 17,000여명의대단위유럽연구에서는 40세이상일반인의 12 22% 가과민성방광증상을나타내고 75세이상에서는 30 40% 의이환율을나타내연령의증가에따른그유병률의증가를보고하였다 (5). 이에따라연령증가에따른과민성방광환자의배뇨형태를면밀히파악하고그에따른적절한치료를모색할필요가있다. 그러나여성에서과민성방광증상을보이는환자의배뇨형태에대한연구는아직부족한실정으로저자들은과민성방광환자의연령증가에따른배뇨형태를비교분석하고자하였다. 대상및방법 1. 연구대상 2007년 1월부터 2008년 5월까지절박뇨, 빈뇨, 야간뇨등의하부요로증상을주소로내원한 30세이상의여성중과민성방광증상을보이는 320명을대상으로하였다. 대상환자는병력청취, 신체검사, 신경학적검사및소변검사를시행하여활동성요로감염, 0.5cm 이상요도카룬클 (caruncle), 이전의신경인성방광의병력이있거나의심되는환자는제외하였다. 고혈압등으로알파차단제를복용하거나기타중증질환과만성질환으로약물치료중인환자및이전에항요실금수술또는골반수술의기왕력이있거나골반장기탈출증, 요도협착등해부학적이상의가능성이있는환자도제외하였다. 2. 연구방법문진을통하여대상군의주배뇨증상과고혈압, 당뇨, 심장및신장질환, 정신질환, 복용중인약물, 수면습관, 요로계를포함한손상및감염의병력에대하여조사하였으며 3일간의배뇨일지와국제전립선증상점수 (International Prostate Symptom Score; IPSS) 를작성하도록하였고요속검사와배뇨후잔뇨량을측정하였다. 배뇨일지에서배뇨시간, 배뇨량, 하루동안총배뇨량, 취침시간및기상시간을기재하도록하였고주간및야간배뇨의횟수, 기능적방광용적, 주간및야간배뇨량을확인하였다. 아침에잠에서깨어난후 1시간이내에배뇨한것은야간배뇨량에포함시켰으나야간배뇨횟수에는포함시키지않았으며기능적방광용적은하루중에최대로배뇨한양으로정의하였다. 배뇨일지분석시모든조사항목에서 3일간값의평균치를구하였다. 야간뇨의원인에대한분석시야간방광용적지수 (nocturnal bladder capacity index) 를실제야간빈뇨횟수 (actual number of nightly voids) 와예측야간빈뇨횟수 (predicted number of nightly voids) 의차이로정의하였을때 0 이상을방광용적감소군으로분류하였다. 이때예측야간빈뇨횟수는야간빈뇨지수에서 1을뺀값이며야간빈뇨지수 (nocturia index) 는기능적방광용적으로야간배뇨량을나눈값으로하였다. 하루배뇨량중에서야간배뇨량이 35% 이상일때는야간다뇨군 (nocturnal polyuria), 두가지를동시에가지고있는군은혼합성 (mixed type), 그리고하루총배뇨량이 2,500ml 이상인군은다뇨 (polyuria) 로분류하였다 (Table 1). 38 대한배뇨장애요실금학회지
과민성방광여성에서나이에따른배뇨형태의변화 3. 통계처리 연령의증가에따른배뇨양상의비교에있어서통계학적비교는분산분석과 Scheffe's test를이용하였으며 p-value가 0.05 미만인경우에의의가있는것으로판 Table 2. Patients characteristics and comorbidities Patients characteristics (n=249) mean±se (%) Age (years) 56.5±13.2 Duration of symptom (months) 29.2±18.9 Menopausal stage (n) 37 hormonal replacement therapy (n) 15 Hysterectomy (n) 9 Additional combined disease (n=69) hypertension 38 (15.2%) diabetes mellitus 13 (5.2%) cardiovascular disease 11 (4.4%) others 7 (2.8%) IPSS-total 14.5±3.8 voiding symptoms 9.5±3.3 storage symptoms 4.9±0.6 Maximal flow rate (ml/sec) 18.88±2.35 Residual urine (ml) 30.98±9.02 IPSS: International Prostate Symptom Score 단하였다. 결과과민성방광환자 320명의여성중완전한배뇨일지분석이가능하였던 249명을대상으로분석하였다. 대상환자들의나이는 56.5±13.2세로 29.2±18.9개월의증상을보였으며동반질환으로고혈압은 38명 (15.2%), 당뇨는 13명 (5.2%), 심혈관질환은 11명 (4.4%) 그리고기타질환은 7명 (2.8%) 에서관찰되었다 (Table 2). 연령이증가함에따라총배뇨량, 주간배뇨량과기능적방광용적감소하였으며야간배뇨량과야간배뇨횟수가증가하였고 (p<0.05) 주간배뇨횟수는큰차이를보이지않았다 (p>0.05) (Table 3). 야간뇨의원인은야간다뇨, 야간방광용적감소, 혼합형, 다뇨순으로관찰되었으며혼합형은연령이증가할수록그비율이높아졌다 (p<0.05) (Table 4). 1. 연령변화에따른과민성방광및임상증상의변화대상환자들의주배뇨증상및 IPSS 분석을통하여, 연령이증가함에따라야간뇨를포함한자극증상뿐 Table 3. Age related change in the IPSS that patients with overactive bladder presented Subjective symptoms Patient's age < 40 (n=47) 40-49 (n=51) 50-59 (n=57) 60-69 (n=49) 70 (n=45) IPSS-total 14.2±3.1 14.3±3.4 14.6±3.2 14.7±2.9 14.9±3.6 voiding symptom* 9.4±3.5 9.5±3.2 9.6±2.9 9.7±3.1 9.7±3.4 storage symptom* 4.8±0.5 4.8±0.7 5.0±0.6 5.0±0.4 5.2±0.5 Sense of incomplete voiding 3.9±0.7 3.9±0.6 4.1±0.9 4.2±0.8 4.4±0.7 Hesitancy 2.1±0.3 2.0±0.4 2.2±0.3 2.0±0.5 2.0±0.3 Slow stream 2.3±0.2 2.3±0.3 2.0±0.2 2.1±0.4 2.2±0.5 Straining while voiding 1.1±0.1 1.3±0.2 1.3±0.3 1.4±0.4 1.1±0.3 Frequency 1.3±0.2 1.2±0.3 1.2±0.2 1.1±0.3 1.2±0.4 Urgency 1.8±0.3 1.8±0.2 1.9±0.3 1.9±0.5 1.9±0.3 Nocturia* 1.8±0.3 1.9±0.4 1.9±0.2 2.0±0.3 2.1±0.4 IPSS: International Prostate Symptom Score Each value represents mean±standard deviation *: p<0.05 by one way analysis of variances among groups Vol. 13, No. 1, 2009 39
만아니라폐색증상도증가함이관찰되었고대부분의증상들은동시에나타났다 (p<0.05) (Table 3). 2. 배뇨일지분석전체대상환자중 3일간의배뇨일지를충실히작성한환자들을대상으로분석하였으며, 모든조사항목에서 3 일간값의평균치를구하였다. 1) 연령의증가에따른배뇨량의변화연령증가에따른총배뇨량 (ml) 은 40세미만에서 1654±385.5, 40대연령군에서 1653±377.6, 50대연령군에서 1651±391.4, 60대연령군에서 1649±381.8, 70세이상연령군에서 1644±396.7이었다. 연령간가장큰차이는 60세이하와 70세이상간으로연령이 60세이상에서총배뇨량은크게감소하였다 (p<0.05) (Table 4). 주간배뇨량 (ml) 은 40세미만에서 1182±280.5, 40대연령군에서 1176±277.3, 50대연령군에서 1170±281.1, 60대연령군에서 1166±279.6, 70세이상연령군에서 1161± 275.8이었으며연령이증가함에따라주간배뇨량은감소하였다 (p<0.05) (Table 3). 야간배뇨량 (ml) 은 40세미만에서 472±144.5, 40대연령군에서 477±150.1, 50대 Tabel 4. Age related change in the uroflowmetric parameters and frequency-volume chart Parameters Patient's age < 40 (n=47) 40-49 (n=51) 50-59 (n=57) 60-69 (n=49) 70 (n=45) Voided volume (ml) daytime* 1182±280.5 1176±277.3 1170±281.1 1166±279.6 1161±275.8 nocturnal* 472±144.5 477±150.1 481±148.6 483±151.8 483±141.5 total* 1654±385.5 1653±377.6 1651±391.4 1649±381.8 1644±396.7 Urinary frequency (n) daytime 7.56±2.01 7.54±1.98 7.54±2.12 7.53±1.87 7.54±2.31 nocturnal* 1.80±0.85 1.91±0.68 1.95±0.74 2.09±0.59 2.18±0.54 FBC (ml)* 286.5±78.2 284.6±81.5 281.1±75.9 273.2±76.5 269.4±78.6 MFR (ml/sec)* 21.56±2.33 21.89±2.65 19.11±2.02 16.02±2.51 14.95±1.98 Residual urine (ml)* 28.61±9.23 28.96±8.91 29.56±9.11 33.19±8.87 35.23±9.87 FBC: Functional bladder capacity MFR: Maximal flow rate Each value represents mean±standard deviation *: p<0.05 by one way analysis of variances among groups Table 5. Age related classification of nocturia in overactive bladder patients Patient's age Classification of nocturia < 40 40-49 50-59 60-69 70 n=34 (72.3%) n=38 (74.5%) n=44 (77.2%) n=41 (83.7%) n=40 (88.8%) Nocturnal polyuria 15(44.1%) 16(42.1%) 18(40.9%) 18(43.9%) 17(42.5%) Low nocturnal bladder capacity 8(23.5%) 9(23.7%) 11(25.0%) 10(24.4%) 8(20.0%) Mixed* 6(17.6%) 7(18.4%) 8(18.2%) 8(19.5%) 9(22.5%) Polyuria 5(14.7%) 6(15.8%) 7(15.9%) 5(12.1%) 6(15.0%) *: p<0.05 by one way analysis of variances among groups 40 대한배뇨장애요실금학회지
과민성방광여성에서나이에따른배뇨형태의변화 연령군에서 481±148.6, 60대연령군에서 483±151.8, 70 세이상연령군에서는 483±141.5이었으며각연령군간의비교에서연령이증가함에따라야간배뇨량이증가하였다 (p<0.05) (Table 4). 2) 연령증가에따른주간및야간배뇨횟수의변화주간배뇨횟수는 40세미만, 40대, 50대, 60대, 70세이상군에서각각 7.56±2.01, 7.54±1.98, 7.54±2.12, 7.53±1.87, 7.54±2.31이었으며연령이증가에따른주간배뇨횟수는유의한변화를보이지않았다 (p>0.05) (Table 4). 야간배뇨횟수는 40세미만, 40대, 50대, 60 대, 70세이상군에서각각 1.80±0.85, 1.91±0.68, 1.95±0.74, 2.09±0.59, 2.18±0.54으로연령이증가할수록야간뇨의횟수가증가하였고그중 60세이하와 60세이상과의차이가더욱현저했다 (p<0.05) (Table 3). 3) 연령증가에따른기능적방광용적의변화하루중최대방광용적 (ml) 인기능적방광용적의변화에대한조사에서 40세미만, 40대, 50대, 60대, 70세이상군에서각각 286.5±78.2, 284.6±81.5, 281.1±75.9, 273.2±76.5, 269.4±78.6이었다. 각각의연령군을비교하였을때연령이증가할수록방광용적감소를보였다 (<0.05) (Table 3). 4) 연령증가에따른야간뇨의원인변화배뇨일지분석을통하여야간뇨의유무를조사하고 1회이상의야간뇨를보이는 197명의환자를대상으로야간뇨의원인을분류하였다. 야간뇨를동반하지않는군, 야간다뇨를동반한군, 야간방광용적감소를동반한군, 혼합형, 다뇨가각각 52명, 84명, 46명, 38 명, 29명이었다. 나이가증가할수록야간뇨의빈도는증가하였으며야간뇨의원인으로야간다뇨가가장큰비중을차지하였으며연령이증가할수록야간방광용적감소와야간다뇨가혼합된혼합형이차지하는비율이증가하였다 (p<0.05) (Table 4). 3. 연령증가에따른최대요속및배뇨후잔뇨량의변화배뇨량이 150ml 이상인경우측정된최대요속 (ml/sec) 은 40세미만, 40대, 50대, 60대, 70세이상연령군에서각각 21.56±2.33, 21.89±2.65, 19.11±2.02, 16.02±2.51, 14.95±1.98이었으며연령이증가할수록최대요속이감소하였다 (p<0.05). 배뇨후잔뇨량 (ml) 은 40세미만, 40대, 50대, 60대, 70세이상군에서각각 28.61±9.23, 28.96±8.91, 29.56±9.11, 33.19±8.87, 35.23±9.87으로연령이증가할수록배뇨후잔뇨량도증가하였다 (p<0.05) (Table 3). 고찰과민성방광의유병률은보고자마다다른데그이유는과민성방광용어의정의및진단기준의적용이다르기때문일것으로생각된다. 과민성방광증후군에대한국제요실금학회기준은배뇨근수축의개념을강조하여요역동학적배뇨근불안 (detrusor instability) 혹은불안정방광 (unstable bladder) 으로방광의자극증상을유발하는상태로표현했다 (6,7). 그러나요역동학검사의침습적인문제에대한인식과환자의주관적증상을강조하려는의지로인해, ICS는증명된감염이나다른명백한병변이없는조건하에서절박성요실금의유무에관계없이요절박을보이며대게빈뇨와야간뇨를동반하는증상증후군으로정의하였다 (1,6). 새로운 ICS의정의를이용한과민성방광의유병률은높지는않지만, 2006년발표된 EPIC 연구는유럽및미국, 캐나다등을포함한 19,165명을대상으로한대규모역학조사로이에따르면연령이증가할수록과민성방광의유병률은증가하며 40세이상연령군의 11.8%, 남성의 11.2%, 그리고여성의 18.4% 가과민성방광증상을보인다고하여남성에비해여성에서더높은유병률을나타냈다 (8). 국내에서시행한연구로, 대한배뇨장애요실금학회는 2002년 ICS의정의를이용한 18세이상의남녀 2005명을대상으로하부요로증상과과민성방광에대한유병률조사결과, 전체에서 12.2% 남성에서 10.0%, 여성에서 14.3% 를나타내어외국의경우와마찬가지로여성에서더높은유병률을보고하였다 (9). 과민성방광증상중가장흔하게보고되는증상은요절박과빈뇨인데, 유럽개원가를방문한 211,648명의환자를대상으로시행한설문조사에서빈뇨증상은 Vol. 13, No. 1, 2009 41
41.9%, 요절박은 24.3%, 절박성요실금은 20.2% 의환자가호소하였다 (10). 5502명의아시아여성을대상으로한설문조사결과요절박이 65.4% 로가장흔하게호소하는증상이었고빈뇨가 27.8%, 절박성요실금이 11.4% 를나타내어전반적인과민성방광유병률은 53.1% 라고보고하였다 (11). 본연구에서대부분의환자는요절박과함께야간뇨와빈뇨등의하부요로증상을동시에호소하였다. 과민성방광은모든연령층에서발생가능하고연령이증가할수록과민성방광의유병율은증가한다고알려지고있다 (12). 연령과과민성방광과의연관성을밝히고자하는연구들에의하면연령이증가할수록콜린성배뇨근수축은감소하고 adenosine triphospate (ATP) 를매개로한퓨린성배뇨근수축이중요한역할을하는것으로보고되었으며고령이될수록비신경성아세틸콜린의증가가나타난다고알려지고있다 (13). 그러나지금까지노화자체는과민성방광의직접원인으로는포함되지않고있으므로노인에서보이는과민성방광증상은치유되기어려운질병으로인식되어서는안될것이다. 과민성방광으로분류된환자군의배뇨형태에대한자세한보고는없으며특이연령증가에따른분석을시행한연구는매우드물다. 노인의배뇨형태를배뇨일지를통하여조사한연구들은그결과가다양한데 Kirkland 등 (14) 은하루동안총배뇨량은차이가없으나야간배뇨량이많아진다고하였다. 그러나 Kawauchi 등 (15) 은연령이증가함에따라야간에요량은변화가없으며기능적방광용적의저하를보인다고하였는데야간배뇨량이변화가없는것은물섭취의감소가한가지원인이될것이라고하였고기능적방광용적감소는연령에따른방광저장능력의저하와잔뇨량의증가때문이라고설명하였다. 연령에따른배뇨횟수에대한연구로 Blanker 등 (16) 은주간배뇨횟수는연령에따라큰차이가없고야간배뇨횟수는연령이증가함에따라증가한다고하였으며야간뇨의원인으로야간다뇨와연관이있음을주장하였다. 본연구결과 60세이상연령군에서그이하의연령군에비해총배뇨량, 주간배뇨량, 기능적방광용적이감소하였으며야간요량, 야간배뇨횟수는증가하였다. 그러나주간배뇨횟수는연령군과연령증가에따라큰차이를보이지않았 다. 대부분의환자들은빈뇨, 절박뇨등의자극증상뿐만아니라약뇨, 요주저, 불완전배뇨감등의저장증상도관찰되었고이러한증상은 2 3개씩함께갖고있는양상을보였다. 따라서노인의과민성방광은젊은연령과는다른임상양상을나타내며나이에따른치료의방향을달리적용하는것이증상조절에도움을줄것으로생각된다. 야간뇨는하부요로증상중가장치료가어렵고환자에게고통을주는증상으로알려져있다 (17). 노인연령층의약 72% 이상이원인과무관하게한번이상배뇨를위해자다가일어나고약 24% 는 3회이상의야간뇨를호소한다고하였다 (18). Han 등 (19) 은정상성인남성 158명의배뇨일지를분석한연구에서 48% 가두번이상수면중배뇨를위해일어난다고하였으며 40세이하에서 17%, 50대 32%, 60대 69%, 70대이상의연령에서 85% 에해당한다고보고하면서연령증가에따라야간뇨가현저히증가한다고하였다. 폐경전후의여성에서 3회이상야간뇨가있는군은그렇지않은군에비해수면장애와양호하지않는건강상태를보이며기타질환에대한이환율도높다고하였다 (12). 야간뇨의원인으로는하부요로장애, 수면무호흡등의수면장애, 당뇨나요붕증등으로다양하다 (20). 특히노인에서야간뇨가증가하는원인으로항이뇨호르몬의일간변화의둔화를생각해볼수있다. 젊은연령에서는주간에는항이뇨호르몬이상대적으로감소되고야간에분비가증가하여야간뇨가없으나나이가증가함에따라이러한항이뇨호르몬의변화가나타난다. 또한방광근육의약화및신사구체여과율의변화신장의요농축능력의감소및신혈류의변화가영향을줄수있다 (21). 노인에서심혈관질환이있는경우도주간에신혈류를감소시키며야간뇨를유발한다고한다 (22). Weiss와 Blaivas 등 (23) 의연구에서야간빈뇨의형태를네가지, 즉야간다뇨, 야간방광용적저하, 야간다뇨와야간방광용적저하의혼합형, 그리고다뇨로분류하고야간뇨의원인을분석한결과혼합형이 36% 로가장많았으며야간다뇨를포함한군이 43% 로가장많았다고하였다. 본연구결과, 과민성방광환자의대부분에서야간뇨를호소하였고야간뇨의원인으로야간다뇨가가장큰비중을차지하였으며연령이증가함에따라야간방광용적저 42 대한배뇨장애요실금학회지
과민성방광여성에서나이에따른배뇨형태의변화 하와야간다뇨가혼합된혼합형의비중이증가함을알수있었다. 또한과민성방광여성에서연령이증가함에따라야간뇨의비율, 야간뇨의횟수와야간뇨량모두증가하였다. 본연구는한계점으로무작위추출조사와는다르게하부요로증상을주소로내원한환자를대상으로시행한설문조사연구로우리나라과민성방광의유병률및질환특성을나타내는데는한계가있다. 또한본연구에포함된대상군은대학병원에내원한환자로서, 비교적질환의정도가심한환자를대상으로조사한것이어서일반적인과민성방광환자의임상적상황을나타낼수는없을것으로생각된다. 결론과민성방광여성에서나이가증가함에따라빈뇨, 요절박, 절박성요실금뿐만아니라배뇨증상및배뇨후증상또한증가한다. 또한과민성방광여성은나이가증가함에따라총배뇨량, 주간배뇨량, 기능적방광용적이감소하였으며야간배뇨량, 야간배뇨횟수는증가하였으나주간배뇨횟수는큰차이를보이지않았다. 야간뇨의원인으로야간다뇨가가장크게기여했으며야간다뇨와야간다뇨의혼합형이나이가증가함에따라그비중이증가하였다. 따라서노인과민성방광환자의치료에있어서증상에대한자세한문진및면밀한배뇨일지분석에의한원인감별에의한치료적접근이필요할것으로보인다. REFERENCES 1) Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology of lower urinary tract function: report from the standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002;21:167-78 2) Stewart WF, Van Rooyen JB, Cundiff GW, Abrams P, Herzog AR, Cortey R, et al. Prevalence and burden of overactive bladder in the united states. World J Urol 2003;20:327-36 3) Milsom I, Abrams P, Cardozo L, Roberts RG, Thuroff J, Wein AJ. How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. BJU Int 2001;87:760-6 4) Wagner TH, Hu TW. Economic costs of urinary incontinence in 1995. Urology 1998;51:355-61 5) Abrams P, Wein Aj. The overactive bladder; A wide-spread but treatable condition. Stockholm, Sweden, Sparre Medical Group, 1998 6) Abrams P, Blaivas JG, Stanton SL, Anderson JT. Standardization of terminology of lower urinary tract function. Neurourol Urodyn 1998;17:403-7 7) Malone-Lee JG. New data on urodynamics in the symptomatic elderly. Neurourol Urodyn 1988;7:119-22 8) Irwin DE, Milsom I, Hunskaar S, Reilly K, Kopp Z, Herschorn S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006;50:1306-14 9) Choo MS, Lee YS, Kim HY, Lee JB, Kwon DD, Lee T. The prevalence of overactive bladder in Korea. Int Urogynecol J Pelvic Floor Dysfunct 2001;12, abstract S169 10) Goepel M, Hoffmann JA, Piro M, Rubben H, Michel MC. Prevalence and physician awareness of symptoms of urinary bladder dysfunction. Eur Urol 2002;41:234-9 11) Lapitan MC, Chye PL. The epidemiology of overactive bladder among females in Asia: a questionnaire survey. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:226-31 12) Farrar DJ, Osborne JL. The use of bromocriptine in the treatment of the unstable bladder. Br J Urol 1976;48: 235-8 13) Palae S, Artibani W, Ostardo E, Trist DG, Pietra C. Evidence for purinergic neurotransmission in human bladder affected by interstitial cystitis. J Urol 1993;150: 2007-12 14) Kirland JL, Lye M, Levy DW, Banerjee AK. Patterns of urine flow and electrolyte excretion in healthy elderly people. Br Med J 1983;287:1665-7 15) Kawauchi A, Tanaka Y, Soh J, Ukimura O, Kojoma M, Miki T. Cause of nocturnal urinary frequency and reasons for its increase with age in healthy older men. J Urol 2000;163:81-4 16) Blanker MH, Bohnen AM, Groeneveld FPMJ, Bernsen RMD, Prins AD, Ruud BJLH. Normal voiding patterns and determinants of increased diurnal and nocturnal voiding frequency in elderly men. J Urol 2000;164: 1201-5 Vol. 13, No. 1, 2009 43
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