产后盆底功能重建的研究进展

女性盆底功能障碍性疾病（PFD）包括盆腔器官脱垂（POP）、尿失禁（UI）和粪失禁（FI）,是妇女常见病,也是影响人类生活质量的五大疾病之一。PFD病因很多,流行病学调查显示,妊娠和分娩是PFD的独立危险因素。针对妊娠与分娩对盆底结构和功能影响、产后盆底功能障碍的发病机制、高危因素及其目前常用的康复技术,如盆底肌肉锻炼、电刺激和生物反馈等治疗方法、利弊、存在的问题及诊治进展等综述。     

盆底超声在女性盆底功能障碍性疾病诊断中的应用

女性盆底功能障碍性疾病是盆底支持结构缺陷或退化、损伤及功能障碍所导致的一类疾病,主要包括盆腔器官脱垂、压力性尿失禁、粪失禁、梗阻型便秘和性功能障碍等,经阴道分娩是其高危因素。盆底超声检查安全、方便、廉价、动态和高分辨率,是盆底功能障碍性疾病诊断与鉴别诊断、盆底功能及疗效评估的重要影像学检查方法。     

不同分娩方式对于盆底功能影响及康复治疗

盆底功能障碍性疾病包括尿失禁、便失禁、盆腔器官脱垂以及与此相关的性生活障碍,国内资料报道发病率可达25.8%～35.3%,是严重影响中老年妇女生活质量的疾病。虽然为中老年妇女发生的疾病,但妊娠及分娩是发病的重要因素。妊娠期间盆腹腔压力的升高、妊娠高激素水平对于盆底结缔组织及肌肉的影响、分娩过程中对于肛提肌、盆底筋膜、阴部神经的损伤均与盆底功能障碍性疾病发病相关。但妊娠及分娩是女性一生中不可回避的问题,关注不同分娩方式对于盆底功能影响,筛查盆底疾病高危因素,适时进行预防干预和康复治疗,是妇产科医生应当关注的问题。本文综述近年文献,对不同分娩方式对于盆底功能的影响及康复治疗进行综述。     

围生期女性盆底重塑

妊娠和分娩是导致盆底功能障碍性疾病（pelvic floor dysfunction,PFD）的根源。围生期是育龄女性生命周期中的一个特殊时期,机体各个系统代谢、功能等方面均受到影响发生改变。随着妊娠子宫的不断增大、盆底承受的压力逐渐增加,围生期的女性盆底组织也发生一系列重塑（remodeling）以维持盆腔脏器解剖位置及功能的稳定。一旦这种稳定状态失去平衡,就表现为盆底功能障碍。盆底组织的重塑贯穿于整个围生期,并存在着个体差异。对围生期女性盆底神经、肌肉和结缔组织的重塑过程做文献综述,为研究盆底功能障碍的发病机制及寻找更有效的PFD防治方法提供理论依据。     

围生期女性盆底重塑

妊娠和分娩是导致盆底功能障碍性疾病（pelvic floor dysfunction，PFD）的根源。围生期是育龄女性生命周期中的一个特殊时期，机体各个系统代谢、功能等方面均受到影响发生改变。随着妊娠子宫的不断增大、盆底承受的压力逐渐增加，围生期的女性盆底组织也发生一系列重塑（remodeling）以维持盆腔脏器解剖位置及功能的稳定。一旦这种稳定状态失去平衡，就表现为盆底功能障碍。盆底组织的重塑贯穿于整个围生期，并存在着个体差异。对围生期女性盆底神经、肌肉和结缔组织的重塑过程做文献综述，为研究盆底功能障碍的发病机制及寻找更有效的PFD防治方法提供理论依据。     

选择性剖宫产对膀胱尿道的结构功能有保护作用吗——我们的立场

近十几年来剖宫产率不断升高,社会因素使选择性剖宫产的比例也有逐年上升的趋势,孕妇及家人担心经阴道分娩会导致盆底组织损伤、阴道松弛,易引起盆底功能障碍性疾病是其中原因之一。女性盆底功能障碍性疾病(pelvicfloor dysfunction,PFD)包括盆腔器官脱垂(pelvic organ pro-lap     

北京市社区中老年妇女泌尿生殖道及盆底功能障碍性疾病相关因素分析

目的调查北京市社区中老年妇女泌尿生殖道症状及盆底功能障碍(pelvic floor dysfunction,PFD)的患病情况及其危险因素。方法选择2013年10—12月在北京市第二医院及月坛社区卫生服务中心所辖范围内3 000名40~70岁的女性进行调查。问卷内容包括一般资料、盆底功能障碍问卷简表(pelvic floor distress inventory-short form 20,PFDI-20)。结果 3 000名女性中,回收有效问卷2 601份,有效应答率86.70%,平均年龄为(53.61±7.06)岁。PFD患病率为65.24%(1 697/2 601)。阴道分娩者与剖宫产者PDF症状的患病率分别为68.23%(1 239/1 816)和58.90%(364/618)。阴道分娩者PFD患病率高于剖宫产者,两者比较,差异有统计学意义(P0.001)。PFD的危险因素为围绝经期及绝经期(OR=1.740,P0.05;OR=1.147,P0.05)、患有躯体疾病(OR=1.489,P0.001)、使用围绝经期药物(OR=1.748,P0.001)、患有外阴阴道萎缩(OR=2.840,P0.001)。保护因素为剖宫产(OR=0.683,P0.001),高中学历(OR=0.758,P0.05)。结论盆底功能障碍的发生与月经情况、分娩方式、躯体疾病、围绝经期药物应用情况及学历有关。     

产后盆底功能重建的研究进展

女性盆底功能障碍性疾病(PFD)包括盆腔器官脱垂(POP)、尿失禁(UI)和粪失禁(FI),是妇女常见病,也是影响人类生活质量的五大疾病之一.PFD病因很多,流行病学调查显示,妊娠和分娩是PFD的独立危险因素.针对妊娠与分娩对盆底结构和功能影响、产后盆底功能障碍的发病机制、高危因素及其目前常用的康复技术,如盆底肌肉锻炼...     

女性盆底功能障碍性疾病的手术治疗

<正>主要讨论内容1.女性盆底功能障碍性疾病概况2.女性盆底功能障碍性疾病的现代手术理念3.女性盆底功能障碍性疾病手术治疗的现状4.女性压力性尿失禁的手术治疗5.女性盆腔器官脱垂的手术治疗6.女性盆底功能障碍性疾病的常见手术并发症及处理7.女性盆底重建手术的问题与展望女性盆底功能障碍性疾病概况童晓文教授女性盆底功能障碍是一个很广泛的概念,包括许多隐藏的问题。除了尿失禁,还有子宫脱垂等一系列盆底功能障碍疾病影响着相当部分女性的正常     

不同分娩方式对盆底功能的损伤及预防康复治疗方法

妊娠和分娩对盆底肌肉均有不同程度的损伤,易导致盆底功能障碍性疾病（PFD）。现将不同分娩方式对盆底功能近远期的损伤,以及盆底肌肉功能检测及损伤康复锻炼的方法和效果做一综述。     

Is Pelvic Floor Dysfunction an Independent Threat to Sexual Function? A Cross-Sectional Study in Women With Pelvic Floor Dysfunction

IntroductionPrior studies have reported an association of sexual dysfunction with pelvic floor dysfunction (PFD), but without defining causation.AimTo investigate predictors of sexual function in women with PFD, including pelvic organ prolapse, stress urinary incontinence, overactive bladder, obstructed defecation, and fecal incontinence.MethodsThis retrospective cross-sectional study included 755 women (mean age = 56 years, 68% postmenopausal) referred for PFD (2008–2013). Subjects underwent standardized history and examination, including demographics and assessment of pelvic floor function and sexual function using validated quality-of-life instruments. The physical examination included body mass index, Pelvic Organ Prolapse Quantification measurements, and pelvic muscle strength (Oxford scale). Proportional odds regression analysis tested patient characteristics, PFD, and other determinants of sexual dysfunction as predictors of sexual function.Main Outcome MeasuresThe Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7) to assess PFD and the Short Personal Experiences Questionnaire to assess sexual function.ResultsThe prevalence of PFD included pelvic organ prolapse (72%), stress urinary incontinence (66%), overactive bladder (78%), fecal incontinence (41%), and obstructed defecation (70%). Most subjects (74%) had a sexual partner and most (56%) reported recent sexual intercourse. Participants reported a low level of sexual desire and sexual enjoyment and moderate levels of sexual arousal and orgasm. When stratified by sexual enjoyment, 46% enjoyed sex and this group had lower PFDI and PFIQ scores, reflecting less quality-of-life burden. Pelvic organ prolapse, obstructed defecation, and fecal incontinence were associated with not enjoying sex. However, when adjusted for other determinants of sexual dysfunction (eg, aging, dyspareunia, atrophy, and partner issues), these associations disappeared.ConclusionWomen with PFD also have a large burden of sexual dysfunction, although this appears to be mediated by factors not unique to PFD.     

Pelvic floor dysfunction,and effects of pregnancy and mode of delivery on pelvic floor

Pelvic floor dysfunction (PFD), although seems to be simple, is a complex process that develops secondary to multifactorial factors. The incidence of PFD is increasing with increasing life expectancy. PFD is a term that refers to a broad range of clinical scenarios, including lower urinary tract excretory and defecation disorders, such as urinary and anal incontinence, overactive bladder, and pelvic organ prolapse, as well as sexual disorders. It is a financial burden on the health care system and disrupts women's quality of life. Strategies applied to decrease PFD are focused on the course of pregnancy, mode and management of delivery, and pelvic exercise methods. Many studies in the literature define traumatic birth, usage of forceps, length of the second stage of delivery, and sphincter damage as modifiable risk factors for PFD. Maternal age, fetal position, and fetal head circumference are nonmodifiable risk factors. Although numerous studies show that vaginal delivery affects pelvic floor structures and their functions in a negative way, there is not enough scientific evidence to recommend elective cesarean delivery in order to prevent development of PFD. PFD is a heterogeneous pathological condition, and the effects of pregnancy, vaginal delivery, cesarean delivery, and possible risk factors of PFD may be different from each other. Observational studies have identified certain obstetrical exposures as risk factors for pelvic floor disorders. These factors often coexist; therefore, the isolated effects of these variables on the pelvic floor are difficult to study. The routine use of episiotomy for many years in order to prevent PFD is not recommended anymore; episiotomy should be used in selected cases, and the mediolateral procedures should be used if needed.     

产科因素对产后早期盆底功能障碍性疾病发生的影响

目的探讨不同产科因素对产后早期盆底功能障碍性疾病（PFD）发生的影响,旨在为其预防和治疗提供理论依据。方法对2008年1月至2009年12月406例单胎初产妇产前及产后6～8周进行问卷调查,同时行POPQ评分,分析产科相关因素与PFD发生的相关性。结果孕期压力性尿失禁（SUI）的发生率为28.33%（115/406）;产后SUI的发生率为18.47%（75/406）,其中58例孕妇SUI症状由分娩前持续至分娩后,占产后SUI的77.33%（58/75）;产后盆腔器官脱垂（POP）发生率为49.51%（201/406）。其中选择性剖宫产组SUI和POP的发生率为7.49%（27/227）和37.89%（86/227）,阴道分娩组为32.40%（58/179）和64.25%（115/179）,剖宫产组与阴道分娩组比较,差异有统计学意义（P〈0.05）。Logistic回归分析显示,产后SUI的发生与妊娠期SUI、年龄、第二产程时间、会阴撕裂、产钳助产、新生儿出生体重和分娩前BMI有关（P〈0.05）。结论孕期SUI的发病率高于产后;选择性剖宫产可能对盆底功能具有保护作用,与产后早期PFD的发生降低有关;产时及其他相关因素可使产后早期PFD发生的风险增加。     

Association between pelvic floor dysfunction,and clinical and ultrasonographic evaluation in primiparous women: a cross-sectional study

Purpose

Disorders related to pelvic floor include urinary incontinence (UI), anal incontinence, pelvic organ prolapse, sexual dysfunction and pelvic pain. Because pelvic floor dysfunctions (PFD) can be diagnosed clinically, imaging techniques serve as auxiliary tools for establishing an accurate diagnosis. The objective is to evaluate the PFD in primiparous women after vaginal delivery and the association between clinical examination and three-dimensional ultrasonography (3DUS).

Methods

A cross-sectional study was conducted in a in tertiary maternity. All primiparous women with vaginal deliveries that occurred between January 2013 and December 2015 were invited. Women who attended the invitation underwent detailed anamnesis, questionnaire application, physical examination and endovaginal and endoanal 3DUS. Crude and adjusted predictor factors for PFD were analyzed.

Results

Fifty women were evaluated. Sexual dysfunction was the most prevalent PFD (64.6%). When associated with clinical features and PFD, oxytocin use increased by approximately four times the odds of UI (crude OR 4.182, 95% CI 1.149–15.219). During the multivariate analysis, the odds of UI were increased in forceps use by approximately 11 times (adjusted OR 11.552, 95% CI 11.155–115.577). When the clinical and obstetrical predictors for PFD were associated with 3DUS, forceps increased the odds of lesion of the pubovisceral muscle and anal sphincter diagnosed by 3DUS by sixfold (crude OR 6.000, 95% CI 1.172–30.725), and in multivariate analysis forceps again increased the odds of injury by approximately 7 times (adjusted OR 7.778, 95% CI 1.380–43.846).

Conclusion

Sexual dysfunction was the most frequent PFD. The use of forceps in primiparous women was associated with a greater chance of UI and pelvic floor muscle damage diagnosed by 3DUS.

     

Pelvic floor muscle function and symptoms of dysfunctions in midwifes and nurses of reproductive age with and without pelvic floor dysfunction

ObjectivesThis study aims to compare pelvic floor muscle (PFM) functions in midwifes and nurses of reproductive age with and without pelvic floor dysfunction (PFD) and investigate the relationship between PFM function and the number, type and symptoms of PFDs.Materials and methods82 midwifes and nurses of reproductive age with (n = 51) and without PFD (n = 31) participated in the study. PFM function was assessed by digital palpation using PERFECT scale. Gynecological examination, ultrasonography, disease-specific questionnaires, questions and tests were used to assess symptoms of PFD. PFD was assessed in terms of risk factors, urinary incontinence, fecal incontinence, pelvic organ prolapse (POP), pelvic pain and sexual dysfunctions.ResultsPower parameter of PERFECT scheme was significantly lower in subjects with PFD compared to Non-PFD group (p = 0.002). 41% of the subjects with Power 5 PFM strength in PFD group were diagnosed as stage 1 POP, 5.8% as stage 2 POP, 15.7% of urge incontinence, 23.3% of stress incontinence and 10.5% of mixed incontinence. Both urinary incontinence and POP were detected in 15.7% of them. Among all subjects, incontinence symptoms decreased whereas POP and sexual function did not change as PFM increased. PFM strength was negatively correlated with the number of PFD (p = 0.002, r = ?0.34). The type of dysfunction did not correlate with PFM strength (p > 0.05).ConclusionPFM strength only affects of urinary incontinence sypmtoms among all PFDs in midwifes and nurses of reproductive age. PFM strength may not be the main factor in the occurrence of PFDs as pelvic floor does not consist solely of muscle structure. However, it strongly affects the number of dysfunctions. Therefore, PFM training should be performed to prevent the occurrence of extra dysfunctions in addition to the existing ones even if it does not alter the symptoms.     

血清松弛素与孕产妇盆底功能变化的关系

目的测定妊娠和产后不同时期的血清松弛素（relaxin,RLX）水平,以探讨孕产妇孕期和产后盆底功能变化的机制。方法选取健康孕产妇36例分别于孕晚期、产后6～8周、产后3～6个月测定其盆底肌肉综合肌力作为研究组,无分娩史、无盆底功能障碍性疾病（PFD）史的非妊娠女性20例作为对照组;应用酶联免疫吸附法检测不同时期的血清RLX水平;并行自制PFD问卷调查。结果妊娠晚期RLX水平明显高于产后两组及对照组（P〈0.001）,产后两组与对照组的血清RLX水平比较,差异无统计学意义（P=0.913）;孕晚期血清RLX水平与孕晚期和产后盆底肌综合肌力呈负相关（r=-0.354、-0.415,P〈0.05）;孕晚期和产后两组有SUI症状者的RLX[（462.17±27.45）pg/ml、（466.00±24.91）、（458.00±27.80）pg/ml]水平高于无症状者[（427.00±31.51）pg/ml、（429.63±32.30）pg/ml、（433.20±33.05）pg/ml;P〈0.05];孕晚期和产后两组的腰骶部酸痛者孕期血清RLX[（449.76±32.13）pg/ml、（450.48±32.55）pg/ml、（442.12±31.95）pg/ml]水平明显增高（P〈0.05）;产后6～8周和3～6个月阴道松弛者孕晚期血清RLX[（446.71±26.96）pg/ml;444.38±36.90）pg/ml]水平均较高。结论妊娠期出现盆底功能改变与体内激素的变化有关;孕期高水平的血清RLX可作用于盆底胶原组织,可能是孕期和产后PFD的病理机制之一。     

女性盆底功能障碍性疾病的手术治疗进展

女性盆底功能障碍性疾病（pelvic floor dysfunction，PFD）是各种原因导致的盆底支撑结构功能障碍从而引起盆腔脏器脱垂的一系列疾病。随着中国步入老龄化社会，PFD发病率呈逐年升高趋势，严重影响老年女性的生活质量，并容易引起精神、心理方面的问题。目前，手术是中重度PFD患者的首选治疗方案。PFD手术历史悠久、术式繁多，随着医学新材料新技术的发展，手术理念的更新，新的PFD术式不断改进，从阴式手术到腹腔镜手术，从自体组织修补到合成网片的全盆底重建，手术成功率明显提高，但新的技术和材料同时也带来了新的并发症。手术的多样化虽然给了患者更多的选择，但不同术式各有利弊，患者亦有个体化差异，因此需要根据患者的年龄、症状、体征、病史、生活习惯、性生活需求、全身状况等情况综合考虑，充分沟通，力求选择适当的手术方案，以达到最好的治疗效果。     

Cognitive Impairment and Pelvic Floor Disorders

Purpose of Review

Cognitive impairment and pelvic floor disorders (PFDs) more frequently affect older women. We aimed to review recent literature on challenges of providing treatment for women with pelvic floor disorders and cognitive impairment, including risks to those with cognitive impairment, challenges in treatment, and non-pharmacologic treatment options.

Recent Findings

Prevalence of cognitive impairment in women seeking PFD treatment ranges between 4.3 and 29.3%. Women with cognitive impairment and urgency incontinence are at risk of cognitive changes from antimuscarinics, and polypharmacy in treatment of incontinence as an adverse effect from acetylcholinesterase inhibitor treatment for dementia. Additionally, older age and cognitive impairment appear to be risk factors for poorer surgical outcomes in urogynecologic surgery. There are no non-pharmacologic care methods with strong evidence to show improved outcomes in women with PFDs and cognitive impairment.

Summary

We are improving our understanding of the challenges in caring for women with urgency incontinence and cognitive impairment, but data is lacking regarding the care of these patients who have pelvic organ prolapse and anal incontinence. More research of interventions to help caregivers is needed to provide directive guidelines that could improve PFD outcomes and caregiver experience.

     

生物力学在女性盆底功能障碍性疾病中的应用

女性盆底功能障碍性疾病（pelvic floor dysfunction，PFD）是妇科常见病，临床表现为压力性尿失禁（stress urinary incontinence，SUI）、盆腔器官脱垂（pelvic organ prolapse，POP）及女性性功能障碍（female sexual dysfunction，FSD）等，严重影响中老年女性的健康及生活质量。近年来全球大部分国家开始重视该疾病，我国也已将预防女性PFD等工作作为政府的主要工作之一。PFD的发病机制尚无统一定论，且诊断上临床大多以患者的主要症状作为依据。生物力学最早应用于骨科及整形外科，现逐渐应用到妇产科领域。生物力学方法的应用为PFD发病机制、临床诊断、治疗方法的选择及疗效评估提供新的参考标准。尤其是阴道触觉成像系统（vaginal tactile imaging，VTI）能可视化地获取阴道壁的压力，是一种非常有前景的盆底生物力学精准评估新技术。综述生物力学在PFD中的应用。