Interobserver variation in the assessment of pelvic organ prolapse

The aim of this study was to determine the interobserver agreement of two grading systems for pelvic organ prolapse: the vaginal profile and the International Continence Society (ICS) draft proposal. Forty-nine consecutive women referred for evaluation of urinary incontinence and/or pelvic organ prolapse were studied. Patients were first examined by a physician and a nurse clinician using the vaginal profile, followed by an examination according to the technique described in the ICS draft proposal for standardization of terminology (1994). statistic and Pearson's correlation coefficient were used to determine interobserver variability for the ICS system by overall stage, by stage-specific comparison, and by specific anatomic location. The vaginal profile was evaluated by obtaining a for overall degree of prolapse, stage-specific comparison and by anatomic area. The for the ICS stage was 0.79 (P<0.001), and the for the vaginal profile by area of greatest prolapse was 0.68 (P<0.001), indicating substantial interobserver agreement for both systems. The ICS system was noted to have substantial interobserver agreement by a stage-specific comparison. All anatomic locations of the ICS staging system were found to correlate significantly, and a high degree of interobserver precision was found. The vaginal profile also showed significant interobserver agreement by overall degree of prolapse, by specific degree of prolapse, and by anatomic area. It was concluded that both the proposed ICS staging system and the traditional vaginal profile show significant interobserver agreement both by overall stage, stage-specific analysis and specific location. The registered nurse examination correlated well with the physican examination, indicating that the most important factor in obtaining reproducible results may be definition and close attention to examination technique.EDITORIAL COMMENT: There has recently been a great deal of interest in the anatomy and physiology of the pelvic floor and the various investigative techniques to define its function. The lack of a standardized and reproducible system to describe pelvic organ prolapse through the hiatus of the pelvic floor has hampered research into its pathophysiology and treatment. The authors applied a validated statistic and Pearson's correlation coefficient to convincingly measure interobserver reliability for the ICS system and indicated an index of trend between points on the ICS scale as well.     

Dynamic assessment of pelvic floor function in women using the intravaginal device test

The aim of the study was to assess pelvic floor function and dysfunction using intravaginal devices (IVD test). One hundred and eighty-five patients were evaluated, 65 (35.1%) in the control group without genital prolapse and 120 (64.9%) in the study group, with prolapse. Anatomic changes were evaluated on a scale described by Halban, and functional classification based on palpation of the muscles of the pelvic floor during contraction. Additionally, weighted vaginal devices were used to assess pelvic floor function. Statistic analysis was performed with the Spearman-Pearson correlation coefficient, the ² test and the response/ operator characteristic curve. There was an acceptable correlation between the IVD test and the functional classification of 0.75. Using this classification, the IVD test showed 86.58% sensitivity, 75.72% specificity, and had a positive predictive value 73.95% and a negative predictive value of 87.64%. Significant differences between pelvic floor muscle activity in those patients with and without genital prolapse were observed (X²=58.28, P=<0.005). It was concluded that pelvic floor assessment can be done through the evaluation of active muscle strength or pelvic floor integrity using the functional classification and the IVD test.EDITORIAL COMMENT: In 1988, Peattie and Plevnick introduced the use of weighted vaginal cones to exercise the pelvic floor muscles and treat stress urinary incontinence [1]. Contreras-Ortiz and Nuñez build on this earlier work, using a similar technique to assess pelvic floor muscle function and integrity. Specifically, pelvic floor function is assessed by a combination of digital palpation of the pubococcygeus muscle at rest and during contraction; pelvic floor integrity is assessed by the patient's ability to retain a weighted cone vaginally for 1 minute. Scoring of these two parameters can then be objectively followed for therapeutic response to treatment for urinary incontinence or pelvic relaxation. Many of us forget to palpate the pubococcygeus muscle at rest and during an elicited contraction during baseline or follow-up examination. As this study indicates, simple assessment of pelvic floor function and integrity is possible, and should be used both clinically and in research.     

绝育术后盆腔痛患者血浆、腹腔液中甾体激素与前列腺素相关性研究

本文测定绝育术后盆腔痛患者44例、输卵管绝育术后行输卵管复通术11例和正常妇女15例血浆与腹腔液中的甾体激素及前列腺素水平。结果发现:血中E_2与PGF_(2α)呈明显正相关,与TXB_2呈负相关,而P则与PGF_(2α)呈明显负相关;腹腔液中E_2与PGF_(2α)、TXB_2呈负相关。盆腔痛患者,包括异位症、无明显病变盆腔痛和盆腔静脉瘀血症3组的某种PG水平高于其他组。结果表明:血与腹腔液中PGs受甾体激素的影响,绝育术后慢性盆腔痛与PGs有关。     

Urogenital injuries in childhood: A strong association of bladder trauma to bowel injuries

We analysed the inter-relationships of the cause and the type of trauma, the presence of pelvic fracture, the associated intraabdominal organ injuries,and the morbidity and mortality rates in 154 patients presenting and being treated for UGT between 1983 and 1997.The cause of injury was blunt in 77% of cases and penetrating in 13%. The most frequently injured organs were kidney followed by urethra and bladder. Bowels, liver and spleen were the most frequently associated injured organs. Moreover, bladder injuries were strongly associated with bowel injuries (p < 0.0001). Hemodynamically normal 49 children with minor or major kidney injuries were managed conservatively. Hemodynamically non-stable 11 patients were explored.The majority of urogenital injuries can be managed conservatively evenwhen associated with intraabdominal organ injuries. Solid genitourinary organ injuries may accompany more frequently to intraperitoneal solidorgan injury. Whereas, non-solid genitourinary organ injuries may more frequently associated with injuries of intraperitoneal hollow viscus. This revised version was published online in August 2006 with corrections to the Cover Date.     

保留盆腔自主神经的直肠系膜全切除术对患者术后排尿和性功能的影响

目的　研究保留盆腔自主神经的直肠系膜全切除术后患者的排尿和性功能。方法　将 63例DukesA、B期直肠癌患者随机分为对照组 (2 9例 )和研究组 (3 4例 )。对照组行Miles手术 (13例 ) ,Dixon手术 (16例 ) ;研究组行保留盆腔自主神经的直肠系膜全切除术 ,保留肛门 2 5例 ,未保留肛门 9例。观察比较 2组患者术后自主排尿的情况 ,膀胱残余尿量及性功能。结果　研究组患者术后轻、中、重度排尿障碍的发生率分别为 11.8%、5 .9%和 0 ,明显低于对照组 (2 4.1%、2 0 .7%和 3 .5 % )。研究组中 17例男性患者术后 2例 (11.8% )阴茎不能勃起 ,4例 (2 3 .5 % )不能完成性交及射精 ;17例女性患者术后 1例 (5 .9% )性交时阴道湿润性差 ;7例男、女患者 (2 0 .6% )术后不能体会性高潮。对照组中 15例男性患者术后 11例 (73 .3 % )阴茎不能勃起 ,13例 (86.7% )不能完成性交及射精 ;14例女性患者术后 6例 (4 2 .9% )阴道湿润性差 ;2 5例男、女患者 (86.2 % )术后不能体会性高潮。研究组男、女患者术后性功能障碍发生率显著低于对照组。结论　保留盆腔自主神经的直肠系膜全切除术能较好保留直肠癌患者术后的排尿和性功能。     

盆腔静脉瘀血症患者瘀血静脉超微结构观察

为探讨盆腔静脉瘀血症患者瘀血静脉形态学改变,本文对11例瘀血症患者和6例结扎术后无任何症状和体征的妇女盆腔静脉进行了扫描及透射电镜观察.发现瘀血静脉壁间渗出增多;内皮细胞数量增多、体积变小且外形肿胀;细胞表面粗糙,突起增粗,小孔及凹陷增多、变大;细胞质致密并含大量饮液泡,线粒体肿胀而数量增多;染色质呈块状分布于核的周边;内皮细胞间嵌合连接和紧密连接正常存在.这些变化说明缺氧是引起本症盆腔静脉超微结构改变的主要原因,提示本症是一种功能性疾病.     

Cytoarchitectonic Basis for Safe Entry Into the Brainstem

This work is a continuation of the anatomical study in which safe approach zones through the floor of the fourth ventricle--infrafacial and suprafacial--were morphologically and morphometrically defined (Acta Neurochir (1997) 139: 1014-1019). The purpose of cytoarchitectonic study was to analyze correlation between morphometry of the facial colliculus and hypoglossal triangle and localization of the corresponding cranial nerves nuclei in the brainstem tegmentum in order to verify morphometrical borders of the previously defined zones. Morphometrical evaluation of the fourth ventricle floor of 10 examined brainstems was initially performed. Distances from obex to the rostral portion of hypoglossal triangle and facial colliculus were determined. Then a series of axial sections of each specimen, stained for Nissl substance, were analyzed to define the distance from obex to the rostral portion of the hypoglossal and abducens nuclei. Distances of motor trigeminal and facial nuclei from the midline sagittal plane were also measured. The obtained results allowed morphometrical determination of the infra-abducental and supra-abducental region of safe entry into the brainstem tegmentum. Infra-abducental region corresponds to infrafacial safe approach zone and supra-abducental to suprafacial zone. The distance of the rostral portion of facial colliculus from obex was longer than the distance of the rostral pole of abducens nucleus from obex in every examined specimen (by 0.7 mm on average). A very similar correlation between the distance of the rostral margin of hypoglossal triangle and localization of the rostral pole of hypoglossal nucleus was found. The rostral portion of hypoglossal triangle was longer by 1.5 mm on average. The obtained results show that previously defined infrafacial and suprafacial safe approach zones via the fourth ventricle floor correspond morphometrically to tegmental regions of safe entry--infra-abducental and supra-abducental respectively. It suggests that morphometrical evaluation of the fourth ventricle floor proposed by the authors could be useful in the intra-operative determination of safe entry via the rhomboid fossa into the brainstem tegmentum.     

多层螺旋CT盆腔扫描重建图像质量与X射线剂量的关系

目的分析扫描参数的设置与图像质量和吸收剂量之间的关系,选择适合于二维和三维重建较高图像质量和较低吸收剂量的扫描方式。方法使用GE L ightspeed U ltra 16层螺旋CT机,对人体盆腔模型进行扫描。扫描条件:120 kV,管电流分别为250 mA或200 mA,螺距分别为1.375或0.985,层厚分别为5 mm或7.5 mm。评价二维和三维图像质量,在辐射剂量观测栏,观测剂量长度乘积(DLP)的变化。选择其中图像质量较好和DLP相对较低的4种扫描方式对患者进行扫描。结果DLP随管电流的增加、螺距的减小而增大,而二维和三维图像质量也随mA的增加、螺距的减小而提高。二维图像选择250 mA、1.375螺距、7.5 mm层厚,图像噪声低,影像细节能清晰显示,且DLP相对较低;三维图像选择200 mA、0.938螺距、7.5 mm层厚,能够满足诊断需要。结论遵循医疗照射的正当性和防护最优化原则,科学地设置管电流、层厚、螺距等扫描参数,一方面能够保证二维和三维图像质量,另一方面又能减少DLP值,减少X射线辐射对盆腔生殖器官的损伤。     

182例不孕妇女腹腔镜诊断结果分析

目的:探讨腹腔镜检查对不孕妇女盆腔因素的诊断价值。方法:对1998~2004年因不孕症在我院行腹腔镜检查患者182例进行分析。结果:盆腔炎、子宫内膜异位症分别占53.8%和29.1%,输卵管阻塞占35.2%,镜下输卵管阻塞与术前比较诊断符合率为82.7%。其余镜下诊断分别为:多囊卵巢、盆腔结核、卵巢肿瘤、盆腔瘀血和正常盆腔。盆腔炎在继发不孕妇女中发生率高,药物流产引起的输卵管阻塞发生率比人工流产高。腹腔镜下行盆腔粘连松解术,其复通率为59.2%。结论:盆腔炎、子宫内膜异位症是不孕患者最常见的盆腔因素。药物流产造成的盆腔炎和输卵管阻塞发生率较人工流产高,应引起重视,腹腔镜下对不孕妇女的盆腔因素诊断有极大的价值。     

盆腔器官脱垂患者盆底支持组织超微结构特征的研究

目的了解盆腔器官脱垂(pelvicorganprolapse,POP)患者盆底支持组织的超微结构特征。方法选择2004年7月至2004年8月于我院手术治疗的POP患者5例,同期因卵巢单纯囊肿行全子宫切除术的绝经后患者2例作为老年对照,宫颈癌手术治疗2例作为年轻对照。在光镜及透射电镜下观察子宫主韧带、阴道壁、肛提肌组织的超微结构特征。结果光镜下POP组标本中平滑肌弥漫性萎缩、变性、纤维化。阴道粘膜固有层广泛小血管周围炎,血管内皮肿胀。电镜下POP组平滑肌细胞共同超微结构特征为细胞膜结构不完整;胞核异染色质增多;线粒体呈基质型肿胀甚至消失。阴道粘膜固有层终末小动脉内皮肿胀,中膜平滑肌萎缩断裂,甚至消失。老年非脱垂组可见平滑肌萎缩,灶状纤维化,但平滑肌变性、血管病变不明显。年轻非脱垂组未见平滑肌萎缩变性及血管病变。同时发现POP组肛提肌中骨骼肌成分损伤不明显,而平滑肌成分出现损伤性改变。结论POP患者主要盆底支持组织如主韧带、阴道壁、肛提肌普遍存在平滑肌细胞不可逆损伤性超微结构改变,可造成盆底组织松弛、支持能力减弱,导致POP的发生。肛提肌中平滑肌成分与POP发生密切相关。