CO_2点阵激光对产后阴道松弛患者的盆底肌肉修复及性功能的影响

目的:探讨CO_2点阵激光对产后阴道松弛患者的盆底肌肉修复及性功能的影响,为患者治疗提供临床参考。方法:回顾性分析2017年6月-2018年6月笔者医院收治的40例产后阴道松弛患者的诊疗情况。所有患者均采用CO_2点阵激光治疗,治疗3个月,记录所有患者治疗前后盆底肌纤维电压、盆底肌纤维疲劳度以及盆底肌力情况,同时治疗前后完成女性性功能量表(Female sexual function index,FSFI)评分,并对评分进行比较。结果:治疗后,患者盆底Ⅰ类、Ⅱ类肌纤维电压与疲劳度均明显优于治疗前,盆底Ⅱ类肌纤维强度、盆底Ⅰ类收缩时间以及手测阴道横断面肌力均明显提高,差异有统计学意义(P0.05);盆底Ⅰ类肌纤维强度治疗前后比较差异不具有统计学意义(P0.05)。治疗后,患者性欲、性唤起、性高潮与治疗前比较差异不具有统计学意义(P0.05);阴道润滑度、性生活满意度、性交疼痛以及FSFI总分均明显改善,差异具有统计学意义(P0.05)。结论:CO_2点阵激光对产后阴道松弛患者的盆底肌肉修复具有显著疗效,同时能够改善患者性生活质量,提高性功能,值得广泛应用。     

阴道后壁黏膜切除联合埋没引线缝合法治疗产后阴道松弛症疗效分析

目的:探讨阴道后壁黏膜切除联合埋没引线缝合法对产后阴道松弛症的疗效。方法:选择2017年3月-2018年3月收治的产后阴道松弛症患者100例作为研究对象,按照随机表法分为A组50例与B组50例。A组采用阴道后壁黏膜切除联合埋没引线缝合法治疗,B组采用阴道后壁环肌紧缩术治疗。比较两组患者术后12个月性生活满意度、阴道松弛程度和手术指标变化及治疗前后阴道黏膜指标变化。结果:A组术后12个月性生活满意度(88.00%)高于B组(70.00%),且A组术后12个月阴道松弛度改善优于B组,差异均有统计学意义(P0.05)。两组术中出血量和术后并发症发生率比较差异无统计学意义(P0.05)。两组治疗后阴道黏膜弹性、阴道湿润度和阴道黏膜上皮评分较治疗前增加,且A组高于B组(P0.05)。结论:阴道后壁黏膜切除联合埋没引线缝合法应用于产后阴道松弛症,可有效改善患者阴道松弛程度,值得临床借鉴。     

埋没导引针缝合法和阴道后壁黏膜切除法治疗阴道松弛的临床比较

阴道松弛是女性随着年龄增长而出现的一种生理状况,常因妊娠或分娩使阴道骨盆底肌肉及筋膜的拉伤导致阴道盆地损伤,或由于年龄增大,雌激素水平下降致阴道黏膜萎缩、盆底组织松弛,从而导致阴道肌肉收缩力下降,阴道口变宽大于3指,严重影响性生活质量。笔者自2007-2013年应用埋没导引针缝合法。和阴道后壁黏膜切除法的阴道紧缩术,对71例阴道松弛患者进行了手术治疗。现将2种手术方法进行对比分析。     

基于信息化管理平台的延续护理对产妇盆底功能康复的影响

目的 探讨基于信息化管理平台的延续护理对产妇盆底功能康复的影响.方法 将134例自然分娩的产妇按照意愿分为观察组(n=67名)和对照组(n=67名),两组住院期间按常规进行产后护理,并由责任护士指导产妇行盆底功能训练.出院后对照组由专人负责进行电话随访,每2周1次,连续3个月;观察组出院后开展基于信息化管理平台的延续护理.干预前和干预后3个月评价产妇盆底肌力、盆底肌电位及盆底功能障碍得分情况.结果 干预后,两组Ⅰ、Ⅱ类盆底肌纤维力和肌电位显著改善,且观察组显著优于对照组(均P＜0.01);两组盆底功能障碍评分显著降低,观察组显著低于对照组(均P＜0.01).结论 对产妇实施基于信息化管理平台的延续护理,可以提升产妇盆底肌力和肌电位,有效改善其盆底功能.     

改良的阴道紧缩术治疗阴道松弛临床观察

目的探讨更安全有效的治疗阴道松弛的阴道紧缩手术方法。方法对132例因阴道松弛导致性生活质量下降,要求行阴道紧缩手术的患者进行改良的阴道缩紧术。手术对松弛的阴道前壁和后壁的肌肉及筋膜进行切实有效修复,同时修复会阴裂伤。对合并张力性尿失禁的患者,根据尿道中断吊床学说理论,在修复前壁时于尿道中段加强缝合肌肉筋膜1针;对合并便秘患者,在后壁修复时加强缝合肛提肌3针;前后壁修复时最大限度保护阴道黏膜。结果术后2～7年,随访118例对术后改善性生活满意度、张力性尿失禁、便秘及阴道排气4项内容进行问卷调查,收到满意的临床效果。结论手术方法设计专业,疗效确切,患者满意度高,适合有经验的专科医师采用。     

提肛肌肌瓣对合重叠缝合法治疗产后阴道松弛

目的 探讨一种有效治疗产后阴道松弛的手术方法。方法 经阴道口皮肤黏膜交界处切开，剥离阴道黏膜，分离出撕裂的提肛肌，形成两个肌瓣。将两肌瓣对合重叠拉紧缝合后缝合阴道黏膜，并形成阴道黏膜隆突。结果 1998年6月至2002年6月将此法用于2l例产后阴道松弛的患者，术后随访16例，随访3个月至2年，患者均感手术后提高了性生活质量。结论 此方法可以提高患者性生活质量，效果确切。     

盆底康复操锻炼对产妇产后盆底肌力及心理状态的影响

目的探讨盆底康复操锻炼对减少产后并发症、改善产妇心理状态及盆底肌力的作用。方法将自然分娩的初产妇按住院号奇偶数分为对照组54例和干预组55例。对照组采取常规护理模式,干预组在常规护理基础上于产后采取盆底康复操锻炼方案,比较两组产后14周内并发症发生情况、盆底肌力及心理变化。结果干预组产后尿失禁、子宫复旧不全及产后失眠等并发症发生率显著低于对照组(均P0.05);干预组在产后6周及14周时盆底肌力显著优于对照组(均P0.01);产后14周干预组SAS、SDS评分显著低于对照组(均P0.01)。结论产后盆底康复操的应用,可规范引导产妇进行有效的盆底功能锻炼,促进产后盆底肌功能恢复,减少产后并发症的发生,改善产妇的心理状态。     

盆底重建术后肌电生物反馈治疗的疗效分析

目的 评价盆底重建术后肌电生物反馈疗法进行盆底肌肉康复效果. 方法 回顾分析本院2009年5月至2010年12月行盆底重建术患者43例,术后随机分为研究组(23例)与对照组(20例),研究组术后3月给予盆底肌电生物反馈治疗,对照组无殊处理.术后3、6、12月随访两组盆底肌电值、肌力提升和P-QOL量分. 结果 与术后3月组比较,研究组术后6、12月盆底Ⅰ、Ⅱ类肌纤维电位值、肌力均呈上升趋势,P-QOL量分呈下降趋势,差异有统计学意义(P＜0.05或P＜0.01).结论 盆底重建术后肌电生物反馈疗法能够提升盆底肌表面肌电值与肌力,改善患者生活质量.     

不同时机的个体化产后盆底康复治疗对盆底肌作用分析

目的评估产后早期不同时间段开始进行的个体化盆底康复治疗对女性盆底肌力及盆底功能改善的作用。方法选取2010年1月至2011年12月期间,回我院门诊进行产后访视,手法检测盆底肌力≤3级的产妇174例作为研究对象,分为观察组与对照组。按照产后开始进行盆底康复治疗的不同时间将观察组(125例)分为3组:A组(39例),产后42~56d;B组(48例),产后57~70d;C组(38例),产后71~91d。对照组(D组,49例):产后6~8周,只进行产后盆底康复知识的宣教。观察组各组的产妇治疗前进行盆腹动力学及盆底肌电生理指标检测,按照肌力等异常的具体情况选择个体化的低频电刺激联合生物反馈治疗。治疗结束时及结束后6个月复测治疗前所检测指标。对照组产妇于产后6~8周及产后6个月回院进行同样的盆底指标检测。结果各个观察组在治疗结束时及治疗结束后6个月,所检测数据与治疗前相比较,盆底肌Ⅰ、Ⅱ类肌纤维的肌力和静态张力都有显著提高,最大肌电位数值增加,肌肉疲劳度得到改善,差异具有统计学意义(P0.05)。观察组各组在治疗结束时、结束后6个月相比较,组间各项检测数据对比无显著性差异(P0.05)。结论产后早期不同时间段开始进行的盆底个体化康复治疗,均可以显著提高盆底肌力及明显改善盆底功能。临床上根据实际情况在产后早期的不同时机都可以积极进行盆底康复治疗,值得临床推广应用。     

阴道旁修补术联合球海绵体肌缝合治疗重度阴道松弛症

目的 探讨重度阴道松弛症的修复方法 及临床效果.方法 对48例重度阴道松弛症患者经阴道旁筋膜修补及球海绵体肌缝合,并随访术后性生活满意度、会阴外观、不自主排尿及阴道分泌物的改善效果.结果 术后随访43例,性满意度改善者40例,有效率为93%.14例对自身会阴外观不满意者术后均有明显改善;不自主排尿、阴道分泌物增多等症状有效缓解.结论 阴道旁修补术联合球海绵体肌缝合治疗重度阴道松弛症,手术安全,疗效可靠.     

Pelvic floor muscle strength and thickness in continent and incontinent nulliparous pregnant women

The aim of the study was to measure pelvic floor muscle function in continent and incontinent nulliparous pregnant women. The study group consisted of 103 nulliparous pregnant women at 20 weeks of pregnancy. Women reporting urinary incontinence once per week or more during the previous month were classified as incontinent. Function was measured by vaginal squeeze pressure (muscle strength) and increment in thickness of the superficial pelvic floor muscles (urogenital diaphragm) assessed by perineal ultrasound. Seventy-one women were classified as continent and 32 women as incontinent. Continent women had statistically significantly higher maximal vaginal squeeze pressure and increment in muscle thickness when compared with incontinent women. There was a strong correlation between measurements of vaginal squeeze pressure and perineal ultrasound measurements of increment in muscle thickness. This study demonstrates statistically significant differences in pelvic floor muscle function measured by strength and thickness in continent compared with incontinent nulliparous pregnant women. Editorial Comment: This study evaluated pelvic floor muscle function in 103 nulliparous continent and incontinent women at 18–20 weeks gestation. Pelvic floor muscle strength was assessed by measuring vaginal squeeze pressure, and thickness of the urogenital diaphragm during both relaxation and contraction was measured using perineal ultrasound. The authors found a statistically significant higher vaginal squeeze pressure and higher mean increment in muscle thickness in the continent compared with incontinent group as well as a strong correlation between pelvic floor muscle strength and increment in thickness. Although describing several benefits of ultrasonography in assessing pelvic floor muscles, the authors did acknowledge the difficulty in identifying and measuring these muscles, and the learning curve involved with perineal ultrasound. Another limitation was the subjective classification of continence status based on self-reported symptoms. The implication of low pelvic floor muscle strength and thickness as risk factors for the development of urinary incontinence is beyond the scope of this study.     

Pelvic floor muscle evaluation in incontinent patients

The aim of this study was to assess pelvic floor muscle (PFM) strength and perception and its correlation with stress urinary incontinence (SUI). One hundred and one women were divided into two groups according to the presence (G1=51 patients) or absence (G2=50 patients) of SUI. Subjective [urine stream interruption test (UST), visual survey of perineal contraction and transvaginal digital palpation to assess pelvic muscle contraction] and objective evaluations of pelvic floor muscles in all patients were performed (vaginal manometry). During the UST, 25.5% of G1 patients and 80% of G2 patients were able to interrupt the urine stream (p<0.05). Digital evaluation of pelvic muscular contraction showed higher strength in G2 than in G1 patients (p<0.0001). Perineometer evaluation of PFM strength was significantly higher in the continent group (p<0.001). Pelvic floor muscle weakness in incontinent patients demonstrates the importance of functional and objective evaluation of this group of muscles.This revised version was published online in February 2005 with corrections to the third authors name. The name of this author, De Oliveira Orsi Gameiro M, was not correctly rendered in the original version.     

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.     

Pelvic floor muscle function in women presenting with pelvic floor disorders

Introduction and hypothesis  This observational study was undertaken to determine knowledge, prior instruction, frequency of performance, and ability to perform pelvic floor muscle exercises in a group of women presenting for evaluation of pelvic floor disorders. Methods  Three hundred twenty-five women presenting for evaluation of pelvic floor disorders were questioned concerning knowledge and performance of pelvic floor muscle exercises (PMEs) and then examined to determine pelvic floor muscle contraction strength. Results  The majority of women (73%) had heard of PMEs, but only 42% had been instructed to perform them and 62.5% stated they received verbal instruction only. Only 23.4% of patients could perform pelvic muscle contractions with Oxford Scale 3, 4, or 5 strengths. Increased age, parity, and stage of prolapse were associated with lower Oxford scores. Conclusions  Although most women with pelvic floor disorders are familiar with PMEs, less than one fourth could perform adequate contractions at the time of initial evaluation.     

The effect of postpartum pelvic floor muscle exercise in the prevention and treatment of urinary incontinence

The aim of this study was to evaluate the effect of postpartum pelvic floor muscle exercise in the prevention and treatment of urinary incontinence. A prospective comparison design of 99 matched pairs (n=198) of mothers, a training group and a control group, was used. Eight weeks postpartum the training group attended an 8-week intensive pelvic floor muscle exercise course, training in groups led by a physical therapist for 45 minutes once a week. In addition they were asked to exercise at home at least three times per week. The control group followed the ordinary written postpartum instructions from the hospital. Pelvic floor muscle strength was measured pretreatment at the eighth, and post-treatment at the 16th week after delivery, using a vaginal balloon catheter connected to a pressure transducer. Vaginal palpation and observation of inward movement of the balloon catheter during contraction were used to test the ability to perform correct the pelvic floor muscle contraction. Urinary leakage was registered by interview, specially designed instruments to measure how women perceive SUI, and a standardized pad test. At baseline (8 weeks postpartum) there was no significant difference in the number of women with urinary incontinence in the training group compared to the control group. At 16 weeks postpartum, after the 8-week treatment period, there was a significant (P<0.01) difference in favor of the training group. In addition, a significantly greater improvement in pelvic floor muscle strength between test 1 and test 2 was found in the training group compared to the control group. The results show that a specially designed postpartum pelvic floor muscle exercise course is effective in increasing pelvic floor muscle strength and reducing urinary incontinence in the immediate postpartum period. EDITORIAL COMMENT: This paper is one of only a few looking at the efficacy of a rigorous pelvic floor muscle exercise training regime to help women with incontinence in the postpartum period. Whether or not these results will translate long-term into a lower incidence of urinary incontinence as these women age, is unknown, and may never be known. However, this paper points out that there is a definite benefit from pelvic floor muscle exercise for the treatment of postpartum incontinence, and we can use this information to more strongly counsel our patients in the use of these exercises.     

针刺联合生物反馈治疗女性产后盆底失弛缓综合征

为探讨针刺联合生物反馈治疗女性产后盆底失弛缓综合征的疗效,选取产后42d的产妇进行盆底肌电图及肛管压力测定,评估其盆底功能,将临床便秘症状明显的40例产后盆底失弛缓综合征患者作为观察对象,随机分为治疗组和对照组各20例。对照组患者自己进行提肛锻炼,治疗组在对照组基础上应用针刺联合生物反馈治疗。比较两组在治疗前、后盆底肌力测定数据及临床症状的改善情况。结果显示,两组患者治疗后盆底肌力情况改善不明显;但肛门压力及临床症状得到明显改善,治疗组优于对照组,差异均有统计学意义（P〈0．05）。结果表明,针刺联合生物反馈治疗可有效改善女性产后盆底肛门压力及临床症状,从而提高患者的生活质量。     

盆底障碍性疾病盆底自主收缩肌肉力量研究

目的比较正常人和盆底障碍性疾病(PFD)患者的盆底肌肉功能。方法对2007年11月至2008年4月在本院就诊的压力性尿失禁(SUI)、盆腔器官脱垂(POP)、POP合并SUI患者以及健康对照组各10例,行阴道指诊、阴道挤压力检测盆底肌肉收缩力量进行评估。结果肛提肌肌肉指诊力量和阴道挤压力呈正相关(r=0.549,P<0.05)。对照组阴道指诊肌力等级为(4.1±0.8),阴道挤压压力为(38.4±21.1)mmH2O,15 s内可自主收缩肛提肌(6.0±1.2)次,收缩持续时间为(4.78±1.78)s。SUI组、POP组、SUI+POP组阴道指诊肌力等级分别为(2.6±0.7)(、3.2±1.2)和(3.0±1.4),均显著低于对照组(P<0.05);阴道内挤压压力分别为(20.2±11.1)、(13.8±10.3)、(20.0±10.4)mmH2O,均显著低于对照组(P<0.05)。SUI组15 s内可自主收缩肛提肌(3.6±1.0)次,显著少于对照组(P<0.05),收缩持续时间为(2.40±1.35)s,与对照组比较显著缩短(P<0.05)。结论肛提肌的阴道指诊的肌力测定,简单易行,可在临床广泛应用。PFD患者普遍存在肛提肌肉收缩力量减弱。SUI患者收缩速率慢、收缩持续时间短,不能对抗连续的腹压增高可能是SUI的发病机制。     

Evaluation of Pelvic Floor Muscle Strength Using Four Different Techniques

The aim of the study was to evaluate whether four different techniques were able to correctly measure pelvic floor muscle strength only. Sixteen volunteers performed a set of muscle contractions using the pelvic floor muscles (PFM) only, the abdominal muscles with and without PFM, gluteal muscles with and without PFM, adductor muscles with and without PFM and Valsalva maneuver with and without PFM. Pelvic floor muscle strength was evaluated by digital palpation, intravaginal EMG, pressure perineometry and perineal ultrasound. A “non-pelvic muscle induced” reading was defined as a significant increase even though the pelvic floor muscles were not contracted. Results were as follows: isolated abdominal muscle contraction: non-pelvic muscle induced readings in 3/8 women with EMG and in 3/8 with pressure perineometry; isolated gluteal muscle contraction: non-pelvic muscle induced readings in 1/2 women with EMG perineometry; isolated adductor muscle contraction: non-pelvic muscle induced readings in 6/11 women with EMG perineometry and in 2/11 women with pressure perineometry; Valsalva maneuver: non-pelvic muscle induced readings in 4/9 women with EMG perineometry and 9/9 women with pressure perineometry. It was concluded that EMG and pressure perineometry do not selectively depict pelvic floor muscle activity.     

盆底超声评估初次经阴道分娩与剖宫产产后盆底功能

目的观察盆底超声评估阴道分娩与剖宫产初次产后盆底功能的价值。方法选取176名产妇,根据初次分娩方式将其分为经阴道分娩组(n=100)和剖宫产组(n=76);对比2组静息态及最大瓦尔萨尔瓦动作下超声各参数,包括肛提肌裂孔左右径、前后径及面积,左、右侧耻骨直肠肌厚度及膀胱颈移动度,观察盆底超声评估初次产后盆底功能的价值。结果静息态及最大瓦尔萨尔瓦动作下,经阴道分娩组肛提肌裂孔左右径、前后径及面积均大于剖宫产组(P均<0.05),左、右侧耻骨直肠肌厚度均小于剖宫产组(P均<0.05);阴道分娩组膀胱颈移动度大于剖宫产组(t=2.177,P=0.031)。结论盆底超声对评估初次产后盆底功能具有一定价值;初次经阴道分娩对盆底功能的影响大于剖宫产;肛提肌裂孔面积增大、膀胱颈移动度增大及耻骨直肠肌厚度变薄可早期提示产后盆底功能障碍可能。     

Pelvic Floor and Abdominal Muscle Interaction: EMG Activity and Intra-abdominal Pressure

Pelvic floor muscle exercises prescribed for the treatment of incontinence commonly emphasize concurrent relaxation of the abdominal muscles. The purpose of this study was to investigate the interaction between individual muscles of the abdominal wall and the pelvic floor using surface and intramuscular electromyography, and the effect of their action on intra-abdominal pressure. Four subjects were tested in the supine and standing positions. The results indicated that the transversus abdominis (TA) and the obliquus internus (OI) were recruited during all pelvic floor muscle contractions. It was not possible for these subjects to contract the pelvic floor effectively while maintaining relaxation of the deep abdominal muscles. A mean intra-abdominal pressure rise of 10 mmHg (supine) was recorded during a maximum pelvic floor muscle contraction. These results suggest that advice to keep the abdominal wall relaxed when performing pelvic floor exercises is inappropriate and may adversely affect the performance of such exercises.