正常女性静息及最大用力下盆底结构改变的MRI表现

背景：MRI因其具有无放射性、良好的软组织对比及多层面多轴向扫描成像等特点,可对盆底的整体结构进行精确的评估。 目的：利用MRI观察无症状女性静息状态及最大盆腔用力时盆底解剖结构的变化,为进一步评价盆底功能障碍性疾病建立正常标准。 方法：对23例无盆底功能障碍及其他盆腔疾患的女性行动态、静态盆腔MRI检查,常规观察盆腔器官及盆底结构,在正中矢状位上分别测量不同状态下膀胱颈、子宫颈、肛直肠连接与耻尾线的距离及HMO分度系统中分别测量肛直肠连接到耻尾线的距离(M线)、肛直肠连接与耻骨联合下缘连线(H线);经肛管中部的冠状位上测量肛提肌板的角度的变化,在经耻骨联合下缘的横断位图像上测量盆隔裂孔的面积的变化。 结果与结论：盆腔用力时膀胱颈、子宫颈及肛直肠连接较静息状态下均有不同程度的下降;盆腔用力时肛提肌板的角度及盆膈裂孔面积轻度增大;盆腔用力时H线及M线均有轻度的增大;与静息状态比较,动态时膀胱颈、子宫颈、肛直肠连接的下降、肛提肌板角度的增大及盆膈裂孔面积的增大、H线及M线的增大差异均有显著性意义(P < 0.05)。提示无症状女性静息时及盆腔用力时盆腔器官的位置会有所改变,在耻尾线系统测量和HMO系统上测量,盆腔器官的下降程度均未超过正常范围。盆腔用力时肛提肌板的角度及盆膈裂孔面积均可见轻度的增大。     

基于静动态磁共振成像比较正常青年男女盆底解剖结构及功能特征的差异

目的 利用静动态盆底磁共振成像技术比较正常青年男女盆底解剖结构及功能特征的差异。方法 前瞻性收集健康青年志愿者男性60例,女性60例,使用3.0T MRI扫描仪行静态动态盆底MRI扫描。在静态及动态最大力排相矢状位T2WI图像上测量H线、M线、膀胱颈（bladder neck,BN）到耻骨尾骨线（pubococcygeal line,PCL）线的垂直距离（BN-PCL）、子宫（uterus）到PCL线的垂直距离（UPCL）、肛管直肠角、肛提肌板角、耻骨前列腺角,并计算上述参数静动态差值;在静态横轴位T2WI图像上测量耻骨直肠肌厚度和髂尾肌厚度。比较各参数两组间差异。结果 正常青年男性静态M线长度、静态及动态最大力排相BN-PCL线长度明显大于女性（P<0.05）;男性髂尾肌厚度明显大于女性（P<0.05）;女性H线、BN-PCL线静动态差值明显大于男性（P<0.05）。结论 静动态盆底MRI发现男性和女性肛直肠交界处、膀胱颈位置及盆底支持结构存在差异,提示临床医生利用磁共振技术评估盆底解剖结构及功能时应关注性别、个体差异,以提高盆底功能障碍性疾病的有效治愈率。     

女性压力性尿失禁患者盆底肌形态改变的磁共振成像评价

目的 磁共振成像(MRI)技术探讨女性压力性尿失禁(SUI)患者盆底肌形态的改变.方法 自2006年1月至2008年6月间,21例SUI患者(尿失禁组)以及10例正常控尿成年女性(对照组)入组研究.所有对象均分别在平静状态以及屏气用力状态下行盆腔MRI扫描.分析尿失禁组和对照组两种状态下耻骨直肠肌厚度以及肛提肌裂隙面积的变化情况与SUI之间的关系.结果 无论在平静或屏气用力状态下,尿失禁组左、右侧耻骨直肠肌厚度均较对照组薄(均P<0.05).尿失禁组肛提肌裂隙多呈横径增宽的纵向椭圆形,平静状态下裂隙面积较对照组大[(1893.44±218.44)mm2比(1661.86±206.62)mm2,P<0.05].尿失禁组阴道呈"H"形占33.3%(7/21),提示存在阴道侧壁损伤占66.7%(14/21);对照组阴道呈"H"形占80.0%(8/10).尿失禁组阴道侧壁损伤明显高于对照组(P<0.05).结论 女性压力性尿失禁患者左、右侧耻骨直肠肌厚度变薄,肛提肌裂隙明显增大.MRI在评价女性SUI患者的肛提肌形态改变的检测中结果可信,能为临床治疗提供明确信息.     

盆底超声量化膀胱颈移动度与尿道倾斜度对女性压力性尿失禁的诊断价值分析

目的:探究盆底超声量化膀胱颈移动度与尿道倾斜度对诊断女性压力性尿失禁(Stress urinary incontinence,SUI)的价值.方法:选取2019年5月～2021年5月本院收治的压力性尿失禁患者60例作为观察组,选取同期健康患者68例作为对照组,比较两组膀胱颈移动度与静止期和压力期尿道倾斜度.采用多因素Logistic回归分析研讨膀胱颈移动度、尿道倾斜度与SUI发生的关系,进一步用受试者特征(Receiver operating characteristic,ROC)曲线进行分析.结果:观察组的膀胱颈移动度、静止期和压力期尿道倾斜度均高于对照组(P＜0.05).多因素Logistic回归分析显示,膀胱颈移动度、静止期尿道倾斜度、压力期尿道倾斜度为SUI发生的危险因素(P＜0.05).ROC曲线图显示,膀胱颈移动度、静止期尿道倾斜度、压力期尿道倾斜度诊断SUI的曲线下面积(Area under the curve,AUC)分别为0.879、0.753、0.767.结论:盆底超声量化膀胱颈移动度与尿道倾斜度诊断SUI的价值较好.     

未育女性盆底断层超声与MRI影像解剖及其临床意义

目的　利用三维超声及MRI观测未育女性静息状态及屏气最大用力时盆底断层解剖结构变化并探讨其临床意义。 方法　30例未育健康妇女进行盆腔三维超声及MRI扫描,观测盆腔器官的位置、运动和盆底肌形态并对其进行测量。 结果　不同断层影像上可获得盆底各结构清晰显像,肛提肌厚度为（8.2±1.8）mm,肛提肌裂孔面积为（11.82±2.25）cm2,静息时及屏气用力时盆底形态变化不明显, 盆腔用力时膀胱颈、子宫颈及肛直肠连接较静息状态下均有不同程度的下降,其中膀胱颈(6.1±2.0) mm, 子宫颈(8.9±4.2)mm, 肛直肠连接(14.9±6.1) mm。 结论　断层显像可清晰显示盆底静息及动态解剖结构,为诊断盆底功能障碍性疾病的提供重要依据。     

基于盆底超声分析分娩方式对初产妇产后早期盆底结构的影响

目的 探讨应用盆底超声检查分析不同分娩方式对初产妇产后早期盆底结构的影响。方法 回顾性队列研究。选取2020年4—10月安徽理工大学第一附属医院妇产科门诊就诊的初产妇175例,年龄20~35 (26.8±2.8)岁,均为足月、单胎,产后6~8周。根据分娩方式不同分为两组,其中经阴道分娩组102例、剖宫产组73例。采用盆底超声测量所有产妇静息和Valsalva状态下膀胱逼尿肌厚度、膀胱颈与耻骨联合间的距离、膀胱后角、膀胱颈移动度、尿道旋转角、肛直角、肛提肌平均厚度和肛提肌裂孔面积指标。(1)比较两组产妇的年龄、孕期增长体质量、孕周及新生儿体质量的差异;(2)比较两组产妇盆底受损情况;(3)比较静息和Valsalva状态下两组超声测量指标的差异;(4)比较经阴道分娩组不同盆底功能障碍疾病Valsalva状态下的超声测量指标。结果 (1)两组患者的年龄、孕期增长体质量、孕周及新生儿体质量比较,差值均无统计学差异(P值均＞0.05)。(2)盆底受损情况:阴道分娩组与剖宫产组患者产后子宫脱垂分别为34例(33.3%)和9例(12.3%),差异有统计学意义(χ²=10.129, P＜0.05),压力性尿失禁、尿道漏斗形成、膀胱膨出和直肠膨出差异均无统计学意义(P值均＞0.05)。(3)静息状态下,阴道分娩组膀胱后角、肛直角和肛提肌裂孔面积均大于剖宫产组,差异均有统计学意义(t=3.211、2.658、2.835,P值均＜0.05);Valsalva状态下,阴道分娩组膀胱颈与耻骨联合的距离明显小于剖宫产组,分别为(-8.2±7.9)mm和(6.3±7.0)mm,而膀胱颈移动度、膀胱后角、尿道旋转角和肛提肌裂孔面积均大于剖宫产组,差异均有统计学意义(P值均＜0.05)。(4)子宫脱垂患者的肛提肌裂孔面积、膀胱颈移动度和尿道旋转角大于Ⅱ型膀胱膨出和尿道漏斗形成患者,而尿道漏斗形成的患者膀胱后角最大,差异均有统计学意义(P值均＜0.05)。结论 盆底超声清楚地显示产后早期女性盆底结构的变化,阴道分娩者较剖宫产分娩者的盆底损伤严重。     

模拟人体尿道插管法行小鼠尿动力学检测

 目的: 国际上传统的小鼠尿动力学检测方法为膀胱造瘘法。该传统方法破坏膀胱连续性,与临床上广泛采用的经尿道法有明显的差异。本研究寻找到合适的小鼠导尿管材,拟探讨模拟人体经尿道插管法行小鼠尿动力学检测的优势和应用价值。方法: 雌性小鼠8只,选择小儿留置针软芯进行导尿,并作为测压管和膀胱灌注管,经三通外接微量泵以及压力感受器。直肠测压采用硬膜外麻醉导管,外套乳胶手套小指末端一截制成球囊,然后导入小鼠直肠。结果: 该方法成功收集到以下尿动力学指标:膀胱基础压力(BBP)、膀胱漏尿点压(BLPP)、最大排尿压(MVP)、膀胱最大容量(MBC)、残余尿量(PVR)、排尿量(VV)、排尿效率(EV)和膀胱顺应性(BC)。结论: 本研究首次成功模拟人体经尿道插管法,实现小鼠尿动力学检测,成功避免膀胱造瘘对小鼠尿动力学的影响,检测后的小鼠能够长期生存,可以顺利进行后续分子和基因实验。     

生物反馈电刺激治疗女性轻中度SUI的临床研究

目的:探讨生物反馈电刺激治疗女性轻中度压力性尿失禁(stress urinary incontinence,SUI)的效果.方法:本研究时间从2019年5月～2020年12月,研究对象为我院收治的83例SUI女性患者,数字表法分为对照组(n=41)和研究组(n=42).对比两组临床疗效、盆底肌功能[采用国际通用会阴肌力测试法(Glazer评估)]、尿动力学参数、不良反应.结果:研究组总有效率高于对照组(97.62％VS 82.93％)(P<0.05);研究组治疗后1个月、2个月Glazer评分均高于对照组(P<0.05);治疗后,两组正常尿意膀胱压、最大膀胱压、尿道最大闭合压均上升,以研究组更为显著(P<0.05);两组患者治疗期间均未出现不良反应(P>0.05).结论:生物反馈电刺激治疗女性轻中度SUI疗效确切,可显著改善患者的盆底肌功能及尿动力学指标,值得临床推广.     

盆底二维超声结合三维超声断层成像在未育女性压力性尿失禁中的初步临床应用

目的探讨盆底二维超声结合三维超声断层成像(TUI)在未育女性压力性尿失禁(SUI)中的临床应用。方法选择2019年1月至2020年12月在西安医学院第二附属医院妇科门诊接诊有流产史未育SUI患者120例(试验组1),年龄21～38岁,平均年龄25.50岁;有流产史无SUI患者80例(试验组2),年龄21～38岁,平均年龄24.49岁;选择同期体检的健康女性50例(对照组),年龄21～38岁,平均年龄25.75岁。行盆底二维超声检查,观察在静息状态和Valsalva动作下膀胱颈、尿道内口形态变化、尿道内口是否有漏斗形成,记录膀胱逼尿肌厚度(DWT)、膀胱颈移动度(BND)、膀胱尿道后角(RA)及尿道旋转角(URA)变化;三维TUI检查,观察膀胱颈、尿道内口形态变化及盆膈裂孔解剖结构及形态学变化,统计膀胱尿道内口漏斗发生率。结果试验组1、试验组2、对照组在静息状态、Valsalva动作下膀胱DWT、膀胱RA、BND、URA比较(静息状态,DWT:4.93 mm±0.39 mm vs 3.38 mm±0.35 mm vs 2.49 mm±0.30 mm;RA:158.70°±5.70°vs ...     

基于流固耦合模型的SUI患者尿液动力学研究

目的针对当前压力型尿失禁(stress urinary incontinence,SUI)疾病严重影响中老年女性患者身体健康和生活质量的问题,开展女性盆底尿路系统尿液动力学的数值研究。方法依据尿液-盆底组织间相互作用的耦合特征,结合计算流体力学(computational fluid dynamics,CFD)技术,建立SUI疾病的尿液动力学模型,分析软组织结构的应变、应力和变形以及尿路系统中尿液流动的压力场、速度场分布。结果尿路系统弹性结构的应力、应变和位移随时间呈波浪形变化,是SUI疾病形成的力学要素。结论开展基于流固耦合模型的尿动力学研究不仅必要,而且可行,能为临床SUI疾病的手术治疗提供理论基础及技术分析手段。     

UROKIN: A Software to Enhance Our Understanding of Urogenital Motion

Transperineal ultrasound (TPUS) allows for objective quantification of mid-sagittal urogenital mechanics, yet current practice omits dynamic motion information in favor of analyzing only a rest and a peak motion frame. This work details the development of UROKIN, a semi-automated software which calculates kinematic curves of urogenital landmark motion. A proof of concept analysis, performed using UROKIN on TPUS video recorded from 20 women with and 10 women without stress urinary incontinence (SUI) performing maximum voluntary contraction of the pelvic floor muscles. The anorectal angle and bladder neck were tracked while the motion of the pubic symphysis was used to compensate for the error incurred by TPUS probe motion during imaging. Kinematic curves of landmark motion were generated for each video and curves were smoothed, time normalized, and averaged within groups. Kinematic data yielded by the UROKIN software showed statistically significant differences between women with and without SUI in terms of magnitude and timing characteristics of the kinematic curves depicting landmark motion. Results provide insight into the ways in which UROKIN may be useful to study differences in pelvic floor muscle contraction mechanics between women with and without SUI and other pelvic floor disorders. The UROKIN software improves on methods described in the literature and provides unique capacity to further our understanding of urogenital biomechanics.     

Three Dimensional Virtual Reality Model of the Normal Female Pelvic Floor

The anatomy of the pelvic floor is complex and difficult to visualize from conventional two-dimensional anatomy pictures. The goal of this project was to establish the methods necessary to develop a static three-dimensional virtual reality model of the normal female pelvic floor from high-resolution magnetic resonance imaging (MRI) scans. An asymptomatic nulliparous 23-year-old female with no urinary incontinence symptoms underwent a high-resolution pelvic floor MRI scan. Selected pelvic floor structures were manually segmented: bladder, urethra, vagina, uterus, cervix, levator ani, obturator externus, obturator internus, and pubic bone. With high-resolution scans, accurate segmentation of the structures was possible. The completed models were displayed on an ImmersaDesk Virtual Reality system and three clinicians verified their accuracy. Stereovision glasses were used to enhance the model while a receiver tracked head position. Three-dimensional virtual reality models of the female pelvic floor can enhance our understanding of anatomy and physiology of this complex part of the body. They can be used as tools for both research and teaching, facilitating improved treatment of pelvic floor pathologies.     

女性尿道控尿机制的组织学研究及其临床意义

目的:探讨女性尿道相关肌肉的形态、比例、分布和类型等,以明确女性控尿机制的组织学基础.方法:对10例女性尸体进行下尿路的组织切片检查,其中5例行纵切片、5例行横切片.切片均予HE染色、结缔组织染色(Masson三色染色法)、肌肉染色(Mallory磷钨酸-苏木素染色法,PTAH)和神经组织染色(Bielschowsky改良法).结果:膀胱肌肉与尿道平滑肌相延续,尿道平滑肌仍分为内层纵形肌、中间的环形肌、外层的纵形肌;平滑肌在近端1/3丰富,向远端逐渐变薄,但仍然保持三层结构.横纹括约肌在尿道的内中1/3交界处出现并与平滑肌相互交错,至中1/3段尿道最厚,在远端1/3有肌纤维同时包饶阴道;整个横纹括约肌、尿道平滑肌与盆底其它肌肉没有联系,是一个独立的形态学单位.结论:女性控尿肌肉称为括约肌复合体,为独立的形态学单位,是女性控尿的主要组织学基础.     

Changes in the extracellular matrix in periurethral tissue of women with stress urinary incontinence

Changes in structural support of the urethra and bladder neck have been proposed as important factors in the pathogenesis of stress urinary incontinence (SUI). In this context, we undertook an ultrastructural study on the periurethral connective tissue with an emphasis on incontinent women with normotonic and hypotonic urethras. Small specimens of periurethral connective tissue were obtained by dissection during a tension-free vaginal tape-implantation procedure in 34 stress urinary incontinent postmenopausal women with a normotonic urethra and 9 stress urinary incontinent postmenopausal women with a hypotonic urethra. In the samples taken from stress-incontinent women with a normotonic urethra, intact elastic fibers were closely connected with collagen fibers, smooth muscle cells and fibrocytes. In the samples taken from stress-incontinent women with a hypotonic urethra, we detected irregular fragmented distribution of the elastin within the tissue. We assume that these structural changes lead to functional consequences, such as diminished tissue extensibility and loss of stability surrounding the female urethra. These altered connective tissue properties may affect the mechanism of urethral closure under stress (e.g., coughing) and therefore contribute to the occurrence of SUI with a hypotonic urethra.     

Bioactive porous beads as an injectable urethral bulking agent: in vivo animal study for the treatment of urinary incontinence

In our previous study, growth factor (basic fibroblast growth factor [bFGF] or vascular endothelial growth factor)-immobilized polycaprolactone (PCL)/Pluronic F127 porous beads were fabricated by an isolated particle-melting/melt-molding particulate-leaching method. The growth factors were easily immobilized onto the pore surfaces of the PCL/F127 beads via heparin binding, and were continuously released for up to 28 days. In this study, the growth factor-immobilized porous beads were investigated for their potential use as an injectable urethral bulking agent for the treatment of stress urinary incontinence (SUI). From the in vivo study using Sprague-Dawley rats as an urinary incontinent animal model, it was observed that the growth factor (bFGF or vascular endothelial growth factor)-immobilized porous beads had effective cure behaviors for SUI as follows: the narrowed urethral lumen and the regeneration of smooth muscle around the urethra. In particular, the bFGF-immobilized PCL/F127 porous beads showed desirable smooth muscle regeneration and electrical contractility, which indicates it can be a good candidate as an injectable bioactive bulking agent for the treatment of SUI.     

Urinary bladder and urethral responses to pelvic and hypogastric nerve stimulation and their relation to vasoactive intestinal polypeptide in the anaesthetized dog

The effects on the urinary bladder and urethra of pelvic and hypogastric nerve stimulation and their relation to vasoactive intestinal polypeptides (VIP) were investigated in the anaesthetized dog. Both pelvic and hypogastric nerve stimulation elicited a twofold increase in urinary bladder blood flow and a clear-cut increase in bladder venous effluent VIP concentration. Hypogastric nerve stimulation induced an initial, partly alpha-adrenergic and partly non-adrenergic, non-cholinergic, contraction of the urinary bladder followed by a relaxation. The urethra response was a maintained alpha-adrenergic contraction. Pelvic nerve stimulation elicited a bladder contraction with an initial non-cholinergic peak, whereafter the bladder pressure was maintained at a lower level, an effect which was mainly cholinergic in origin. The urethral response was an initial non-adrenergic, non-cholinergic contraction followed by a maintained cholinergic contractile response. Afferent pelvic nerve stimulation led to an efferent activity that seemed to be a combination of activity in pelvic and hypogastric pathways to the urinary bladder and the urethra. VIP (10 nmol) injected i.v. induced a relaxation of the urinary bladder and the urethra, together with a fall in systemic blood pressure. However, despite high plasma concentrations, no vasodilation was elicited in the urinary bladder. Thus, the main target for the VIP release during pelvic and hypogastric nerve stimulation is probably not the bladder vasculature, but instead perhaps the bladder smooth muscle proper.     

Morphological analysis of the urethral muscle of the male pig with relevance to urinary continence and micturition

To investigate whether the pig could be considered a suitable model to study lower urinary tract function and dysfunction, the pelvic urethra of 24 slaughtered male pigs were collected, and the associated muscles were macroscopically, histologically and histochemically analyzed. In cross‐sections of the urethra, a muscular complex composed of an inner layer of smooth muscle and an outer layer of striated muscle that are not separated by fascial planes was observed. A tunica muscularis, composed of differently oriented smooth muscle bundles, is only evident in the proximal part of the pelvic urethra while, in the remaining part, it contributes to form the prostatic fibromuscular stroma. The striated urethral muscle surrounds the pelvic urethra in a horseshoe‐like configuration with a dorsal longitudinal raphe, extending from the bladder neck to the central tendon of perineum. Proximally to the bladder, it is constituted of slow‐twitch and fast‐twitch myofibers of very small diameter, and embedded in an abundant collagen and elastic fiber net. Moving caudally it is gradually encircled and then completely substituted by larger and compact myofibers, principally presenting circular orientation and fast‐twitch histochemical characteristics. So, like in humans, the cranial tract of the muscular system surrounding the pelvic urethra is principally composed of smooth musculature. The striated component cranially may have a role in blocking retrograde ejaculation, while the middle and caudal tracts may facilitate urine and semen flow, and seem especially concerned with the rapid and forceful urethral closure during active continence. Some differences in the morphology and structure between pigs and humans seem due to the different morphology of the ‘secondary’ sexual organs that develop from the urethral wall and to the different effect of gravity on the mechanics of the urinary system in quadruped and bipedal mammals.