盆底功能障碍性疾病患者盆底肌训练依从性评估的研究进展

介绍了依从性概念、盆底肌训练依从性判断标准，以及对国内外盆底功能障碍性疾病患者盆底肌训练依从性的评估方法，包括主观评估方法、客观评估方法，并对主观评估工具和客观评估工具进行比较分析，以期为医护人员选择合适的评估方法和干预依从性不佳行为提供参考。     

Australian pelvic floor questionnaire: a validated interviewer-administered pelvic floor questionnaire for routine clinic and research

The aim of this study was to design and validate an interviewer-administered pelvic floor questionnaire that integrates bladder, bowel and sexual function, pelvic organ prolapse, severity, bothersomeness and condition-specific quality of life. Validation testing of the questionnaire was performed using data from 106 urogynaecological patients and a separately sampled community cohort of 49 women. Missing data did not exceed 2% for any question. It distinguished community and urogynaecological populations regarding pelvic floor dysfunction. The bladder domain correlated with the short version of the Urogenital Distress Inventory, bowel function with an established bowel questionnaire and prolapse symptoms with the International Continence Society prolapse quantification. Sexual function assessment reflected scores on the McCoy Female Sexuality Questionnaire. Cronbach’s α coefficients were acceptable in all domains. Kappa coefficients of agreement for the test–retest analyses varied from 0.5 to 1.0. The interviewer-administered pelvic floor questionnaire assessed pelvic floor function in a reproducible and valid fashion in a typical urogynaecological clinic. The validation of the interviewer-administered pelvic floor questionnaire was presented at the Annual Meeting of the International Continence Society in 2004, Paris (podium presentation; extended abstract): A validated female pelvic floor questionnaire for clinicians and researchers, Baessler K, O’Neill S, Maher C, Battistutta D, Neurourol Urodynam 2004; 23: 398–399.     

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。     

Barium proctography vs magnetic resonance proctography for pelvic floor disorders: a comparative study

Aim Accurate and reliable imaging of pelvic floor dynamics is important for tailoring treatment in pelvic floor disorders; however, two imaging modalities are available. Barium proctography (BaP) is widely used, but involves a significant radiation dose. Magnetic resonance (MR) proctography allows visualization of all pelvic midline structures but patients are supine. This project investigates whether there are measurable differences between BaP and MR proctography. Patient preference for the tests was also investigated. Methods Consecutive patients referred for BaP were invited to participate (National Research Ethics Service approved). Participants underwent BaP in Poole and MR proctography in Dorchester. Proctograms were reported by a consultant radiologist with pelvic floor subspecialization. Results A total of 71 patients were recruited. Both tests were carried out on 42 patients. Complete rectal emptying was observed in 29% (12/42) on BaP and in 2% (1/42) on MR proctography. Anismus was reported in 29% (12/42) on BaP and 43% (18/42) on MR proctography. MR proctography missed 31% (11/35) of rectal intussusception detected on BaP. In 10 of these cases no rectal evacuation was achieved during MR proctography. The measure of agreement between grade of rectal intussusception was fair (κ = 0.260) although MR proctography tended to underestimate the grade. Rectoceles were extremely common but clinically relevant differences in size were evident. Patients reported that they found MR proctography less embarrassing but harder to empty their bowel. Conclusions The results demonstrate that MR proctography under‐reports pelvic floor abnormalities especially where there has been poor rectal evacuation.     

The evaluation of pelvic floor muscle strength in women with pelvic floor dysfunction: A reliability and correlation study

Aims

The purposes of this study were: (i) to evaluate the reliability of vaginal palpation, vaginal manometry, vaginal dynamometry; and surface (transperineal) electromyography (sEMG), when evaluating pelvic floor muscle (PFM) strength and/or activation; and (ii) to determine the associations among PFM strength measured using these assessments.

Methods

One hundred and fifty women with pelvic floor disorders participated on one occasion, and 20 women returned for the same investigations by two different raters on 3 different days. At each session, PFM strength was assessed using palpation (both the modified Oxford Grading Scale and the Levator ani testing), manometry, and dynamometry; and PFM activation was assessed using sEMG.

Results

The interrater reliability of manometry, dynamometry, and sEMG (both root‐mean‐square [RMS] and integral average) was high (Lin's Concordance Correlation Coefficient [CCC] = 0.95, 0.93, 0.91, 0.86, respectively), whereas the interrater reliability of both palpation grading scales was low (Cohen's Kappa [k] = 0.27‐0.38). The intrarater reliability of manometry (CCC = 0.96), and dynamometry (CCC = 0.96) were high, whereas intrarater reliability of both palpation scales (k = 0.78 for both), and of sEMG (CCC = 0.79 vs 0.80 for RMS vs integral average) was moderate. The Bland‐Altman plot showed good inter and intrarater agreement, with little random variability for all instruments. The correlations among palpation, manometry, and dynamometry were moderate (coefficient of determination [r²] ranged from 0.52 to 0.75), however, transperineal sEMG amplitude was only weakly correlated with all measures of strength (r² = 0.23‐0.30).

Conclusions

Manometry and dynamometry are more reliable tools than vaginal palpation for the assessment of PFM strength in women with pelvic floor disorders, especially when different raters are involved. The different PFM strength measures used clinically are moderately correlated; whereas, PFM activation recorded using transperineal sEMG is only weakly correlated with PFM strength. Results from perineal sEMG should not be interpreted in the context of reporting PFM strength.     

Interactive computer games for treatment of pelvic floor dysfunction

PURPOSE: We reviewed our experience with a conservative medical program and computer game assisted pelvic floor muscle retraining in patients with voiding dysfunction to substantiate our previous findings that demonstrated improvement and/or cure in a majority of patients, and identify factors that may be associated with unsuccessful treatment. MATERIALS AND METHODS: All patients presenting with symptoms of dysfunctional voiding enrolled in our pelvic floor muscle retraining were examined. Cases were subjectively evaluated for improvement of nocturnal enuresis, diurnal enuresis, constipation, encopresis and incidence of break through urinary tract infection. Patients in whom our initial conservative approach that included our biofeedback program failed were further treated with medication, and outcomes were reviewed as well. Fisher's exact test was used for statistical analysis to identify factors that may predict failure with our program. RESULTS: During the last 2 years 134 girls and 34 boys were enrolled in the pelvic floor muscle retraining program. Of the patients 160 (95%) were compliant with the program. Mean patient age was 7.6 years (range 4 to 18). The average number of hourly treatment sessions was 4.9 (range 2 to 13). Uroflowmetry and electromyography demonstrated a flattened flow pattern with increased post-void residual volume in 32% of patients, flattened flow pattern with normal post-void residual 47%, staccato flow pattern with increased post-void residual 11% and staccato flow pattern with normal post-void residual 10%. Subjective improvement was demonstrated in 87% (146) of patients, while 13% (22) had no improvement. Statistically significant predictors of failure included bladder capacity less than 60% of predicted volume (p <0.03) and patient noncompliance (p <0.04). Twelve patients who had no improvement with biofeedback were treated with medication and 10 (83%) improved. Multichannel urodynamics or spinal magnetic resonance imaging (MRI) was obtained in only 7 (4%) of our patients with no neurological lesion identified by spinal MRI. CONCLUSIONS: A conservative program combined with computer game assisted pelvic floor muscle retraining improves symptoms in most patients with voiding dysfunction. A majority of patients can be treated without medication. However, in a select population of patients with a small capacity bladder in whom biofeedback fails, anticholinergic medication appears to alleviate symptoms. In our experience almost all patients presenting with symptoms of voiding dysfunction can be treated without multichannel urodynamics, spinal MRI or medication.     

盆底肌电图在出口梗阻性便秘中的诊断价值

目的:探讨各类型出口梗阻型便秘的盆底肌电图诊断价值.方法:对90例出口梗阻型便秘患者,进行盆底肌电图检查,并分析其结果.结果:①静息相:5种出口梗阻型便秘均可出现异常电位,以松弛性盆底疾病多见,尤以会阴下降患者居多.松弛性疾病表现出内外括约肌的异常静息电位居多,痉挛性疾病表现出耻骨直肠肌的异常电位居多.②轻度收缩相:5种出口梗阻型便秘疾病的动作电位电压下降,波幅缩短,表明肌源性损伤.③重度收缩相松弛性盆底疾病多见异常,痉挛性盆底疾病相对较少.④模拟排便相以痉挛性盆底疾病多见反常收缩,并以耻骨直肠肌异常居多,松弛性盆底疾病相对较少.⑤总体评价出口梗阻型便秘的盆底肌电图异常率高达95.56%.结论:盆底肌电图应作为便秘的常规检查方法,不仅方便综合评定盆底功能,更能早期发现异常,还可以鉴别出松弛性盆底疾病和痉挛性盆底疾病.出口梗阻型便秘耻骨直肠肌的自制功能保存良好.松弛性出口梗阻型便秘患者内、外括约肌收缩障碍;痉挛性出口梗阻型便秘症状多由于耻骨直肠肌松弛障碍引起.     

Development and validation of the pelvic floor inventories Leiden (PelFIs)

AIMS: To evaluate the validity and reliability in Dutch of the Pelvic Floor Inventories Leiden (PelFIs) for men and women, an administered questionnaire, developed to create a condition-specific pelvic floor questionnaire addressing all symptoms of micturition, defecation and sexual dysfunction related to pelvic floor dysfunction. METHODS: The PelFIs is an 83-item instrument for women and 76-item instrument for men measuring the degree of pelvic floor dysfunction, containing nine different domains. Questions have been selected which, from a clinical point of view, should configure a domain. The PelFIs was administered to healthy volunteers (N = 120), and to patients (N = 100). Reliability of the PelFIs was assessed by internal consistency and test-retest reliability. Construct validity was established comparing healthy volunteers and patients by intercorrelating the domains. RESULTS: A total of 220 questionnaires were completed; by 147 women and 73 men. Some domains in the men's questionnaire had a low alpha (alpha) although the overall alpha was good. The overall of the domains for men ranged from 0.53 to 0.90. The internal consistency for the total scale of men's questionnaire was 0.84. The overall of the domains in women ranged from 0.60 to 0.85. The internal consistency of the women's questionnaire was 0.88 for the total scale. Intraclass correlation ranged from 0.65 to 0.88. Differences between healthy volunteers and patients were statistically significant for all domains. CONCLUSION: The PelFIs is a new, practical and conceptually clear questionnaire, which focus on micturition, defecation and/or sexual dysfunction related to pelvic floor dysfunction.     

彩色多普勒超声对盆底疝的诊断价值

目的探讨彩色多普勒超声在盆底疝诊断中的临床价值。 方法回顾性分析2013年4月至2018年11月,首都医科大学附属北京朝阳医院13例盆底疝患者的彩色多普勒超声表现及临床资料。 结果13例均采取手术治疗,超声确诊11例,其中单纯会阴疝7例,会阴疝合并会阴部血管瘤1例,会阴疝合并侵袭性血管黏液瘤2例,闭孔疝1例;超声误诊2例,均为会阴部血管瘤。 结论彩色多普勒超声对诊断盆底疝具有重要的临床价值。     

女性盆底重建术后疼痛管理的最佳证据应用

目的将盆底重建术后疼痛管理最佳证据应用于临床,以缓解患者术后疼痛,提高医护人员对患者疼痛管理的认知及重视度。方法对盆底功能障碍性疾病行盆底重建术后患者疼痛管理相关主题进行系统检索和质量评价,总结生成14条最佳证据,结合临床情景和专业判断,制定12条基于证据的质量审查指标,证据应用前后分别以30例患者及20名护理人员为对象,开展分阶段质量审查和效果评价。结果与基线审查结果相比,证据应用后患者术后疼痛评分、对镇痛管理的满意程度、患者镇痛行为的自主性、患者疼痛知识掌握程度、护士疼痛知识掌握程度显著提升(P0.05,P0.01);证据应用后,医护人员为患者共同制定个性化疼痛管理方案的比率由53.3%升至100%、药物+非药物联合镇痛模式的应用率由10.0%升至53.3%(均P0.01)。结论盆底重建术后患者疼痛管理最佳证据的临床应用,可规范护士的临床行为,促进护理管理质量的持续改进,从而缓解患者术后疼痛程度,提高患者对术后镇痛的正向体验和自我效能。     

Postural and respiratory functions of the pelvic floor muscles

AIMS: Due to their contribution to modulation of intra-abdominal pressure (IAP) and stiffness of the sacroiliac joints, the pelvic floor muscles (PFM) have been argued to provide a contribution to control of the lumbar spine and pelvis. Furthermore, as IAP is modulated during respiration this is likely to be accompanied by changes in PFM activity. METHODS: In order to evaluate the postural and respiratory function of the PFM, recordings of anal and vaginal electromyographic activity (EMG) were made with surface electrodes during single and repetitive arm movements that challenge the stability of the spine. EMG recordings were also made during respiratory tasks: quiet breathing and breathing with increased dead-space to induce hypercapnoea. RESULTS: EMG activity of the PFM was increased in advance of deltoid muscle activity as a component of the pre-programmed anticipatory postural activity. This activity was independent of the direction of arm movement. During repetitive movements, PFM EMG was tonic with phasic bursts at the frequency of arm movement. This activity was related to the peak acceleration of the arm, and therefore the amplitude of the reactive forces imposed on the spine. Respiratory activity was observed for the anal and vaginal EMG and was primarily expiratory. When subjects moved the arm repetitively while breathing, PFM EMG was primarily modulated in association with arm movement with little respiratory modulation. CONCLUSIONS: This study provides evidence that the PFM contribute to both postural and respiratory functions.     

Evaluation of knowledge and anxiety level of patients visiting the colorectal pelvic floor clinic

OBJECTIVE: Discussing defaecating disorders is difficult for patients and many view anal physiology investigations (ultrasound, manometry, electromyography and pudendal nerve studies) as distasteful. This pilot study sought to assess whether present information sheets supplied to patients and the visit to the colorectal Pelvic Floor Clinic itself influenced patients' knowledge and anxiety. PATIENTS AND METHODS: Thirty Pelvic Floor Clinic patients from Auckland City Hospital were included. Each patient filled in a questionnaire before and after the clinic. This included objective questions about their knowledge of the structure and function of the pelvic floor and satisfaction with and understanding of the information sheet. Both visual analogue scale (VAS) and multiple choice questions (MCQ) were used. Their subjective and objective knowledge were compared. Anxiety was assessed on a visual analogue anxiety scale (VAAS). Results were expressed as VAS scores or percentage correct and relationships were tested using Fisher's Exact test and paired T-test. RESULTS: Subjective knowledge increased in 93% of the patients. The doctor's explanation led to a greater increase in subjective knowledge than the information sheet (35/100 mm, P<0.001 and 10/100 mm, P=0.01, respectively). Subjective improvement in knowledge did not however, translate into an increase in objective knowledge (P=0.63). The information sheet was read by 87% of the patients. The information sheet had reduced anxiety only in 23% of the patients and increased in 10%. Anxiety levels were not significantly influenced by the information sheet, but reduced significantly by the clinic visit in 87% of patients (P<0.001). The mean anxiety level reduced from 44/100 to 12/100 after the clinic visit. CONCLUSION: Anxiety levels are high in those visiting the Pelvic Floor Clinic. It appears that it is the interaction with the doctor that has a profound influence on anxiety levels and subjective knowledge rather than written information.