【作者】 王洁；

【导师】 王鑫璐；

【作者基本信息】 中国医科大学 ， 影像医学与核医学， 2020， 硕士

【摘要】 目的:女性盆底功能具有整体性,其肌肉、神经、韧带等结构相互平衡与关联。盆底功能障碍性疾病(Pelvic floor disorders,PFDs)是指盆底支持组织薄弱、损伤造成的一类疾病,主要表现为压力性尿失禁(Stress Urinary incontinence,SUI)、盆腔器官脱垂(Pelvic organ prolaps,POP)和性功能障碍等。PFDs的发病因素复杂多样,其中以孕产因素最为重要。子宫全切术后盆底结构改变,由于现阶段对于子宫全切术后远期盆底功能状态研究相对局限,大多数研究着重介绍子宫全切术后女性PFDs的症状表现,缺乏影像学资料对其盆底结构与功能的深入研究。经会阴盆底超声(Transperineal pelvic ultrasound,TPUS)因其实时动态、操作便捷的优势,目前已经成为评估PFDs的首选检查。故本研究针对子宫全切术后5年女性的盆底结构功能进行症状学及TPUS相结合的评估,使我们对子宫全切术后远期盆底功能及结构状态有新的认识。方法:选择中国医科大学附属盛京医院2013年1月至2013年12月住院行子宫全切术女性,经电话随访300名女性同意加入这项研究,所有研究对象术前均无临床诊断的PFDs,于2018年12月至2019年5月填写《盛京医院盆底结构与功能调查表》并进行TPUS评估,最终本次研究共纳入285名女性的盆底评估结果。统计《盛京医院盆底结构与功能调查表》中SUI、阴道坠胀感、便秘的发生率及盆底超声表现上盆腔器官位置异常的发生率;进一步分析SUI和盆腔器官位置异常发生的风险因素及盆底结构功能状态,应用ROC曲线评估相关超声指标对于SUI和盆腔器官位置异常这两种状态的诊断价值。应用Excel 2013建立数据库,采用SPSS(24.0)统计分析软件进行统计分析,计量资料以均数±标准差(X±SD)表示,组间计量资料比较采用t检验;计数资料以百分比(%)表示,组间计数资料比较采用?2检验或Fisher确切概率法;检验标准以P<0.05为差异具有统计学意义。结果:1、通过填写《盛京医院盆底结构与功能调查表》,285名女性中SUI发生率为53.68%(153例),阴道坠涨感发生率为21.05%(60例),便秘发生率为35.09%(100例)。根据问卷调查结果将285名进行子宫全切术的女性分为SUI组(153例)和非SUI组(132例)。2、经TPUS评估285名女性盆底结构功能,盆腔器官位置异常发生率为50.18%(143例),包括膀胱位置异常发生率48.07%(137例),穹窿位置异常发生率5.26%(15例),直肠膨出发生率5.26%(15例)。根据有无盆腔器官位置异常将285名女性分为盆腔器官位置正常组(142例)和盆腔器官位置异常组(143例)。3、在有无SUI的两组女性中,体重质量指数(body mass index,BMI)的增加(超重及肥胖)是SUI发生的风险因素;膀胱颈移动度(Bladder neck descent,BND)和最大Valsalva状态下膀胱后角(Retrovesical angle,RA)在两组女性中的差异具有统计学意义(P<0.05)。应用ROC曲线分析,BND和最大Valsalva状态下RA诊断SUI的临界值分别为19.5mm和148.5°,其敏感度为83.0%和49.7%,特异度为33.3%和68.9%,曲线下面积(Under the curve,AUC)为0.58和0.60(P均<0.05)。4、在有无盆腔器官位置异常的两组女性中,阴道分娩是盆腔器官位置异常发生的风险因素;肛提肌裂孔左右径(Levator hiatal lateral diameter,LHLR)、肛提肌裂孔前后径(Levator hiatal anteroposterior diameter,LHAP)、肛提肌裂孔面积(Levator hiatal Area,LHA)在两组女性中的差异均具有统计学意义(P均<0.05),应用ROC曲线分析,LHLR、LHAP和LHA诊断盆腔器官位置异常的临界值分别为4.62cm、5.59cm和20.34 cm2,其敏感度为75.5%、74.1%和69.2%,其特异度为67.6%、67.6%和83.1%,AUC为0.78,0.76和0.85(P均<0.05)。结论:1、在因良性病变而行子宫全切术术后远期的女性中,PFDs有其发生的复杂性和特异性。2、超重与肥胖是子宫全切术后女性发生SUI的重要风险因素;仅通过尿道活动度不能够客观评估术后SUI。3、阴道分娩是子宫全切术后女性发生盆腔器官位置异常的重要风险因素,肛提肌的结构功能与盆底器官位置息息相关。更多还原

【Abstract】 Objective:Female pelvic floor is integrated,and its muscles,nerves,ligaments and other structures are balanced and related to each other.Pelvic floor disorders(PFDs)are a group of diseases caused by weak and damaged pelvic floor support tissues,it mainly manifested as stress urinary incontinence(SUI),pelvic organ prolapse(POP),and sexual dysfunction,etc.The pathogenesis of PFDs is complex and diverse,with pregnancy and delivery being the most important factors.The pelvic floor structure changes after hysterectomy,but the current research on the long-term pelvic floor function after hysterectomy is relatively limited.Most studies focus on the symptoms of PFDs in women after hysterectomy,and there is a lack of in-depth research on the structure and function of the pelvic floor in terms of imaging.Transperineal pelvic floor ultrasound(TPUS)has become the first choice for PFDs evaluation due to its advantages of real-time dynamics and convenient.Therefore,in this study,the combined evaluation of symptomology and TPUS was performed on women 5 years after hysterectomy,so that we have a new understanding of the long-term pelvic floor function and structural status after hysterectomy.Methods: Women who were underwent hysterectomy in Shengjing Hospital affiliated to China Medical University from January 2013 to December 2013 were selected.After phone follow-up,300 women agreed to participate in the study.All subjects had no clinical diagnosis of PFDs.From December 2018 to May 2019,the pelvic floor structure and function questionnaire of Shengjing Hospital and TPUS evaluation were completed,and the evaluation results of 285 women were included in this study.Statistical analysis of the incidence of SUI,vaginal bulging,constipation in the Shengjing Hospital Pelvic Floor Structure and Function Questionnaire and the incidence of abnormal pelvic organs position related to results of TPUS.The risk factors and functional and structure of pelvic floor in women with SUI and abnormal pelvic organs position were further analyzed,and the ROC curve was used to evaluate the diagnostic value of related ultrasound indicators for two disease states.Use Excel 2013 to establish a database,and use SPSS(24.0)statistical analysis software for statistical analysis.The measurement data is expressed as mean ± standard deviation(X ± SD),and the measurement data between groups is tested by t-test.Count data was expressed as a percentage(%).Comparison of count data between groups was performed using the χ2 test or Fisher exact probability method;the test level was statistically significant with P <0.05.Results: 1.By filling in the Shengjing Hospital Pelvic Floor Structure and Function Questionnair,the incidence of SUI in 285 women was 53.68%(153 cases),and the incidence of vaginal bulging was 21.05%(60 cases),and the incidence of constipation was 35.09%(100 cases).According to the results of the questionnaire,285 women were divided into SUI group(153 cases)and non-SUI group(132 cases).2.285 women underwent TPUS examination,the incidence of abnormal pelvic organs position was 50.18%(143 cases),including the incidence of cystocele 48.07%(137 cases),and the incidence of valut prolapse was 5.26%(15 cases),The incidence of rectal bulge was 5.26%(15 cases).285 women were divided into the normal pelvic organ position group(142 cases)and the abnormal pelvic organ position group(143 cases).3.Overweight and obesity are risk factors for SUI;we found that the differences in bladder neck descent(BND)and retrovesical angle(RA)between the SUI groups and non-SUI were statistically significant(P <0.05).Using ROC curve analysis,we found that the values for the diagnosis of SUI of the BND and RA were 19.5mm and 148.5 °,respectively,with sensitivity of 83.0% and 49.7% and specificity of 33.3% and 68.9% and the area under the curve(AUC)was 0.58 and 0.60(P <0.05).4.Vaginal delivery was a risk factor for abnormal pelvic organs position;we found that the differences in levator hiatal lateral diameter(LHLR),levator hiatal anteroposterior diameter(LHAP),and levator hiatal area(LHA)were statistically significant(P <0.05).Using ROC curve analysis,we found that the values for the diagnosis of abnormal pelvic organs position in LHLR,LHAP,and LHA were 4.62 cm,5.59 cm,and 20.34 cm2,respectively with sensitivity of 75.5%,74.1% and 69.2%,and specificity of 67.6%,67.6% and 83.1%,and AUC was were 0.78,0.76 and 0.85(P <0.05).Conclusions: 1.In women who have underwent hysterectomy due to benign lesions,the complexity and specificity of PFDs.2.Overweight and obesity are important risk factor for SUI in women after hysterectomy;urinary tract activity alone cannot objectively assess postoperative SUI.3.Vaginal delivery is an important risk factor for abnormal pelvic organ position in women after hysterectomy,and the structure and function of the levator ani muscle are closely related to the position of the pelvic floor organs.更多还原