【作者】 陈丽丽；

【导师】 宋岩峰；

【作者基本信息】 福建医科大学 ， 妇产科， 2008， 硕士

【摘要】 目的:阐明尿动力学检查在临床诊断中的意义,探讨尿动力检查结合经会阴超声检查对女性压力性尿失禁(stress urinary incontinence, SUI)患者膀胱尿道功能的评估价值,并进一步研究TVT-O术后达到控尿的机理。方法:本研究第一部分选取169例门诊尿失禁患者,通过临床病史采集以及尿动力学检查,分别进行临床症状诊断与尿动力学诊断。本研究第二部分,选取24例SUI患者,于术前、术后1个月和术后3个月分别采用尿动力学检查测量初急(ND)、最大尿流率(Qmas)、最大尿流率时逼尿肌压力(PdetQ)、腹压漏尿点压(ALPP)、尿道全长(UL)、功能性尿道长度(FUL)、控制带长(Z)、控制带/尿道全长(Z/UL)和最大尿道闭合压力(MUCP)等功能参数;并于术前、术后3个月分别在静息状态与Valsalva动作状态下,经会阴超声检测膀胱颈移动度(Mu)、尿道膀胱后角(αr,αs)与尿道角(βr,βs),于术后3个月在静息状态下测量膀胱颈到吊带中点的距离(D)。另设正常对照组15例,检测以上指标。结果:1、169例尿失禁患者临床症状诊断为MUI的占54%、SUI占28%、UUI占18%;而尿动力学诊断为USUI的占45%、UMUI占21%、DO占16%、NUI占18%。虽然临床症状诊断与尿动力学诊断结果之间是有关的(Χ2=18.94,P = 0.001),但二者存在显著性差异(P < 0.001),且一致性较差(Kappa值=0.16)。2、SUI组术前UI、FUL、Z、Z/UL和MUCP均较对照组显著降低(均P < 0.05)。正常尿道压力曲线呈圆滑对称形,而SUI患者尿道压力曲线变化多样,曲线下面积均下降,尿道闭合功能受损。TVT-O术平均操作时间为17min,症状改善情况好,术中术后并发症少。SUI组术前可诱导出ALPP,而术后均未诱导出。术后ND和PdetQ与术前无明显差异。术后1个月Qmax较术前与术后3个月均显著降低(均P < 0.05);UL、FUL、Z与Z/UL较术前显著增高(均P < 0.05),但与术后3个月间无明显差异;MUCP与术前无显著差异。术后3个月FUL、Z与Z/UL较术前显著增高(均P < 0.05),但与对照组无明显差异;UL与MUCP较术前显著增高,但比对照组显著减低(P < 0.05);Qmax较术前与对照组无明显差异。3、SUI组术前Mu,αr、αs较术后3个月和对照组均显著增大,而βr、βs显著减小(均P < 0.01);但是术后3个月与对照组间无显著差异。D测得18.23±1.73(mm),D/UL为52.6±2.96(%)。4、ISD组术前UL、FUL、Z、Z/UL与MUCP较非ISD组显著降低、Qmax显著增高(均P < 0.05)。术后3个月Qmax、UL、FUL、Z和Z/UL与非ISD组均无明显差异;MUCP较非ISD组降低,但是△MUCP两组间无明显差异。而ISD组与非ISD组超声参数之间均无明显差异。结论:单纯临床症状诊断与尿动力学诊断之间一致性较差,不能准确诊断尿失禁类型。SUI患者尿道基础闭合功能及阻抗应力的作用障碍、膀胱颈和尿道周围的支持组织薄弱,ISD组与非ISD组之间存在膀胱尿道功能差异但无明显的解剖形态学差异。TVT-O术通过提高尿道闭合功能、加强支持组织的作用来恢复正常的解剖位置及形态,进而达到术后控尿作用。因此,尿动力学检查结合经会阴超声检查对SUI的诊断以及TVT-O术后随访等方面具有重要意义。更多还原

【Abstract】 Objective: To elucidate the significance of urodynamic testing in clinical diagnosis, investigate the role of urodynamic associated with perineal ultrasonography on the the vesicourethral functional evaluation in patients with stress urinary incontinence, and further investigate the mechanism of urinary continence after tension-free vaginal tape obturator (TVT-O) procedure.Methods: In the first part, 169 female outpatients with urinary incontinence were included, clinical history was collected and urodynamic testing was performed for clinical and urodynamic diagnosis, respectively. In the second part, 24 patients with SUI and 15 controls were underwent Urodynamic test to determine the normal desire to void, maximum void, voided at higher pressure, abdomen leak point pressure, urethral length, functional urethral length, continence zone, continence zone/ urethral length, maximum urethral closure pressure at pre-operation、1 month and 3 months after operation. In addition, at pre-operation and 3 months after operation, perineal ultrasonography was performed for Mu, posterior urethra-vesical angle(αr,αs) and the urethral knee angulation (βr,βs) at rest or during the Valsalva maneuver. Furthermore, the distance between bladder neck and the middle of the tape (D) was also measured at rest at 3 months after operation.Results: (1) 54% of the 169 urinary incontinent patients are clinically diagnosed as MUI, 28% SUI, and 18% UUI. However, 45% of them are finally diagnosed as USUI, 21% UMUI, 16% DO, and 18% NUI by urodynamic testing. Although the clinical diagnosis is related to urodynamic diagnosis (Χ~2=18.94, P = 0.001), the results exhibit a significant difference (P < 0.001) with a worse consistency (Kappa value is 0.16) between them. (2) FUL, Z, Z/UL and MUCP in SUI group were significantly reduced compared with control (all P < 0.05). In the control, urethral pressure profile showed a slick and symmetric property,however the curves are varied wth a decreased area under curve and an impaired urethral close function in SUI group. The mean operative duration of TVT-O is 17min, with better relief from clinical symptoms and fewer intra- or post-operative complication. ALPP was appeared at pre-operation, but not at post-opration. There were no significant differences in ND and Pdet.Qmax between pre- and post-operation. At 1 month after operation, Qmax was significant decreased compared with pre-operation or 3 months after operation (all P < 0.05), UL, FUL, Z and Z/UL were all increased compared with pre-operation (all P < 0.05), but not significantly different when they were compared with 3 months after operation. While the MUCP did not differ between pre- and 1 month after operation. At 3 month after operation, FUL, Z and Z/UL were persistently increased compared with pre-operation (all P < 0.05), but did not significantly differ from the control. Meanwhile, significantly reduced UL and MUCP compared with the control, and increased UL and MUCP compared with pre-operation were observed. However, by 3 month after operation, there were no difference in Qmax compared with pre-operation or control.(3) Promimently increased Mu,αr,αs and decreasedβr,βs were found in SUI group before operation compared with 3 months after operation or with control (all P < 0.01). However, no significant differences in them were observed in the comparision of control and SUI group at 3 months after operation. In addition, the distance between bladder neck to the middle of the tape was 18.23±1.73 mm, The D/UL was 52.6±2.96 (%). (4) Compared with non-ISD group, UL、FUL、Z、Z/UL and MUCP were significantly declined and Qmax showed significantly enhanced in ISD group before operation (all P < 0.01). By 3 months after operation, except MUCP which was reduced in ISD group, there were no longer any differences in Qmax, UL, FUL, Z, Z/UL, and the discrepancy before and 3 month after operation of MUCP between these two groups. Likewise, there were no significant differrences in all of the ultrasound parameters between these two groups.Conclusions: Clinical diagnosis based on clinical history has a bad consistency wth urodynamic diagnosis, thus it can not be used to accurate diagnose urinary incontinence. Patients with SUI exhibit disturbances in static and dynamic urethral closure function, and disorders of weakness in bladder neck and periurethral supporting tissue. There were significant differences in vesicourethral function but not in anatomic morphological changes between ISD and non-ISD groups. TVT-O procedure exerts its actions on urinary continence through the recovery of normal anatomic position and morphous attributed to improved urethral closure function and enhanced supporting tissue. Therefore, urodynamic testing associated with perineal sonography may play an important role in the diagnosis of SUI and the follow-up visit after TVT-O procedure.更多还原