经会阴超声评价不同类型膀胱膨出患者盆底结构的价值

Transperineal Ultrasound in the Evaluation of Pelvic Floor Structure in Patients with Different Types of Cystocele

目的 应用经会阴超声观察膀胱膨出患者的盆底信息,分析Ⅱ型和Ⅲ型膀胱膨出患者盆底结构改变及临床表现的差异,以期为探索膀胱膨出亚型的发病机制提供影像学依据。资料与方法 回顾性分析2019年1月—2020年3月陕西省人民医院经盆底超声诊断为膀胱膨出的患者253例,其中Ⅱ型膀胱膨出141例,Ⅲ型膀胱膨出112例。依据POP-Q分期系统标定2种类型膀胱膨出患者阴道前壁Aa点和Ba点位置,随后应用经会阴实时动态三维超声观察患者最大Valsalva状态尿道内口是否呈漏斗状开放、测量膀胱颈移动度、尿道旋转角以及静息期和最大Valsalva状态盆膈裂孔面积,并于缩肛期观察肛提肌损伤情况。比较Ⅱ型膀胱膨出和Ⅲ型膀胱膨出患者临床表现、超声测量参数、肛提肌损伤发生率以及Aa点和Ba点位置的差异。结果 与Ⅱ型膀胱膨出组比较,Ⅲ型膀胱膨出组年龄较大(t=14.016,P<0.001)、产次较多(t=3.506,P<0.001),膀胱颈移动度较大(t=2.446,P<0.001),膀胱最低点位置较低(t=8.291,P<0.001),同时POP-Q分期系统显示Aa点和Ba点均较Ⅱ型膀胱膨出组位置更低(t=2.291、 2.280,P=0.022、0.023),与超声测量结果一致;其排尿困难、排空功能障碍以及肛提肌损伤发生率较高(χ^(2)=23.731、36.582、20.067,P均<0.001)。与Ⅲ型膀胱膨出组比较,Ⅱ型膀胱膨出组尿道内口漏斗状开放和压力性尿失禁发生率高(χ^(2)=40.146、16.330,P均<0.001)。结论 不同类型膀胱膨出的临床表现和盆底解剖结构改变不同,经会阴超声可为膀胱膨出亚型的诊断及其发病机制的探索提供有价值的影像学信息。

Purpose Observing the pelvic floor of cystocele patients by transperineal ultrasound, and analyze the structural changes of the pelvic floor and clinical manifestations in patients with type Ⅱ and type Ⅲ cystocele, with the aim to provide imaging basis to facilitate further investigations of the pathogenesis of cystocele subtypes. Materials and Methods 253 patients with cystocele diagnosed by pelvic floor ultrasound in Shaanxi Provincial people’s Hospital from January 2019 to March 2020 were analyzed retrospectively, including 141 cases of type Ⅱ cystocele and 112 cases of type Ⅲ cystocele. POP-Q system was used to determine the Aa point and Ba point in the anterior vaginal wall, and then real-time three-dimensional transperineal ultrasound was used to observe whether the internal urethra showed funnel-shaped opening and measure the bladder neck mobility and the urethral rotation angle during the maximum Valsalva maneuver. The hiatal area at rest and the maximum Valsalva maneuver were recorded, and the levator ani muscle injury was evaluated during levator ani muscle contraction.The clinical manifestations, ultrasonic parameters, incidence of levator ani muscle injury, and the position of Aa and Ba were compared between cystocele type Ⅱ and type Ⅲ patients. Results Compared with type Ⅱ cystocele group, Women with cystocele type Ⅲ were older(t= 14.016, P<0.001), had more deliveries(t= 3.506, P<0.001), the mobility of bladder neck was greater(t= 2.446, P<0.001), and the lowest point of the bladder was lower(t= 8.291, P<0.001). Meanwhile, the position of Aa and Ba was lower than that in the cystocele type Ⅱ group(t= 2.291, 2.280, P=0.022, 0.023), which were consistent with the ultrasound findings. The incidence of dysuria, voiding dysfunction and levator ani muscle injury was higher in the cystocele type Ⅲ group(χ^(2)=23.731, 36.582, 20.067, P<0.001). While the incidence of urethral funnel opening and stress urinary incontinence in type Ⅱ cystocele group was higher than that in type Ⅲ cystocele group(χ^(2)=40.146, 16.330,P<0.001). Conclusion The clinical manifestations and anatomical changes of the pelvic floor perform differently in patients with different types of cystocele. Transperineal ultrasound may provide valuable imaging information for the diagnosis and the pathogenesis exploration of cystocele subtypes.