经阴道超声探头触痛引导的女性盆腔肌筋膜疼痛扳机点的定位研究

Localization of trigger points of female myofascial pelvic pain guided by tenderness with transvaginal ultrasound probe

目的研发一种简单实用、可重复的超声检查方法定位女性盆腔肌筋膜疼痛扳机点所在肌肉, 继而为临床精准治疗提供影像学参考。方法前瞻性选取2021年9月1日至2023年4月20日于浙江大学医学院附属妇产科医院就诊的临床怀疑盆腔肌筋膜疼痛的患者共113例, 妇科医生分别对部分盆底肌(耻骨直肠肌、耻尾肌、髂尾肌、尾骨肌)和盆壁肌(梨状肌、闭孔内肌)进行指检内诊, 寻找疼痛扳机点所在的肌肉, 参照视觉模拟评分法(VAS)和数字分级法(NRS)疼痛评分方法进行疼痛评分, 将患者转介到超声科, 由超声医生使用经阴道超声探头实时显示上述肌群进行观察并对其适当加压, 通过触痛寻找疼痛扳机点所在肌肉并进行疼痛评分。将两次评分作对比, 进行一致性及差异性分析。结果疼痛扳机点明确, 再现性好, 对位于双侧耻骨直肠肌、耻尾肌、尾骨肌的疼痛扳机点定位及评分, 经阴道超声探头触痛引导法与临床触诊法一致性较强(一致率均≥70%), 对位于耻骨直肠肌和尾骨肌的扳机点疼痛评分, 两种方法差异不明显(P>0.05), 对位于其余盆底及盆壁肌群的扳机点疼痛评分差异有统计学意义(均P<0.05), 同时超声检查弥补了临床触诊对梨状肌评估不足的缺点。结论笔者研发的超声探头触痛引导的女性盆腔肌筋膜疼痛扳机点的寻找方法是一种新型无创、安全简便且实用的影像学方法, 可以为临床诊断盆腔肌筋膜疼痛、制定治疗策略提供影像学参考依据。

Objective To develop a simple,practical and repeatable ultrasound method to locate the muscle at the trigger point of female myofascial pelvic pain(MPP),which can provide imaging reference for clinical precision treatment.Methods A total of 113 patients with suspected MPP who came to the Women′s Hospital School of Medicine Zhejiang University from September 1,2021 to April 20,2023 were prospectively selected.The gynecologist performed internal examination with index finger on some pelvic floor muscles(puborectalis,pubococcygeus,iliococcygeus,coccygeus)and pelvic wall muscles(piriformis and obturator internus)respectively,searched for the muscles where the pain trigger point was located,and scored the pain by referring to visual analogue scale(VAS)and numerical rating scale(NRS),and then referred the patients to the ultrasound department.The ultrasound doctor used transvaginal ultrasound to display the above muscle groups in real time for observation and appropriate pressure.The muscle where the painful trigger point was located was found through tenderness and the pain score was performed.The two scores were compared for consistency and difference analysis.Results The trigger point was clear and of good reproducibility.For the location and score of pain trigger points located in bilateral puborectalis,pubococcygeus and coccygeus,there was a strong consistency between the tenderness guided by vaginal ultrasound probe and clinical palpation(the consistency rate was≥70%),and there was no significant difference in the pain scores of the trigger points located in the puborectalis muscle and coccygeal muscle between the two methods(P>0.05),and there was statistically significant difference in the pain scores of the trigger points located in the other pelvic floor and pelvic wall muscles(all P<0.05).At the same time,ultrasonic examination made up for the deficiency of clinical palpation in the evaluation of piriformis muscle.Conclusions The present method for finding the trigger point of MPP guided by the ultrasound probe is a new non-invasive,safe,simple and practical imaging method,which can provide a new imaging reference for the clinical diagnosis of MPP and the formulation of treatment strategies.