产时肛门括约肌损伤妇女肛提肌形态及功能

Levatoranimusclemorphologyandfunctioninwomenwithobstetricanalsphincterinjury产时肛门括约肌损伤妇女肛提肌形态及功能Approximately,oneoutoffivewomenwillundergosurgicalrepairforpelvicorganprolapseduringtheirlifetime.约1/5的妇女一生中会接受盆腔器官脱垂修复手术Levatoraniavulsionisasignificantriskfactorforpelvicorganprolapsewhichcanbedetectedbypalpation,ultrasoundorMRI.肛提肌撕裂是盆腔器官脱垂的重要风险因素，通过触诊、超声、MRI发现However,itiscontroversialwhetherlevatoraniavulsionisalsoariskfactorforurinaryoranalincontinence.而肛提肌撕裂是否为尿失禁或粪失禁的高危因素存在争议INTRODUCTION介绍~%20Obstetricanalsphincterinjury(OASI)canbediagnosedafterdeliveryviapalpationwhereasmostlevatoraniavulsionsareoccult.

产时肛门括约肌损伤（OASI）可在产后通过触诊诊断，而大多数肛提肌损伤是隐匿性的INTRODUCTION

介绍Levatoranimuscle(LAM)avulsion肛提肌撕裂Analsphincterinjury肛门括约肌损伤TheprimaryaimofthisstudywastoestimatetheprevalenceofmajorLAMinjuryinwomenwithclinicallydiagnosedOASIandtoexploretheriskfactorsassociatedwithLAMinjury.本研究主要目的是评估临床上诊断为OASI的妇女中肛提肌撕裂的发生率，探讨肛提肌损伤相关的风险因素ThesecondaryaimwastoassesstheassociationbetweenLAMinjuryandpelvicfloormusclecontraction,analincontinence(AI)andurinaryincontinence(UI)inwomenwithOASI.另外的目的是评价肛提肌损伤与盆底肌肉收缩、粪失禁及尿失禁的相关性(n=250)WomenreferredtoCroydonUniversityHospitalbetween2013and2015withaclinicaldiagnosisofOASIwereincludedinthestudy.Includedwomenwereevaluatedvia:2013-2015年因诊断为OASI转诊至Croydon大学医院的妇女纳入本研究，并通过下列方法进行评价Clinicalhistory临床病史Analincontinence-St.Mark’sincontinencescore粪失禁-St.Mark’s失禁评分Urinaryincontinence–ICIQ-UI-SF尿失禁-ICIQ-UI-SFPelvicmusclestrength-ModifiedOxfordScale盆底肌力-改良Oxford量表LAMintegrity–transperineal4Dultrasound肛提肌完整性-经会阴4D超声METHODS方法Atthetimeofevaluation,88(35.2%)womenwerepregnantagain.进行评估时，88例（35.2%）妇女再次妊娠Themediantimeintervalbetweenlastpregnancyandevaluationwas5months.末次妊娠距评估间隔时间中位数为5个月Twowomenwereexcludedfromanalysisduetoartifactsinthesavedimagevolumes(levatormusclewasassessedin248ultrasoundvolumes).排除了存储图像容积有伪像的2例（248个超声容积数据中评价了肛提肌）RESULTS结果MajorLAMavulsion肛提肌明显撕裂

(73/248,29.4%)IntactLAM肛提肌完整(177/248,70.6%)Evaluatedwith4Dtransperinealultrasonography使用经会阴4D超声评价Unilateral单侧(49/248,19.8%)Bilateral双侧(24/248,9.7%)RESULTSRESULTS结果FactorsassociatedwithmajorLAMavulsion(univariateanalysis)肛提肌明显撕裂相关因素（单因素分析）PreviousoperativedeliveryincreasedsignificantlytheoddsofmajorLAMavulsionalongwithobesityintheunivariateanalysis在单因素分析中手术产及肥胖明显增高了肛提肌明显撕裂的几率P<0.05因素手术产胎吸产钳胎吸+产钳3c+4级撕裂风险减低风险增高RESULTS结果FactorsassociatedwithmajorLAMavulsion(multivariableanalysis)肛提肌明显撕裂的相关因素（多因素分析）Previousoperativedelivery(forceps)andlowerBMIremainedassignificantriskfactorsformajorLAMavulsion.手术产（产钳）及BMI减低是肛提肌明显撕裂有意义的风险因素Womenwithpreviousoperativedeliveryhad4.1timesincreasedoddsofmajorLAMavulsion.有手术产史的妇女发生肛提肌明显撕裂的几率升高4.1倍One-pointincreaseinBMIwasassociatedwitha10%reducedriskofmajorLAMavulsion.

BMI增长一个点，肛提肌明显撕裂的风险减少10%RESULTS结果WomenwithmajorLAMavulsionhadweakerpelvicmusclecontractioninbothdigitalandultrasoundexamination.指检和超声检查均显示肛提肌明显撕裂的妇女肌力减低However,majorLAMavulsionwasnotassociatedwithanincreasedseverityofanalorurinaryincontinencesymptoms.而肛提肌明显撕裂与粪失禁和尿失禁症状严重程度并不相关DISCUSSION讨论Inthisstudy,operativevaginaldeliverywasassociatedwithafour-foldhigherriskofLAMinjurythanwasnormalvaginaldelivery.此研究中手术助产的阴道分娩较正常阴道分娩与肛提肌损伤风险增高4倍相关WomenwithmajorLAMinjuryhadweakerpelvicfloormusclecontractionasassessedbypalpationandonultrasound.指检和超声评价显示肛提肌明显损伤的妇女盆底肌收缩弱NoassociationbetweenLAMinjuryandAIorUI,andnoassociationbetweenmusclecontractionandincontinenceweredemonstrated.肛提肌损伤与粪失禁或尿失禁无相关性，肌肉收缩与失禁无相关POINTSFORDISCUSSION讨论重点TheeffectofmajorLAMavulsionsonincontinencesymptomsinelderlywomen.肛提肌明显损伤对老年妇女失禁症状的影响Possibleimplicationsofuniversal