何 偉, 陳容容, 張桂輝, 陳文娟, 夏學(xué)穎, 孫 賽, 李麗燕, 胡葵葵

作者單位：510010 廣州，廣州醫(yī)科大學(xué)(何 偉)；廣東省婦幼保健院 整形美容科(陳容容,張桂輝,陳文娟,夏學(xué)穎,孫 賽,李麗燕,胡葵葵)

?

陰道緊縮術(shù)術(shù)前評(píng)估的臨床應(yīng)用

何 偉, 陳容容, 張桂輝, 陳文娟, 夏學(xué)穎, 孫 賽, 李麗燕, 胡葵葵

作者單位：510010 廣州，廣州醫(yī)科大學(xué)(何 偉)；廣東省婦幼保健院 整形美容科(陳容容,張桂輝,陳文娟,夏學(xué)穎,孫 賽,李麗燕,胡葵葵)

目的 探討陰道松弛患者的術(shù)前評(píng)估要點(diǎn)和必要性。方法 對(duì)40例施行陰道緊縮術(shù)患者的術(shù)前相關(guān)癥狀與體征按照陰道松弛問卷調(diào)查表進(jìn)行評(píng)估，然后再設(shè)計(jì)手術(shù)方案。對(duì)合并Ⅲ度以上陳舊性會(huì)陰裂者要重建肛門括約肌。結(jié)果 按照問卷調(diào)查表進(jìn)行評(píng)估，所有患者手術(shù)安全，術(shù)后滿意度高，并能及時(shí)發(fā)現(xiàn)部分患者隱匿的相關(guān)癥狀和體征，規(guī)避了可能出現(xiàn)的風(fēng)險(xiǎn)。部分患者隨訪6～24個(gè)月，效果良好。結(jié)論 陰道松弛是盆底功能性障礙疾病中的一個(gè)表現(xiàn)，術(shù)前進(jìn)行必要評(píng)估有利于醫(yī)師正確理解患者的相關(guān)盆底病理解剖，以提高手術(shù)安全性，達(dá)到成功修復(fù)的術(shù)后效果。

陰道松弛； 陰道緊縮術(shù)； 問卷調(diào)查； 術(shù)前評(píng)估

陰道松弛是盆底障礙性疾病中的一個(gè)表現(xiàn)[1-2]，近年來已有越來越多的美容整形醫(yī)師涉足該領(lǐng)域[3-4]。然而，如果對(duì)陰道松弛的病理解剖認(rèn)識(shí)不足，將致臨床中存在很多問題和隱患。自2009年8月至2013年12月，廣東省婦幼保健院整形美容科對(duì)40例陰道松弛患者進(jìn)行陰道緊縮術(shù)，并重視患者的術(shù)前評(píng)估，提高了手術(shù)安全性和術(shù)后效果?，F(xiàn)報(bào)道如下。

1 臨床資料

本組共40例患者，年齡24～53歲；均因陰道松弛致性生活不滿意。其中，生育3胎6例,生育2胎16例，其余18例均生育一胎。胎兒體質(zhì)量超過3.5 kg者24例?；颊咝g(shù)前陰道松弛均可達(dá)3指或3指以上，均合并陰道口松弛；39例合并會(huì)陰體缺損(Ⅰ度裂傷12例，Ⅱ度裂傷20例，Ⅲ度裂傷7例)，合并子宮下垂10例，合并張力性尿失禁9例，合并稀便失禁和不能控制排氣7例；會(huì)陰體高度平均2.2 cm。對(duì)所有陰道松弛的病例予以手術(shù)前評(píng)估。

2 評(píng)估方法

術(shù)前對(duì)患者進(jìn)行系統(tǒng)問卷調(diào)查及陰道檢查和評(píng)估。問卷內(nèi)容包括：⑴孕、產(chǎn)情況。如懷孕次數(shù)、人流次數(shù)、陰道產(chǎn)次數(shù)、陰道產(chǎn)胎兒體質(zhì)量、有無肩難產(chǎn)史、有無胎頭過大史、有無側(cè)切史、有無產(chǎn)鉗術(shù)史。⑵肛提肌及周圍肌肉情況。如有無陰道后壁膨出、陰道前壁膨出、子宮脫垂、肛門排氣不能自控、張力性尿失禁、稀便失禁、肛門完全失禁。⑶患者性生活及心理情況。如性生活是否有陰道排氣、有無性生活時(shí)性感不快及性高潮障礙。⑷陰道及會(huì)陰體檢查情況。如陰道口可容納手指數(shù)、陰道內(nèi)可容納手指數(shù)、陰道皺襞是否存在、會(huì)陰體高度、會(huì)陰體有無裂傷及裂傷程度、有無肛門松弛變形、兩側(cè)肛提肌是否對(duì)稱等。

3 手術(shù)方法

所有患者術(shù)前行陰道清潔，確定無炎癥后做腸道準(zhǔn)備1～5 d，給予無渣半流質(zhì)飲食，做清潔灌腸等;均采用硬膜外麻醉。先用兩把Allis鉗鉗夾處女膜環(huán)下緣后向中線牽拉合攏，以陰道口寬2指(4.0 cm)為宜[5]；然后行會(huì)陰切口，于陰道后壁深面、兩側(cè)的直腸以及直腸旁間隙注射水墊[6]，游離陰道直腸間隙，由于間隙的組織疏松，剪刀易于前進(jìn)且不易出血;用剪刀自陰道口向陰道深部銳性分離5.0～6.0 cm，顯露肛提肌;對(duì)合并肛門括約肌損傷者重建肛門括約肌，縫合肛提肌；兩側(cè)向中線靠攏的距離需要參考縫合后陰道的大小，并適當(dāng)切除過多的陰道黏膜；最后重建會(huì)陰體，使成形后陰道寬度約容納2指[7-8]，并直腸指診檢查縫線是否穿透直腸。術(shù)后陰道內(nèi)填塞碘仿紗布,于術(shù)后48 h取出;傷口外涂紅霉素眼膏,術(shù)后7 d拆線,1.5個(gè)月內(nèi)禁止性生活，同時(shí)指導(dǎo)患者進(jìn)行肛提肌訓(xùn)練，避免大便干燥。

4 結(jié)果

本組共40例患者, 隨訪6～24個(gè)月,未出現(xiàn)陰道直腸瘺或感染等并發(fā)癥；會(huì)陰體高度平均3.5 cm，從陰道口向內(nèi)5.0～6.0 cm的陰道松緊度適宜，均述肛門括約功能改善，陰道收縮能力增強(qiáng)，術(shù)后性生活質(zhì)量有所提高。見圖1。其中，3例術(shù)后圍絕經(jīng)期患者述陰道正常分泌物減少，未再次出現(xiàn)泌尿和生殖系感染；7例原有肛門失禁者，對(duì)術(shù)后解剖上的修復(fù)較滿意，其中1例仍遺留一定程度的括約肌功能紊亂。

5 討論

陰道松弛患者除了有性生活障礙，還可能合并排尿和排便的異常。因分娩造成的會(huì)陰損傷，有的是可見的，有的是看不見的，雖然會(huì)陰表面正常，但其深部肌肉已經(jīng)受損。經(jīng)修復(fù)后，其功能可恢復(fù)或部分恢復(fù)，而且隨著年齡的增加，因盆底組織松弛加重，部分患者還會(huì)出現(xiàn)更嚴(yán)重的盆底組織松弛和器官脫垂。陰道松弛是盆底功能障礙性疾病中的一個(gè)表現(xiàn)，因此，施術(shù)者應(yīng)該獲取完整的病史，特別是患者的產(chǎn)科分娩史或會(huì)陰手術(shù)史及其癥狀和體征，均應(yīng)在認(rèn)真進(jìn)行檢查后，做好術(shù)前評(píng)估。

圖1 陰道外口手術(shù)前后對(duì)比 a.術(shù)前 b.術(shù)后80 d

Fig 1 Comparison between preview and postview of vaginal orifice. a. preview. b. postview at 80 days.

一般陰道松弛的程度與懷孕、人流、陰道產(chǎn)的次數(shù)及胎兒體質(zhì)量、胎頭大小、急產(chǎn)、肩難產(chǎn)是密切相關(guān)的。無會(huì)陰側(cè)切史的產(chǎn)婦容易并發(fā)會(huì)陰撕裂，而陰道皺襞消失則提示陰道黏膜下筋膜斷裂;性生活時(shí)陰道排氣，提示有陰道松弛情況。如果有尿失禁、尿頻和尿急，尿流緩慢、不連續(xù)、變形及膀胱不能完全排空的感覺，則提示有下尿路感染癥狀。張力性尿失禁患者較盆底功能正常的婦女肛提肌退化的比例升高，陰道最大擠壓力和盆底肌厚度降低[9]。對(duì)膀胱過度活動(dòng)癥,不管是否有尿失禁，都會(huì)影響女性的性健康，降低性欲和達(dá)到性高潮的能力[10]。我們結(jié)合以上諸多臨床經(jīng)驗(yàn)，對(duì)傳統(tǒng)的女性性行為滿意度調(diào)查表進(jìn)行了調(diào)整修改，制定了全新的陰道緊縮術(shù)術(shù)前評(píng)估問卷，對(duì)問卷溝通中應(yīng)重點(diǎn)了解的內(nèi)容，如是否合并有排便障礙、功能性便秘、大便失禁、直腸或肛門脫垂等低位腸道癥狀及盆腔器官脫垂合并的性生活障礙等，與患者進(jìn)行深入地溝通。筆者認(rèn)為，對(duì)有陰道松弛合并張力性尿失禁的患者，單純行陰道緊縮術(shù)有可能加重張力性尿失禁，而對(duì)部分陰道松弛可能合并隱匿性肛門括約肌的損傷，同時(shí)給予肛門括約肌的重建，可極大地提高手術(shù)效果和患者的滿意度。所以，對(duì)陰道松弛有合并尿瘺和糞瘺的患者，單純行陰道緊縮術(shù)則不能有效改善陰道松弛癥狀。

總之，陰道松弛有著它的復(fù)雜性和多樣性[11-13]，但是否進(jìn)行了充分的術(shù)前評(píng)估，對(duì)陰道松弛的手術(shù)修復(fù)效果有著極大的影響。術(shù)前，醫(yī)師應(yīng)通過與患者溝通過程中，對(duì)其相關(guān)盆底疾病的病理解剖有充分了解，以提高手術(shù)安全性和術(shù)后效果。

[1] Thubert T, Bakker E, Fritel X. Pelvic floor muscle training and pelvic floor disorders in women[J]. Gynecol Obstet Fertil, 2015,43(5):389-394.

[2] Goodman MP, Placik OJ, Benson RH 3rd, et al. A large multicenter outcome study of female genital plastic surgery[J]. J Sex Med, 2010,7(4 Pt 1):1565-1577.

[3] Kosciński T, Friebe Z, Stadnik H, et al. Anatomical and functional results of a modified sacral perineocolporectopexy for extreme forms of complex pelvic organs prolapse-own experience[J]. Ginekol Pol, 2015,86(6):429-433.

[4] Abedi P, Jamali S, Tadayon M, et al. Effectiveness of selective vaginal tightening on sexual function among reproductive aged women in Iran with vaginal laxity: a quasi-experimental study[J]. J Obstet Gynaecol Res, 2014,40(2):526-531.

[5] Law T S, Cheung R Y, Chung T, et al. Efficacy and outcomes of transobturator tension-free vaginal tape with or without concomitant pelvic floor repair surgery for urinary stress incontinence: five-year follow-up[J]. Hong Kong Med J, 2015,21(4):333-338.

[6] Coyne KS, Margolis MK, Brewster-Jordan J, et al. Evaluating the impact of overactive bladder on sexual health in women: what is relevant?[J]. J Sex Med, 2007,4(1):124-136.

[7] Kaartinen IS, Vuento MH, Hy?ty MK, et al. Reconstruction of the pelvic floor and the vagina after total pelvic exenteration using the transverse musculocutaneous gracilis flap[J]. J Plast Reconstr Aesthet Surg, 2015,68(1):93-97.

[8] Detollenaere RJ, den Boon J, Stekelenburg J, et al. Sacrospinous hysteropexy versus vaginal hysterectomy with suspension of the uterosacral ligaments in women with uterine prolapse stage 2 or higher: multicentre randomised non-inferiority trial[J]. BMJ, 2015,351:h3717.

[9] Thomas V, Shek KL, Guzmán Rojas R, et al. Temporal latency between pelvic floor trauma and presentation for prolapse surgery: a retrospective observational study[J]. Int Urogynecol J, 2015,26(8):1185-1189.

[10] Osmundsen B, Gregory WT, Denman MA, et al. Tension-free vaginal tape failure after robotic sacrocolpopexy and tension-free vaginal tape for concomitant prolapse and stress incontinence[J]. Female Pelvic Med Reconstr Surg, 2015,21(5):244-248.

[11] Li C, Gong Y, Wang B. The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis[J]. Int Urogynecol J, 2015,25.

[12] Roos AM, Thakar R, Sultan AH, et al. The impact of pelvic floor surgery on female sexual function: a mixed quantitative and qualitative study[J]. BJOG, 2014,121(1):92-100.

[13] Attenberger UI, Morelli JN, Budjan J, et al. The value of dynamic magnetic resonance imaging in interdisciplinary treatment of pelvic floor dysfunction[J]. Abdom Imaging, 2015,40(7):2242-2247.

Clinical application of preoperative evaluation of vaginal tightening surgery

HEWei,CHENRong-rong,ZHANGGui-hui,CHENWen-juan,XIAXue-ying,SUNSai,LILi-yan,HUKui-kui.

(DepartmentofPlasticSurgeryGuangzhouMedicalUniversity,Guangzhou510010,China)

HUKui-kui,Email：hukuikui68@163.com

Objective To evaluate the main points and necessity of preoperative evaluation for the treatment of vaginal relaxation. Methods The study was carried out on 40 women with vaginal relaxation. According to the questionnaires, preoperatively correlated symptoms and signs were collected by and evaluated, and then the operative methods were designed. Some of them with more than Ⅲ degree perineal lacerations were also performed the reconstruction of anal sphincter. Results All of the 40 patients evaluated by questionnaires underwent successful operation with high degree of satisfaction after operation. Some of the concealed symptoms were discovered preoperatively which could avoid possible risks. Some patients were followed up for 6 to 24 months and the results were good. Conclusion Pelvic floor dysfunction disease may contribute to the vaginal relaxation, questionnaire assessments included pelvic examinations and documentation of adverse events need to be carried out preoperatively to improve the safety and efficacy of vaginal tightening surgery.

Vaginal relaxation; Vaginal tightening surgery; Questionnaire; Preoperative relaxation

何 偉(1987-)，男，黑龍江雞西人，醫(yī)師，碩士研究生.

胡葵葵，510010，廣東省婦幼保健院 整形美容科，電子信箱：hukuikui68@163.com

10.3969/j.issn.1673-7040.2016.01.014

R713.2

A

1673-7040(2016)01-0037-03

2015-10-08)