多模态超声定量评估高龄产妇产后早期盆底结构和功能变化及诊断压力性尿失禁的价值研究

doi:10.12114/j.issn.1007-9572.2021.02.104

摘要/Abstract

摘要： 背景我国高龄产妇在产妇中的占比呈上升趋势，而高龄产妇是女性压力性尿失禁（SUI）的高危人群。目的应用盆底二维、三维超声及实时剪切波弹性成像（SWE）定量评估高龄产妇产后早期盆底结构及功能的变化，确立高龄产妇产后早期SUI的超声诊断指标及界值。方法选取2016年8月至2021年2月于华北理工大学附属医院门诊就诊的产后早期（6~8周）高龄产妇（年龄≥35岁）105例为高龄组，并依据病史、体格检查结果、排尿日记、尿动力学检查结果等临床综合指标及临床诊断分为SUI亚组（51例）与非SUI亚组（54例）；选取同期来本院门诊就诊的产后早期适龄产妇（<35岁）89例为适龄组。产妇均接受多模态超声检查并记录检查结果：静息及张力状态下膀胱颈的位置及移动度（h1BL、h2BL、ΔhBL）、尿道倾斜角及尿道旋转角度（UIA1、UIA2、URA）、膀胱尿道后角（PVUA1、PVUA2）、肛提肌裂孔面积（LHA1、LHA2）、静息及缩肛状态下耻骨直肠肌弹性模量值及变化量（E1、E2、ΔE）。比较高龄组与适龄组多模态超声参数、SUI检出率；比较SUI亚组与非SUI亚组多模态超声参数；以临床诊断SUI为金标准，绘制多模态超声参数诊断高龄产妇产后早期SUI的受试者工作特征（ROC）曲线，计算ROC曲线下面积（AUC）。结果高龄组产妇h1BL、h2BL、ΔhBL、PVUA1、LHA2均大于适龄组，E1双侧、E2双侧、ΔE双侧均小于适龄组（P<0.05）。高龄组产妇中SUI检出率〔48.6%（51/105）〕高于适龄组〔32.6%（29/89）〕（χ2=5.081，P=0.028）。SUI亚组产妇h1BL、h2BL、ΔhBL、UIA2、URA、PVUA1、PVUA2、LHA1、LHA2均大于非SUI亚组，E1双侧、E2双侧、ΔE双侧均小于非SUI亚组（P<0.05）。绘制多模态超声参数诊断高龄产妇产后早期SUI的ROC曲线，结果显示，h1BL、h2BL、ΔhBL、PVUA1、PVUA2、LHA1、LHA2、E2双侧、ΔE双侧诊断高龄产妇产后早期SUI的AUC均>0.700，其中h1BL、h2BL、LHA1、ΔE双侧诊断高龄产妇产后早期SUI的AUC均>0.850，当最佳截断值分别为-2.28 cm、-0.50 cm、16.79 cm2、16.85 kPa时，灵敏度分别为82.4%、83.3%、94.1%、88.9%，特异度分别为90.2%、85.2%、90.2%、87.0%。采用二元Logistic回归分析构建的联合指标诊断SUI的函数为PRESUI=-3.691×h2BL-0.952×LHA1+0.675×ΔE，联合指标诊断高龄产妇产后早期SUI的AUC为0.992〔95%CI（0.982，0.999）〕，最佳截断值为0.571时，灵敏度及特异度分别为96.1%、96.3%。结论高龄产妇产后早期盆底结构较适龄产妇松弛明显，尤其是SUI患者，多模态超声可以定量评估高龄产妇产后早期盆底结构及功能的变化，h1BL、h2BL、LHA1、ΔE双侧及联合指标均可作为高龄产妇产后早期SUI的超声诊断指标，其中联合指标的诊断价值较高。

关键词: 尿失禁, 压力性, 盆底, 产后期, 超声检查, 多普勒, 弹性成像技术, 孕产妇健康, 诊断技术和方法

Abstract: Background

China is seeing an increase in the ratio of parturients of advanced maternal age, a population at high risk of stress urinary incontinence (SUI) .

Objective

To quantitatively assess pelvic floor structure and function changes and SUI, and to determine the ultrasonic diagnostic indices and threshold values for SUI in the early postpartum period in parturients of advanced maternal age using 2D and 3D ultrasound and real-time shear wave elastography (SWE) of the pelvic floor.

Methods

Participants were 194 puerperants who received ambulatory services in the early postpartum period (within the first 6-8 weeks after childbirth) from North China University of Science and Technology Affiliated Hospital from August 2016 to February 2021, including 105 of advanced maternal age (≥35 years old) and 89 of proper maternal age (<35 years old). SUI was determined by medical history, physical examination, urination diary and urodynamic test results and clinical diagnosis. Intergroup comparisons were conducted in terms of the detection rate of SUI, and parameters of 2D and 3D ultrasound and real-time SWE of the pelvic floor〔bladder neck position at rest (h_1BL) and tension (h_2BL), degree of mobility of bladder neck (Δh_BL), urethral inclination angle at rest (UIA₁) and tension (UIA₂), and urethral rotation angle (URA), posterior vesicourethral angle at rest (PVUA₁) and tension (PVUA₂), levator ani hiatus area at rest (LHA₁) and tension (LHA₂), elastic modulus of puborectal muscle in resting (E₁) and anal constriction state (E₂), and the difference between E₁ and E₂ (ΔE) 〕. The above-mentioned multimodal ultrasound parameters were also compared between those with SUI (n=51) and without (n=54) in the advanced maternal age group. The performance of multimodal ultrasound parameters in predicting early postpartum SUI was analyzed using the analysis of the area under the receiver operating characteristic curve (AUC), and was estimated with the accuracy of clinical diagnosis as the gold standard.

Results

Compared to parturients of proper maternal age, those of advanced maternal age had higher h_1BL, h_2BL, Δh_BL, PVUA₁, and LHA₂, and lower bilateral E₁, E₂, and ΔE (P<0.05). Moreover, they had higher detection rate of SUI〔48.6% (51/105) vs 32.6% (29/89) 〕 (χ²=5.081, P=0.028). Parturients of advanced maternal age with SUI had greater h_1BL, h_2BL, Δh_BL, UIA₂, URA, PVUA₁, PVUA₂, LHA₁, LHA₂, and less bilateral E₁, E₂, and ΔE than those without (P<0.05). For parturients of advanced maternal age, the analysis of the receiver operating characteristic curve of multimodal ultrasound parameters predicting early postpartum SUI revealed that the AUC for h_1BL, h_2BL, Δh_BL, PVUA₁, PVUA₂, LHA₁, LHA₂, bilateral E₂, or bilateral ΔE was greater than 0.700. In particular, the AUC was greater than 0.850 for h_1BL (-2.28 cm optimal cutoff, 82.4% sensitivity, 90.2% specificity), h_2BL (-0.50 cm optimal cutoff, 83.3% sensitivity, 85.2% specificity), LHA₁ (16.79 cm² optimal cutoff, 94.1% sensitivity, 90.2% specificity), or bilateral ΔE (16.85 kPa optimal cutoff, 88.9% sensitivity, 87.0% specificity). Binary Logistic regression analysis of PRESUI=-3.691×h_2BL-0.952×LHA₁+0.675×bilateral ΔE, an algorithm with three ultrasound parameters incorporated for predicting SUI in parturients of advanced maternal age, indicated that the AUC of h_2BL in combination with LHA₁ and bilateral ΔE was 0.992〔95%CI (0.982, 0.999) 〕, with 0.571 optimal cutoff, 96.1% sensitivity and 96.3% specificity.

Conclusion

The early postpartum pelvic floor structure of parturients of advanced maternal age, especially those with SUI, was more relaxed than that of those of proper maternal age. Multimodal ultrasound can quantitatively evaluate the changes of early postpartum pelvic floor structure and function in parturients of advanced maternal age. h_1BL, h_2BL, LHA₁, bilateral ΔE or the combination of h_2BL, LHA₁ and bilateral ΔE could be used as an ultrasonic predictor of early postpartum SUI in this group, and the latter has higher diagnostic value.

Key words: Urinary incontinence, stress, Pelvic floor, Postpartum period, Ultrasonography, doppler, Elasticity imaging techniques, Maternal health, Diagnostic techniques and procedures

中图分类号:

R694.54

李宁,阚艳敏,王艺桦,等. 多模态超声定量评估高龄产妇产后早期盆底结构和功能变化及诊断压力性尿失禁的价值研究[J]. 中国全科医学, 2022, 25(06): 706-713. DOI: 10.12114/j.issn.1007-9572.2021.02.104.

LI Ning, KAN Yanmin, WANG Yihua, LI Jie, SHI Chaohui, ZHANG Man, ZHANG Shuhua.

Value of Multimodal Ultrasound for the Quantitative Assessment of Early Postpartum Pelvic Floor Structure and Function Changes as Well as Stress Urinary Incontinence in Parturients of Advanced Maternal Age [J]. Chinese General Practice, 2022, 25(06): 706-713.

图/表 10

参考文献 21

[1]	丁荣楣，王平，马丽君，等. 高龄初产妇妊娠和分娩情况回顾性分析[J]. 护理研究，2019，33(1)：108-111. DOI：10.12102/j.issn.1009-6493.2019.01.024.
[2]	KHATRI G, CARMEL M E, BAILEY A A，et al. Postoperative imaging after surgical repair for pelvic floor dysfunction[J]. Radiographics，2016，36(4)：1233-1256. DOI：10.1148/rg.2016150215.
[3]	施素娟，俞小英，马银芬，等. 早期康复训练结合电刺激生物反馈治疗产后压力性尿失禁的临床观察[J]. 中国妇幼保健，2021，36(11)：2469-2472. DOI：10.19829/j.zgfybj.issn.1001-4411.2021.11.009.
[4]	KOSHIDA S, ARIMA H, FUJII T，et al. Impact of advanced maternal age on adverse infant outcomes：a Japanese population-based study[J]. Eur J Obstet Gynecol Reprod Biol，2019，242：178-181. DOI：10.1016/j.ejogrb.2019.08.011.
[5]	杜彦芳，蒋妍，黄向华. 女性尿失禁的分类及诊断标准[J]. 实用妇产科杂志，2018，34(3)：164-167.
[6]	罗丹. 基于整体理论孕期压力性尿失禁盆底形态学的超声评估[D]. 广州：南方医科大学，2018.
[7]	YIN Y, XIA Z, FENG X，et al. Three-dimensional transperineal ultrasonography for diagnosis of female occult stress urinary incontinence[J]. Med Sci Monit，2019，25：8078-8083. DOI：10.12659/msm.917086.
[8]	SZUMILEWICZ A, DORNOWSKI M, PIERNICKA M，et al. High-low impact exercise program including pelvic floor muscle exercises improves pelvic floor muscle function in healthy pregnant women—a randomized control trial[J]. Front Physiol，2018，9：1867. DOI：10.3389/fphys.2018.01867.
[9]	喻虹祯. 经会阴三维超声结合应变弹性成像评估前盆腔器官脱垂的临床研究[D]. 南宁：广西中医药大学，2020.
[10]	GACHON B, NORDEZ A, PIERRE F，et al. In vivo assessment of the levator ani muscles using shear wave elastography：a feasibility study in women[J]. Int Urogynecology J，2019，30(7)：1179-1186. DOI：10.1007/s00192-018-3693-4.
[11]	王瑾，王慧芳，陈华，等. 实时剪切波弹性成像测量女性耻骨直肠肌杨氏模量值[J]. 中国医学影像技术，2015，31(4)：586-589. DOI：10.13929/j.1003-3289.2015.04.028.
[12]	HOLLAND M A, JOYCE J S, BRENNAMAN L M，et al. Intravaginal diazepam for the treatment of pelvic floor hypertonic disorder：a double-blind，randomized，placebo-controlled trial[J]. Female Pelvic Med Reconstr Surg，2019，25(1)：76-81. DOI：10.1097/SPV.0000000000000514.
[13]	蒋云秀，潘永寿，潘焕贵，等. 经会阴三维超声联合实时剪切波弹性成像评价产后女性盆底功能的研究[J]. 生物医学工程与临床，2020，24(1)：45-49. DOI：10.13339/j.cnki.sglc.20200107.009.
[14]	孙立倩，王宏桥，付青，等. 经会阴盆底超声在女性压力性尿失禁诊疗中的应用进展[J]. 中华医学超声杂志：电子版，2015，12(2)：99-102. DOI：10.3877/cma.j.issn.1672-6448.2015.02.003.
[15]	HUANG I S, FAN Y H, LIN A T，et al. Correlation between bladder neck mobility and voiding phase urodynamic parameters in female patients with stress urinary incontinence[J]. Low Urin Tract Symptoms，2016，8(1)：44-48. DOI：10.1111/luts.12076.
[16]	BUSH M B, LIEDL B, WAGENLEHNER F，et al. A finite element model validates an external mechanism for opening the urethral tube prior to micturition in the female[J]. World J Urol，2015，33(8)：1151-1157. DOI：10.1007/s00345-014-1419-x.
[17]	肖汀，张新玲，毛永江，等.盆底超声在压力性尿失禁诊断中的应用研究[J]. 中华超声影像学杂志，2017，26(7)：618-622. DOI：10.3760/cma.j.issn.1004-4477.2017.07.014.
[18]	王丽华，陈军，邱月，等. 经会阴超声对压力性尿失禁的诊断价值分析[J]. 中国超声医学杂志，2019，35(1)：89-91. DOI：10.3969/j.issn.1002-0101.2019.01.030.
[19]	张红彬，栗河舟. 肛提肌裂孔面积与盆底功能障碍的相关性研究初探[J]. 中国临床医学影像杂志，2017，28(7)：513-515. DOI：10.3969/j.issn.1008-1062.2017.07.014.
[20]	钟婷婷，王丽，李载红，等. 声触诊组织定量剪切波弹性成像技术评估女性盆底功能障碍性疾病的应用研究[J]. 海南医学院学报，2021，27(1)：24-29. DOI：10.13210/j.cnki.jhmu.20200628.003.
[21]	郝岩，王丽，张坤，等. 社区综合干预辅助治疗女性轻中度压力性尿失禁患者的临床疗效[J]. 实用心脑肺血管病杂志，2018，26(4)：89-92. DOI：10.3969/j.issn.1008-5971.2018.04.021.

组别	例数	年龄（岁）	孕次（次）	产次（次）	BMI（kg/m²）	ΔW（kg）
高龄组	105	38.6±3.2	2.1±0.6	1.5±0.5	24.8±4.7	15.3±2.0
适龄组	89	28.3±3.2	1.5±0.5	1.2±0.4	23.0±4.6	15.2±1.9
t值		22.320	6.627	4.457	2.733	0.169
P值		<0.001	<0.001	<0.001	0.007	0.866

组别	例数	年龄（岁）	孕次（次）	产次（次）	BMI（kg/m²）	ΔW（kg）
高龄组	105	38.6±3.2	2.1±0.6	1.5±0.5	24.8±4.7	15.3±2.0
适龄组	89	28.3±3.2	1.5±0.5	1.2±0.4	23.0±4.6	15.2±1.9
t值		22.320	6.627	4.457	2.733	0.169
P值		<0.001	<0.001	<0.001	0.007	0.866

组别	例数	年龄（岁）	孕次（次）	产次（次）	BMI（kg/m²）	ΔW（kg）	分娩方式〔n（%）〕
组别	例数	年龄（岁）	孕次（次）	产次（次）	BMI（kg/m²）	ΔW（kg）	经阴道分娩	选择性剖宫产
SUI亚组	51	38.0±3.2	2.1±0.7	1.5±0.5	24.0±4.7	16.0±1.9	31（60.8）	20（39.2）
非SUI亚组	54	39.2±3.1	2.1±0.6	1.5±0.6	25.5±4.6	14.6±1.8	25（46.3）	29（53.7）
t（χ²）值		-1.949	-0.103	-0.268	-1.649	4.101	2.212^a
P值		0.054	0.918	0.789	0.102	<0.001	0.172

组别	例数	年龄（岁）	孕次（次）	产次（次）	BMI（kg/m²）	ΔW（kg）	分娩方式〔n（%）〕
组别	例数	年龄（岁）	孕次（次）	产次（次）	BMI（kg/m²）	ΔW（kg）	经阴道分娩	选择性剖宫产
SUI亚组	51	38.0±3.2	2.1±0.7	1.5±0.5	24.0±4.7	16.0±1.9	31（60.8）	20（39.2）
非SUI亚组	54	39.2±3.1	2.1±0.6	1.5±0.6	25.5±4.6	14.6±1.8	25（46.3）	29（53.7）
t（χ²）值		-1.949	-0.103	-0.268	-1.649	4.101	2.212^a
P值		0.054	0.918	0.789	0.102	<0.001	0.172

组别	例数	E₁				E₂				ΔE
组别	例数	左侧	右侧	t值	P值	左侧	右侧	t值	P值	左侧	右侧	t值	P值
高龄组	105	21.39±4.23	21.27±4.04	0.205	0.838	38.15±7.56	38.76±7.92	-0.574	0.567	16.76±4.59	17.49±5.67	-1.025	0.307
适龄组	89	23.42±5.01	22.74±5.20	0.900	0.369	47.43±5.72	47.49±5.85	-0.073	0.942	24.00±5.43	24.75±5.59	-0.909	0.365