尿失禁治疗解剖和尿道中段理论.ppt

1、请陈述你的两个事实,举例 一个你希望大家知道的事实 一个你从没和任何人说过的事（包括不希望大家知道的事实）,泌尿生殖系统,耻骨联合,盆膈上筋膜,闭孔管,尿道,阴道,耻骨宫颈 韧带,直肠,弓腱,直肠,宫颈,输尿管,膀胱,尿道,闭孔肌和筋膜,耻骨宫颈筋膜,耻骨联合,直肠,阴道,膀胱,耻骨联合,尿道,尿道口,盆膈,膀胱,Pelvic Diaphragm - Female,Medial View,Pelvic brim (inlet),Obturator internus muscle,Tendinous arch of levator ani muscle,Obturator canal,Ilioc

2、occygeus portion of levator ani muscle,Pubococcygeus portion of levator ani muscle,Vagina,Urethra,Transverse perineal ligament,Piriformis muscle,Ischial spine,Coccygeus muscle,Rectum,Left levator ani muscle (cut),External anal sphincter muscle,Superficial transverse perineal muscle,尿失禁的类型,压力性尿失禁 急迫性

3、尿失禁 混合性尿失禁 充盈性尿失禁,I.盆底支持组织缺损（I & II) A. 阴道尿道韧带 Pubourethral ligaments B. 尿道下阴道吊筋膜 Suburethral vaginal hammock (endopelvic fascia) C. 连接上述组织的结缔组织(胶原纤维) Connective tissue (collagen fibers) interconnecting the above structures D. 提肛肌 Levator ani muscles - tone/contractility II.内源性和外源性尿道功能障碍 Defects in

4、both intrinsic and extrinsic urethral function: (III) A. Denervation B. Devascularization C. Aging,真性压力性尿失禁的病理特征,尿道功能的评估,尿道固有括约肌缺失 （intrinsic sphincter deficiency, ISD） 或称III型压力性尿失禁,尿道压力描记：最大尿道闭合压20cmH2O 腹压漏尿点压力测定：ALPP 60 cmH2O,诊断方法,尿动力学检查 是否需要尿动力学检查？ 什么情况下需要？什么情况下可以不要？,尿流率+残余尿量检查 其它检查方法 尿垫试验/棉签试验/V

5、alsava检查,根据病因选择手术方法,Hypermobility ISDBoth 尿道活动过度内源性括约肌功能障碍 合并 1. 经腹耻骨后尿道成形术1. 胶原注射1. 袖带式悬吊 2. 针刺尿道成形术2. 袖带式悬吊 3. 袖带式悬吊,尿道中段理论,THEORIES ON THE CAUSE OF STRESS INCONTINENCE 压力性尿失禁的成因 *Damage to internal urethral sphincter(Kennedy 1937) 尿道内括约肌损伤 *Changes in the posterior urethrovesical angle(Jeffcoate&

6、Roberts 1952) 尿道膀胱后角度的改变 *Shortening and funneling of the proximal urethra(Lapides 1960) 近端尿道变短和呈漏斗型 *The pressure equalization theory(Enhorning 1961) 压力相同理论 *The mid-urethra theory(Ulmsten 1990,1993),尿道中段理论,*THE BLADDER NECK CONCEPT 膀胱颈概念 *THE MID-URETHRA CONCEPT 尿道中段概念,尿道中段理论,THE BLADDER NECK CONC

7、EPT 膀胱颈概念 *Bladder neck sphincter-is not identified(Tanagho & Smith 1966) 膀胱颈括约肌-不明确 *Bladder neck mobility-no correlation with incontinence (Greenwald&al 1967, Kitzmiller&al 1972, Fantl&al 1986) 膀胱颈活动-与尿失禁无关 *Pressure transmission at the bladder neck is not greatly reduced in incontinent women(Lose

8、 1991) 尿失禁妇女的膀胱颈的压力传递无明显降低,尿道中段理论,THE MID-URETHRA CONCEPT尿道中段概念 ANATOMICAL ASPECTS解剖 *Vascular plexus at mid-urethra(Huisman 1983, Asmussen,Ulmsten 1983) 尿道中段血管从 *Supportive structures: Pubourethral ligament and Urogenital diaphragm located at mid-urethra(Zacharin 1968, Delancey 1994) 支持结构：耻骨尿道韧带和泌尿

9、生殖膈位于尿道中段处 *M.Pubococcygeus insers in the vaginal wall at the mid-urethra(Ingelman-Sundberg 1972) 耻尾肌在尿道中段处插入阴道壁,尿道中段理论,THE MID-URETHRA CONCEPT尿道中段概念 FUNCTIONAL ASPECTS功能 *Maximal urethral closure pressure at mid-urethra (Asmussen&Ulmsten 1976) 尿道中段具有最大尿道关闭压 *Highest pressure rise in distal part of

10、urethra on straining 压力下尿道远端具有最高压力升值 *Urinary flow interrupted at mid-urethra on holding 憋尿时尿流在尿道中段中断 *Dens innervation at mid-urethra 尿道中段神经分布密集,The Mid-Urethra Concept,Dysfunction of pubourethral ligaments, Pubococcygeus muscles or sub-urethral Wall allows urethra to stay open during Stress 耻骨尿道韧带，耻尾肌或尿道下壁功能 障碍使压力下尿道无法关闭,The Mid-Urethra Concept尿道中段理论Summary 总结,*Anatomical structures-Mid-urethra 解剖结构 尿道中段 *Functional featur