CAJ | 학술논문

目的探讨妊娠期和阴道分娩后尿失禁(UI)患者盆底神经肌肉病理学特征. 方法对常规产前检查的正常初产妇100例,于妊娠37周后和产后42 d采用女性下尿路症状国际UI标准问卷进行问卷调查,记录UI情况,阴道分娩者于第三产程后取阴道前、后壁黏膜组织和肛提肌组织.阴道分娩的75例中39例产妇肛提肌取材成功,27例成功进行组织学染色,观察肌肉形态学变化、测量肌纤维直径并进行分型.共64例产妇阴道黏膜成功取材,40例成功进行蛋白基因产物9.5、血管活性肠肽(VIP)和神经肽Y等三种免疫组化染色,分别计数阴道黏膜内三种抗体阳性神经纤维末梢的数目. 结果孕期及产后UI和非UI组肛提肌标本中I型纤维均占优势(76.5%～79.6%),Ⅰ型和Ⅱ型肌纤维的直径和比例在孕期及产后UI和非UI组间差异无统计学意义(P>0.05).产后UI组阴道前壁固有层内VIP神经分布少于产后非UI组(3.7±1.0和5.2±2.1,P=0.012).产后UI组第二产程时间明显长于产后非UI组[(63.3±25.4)min和(44.8±23.3)min,p=0.018];第二产程时间长是发生产后UI的危险因素(Logistic回归系数为0.028,P=0.028).结论肛提肌形态学改变、肌纤维直径以及Ⅰ型和Ⅱ型肌纤维比例的改变,不是引起妊娠期和产后UI的直接原因.阴道前壁固有层内的VIP神经分布减少,可能是产后UI的发病机制之一.第二产程时间长是发生产后UI的危险因素.
목적 탐토임신기화음도분면후뇨실금(UI)환자분저신경기육병이학특정. 방법대상규산전검사적정상초산부100례,우임신37주후화산후42 d채용녀성하뇨로증상국제UI표준문권진행문권조사,기록UI정황,음도분면자우제삼산정후취음도전、후벽점막조직화항제기조직.음도분면적75례중39례산부항제기취재성공,27례성공진행조직학염색,관찰기육형태학변화、측량기섬유직경병진행분형.공64례산부음도점막성공취재,40례성공진행단백기인산물9.5、혈관활성장태(VIP)화신경태Y등삼충면역조화염색,분별계수음도점막내삼충항체양성신경섬유말소적수목. 결과잉기급산후UI화비UI조항제기표본중I형섬유균점우세(76.5%～79.6%),Ⅰ형화Ⅱ형기섬유적직경화비례재잉기급산후UI화비UI조간차이무통계학의의(P>0.05).산후UI조음도전벽고유층내VIP신경분포소우산후비UI조(3.7±1.0화5.2±2.1,P=0.012).산후UI조제이산정시간명현장우산후비UI조[(63.3±25.4)min화(44.8±23.3)min,p=0.018];제이산정시간장시발생산후UI적위험인소(Logistic회귀계수위0.028,P=0.028).결론 항제기형태학개변、기섬유직경이급Ⅰ형화Ⅱ형기섬유비례적개변,불시인기임신기화산후UI적직접원인.음도전벽고유층내적VIP신경분포감소,가능시산후UI적발병궤제지일.제이산정시간장시발생산후UI적위험인소.
Objective To investigate the neuromuscular characteristics of the pelvic floor in women with urinary incontinence (UI) during pregnancy and after vaginal delivery and the pathologic characteristics of the levator ani muscle (LAM)and innervation of the vaginal mucosa. Methods From Jul. to Dec. 2006, 100 primiparas presented to Peking Union Medical College Hospital were enrolled, and symptoms of UI were assessed by International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms Module. After the third stage of labor, biopsies of levator ani muscle (LAM) and anterior and posterior vagina mucoaa were obtained. LAMs's structure were successfully stained in 27 cases for examination of the morphological changes, classification and measurement. Vaginal mucosa specimens were successfully stained in 40 cases with the following immunohistochemistry stainings: PGP9.5, VIP and NPY staining, and the positive stained nerve fibers were calculated respectively. Results The type Ⅰ muscular fibers were predominant(76.5%～79.6%) in LAMs in both UI and non-UI groups and no significant difference was observed in either diameters or ratio of muscular fibers of type Ⅰ or Ⅱ fibers (P>0.05).Innervation of VIP nerve fibers in the lamina propria of the anterior vaginal wall was different between the UI and non-UI group post delivery[(3.7±1.0)/HPE vs (5.2±2.1)/HPE, P<0.05)].Parturients in the UI group had experienced longer duration in the second stage than those in non-UI group [(63.3±25.4) min vs (44.8±23.3) rain, P<0.05]. Prolonged second stage of labor is the risk factor of UI after vaginal delivery (Logistic regression coefficient = 0.028, P< 0.05).Conclusions The changes of morphology, muscular fiber diameters and proportions in LAMs of parturients is directly associated with neither antipartum nor postpartum UI. Decreased innervation of VIP nerve fibers in the lamina propria of the anterior vaginal wall may contribute to the pathogenesis of UI after normal delivery. Prolonged second stage constitutes a risk factor for postpartum UI.