Wall L L, Hewitt J K
Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina.
Urology. 1994 Sep;44(3):336-41; discussion 341-2. doi: 10.1016/s0090-4295(94)80088-x.
To review the symptoms and lower urinary tract function in women with posthysterectomy vaginal vault prolapse.
A retrospective review was carried out of the urodynamic records of 19 women with posthysterectomy vaginal vault prolapse who had been evaluated in the Bladder Function Laboratory of the Department of Obstetrics and Gynecology at Duke University Medical Center.
A full urodynamic evaluation was carried out on 19 women who had had a hysterectomy and who had subsequently experienced complete prolapse of the vaginal vault. Vaginal eversion produced massive distortion of the lower urinary tract and was associated with complex symptoms. Among the cystometric findings in these patients was an early average first desire to void (94 mL) and a reduced average cystometric capacity (370 mL). Symptoms of voiding difficulty were common. During noninstrumented uroflowmetry, the average peak and mean flow rates were reduced in these women (16.5 mL/s and 8.1 mL/s, respectively), suggestive of functional obstruction of the outlet due to the prolapse. Pressure-flow voiding studies showed a reduced peak flow rate (11 mL/s) with an increased detrusor pressure at peak flow (50 cm H2O), also indicative of functional obstruction. All women underwent urethrocystoscopy, and no patient had a urethral stricture or urethral stenosis. Although symptoms of urgency (79%) and urge incontinence (63%) were common, detrusor instability was confirmed by urodynamic studies in only 3 women (16%), suggesting that urge-related symptoms in these women may often be due to anatomic distortion of the lower urinary tract rather than to detrusor overactivity. "Genuine" stress incontinence was documented in only 2 women (11%) during cystometry; however, when these patients were examined with full bladders with their prolapses reduced and returned to a normal anatomic position with a single-bladed speculum, the physical sign of stress incontinence was demonstrated in all 9 women (47%) who had a complaint of stress incontinence. This suggests that massive vaginal prolapse may mask an incompetent continence mechanism, which may then be revealed after surgical repair of the prolapse.
Women with posthysterectomy vaginal vault prolapse present complicated reconstructive problems for the pelvic surgeon. The same pathophysiological process may produce both voiding dysfunction and stress incontinence. These patients should be evaluated carefully before surgical repair is undertaken. Stress incontinence may not be demonstrated in these patients unless they are examined with a full bladder with their prolapse carefully reduced to a normal anatomic position. Women who demonstrate stress incontinence with the vaginal prolapse reduced and the urethra supported normally should be suspected of having "type III" incontinence (demonstrable stress incontinence in the presence of normal urethral support). Women with these findings may require a suburethral sling procedure if they are to remain continent after correction of posthysterectomy vaginal vault eversion.
回顾子宫切除术后阴道穹窿脱垂女性的症状及下尿路功能。
对在杜克大学医学中心妇产科膀胱功能实验室接受评估的19例子宫切除术后阴道穹窿脱垂女性的尿动力学记录进行回顾性分析。
对19例已行子宫切除术且随后出现阴道穹窿完全脱垂的女性进行了全面的尿动力学评估。阴道外翻导致下尿路严重变形，并伴有复杂症状。这些患者的膀胱测压结果包括早期平均首次排尿欲望容量（94毫升）及平均膀胱测压容量降低（370毫升）。排尿困难症状常见。在非仪器化尿流率测定期间，这些女性的平均峰值流速和平均流速降低（分别为16.5毫升/秒和8.1毫升/秒），提示脱垂导致出口功能性梗阻。压力 - 流率排尿研究显示峰值流速降低（11毫升/秒），峰值流时逼尿肌压力升高（5 ... 展开全部
子宫切除术后阴道穹窿脱垂的女性给盆腔外科医生带来了复杂的重建问题。相同的病理生理过程可能导致排尿功能障碍和压力性尿失禁。在进行手术修复前，应对这些患者进行仔细评估。除非在膀胱充盈且脱垂被仔细复位至正常解剖位置的情况下检查，否则这些患者可能不会表现出压力性尿失禁。对于阴道脱垂复位且尿道正常支撑时表现出压力性尿失禁的女性，应怀疑患有“III型”尿失禁（在尿道支撑正常的情况下可证实的压力性尿失禁）。有这些表现的女性在子宫切除术后阴道穹窿外翻矫正后若要保持控尿，可能需要进行尿道下吊带手术。
