The Clinical Application Of Transperineal Sonography On Evaluating Female Severe Pelvic Organ Prolapse With Occult Stress Urinary Incontinence

Objective:Evaluate the clinical value of transperineal sonography in diagnosing occult stress urinary incontinence and predicting postoperation stress incontinence. Provide new ideas and basis for preoperative assessment and operation selection of women who have severe pelvic organ prolapse and occult stress urinary incontinence, by combining clinical examination with comparison of two and three-dimensional images of pelvic floor structure at rest, on Valsalva and contraction in women suffering from severe pelvic organ prolapse with and without stress incontinence and in women preoperative and postoperative.Methods:1. The first part: Validity Analysis of Transperineal Sonography in Diagnosing Occult Stress Urinary Incontinence in Severe Pelvic Organ Prolapse. Patients with Severe POP(pelvic organ prolapse), according to whether complicated with OSUI(occult stress urinary incontinence), divided into SUIPOP(POP with stress urinary incontinence) group and POP(POP without stress urinary incontinence) group with 60 cases for each. Parameters such as distance between the neck of bladder and the inferior edge of the symphysis pubis, retrovesical angle and the area of levator hiatal, etc. were compared by using 2D and 3D transperineal ultrasound.2. The second part: Analysis of Ultrasound Characteristics of Stress Urinary Incontinence before and after Pelvic Floor Reconstruction Surgery. Severe POP patients, who were complicated with OSUI and cured successfully by TVM(transvaginal placement of surgical mesh) participated in this part of the study. They were divided into POSUI(postoperative stress urinaryincontinence) group and control group according to whether complicated with postoperative SUI, with 12 cases for the former and 27 cases for the latter. Parameters such as distance between the neck of bladder and the inferior edge of the symphysis pubis, retrovesical angle, the area of levator hiatal, and the position of the mesh, etc. were compared by using 2D and 3D transperineal ultrasound in the same state.Results:1. The first part: Validity Analysis of Transperineal Sonography in Diagnosing Occult Stress Urinary Incontinence in Severe Pelvic Organ Prolapse.There were no significant differences between two groups in general information. SUIPOP group had a higher rate of levator injuries than POP group. There were significant differences between two groups in levator urethra gap, the area of levator hiatal, width of levator hiatal at rest, on contraction and Valsalva(P<0.05).Length of levator hiatal on contraction and Valsalva were longer and the thickness of the levator was thinner on contraction(P=0.03) in SUIPOP group than those in POP group(P=0.01). Compared with POP group, on Valsalva, the retrovesical angle was increased significantly, the position of the knee of urethral was higher, while ∠α was reduced dramatically in SUIPOP group. In SUIPOP group the area under the Receiver Operating Characteristic curve of levator urethra gap at rest, on contraction and Valsalva were 0.844、0.829、0.800, and the area under the Receiver Operating Characteristic curve of the width and the length of levator hiatal on contraction were 0.829 and 0.781, which indicated good validity.2. The second part: Analysis of Ultrasound Characteristics of Stress Urinary Incontinence After TVM Pelvic Floor Reconstruction Surgery.There were no significant differences between POSUI group and control group in general information. Before operation, there was a significant increase in the area of levator hiatal, levator urethra gap, length of levator hiatal on contraction and Valsalva and a significant increase in width of levator hiatal on Valsalva in POSUI group than that in control group. TVM pelvic floorreconstruction had no effect on urethral funnel and levator injury. On Valsalva, the levator urethra gap of POSUI group was no less than 2.50 cm, ∠α was less than 180°, the area of levator hiatal was no less than25.00cm2,and the width of levator hiatal was no more than 5.00 cm,the length of levator hiatal was no more than 6.50 cm.After operation, there was a significant increase in the area of levator hiatal, length of levator hiatal, levator urethra gap on contraction and Valsalva and a significant increase in width of levator hiatal and retrovesical angle on Valsalva in POSUI group than that in control group. But neither the thickness and injury of the levator nor the urethral funnel did changed after operation.Conclusions:1. Pelvic structures of severe POP patients who complicated with OSUI can be clearly showed by transperineal sonography. This can provide imaging support for the diagnosis of OSUI in severe POP patients.2. OSUI and POSUI are concerned with the area of levator hiatal, levator urethra gap.3. TVM Pelvic Floor Reconstruction Surgery is playing a limited role on limiting the expansion of the levator hiatus. The mechanisms of anti-urinary incontinence might be connected to the repair of under urethra vaginal hammock, and might be irrelevant to the repair of pubourethral ligament or uterosacral ligament.4.Combine with urodynamic study, multiple parameters measurement can improve the diagnostic accuracy of postoperative stress urinary incontinence.