泌尿外科专业 女性压力性尿失禁（SUI） 第二讲 上海交通大学医学院专科医师规范化培训课程 授课老师：上海仁济医院 冷静 副主任医师

主动性盆底肌训练 （kegel操锻炼）盆底肌肉训练 电刺激盆底肌肉锻炼 （被动性） 膀胱训练 行 为 治 疗

盆底肌肉操锻炼 主动性盆底肌训练 盆底肌训练法（pelvic muscle exercise）早在1948年由妇科医生Kegel提出，主要用以治疗压力性尿失禁。 盆底肌功能障碍与某些下尿路功能障碍的发生、发展和转归有关：盆底肌支托力下降和尿道括约肌的张力降低，使尿道下垂或活动度增加，尿道关闭功能不全，是出现压力性尿失禁的重要原因。

主动性盆底肌训练 盆底肌肉锻炼的目的就是重建和加强盆底控制排尿的肌肉组织——提肛肌群，从而加强了尿道外括约肌，使尿道关闭压升高，起到防治压力性尿失禁的作用 。 这些肌肉常起到维持盆腔内脏器（膀胱、子宫、阴道以及肛肠等）正常解剖位置的作用，从而防止它们的脱垂。当提肛肌群薄弱时，则较易形成盆腔脏器的脱垂，以及压力性尿失禁的产生。在临床中其常常作为医生治疗压力性尿失禁的一线方案。

盆底肌肉锻炼在年轻女性中往往效果较佳，原因是她们能较准确地锻炼到盆底肌肉群，老年患者锻炼的顺应性较差，在行锻炼时最好再配合一些辅助的锻炼，从而帮助她们尽量准确地锻炼到盆底肌肉群（如：生物反馈和电刺激治疗等）。 盆底肌肉锻炼对于轻度的解剖型压力性尿失禁效果最佳，对固有括约肌障碍型的压力性尿失禁效果不佳。 盆底肌肉锻炼可以治疗急迫性尿失禁或混合性尿失禁，对于男性前列腺术后的尿失禁也有一定帮助。

具体方法 盆底肌肉锻炼的方法简单而言就是训练提肛肌群的收缩，就好像人们在控制排尿或大便时的动作一样，可以同时伴有轻微的腹部、臀部以及大腿内侧肌群的收缩，但必须是以盆底提肛肌群收缩为主。

为什么传统Kegel操效果不理想 病人不知什么是盆底肌, 锻炼的常常会是腹部和大腿肌肉。 单纯没有阻力的收缩运动, 不能有效地使萎缩松弛的盆底肌得到锻炼, 就象不用哑铃在锻炼肱二头肌。

具体方法 患者开始时可以模仿以下动作 1、类似终断排尿的过程； 2、类似抑制肛门排气的过程； 3、如果仍不能掌握，则可以把自己的手指伸入阴道内，并进行阴道收缩，如果手指感觉到阴道的收缩即可。

具体方法 应遵循个体化方案，对于初学者来说，开始可以每组收缩5次，（每次收缩5秒，放松5秒），每隔一小时做一组。患者可以在非剧烈运动下的任何状态进行锻炼，如果练到腰酸背疼，则说明你锻炼的肌肉不正确 。 患者必须每天坚持锻炼，一般疗程为至少3-4个月。

具体方法 如果平时较忙的患者，每天只要锻炼两次，每次大约化时10分钟左右。方法是每组收缩25次，每次收缩时间为10秒，相应放松时间也是10秒。做第一组时可以慢慢的收缩，第二组则相应要加快收缩的速度，该方法也可起到同样的作用，一般需锻炼4-6个月。 对于较易健忘的患者，可以指导她们于当日每次上厕所时进行锻炼 。

借助辅助工具的盆底 肌肉锻炼方法 1、 阴道内置入类似塞子一样的锥形重物，并进行收缩，通过逐渐增加重物的重量，起到锻炼盆底肌群的目的。 一般重物的重量可分为5级：分别为20g、32.5g、45g、60g和75g。锥形重物合适地放入阴道后，阴道周围的肌肉群进行有规律的收缩时间约为10-15分钟左右，随着肌肉力量的加强，以后锻炼时间可增加至20-30分钟，每日锻炼两次。

曾经使用过的辅助器材 基于Kegel的基本原理，通过借着辅助器材来训练强化骨盆肌。以往是用各种“重锤”置于阴道内，通过收缩盆底肌含住“重锤”来强化骨盆肌。由于病人需要站立练习，较易疲劳，并且“重锤”不断置于阴道内很不方便，已经逐步淘汰。近年来已被盆底肌锻炼器取代。

2、盆底肌锻炼器 盆底肌锻炼器置于阴道内，通过正确的收缩盆底肌使锻炼器张开的两翼闭合。 就像用拉力器来锻炼身体其他部位的肌肉一样，盆底肌锻炼器提供了不同强度的阻力，使尿道，阴道周围的肌群得到逐步增强。

盆底肌锻炼器的构造 盆底肌锻炼器的结构由上下两翼和二个相同大小的弹力装置S1和一个较小的弹力装置S2组成 P1 P2 P3 S1 S2 盆底肌锻炼器的结构由上下两翼和二个相同大小的弹力装置S1和一个较小的弹力装置S2组成 S1=弹力装置1; S2=弹力装置2; P1=位子1； P2=位子2； P3=位子3  不同的组合可以产生不同大小不同的阻力。例如 第一阶段锻炼中的阻力组合 S2P3; S1P2; S1P1 第二阶段锻炼中的阻力组合 S1P2,S2P3; S1P1,S2P3; S1P1,S1P2; S1P1,S1P2,S2P3

使用方法 初次使用盆底肌锻炼器应该在医院里，经医生指导下使用。通过医生指导能更好地正确掌握锻炼方法，并遵医嘱定期随访。在熟练掌握使用方法后可以回家练习。具体操作步骤如下： 排空膀胱；洗净双手；用洗净擦干备用的盆底肌锻炼器开始锻炼。 第一阶段 对于刚开始练习使用的患者，建议从一个弹力装置开始，选择适合自己的弹力组合，并做好记录。握住手柄使盆底肌锻炼器闭合。在盆底肌锻炼器的头部涂上润滑剂做3-4次深呼吸。将盆底肌锻炼器慢慢放入阴道到插入停止点。平躺，垫两个枕头；双腿弯曲脚掌向下；双腿分开大约两只脚的距离；然后慢慢放松手柄让装置打开，使之贴住阴道壁。收紧盆底肌（要有解尿时憋回去的感觉）。不要用腹肌或只是收缩肛门。收紧盆底肌持续2秒钟，然后放松2秒钟。每一次的收紧放松代表一次运动。练习可分3组进行，每组练习30次。每组间休息15秒。当你适应了此阶段的训练强度，可以进入第二阶段的锻炼。 第二阶段 建议选用S1P1,S1P2弹力组合进行第二阶段的锻炼，你会发现在收紧盆底肌时遇到更大的阻力。如同第一阶段锻炼方法一样，但此阶段的练习可分为6组，每组练习30次。你可以尝试着延长收紧盆底肌的时间，这样可以更有效的锻炼你的盆底肌。但是要注意不要使肌肉过度疲劳。一般开始训练时每天练习一次，每星期练习2~3次，然后可以逐步根据你的情况增加到每星期5~7次。

总之，如果患者在进行Kegel操盆底锻炼的同时，配合以辅助工具锻炼的方法，往往能取得最佳的锻炼效果。对于绝经前的患者应用该方法治疗4-6周后的主观治愈率和改善率约为70-80%；对于绝经后的患者进行该方法锻炼也会有一定的疗效；但是对于有盆腔脏器脱垂的患者则效果不佳。

生物反馈在盆底肌肉 锻炼中的应用 对于仍无法正确锻炼到盆底肌肉的患者来说，可以应用盆底肌肉生物反馈的方法来找到正确的锻炼方法。盆底肌肉生物反馈治疗是提供反映会阴肌肉活动情况的信号，以指导患者很好的有选择性的收缩和放松盆底肌，而保持其他肌肉松弛。 最早的盆底肌肉生物反馈治疗仪器是Kegel设计的阴道测压计。

近来随着医学的不断发展，人们可以借助电子仪器和计算机的帮助，感受盆底肌肉收缩的信号，视觉或听觉的形式表现出来，这样患者就能据此进行准确有效的肌肉锻炼了。 我们认为对于那些较难掌握正确进行盆底操的患者而言，在盆底操锻炼时协同应用生物反馈的方法往往能取得较佳的效果。

电刺激盆底肌肉锻炼 电刺激是指用特定参数的电流，刺激盆腔组织器官或支配它们的神经纤维，通过对效应器的直接作用，或对神经通路活动的影响，改变膀胱／尿道的功能状态，以改善储尿或排尿功能。

电刺激不仅可以作用于盆底肌，它还可以作用于逼尿肌，抑制其不稳定收缩，达到治疗急迫性尿失禁的目的。应用功能性电刺激（functional electrical stimulation，FES）来治疗女性压力性尿失禁是近年来国外认为较为有效的疗法之一。

1、刺激阴部神经传出纤维，直接作用于盆底肌肉和尿道横纹肌 2、刺激阴部神经穿入纤维，抑制逼尿肌核的兴奋性，通过盆神经抑制逼尿肌的收缩 3、刺激上行兴奋交感神经，激活a受体，提高尿道压。

具体方法 经阴道插入电极，电极多呈棒状，以间歇式电流刺激盆底肌肉群。 刺激电使用的电刺激参数各家报道不一。 电刺激可直接和通过神经反射两条途径激活盆底肌，重建其神经肌肉兴奋性，使肌肉的收缩力增加；在接受较长期电刺激后还可增加盆底横纹肌中抗疲劳的肌纤维数量，并增强其活性。 每天2次，疗程8-12周

电刺激在治疗压力性尿失禁、急迫性尿失禁时， 可利用不同的频率，达到不同的效果。 当设定为低频（12.5Hz）时，可使骨盆神经（pelvic nerve）反射降低，从而达到降低膀胱逼尿肌敏感性，增加膀胱容量的目的。 当电刺激频率设定于高频（50Hz）时，可使骨盆底肌肉收缩，增强力度，达成与主动运动（凯格尔运动）相类似的效果。

有关盆底肌电刺激的疗效报道较多，但结果差异较大，有效率为 7％一91%不等，但大部分作者认为效果较满意，平均有效率在50%以上；在主观指标（包括排尿状况、24小时尿失禁次数、尿失禁量等）和客观指标（包括漏尿点压、排尿量、残余尿量、膀胱及各段尿道压、最大尿道压等）方面都有明显改善。 主要副作用为：少数患者因反复操作可能发生的阴道激惹和感染。

总之，一般而言，治疗压力性尿失禁总是首选侵袭性最小、副作用最少的治疗方法，如：药物治疗或功能锻炼等。 但是，损伤最小的治疗方法却并不意味着能到最佳的治疗效果；许多时候必需依靠外科手术来治疗压力性尿失禁。

经阴道无张力尿道中段吊带术 TVT术

TVT微创伤手术 1. 减少手术时间 Reduce surgical time 2. 减少住院时间 Reduce length of hospitalization 3. 减少并发症 Reduce complication rates/risks 4. 复原快 Allow quicker return to normal, daily activities 5. 减少费用 Lower costs

GYNECARE TVT Tension-free Support for Incontinence TVT尿失禁的无张力支撑 GYNECARE TVT Tension-free Support for Incontinence is an innovative minimally invasive surgical alternative for the effective treatment of stress urinary incontinence, with proven results 使用Prolene网带进行无张力尿道中段悬吊术 The placement of a piece of PROLENE mesh (45 cm x 1.1 cm x 0.7 mm) without tension, at the mid urethra

GYNECARE TVT Tension-free Support for Incontinence TVT尿失禁的无张力支撑 局麻, 阻滞/硬膜外Local anesthesia,sedation/regional 经阴道进路，切口小, 分离少 Minimal incisions and dissection 网带无张力地置于尿道中段下Tape placed at mid urethra without tension 普理灵聚丙烯网带无需和任何组织固定 No fixation 术中使用膀胱镜 Cystoscopy performed 术后插尿管时间短 Infrequent use of post-op catheters

怀孕病人 Pregnant patients 未完成发育的病人 Patients with future growth potential GYNECARE TVT Contraindications TVT尿失禁的无张力支撑禁忌征 怀孕病人 Pregnant patients 未完成发育的病人 Patients with future growth potential 计划要怀孕的病人 Women with plans for future pregnancy Please review the complete package insert is included in the Preceptee Binder.

TVT 网带 GYNECARE TVT Device GYNECARE TVT Tension-Free Support for Incontinence System TVT穿刺系统 TVT 网带 GYNECARE TVT Device 推针器 GYNECARE TVT Introducer 导引杆 GYNECARE TVT Rigid Catheter Guide The TVT Device is a PROLENE* polypropylene mesh tape, that is covered with a plastic sheath and attached to two stainless steel introducer needles. The device when used in conjunction with the TVT Introducer and TVT Rigid Catheter Guide make up the TVT System.

Prolene*网 带: 网 状 钩 形 编 织 , 外 面 套 有 塑 料 膜 GYNECARE TVT Tension-free Support for Incontinence Description: PROLENE*polypropylene mesh covered by a plastic sheath Prolene*网 带: 网 状 钩 形 编 织 , 外 面 套 有 塑 料 膜 The Prolene mesh tape is encased in a protective plastic sheath which remains in place until placement. This sheath, and the minimal dissection involved in its placement, minimizes the risk of infection of the tape.

Prolene*网 带 The protected mesh attached to introducer needles ready for the application.

TVT网带 长45公分, 宽一公分的网带, 成分为聚丙烯 网带的两侧边有特意编制的毛刺, 增加其在腹壁中的摩擦力, 将带子固定在腹壁中 网带的网眼大小适中, 术后结缔组织会长在网眼中, 加强盆底的组织

GYNECARE TVT Introducer 推针器 This is a reusable instrument. . .

GYNECARE TVT Rigid Catheter Guide 导引杆 This guide fits a standard 18 Fr Foley catheter. The guide passed into the bladder through the urethra, allows mobilization of the bladder neck and urethra away from the path of the TVT device.

导引杆 导引杆在手术中的作用主要是推开膀胱, 防止穿针过程中产生膀胱穿孔 它从18号导尿杆进入膀胱, 从左侧穿针, 就将膀胱推向右侧, 反之亦然

Instrument Requirements 手术需要的器械 阴道重锤/拉钩 弯剪-分 蚊式钳 - 钳住塑料套, 抽出. 长的硬膜外针头-局麻 膀胱镜 - 观察膀胱情况 18号(双枪)导尿管

GYNECARE TVT - Procedure 手术过程 病人准备 Patient preparation 切口 Incisions 分离，穿针，放置网带 Dissection, needle passage and tape placement 网带松紧度调整 Tension adjustment 结束手术 Completing the procedure Preparation includes positioning and anesthetizing the patient.

Anesthesia 麻醉 Abdomen 腹部 Apply local anesthesia in the skin just above the symphysis on both sides of the midline. Continue on each side in the abdominal wall, down in the muscles and fascia. Anesthesia is placed behind this symphysis in the retropubic space.

Anesthesia 麻醉 Vaginal Wall 阴道前壁 Insert speculum. Local anesthesia is applied sub-urethrally. Starting approximately 1.0 cm from the external urethra meatus. Apply local on each side of the urethra into the retropubic space. 3-4 minutes should be allowed for the anesthesia at act.

Incisions 切口 阴道前壁 Vaginal 在离尿道外口1cm处作1.5 cm 纵向切口 腹部 Abdominal 在耻骨联合上方，腹中线两侧各作一个0.5 cm - 1.0 cm切口 2 incisions each side of midline 两切口相距最宽4-5公分 just above symphysis 4 - 5 cm apart max.

在离尿道外口1cm处作1.5 cm 纵向切口 Vaginal Wall Incision 阴道前壁切口 The anterior vaginal wall overlying the mid to distal urethra is elevated with Allis clamps and incised vertically in the midline. The incision should begin approximately 1.0 cm from the external urethra meatus and extend for 1.5 cm. The incision should be long enough to accommodate the width of the TVT tape.

Abdominal Incisions 腹部切口 在耻骨联合上方，腹中线两侧各作一个0.5 cm - 1.0 cm切口，两切口相距最宽4-5公分 Two small incisions of .5 cm - 1.0 cm are made just above the pubic symphysis. These incisions are made about 2 cm on each side of the midline. The maximum distance between the incisions should be 4-5 cm. These are skin incisions only, no dissection is necessary.

Dissection of Anterior Wall 阴道前壁分离 Blunt Dissection sub and paraurethrally 在尿道旁和尿道下进行钝性分离 Metzenbaum scissors are used to dissect the vaginal incision sub and paraurethrally. Care should be take not to puncture the pubocervical fascia. The purpose of this dissection is to make a space lateral to the urethra which is the starting position for the TVT needle. The dissection through the pubocervical fascia, into the retropubic space and up to the abdomen is completed with the TVT Device.

Insert TVT Rigid Catheter Guide 插入TVT导引杆 Insert the TVT Rigid Catheter Guide into the 18 Fr Foley catheter. This is completed while the catheter is in situ. The purpose of the TVT catheter guide is to help identify the the urethra and most importantly to move the bladder neck from the path of the needle passage. After the guide is placed in the catheter, the handle is gently pushed inward and lateral to the side of needle passage. Moving the handle of the guide to the patients side where the needle will pass, will move the bladder in the opposite direction of the needle passage.

Introduction of the GYNECARE TVT Device 推入TVT网带 通过阴道切口推入 Introduce through vaginal incision 针头指向同侧乳头 Aim toward nipple 绕过耻骨 Hug the pubic bone (do not scrap 从腹壁切口出 Exit at abdominal incision Remove the Speculum. The needle and introducer should be assembled. Place the needle tip in the starting position within the paraurethral incision. With one hand take a gentle grip on the introducer. Position the needle tip through the vaginal incision lateral to the urethra. Your other hand should be placed where your index or middle finger can be placed on the pelvic rim under the vaginal wall. The curve of the TVT needle should rest in the palm of this hand. As the needle is passed into the retropubic space you should feel the needle pass behind the pubic bone. Correct positioning is as follows, the needle tip lateral to the urethra and horizontal aiming towards the ipsilateral should while perforating the urogenital diaphragm.

Introduction of the GYNECARE TVT Device 推入TVT网带 Remove the Speculum. The needle and introducer should be assembled. Place the needle tip in the starting position within the paraurethral incision. With one hand take a gentle grip on the introducer. Position the needle tip through the vaginal incision lateral to the urethra. Your other hand should be placed where your index or middle finger can be placed on the pelvic rim under the vaginal wall. The curve of the TVT needle should rest in the palm of this hand. As the needle is passed into the retropubic space you should feel the needle pass behind the pubic bone. Correct positioning is as follows, the needle tip lateral to the urethra and horizontal aiming towards the ipsilateral should while perforating the urogenital diaphragm.

Guide the Needle Tip to the Abdominal Incision 将针头导向腹壁切口

针不要拔出 After penetration of the abdominal fascia, one hand can be used to guide the needle tip through the suparpubic incision. After the needle tip has cleared the surface of the abdomen, release the needle from the introducer.

Cystoscopy 膀胱镜 针穿过后, 使用膀胱镜确保膀胱完好 After each passage of the needle, cystoscopy should be completed to verify bladder integrity 将膀胱注液后使用膀胱镜 Cystoscopy should be done with bladder half-full Urethrocystoscopy is performed after each passage of the introducer needle through the vagina and abdominal wall to verify that the lower urinary tract has not been injured. The cystoscopy should be preformed with the needle in situ, from the vagina to the abdomen. The purpose of cystoscopy at this point in the procedure is in the event of a bladder perforation the needle will be easy to identify. Also, the needle can be removed and re-introduced more laterally. If the needle is passed completely to the abdomen the the tape would have to be cut in order to remove it from the bladder. Destruction of the tape would necessitate opening a new device to complete the procedure. After bladder integrity has been confirmed, the needles should be pulled through the retropubic space and placed on the abdomen.

Bladder Perforation 膀胱穿孔 Urethrocystoscopy is performed after each passage of the introducer needle through the vagina and abdominal wall to verify that the lower urinary tract has not been injured. The cystoscopy should be preformed with the needle in situ, from the vagina to the abdomen. The purpose of cystoscopy at this point in the procedure is in the event of a bladder perforation the needle will be easy to identify. Also, the needle can be removed and re-introduced more laterally. If the needle is passed completely to the abdomen the the tape would have to be cut in order to remove it from the bladder. Destruction of the tape would necessitate opening a new device to complete the procedure. After bladder integrity has been confirmed, the needles should be pulled through the retropubic space and placed on the abdomen.

Bladder Perforation 膀胱穿孔

Second Passage of the GYNECARE TVT Device 第二根针的穿入 重新插导尿管, 排空膀胱 Re-insert the catheter and drain the bladder 重复第一次穿针的步骤 The opposite side is completed in the same manner as the first 确保网带没有扭转 Ensure that the tape does not twist 再次使用膀胱镜 Cystoscopy after the second pass of the TVT needle 针从腹壁切口拉出 Pull TVT needle through the abdomen incision For the second pass of the needle the Foley catheter should be re-inserted into the bladder and the saline drained. Insert the catheter guide and again move the handle to the same side the the needle will pass. As the needle tip in placed in starting position care should be taken to ensure that the tape is not twisted. The second needle passage is completed in the same manner as the first. Conduct a second cystoscopy. After bladder integrity is confirmed pull the second needle through to the abdomen.

将针剪去 Separate needles from the tape Tape Adjustment 调整网带 在网带和尿道间放置一把剪刀或止血钳 Place scissors or hemostat between the tape and the urethra 拉腹壁端的网带, 直到网带贴住剪刀 Pull the abdominal ends of the tape until there is contact between tape and instrument 将针剪去 Separate needles from the tape 先不要拉出塑料薄膜 Do not remove the plastic sheath Before starting the tension test, place scissors or a hemostat between the tape and urethra. Pull the abdominal end of the tape until there is slight contact between the tape and the instrument. Cut the needles from the tape. Do not remove the plastic sheath.

Cough Test 腹压测试 膀胱注液250毫升 Fill bladder with 250 ml of saline 取出尿道下的剪刀/或止血钳 Remove instrument under the urethra 取下阴道重锤 Remove vaginal speculum 要病人用力咳嗽 Ask patient to cough 调整网带松紧度 Adjust TVT tape 调整松紧度时, 剪刀要置于网带和尿道之间 Instrument should be placed between the tape and the urethra during adjustment The tension test should be conducted with a full bladder. The test should be preformed after removing all instruments. There should be no artificial pressure on the vaginal walls. During the tension test cooperation with the anesthesiologist is recommended. At this point in the procedure the patient should aware and able to generate a normal cough. After the first cough and the patient leaks, the tape should be pull upwards slightly from the abdominal ends. The patient should be ask to cough again. The tape should be positioned so that during the cough test only one or two drops of urine leak. The purpose of this is to ensure that the tape is not overly tensioned under the urethra. To simulate a closed vaginal wall during the stress test, reapproximate vaginal wall gently using small forceps.

Adjust Tape with Instrument in Place 器械放置在网带和尿道间, 调整网带

Completing the Procedure 完成手术 抽出塑料薄膜 Remove plastic sheath 剪去腹壁上多余的网带 Cut Prolene Mesh 缝合皮肤和阴道粘膜切口 Close skin and vaginal epithelium 排空膀胱 Empty bladder 置入导尿管 catheter Identify the plastic sheath at the abdominal ends of the tape and grasp it with forceps. Place and instrument, scissors or forceps, between the urethra and the tape. Hold the tape in place and remove the plastic sheath. The sheath has preformed its two major task. It has protected the tape during insertion and it has provided a smooth transition for the tape through the tissues. The tape is now in place, without tension, underneath the mid-urethra. Cut the abdominal ends of the tape just below the surface of the skin. DO NOT SUTURE OT ANCHOR THE ABDOMINAL ENDS OF THE TAPE. The friction from the opposing tissues to the tape secures the tape in place. Close the incisions in a normal manner. Complete testing with a Hegar dilator number 7-8. When inserted through the urethra there should be no resistance, i.e., the tape should not be noticed, Also, check that the proximal urethra is not in a fixed position. The bladder neck should be mobile. Empty bladder and remove catheter.

Trimming the mesh剪去多余的网带

Warnings and Precautions 注意事项 不要进行抗凝治疗 No anticoagulation therapy 没有尿路感染 NO UTI 要有一定膀胱颈悬吊术的经验 Familiar with bladder neck suspension surgery 用最小的张力在尿道中段下放置TVT网带 TVT placed with minimal tension at mid urethra 使用膀胱镜观察确保膀胱完好 Cystoscopy to confirm bladder integrity 注意盆腔结构, 避免组织损伤 Attention to pelvic anatomy to avoid injuries to structures 出院前观察是否有耻骨后血肿 Observe for retropubic hematoma before discharge

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