UOG Journal Club: March 2019 Levator ani muscle morphology and function in women with obstetric anal sphincter injury 产时肛门括约肌损伤妇女肛提肌形态及功能 I. Volløyhaug, A. Taithongchai, I. Van Gruting, A. Sultan and R. Thakar Volume 53, Issue 3, pages 410–416 Journal Club slides prepared by Dr Erkan Kalafat (UOG Editor for Trainees) Translated by Dr. Yinghua Xuan, Prof. Qingqing Wu 幻灯制作：Dr Erkan Kalafat 翻译 ：玄英华 吴青青

Levator ani muscle morphology and function in women with obstetric anal sphincter injury Volløyhaug et al., UOG 2019 INTRODUCTION 介绍 Approximately, one out of five women will undergo surgical repair for pelvic organ prolapse during their lifetime. 约1/5的妇女一生中会接受盆腔器官脱垂修复手术 ~%20 Levator ani avulsion is a significant risk factor for pelvic organ prolapse which can be detected by palpation, ultrasound or MRI. 肛提肌撕裂是盆腔器官脱垂的重要风险因素，通过触诊、超声、MRI发现 However, it is controversial whether levator ani avulsion is also a risk factor for urinary or anal incontinence. 而肛提肌撕裂是否为尿失禁或粪失禁的高危因素存在争议

Levator ani muscle (LAM) Levator ani muscle morphology and function in women with obstetric anal sphincter injury Volløyhaug et al., UOG 2019 INTRODUCTION 介绍 Obstetric anal sphincter injury (OASI) can be diagnosed after delivery via palpation whereas most levator ani avulsions are occult. 产时肛门括约肌损伤（OASI）可在产后通过触诊诊断，而大多数肛提肌损伤是隐匿性的 Levator ani muscle (LAM) avulsion 肛提肌撕裂 Anal sphincter injury 肛门括约肌损伤 The primary aim of this study was to estimate the prevalence of major LAM injury in women with clinically diagnosed OASI and to explore the risk factors associated with LAM injury. 本研究主要目的是评估临床上诊断为OASI的妇女中肛提肌撕裂的发生率，探讨肛提肌损伤相关的风险因素 The secondary aim was to assess the association between LAM injury and pelvic floor muscle contraction, anal incontinence (AI) and urinary incontinence (UI) in women with OASI. 另外的目的是评价肛提肌损伤与盆底肌肉收缩、粪失禁及尿失禁的相关性

Levator ani muscle morphology and function in women with obstetric anal sphincter injury Volløyhaug et al., UOG 2019 METHODS 方法 Women referred to Croydon University Hospital between 2013 and 2015 with a clinical diagnosis of OASI were included in the study. Included women were evaluated via: 2013-2015年因诊断为OASI转诊至Croydon大学医院的妇女纳入本研究，并通过下列方法进行评价 Clinical history 临床病史 Anal incontinence- St. Mark’s incontinence score 粪失禁-St. Mark’s 失禁评分 Urinary incontinence – ICIQ-UI-SF 尿失禁-ICIQ-UI-SF Pelvic muscle strength - Modified Oxford Scale 盆底肌力-改良Oxford量表 LAM integrity – transperineal 4D ultrasound 肛提肌完整性-经会阴4D超声 (n = 250)

Levator ani muscle morphology and function in women with obstetric anal sphincter injury Volløyhaug et al., UOG 2019 RESULTS 结果 At the time of evaluation, 88 (35.2%) women were pregnant again. 进行评估时，88例（35.2%）妇女再次妊娠 The median time interval between last pregnancy and evaluation was 5 months. 末次妊娠距评估间隔时间中位数为5个月 Two women were excluded from analysis due to artifacts in the saved image volumes (levator muscle was assessed in 248 ultrasound volumes). 排除了存储图像容积有伪像的2例（248个超声容积数据中评价了肛提肌）

RESULTS Intact LAM 肛提肌完整 (177/248, 70.6%) Levator ani muscle morphology and function in women with obstetric anal sphincter injury Volløyhaug et al., UOG 2019 RESULTS Intact LAM 肛提肌完整 (177/248, 70.6%) Major LAM avulsion 肛提肌明显撕裂 (73/248, 29.4%) Evaluated with 4D transperineal ultrasonography 使用经会阴4D超声评价 Unilateral 单侧 (49/248, 19.8%) Bilateral 双侧 (24/248, 9.7%)

Levator ani muscle morphology and function in women with obstetric anal sphincter injury Volløyhaug et al., UOG 2019 RESULTS 结果 Factors associated with major LAM avulsion (univariate analysis) 肛提肌明显撕裂相关因素（单因素分析） 风险减低 风险增高 因素 手术产 胎吸 产钳 胎吸+产钳 3c+4级撕裂 Previous operative delivery increased significantly the odds of major LAM avulsion along with obesity in the univariate analysis 在单因素分析中手术产及肥胖明显增高了肛提肌明显撕裂的几率 P < 0.05

Factors associated with major LAM avulsion (multivariable analysis) Levator ani muscle morphology and function in women with obstetric anal sphincter injury Volløyhaug et al., UOG 2019 RESULTS 结果 Factors associated with major LAM avulsion (multivariable analysis) 肛提肌明显撕裂的相关因素（多因素分析） Previous operative delivery (forceps) and lower BMI remained as significant risk factors for major LAM avulsion. 手术产（产钳）及BMI减低是肛提肌明显撕裂有意义的风险因素 Women with previous operative delivery had 4.1 times increased odds of major LAM avulsion. 有手术产史的妇女发生肛提肌明显撕裂的几率升高4.1倍 One-point increase in BMI was associated with a 10% reduced risk of major LAM avulsion. BMI增长一个点，肛提肌明显撕裂的风险减少10%

Levator ani muscle morphology and function in women with obstetric anal sphincter injury Volløyhaug et al., UOG 2019 RESULTS 结果 Women with major LAM avulsion had weaker pelvic muscle contraction in both digital and ultrasound examination. 指检和超声检查均显示肛提肌明显撕裂的妇女肌力减低 However, major LAM avulsion was not associated with an increased severity of anal or urinary incontinence symptoms. 而肛提肌明显撕裂与粪失禁和尿失禁症状严重程度并不相关

Levator ani muscle morphology and function in women with obstetric anal sphincter injury Volløyhaug et al., UOG 2019 DISCUSSION 讨论 In this study, operative vaginal delivery was associated with a four-fold higher risk of LAM injury than was normal vaginal delivery. 此研究中手术助产的阴道分娩较正常阴道分娩与肛提肌损伤风险增高4倍相关 Women with major LAM injury had weaker pelvic floor muscle contraction as assessed by palpation and on ultrasound. 指检和超声评价显示肛提肌明显损伤的妇女盆底肌收缩弱 No association between LAM injury and AI or UI, and no association between muscle contraction and incontinence were demonstrated. 肛提肌损伤与粪失禁或尿失禁无相关性，肌肉收缩与失禁无相关

POINTS FOR DISCUSSION 讨论重点 Levator ani muscle morphology and function in women with obstetric anal sphincter injury Volløyhaug et al., UOG 2019 POINTS FOR DISCUSSION 讨论重点 The effect of major LAM avulsions on incontinence symptoms in elderly women. 肛提肌明显损伤对老年妇女失禁症状的影响 Possible implications of universally screening postpartum women with transperineal ultrasonography for the detection of pelvic muscle trauma. 产后经会阴超声普查盆底肌肉损伤的意义 Importance of pelvic rehabilitation for women with pelvic muscle trauma. 盆底肌肉损伤妇女盆底康复的重要性