婦女泌尿暨骨盆重建醫學

奇美醫學中心 婦產部婦女泌尿暨骨盆醫學科主任 台北醫學大學醫學院 婦產學科 副教授

成功大學醫學院臨床醫學研究所 博士

吳銘斌 醫師

泌尿及骨盆之解剖生理及診斷

婦女泌尿暨骨盆重建醫學

膀胱 (泌尿科) 直腸

(直腸外科)

子宮&陰道

(婦產科)

男女大不同

男女大不同

男女大不同

男女大不同

邀請您參訪我們"婦女泌尿暨骨盆重建 醫學 "網頁

http://www.chimei.org.tw/

←enter

←enter

永康各科部室介紹

←enter

骨盆解剖

腸骨

恥骨 坐骨

Pelvic bony structure

Walters MD, Karram MM 1999 Mosby

Normal vaginal axis in nulli-parous woman in the standing position

Obturator Internus muscle

DeLancey (level)

Suspension

I

Endopelvic fascia

Lateral

II

attachment

III

Pelvic Floor Support (骨盆支撐)

• DeLancey JOL 1994 Am J Obstet Gynecol

• Level I: suspension

– Cardinal ligament (主韌帶)

– Utero-sacral ligament (子宮薦骨韌帶)

• Level II: attachment

– Ant: pubo-cervical fascia (恥骨子宮頸筋膜) – Post: recto-vaginal septum (直腸陰道筋膜)

– arcus tendineus fasciae pelvis (弓型韌帶)(白線) – PUL: pubo-urethral ligament (恥骨尿道韌帶)

• Level III: fusion

– Perineum (會陰)

Cardinal ligament

arcus tendineus fasciae pelvis Rectovaginal fascia

Pubocervical ligaments

Pelvic suppport structures

6 Ligaments, 2 Fascia, 1 Ring

TeLinde’s Operative Gynecology

主韌帶

子宮薦骨韌帶

Laparoscopic uterine sling suspension:

management of uterine prolapse with uterine conservation

Mersilene tape is used to suspend the uterus to the sacral promontory bilaterally and to recreate new uterosacral ligaments. (n=8)

Cutner et al. BJOG 2007;114:1159–1162

Level I:

弓型韌帶 (白線) Ischial spine(坐骨棘)

Pelvic Fascia and Ligaments

主韌帶(Cardinal lig.

恥骨子宮頸筋膜 Pubo-cervical fas.

弓型韌帶 (白線)ATFP

子宮薦骨韌帶(U-S lig)

薦坐骨棘韌帶(S-S lig 子宮薦骨韌帶(U-S lig)

弓型韌帶 (白線)ATFP

ATFP

Cardinal U-S lig.

Cooper

Cooper’’s Ligs Lig

B

SS. Lig.

Pelvic organ support

ATFP: arcus tendinous fascia pelvis; OIMF: Obturator internus muscle fascia; PCF:

pubo-cervical fascia; PUL: pubo-urethral ligament; SS: sacrospinous

Ischial spine(坐骨棘)

薦坐骨棘韌帶

Sacro-spinous

ligament(薦坐骨棘韌帶) ATFP弓型韌帶(白線)

Cardinal ligament (主韌帶)

Utero-sacral ligament (子宮薦骨韌帶)

Ischial spine(坐骨棘)

Level II: pubo-cervical fascia

(恥骨子宮頸筋膜)

recto-vaginal septum

(直腸陰道筋膜)

Ant.

Post.

陰道前壁筋膜

陰道後壁筋膜 膀胱

直腸

陰道

直腸 膀胱

陰道

陰道前後壁筋膜鬆弛

造成骨盆底鬆弛

Int. Pud. V, N.

ATFP PUL

Cardinal U-S lig.

Cooper

Cooper’’s Ligs Lig

B U

PCF

OIMF

Cx (V)

SS. Lig.

Peri-cervical ring

Pelvic organ support

ATFP: arcus tendinous fascia pelvis; OIMF: Obturator internus muscle fascia; PCF:

pubo-cervical fascia; PUL: pubo-urethral ligament; SS: sacrospinous

閉孔動脈

(前分支)

閉孔膜

閉孔動脈

(前分支)

骨盆底閉孔膜(obturator membrane)

Bladder & Urethra

Normal Storage Voiding

Bladder Relaxed Contracted Urethra contracted relaxed

Abnormal Storage Voiding

Bladder Overactive Underactive Acontractile Urethra Incompetent

under stress Functional or anatomic

obstruction Inappropriate

relaxed

Stanton SL,Tanagho EA 1986 Springer-Verlag

正常解尿機轉Normal micturition cycle

PUL: 恥骨尿道韌帶 PCM: 恥骨尾肌

LMA: 肛門縱肌

USL: 子宮薦骨韌帶 LP: 提肌板

Radiological View of System in Balance:

NORMAL CLOSURE

AT REST

Bony Co-ordinatesOrgans stretched by 3 directional forces (arrows) against PUL & USL STRAININ

G Lateral xray

PUL

USL

V

R

LP B

CX

Every anatomical structure in the system plays a role

R = rectum V = vagina LP = levator plate

PUL = pubourethral ligament USL = uterosacral ligament

U = urethra X = bladder base B = bladder CX = cervix S=sacrum

3 ligaments • 3 muscles • 3 zones of dysfunction

INTEGRAL THEORY

an anatomical systems approach ANT MID POST

anterior posterior middle

posterior muscle forces

NORMAL CLOSURE: A System in Balance

are equal to

anterior muscle forces

anterior

posterior middle

Stress Incontinence Funnelling

posterior muscle forces

are weaker than

anterior muscle forces

ABORMAL CLOSURE: A System in Imbalance

Hammock theory 吊床理論

--

Abdominal pressure on urethra and pelvic floor

DeLancey JOL 19994 Am J Obstet Gynecol:

手術理論基礎

平 時 用力時

提肛肌 Levator ani

muscle

Deep transverse

muscle 閉孔肌 Obturators

muscles

Fatty avascular

perineal space

TVT-O

Anterior perineal prolongation of the ischio-rectal fossa

Back to Menu

第三代 TVT-Secure, MiniArc迷你手術

Kelly plication

Tradition bladder-neck sling

1st generation: Supra-pubic TVT, SPARC, IVS

2nd generation: Trans-obturator TVT-O, Monarc

The evolution of midurethral sling (MUS)

3rd generation: Single-incision TVT-secure, MiniArc

TVT: tension-free vaginal tape TVT-O: tension-free vaginal tape -obturator

SPARC: suprapubic arc

Endoscopic bladder neck

suspension (EBNS)

骨盆器官脫垂

Pelvic organ prolapse (POP)

z

陰道前壁脫垂

{

膀胱膨出

z

陰道後壁脫垂

{

直腸膨出

z

陰道頂端脫垂

{

子宮脫垂

{

陰道穹窿脫垂 (子宮切除後)

Prolapse of the apical segment of the vagina

Miklos JR 2002 Curr Opin Obstet Gynecol

陰道前後壁筋膜鬆弛造成骨盆底鬆弛

正常骨盆 (前)膀胱膨出

膀胱

(上)子宮脫垂

子宮

(後)腸膨出

小腸 直腸

膀胱

直腸 子宮

子宮脫垂嚴重度

www.moondragon.org/obgyn

第一度 第二度

第三度

子宮切除後之

陰道穹窿脫垂

Pelvic organ prolapse- quantitation (POP-Q)

Bump RC 1996 AJOG

Â

新陰道前壁人工網膜

新陰道後壁人工網膜

陰道前壁脫垂PerigeePerigee^™™

懸吊系統

American Medical System (AMS)

‧適用於:陰道前壁膀胱膨出

前壁人工筋膜 前壁人工筋膜

膀胱

American Medical System (AMS).

陰道後壁脫垂

PCF

B U

PVRPVR Burch VOSVOS

SSVS

Sacral colpopexy

High High McCall McCall’’s s

OpOp

TVT,IVS

Cx (V) Sling Sling

Cooper’s Lig.

Surgical approaches to PFR

PVR: para-vaginal repair; SSVS: sacrospinous vaginal suspension ; USS:

utero-sacral suspension; VOS: vaginal obturator shelf;

症狀 vs 診斷

• 應力性尿失禁

• Stress urinary incontinence (SUI) vs Urodynamic stress incontinence (USI)

尿 失 禁 (urinary incontinence)

小便不自主的漏出 造成衛生及社交的困擾

International Continence Society, ICS

為什麼我運動時 都會漏尿?

我咳嗽也會漏尿!

應 力 性 尿 失 禁 (stress urinary incontinence,

SUI)

頻尿 (frequency) 與夜尿 ^(nocturia)

白天小便次數多(等)於八次 每晚起床小便超過(等於)二次

急尿 急迫感 ^(urgency)

急迫性尿失禁 (urge incontinence)

膀 胱 過 動 症

頻尿

膀胱過動症

急尿

急迫性尿失禁

尿失禁種類

‧應力性尿失禁

‧急迫性尿失禁

‧混合型尿失禁

‧溢出性尿失禁

‧其他類型: 脊髓損傷､瘺管等

應 力 性 尿 失 禁

(1) 正常 (2)尿失禁

急迫性尿失禁

混 合 性 尿 失 禁

溢 出 性 尿 失 禁

ƒ

典型症狀包括：疼痛、尿頻、尿急

ƒ

下腹部（骨盆腔）疼痛

ƒ

頻繁、强烈的尿急感

ƒ

尿頻、夜尿

間質性膀胱炎(

Slide courtesy of A. Morales, MD

腎絲球狀出血點 亨納氏潰瘍

Glomerulations Hunners’ ulcer

儲尿(storage)

• 逼尿肌活性增強

– Detrusor overactivity

• 逼尿肌活性增強致尿失禁

– Detrusor overactivity incontinence

• 尿動力學應力性尿失禁

– Urodynamic stress incontinence (USI)

• 尿道放鬆致尿失禁

– Urethral relaxation incontinence

Urodynamic stress incontinence (USI) 尿動力學應力性尿失禁

Nygaard & Heit 2004 Obstet Gynecol

LP LP

Detrusor overactivity 逼尿肌活性增強

Nygaard & Heit 2004 Obstet Gynecol

LP LP LP LP

ICS Terminology

Chapple CR 2005 Nat Clin Practice Urol

排尿(voiding)

• 逼尿肌活性低下

– Detrusor

underactivity

• 逼尿肌無收縮力

– Acontractile detrusor

• 排尿後殘尿

– Post void residual (PVR)

• 膀胱出口阻塞

– Badder outlet obstruction

• 功能異常性排尿

– Dysfunctional voiding

• 逼尿肌括約肌共濟失調

– Detrusor sphincter

dyssynergia (DSD)

Stanton S L,Tanagho E A 1986 Springer-Verlag

尿失禁機轉Mechanism of urinary incontinence

a: normal voiding or DO; b: DSD; c: impair bladder compliance;

d: urethral instability; e: USI