Menopausal pelvic organ prolapse

Introduction to menopausal pelvic organ prolapse The pelvic organ is displaced forward or downward from its normal position, called pelvic organ prolapse (POP). Traditional classifications include uterine prolapse, bladder bulging, and rectal bulging. Nowadays, urethral bulging, intestinal bulging, and perineal prolapse are becoming more and more important. basic knowledge The proportion of illness: 0.012% Susceptible people: women Mode of infection: non-infectious Complications: renal insufficiency

Causes of pelvic organ prolapse during menopause

(1) Causes of the disease

Pelvic organ prolapse is mainly caused by childbirth and birth injury, pelvic organ prolapse caused by severe birth injury, symptoms have appeared after childbirth, most of the pelvic organ prolapse is delayed, with the increase of menopause years The rate increases and the symptoms worsen.

Because women with pelvic organ prolapse are basically maternal, birth injury is the anatomical basis of pelvic organ prolapse. Occasionally, uterine prolapse occurs in women with no birth history, which is congenital dysplasia with pelvic floor tissue. Related, whether the pelvic floor support tissue defect is due to birth injury or congenital dysplasia, but the symptoms of pelvic organ prolapse often in the perimenopausal period, postmenopausal pelvic organ prolapse symptoms are more serious, so estrogen is regulating the pelvic floor Tissue tension plays an important role.

(two) pathogenesis

There are enough research and literatures to prove that the uterus supports the ligament in the normal position, the main ligament, the patellofemoral ligament has estrogen and progesterone receptors, supports the urethral bladder, the vaginal fascia of the rectum in the normal position, the levator ani muscle and its The fascia also has estrogen and progesterone receptors. The postmenopausal estrogen level and its receptor decrease, which plays an important role in the occurrence of pelvic organ prolapse. There are many researches in the field of pelvic organ support tissue receptors.

Through immunohistochemical staining studies: regardless of age, race, parity, body mass index, whether menopause, uterine fibular ligament smooth muscle nucleus in the presence of estrogen and progesterone receptors, and uterine fibular ligament collagen, blood vessels or neuronal tissue No estrogen and progesterone receptors were found, so the uterine fibular ligament is the target organ of estrogen and progesterone, and hormones play a role in pelvic support through this action.

Immunocytochemical staining and image analysis were used to quantitatively determine the levator ani muscle progesterone in 55 gynecological patients. The androgen receptor (ER, PR, AR) was found to detect ER in the levator ani muscle interstitial cells. The levator ani muscle fascia has different degrees of ER, PR, AR expression, but no ER expression of the muscle fiber nucleus.

In the study of animal models of macaques, it was found that the adjacent tissues of the vagina consisted of levator ani muscles and dense collagen and elastic fibers infiltrating the muscle fibers. The fibroblasts in the tissues were positive for estrogen and progesterone receptors and responded to hormones. .

Lang Jinghe (2003) and semi-quantitative determination of estrogen receptors in the main ligament and patellofemoral ligament of the uterus by immunohistochemical methods, found that serum estrogen levels and ER values of uterine ligaments were significantly reduced in peri-menopausal women with pelvic organ prolapse. Its reduction is directly proportional to the extension of menopause years. Lang Jinghe's research is more powerful in explaining the pelvic organ prolapse and estrogen reduction in perimenopausal and menopausal women, and the reduction of ER in pelvic floor support tissues.

Histological studies of pelvic organ prolapse in menopausal women focused on changes in smooth muscle cells, fibroblasts, and collagen in supporting tissues.

The histological study of collagen synthesis and type I procollagen mRNAs in vaginal fascia fibroblasts was performed to investigate whether connective tissue in patients with pelvic relaxation was dysfunctional. The results showed that the composition of women with fascial tissue increased with age. The biosynthesis of fibroblast collagen decreased, and these two changes were related to age and hormonal status. It was not related to uterine prolapse. The growth of fibroblasts and the synthesis of collagen in patients with uterine prolapse showed the same as the control group. Or a slight increase, Makinen's study shows that, not because of the growth of fibroblasts, the synthesis of collagen decreases, causing pelvic relaxation, but the increase in age and the decrease in estrogen lead to the cell structure of fascia tissue and fibroblast collagen. Biosynthesis declines.

The results of the study were slightly different from those of Makinen. The histopathology was used to examine the connective tissue content of the vaginal fascia, main ligament, patellofemoral ligament, and round ligament in women with pelvic organ prolapse, and compared with women without prolapse. The key factor for weak tissue support in women with organ prolapse is a decrease in fibroblasts and an increase in collagen content in connective tissue.

Uterine humeral ligament recovery (UsR) was measured by surface tension measurement, and it was found that UsR was significantly reduced in patients with symptomatic uterine vaginal prolapse (P=0.02), UsR and vaginal delivery (P=0.003), menopause (P=0.009) ), age-related (P = 0.005) is related, it is believed that the uterine fibular ligament is significantly thinner after menopause, containing less estrogen and progesterone receptors, lowering the UsR, and lowering the tension, which promotes the visceral prolapse of the pelvic cavity.

The uterine humerus ligament (US ligament), the main ligament, and the US ligament of the SUI and POP patients, the collagen of the main ligament, were observed by transmission electron microscopy (TEM) in patients with stress urinary incontinence (SUI) and pelvic organ prolapse (POP). It is the same in histology, its smooth muscle bundle is thin and abnormally arranged; collagen metabolism is active; the diameter of collagen fibrils is 25% thicker than that of the control group, and the smooth muscle arrangement and collagen superactivity of the ligaments of the SUI and POP groups are considered. The microstructure is obviously abnormal. These collagen fibrils lack elasticity and are more likely to break. In tissue repair, collagen denaturation may lead to SUI and POP.

Immunohistochemistry was used to study the anterior vaginal wall of patients with pelvic organ prolapse. It was found that the vaginal non-vascular area smooth muscle component of prolapsed patients was significantly reduced compared with the control group, which was not related to age, race, or degree of prolapse. Women with peri-menopausal prolapse have been significantly reduced, and the number of prolapsed women without HRT after menopause is most pronounced.

In summary, due to birth injury, the smooth muscle component of the vaginal wall tissue is reduced, the uterine fibular ligament, the main ligament in the tissue repair, the smooth muscle bundle becomes thin, the arrangement is disordered, the collagen is proliferated, and the tissue is deformed, so the pelvic floor supports the tissue tension. Decreased, these changes are the histological basis of pelvic organ prolapse, increasing with age, with the onset of menopause, increased menopause, decreased estrogen levels, cell composition of fascia tissue and fibroblast collagen Biosynthesis decreased, and ER of pelvic support tissues decreased. These changes were further aggravated, resulting in a marked increase in the incidence of pelvic organ prolapse.

Menopausal prevention of pelvic organ prolapse

Prevention of birth trauma, early detection, early treatment, and strengthening the exercise of the pelvic muscles.

Menopausal pelvic organ prolapse complications Complications, renal insufficiency

Severe bladder bulging can be complicated with bilateral hydronephrosis and even renal insufficiency.

Menopausal pelvic organ prolapse symptoms common symptoms urinary pain urinary frequency constipation backache acid congestion sexual intercourse lumbosacral pain urinary incontinence menopause dysuria and urinary retention

1. Clinical stage of pelvic organ prolapse

There are different methods for quantitative staging of pelvic organ prolapse. The most common use in the world is the quantitative system developed by Baden in 1968. The current domestic textbook introduces some provinces, municipalities and autonomous regions in 1981. "The research collaboration group's opinion, both methods use the hymen as a reference point to bulge any bladder, rectal bulging, intestinal bulge, uterine or vaginal dome reduction, due to the lack of repeatability of the measurement system and Specificity, its terminology is not accurate enough to describe the location of tissue prolapse. In 1996, the International Association of Urinary Control (ICS) recommended the Quantitative Staging Method for Pelvic Organ Prolapse (POP-Q). The three staging methods are now described below.

(1) Domestic staging method: The opinions of the two diseases scientific research collaboration group held in some provinces, municipalities and autonomous regions held in Qingdao in 1981: the patient was lying flat during the examination, and the degree of uterus decreased when the force was lowered, the uterus prolapsed For 3 degrees:

I degree: light type: the outer cervix is at the distance of the hymen margin <4cm, not reaching the hymen edge; heavy: the cervix has reached the virgin margin, the vaginal opening can be seen in the cervix.

II degree: light: the cervix is pulled out of the vaginal opening, the uterus is in the vagina; heavy: part of the palace is pulled out of the vaginal opening.

III degree: the cervix and the uterus are all removed from the vaginal opening.

(2) Baden classification method:

0 degrees: no prolapse.

I degree: The prolapsed tissue is located between the ischial spine and the hymen.

II degree: prolapsed tissue up to the vaginal opening.

III degree: The prolapsed tissue partially exits the vaginal opening.

IV degree: The prolapsed tissue completely exits the vaginal opening.

(3) International Urinary Control Association pelvic organ prolapse quantitative staging method (POP-Q): This method divides the vagina into 6 sites and 3 radial lines, and the relationship with the hymen is measured in centimeters.

Point Aa: Located in the middle of the anterior wall of the vagina 3 cm from the urethral opening, equivalent to the urethral bladder fold, the value range is -3 to +3.

Point Ba: The most obvious point of vaginal reflexation between the vaginal apex of the vaginal apex or the anterior vagina of the vagina to the Aa point. When there is no prolapse, the point is at -3.

Point C: the most distal end of the cervix, or the vaginal apex after total hysterectomy.

Point D: Located in the posterior fornix, equivalent to the attachment of the humeral ligament of the uterus to the cervix; if the cervix has been removed, this point is omitted.

Point Ap: Located in the middle of the posterior wall of the vagina, 3 cm away from the female membrane, the value range is -3 to +3.

Point Bp: Located at the farthest end of the posterior axis of the posterior wall of the vagina, that is, the most obvious part of the posterior vaginal reflex of the posterior iliac crest to the point of prolapse of the vaginal wall of the Ap point. When there is no prolapse, the distance from the hymen is 3 cm.

Gh: length of genital fissure, from the outer urethra to the midline of the hymen.

Pb: the height of the perineal body, from the trailing edge of the vulvar fissure to the anus.

Tvl: The full length of the vagina, the number of centimeters of the maximum depth of the vagina when C or D is in the fully normal position.

The measurement recording method is according to the 3×3 grid shown in Fig. 2, and the final prolapsed stage is counted according to the most serious prolapse.

0 degree: no prolapse, points Aa, Ap, Ba, Bp are -3, D is equivalent to the negative value of tvl, C is 2 cm shorter than D.

I degree: the most distal end of the prolapse is 1 cm on the hymen, and the quantitative value is <-1 cm.

II degree: the farthest end of prolapse is 1cm outside the hymen, the quantitative value is -1cm, +lcm.

III degree: the farthest end of prolapse is >1 cm outside the hymen.

Quantitative value > +1 cm, <+ (tvl - 2 cm).

IV degree : the lower genital tract completely turned out of the vaginal opening, the most distal end of the prolapse is at least tvI-2cm, the quantitative value tvl-2cm;

2. Symptoms and signs of pelvic organ prolapse in menopausal women

I degree prolapse women generally have no discomfort, often found in gynecological examination, more than 2 degrees of pelvic organ prolapse, according to different prolapsed organs, different degrees of prolapse, have different symptoms and signs, the common symptoms are After standing for too long or tired, there is a "block" in the vaginal opening. After the bed rests, the "block" retracts by itself. The symptoms of prolapse gradually increase with age, and the "block" can not be returned by hand. The cervix and/or vaginal wall may be rubbed against clothing for a long time, and ulcers may occur, accompanied by purulent secretions.

Uterine prolapse causes traction on the uterine ligament, pelvic congestion, patients have varying degrees of lumbosacral pain or falling, standing symptoms after a long time or tired, symptoms are relieved after bed rest.

Bladder bulging, may occur dysuria, urinary retention, prone to cystitis, patients may have frequent urination, urgency, dysuria and other symptoms, bladder bulging often accompanied by urethral bulging, bladder neck hyperactivity, often pressure urine incontinence.

Patients with severe rectal bulging have a sense of falling, back pain, difficulty in defecation, constipation, and stress incontinence.

Intestinal prolapse, also known as uterine rectum depression, often manifested as low back pain, pelvic pressure, due to gravitational pull the mesenteric cavity of the cyst, standing for a long time, the feeling of falling is aggravated, because the vaginal mass is prolapsed, often vaginal discomfort It is difficult to have sexual intercourse and is aggravated by the dryness of the vagina.

Clinically, pelvic organ prolapse is often not a single organ prolapse. Uterine prolapse is often accompanied by bladder and urethral bulging, rectal bulging and intestinal bulging, so the symptoms are diverse and can exist simultaneously. .

Examination of menopausal pelvic organ prolapse

Blood routine, urine routine, vaginal secretion examination, hormone level detection.

Different imaging methods have been used to display pelvic floor anatomy, support tissue defects, and the relationship between adjacent organs. Since each method has certain defects, there is no specific method so far. The commonly used methods include ultrasonography and magnetic resonance imaging. , CT, X-ray examination.

Dietz's study showed that the prolapse of the female pelvic organ can be quantitatively examined by the labia majora ultrasound. The results are well correlated with the International Control Association's prolapsed grading staging method. This method is suitable for objective evaluation of the surgical outcome. Zhang Yongxiu studied vestibular B. Ultra-dynamic observation of anatomical changes in the urethra, bladder and bladder neck due to pelvic floor tissue defects, and determination of indicators and thresholds for the diagnosis of stress urinary incontinence in women, ultrasound diagnosis of pelvic organ prolapse diagnosis, before and after surgery The assessment provides an objective basis, as it is the safest, cheapest, and most accessible to the human body.

Recently, there are many literatures recommending the use of magnetic resonance imaging (MRI) to assist in the diagnosis of POP. Soft tissues of different densities can be distinguished in MRI. MRI can clearly show the prolapse of pelvic organs and the structure of the pelvic floor when the abdominal pressure increases. Quantitative determination of bladder bulging, rectal bulging, intestinal bulging, uterine prolapse, genital tract fissures, and can be used for dynamic observation, MRI can determine the exact diagnosis of pelvic floor support defects, MRI changes the traditional Diagnostic methods can be used to guide surgical procedures. Kaufman believes that MRI has broad prospects in the study of pelvic organ prolapse, but it is expensive and currently difficult to popularize.

CT examination of the pelvic cavity, can show the length of the levator ani muscle, the transverse and long diameter of the levator ani muscle fissure, the obturator muscle and the obturator muscle outside the heart, CT also provides non-invasive damage to the pelvic muscles and fascia Sexual objective inspection method.

The placement of metal chains in urethral X-ray urethrography has been an important method of imaging for female stress urinary incontinence. Due to its invasiveness, it has been gradually replaced by other imaging methods. Kenton attempts to pass X-ray pelvic fluoroscopy. The position of pelvic organ prolapse is determined by mid-vaginal angiography. The conclusion is negative. Because of the X-ray examination, the viscera must have contrast agent contrast. The pelvic organ prolapse involves various organs. At present, there is no bladder, small intestine or rectum. At the same time, the contrast agent developed at the same time seems to have a small future in the diagnosis of POP.

Diagnostic diagnosis of pelvic organ prolapse during menopause

According to the medical history, clinical manifestations, physical signs and auxiliary examinations can be clearly diagnosed, the disease increases with menopause time, the incidence increases and the condition worsens.

Identification of non-productile organic lesions associated with tissues of prolapsed organs.

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