Pelvic floor disorder (PFD) is a common female disease, and it is very important to evaluate the condition and efficacy of PFD. It is especially important to standardize the application of the above auxiliary examination methods and scientifically evaluate the clinical value. According to domestic and international clinical epidemiological data, the incidence of pelvic floor prolapse is as high as 15%-20% in the female population. In addition to pelvic organ prolapse (POP), patients often have urinary and anal system symptoms, such as urinary incontinence, dyspareunia, urinary retention, overactive bladder (OAB), dyspareunia, constipation and fecal incontinence.
I. Urodynamic examination
Urodynamics test (UDS) is based on the basic principles and methods of fluid dynamics and electrophysiology to detect the pressure and flow rate in various parts of the lower urinary bladder and urethra, so as to understand the function and mechanism of lower urinary tract storage and voiding, as well as the pathophysiological changes of voiding abnormalities, and to assess the functional status of the bladder, urethra, pelvic floor and sphincter during the storage and voiding periods. The functional status of the patient’s lower urinary tract is expressed in objective figures and charts. Urodynamic examination generally includes free urethral flow rate measurement, combined pressure volume/pressure flow rate/electromyography measurement (initial bladder volume, maximum bladder pressure measurement volume, bladder compliance, stability of the detrusor muscle, maximum detrusor pressure during voiding, detrusor pressure at maximum flow rate, abdominal leakage point pressure) and urethral pressure measurement, which can evaluate the function of the lower urinary tract in detail. Among them, free uroflowmetry (uroflowmetry) is non-invasive, while the rest are invasive tests.
Currently, the indications for the use of urodynamics in patients with pelvic floor dysfunctional disease are not clear, and some hospitals overapply it and perform UDS preoperatively in all patients with PFD. Since urodynamic tests are invasive and expensive, their excessive use will increase patients’ medical costs and the probability of infection. Conversely, some hospitals have little to no equipment or technical staff to perform this test, which may affect the accurate assessment of the condition.
Urodynamics in the management of urinary incontinence: Urinary incontinence is an objectively verifiable involuntary flow of urine, and UDS is of great value in the management of urinary incontinence. It helps to clarify the cause and type of incontinence. However, the question of whether all incontinence requires UDS is controversial.
Urodynamics in pelvic floor organ prolapse (POP): Patients with POP are often combined with various lower urinary tractsymptoms (LUTS), which are mainly manifested by stress incontinence, overactive bladder and urinary tract obstruction and retention in urodynamic examination. a problem for clinicians. Studies have shown that new-onset incontinence after POP can be as high as 11% to 22%. UDS can help detect de novo incontinence and provide guidance on the need for anti-incontinence surgery in conjunction with pelvic floor reconstruction surgery. In patients with POP who have clearly combined SUI symptoms, there is a high risk of persistent SUI or exacerbation of SUI after surgery, and concurrent anti-incontinence surgery is recommended.
II. Anal kinetic examination
Anorectal kinetic examination provides information on the functional status of the anorectum and is the preferred method of assessment of sphincter function, rectal reflex and sensory function. Indirect manometry with multi-channel water perfusion or high-resolution solid-state manometry devices are often used clinically. The main indices of anal dynamics include anal canal resting pressure, anal canal systolic pressure, recto-anal reflex, defecation flaccid reflex and rectal sensory function.
POP its is posterior pelvic prolapse can present with varying degrees of rectal prolapse or even small bowel herniation. Patients develop fecal incontinence due to damage to the anal sphincter during childbirth and long-term loss of compensation for pelvic floor relaxation. For the above-mentioned POP with obvious symptoms that seriously affect the quality of life, clinical symptoms alone cannot provide an accurate diagnosis, and anorectal kinetic examination should be performed to classify the kinetic subtypes according to anorectal manometry, so as to correctly determine the type of anorectal dysfunction of the patient and guide the treatment. Therefore, for POP with obvious intestinal symptoms, anorectal kinetic examination is recommended before pelvic floor reconstruction surgery to assess rectal function, which can help to predict the possible defecation difficulties of patients after surgery, and to make good communication and prevention.
III. Pelvic floor ultrasound
The application of ultrasound imaging in gynecological pelvic floor dysfunctional diseases began in the 1980s, and has been widely used by clinicians for PFD, treatment and efficacy observation because of its advantages of non-invasive, radiation-free, real-time, convenient, economical, and easily accepted by patients. It can show the relationship between the urethra, vagina, bladder, bladder neck and rectum and the inferior border of the pubic symphysis in the resting state, and also dynamically observe the changes of the above structures to understand the mobility of the bladder neck, the degree of urethral rotation and the changes of the supporting structures of the pelvic floor, which is one of the important indicators for assessing SUI and POP.
1. Diagnostic value of pelvic floor ultrasound for SUI: ultrasound diagnoses SUI by measuring the degree of movement of the urethral bladder connection, urethral rotation, and the distance between the bladder neck and the pubic symphysis during the pressure period, etc. It also allows visual evaluation of the degree of urethral downward migration and urethral sphincter function by dynamically observing the bladder neck opening in a funnel shape and urine outflow during Vasalva, which can provide a judgment of the type and degree of urinary incontinence It can help to determine the type and degree of incontinence.
2. Diagnostic value of pelvic floor ultrasound for POP: relaxation and rupture of pelvic floor support structures are the main causes of POP. The application of trans-perineal three-dimensional ultrasound can simultaneously display three mutually perpendicular sagittal, transverse and coronal sections to obtain a complete three-dimensional sonogram of the pelvic diaphragm fissure, clearly display the morphology and structure of the genital tract fissure, accurately measure the size of the fissure, and also visually observe the alignment and degree of damage of the anal levator muscle and ligaments, providing an imaging basis for the diagnosis of PFD and guidance for the development of individualized surgical plans.
IV. Pelvic magnetic resonance imaging
Currently, the vast majority of clinical methods for assessing POP are based on gynecological examinations, and the pelvic support structures cannot be evaluated comprehensively and accurately, thus increasing the risk of treatment failure, recurrence, and post-surgical complications. Magnetic resonance imaging (MRI), as a radiation-free, non-invasive examination method, provides clear visualization of soft tissues and allows multi-angle and multi-plane display imaging of fine structures and anatomical details, repeated use, and precise measurement and quantitative analysis. Its accuracy is superior to that of pelvic floor ultrasound. Dynamic MRI imaging can accurately reproduce dynamic series of images of pelvic organ prolapse sites in the in vivo state, and is now widely used in clinical practice. The 3D reconstructed geometric model based on pelvic MRI can visualize the alignment direction, diameter and 3D spatial position relationship of each supporting structure of the pelvis with the adjacent tissues in a three-dimensional manner, which can comprehensively analyze and evaluate the defect site and its interrelationship with POP from a holistic perspective, thus potentially guiding the individualized selection of clinical surgical plans, which is the future development direction.