2019 NICE女性尿失禁和盆腔器官脫垂管理指南(下)

2019NICE女性尿失禁和盆腔器官脫垂管理指南（下）導(dǎo)讀

2019年4月，英國(guó)國(guó)家衛(wèi)生與臨床優(yōu)化研究所（NICE）發(fā)布了女性尿失禁和盆腔器官脫垂的管理指南，主要內(nèi)容涵蓋了年齡≥18歲女性尿失禁和盆腔器官脫垂的評(píng)估和管理，同時(shí)也包含相關(guān)手術(shù)并發(fā)癥的管理。本指南內(nèi)容分兩次報(bào)道，現(xiàn)為第二部分，主要內(nèi)容為盆腔器官脫垂的評(píng)估、非手術(shù)療法和外科療法。盆腔器官脫垂的評(píng)估Forwomenpresentinginprimarycarewithsymptomsoranincidentalfindingofvaginalprolapse:Takeahistorytoincludesymptomsofprolapse,urinary,bowelandsexualfunction.Doanexaminationtoruleoutapelvicmassorotherpathologyandtodocumentthepresenceofprolapse.Discussthewoman'streatmentpreferenceswithher,andreferifneeded.

對(duì)于在初級(jí)保健中出現(xiàn)癥狀或偶然發(fā)現(xiàn)陰道脫垂的女性：請(qǐng)記錄包括脫垂、尿路、腸道和性功能癥狀。進(jìn)行檢查以排除盆腔腫塊或其他病狀，并記錄脫垂的存在。與患者討論其治療偏好，如果需要的話可以參考。

Forwomenreferredtosecondarycareforanunrelatedconditionwhohaveincidentalsymptomsoranincidentalfindingofvaginalprolapse,considerreferraltoaclinicianwithexpertiseinprolapse.

對(duì)于二級(jí)醫(yī)療機(jī)構(gòu)出現(xiàn)偶發(fā)陰道脫垂無(wú)法治療的女性，請(qǐng)轉(zhuǎn)診到脫垂?？漆t(yī)療機(jī)構(gòu)。

Forwomenwhoarereferredforspecialistevaluationofvaginalprolapse,performanexaminationto:assessandrecordthepresenceanddegreeofprolapseoftheanterior,centralandposteriorvaginalcompartmentsofthepelvicfloor,usingthePOP-Q(PelvicOrganProlapseQuantification)system.Assesstheactivityofthepelvicfloormuscles.Assessforvaginalatrophy.Ruleoutapelvicmassorotherpathology.

轉(zhuǎn)診至陰道脫垂?？茩C(jī)構(gòu)的女性，請(qǐng)進(jìn)行以下檢查：使用POP-Q（盆腔器官脫垂量表）評(píng)估，并記錄盆底前、中、后陰道腔室脫垂的存在情況和嚴(yán)重程度。評(píng)估盆底肌肉活動(dòng)。評(píng)估陰道萎縮程度。排除盆腔腫塊或其他病狀。

Forwomenwithpelvicorganprolapse,considerusingavalidatedpelvicfloorsymptomquestionnairetoaidassessmentanddecisionmaking.Donotroutinelyperformimagingtodocumentthepresenceofvaginalprolapseifaprolapseisdetectedbyphysicalexamination.Ifthewomanhassymptomsofprolapsethatarenotexplainedbyfindingsfromaphysicalexamination,considerrepeatingtheexaminationwiththewomanstandingorsquatting,oratadifferenttime.

對(duì)于盆腔器官脫垂女性，請(qǐng)使用經(jīng)驗(yàn)證的盆底癥狀問(wèn)卷幫助評(píng)估和決策。如經(jīng)體檢發(fā)現(xiàn)脫垂，切勿例行影像檢查以證實(shí)陰道脫垂的存在。如果女性有脫垂癥狀，但不能用體檢結(jié)果解釋，可考慮再次檢查，讓女性站立或蹲下，或在不同時(shí)間點(diǎn)檢查。

Considerinvestigatingthefollowingsymptomsinwomenwithpelvicorganprolapse:urinarysymptomsthatarebothersomeandforwhichsurgicalinterventionisanoption.Aymptomsofobstructeddefaecationorfaecalincontinence.Pain.Symptomsthatarenotexplainedbyexaminationfindings.

研究脫垂女性的以下癥狀：可選擇手術(shù)治療的嚴(yán)重泌尿癥狀。大便阻塞或大便失禁癥狀。疼痛。檢查結(jié)果無(wú)法解釋的癥狀。非手術(shù)療法Discussmanagementoptionswithwomenwhohavepelvicorganprolapse,includingnotreatment,non-surgicaltreatmentandsurgicaloptions,takingintoaccount:Thewoman'spreferences,siteofprolapse,lifestylefactors,comorbidities,includingcognitiveorphysicalimpairments,age,desireforchildbearing,previousabdominalorpelvicfloorsurgery,benefitsandrisksofindividualprocedures.

在選擇治療方案時(shí)（包括不處理、非手術(shù)療法和手術(shù)方案），應(yīng)綜合考慮：女性偏好、脫垂部位、生活方式、合并癥（包括認(rèn)知或身體損傷）、年齡、生育欲望、腹部或盆底手術(shù)史、手術(shù)收益和風(fēng)險(xiǎn)。

Lifestylemodifificationlosingweight,ifthewomanhasaBMIgreaterthan30kg/m2.Minimisingheavylifting.Preventingortreatingconstipation.

生活方式調(diào)整

如果女性BMI指數(shù)＞30kg/m2，則建議減肥。減輕日常負(fù)重。預(yù)防或治療便秘。

PelvicfloormuscletrainingConsideraprogrammeofsupervisedpelvicfloormuscletrainingforatleast16weeksasafirstoptionforwomenwithsymptomaticPOP-Q(PelvicOrganProlapseQuantification)stage1orstage2pelvicorganprolapse.Iftheprogrammeisbeneficial,advisewomentocontinuepelvicfloormuscletrainingafterwards.

盆底肌肉訓(xùn)練

對(duì)于POP-Q評(píng)分1期或2期的癥狀性脫垂女性，應(yīng)將盆底肌肉訓(xùn)練至少16周作為首選方案。如果該方案有益，則建議女性繼續(xù)盆底肌肉訓(xùn)練。

Consideravaginalpessaryforwomenwithsymptomaticpelvicorganprolapse,aloneorinconjunctionwithsupervisedpelvicfloormuscletraining.Referwomenwhohavechosenapessarytoaurogynaecologyserviceifpessarycareisnotavailablelocally.

子宮托

對(duì)于癥狀性脫垂女性，考慮使用陰道子宮托（單獨(dú)或與盆底肌肉訓(xùn)練一起使用）。如果在當(dāng)?shù)責(zé)o法獲得子宮托護(hù)理，可轉(zhuǎn)診到泌尿婦科醫(yī)療機(jī)構(gòu)。

Beforestartingpessarytreatment:considertreatingvaginalatrophywithtopicaloestrogen.Explainthatmorethan1pessaryfittingmaybeneededtofindasuitablepessary.Discusstheeffectofdifferenttypesofpessaryonsexualintercourse.Describecomplicationsincludingvaginaldischarge,bleeding,difficultyremovingpessaryandpessaryexpulsion.Explainthatthepessaryshouldberemovedatleastonceevery6monthstopreventseriouspessarycomplications.

在采用子宮托治療前：應(yīng)考慮使用局部雌激素治療陰道萎縮。向患者解釋可能需要多個(gè)子宮托，以找到合適的一個(gè)。討論不同類型的子宮托對(duì)性交的影響。描述并發(fā)癥，包括陰道分泌物、出血、子宮托移除困難和排出。解釋子宮托應(yīng)至少每6個(gè)月取出一次，以防止嚴(yán)重的子宮托并發(fā)癥。

Offerwomenusingpessariesanappointmentinapessaryclinicevery6monthsiftheyareatriskofcomplications,forexamplebecauseofaphysicalorcognitiveimpairmentthatmightmakeitdifficultforthemtomanagetheirongoingpessarycare.[2019]

若使用子宮托女性有并發(fā)癥風(fēng)險(xiǎn)，如因身體或認(rèn)知障礙，難以掌控正在進(jìn)行的子宮托護(hù)理，請(qǐng)每6個(gè)月在子宮托診所就診。盆腔器官脫垂的外科療法

Explaintowomenconsideringsurgeryforanteriororapicalprolapsewhodonothaveincontinencethatthereisariskofdevelopingpostoperativeurinaryincontinenceandfurthertreatmentmaybeneeded.

向考慮手術(shù)治療的前壁脫垂或后壁脫垂女性（無(wú)尿失禁）解釋，術(shù)后有尿失禁的風(fēng)險(xiǎn)，可能需進(jìn)一步治療。

Forwomenwithuterineprolapsewhohavenopreferenceaboutpreservingtheiruterus,offerachoiceof:Vaginalhysterectomy,withorwithoutvaginalsacrospinousfixationwithsuturesor.Vaginalsacrospinoushysteropexywithsuturesor.Manchesterrepair.

對(duì)于沒(méi)有保留子宮意愿的脫垂女性，可選擇：經(jīng)陰道子宮切除術(shù)，采用或不采用陰道骶棘縫線固定。采用縫線的陰道骶棘子宮固定術(shù)。曼徹斯特修復(fù)。

Forwomenwithuterineprolapsewhowishtopreservetheiruterus,offerachoiceof:Vaginalsacrospinoushysteropexywithsuturesor.Manchesterrepair,unlessthewomanm