Effect of postpartum pelvic floor muscle training on improving pelvic floor function

RAO Lin ,, ZHANG Linna, YUAN Jiaqi, LU Bangchun ,

Department of Obstetrics and Gynecology, The International Peace Maternity & Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China

摘要

目的·評(píng)價(jià)產(chǎn)后1年內(nèi)盆底肌訓(xùn)練（Kegel訓(xùn)練）對(duì)產(chǎn)婦盆底功能康復(fù)的作用。方法·選取2020年1—4月在上海交通大學(xué)醫(yī)學(xué)院附屬國(guó)際和平婦幼保健院產(chǎn)后6周檢查有不同程度尿失禁和/或盆腔器官脫垂的陰道分娩初產(chǎn)婦，分為鍛煉組（147例）和對(duì)照組（194例）。鍛煉組于產(chǎn)后6周開(kāi)始進(jìn)行Kegel訓(xùn)練，對(duì)照組進(jìn)行一般的產(chǎn)后健康教育。在產(chǎn)后6周及產(chǎn)后1年，對(duì)2組產(chǎn)婦進(jìn)行一般情況問(wèn)卷及國(guó)際尿失禁咨詢委員會(huì)尿失禁問(wèn)卷表簡(jiǎn)表（International Consultation Incontinence Questionnaire-UI Short Form，ICIQ-SF）調(diào)查，并進(jìn)行盆底肌力測(cè)定和分級(jí)（盆底肌力分級(jí)>Ⅲ級(jí)表明肌力正常）；根據(jù)盆腔器官脫垂分度法（pelvic organ prolapsed quantitation，POP-Q）定量評(píng)估脫垂程度。比較2組產(chǎn)婦的盆底肌力分級(jí)、尿失禁評(píng)分以及盆底器官脫垂情況，評(píng)價(jià)盆底肌訓(xùn)練的效果。結(jié)果·隨訪至產(chǎn)后1年，鍛煉組和對(duì)照組失訪數(shù)分別為20例和28例。鍛煉組產(chǎn)后1年盆底肌力正常的比例顯著高于產(chǎn)后6周（56.0% vs 34.7%，P=0.000），尿失禁發(fā)生率顯著低于產(chǎn)后6周（25.2% vs 36.7%，P=0.040）。對(duì)照組產(chǎn)后1年盆底肌力正常的比例顯著高于產(chǎn)后6周（43.4% vs 32.5%，P=0.033），尿失禁發(fā)生率顯著低于產(chǎn)后6周（17.5% vs 28.9%，P=0.011）。產(chǎn)后1年，鍛煉組盆底肌力正常的比例高于對(duì)照組（56.0% vs 43.4%，P=0.033），盆底肌力好轉(zhuǎn)率高于對(duì)照組（50.4% vs 35.5%，P=0.011）。盆腔器官脫垂程度改善率和尿失禁好轉(zhuǎn)率在鍛煉組和對(duì)照組之間分別比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義（P>0.05）。結(jié)論·產(chǎn)后進(jìn)行盆底肌訓(xùn)練可提高盆底肌力，但對(duì)改善產(chǎn)婦盆底功能障礙的效果并不明顯；產(chǎn)后1年產(chǎn)婦尿失禁和盆底肌力均有改善，表明盆底肌有自行恢復(fù)的機(jī)制，但可能需要較長(zhǎng)的時(shí)間。

關(guān)鍵詞：盆底肌訓(xùn)練;產(chǎn)后;尿失禁;盆腔器官脫垂;盆底肌;自然分娩

Abstract

Objective ·To evaluate the effect of pelvic floor muscle training (Kegel training) on the rehabilitation of pelvic floor function within 1 year after delivery. Methods ·From January to April 2020, primiparas with different degrees of urinary incontinence or pelvic organ prolapse were selected and divided into exercise group (147 cases) and control group (194 cases). The exercise group received Kegel training at 6 weeks of the postpartum period, while the control group received general postpartum health education only. At 6 weeks and 1 year after delivery, these postpartum women in the two groups were investigated with the general information questionnaire and International Consultation Incontinence Questionnaire-UI Short Form (ICIQ-SF). The pelvic floor muscle strength was measured (the pelvic floor muscle strength grade>Ⅲ indicates normal muscle strength). The pelvic organ prolapsed quantitation (POP-Q) score was assigned accordingly. The urinary incontinence score, pelvic floor muscle strength and pelvic floor organ prolapse were compared between the two groups, and the effect of pelvic floor muscle training was evaluated. Results ·In the exercise group, 20 postpartum women lost contact during follow up sections, and 28 women in the control group were unable to be contacted within 1 year. In the exercise group, the proportion of women with normal pelvic floor muscle strength at 1 year postpartum was significantly higher than that at 6 weeks postpartum (56.0% vs 34.7%, P=0.000), and the incidence of incontinence at 1 year postpartum was significantly lower than that at 6 weeks postpartum (25.2% vs 36.7%, P=0.040). In the control group, the proportion of women with normal pelvic floor muscle strength at 1 year postpartum was significantly higher than that at 6 weeks postpartum (43.4% vs 32.5%, P=0.033), and the incidence of incontinence at 1 year postpartum was significantly lower than that at 6 weeks postpartum (17.5% vs 28.9%, P=0.011). At 1 year postpartum, the proportion of women with normal pelvic floor muscle strength in the exercise group was higher than that in the control group (56.0% vs 43.4%, P=0.033). The improvement rate of muscle strength in the exercise group was higher than that in control group (50.4% vs 35.5%, P=0.011). There was no significant difference in the improvement rate of pelvic organ prolapse and frequency of urinary incontinence between the exercise group and the control group (P>0.05). Conclusion ·Postpartum pelvic floor muscle training can improve pelvic floor muscle strength, but has no significant effect on improving pelvic floor dysfunction in the current samples. The urinary incontinence condition and pelvic floor muscle strength of women improve 1 year after delivery, indicating that there is a mechanism for self recovery of pelvic floor muscle, but it may take a long time.

Keywords：pelvic floor muscle training;postpartum;urinary incontinence;pelvic organ prolapse;pelvic floor muscle;natural childbirth

盆底功能障礙性疾?。╬elvic floor dysfunction，PFD）主要包括盆腔器官脫垂（pelvic organ prolapse，POP）和尿失禁（urinary incontinence，UI），是影響女性生活質(zhì)量的常見(jiàn)病。妊娠和分娩是導(dǎo)致PFD的常見(jiàn)病因。有文獻(xiàn)報(bào)道，產(chǎn)后UI發(fā)病率可高達(dá)30%［1］，一半以上的產(chǎn)婦存在不同程度的POP［2-3］。妊娠分娩導(dǎo)致盆底肌功能受損可能是UI和POP發(fā)生的原因［4］。產(chǎn)后盆底肌訓(xùn)練（Kegel訓(xùn)練）被認(rèn)為是產(chǎn)后PFD的一線治療方法［5］，但其對(duì)PFD是否具有改善作用目前仍不確定。國(guó)外已經(jīng)開(kāi)展了一些隨機(jī)對(duì)照研究，但結(jié)果不一致，存在一定爭(zhēng)議［1，6-8］。WOODLEY等［1］認(rèn)為，Kegel訓(xùn)練對(duì)產(chǎn)后UI的治療效果存在不確定性；SIGURDARDOTTIR等［8］的研究表明Kegel訓(xùn)練至產(chǎn)后6個(gè)月可顯著改善產(chǎn)婦的UI情況，但至產(chǎn)后1年效果不明顯。在國(guó)內(nèi)，產(chǎn)后康復(fù)訓(xùn)練的研究多集中在電刺激生物反饋治療方面，但該療法需要特殊設(shè)備，且要求產(chǎn)婦反復(fù)前往醫(yī)院治療，給哺乳期產(chǎn)婦帶來(lái)不便；此外，該療法還具有陰道炎或陰道出血等禁忌證。單純Kegel訓(xùn)練具有便捷、經(jīng)濟(jì)、隨時(shí)可進(jìn)行的優(yōu)勢(shì)。本研究旨在探討產(chǎn)后1年內(nèi)行Kegel訓(xùn)練對(duì)產(chǎn)婦盆底功能康復(fù)的作用，以期為PFD產(chǎn)婦的康復(fù)訓(xùn)練提供依據(jù)。

1 對(duì)象與方法

1.1 研究對(duì)象

選取2020年1—4月在上海交通大學(xué)醫(yī)學(xué)院附屬國(guó)際和平婦幼保健院產(chǎn)后6周檢查發(fā)現(xiàn)有不同程度UI和/或POP的陰道分娩初產(chǎn)婦作為研究對(duì)象。納入標(biāo)準(zhǔn)：① 足月、單胎。② 陰道分娩。③ 產(chǎn)后惡露已凈。排除標(biāo)準(zhǔn)：① 既往有引產(chǎn)史。② 合并慢性咳嗽、便秘、哮喘等內(nèi)科疾病。③ 既往盆腔手術(shù)史。④ 孕前有POP和UI病史。⑤ 有Ⅲ度及Ⅲ度以上會(huì)陰裂傷。退出標(biāo)準(zhǔn)：① 未完成隨訪中途退出或者信息不全影響判斷。② 中途采用其他物理治療手段。③ 未達(dá)到訓(xùn)練標(biāo)準(zhǔn)強(qiáng)度。④ 再次妊娠。本研究在中國(guó)臨床實(shí)驗(yàn)中心（www.chictr.org.cn）注冊(cè)，注冊(cè)號(hào)：ChiCTR1800017354。

1.2 研究方法1.2.1 研究分組

于產(chǎn)后6周常規(guī)檢查時(shí)篩選存在PFD情況的產(chǎn)婦，告知產(chǎn)婦可行Kegel訓(xùn)練治療，但效果有賴于長(zhǎng)期觀察，且需堅(jiān)持鍛煉1年。將參加Kegel訓(xùn)練并堅(jiān)持隨訪1年者，入組為鍛煉組；將不參加Kegel訓(xùn)練、僅接受健康宣教者，入組為對(duì)照組。對(duì)鍛煉組產(chǎn)婦進(jìn)行一對(duì)一的Kegel訓(xùn)練口頭指導(dǎo)，介紹訓(xùn)練目的、方法、注意事項(xiàng)，觀察和陰道觸診檢查產(chǎn)婦盆底肌的收縮情況，直至產(chǎn)婦完全掌握盆底肌訓(xùn)練的方法。告知產(chǎn)婦后續(xù)每周至少進(jìn)行3 d的Kegel訓(xùn)練，每日3次，每次15 min或者50次盆底肌收縮，收縮1次至少持續(xù)5 s，再放松10 s；并告知在行走、站位、坐位、臥位均可進(jìn)行訓(xùn)練；產(chǎn)婦每日記錄訓(xùn)練日記并且每周在微信上傳訓(xùn)練達(dá)標(biāo)情況。為提高依從性，由專人負(fù)責(zé)微信訓(xùn)練群的管理，每周發(fā)布健康科普宣傳，提醒產(chǎn)婦進(jìn)行盆底肌訓(xùn)練3~6個(gè)月后再?gòu)?fù)查康復(fù)情況，并叮囑其繼續(xù)訓(xùn)練至產(chǎn)后1年。產(chǎn)婦如未達(dá)到訓(xùn)練要求（每周至少3 d，每日至少1次Kegel訓(xùn)練［8］）則退出鍛煉組。對(duì)照組在產(chǎn)后6周進(jìn)行盆底功能篩查，同時(shí)進(jìn)行一般的PFD健康宣教，后期不再干預(yù)。

1.2.2 觀察指標(biāo)

根據(jù)國(guó)際通用的會(huì)陰肌力測(cè)試法（general report revised urinary grade， GRRUG），由經(jīng)過(guò)專科培訓(xùn)的2名醫(yī)師進(jìn)行臨床查體并進(jìn)行盆底肌力分級(jí)：盆底肌收縮持續(xù)0 s為0級(jí)，以此類推，持續(xù)5 s或以上為Ⅴ級(jí)；其中0~Ⅲ級(jí)為肌力異常，Ⅳ~(yú)Ⅴ級(jí)為肌力正常。

由經(jīng)過(guò)?？婆嘤?xùn)的2名醫(yī)師進(jìn)行臨床查體，根據(jù)盆腔器官脫垂分度法（pelvic organ prolapsed quantitation，POP-Q）定量評(píng)估脫垂程度。檢查方法：在安靜環(huán)境下，受試者排空膀胱后取膀胱截石位于婦科檢查床，囑受試者做Valsalva動(dòng)作（屏氣用力），重復(fù)2次。

采用自編問(wèn)卷，調(diào)查產(chǎn)婦年齡、身高、體質(zhì)量、文化程度、哺乳時(shí)間等基本情況；根據(jù)國(guó)際尿失禁咨詢委員會(huì)尿失禁問(wèn)卷表簡(jiǎn)表（International Consultation Incontinence Questionnaire-UI Short Form，ICIQ-SF）對(duì)UI情況進(jìn)行評(píng)分。

1.3 統(tǒng)計(jì)學(xué)方法

采用SPSS 23.0軟件進(jìn)行數(shù)據(jù)處理。正態(tài)分布的定量資料以x±s表示，組間比較采用兩獨(dú)立樣本t檢驗(yàn)；非正態(tài)分布的定量資料以M（Q1，Q3）表示，組間比較采用Man-Whitney U檢驗(yàn)。定性資料以n（%）表示，組間比較采用χ2檢驗(yàn)。P<0.05表示差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 一般臨床資料及產(chǎn)后6周產(chǎn)婦PFD情況比較

共納入341例產(chǎn)婦，其中鍛煉組147例，對(duì)照組194例。產(chǎn)后1年，鍛煉組共有20例退出研究，包括14例未達(dá)到鍛煉標(biāo)準(zhǔn)，4例因在外地中途退出，1例再次妊娠，1例采用物理治療；對(duì)照組共有28例退出研究，包括21例中途退出（9例無(wú)法聯(lián)系，12例拒絕復(fù)診），2例再次妊娠，3例采用物理治療，2例資料不全。鍛煉組和對(duì)照組的失訪率分別為13.6%和14.4%。2組產(chǎn)婦的年齡、分娩孕周、孕前體質(zhì)量指數(shù)（body mass index，BMI）、孕期增加體質(zhì)量、新生兒出生體質(zhì)量、第二產(chǎn)程時(shí)長(zhǎng)、哺乳時(shí)間、文化程度、孕次、會(huì)陰側(cè)切率、產(chǎn)鉗助產(chǎn)率等指標(biāo)比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義。結(jié)果見(jiàn)表1。

表1  2組產(chǎn)婦的一般情況比較

Tab 1  Comparison of baseline data between the two groups of postpartum women

ItemExercise group (n=147)Control group (n=194)t/Z/χ2 valueP valueAge/year30.35±3.1529.95±3.211.1640.245Gestational length/week39.01±1.1539.11±1.02-0.8470.398Pre-gestational BMI/(kg·m-2)20.54±2.1720.34±2.240.8180.414Weight gain/kg15.69±4.3915.50±4.360.4080.684Neonatal birth weight/g3 366.84±330.853 329.15±393.470.9370.349Duration of the second stage/min50.00 (31.00, 81.00)55.00 (30.00, 83.25)-0.2450.807Breast-feeding time/month9.69±3.389.68±3.520.0340.973Education/n (%)0.0030.999Secondary education9 (6.1)12 (6.2)College or university114 (77.6)150 (77.3)Graduate24 (16.3)32 (16.5)Gravidity/n (%)3.2500.1971112 (76.2)138 (71.1)224 (16.3)46 (23.7)≥311 (7.5)10 (5.2)Episiotomy/n (%)1.4160.234Yes40 (27.2)42 (21.6)No107 (72.8)152 (78.4)Perineal laceration/n (%)1.4790.477041 (27.9)43 (22.1)Ⅰ84 (57.1)120 (61.9)Ⅱ22 (15.0)31 (16.0)Delivery mode/n (%)0.5140.473Natural delivery129 (87.8)165 (85.1)Forceps18 (12.2)29 (14.9)

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產(chǎn)后6周時(shí)，比較2組產(chǎn)婦的POP程度、UI發(fā)生率、ICIQ-SF評(píng)分和盆底肌力強(qiáng)度，其差異均無(wú)統(tǒng)計(jì)學(xué)意義（表2）。

表2  產(chǎn)后6周時(shí)2組產(chǎn)婦PFD情況比較

Tab 2  Comparison of PFD at 6 weeks postpartum between the two groups

ParameterExercise group (n=147)Control group (n=194)χ2 /Z valueP valuePOP stage/n (%)5.4140.067Grade 023 (15.6)36 (18.6)Grade 168 (46.3)107 (55.1)Grade 256 (38.1)51 (26.3)Muscle strength/n (%)0.1850.728>Ⅲ51 (34.7)63 (32.5)≤Ⅲ96 (65.3)131 (67.5)UI/n (%)2.3700.124No93 (63.3)138 (71.1)Yes54 (36.7)56 (28.9)ICIQ-SF score0 (0, 4.00)0 (0, 3.35)-1.4930.136

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2.2 產(chǎn)后1年2組產(chǎn)婦PFD改善情況比較

產(chǎn)后1年時(shí)，鍛煉組肌力正常（盆底肌力分級(jí)>Ⅲ級(jí)）比例為56.0%，高于對(duì)照組的43.4%，2組間差異有統(tǒng)計(jì)學(xué)意義（P=0.033）；鍛煉組肌力好轉(zhuǎn)率為50.4%，高于對(duì)照組的35.5%，2組間差異有統(tǒng)計(jì)學(xué)意義（P=0.011）。2組產(chǎn)婦之間POP-Q分度、POP好轉(zhuǎn)率、UI發(fā)生率和ICIQ-SF評(píng)分，差異均無(wú)統(tǒng)計(jì)學(xué)意義（P>0.05）。結(jié)果見(jiàn)表3。

表3  產(chǎn)后1年2組產(chǎn)婦PFD改善情況比較

Tab 3  Change of PFD after 1 year postpartum between the two groups

ParameterExercise group (n=127)Control group (n=166)χ2 /Z valueP valuePOP stage change/n (%)0.8140.367Better30 (23.6)32 (19.3)No better97 (76.4)134 (80.7)POP stage/n (%)0.9330.627Grade 019 (15.0)32 (19.3)Grade 167 (52.8)83 (50.0)Grade 241 (32.2)51 (30.7)Muscle strength/n (%)4.5230.033>Ⅲ71 (56.0)72 (43.4)≤Ⅲ56 (44.0)94 (56.6)Muscle strength change/n (%)6.5160.011Better64 (50.4)59 (35.5)No better63 (49.6)107 (64.5)UI/n (%)2.6060.106No95 (74.8)137 (82.5)Yes32 (25.2)29 (17.5)ICIQ-SF score0 (0, 3.00)0 (0, 2.00)-1.7300.084

新窗口打開(kāi)|下載CSV

2組產(chǎn)婦在產(chǎn)后6周和產(chǎn)后1年比較，盆底肌力隨著時(shí)間的變化均顯著提高，UI發(fā)生率也顯著下降。鍛煉組盆底肌力正常比例從產(chǎn)后6周的34.7%提高到產(chǎn)后1年的56.0%，前后比較差異有統(tǒng)計(jì)學(xué)意義（P=0.000）；UI發(fā)生率從產(chǎn)后6周的36.7%下降到產(chǎn)后1年的25.2%，前后比較差異有統(tǒng)計(jì)學(xué)意義（P=0.040）。對(duì)照組盆底肌力正常比例從產(chǎn)后6周的32.5%提高到產(chǎn)后1年的43.4%，前后比較差異有統(tǒng)計(jì)學(xué)意義（P=0.033）；UI發(fā)生率從產(chǎn)后6周的28.9%下降到產(chǎn)后1年的17.5%，前后比較差異有統(tǒng)計(jì)學(xué)意義（P=0.011）。結(jié)果見(jiàn)表4。

表4  2組產(chǎn)后6周和產(chǎn)后1年PFD情況比較

Tab 4  Comparison of PFD between 6 weeks and 1 year postpartum in the two groups

ParameterExercise groupControl group

6 weeks postpartum

(n=147)

1 year postpartum

(n=127)

χ2 valueP value

6 weeks postpartum

(n=194)

1 year postpartum

(n=166)

χ2 valueP valuePOP stage/n (%)1.2550.5341.0960.578Grade 023 (15.6)19 (15.0)36 (18.6)32 (19.3)Grade 168 (46.3)67 (52.8)107 (55.1)83 (50.0)Grade 256 (38.1)41 (32.2)51 (26.3)51 (30.7)Muscle strength/n (%)12.4110.0004.5340.033>Ⅲ51 (34.7)71 (56.0)63 (32.5)72 (43.4)≤Ⅲ96 (65.3)56 (44.0)131 (67.5)94 (56.6)UI/n (%)4.2120.0406.4410.011No93 (63.3)95 (74.8)138 (71.1)137 (82.5)Yes54 (36.7)32 (25.2)56 (28.9)29 (17.5)

新窗口打開(kāi)|下載CSV

3 討論

1948年美國(guó)婦產(chǎn)科醫(yī)師KEGEL提出Kegel訓(xùn)練法，最初報(bào)道利用該方法治愈了64例UI患者［9］。此后該治療手段逐漸被推廣到包括POP在內(nèi)的所有PFD患者。對(duì)于Kegel訓(xùn)練的效果已經(jīng)有較多的前瞻性研究，但結(jié)論卻存在很大爭(zhēng)議［1，6-8］。其中患者依從性差和訓(xùn)練強(qiáng)度不一致可能是導(dǎo)致不同研究結(jié)果差異較大的原因。有報(bào)道［8］顯示只有26%的產(chǎn)婦在產(chǎn)后1年仍能堅(jiān)持每周3 d的提肛運(yùn)動(dòng)。本研究采用微信群組模式管理鍛煉組［10］，每日提醒產(chǎn)婦鍛煉，這種密切的聯(lián)系與溝通能較好地提高產(chǎn)婦的依從性；至產(chǎn)后1年每周堅(jiān)持提肛運(yùn)動(dòng)3 d的產(chǎn)婦達(dá)到86.4%（127/147），且失訪率較低。為避免樣本偏差導(dǎo)致數(shù)據(jù)誤差，本研究未納入未達(dá)到鍛煉標(biāo)準(zhǔn)次數(shù)及鍛煉量的產(chǎn)婦，從而保證鍛煉組產(chǎn)婦均為Kegel訓(xùn)練達(dá)標(biāo)者，以減少案例偏差的影響。

既往有研究［11-12］表明，盆底肌鍛煉可改善產(chǎn)后UI癥狀。而一項(xiàng)meta分析［1］提示，產(chǎn)后盆底肌訓(xùn)練對(duì)產(chǎn)后6~12個(gè)月UI的改善作用不明顯。也有研究［8］認(rèn)為盆底肌鍛煉在產(chǎn)后6個(gè)月內(nèi)對(duì)UI的改善有顯著作用，但是隨訪到產(chǎn)后12個(gè)月未見(jiàn)明顯作用，原因可能是隨著時(shí)間的推移能夠持續(xù)進(jìn)行提肛運(yùn)動(dòng)的產(chǎn)婦數(shù)量顯著下降。本研究結(jié)果顯示，鍛煉組和對(duì)照組比較，UI發(fā)生率和ICIQ-SF評(píng)分差異均無(wú)統(tǒng)計(jì)學(xué)意義，提示Kegel訓(xùn)練在本研究中未能顯著改善UI的情況，其原因有待后續(xù)研究進(jìn)一步探討。未來(lái)仍需要更科學(xué)地確定產(chǎn)婦執(zhí)行Kegel訓(xùn)練的強(qiáng)度、密度、依從性。此外，因考慮到產(chǎn)后6個(gè)月內(nèi)產(chǎn)婦較繁忙，可能導(dǎo)致隨訪困難，故本研究未在產(chǎn)后6個(gè)月內(nèi)進(jìn)行隨訪。

一些對(duì)非孕產(chǎn)婦POP患者的研究［13-14］結(jié)果提示，盆底肌鍛煉可改善脫垂相關(guān)功能癥狀，對(duì)POP-Q分度的改善也有作用。但是一項(xiàng)多中心隨機(jī)對(duì)照研究［15］表明，盆底肌鍛煉只能改善癥狀，對(duì)POP的解剖復(fù)位的作用并不明顯。雖然一些對(duì)中老年P(guān)OP患者的研究［15］表明提肛運(yùn)動(dòng)可以改善脫垂癥狀，但是這不一定適用于孕產(chǎn)婦。國(guó)外學(xué)者對(duì)產(chǎn)婦POP的研究［6-7，16］結(jié)果顯示，提肛運(yùn)動(dòng)對(duì)改善脫垂癥狀和POP-Q分度均無(wú)明顯效果。本研究也獲得了同樣的結(jié)果，即產(chǎn)后12個(gè)月鍛煉組和對(duì)照組之間脫垂程度好轉(zhuǎn)率和POP-Q分度差異均無(wú)統(tǒng)計(jì)學(xué)意義。產(chǎn)婦在養(yǎng)育照看嬰兒的過(guò)程中可能產(chǎn)生諸多軀體和精神癥狀，這些可能混淆脫垂引起的癥狀，并且輕度脫垂通常也無(wú)癥狀，故本研究未對(duì)POP癥狀進(jìn)行調(diào)查比較。筆者認(rèn)為提肛運(yùn)動(dòng)主要是鍛煉盆底肌，提高肌力強(qiáng)度，而POP是黏膜、肌肉、筋膜、韌帶等多種組織過(guò)度牽拉所致，單純提高盆底肌強(qiáng)度可能并不能達(dá)到治療PFD的效果。

目前多項(xiàng)研究［7-8，11，17］提示通過(guò)盆底肌訓(xùn)練可以提高盆底肌肌力強(qiáng)度。本研究也得出了相似的結(jié)論，顯示鍛煉組盆底肌力改善情況明顯好于對(duì)照組。值得一提的是，本研究結(jié)果顯示2組產(chǎn)婦產(chǎn)后1年盆底肌力均有顯著提高，UI發(fā)生率均顯著減低，與既往研究［18-19］結(jié)果一致；這提示盆底肌可能有自行恢復(fù)的機(jī)制，部分存在UI和盆底肌力較弱的產(chǎn)婦在產(chǎn)后1年相關(guān)癥狀也可自行恢復(fù)。該康復(fù)機(jī)制是否與孕產(chǎn)次、年齡、失禁程度、盆底肌強(qiáng)弱及Kegel訓(xùn)練強(qiáng)度和密度有關(guān)，還需進(jìn)一步大樣本研究。

本研究不足之處在于非隨機(jī)對(duì)照研究，可能存在選擇上的偏倚，也缺少更多時(shí)間點(diǎn)的隨訪。產(chǎn)后盆底肌訓(xùn)練是無(wú)侵入性且經(jīng)濟(jì)的操作，是產(chǎn)后骨盆底肌復(fù)原的首選方式，但其對(duì)初產(chǎn)婦及經(jīng)產(chǎn)婦PFD的治療效果及Kegel訓(xùn)練干預(yù)所需的有效劑量還需要多中心、大樣本的隨機(jī)對(duì)照研究繼續(xù)探討。

作者貢獻(xiàn)聲明

饒琳、盧邦春負(fù)責(zé)研究設(shè)計(jì)、論文寫(xiě)作和修改，張琳娜、袁嘉琪、盧邦春負(fù)責(zé)產(chǎn)婦隨訪、數(shù)據(jù)整理以及統(tǒng)計(jì)。所有作者均閱讀并同意了最終稿件的提交。

RAO Lin and LU Bangchun participated in the design of the study, writing and revision of the manuscript. ZHANG Linna, YUAN Jiaqi and LU Bangchun participated in maternal follow-up, data collection and statistics. All the authors have read the last version of paper and consented for submission.

利益沖突聲明

All authors disclose no relevant conflict of interests.

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