127 PHỄCă ăCH Nă OỄN VẨăX ăTRệ SA CỄCăT NGăVỐNGăCH U 50 I nhăngh a Saăcácăt ngătrongăvùngăch uă(POP = pelvic organ prolapse), lƠăs ăt tăxu ngăc aăTC, BQ, TrTr,ăthƠnhătr c,ăthƠnhăsauăỂ ầăra kh iăv ătríăgi iăph uăbìnhăth ng,ădoăs ă t năth ngăvƠăsuyăy uăcácăc uătrúcăcơnăc ăvà dây ch ngănơngăđ ăt iăsƠnăch u.ă H ăth ngănơngăđ ăcácăc ăquanătrongăti uăkhung:ă H ăth ngănơngăđ :ăc ănơngăHMăvƠăc ănơngăc aăsƠnăh iăơm H ăth ngătreo:ădơyăch ngămuăni uăđ o,ăm cămuăCTC,ădơyăch ngăTCăcùng,ădơyă ch ngăngangăCTC,ăcơnăHalban,ăcơnăTrTr-A H ăth ngăđ nhăh ng:ădơyăch ngătròn,ădơyăch ngăr ng Phơnălo iăvƠăphơnăđ ăsaăt ngăvùngăch u [1-5] V ătríăgi iăph uă soăv iăthƠnhăA T ngăch uăsaăvƠăphơnălo i Thànhătr c (ng n ỏr c) SaăBQ:ătrungătơm,ăbên,ăk tăh p Vòmăơmăđ o (ng n gi a) TúiăsaăRN:ătr Thành sau (ng n saỐ) TúiăsaăTrTr:ăcao,ăgi a,ăth p T năth SC T năth T D Sa TC SaăN Ni uăđ ngăh c Sa MC MRIăđ ngă± Ni uăđ ngăh c Saătr cătrƠng Kh iăl ngătrongăTrTr-HM ngăc ăth tătrongăvƠăngoƠiăHM BV ngănútă c,ăsau XNăc năthi t MRIăđ ngă± Ni uăđ ngăh c Siêuăơmă3Dăc ăth tăHMă ng ăTrTr Ghi ối ỏ ỏ ỏ: A (âm đ o), BQ (bàng qỐang), N (ni Ố đ o), RN (rỐ ỏ non), TC (ỏ cỐng), MC (m m c ỏ), TrTr (ỏr c ỏràng), HM (h Ố mơn), SC (sàn ch Ố) Phơnălo iăvƠăđ ăsaăt ngăvùngăch uătheoăh ăth ngăPOPăậ Q a Giúpăphơnălo iăsaăt ngăch uătùyătheoăthƠnhăph năb ă nhăh ngăthu căv :ă Ng nătr că(saăBQ,ăsaăni uăđ o) Ng năgi aă(saăRN,ăCTCăậ TC,ăvòmăỂ ăn uăđưăc tăTCă) Ng năsauă(saătr cătrƠng)ă b Th ăhi năm tăb nhănhơnăcóăth ăsaăm tăhayănhi uăcácăthƠnhăph nănêuătrên,ăquy tăđ nhă uătr ăt ngă ngătheoăngunăt căph căh iătheoăm iăc uătrúcăb ă nhăh ng c Phơnăđ ăsaăt ngăch uăkháchăquan,ăchínhăxácăgiúpătheoădõiăvƠăđánhăgiáăhi uăqu ăđi uă tr ădoădùngăth B ỉh ối ỉ T D căđoăvƠăth ăhi n raăđ năv ăcm Phác đ u tọ s ỉ ịh ỆhỊa - 2012 128 Quiă c:ăcóă9ăm căc năđo năv ăcm,ăBNă ăt ăth ăSPK,ăđ uăcaoă450,ăr nătrongăqătrìnhăđánhăgiá D D ngăc :ăvanăA ,ăth căđo,ăk pătim,ă pozzi i măc ăđ nh:ăAa,ăApăcáchăN ,ămépă màng trinh 3cm i măthayăđ i:ăBa,ăBpălƠăđi măph ngă raăxaănh tăc aăđo năA ăt ăAa,ăApăđ nă túiăcùngătr căvƠăsauăkhiăBNăr nă±ăh ă tr ă kéoă CTCă raă b ngă pozziă ho că k pă tim Cùngă đ :ă C,ă Dă (đ că tínhă n uă cònă TC) Gh:ăKheăni uăd c Pb:ăth ăsƠnăch uă(nútăsƠnăch u) Tvl:ăchi uădƠiăỂ Trên/d iămépămƠngătrinh đánhăd uă-/+ tr Phânăđ BV ă0:ăăkhơngăsaăt ngăch u Aa,ăBa,ăAp,ăBp:ăă3cmăăn mătrênămƠngătrinh i măC hay D: tvl ậ2cmă 1cm màng trinh ăII:ăBătrongăkho ngă±1cmătrênăd iămƠngătrinh ăIII:ăBă>1cmăd iămƠngătrinhăđ năă2ăti ng B ỉh ối ỉ T D Phác đ u tọ s ỉ ịh ỆhỊa - 2012 133 ThƠnh tr ăCH Nă ỐN VÀ X ăTRÍ SA CÁCăT NGăVÙNGăCH U cỂ Vòm Ể ThƠnh sau Ể Sa BQ: trung tâm, bên, k t h p TKKSKGS Sa TC, sa MC Túi sa RN; tr c, sau Ni u đ ng h c (urodynamic) Siêu ơm b ng t ng qt MRI đ ng (Defecography) ± Ni u đ ng h c i u tr Túi sa TrTr: cao, gi a, th p Sa niêm HM-TT, t n th ng nút sƠn ch u, c MRI đ ng (defecography) S 3D lòng tr c trƠng o áp l c ng HM vƠ c th t HM (Manometry) ± Ni u đ ng h c i u tr n i khoa Ch đ nh Các PT (xem s đ PT ngư  ) Ch đ nh đ t m nh ghép t ng h p BV ng s ng BN T Ch đ nh Thay đ i thói quen, sinh ho t VLTL ru t, b ng đái T p sƠn ch u; t t p, t p v i máy; Thu c Kích thích n c SC Mang vòng nơng Ể nơng BQ, TrTr, u tr TKKSKGS, TKKS h h p Các ph ng pháp i u tr ngo i khoa sa t ng đ I – II ch a có bi n ch ng ch a nh h ng ch t l B ỉh ối ỉ T D th t HM D CLS POP-Q PHÁC POP-Q; sa t ng t đ 2 Có bi n ch ng; ti u khó, bí ti u, ti u t n l u, th n ch ng, BQ th n kinh, táo bón, ti u khơng ki m sốt nh h ng ch t l ng s ng BN Ngư ơm đ o Ngư b ng; m h , n i soi b ng Sa t ng ch u nơng t đ Sa tái phát Sa m m c t Tình tr ng BN khơng cho phép PT kéo dƠi ho c gây mê tồn thân Phác đ u tọ s ỉ ịh ỆhỊa - 2012 134 PT ngư b ng Treo TC/MC vào m m nhơ SA TC/MC kèm sa BQ ≥ăđ ă2 Sa TC/MC kèm sa TrTr ≥ăđ ă2 PT ngư b ng đ n thu n PT ngư b ng k t h p ngư Ể C đ nh sƠn ch u vƠo m m nhơ s d ng m nh ghép t ng h p nơng BQ Treo TC/MC vào m m nh vƠ may ph c h i ngang BQ-CTC (repair of paravaginal defect) Treo TC/MC vào m m nhơ ho c may ng n dơy ch ng TC K t h p ngư Ể đ t m nh ghép t ng h p thƠnh tr c Ể nâng BQ PT ngư b ng đ n thu n PT ngư b ng k t h p ngư Ể C đ nh sƠn ch u vƠo m m nhơ s d ng m nh ghép t ng h p nơng TrTr Treo TC/MC vào m m nhơ ho c may ng n dơy ch ng TC K t h p ngư Ể đ t m nh ghép t ng h p thƠnh tr c Ể nâng BQ D Ch sa TC/MC ≥ăđ ă2 BV C t TC T PT ngư ơm đ o t m nh ghép t ng h p thƠnh tr c ơm đ o nâng BQ C đ nh MC vƠo DC gai (Richter) ho c may ng n dơy ch ng t cung (PT McCall) t m nh ghép thƠnh sau Ể nơng tr c trƠng (Posterior Intravaginal Sling – Infracoccygeal Sacropexy) B ỉh ối ỉ T D Khơng c t TC t m nh ghép t ng h p thƠnh tr c ơm đ o nâng BQ C đ nh TC vƠo DC gai (Richardson) ho c c t đo n c t cung + May ng n dơy ch ng t cung (Manchester) t m nh ghép thƠnh sau Ể (Posterior Intravaginal Infracoccygeal Sacropexy) Phác đ u tọ s ỉ ịh ỆhỊa - 2012 135 TẨIăLI UăTHAMăKH O 10 11 12 13 14 15 16 17 18 19 20 21 22 23 D T G.Willy Davila, Section I: Concept of the Pelvic Floor as a Unit, in Pelvic Floor Dysfunction A Multidisciplinary Approach 2006, Springer p 3-6 Whitcomb, E.L., et al., Prevalence of Defecatory Dysfunction in Women With and Without Pelvic Floor Disorders 2009 p 179-187 10.1097/SPV.0b013e3181b12e01 Haylen, B.T., et al., An international urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for female pelvic floor dysfunction Neurourology and Urodynamics, 2010 29(1): p 4-20 Chao, F., et al., Does pre-operative traction on the cervix approximate intra-operative uterine prolapse? 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