研究背景：

女性外生殖器整形美容和年轻化手术作为外阴塑形和提高性生活质量的有效术式目前已逐渐被广泛接受，甚至追捧。在中国，虽然互联网及媒体广泛传播，但由于几千年的文化影响，中国女性长期性格内向、性压抑，与面部整形、脂肪移植等其他整形美容手术相比，女性外生殖器相关整形手术尤其是阴道年轻化手术受传统社会伦理的影响发展较晚，但近年来女性认知和思想观念的转变，大大加速了此类技术的发展进程。性生活是夫妻生活的重要组成部分。阴道作为重要的性器官，对这一过程有着重要的影响。阴道松弛目前被认为是盆底肌肉筋膜损伤导致盆底功能障碍的早期表现之一，妊娠和分娩是其主要原因，早期表现常合并尿失禁、反复性阴道炎或便秘等情况，严重影响女性生理及心理健康，进而影响家庭稳定及社会和谐。目前文献报道指出临床上对于阴道松弛治疗主要包括物理治疗和手术治疗，而手术治疗是最有效的方式。国内外以往的研究显示阴道松弛手术治疗后满意度较高，但所报道的样本量少，随访时间短，难以提供可靠的数据支持。另一方面，目前国内外对于手术有效性的判断基本依据患者的主观感受，缺乏客观数据的验证。

研究目的

第一部分：探讨肛提肌重塑联合会阴体重建的阴道紧缩术在女性阴道年轻化治疗的远期临床效果，包括患者满意度、性功能、并发症、以及伴发尿失禁、器官脱垂等方面的情况，评估该术式的长期有效性、安全性。

第二部分：通过手术前后盆底超声对比，分析术后盆底解剖结构的变化，评估肛提肌重塑联合会阴体重建的阴道紧缩术治疗阴道松弛的手术效果，同时探索该术式对尿失禁、盆腔脏器脱垂等的干预机制，为该术式的有效性和安全性提供客观数据的支持。

研究方法

第一部分：采用回顾性研究，对我中心2012年1月至2022年12月接受肛提肌重塑联合会阴体重建治疗阴道松弛的病例资料进行回顾，并采用电话随访进行术后问卷调查，包括阴道松弛问卷（VLQ）、性生活满意度问卷（SSQ）、患者术后全身状况改善问卷（PGI-I）、女性性功能问卷（FSFI）、国际尿失禁咨询委员会尿失禁调查问卷表(ICIQ-SF）等，整合数据信息，统计学分析，评估患者长期满意度、性功能改善情况及对伴发症状的影响，为该术式的有效性和安全性提供数据支持。

第二部分：采用前瞻性自身对照研究，对我中心2022年1月至2022年12月因不同程度阴道松弛进行阴道紧缩术治疗的病例进行调查统计，完善术前及术后3月盆底4D超声影像学检查，观察分析相关盆底解剖结构变化，统计分析膀胱颈移动度（BND）、膀胱尿道后角（RVA）、尿道旋转角（URA）、肛提肌裂孔面积（LHA）、尿道内口漏斗（IUF）形成情况、肛提肌尿道间隙（LUG）以及器官脱垂相关指标BSD、 CSD、 RSD等指标，为该术式的有效性和安全性提供有效的客观数据支持。

研究结果

第一部分：临床资料：本组研究中初步筛选出837例患者，有效随访478人，失访359人，失访率42.9%。最终纳入患者478人，手术时平均年龄37.13±6.45岁，最大年龄57岁，最小年龄20岁。随访时平均年龄40.89±7.17岁，最大年龄61岁，最小年龄25岁。研究结果如下：

患者术前阴道松弛程度（VLQ）评分为1.84±0.62，术后1年4.89±0.71、术后5年4.01±0.63，术后10年3.85±0.57，p＜0.05；

性生活满意度（SSQ）评分：术前2.26±0.68，术后1年4.02±0.40，术后5年3.85±0.35，术后10年3.76±0.43，p＜0.05；

术后90%以上患者自觉外阴形态改善明显，且各随访时间无统计学差异（χ2=1.762，p=0.414）；患者总体满意度：术后1年90.2%，术后10年88.1%，无统计学差异（χ2=3.605，p=0.165）；80%以上患者自觉术后全身症状明显改善，术后1年、5年、10年无明显统计学差异（χ2=3.920，p=0.141）。

女性性功能整体较术前明显改善（术前21.94±4.96，术后1年26.05±2.28，术后2年24.83±2.95，p＜0.05）；其中性欲望、性唤起、性高潮以及性满意度等维度评分与术前相比差异显著（p＜0.05），疼痛和润滑度等维度评分与术前相比没有统计学差异（p＞0.05）。

396例患者完成尿失禁相关问卷随访，术前尿失禁总体发生率为38.6%（153/396），随访时尿失禁发生率为23.0%（90/396），随访时尿失禁发生率较术前低，且具有统计学差异，χ²=17.64，p＜0.05。153例尿失禁患者中轻度尿失禁 107例，中度尿失禁 42例，重度尿失禁患者6例，以压力性尿失禁为主，占尿失禁构成比87.6%。患者术后1年、5年、10年报告尿失禁主观改善率分别为84.3%、80.8%和63.7%。

第二部分：临床资料：本组研究中77例阴道松弛患者符合纳入标准，而16例患者未完成术后盆底超声检查及随访予以排除，最终61例患者纳入研究。患者平均年龄39.5±6.5岁，其中 48例（78.7%）仅有阴道分娩史，9例（14.7%）有阴道分娩和剖宫产史。其中52例(85.2%)为绝经前患者，6例(9.8%)为围绝经期患者，3例（4.9%）患者已绝经。研究结果如下：

术后阴道内径较术前明显减小(p＜0.05)；阴道松弛程度评分和性生活满意度评分较术前明显改善(p＜0.05)。

女性性功能量表（FSFI）显示：总分术后较术前明显提高，差异有统计学意义；其中性欲望、性唤起以及性高潮等维度评分与术前相比差异显著（p＜0.05），疼痛和润滑度等维度评分与术前相比没有统计学差异（p0.05）。

纳入病例中46人术前主诉有压力性尿失禁相关症状，盆底4-D超声显示术前和术后3月对比BND、RVA、URA、LHA等差异具有统计学意义（p＜0.05），且伴有压力性尿失禁的患者术前术后对比差异更显著；术前有44例（72.1%）检出IUF/+，其中压力性尿失禁患者中42（68.9%）人检出IUF/+，术后3个月，压力性尿失禁患者中仅有3人检出IUF/+。此外，术后BSD、CSD、RSD与术前对比差异有统计学意。42例（91.3%）自觉尿失禁症状较术前改善（PGI-I）。

UDI-6、 ICI-Q-SF、IIQ-7、PISQ-12等各量表评分术后较术前均有明显统计学差异（p＜0.05），而在术后6月与术后1年，各量表相应评分无统计学差异。

患者总体满意度：术后半年90.2%，术后1年为93.4%，术前18人(29.5%)报告伴有反复性阴道炎症状，术后12人报告阴道炎发作次数明显减少；4人（4/6）术后报告产后顽固性便秘明显改善；80%以上患者自觉外阴形态较术前改善。

研究结论：

第一部分：肛提肌重塑联合会阴体重建的阴道紧缩术比以往更明确强调阴道收紧的范围是比邻肛提肌的范围；会阴体的重建过程中不仅加强了远端直肠阴道隔，还缩小了远端阴道管径和阴道外口，最大程度地重塑肛提肌及会阴肌肉和筋膜组织，收紧阴道，明显改善女性阴道松弛症状，显著提高女性性功能，且并发症少，值得临床推广应用。同时该术式对于伴发尿失禁等症状有不同程度的改善，起到了一定的治疗作用，其作用机制及有效性需要进一步研究。

第二部分：盆底超声显示肛提肌重塑联合会阴体重建的阴道紧缩术通过对两侧肛提肌进行折叠缝合同时重建会阴体，缩小了阴道管径和阴道口，明显改善女性阴道松弛症状，该术式加强远端直肠阴道隔和阴道后壁，增强尿道和膀胱颈的支撑结构，防止尿道在压力下过度活动，防止尿道膀胱颈连接处形成“漏斗”，此外肌肉收紧间接牵拉盆底松弛的筋膜及韧带，增强盆底承托能力，改善包括尿失禁以及盆腔器官脱垂等在内的盆底功能障碍，为临床上改善尿失禁和盆底器官脱垂提供新方向。同时该术式能够明显改善性生活质量，且并发症少，安全性高，是行之有效的阴道年轻化术式。

Background

Female external genital cosmetic and rejuvenation surgery, as an effective surgical procedure for shaping vulva and improving the quality of sexual life, has been gradually accepted and even sought after. In China, despite the wide spread of the Internet and media, due to the influence of thousands of years of culture, Chinese women have a long-term introverted personality and sexual repression. Compared with other plastic surgery such as facial plastic surgery and fat transplantation, female genital related plastic surgery, especially vaginal rejuvenation surgery, is affected by traditional social ethics and developed late. It has greatly accelerated the development process of such technology. Sex is an important part of a couple's life. As an important sexual organ, the vagina has an important impact on this process. Vaginal relaxation is one of the early manifestations of pelvic floor dysfunction caused by pelvic floor muscle and fascia injury, and pregnancy and childbirth are the main causes. The early manifestations are often combined with urinary incontinence, recurrent vaginitis, or constipation, which seriously affects women's physical and mental health, even family stability and social harmony. The current literature reports that the clinical treatment of vaginal relaxation mainly includes physical therapy and surgical treatment, and the latter is the most effective way. Studies at home and abroad have reported high satisfaction after vaginal relaxation surgery, however, the sample size is limited, and the follow-up period is brief. It is difficult to provide reliable data support. On the other hand, the judgment of the effectiveness of surgery at present is basically based on the subjective feelings of patients, and there is a lack of objective data verification.

Objective

Part I: To investigate the long-term clinical effect of transvaginal posterior levatorplasty combined with perineoplasty on female vaginal rejuvenation, including patient satisfaction, sexual function, complications, urinary incontinence, organ prolapse, etc., and to evaluate the long-term efficacy, safety, and related influencing factors of this operation.

Part II: By comparing pelvic floor ultrasound before and after surgery, the changes of pelvic floor anatomy before and after surgery were analyzed, and the effect of transvaginal posterior levatorplasty combined with perineoplasty in the treatment of vaginal laxity was evaluated, and explore the intervention mechanism of this surgery on urinary incontinence and pelvic organ prolapse，so as to provide objective data support for the effectiveness and safety of this surgical method.

Methods:

Part I: A retrospective study was conducted to analyze the clinical data of female patients with vaginal relaxation who underwent transvaginal posterior levatorplasty combined with perineoplasty in our center from January 2012 to December 2022. The postoperative questionnaire was followed up by telephone. The data included Vaginal Laxity Questionnaire (VLQ), Sexual Satisfaction Questionnaire (SSQ), Patient General Improvement Index (PGI-I), Female Sexual Function Index (FSFI), International Consultation on Incontinent Questionnaire Short Form (ICIQ-SF), etc. The data were integrated and statistically analyzed. The long-term patient satisfaction, improvement of sexual function and the impact on accompanying symptoms were evaluated to provide data support for the effectiveness and safety of the surgical procedure.

Part II: A prospective study was conducted on patients who underwent vaginal tightening surgery due to different degrees of vaginal relaxation in our center from January 2022 to December 2022. The pelvic floor 4D ultrasound imaging examination before and 3 months after surgery was improved. By analyzing the changes of pelvic floor anatomy，and the bladder neck distance (BND), retrovesical angle (RVA), urethral rotation Angle (URA), levator ani hiatus area (LHA), and the formation of internal urethral meatus infundibulum (IUF) were statistically analyzed. The levator urethral space and organ prolapse related indicators such as BSD, CSD, and RSD provide effective objective data support for the effectiveness and safety of this procedure.

Results:

Part I: In this study, a total of 837 patients were initially screened, 478 patients were effectively followed up, and 359 patients were lost to follow-up, with a loss rate of 42.9%. Finally, 478 patients were enrolled. The average age of the patients with effective follow-up was 37.13±6.45 years at the time of surgery, with the oldest age of 57 years and the youngest age of 20 years. The average age at follow-up was 40.89±7.17 years, with the oldest age 61 years and the youngest age 25 years. Results of the study:

Vaginal laxity score(VLQ)：preoperative 1.84±0.62, postoperative 1 year 4.89±0.71, postoperative 5 years 4.01±0.63, postoperative 3.85±0.57, p＜0.05.

Sexual satisfaction score（SSQ）：preoperative 2.26±0.68,postoperative 1 year 4.02±0.40, postoperative 5 years 3.85±0.35, postoperative 10 years 3.76±0.43, p＜0.05.

More than 90% patients felt that the appearance was improved significantly after operation, and there was no statistically significant difference at each follow-up time (χ2=1.762, p=0.414); The overall satisfaction of patients was 90.2% at 1 year after operation and 88.1% at 10 years after operation, with no significant difference (χ2=3.605, p=0.165). More than 80% patients felt that their systemic symptoms were significantly improved after operation, and there was no significant difference between 1 year, 5 years and 10 years postoperatively (χ2=3.920, p=0.141).

Female sexual function including libido, sexual arousal, lubrication, and sexual satisfaction were significantly improved (preoperative: 21.94±4.96; 1 year postoperatively: 26.05±2.28; 2 years postoperatively: 24.83±2.95; p＜0.05); and there were no statistically significant differences in the scores of pain and lubrication (p＞0.05) compared with those of the preoperative period.

396 patients completed follow-up related to urinary incontinence, the overall incidence of urinary incontinence was 38.6% (153/396) preoperatively, and the incidence of urinary incontinence at the follow-up was 23.0% (90/396), the incidence of UI at the follow-up was lower than that of preoperative, and statistically different, χ2=17.64, p＜0.05. 107 out of 153 patients with urinary incontinence were incontinent of mild urinary incontinence, 42 out of moderate urinary incontinence 42 patients, and 6 patients with severe urinary incontinence, mainly SUI, accounting for 87.6% of the composition ratio of urinary incontinence. Patients reported subjective improvement rates of urinary incontinence of 84.3%, 80.8%, and 63.7% at postoperative 1 year,5 years and 10 years respectively.

Part II: A total of 77 patients with vaginal relaxation met the inclusion criteria, while 16 patients did not complete the postoperative pelvic floor ultrasonography and follow-up to be excluded. Finally, 61 patients were included in the study. The mean age of the patients was 39.5±6.5 years, of which 48 (78.7%) had a history of vaginal delivery only and 9 (14.7%) had a history of vaginal delivery and cesarean section. Fifty-two (85.2%) of them were premenopausal, 6 (9.8%) were perimenopausal and 3 (4.9%) patients were menopausal. Results of the study：

Postoperative vaginal diameter decreased significantly compared with that before operation (p＜0.05); The scores of vaginal relaxation and sexual satisfaction were significantly improved compared with those before operation (p＜0.05).

Meanwhile, female sexual function significantly improved during follow-up ( p＜0.05). The scores of sexual desire, arousal and orgasm were significantly different from those before surgery (p＜0.05), while the scores of pain and lubrication were not statistically different from those before surgery(p＞0.05).

46 of the included cases complained of symptoms related to stress urinary incontinence before surgery, and 4-D ultrasound of the pelvic floor showed statistically significant differences between preoperative and 3-month postoperative comparisons of BND, RVA, URA, and LHA (p＜0.05), and the differences between the preoperative and postoperative comparisons were more significant in the patients with stress urinary incontinence; IUF/+ was detected in 44 (72.1%) of the patients with stress urinary incontinence before surgery, and among them, stress IUF/+ was detected in 42 (68.9%) of the patients with urinary incontinence, and 3 months after surgery, IUF/+ was detected in only 6 of the patients with stress urinary incontinence. In addition, there was a statistically significant difference between postoperative BSD, CSD, and RSD compared to preoperative. 42 (91.3%) had improvement in self-perceived urinary incontinence symptoms compared to preoperative (PGI-I).

UDI-6, ICI-Q-SF, IIQ-7, and PISQ-12 scores of each scale were statistically significantly different postoperatively compared to preoperatively (p＜0.05), and the difference was not statistically significant at 6 months postoperatively compared to 1 year postoperatively.

The overall satisfaction of patients was 90.2% in the first half year and 93.4% in the first year after the operation. 18 patients (29.5%) reported recurrent vaginitis before the operation, and 12 patients reported that the frequency of recurrent vaginitis was significantly reduced after the operation. Four patients (4/6) reported significant improvement in postpartum intractable constipation. More than 80% patients reported that the appearance of vulva was improved.

Conclusion：

Part I: Transvaginal posterior levatorplasty combined with perineoplasty resets the levator ani muscle and reconstruct the perineal body, which emphasizes more clearly than before that the range of vaginal tightening is the adjacent to levator ani muscle; the reconstruction of the perineal body not only strengthens the distal rectovaginal septum, but also narrows the distal vaginal diameter and vaginal opening. This approach could anatomically reset the levator ani muscle, perineal muscle, and fascia tissue to the greatest extent, tighten the vagina, significantly improve female vaginal relaxation symptoms, significantly improve female sexual function, and had high postoperative satisfaction, which is worthy of clinical application. Additionally, patients with urinary incontinence, had significant improvement in postoperative symptoms. This surgical procedure has played a certain therapeutic role, its mechanism and effectiveness need to be further studied.

Part II: Pelvic floor ultrasonography suggests that transvaginal posterior levatorplasty combined with perineoplasty by folding the bilateral levator ani muscles and reconstructing the perineum at the same time, reduces the vaginal diameter and vaginal orifice, and significantly improves the symptoms of vaginal relaxation in women. This surgery strengthens the distal rectovaginal septum and posterior vaginal wall, enhances the supportive structure of the urethra and the bladder neck, prevents the urethra from moving excessively under pressure, and prevents the formation of urethral funnel, and avoids excessive movement of the urethra under pressure. In addition, the muscle tightness indirectly tightens the laxity of the pelvic floor by pulling and tightening the fascia and ligament, enhances the supporting capacity of the pelvic floor. Finally, the procedure improves the pelvic floor dysfunction including urinary incontinence and pelvic organ prolapse, which provides a new direction for improving urinary incontinence and pelvic floor organ prolapse. At the same time, this procedure can significantly improve the quality of sexual life, fewer complications, and high safety, it is an effective method for proven vaginal rejuvenation.