肛管直肠周围肌组织感染的MRI表现及术后随访

  目的  分析肛管直肠周围肌组织脓肿长期被临床忽视的原因,并总结术后患者肛门功能的恢复情况。  方法  回顾性分析39例肛门外括约肌和/或耻骨直肠肌、肛提肌脓肿患者的MRI表现,并随访术后患者控便及排便能力。  结果  18例为单一肌组织脓肿,21例并发两组以上肌组织脓肿,其中存在肛门外括约肌深部脓肿28例,浅部脓肿26例,耻骨直肠肌脓肿9例,肛提肌脓肿4例,肛门外括约肌皮下部脓肿1例;感染肌组织肿胀增粗,基本保持解剖形态,其中外括约肌深部呈典型“U”形,肛提肌呈对称“蝴蝶翅膀样”表现;肛周脂肪间隙清晰34例,脂肪间隙结构不清5例,术中触及内口26例。35例未累及肛提肌患者术后控便和排便良好,3例肛提肌脓肿患者存在不同程度控便不良及排便无力,另1例失联。  结论  肛门外括约肌和/或耻骨直肠肌、肛提肌有时不能阻挡肛周感染的传播,甚至肌组织内部形成脓肿,肛门外括约肌及耻骨直肠肌脓肿术后患者肛门控便及排便功能很可能不受影响,肛提肌脓肿术后患者可能会出现肛门控便及排便功能不同程度降低。      

三维盆底超声可动态观察初产妇早期盆底结构及功能的变化

  目的  分析利用会阴三维盆底超声观察产后早期盆底结构及功能受到不同分娩形式所产生的影响,为盆底功能障碍性病症的治疗及预防提供参考。  方法  选取2019年12月~2020年6月在我院产科门诊产后6~8周复查的初产妇67例,根据不同分娩方式,将患者分为剖宫产组（n=23）和经阴道顺产组（n=44）。利用经会阴三维盆底超声对两组患者分别在静息状态下及最大Valsalva状态下,膀胱颈位置、尿道倾斜角、膀胱尿道后角及宫颈外口位置进行观察,计算最大Valsalva动作状态下的膀胱颈移动度、尿道旋转角、宫颈移动度,比较尿道漏斗形成率、膀胱膨出形成率以及类型、子宫脱垂形成率,对比最大Valsalva动作状态、缩肛及静息状态下的肛提肌裂孔面积及左右侧肛提肌的厚度,在缩肛情况下,对肛门内外括约肌及肛提肌是否存在撕裂进行观察。  结果  静息状态下的膀胱颈位置水平远低于剖宫产分娩组（t=-3.43,P < 0.05）,Valsalva状态膀胱颈移动度及尿道旋转角大于剖宫产分娩组（t=3.53、3.82,P < 0.05）,膀胱膨出发生率高于剖宫产分娩组（t=11.075,P < 0.05）,静息、缩肛以及Valsalva状态下的肛提肌裂孔面积均大于剖宫产分娩组（t=4.17、2.95、2.80,P < 0.05）。两组间在膀胱膨出类型上,Ⅱ型膀胱膨出发生率均高于其他两个类型,且经阴道顺产组膀胱膨出三种类型发生率均高于剖宫产组（χ2=13.39,P < 0.05）。而静息状态下的宫颈外口位置、膀胱尿道后角,Valsalva状态下宫颈移动度、尿道漏斗形成、子宫脱垂、直肠膨出以及会阴体过度运动等发生率差异无统计学意义（P>0.05）。3种状态下左右侧肛提肌厚度无明显差异,两组产妇均未发现肛门内外括约肌损伤及肛提肌撕裂。  结论  经会阴三维盆底超声能很好的动态观察到前、中、后盆腔脏器的各项指标,无论哪种分娩方式均可对盆底造成不同程度的损伤,相对于经阴道分娩,早期剖宫产分娩组在前盆腔以及肛提肌裂孔面积方面较经阴道顺产组程度轻。      

Inhibition of the external urethral sphincter and sacral reflex by anal stretch in spinal cord injured patients

Relaxation of both detrusor and external sphincter muscles by mechanical stretch instead of cutaneous stimulation of the anal sphincter has been recognized and applied clinically for bladder emptying and for aiding catheterization in patients with spastic urethral sphincter. In a three-year study anal stretch was included as part of urodynamic examination in patients who could potentially use this method for bladder management. Anal stretch was found to inhibit the bulbocavernosus reflex and to be a useful alternative technique for bladder emptying in patients having complete paraplegia with normal hand function and with detrusor-sphincter dyssynergia. It is recommended that anal stretch combined with Credé or Valsalva maneuvers be a part of the urodynamic study of such patients to determine whether or not these techniques can be utilized for bladder management.     

Activation of the external anal and urethral sphincter muscles by repetitive transcranial cortical stimulation during spine surgery

OBJECTIVE: Clinical utility of high intensity repetitive transcranial electrical stimulation (rTES) to elicit a response in external anal and urethral sphincter muscles was investigated in 23 patients undergoing spine surgery. METHODS: During surgery, motor evoked potentials (MEPs) were recorded from external anal sphincter (EAS), external urethral sphincter (EUS), and tibialis anterior (TA) muscles following high voltage rTES under total intravenous anesthesia. RESULTS: No neurologic sequelae occurred during or after the rTES of the motor cortex. Onset latency for the EAS muscle was 20.2 +/- 3.5 msec which was not significant compared to the EUS muscle latency at 19.9 +/- 1.8 msec. The average electrical intensity to evoke EAS response was 789 +/- 78 volts compared to the 831 +/- 11 volts of the EUS muscle. Waveform latency for the TA muscle was robust in all cases while the latencies for EAS and EUS were not always clear. CONCLUSIONS: This preliminary study shows that intraoperative MEP monitoring of the external anal and urethral muscles is feasible method in particular in circumstances where bowel and bladder function are at risk of an inadvertent injury due to surgical manipulation.     

经肛内括约肌切除术联合经腹全直肠系膜切除术患者围术期护理

目的 探讨超低位肿瘤患者经肛内括约肌切除术( intersphincteric resection,ISR)联合经腹全直肠系膜切除术(total mesorectal excision,TME)的围术期护理.方法 对34例无肛门外括约肌受侵的超低位直肠肿瘤患者实施经肛ISR联合经腹TME,术前加强心理护理及肠道准备,术...     

阴道助产对初产妇产后早期盆底功能的影响

目的 探讨阴道助产对初产妇产后早期盆底功能的影响。方法 收集345例阴道分娩初产妇的临床资料,根据分娩方式分为自然分娩组170例、胎头吸引器助产组130例、产钳助产组45例,在产妇产后6~12周进行盆底肌力和盆底三维超声检查。比较3组产妇的盆底肌力异常率、膀胱颈移动度增大率、膀胱膨出率、肛提肌裂孔面积增大率、肛提肌损伤率及肛门括约肌损伤率。结果 3组产妇的年龄、BMI、孕期增重、孕周、新生儿出生体质量比较差异均无统计学意义（P均> 0.05）。产钳助产组盆底肌力的异常率高于自然分娩组（P < 0.017）,其余两两比较差异均无统计学意义（P均> 0.017）。产钳助产组的肛提肌损伤发生率高于自然分娩组及吸引器助产组（P均< 0.017）,吸引器助产组的肛提肌损伤发生率高于自然分娩组（P < 0.001）。3组产妇的膀胱颈移动度增大、膀胱膨出、肛提肌裂孔面积增大及肛门括约肌损伤发生率比较差异均无统计学意义（P均> 0.05）。盆底超声提示盆底肌肉损伤的52例产妇中,产后盆底肌力筛查示正常9例,2种检查方法的一致性检测结果为Kappa = 0.061,P = 0.029。结论 与自然分娩的产妇相比,产钳助产对盆底肌力的损伤最大,接受产钳助产者的肛提肌损伤发生率最高;2种产后盆底肌力检查方法相互独立,盆底超声能清晰显示盆底肌损伤状况,在产后盆底筛查中起重要作用。     

经会阴四维超声观察新生儿体重及不同的分娩方式对产妇盆底结构的近期影响

【摘要】目的 应用经会阴四维超声观察新生儿体重及不同的分娩方式引起盆底结构改变的图像特征。方法 对2016年5月至2016年12月在我院初产的产妇于产后第42天依照新生儿体重及分娩方式不同分：巨大新生儿自然分娩组40 例、巨大新生儿剖宫产组55 例,以及对照组：正常体重新生儿自然分娩组150 例、正常体重新生儿剖宫产组150 例（均初产,于产后第42天）均进行盆底超声检查,观察并记录静息、缩肛和Valsalva动作三个时态下膀胱颈、子宫颈、直肠肛管形态及活动度。四维图像重建后观察三个时态下肛提肌裂口形态及连续性,并测量肛提肌裂口面积,记录超声检查结果并与进行统计分析。结果 经自然分娩的巨大新生儿组与自然分娩正常新生儿组比较膀胱颈活动度和三个状态下的肛提肌裂口均明显增大,子宫下垂发病率也增加,而直肠膨出发病率和Valsalva状态下膀胱后角、膀胱颈倾斜角和膀胱颈旋转角均没有明显统计学差别。剖宫产 的巨大新生儿组与剖腹产的正常体重新生儿组比较仅膀胱颈活动度和膀胱颈旋转角增大,余各指标无统计学差别。巨大新生儿自然分娩组与剖宫产组比较,仅Valsalva状态下膀胱后角和直肠膨出发病率无统计学差异,余各指标均明显增大。结论 与正常体重新生儿组比较,巨大新生儿组对产妇盆底结构的近期影响较明显,尤其是自然分娩的巨大新生儿组。     

MRI增强扫描在肛周脓肿术前诊断中的价值

目的探讨MRI不同方位及序列成像,尤其是冠状位及轴位T1WI压脂增强序列在肛周脓肿的术前诊断中的价值。方法经手术证实的30例脓肿患者全部进行增强MRI扫描。以手术结果为对照标准,统计分析MRI扫描三种序列组合对各种类型肛周脓肿及内口的检出率,并与直肠指诊进行对照分析。结果 30例患者手术证实52个脓肿,30个内口。直肠指诊肛周脓肿43个,检出率为82.69%,其中括约肌间脓肿15个,坐骨肛管间隙脓肿23个,肛提肌上方脓肿5个,正确的内口22个,检出率为73.33%。MRI轴位联合冠状位T1WI压脂增强序列检出肛周脓肿52个,检出率最高为100%,其中括约肌间脓肿18个,坐骨肛管间隙脓肿23个,肛提肌上方脓肿11个,正确的内口29个,检出率为96.67%。两组比较,对于肛提肌上方脓肿和内口的检出有统计学意义(P值分别为0.017和0.030)。结论肛周脓肿术前MRI增强扫描,能发现更多的肛提肌上方脓肿及明确的内口,为外科手术方式的选择提供更可信的影像资料。     

Female urinary incontinence: pathophysiology, methods of evaluation and role of MR imaging

Urinary incontinence (UI) is one of the most common conditions that cause a significant psychosocial and hygienic problem in an aging female population. In this article we focus on the sphincteric type of stress UI in women, review the anatomy of the urethral sphincter and its support mechanism, and discuss methods of the evaluation of urethral function. Stress UI is the functional consequence of an anatomical abnormality, urethral hypermobility (UH) and intrinsic sphincter deficiency (ISD). Imaging plays an adjunct role to urodynamics in the assessment of women with UI. MR imaging due to its superior soft tissue contrast resolution contributes many findings that are predictive of UH, such as abnormal descent of the bladder neck, disruption of periurethral ligaments and vaginal attachments, and defects within the levator ani muscle. In ISD, MR imaging may show foreshortening or thinning of the sphincter muscle and bladder neck insufficiency manifested by funneling. MR imaging is ideal to evaluate the anatomy of the bladder neck and urethra; functional implications correlate well with functional studies and make MR imaging central to understanding the causes of stress UI and its thorough evaluation.     

Urinary manometry in patients with spinal cord injury: neurourological considerations in the rehabilitation of acute and chronic neurogenic bladder.

Recordings of pressure within the bladder, urethra, rectum, and external anal sphincter with image intensification and videotaping were carried out in spinal cord injury patients with complete and incomplete lesions, during spinal shock and in the chronic stage. The behavior of the external urethral sphincter and the somatic and visceral motor reflexes of the sacral segments were studied, during and after spinal shock. During spinal shock the majority of patients retained sacral somatomotor activity, in the absence of visceromotor activity, and resistance values at the external urethral sphincter remained high. Vascular oscillations were recorded in the membranous urethra. The highest resistance found in the membranous urethra was at the distal part of the external sphincter.     

Urodynamic evaluation of voluntary detrusor response in healthy subjects

The ability of healthy subjects to voluntarily inhibit a bladder detrusor contraction was evaluated using standard urodynamic techniques. Ten healthy subjects (five men and five women) were appraised using trichannel techniques which included measuring bladder volume, bladder pressure, intraabdominal pressure, and electromyographic activity of the anal or external urethral sphincter. Each subject was first evaluated to determine normalcy of urine flow rate. All subjects were assessed in three positions: supine, sitting, and standing. All ten subjects were able to inhibit their detrusor responses without increasing external urethral or anal sphincter activity or raising the tonus pressure limb of the bladder. Three of the subjects were unable to void during any part of the urodynamic evaluation. In one subject, voiding was accomplished by Valsalva maneuver which mimicked detrusor contraction. At least two subjects did not demonstrate their first urge to void until 300 to 400 cc, and one of these individuals was unable to void until his bladder capacity reached 600cc. These results indicated that normal subjects can inhibit their detrusor response during urodynamic studies. Inability to inhibit this response would therefore appear to be an abnormal pattern. Conversely, inability to produce a detrusor response cannot be called an abnormal retention pattern. Bladder volumes in healthy subjects may be higher than the traditional norms, and this must be taken into account during urodynamic evaluations.     

护理干预预防前列腺术后尿失禁效果观察

目的探讨护理干预对经尿道前列腺等离子电切术(TURP)后尿失禁的预防效果。方法采取TURP治疗良性前列腺增生症患者200例,其中100例(试验组)术前、术后均采用肛提肌功能锻炼方法训练盆底肌及尿道扩约肌肌力并进行排尿行为训练,预防术后尿失禁的发生;对照组100例采用常规护理方法。结果试验组发生尿失禁2例,对照组尿失禁10例,两组比较差异有统计学意义(P0.05);试验组平均住院日、住院费用明显低于对照组(P0.05);术后3个月两组国际前列腺症状评分(I-PSS评分)差异无统计学意义(P0.05)。结论采用肛提肌功能锻炼方法训练盆底肌及尿道扩约肌肌力并进行排尿行为训练,预防术后尿失禁效果显著,具有可行性、实用性,应当作为术前术后健康指导的重点内容之一。     

Cerebro-cortical innervation of the urinary bladder

In this report cerebro-cortical innervation of the urinary bladder has been investigated in man by the use of electroencephalography and in the cat by the application of the evoked potential technique. Electroencephalographic monitoring during bladder filling while the patient was asleep was a useful method to determine cerebral response to stimulation of bladder sensory receptors. Bladder filling was performed during stage IV sleep. In the intact individual detrusor reflex contraction or attainment of bladder capacity was followed by prompt arousal and desynchronization of EEg rhythms. In patients with interruption of bladder sensory pathways in the periphery or in the spinal cord there was loss of impairment of the EEG response to bladder filling. In the cat, anesthetized with sodium pentobarbital, electrical stimulation of the nerve supply to the urinary detrusor muscle and to the pudendal nerve innervation to the periurethral striated muscle and anal sphincter, evoked a diphasic response in the cerebral cortex of the frontal lobe. All responses were grouped in the same area and were of short latency. Similar potentials have been evoked in man. These studies demonstrate that the peripheral, spinal and cerebral innervation of the urinary bladder in man are definable by electrophysiologic techniques. As a result, these electrophysiologic techniques are applicable to defining neuropathic changes in the urinary bladder innervation in man.     

High-resolution magnetic resonance imaging of the anorectal region without an endocoil

Background: To evaluate the feasibility of a high-resolution magnetic resonance imaging (MRI) technique in detailed imaging of the anal sphincter and lower pelvic region without the use of an endoluminal coil. Methods: MRIs with an external phased array coil (T1- and T2-weighted turbo spin echo) were performed in 22 volunteers and 12 patients with an anal fistula, an anal sphincter defect, or a rectal tumor. The normal scans were evaluated by three independent observers. The scans of the patients were compared with surgical and/or histologic findings. Results: The anal sphincter was visualized with detail. In the anal canal, hemorrhoidal tissue and the submucosae ani muscle could be seen. The MRI technique also allowed detailed imaging of anatomical structures above the pelvic floor. The MR findings in the 12 patients showed exact correlation with surgery and/or histology. Conclusions: High-resolution MRI of the anorectal region without an endoluminal coil is feasible. The MR technique with an external phased array coil allows detailed imaging of the anal sphincter at rest, the rectum, and the surrounding pelvic structures with one single investigation. The results are promising and suggest useful applications in the management of anorectal diseases.     

Selective inhibitory effects of ethylketocyclazocine on reflex pathways to the external urethral sphincter of the cat

In the ventral horn of the sacral spinal cord of the cat, opioid terminals are preferentially localized in Onuf's nucleus, an area containing motor neurons that innervate the striated muscle of the external urethral sphincter. The present study was undertaken to 1) compare the effects of selective opioid agonists on sphincter reflex pathways with the effects of these drugs on hindlimb reflexes and urinary bladder reflexes and 2) determine if the physiological inhibition of sphincter reflexes, which accompany bladder contractions, is mediated by endogenous opioids. The effects of intrathecal (i.t.) and i.v. drug administration on bladder activity, sphincter reflexes and reflexes to the hindlimb musculature were monitored in chloralose-anesthetized cats. Ethylketocyclazocine (0.05-500 micrograms i.t.) produced a dose-dependent, naloxone-sensitive, inhibition of sphincter reflexes to less than 10% of control amplitude while having no consistent effects on hindlimb reflexes or bladder activity. D-Ser2-leu5-enkephalin-thr6 (DSLET; 0.1-2.0 micrograms i.t.) abolished rhythmic bladder activity, while having no effects on sphincter or hindlimb reflexes. Larger doses of DSLET (5.0-10 micrograms i.t.) produced a modest reduction of sphincter reflexes (to 60% of control amplitude), without affecting hindlimb reflexes. Naloxone (50 micrograms i.t.) reversed DSLETs marked inhibition of bladder activity, whereas large doses (greater than 250 micrograms i.t.) only partially antagonized DSLETs weak inhibition of sphincter reflexes. Morphine (5-500 micrograms i.t.) had no consistent effect on any of the measures.(ABSTRACT TRUNCATED AT 250 WORDS)     

产后盆底肌肉松弛症的康复治疗之影响

目的评估产后盆底肌肉松弛症患者的治疗情况并探讨其对预防女性尿失禁的作用。方法回顾性分析157例产后42 d检测为盆底肌肉松弛的产妇使用生物反馈电刺激治疗后盆底肌肉收缩力及盆底肌力的变化情况。结果治疗1个疗程后,75%的患者盆底肌肉平均收缩力或盆底肌力都有所增强。结论产后尽早进行盆底肌肉松弛症的康复治疗,加强盆底肌肉收缩训练,可增强盆底肌肉的收缩力度,达到改善尿道括约肌和肛提肌功能的目的,并起到预防女性尿失禁的作用。     

三维超声监测肛提肌裂孔形态改变动态评估女性产后盆底器官脱垂的研究

目的:研究分析三维超声监测肛提肌裂孔形态改变动态评估女性产后盆底器官脱垂的价值。方法:选取2019年6月—2020年10月在我院诊治的40例肛提肌裂孔形态改变研究对象作为此次研究组研究对象,收集40例同一时期的未孕女性为参照组。同时给予两组研究对象三维超声监测,分析三维超声监测在,女性提肌裂孔形态改变动态评估女性产后盆底器官脱垂的价值。结果:在三维超声监测下,可以知道在不同状态下研究组的肛提肌裂孔面积均大于参照组,组间差异有统计学意义(P<0.05);在不同状态下研究组的产后盆底器官脱垂情况对比,研究组与参照组研究对象的静息下直肠壶腹部组间没有明显差异,其自身不存在统计学意义(P>0.05),除此之外的静息下子宫颈、静息下膀胱、瓦氏动作下直肠壶腹部、瓦氏动作下子宫颈以及瓦氏动作下膀胱的两组研究对象的位置存在很大的差异,经过统计学软件分析可以得到其自身组间差异有统计学意义(P<0.05)。结论:肛提肌裂孔形态改变研究对象经过三维超声监测,可以动态评估自身存在产后的盆地器官脱落情况,得到肛提肌裂孔的形态、大小以及变化趋势,实现疾病的良好预测。     

The predictive value of plantar flexion of the toes in the assessment of neuropathic voiding disorders in patients with spine lesions at the thoracolumbar level.

OBJECTIVE: To correlate the presence of voluntary contraction of the plantar flexors of the toes with neuropathic voiding disorders in patients with spinal cord injury (SCI) after thoracolumbar fracture. SUBJECTS AND METHODS: Sixty-three SCI patients with thoracolumbar fractures were prospectively examined neurologically (American Spinal Cord Injury Association protocol) and urodynamically during their first hospitalization. To assess neurologic recovery, patients were reassessed after at least 1 year. Bladder function was also reevaluated and correlated to neurologic evaluation performed on the same day. SETTINGS: Primary care center, university facility. RESULTS: There was a significant correlation between score of the plantar flexors of the toes and the presence or absence of voluntary contraction of the external anal/urethral sphincter (p < .001). However, this was of no predictive value concerning neuropathic bladder type (p > .05). Seven patients recovered from their neuropathic voiding disorders. There was a significant correlation between the reappearance of a voluntary external anal/urethral sphincter contraction and bladder recovery (p < .01), but there was no significant correlation between the score obtained for the plantar flexors of the toes and the presence or absence of the bulbocavenosus reflex (p > .05). CONCLUSIONS: It appears that in SCI patients with thoracolumbar fractures, the presence of a voluntary contraction of the plantar flexors of the toes correlates with active contraction of the external anal/urethral sphincter but does not enable differentiation of the types of neuropathic voiding disorders. Urodynamic examination remains mandatory for assessment of the functional aspect of the neuropathic voiding disorders.     

Transperineal three-dimensional ultrasound in evaluating anal sphincter muscles.

OBJECTIVES: To evaluate whether transperineal three-dimensional (3D) ultrasound can be used to depict normal anal sphincter anatomy and to measure the thickness of muscle layers and the anteroposterior length of the levator hiatus. METHODS: The study included 22 normal nulliparous female volunteers. Transperineal 3D sonographic evaluation of the anal canal included assessment of sphincter shape, echogenicity, marginal definition and muscle thickness. Measurements of the thickness of the internal anal sphincter (IAS) and puborectalis muscle (PRM) were determined with the women at rest and during squeezing by two observers, and interobserver reliability was determined. The anteroposterior length of the levator hiatus at rest and during squeezing was measured. RESULTS: The proximal end of the anal canal (towards the rectum) consisted of overlapping IAS and PRM, and the distal end (towards the anus) consisted of overlapping IAS and external anal sphincter (EAS). At the PRM level, the mean +/- SD IAS thickness was 2.3 +/- 0.5 mm at rest and 2.5 +/- 0.4 mm during squeezing, and at the mid-EAS level it was 2.9 +/- 0.5 mm at rest and 2.8 +/- 0.5 mm during squeezing. The PRM thickness was 6.5 +/- 1.0 mm at rest and 6.4 +/- 1.2 mm during squeezing. The difference in muscle thickness of the sphincter layers with the woman at rest and during squeezing was not significant. The anteroposterior length of the levator hiatus was 51.7 +/- 5.0 mm at rest and 47.4 +/- 4.1 mm during squeezing (P < 0.01). CONCLUSION: Transperineal 3D ultrasound may be useful in evaluating the anatomy of the anal canal.