盆底失弛缓综合征的诊治进展

盆底失弛缓综合征（unrelaxed pelvic floor syndrome,UPS）是最为常见的一种出口梗阻型便秘。表现为患者静息时盆底肌呈持续收缩状态,排便时盆底肌不仅不放松,反而收缩;肛直肠角不增大,反而缩小,因而导致排便困难。盆底失弛缓综合征的概念出现仅仅几年时间,Wasserman于1964年首先命名为“耻骨直肠肌综合征”,     

肌电图在诊断出口梗阻型便秘中的应用

出口梗阻型便秘是临床上常见的慢性顽固性便秘,病因繁多,其中盆底肌痉挛和耻骨直肠肌肥厚是常见的原因.在作病因诊断过程中,肌电图检查对确定盆底痉挛和耻骨直肠肌肥厚有重要作用.我们于1997年3月至1999年12月对85例出口梗阻型便秘病人进行了肌电图检查,并对肌电图在出口梗阻型便秘诊断中的价值进行了探讨,现总结报告如下.     

梗阻性排便与慢运输型便秘的直肠描记参数

便秘不是一种疾病而是一些疾病的症状表现。若无器质性的原因,就认为是功能性便秘。功能性便秘的病理生理改变与下列因素有关:①括约肌压力异常增高,②直肠膨胀时肛管内括约肌不能松弛;③直肠感受性下降;④结肠推进减弱;⑤乙状结肠功能性梗阻;⑥耻骨直肠肌伴有(或无)肛管外括约肌松弛障碍或异常收缩;⑦各种因素共同作用。     

耻骨直肠肌后位切断术治疗耻骨直肠肌综合征25例

耻骨直肠肌综合征（puborectal muscle syndrome,PRMS）是以耻骨直肠肌痉挛性肥大、盆底出口梗阻为特征的排便障碍性疾病,是紧张型出口梗阻型便秘的主要原因之一。我科采用耻骨直肠肌后位切断术治疗25例因耻骨直肠肌综合征而致便秘的患者,取得了良好的效果,现报告如下。     

耻骨直肠肌综合征诊治进展

耻骨直肠肌综合征(puborectalis syndr-ome,PRS)是顽固性便秘的常见原因之一。其名称较多,如:肛门痉挛、痉挛性盆底综合征、反常性耻骨直肠肌收缩及耻骨直肠肌肥厚     

闭孔内肌自身移植:治疗梗阻性便秘的新概念

原发性便秘有出口梗阻、直肠功能不良和结肠隋性等型之分.对痉挛性盆底综合征,过去曾有采用部分切断痉挛性肛括约肌机制中的不同组成等方法,结果均令人失望.作者利用闭孔内肌自身移植建立肛管扩张机制以对抗痉挛性括约肌,初步证实这一手术方法治疗梗阻性便秘是可行的.作者选择10例健康志愿成人和3例梗阻性便秘成年患者(由于痉挛性处骨直肠机或肛管外括约肌所致)进行了闭孔内肌肌电图测定.结果发现在10例健康志愿者中15侧闭孔内肌的测定中,均见该肌肉在最大挤压动作时有活跃的肌力收缩,其运动单位动作电位(MUAP)为583.0μV±451.2μV,在排便摒力时     

肌电图在诊断出口梗阻型便秘中的应用（附85例报告）

出口梗阻型便秘是临床上常见的慢性顽固性便秘 ,病因繁多 ,其中盆底肌痉挛和耻骨直肠肌肥厚是常见的原因。在作病因诊断过程中 ,肌电图检查对确定盆底痉挛和耻骨直肠肌肥厚有重要作用。我们于 1 997年 3月至 1 999年 1 2月对 85例出口梗阻型便秘病人进行了肌电图检查 ,并对肌电图在出口梗阻型便秘诊断中的价值进行了探讨 ,现总结报告如下。1　资料与方法1 .1　临床资料 :85例中 ,男 40例 ,女 45例。年龄1 8～ 78岁 ,平均 45岁。病史 7个月至 2 6年。主要症状为排便时肛门出口处梗阻感 ,排便时间延长。临床诊断为盆底痉挛综合征 31例 ,耻骨直…     

盆底痉挛综合征患者的生物反馈治疗疗效观察

盆底痉挛综合征是一种以耻骨直肠肌和外括约肌的反常收缩为特征的盆底肌功能失调的综合征。本病是一种功能性疾病，没有肌肉的组织学改变，正常盆底肌在安静状态下有紧张性电活动，排便时盆底肌受抑制而松弛，肛直肠角度增大，如果排便时盆底肌非便不松弛反而收缩（即反常收缩），就产生排便困难。     

肉毒毒素A治疗盆底失弛缓综合征

盆底失弛缓综合征是引起出口梗阻型便秘的一个常见原因 ,普通用泻药或生物反馈治疗均有利有弊 ,手术治疗因效果不佳临床很少采用。肉毒毒素A是一种神经毒素 ,通过抑制突触前乙酰胆碱的释放而用于治疗神经源性的肌肉收缩过度 ,近年来应用于治疗盆底失弛缓综合征。目的 :本研究在于评价肉毒毒素 A注入耻骨直肠肌的疗效。方法 :2 5例( 1 5例女性 ,平均年龄 2 3.2岁 )有出口梗阻型便秘症状的患者接受肛管直肠测压和排粪造影 ,所有患者在两种检查中均发现耻骨直肠肌紧张 ,所有患者都不能排出直肠气囊。每例患者被随机分配接受耻骨直肠肌的局部注…     

便秘的手术治疗指征和手术方式选择

慢性便秘根据与解剖相关的发生机制可分为慢传输性便秘、出口梗阻性便秘和混合型便秘。慢传输性便秘是由于各种原因引起的结肠运动功能迟缓、传输粪便功能下降而导致的便秘,临床上比较常见;主要表现为没有便意、大便干结、需依赖泻剂进行排便。根据其发病机制可分为继发性便秘和特发性便秘两种类型。出口梗阻性便秘则是由于直肠、肛门或盆底解剖或功能异常导致的排便困难。患者通常有比较强的便意,但排出困难,每天需要很长时间排便,或需使用开塞露、灌肠,用手压迫会阴或阴道排便,并且常有排便不尽感。发病原因包括盆底、直肠松弛性病变(如直肠内套叠、直肠内脱垂、直肠前突、盆底和会阴下降等)及肛管痉挛性病变(如耻骨直肠肌肥厚、耻骨直肠肌或盆底肌痉挛综合征等)。混合型便秘包括慢传输性便秘和出口梗阻性便秘两方面的特点。     

Dynamic assessment of pelvic floor function in women using the intravaginal device test

The aim of the study was to assess pelvic floor function and dysfunction using intravaginal devices (IVD test). One hundred and eighty-five patients were evaluated, 65 (35.1%) in the control group without genital prolapse and 120 (64.9%) in the study group, with prolapse. Anatomic changes were evaluated on a scale described by Halban, and functional classification based on palpation of the muscles of the pelvic floor during contraction. Additionally, weighted vaginal devices were used to assess pelvic floor function. Statistic analysis was performed with the Spearman-Pearson correlation coefficient, the ² test and the response/ operator characteristic curve. There was an acceptable correlation between the IVD test and the functional classification of 0.75. Using this classification, the IVD test showed 86.58% sensitivity, 75.72% specificity, and had a positive predictive value 73.95% and a negative predictive value of 87.64%. Significant differences between pelvic floor muscle activity in those patients with and without genital prolapse were observed (X²=58.28, P=<0.005). It was concluded that pelvic floor assessment can be done through the evaluation of active muscle strength or pelvic floor integrity using the functional classification and the IVD test.EDITORIAL COMMENT: In 1988, Peattie and Plevnick introduced the use of weighted vaginal cones to exercise the pelvic floor muscles and treat stress urinary incontinence [1]. Contreras-Ortiz and Nuñez build on this earlier work, using a similar technique to assess pelvic floor muscle function and integrity. Specifically, pelvic floor function is assessed by a combination of digital palpation of the pubococcygeus muscle at rest and during contraction; pelvic floor integrity is assessed by the patient's ability to retain a weighted cone vaginally for 1 minute. Scoring of these two parameters can then be objectively followed for therapeutic response to treatment for urinary incontinence or pelvic relaxation. Many of us forget to palpate the pubococcygeus muscle at rest and during an elicited contraction during baseline or follow-up examination. As this study indicates, simple assessment of pelvic floor function and integrity is possible, and should be used both clinically and in research.     

Australian pelvic floor questionnaire: a validated interviewer-administered pelvic floor questionnaire for routine clinic and research

The aim of this study was to design and validate an interviewer-administered pelvic floor questionnaire that integrates bladder, bowel and sexual function, pelvic organ prolapse, severity, bothersomeness and condition-specific quality of life. Validation testing of the questionnaire was performed using data from 106 urogynaecological patients and a separately sampled community cohort of 49 women. Missing data did not exceed 2% for any question. It distinguished community and urogynaecological populations regarding pelvic floor dysfunction. The bladder domain correlated with the short version of the Urogenital Distress Inventory, bowel function with an established bowel questionnaire and prolapse symptoms with the International Continence Society prolapse quantification. Sexual function assessment reflected scores on the McCoy Female Sexuality Questionnaire. Cronbach’s α coefficients were acceptable in all domains. Kappa coefficients of agreement for the test–retest analyses varied from 0.5 to 1.0. The interviewer-administered pelvic floor questionnaire assessed pelvic floor function in a reproducible and valid fashion in a typical urogynaecological clinic. The validation of the interviewer-administered pelvic floor questionnaire was presented at the Annual Meeting of the International Continence Society in 2004, Paris (podium presentation; extended abstract): A validated female pelvic floor questionnaire for clinicians and researchers, Baessler K, O’Neill S, Maher C, Battistutta D, Neurourol Urodynam 2004; 23: 398–399.     

Female pelvic floor reflex responses

The object of this work was to study bulbocavernosus and deep pudendal reflex (BCR and DPR) latencies and amplitudes as an indicator of pelvic nerve damage in patients with pelvic floor disorders, with or without a previous surgery. 124 women were studied: 68 were normal, 38 had genital prolapse (GP) and 18 had recurrent GP. Clinical and urodynamic studies were carried out. Delayed reflex responses were found in 44/56 patients (79%), 27/38 in the genital prolapse group (71%) and 17/18 in the group with recurrent GP (94%). Thus the evaluation of pelvic floor reflex responses is a test that can be taken into account in the diagnosis of management of pelvic floor disorders.     

Severe orbital floor fractures: repair with a titanium implant

Summary Fractures of the orbital floor which require exploration are usually treated with an alloplastic floor implant or an autogenous bone graft. When large portions of the orbital floor, together with the lower parts of lateral and medial walls, are destroyed there may be no possibility of providing a conventional orbital floor reconstruction. In this situation, a titanium orbital floor implant may well be required to support the globe. 4 cases of traumatic orbital floor blow-out fractures are described. Clinically, all patients had diplopia, enophthalmos and radiological evidence of extensive loss of the orbital floor. A titanium orbital floor implant was molded and secured to the infraorbital rim with miniscrews to reconstruct the orbital floor and to reconstitute the orbital volume. No additional bone grafting was performed. Complications were minimal. From this experience, in severe orbital floor fractures, good results are obtained by supporting the globe using only a titanium implant.     

Pelvic floor muscle function in women presenting with pelvic floor disorders

Introduction and hypothesis  This observational study was undertaken to determine knowledge, prior instruction, frequency of performance, and ability to perform pelvic floor muscle exercises in a group of women presenting for evaluation of pelvic floor disorders. Methods  Three hundred twenty-five women presenting for evaluation of pelvic floor disorders were questioned concerning knowledge and performance of pelvic floor muscle exercises (PMEs) and then examined to determine pelvic floor muscle contraction strength. Results  The majority of women (73%) had heard of PMEs, but only 42% had been instructed to perform them and 62.5% stated they received verbal instruction only. Only 23.4% of patients could perform pelvic muscle contractions with Oxford Scale 3, 4, or 5 strengths. Increased age, parity, and stage of prolapse were associated with lower Oxford scores. Conclusions  Although most women with pelvic floor disorders are familiar with PMEs, less than one fourth could perform adequate contractions at the time of initial evaluation.     

新型三维钛网在眶底缺损重建整形手术中的应用

目的:介绍三维钛网在眶底缺损整复中的应用.方法:对4例因上颌骨鳞癌行上颌骨全切或扩大切除的患者以三维钛网行眶底及眶下缘的重建,评价术后眶部外形及眼的功能.结果:4例手术均获得满意效果,眶部外形恢复好,眶下区无明显塌陷,眼球运动好,无复视、感染等并发症.结论:采用新型三维钛网重建上颌骨肿瘤术后眶底及眶下缘缺损畸形能获得满意的眶部外形;防止术后复视;利于术后观察和复诊;术式简单、创伤小.三维钛网具有易成形、可塑性强、组织相容性好等特点.是理想的眶底重建整复材料,值得在临床推广.     

The effect of training with vaginal weighted cones and pelvic floor exercises on the strength of the pelvic floor muscles: A pilot study

A pretest-post-test design (n=14) was used to investigate pelvic floor muscle (PFM) strength over a 2-month training period using vaginal cones with pelvic floor exercises in the treatment of female stress incontinence, and to correlate any changes in muscle strength with objective and subjective measures of stress incontinence. PFM strength was assessed by vaginal examination and the ability to retain the cones. The symptom of stress incontinence was assessed using rating scales, and measured objectively by the extended pad test. The results showed a significant increase in muscle strength (P<0.05). An unexpected finding was that most of the improvement in PFM function occurred in a 1-week baseline assessment period before training was commenced. It is therefore suggested that the increase in force generation occurred due to a process of neural adaptation rather than muscle hypertrophy. No significant correlations were found between muscle strength and objective or subjective measures of stress incontinence.Editorial Comment: Vaginal cones are gaining in popularity as a method of therapy for stress incontinence. As in this study, the symptom of stress incontinence was enough to begin treatment and objective documentation of the diagnosis was not undertaken. The therapy has no side-effects and only requires that the patient is motivated enough to put the cone in the vagina and take it out after a prescribed time period. Everything else is automatic. Biofeedback from the perception of the cone falling out provides the stimulus for pelvic floor contraction. Success rates are high, with 21% cured and 29% improved for an overall improvement rate of 50%. Such therapies may be tried before diagnosis, and certainly before expensive surgical treatment.     

Barium proctography vs magnetic resonance proctography for pelvic floor disorders: a comparative study

Aim Accurate and reliable imaging of pelvic floor dynamics is important for tailoring treatment in pelvic floor disorders; however, two imaging modalities are available. Barium proctography (BaP) is widely used, but involves a significant radiation dose. Magnetic resonance (MR) proctography allows visualization of all pelvic midline structures but patients are supine. This project investigates whether there are measurable differences between BaP and MR proctography. Patient preference for the tests was also investigated. Methods Consecutive patients referred for BaP were invited to participate (National Research Ethics Service approved). Participants underwent BaP in Poole and MR proctography in Dorchester. Proctograms were reported by a consultant radiologist with pelvic floor subspecialization. Results A total of 71 patients were recruited. Both tests were carried out on 42 patients. Complete rectal emptying was observed in 29% (12/42) on BaP and in 2% (1/42) on MR proctography. Anismus was reported in 29% (12/42) on BaP and 43% (18/42) on MR proctography. MR proctography missed 31% (11/35) of rectal intussusception detected on BaP. In 10 of these cases no rectal evacuation was achieved during MR proctography. The measure of agreement between grade of rectal intussusception was fair (κ = 0.260) although MR proctography tended to underestimate the grade. Rectoceles were extremely common but clinically relevant differences in size were evident. Patients reported that they found MR proctography less embarrassing but harder to empty their bowel. Conclusions The results demonstrate that MR proctography under‐reports pelvic floor abnormalities especially where there has been poor rectal evacuation.