经会阴部动态超声检查盆底的初步报告

目的 探讨经会阴部动态超声检查对评价静息及力排时盆底与肛管和直肠之间关系的可能性。方法 选择5例正常志愿者作为对照组，10例因大便习惯改变而就诊的患者作为异常组。所有患者取膀胱截石位，选用3．75～6MHz线凸阵探头进行检查。通过向肛门内注入超声耦合剂，让患者作排便动作，观察静息及力排时肛管直肠连接部的变化及耦合剂排出情况，并与临床手术及其他影像学检查进行对照。结果 正常组在力排时均能顺利排出造影剂；直肠前壁连续性好，肛管直肠连接部位置下移、肛直角增大或无变化；异常组显示直肠前突7例，耻直肌痉挛2例，直肠前壁黏膜脱垂1例。结论 经会阴部超声检查可以实时显示提肛肌水平以下的盆腔结构，通过观察静息及力排时肛管直肠的变化，可以显示排便时的生理过程，对于某些特异性的病变可以迅速作出诊断。     

Intra-anal intussusception: diagnosis by posteroanterior stress proctography

Intra-anal intussusception was diagnosed in eight of 39 patients on evacuation proctography. Posteroanterior views revealed prolapse of the infolded rectum into the anal canal on straining in seven of eight patients, associated with splaying open of the anal canal and sudden distal movement of the fold during prolapse. Similar changes were seen in four of 31 patients in whom intussusception had not been diagnosed on lateral evacuation proctography. The pattern of the collapsed rectum was assessed for fold length, thickness, and angulation in relation to the midline of the rectum. Infoldings that prolapsed were closer to the anorectal junction on stress (mean 14.6 42.4 mm, p < 0.0001) showed greater change in height between rest and strain (28.8 14.6 mm, p < 0.05) and became more acutely angled during straining (41.9 5.3°, p < 0.01). Intra-anal intussusception may be missed in 33% (four of 12 patients) on routine evacuation proctography. Posteroanterior stress proctography is a simple supplementary examination to validate intussusception.     

Defecography: Results in 55 patients and impact on clinical management

We reviewed the medical records and defecograms in 55 consecutive patients to determine the impact of results of defecography on clinical management. Main indication for defecography was constipation, present in 40 (73%) of 55 patients. In the remaining 15 patients, indications included obstructed defecation (5), incontinence (5), and miscellaneous symptoms (5). Defecography evaluated pelvic floor motion by assessing changes in the anorectal angle (ARA) and anorectal junction (ARJ) during various maneuvers, extent of evacuation, and structural abnormalities. Patients were grouped based on results of defecography as being normal (26) or abnormal (29). Comparison of measurements of the ARA and ARJ with various maneuvers showed no significant differences between the two groups. Clinical impact was determined by analyzing therapy done following defecography and subsequent patient response. In the normal group, 15 patients were managed medically, seven surgically, and four lost to follow-up. Clinical improvement occurred in 13 (59%) of 22 patients, with similar results between medical (60%) and surgical (57%) therapy. In the abnormal group, 16 had medical management, seven surgical therapy, and six lost to follow-up. Clinical improvement occurred in 13 (57%) of 23 patients but surgical therapy showed more improvement. In conclusion, most standard measurements of the ARA and ARJ were of no value in determining abnormality. Results of defecography did not alter selection of medical or surgical therapy, and had little impact on patient response to therapy.     

Intraobserver variation in the radiological measurement of the anorectal angle

Seven experts drew the rectal axes of 18 representative proctographic images on two occasions, with a 1-year interval, in order to assess intraobserver variation in the determination of the anorectal angle (ARA). Intraobserver variation (6%) and interobserver variation (17%) were smallest when the central rectal axis was used to determine the ARA. A strong relation was found between inter- and intraobserver variation (r=0.77). Intraobserver variation tended to be rather small for pictures made during straining, but a relation with the magnitude of the ARA was not found. Although none of the seven experts could reproduce the rectal axes with 10% variation in all 18 pictures, redrawing of the central rectal axis delivered 10% variation in 86% of determinations. It is concluded that intraobserver variation is influenced by the expertise of the investigator, the method of analysis, and the anorectal configuration to be analyzed. Radiologic assessment of the ARA may yield reliable data on the dynamics of the anorectum if performed by a single investigator on x-ray films that allow confident analysis.     

经会阴超声评估女性直肠脱垂性病变患者直肠脱垂程度

目的 探讨经会阴超声评估女性直肠脱垂性病变患者直肠脱垂程度的价值。方法 根据直肠是否脱出肛管将26例女性直肠脱垂性病变患者分为内脱垂组（IRP组,n=18）和外脱垂组（ERP组,n=8）,另选20名健康女性作为对照组。行经会阴超声检查,测量并比较静息时和力排时直肠壶腹部位置、直肠移动度、盆膈裂孔面积及肛直角。结果 与静息时比较,3组力排时盆膈裂孔面积均增大,直肠壶腹部位置均下降（P均<0.05）。IRP组和ERP组静息时和力排时盆膈裂孔面积均大于对照组,力排时直肠壶腹部位置下降均大于对照组（P均<0.05）。ERP组静息时直肠壶腹部位置低于IRP组和正常组（P均<0.05）,IRP组与对照组差异无统计学意义（P>0.05）。IRP组和ERP组直肠移动度均大于对照组（P均<0.05）。3组静息时和力排时肛直角大小差异均无统计学意义（P均>0.05）。结论 经会阴超声可评估女性直肠脱垂性病变患者直肠脱垂程度。     

Evacuation proctography: An investigation of rectal expulsion in 20 subjects without defecatory disturbance

Evacuation proctography is a dynamic investigation of rectal expulsion that records the voluntary evacuation of thick barium paste on videotape. Evacuation is a passive phenomenon in a defined zone of the rectum, associated with pelvic floor descent of 3 cm from a resting position of the anorectal junction <2 cm above the plane of the ischial tuberosities. The anal canal does not open immediately; it takes about 4.5 sec to open to a maximum diameter of 1.5 cm, with rectal emptying in 11 sec. Anterior rectoceles commonly invert over the anal canal as the rectum collapses in at the end of evacuation.     

Post-exercise depression of baroreflex slowing of the heart in humans

In normal human subjects, we tested whether a 20- to 30-min period of rhythmic exercise, intended to provoke strong activation of the sympathetic nerves, would lead to prolonged inhibition of vagally mediated bradycardia evoked reflexly by stimulation of the baroreceptors by neck suction. Negative pressure within the neck cuff (?40 to ?80 mmHg) reflexly evoked a reproducible increase in pulse interval. Following exercise, this increase in pulse interval was reduced from 444±104 ms to 76±57 ms (mean±SEM). Recovery time was 42±9 min. These findings demonstrate a prolonged attenuation of cardiac vagal action following rhythmic exercise in normal human subjects. It is known that neuropeptide Y (NPY) is released from cardiovascular sympathetic nerves, that it attenuates cardiac vagal action and that plasma levels of NPY are elevated for a prolonged period after exercise. Therefore, it is proposed that NPY, released from sympathetic nerves during exercise, attenuates reflexly evoked cardiac vagal action for a prolonged period after exercise ends.     

比较两种动态MRI方法评价盆底功能障碍患者盆底结构改变的价值

目的 比较耻尾线(PCL)及HMO分度系统两种测量方法在动态MRI评价女性盆底功能障碍(PFD)患者盆底改变中的价值。方法 对16例女性PFD患者(PFD组)及24名正常女性(无症状组)行静息及最大用力下盆腔MR检查,常规观察盆腔器官及盆底结构。按照PCL系统,在正中矢状位上分别测量膀胱颈、子宫颈、肛直肠连接与PCL的距离;按照HMO分度系统,测量H线(耻骨联合下缘至肛直肠连接后缘的连线)及M线(肛直肠连接后缘到PCL线的最短距离),对盆底松弛进行评价,同时观察膀胱、子宫及直肠位置。对两种测量方法的结果进行对照,并与临床盆腔器官脱垂定量(POP-Q)系统进行对比。结果 无症状组盆腔最大用力时膀胱颈、子宫颈及肛直肠连接下降值分别为(2.63±1.71)mm、(4.31±3.24)mm、(7.32±2.11 )mm;H线及M线轻度增长约(2.85±2.62)mm及(7.33±2.14)mm。PFD组中膀胱颈、子宫颈、肛直肠连接分别下降(24.74±10.12)mm、(21.43±14.91)mm及(24.55±13.43)mm;H线及M线分别增加(13.16±10.82)mm及(22.54±11.30)mm。PCL系统诊断9例子宫脱垂、7例膀胱脱垂和6例直肠脱垂,HMO系统分别为4例、7例和5例,两种方法评价膀胱脱垂和直肠脱垂的差异无统计学意义(P=0.25、0.06),HMO系统评价子宫脱垂较优(P=0.007)。结论 对于正常女性,PCL系统及HMO系统的测量结果一致;对于PFD患者,HMO系统可更全面显示盆底松弛与器官脱垂。     

Dynamic pelvic floor imaging: MRI techniques and imaging parameters

Magnetic resonance imaging (MRI) is an excellent tool to understand the complex anatomy of the pelvic floor and to assess pelvic floor disorders. MRI enables static and dynamic imaging of the pelvic floor. Using static T2-weighted sequences the morphology of the pelvic floor can be visualized in great detail. A rapid half-Fourier T2-weighted, balanced steady state free precession, or gradient-recalled echo sequence are used to obtain sagittal images while the patient is at rest, during pelvic squeeze, during pelvic strain and to document the evacuation process. On these images the radiologist identifies the pubococcygeal line (PCL) (which represents the level of the pelvic floor). In normal findings, the base of the anterior and the middle compartment are above the PCL at rest, and the pelvic floor elevates during contraction. During straining the pelvic floor muscles should relax and the pelvic floor descends normally less than 3 cm below the PCL. Pelvic floor MRI based on the static and dynamic MRI sequences allows for the detection and characterization of a vast array of morphologic and functional pelvic floor disorders. In this review, we focus on technical aspects of static and dynamic pelvic floor MRI.     

正常女性盆底解剖、形态的动态MRI研究

目的　采用静息与最大盆腔用力时盆腔动态MRI评价正常盆腔器官的位置、运动和盆底形态 ,为动态MRI在盆底功能性疾病诊断上的临床应用建立盆腔器官运动程度和盆底形态学的正常标准。方法　对 3 0例健康女性志愿者进行静息与最大盆腔用力时盆腔动态MRI检查。采集的MR影像用于观测盆腔器官的位置、运动和盆底形态。结果　最大盆腔用力时正常盆底在形态上变化不明显 ,盆腔器官的平均下降值是膀胱颈 ( 15 .3± 4.3 )mm ,子宫颈 ( 10 .7± 3 .4)mm ,肛直肠连接 ( 19.2± 6.8)mm ,盆隔裂孔的平均增大百分比是 ( 12 .2± 6.4) %。盆腔器官运动的范围是膀胱颈不超过耻尾线下1cm ,子宫颈不超过耻尾线以下 ,肛直肠连接不超过耻尾线以下 2 .5cm。结论　MRI是研究活体盆底解剖与形态学的有效方法。正常妇女盆腔动态MR影像上 ,最大盆腔用力时盆腔器官有一定程度的运动 ,但无脱垂 ,盆底形态上变化不明显。     

The effects of length on fatigue and twitch potentiation in human skeletal muscle

Fatigue is the decrease in active force that happens after repeated muscle stimulation, and post tetanic twitch potentiation (PTP) is the increase in twitch force observed after repeated muscle stimulation. This study investigated the effects of length on the interaction between fatigue and PTP, as these two forms of force regulation are length‐dependent and may coexist. A total number of 14 subjects were tested in 3 days, in which fatigue and PTP were induced in the knee extensor muscles in three different knee angles (30°, 60° and 90°; full extension=0°). PTP was evaluated in rested and fatigued muscles with twitch contractions elicited before and after 10 s maximal voluntary contraction (MVC), and fatigue was evaluated with nine 50 Hz electrically elicited contractions (5 s duration, 5 s interval between contractions). Fatigue was length‐dependent, with force values that were (mean ± SEM) 59 ± 5, 56 ± 3 and 38 ± 1% of maximal force at 90°, 60° and 30°, respectively. PTP was also length‐dependent. Rested muscles showed PTP of 39 ± 4, 47 ± 2 and 68 ± 5% at 90°, 60° and 30°, respectively. Fatigued muscles showed PTP of 44 ± 3, 55 ± 6 and 68 ± 5%, at 90°, 60° and 30°, respectively. This study shows that fatigue and PTP may represent independent mechanisms, as they regulate force in opposite directions and are both enhanced in short muscle lengths.     

Posterior pelvic floor disorders: a prospective comparison using introital ultrasound and colpocystodefecography.

OBJECTIVE: To compare introital ultrasound with colpocystodefecography (CCD) in quantifying the anorectal angle and in the diagnosis of posterior pelvic floor disorders. METHODS: Forty-three consecutive women with functional impairment of the posterior pelvic floor were enrolled after a clinical evaluation. Using both CCD and introital ultrasound examination, the anorectal angle was measured during squeezing to evaluate the strength of voluntary muscle contraction and during straining to assess pelvic floor relaxation. Rectocele depth and the presence of intussusception were assessed. The performance of CCD and that of introital ultrasound were compared. RESULTS: Good concordance was obtained between introital ultrasound and CCD. The intraclass correlation coefficient was 0.82 (95% CI, 0.69-0.89) for measurement of the anorectal angle during squeezing and 0.67 (95% CI, 0.47-0.81) during straining. Rectoceles > 4 cm on CCD were detected by introital ultrasound in 100% of cases, and there was 91% agreement for rectal intussusception. Cohen's kappa index was moderate for rectocele assessment (0.41, P < 0.01) and excellent for intussusception (0.91, P < 0.001). It was also noted that introital ultrasound could be used to detect pelvic floor dyssynergia. CONCLUSIONS: Introital ultrasound is a simple, accurate, non-invasive method with which to assess anorectal dynamics.     

Sex differences in anorectal angle and perineal descent

To elucidate whether sex differences have a significant influence on anorectal angle (ARA) and perineal descent (D), female and male asymptomatic volunteers were examined, using cinedefecography. We found ARA generally bigger in male than in female patients. Mean male values resembled those measured in females with anal incompetence. We also found that the spread of normal ARA in male patients was nearly twice that in female patients, suggesting little value of this variable. D, however, is similar in the 2 groups. Our conclusion is that ARA measured in males has no clinical value. D can probably be useful in both male and female patients for preoperative evaluation of corrective surgery.     

排便训练技术在功能性便秘患者中的应用

目的探讨排便训练技术对功能性便秘(functional constipation,FC)患者肛管直肠功能和临床症状的作用。方法按纳入标准选取门诊及住院的28例FC患者为试验组,根据试验组患者肛管直肠压力和直肠感觉功能的评估结果分别选择压力反馈训练法、直肠感受性训练法和腹式呼吸法进行排便训练。试验组于训练前及训练结束3个月后评估肛管直肠压力和直肠感觉功能;同期选择24名健康志愿者为对照组,入组时评估其肛管直肠压力和直肠感觉功能。结果试验组患者排便训练前用力排时肛管剩余压力高于对照组(P<0.05);排便训练后用力排时肛管剩余压力低于训练前(P<0.01),且与对照组的差异无统计学意义(P<0.05);试验组训练后用力排时直肠压力和排便指数高于训练前(P<0.01),且用力排时直肠压力高于对照组(P<0.05)。试验组患者排便训练前直肠初始感觉容量、直肠初始便意感容量、排便窘迫容量和直肠最大耐容量均高于对照组(P<0.05):而排便训练后以上4项指标较训练前降低(P<0.01),且以上4项指标与对照组比较差异均无统计学意义(P>0.05)。试验组训练后,自发排便次数、大便性状和粪便量少等症状较训练前改善(P<0.01);且排便困难、排便不尽感、肛门阻塞感和腹部胀气等伴随症状也较训练前改善(P<0.01)。结论排便训练技术能有效改善FC患者的盆底肌、肛门括约肌的功能,改善肛门外括约肌的协调性,降低直肠感觉阈值,并促进其临床症状的改善。     

Muscle thickness and echo intensity measurements of the rectus femoris muscle of healthy subjects: Intra and interrater reliability of transducer tilt during ultrasound

This study aimed to assess the intra and interrater reliability of transducer tilt during the ultrasound (US) measurements of the muscle thickness and the echo intensity of the rectus femoris muscle (RF). Fourteen healthy male subjects (20.8 ± 0.8 years) participated in this study. The transducer tilt was measured using a digital angle gauge (°) during US. Two experimenters took two images to measure the muscle thickness (mm) and the echo intensity (a.u.: arbitrary unit). The intra and interclass correlation coefficient (ICC), standard error of measurement (SEM), and minimal detectable change (MDC) were also calculated. These measurements were immediately repeated. The ICC for the intrarater reliability for the transducer tilt, muscle thickness, and echo intensity were 0.96 (SEM: 0.9°, MDC: 2.6°), 0.99 (SEM: 0.4 mm, MDC: 0.1 mm), and 0.97 (SEM: 0.6 a.u., MDC: 1.7 a.u.), respectively. The ICC for the interrater reliability for the transducer tilt, muscle thickness, and echo intensity were 0.40 (SEM: 4.0°, MDC: 11.1°), 0.96 (SEM: 0.7 mm, MDC: 2.0 mm), and 0.95 (SEM: 0.9 a.u., MDC: 2.4 a.u.), respectively. The intrarater reliability of the transducer tilt was reliable, but the interrater reliability was questionable. Meanwhile, both the intra- and interrater reliability of the muscle thickness and the echo intensity were reliable.     

Left ventricular function at rest and during exercise in coronary insufficiency — A simultaneous evaluation by means of radionuclide angiocardiography and catheterization

Summary. Left ventricular function was assessed simultaneously with heart catheterization and equilibrium radionuclide angiocardiography at rest and during supine exercise in ten patients with effort angina. At rest all had normal haemodynamics. During exercise all developed angina with signs of left ventricular dysfunction in the form of high left ventricular filling pressure, 31±2 mm Hg (mean±SEM) and pathological decreases in left ventricular ejection fraction (11 ± 1 % units). Left ventricular end-systolic volume increased significantly (43 ± 7%), but the increase in left ventricular end-diastolic volume (13 ± 7%) was not significant. The discordance between the changes in left ventricular filling pressure and the changes in left ventricular end-diastolic volume is discussed. Radionuclide angiocardiography revealed left ventricular dysfunction as frequently as did heart catheterization.     

CT排便造影评价肛门外括约肌的功能

目的 采用CT排便造影显示肛门外括约肌(EAS)的形态及变化,评价其功能。方法 分静息、缩肛、排便3期采集60名健康志愿者的坐位CT排便造影图像,重建标准的肛管冠状位及正中矢状位图像,对耻骨直肠肌(Pr)和EAS进行形态学测量。结果 Pr、EAS的深部和浅部分别在肛门直肠结合部、肛管上部和中下部水平压缩肛管,EAS皮下部位于肛管下方,内翻呈圆锥状,与肛周皮肤共同自下而上封堵肛管。静息期,EAS深部间距(31.50±4.10)mm,浅部间距(28.36±4.14)mm,肛管-EAS皮下部夹角(60.95±19.20)°;缩肛期,EAS作向心运动,更紧地闭合肛管,深部间距(30.85±4.10)mm,浅部间距(26.04±3.48)mm,皮下部内翻程度加大,肛管-EAS皮下部夹角(56.87±16.18)°;排便期,EAS作离心运动,肛管开放,深部间距(37.51±5.17)mm;浅部间距(31.68±5.10)mm,皮下部自内上向外下翻转,肛管-EAS皮下部夹角(112.23±22.48)°。结论 EAS主要通过压缩、悬吊、绞索和套塞方式维持肛门自制。EAS的深部、浅部和皮下部在排便时依次开放,其皮下部作翻转运动参与排便。     

Stability of Intracavitary Applicator Placement for HDR Brachytherapy of Cervix Cancer

Introduction/BackgroundCervical cancer is often treated with a combination of external beam radiation therapy and high-dose-rate intracavitary brachytherapy. An intrauterine ring and tandem applicator is used for intracavitary brachytherapy. The dose is prescribed to the high-risk clinical target volume. The goals of this study were to investigate the stability of intracavitary applicator placement during patient transfer and to evaluate the dosimetric impact of displacement.MethodsFourteen patients with cervical cancer were analyzed. Three sets of orthogonal fluoroscopic radiographs were obtained in the high-dose-rate suite after the insertion and before treatment: pre–computed tomography (CT) fluoroscopic radiograph with patient in the lithotomy position, pre-CT fluoroscopic radiograph with patient in the legs down position, and post-CT fluoroscopic radiograph with patient in the legs down position. Applicator position after CT was compared with the pre-CT radiographs to determine if the position changed during patient transfer. The displacement was measured in the anterior-posterior, medio-lateral, and superior-inferior directions, as well as the degree of pitch, roll, and yaw. To study the impact of applicator shifts on dose to organs at risk (OARs), the ring and tandem applicator was shifted virtually in the BrachyVision treatment planning system. The OARs studied included the small bowel, sigmoid colon, rectum, and bladder. Five millimeter shifts were made in the superior-inferior, medio-lateral, and anterior-posterior direction. Three degree rotations were made in the pitch, yaw, and roll directions. Applicator shifts were analyzed in only one direction at a time. The dosimetric impact on OARs was evaluated by comparing the original and shifted/rotated plans to dose-volume histogram–based criteria.ResultsThe average displacements were 1.9 ± 0.5 mm laterally, 3.0 ± 0.6 mm longitudinally, and 9.5 ± 1.5 mm anterior-posterior. The average applicator rotation on the posterior-anterior radiograph was 1.0 ± 0.2° and 2.6 ± 0.6° on the lateral radiograph. Five millimeter anterior-posterior shifts had the greatest effect on dose to OARs. On average, 5 mm anterior shifts had the greatest effect on the small bowel dose, where there was a 13.7% (79.6 cGy) increase in D2cc. Five millimeter anterior shifts also affected bladder dose, with a 36.5% (141.1 cGy) increase in D2cc. Five millimeter POST shifts increased the rectal D2cc by 28.6% (168.7 cGy). Other directional shifts had negligible effects on dose. The largest effect on OAR dose arising from rotations was to the sigmoid colon, when the applicator rotated in the POST pitch direction. As a result, the dose increased by 4.7% (7.6 cGy). All other rotations had minimal impact on OAR doses.ConclusionPatient transfer resulted in applicator shifts and rotations that had a measurable effect on dose to OARs. The displacements were the result of either a direct shift or rotation of the applicator. Additional tracking of these shifts and rotations may clarify the sources of these unwanted motions and suggest possible mitigation strategies.     

正常儿童年龄与胫骨力学轴线的关系在评介正常儿童生理性胫骨旋转中的作用

目的绘制出6个月~15岁儿童正常胫骨旋转解剖轴线的发育曲线图,为诊断儿童胫骨旋转畸形提供理论依据。方法随机抽取门诊体检的正常儿童345例,排除骨骼、肌肉及神经疾病和双侧下肢其他疾病引起的畸形,对每例儿童分别进行双侧下肢胫骨旋转轴线(包括内旋角度、外旋角度)角度测量,并根据年龄进行分组统计:第1组,6个月~2周岁82例,男47例,女35例,平均年龄(1.1±0.5)岁;第2组,25个月~4周岁66例,男32例,女34例,平均年龄(3.3±0.4)岁;第3组,5~12岁112例,男61例,女51例,平均年龄(9.1±0.6)岁;第4组,12~15周岁85例,男36例,女49例,平均年龄(12.9±0.8)岁。结果初始大腿-足轴角从左侧(6±14.2)°、右侧(6±14.3)°,到15岁时的左侧(12±14.0)°、右侧(12±13.9)°,大腿-踝轴角从初始的左侧(6±17.1)°、右侧(6±17.4)°,到15岁时左侧(12±11.8)°、右侧(12±12.7)°,分别绘制出不同年龄段的正常胫骨旋转解剖轴线的发育曲线图。结论儿童胫骨旋转解剖轴线具有随着年龄增加而发生变化的特点,不同的年龄段,标准差大于正常年龄儿童时,即可作为诊断胫骨旋转异常的依据;该曲线同时可作为临床进一步研究的基础。