磁共振成像在女性盆底功能障碍性疾病诊断中的价值

盆底功能障碍性疾病是指因盆底支持系统退化、损伤所致松弛而引发的一类疾病的总称,子宫阴道及直肠的异常下降可导致尿失禁、排便困难及盆腔器官脱垂。约50％50岁以上中老年女性受盆底功能障碍性疾病的困扰［1～3］。盆底功能障碍性疾病的病因复杂,其危险因素包括妊娠、产次、大龄、绝经、肥胖、连接组织功能失调、吸烟、慢性阻塞性肺疾病及任何其他可以导致慢性腹内压增加的疾病。盆底支持结构包括盆底肌肉、筋膜及韧带。盆底支持结构的松弛将导致盆腔器官的异常下降,从而引起尿失禁、排便困难、性功能障碍及盆腔器官脱垂等症状。盆底功能失调往往累及盆腔多个器官,美国国立卫生研究院发表声明,将年龄、性别及经阴道分娩次数定为明确的危险因素［4］。盆腔磁共振成像（ MRI）技术具有无创、软组织分辨率高、可直观显示盆腔器官及其支持结构等优点,可为盆腔器官脱垂范围和严重程度提供有价值的信息,是诊断盆底功能障碍性疾病的首选检查方法。本文就MRI在评估女性盆底功能障碍性疾病中的价值和研究现状予以综述。     

重庆市高龄女性盆腔器官脱垂的危险因素

目的探讨重庆市高龄女性盆腔器官脱垂的危险因素。方法对就诊的盆腔器官脱垂资料进行调查分析。采用该院妇产科医师设计的调查表,对患者进行询问调查。包括患者人口学特征、生育情况、既往病史、慢性疾病史等。结果体重指数(BMI)24、产次、慢性咳嗽、便秘、盆腔手术史是引发盆腔器官脱垂的危险因素。结论文化程度、BMI值、分娩次数、便秘、慢性咳嗽、患有慢性盆腔炎、有盆腔手术史是导致高龄女性盆腔脱垂的危险因素,临床对盆腔器官脱垂的危险因素进行研究分析,对预防及控制盆腔器官脱垂有积极意义。     

女性盆底功能障碍性疾病的临床研究进展

女性盆底功能障碍性疾病(pelvic floor dysfunctional disease,PFD)是产后及中老年女性的多发病、常见病,是近年来妇产科领域的研究热点。主要病因为盆腔及生殖道支持组织缺陷、失去正常的支持作用,进而导致盆底结构和功能异常。主要症状和体征包括盆腔器官脱垂(pelvic organ prolapse,POP)、压力性尿失禁(stress urinary incontinence,SUI)以及慢性盆腔疼痛(chronic pelvic pain)等,严重影响女性身心健康和生活质量。该文对女性PFD的病理机制、临床诊断方法及治疗方法的进展进行综述。     

盆底三维超声在老年女性盆腔器官脱垂诊断中的应用

目的观察老年女性盆腔器官脱垂时三维超声检查时各参数水平,分析盆底三维超声在老年女性盆腔器官脱垂中的诊断价值。方法回顾分析2017年4月至2019年4月确诊的100例老年盆腔器官脱垂女性患者的病历资料为观察组,另选取同时期来院就诊并确诊为其他非盆腔器官脱垂85例为对照组,全部患者接受盆底三维超声检查,比较两组超声检查主要参数(盆膈裂孔静止期、缩肛期、Valsava运动时肛提肌裂孔前后径、横径及面积)水平,分析各参数对老年盆腔脱垂的预测价值。结果观察组盆膈裂孔静止期、缩肛期、Valsava运动时肛提肌裂孔前后径、横径及面积均高于对照组,差异有统计学意义(P<0.001);绘制受试者工作特征(ROC)曲线结果显示,静止期、缩肛期、Valsava运动时肛提肌裂孔前后径、横径及面积预测老年患者是否存在盆底器官脱垂的曲线下面积均>0.80,均有一定诊断价值;将经ROC曲线图得到各指标的最佳阈值作为预测老年盆底器官脱垂患者的阳性分界值,100例老年盆腔器官脱垂患者经盆底三维超声检出盆底器官脱垂91例(91.00%),且患者在静息期、缩肛期、Valsava运动时,影像学征象显示盆膈裂孔形态尚在,但排列不规整,可见脱垂的阴道前后壁及宫颈,耻骨直肠肌薄弱甚至撕裂,耻骨直肠肌包绕的脏器于撕裂处向外膨出。结论盆底三维超声可清晰显示老年女性盆腔器官脱垂时各器官的形态特征及位置,用于盆底器官脱垂的诊断有一定价值,其影像学特征还对疾病的治疗有一定指导意义。     

老年女性盆腔器官脱垂的治疗进展

盆腔脏器脱垂指机体盆底肌肉、骨骼支持系统作用逐渐减弱,导致盆腔内直肠、子宫和膀胱等器官组织位置出现下移的一种疾病[1]。其中女性盆腔脏器脱垂(pelvic organ prolapse,POP)作为常见类型之一,指盆腔器官在各种因素影响下导致盆底功能支持薄弱,进而造成盆腔脏器移位,从而自然脱出阴道外。     

阴道全封闭术治疗老年女性盆腔器官脱垂的疗效

目的 分析老年女性盆腔器官脱垂(POP)患者实施阴道全封闭术的临床疗效及安全性.方法 选取2012年1月至2018年1月在佛山市妇幼保健院妇科住院治疗、盆腔器官脱垂分期法(POP-Q)评定为Ⅲ～Ⅳ期、并接受阴道全封闭术治疗的78例老年POP患者.所有患者治疗后进行1年随访观察,记录术前和术后POP-Q分期情况.分析患者...     

应用全盆底重建术治疗老年女性重度盆腔器官脱垂临床分析

目的 评价全盆底重建术治疗老年女性重度盆腔器官脱垂的疗效.方法 回顾性分析34例POP-QⅢ～Ⅳ期盆腔器官脱垂行全盆底重建术的老年患者临床资料,评价该手术疗效及对患者生活质量的影响.结果 所有手术均安全顺利进行,未见膀胱、直肠等损伤;手术时间（105±31.2） min,出血（185.4±65.9） mL;所有患者术后4～5d后均自主排尿.随访2年,复发率为0（0/34）;PFIQ评分由术前的（84.3±22.6）分降至术后2年的（11.2±6.5）分,PFDI评分由术前的（75.8±19.4）分降至术后2年的（12.4±5.3）分.结论 全盆底重建术用于纠正老年女性重度盆腔器官脱垂,手术安全,术后生活质量改善明显,值得临床推广应用.     

慢性便秘与女性盆腔器官脱垂的关系

背景:盆腔器官脱垂是妇科常见疾病,其病理生理机制尚未明确.目前观点认为慢性便秘很可能是女性盆腔器官脱垂的促发因素之一.目的:回顾性分析女性盆腔器官脱垂患者的慢性便秘患病情况,初步探讨两种疾病之间的关系.方法:收集2005年1月1日～12月31日1年间北京协和医院妇产科诊断为盆腔器官脱垂的住院患者的病史资料,由经统一培训的调查员对其进行电话问卷调查.慢性便秘的诊断参照罗马Ⅱ标准.结果:201例人选患者中.122例接受了电话问卷调查,应答率为60.7%.其中符合慢性便秘罗马Ⅱ标准者35例,患病率为28.7%,病程2～43年.轻度与中重度盆腔器官脱垂患者合并慢性便秘的比例差异无统计学意义(26.7%对29.3%,P＞0.05).结论:本研究中女性盆腔器官脱垂患者的慢性便秘患病率(28.7%)明显高于普通成年女性人群(4.28%～9.68%),慢性便秘与女性盆腔器官脱垂的关系尚有待进一步研究.     

盆腔重建Prolift手术对老年女性重度盆腔器官脱垂的临床疗效

<正>盆腔器官脱垂(POP)是由多种原因导致的盆底肌肉、韧带支持薄弱,引起盆腔脏器移位,连锁引发其他盆腔器官的位置和功能异常。随着人类寿命延长和老龄化加速,POP发病率呈上升趋势,严重影响中老年女性身体健康和生活质量〔1³〕。目前,手术是治疗中重度POP的重要方法之一,但传统手术术后患者复发率较高〔4〕。因此,本研究通过观察Prolift盆腔重建术治疗老年女性POP的临床疗效,为临床治疗提高参考。     

中盆腔功能障碍手术治疗进展

女性盆底功能障碍性疾病是中老年女性常见病,50%经产妇可能会发生盆腔器官脱垂。中盆腔功能障碍,主要表现为子宫或阴道穹窿脱垂以及直肠子宫陷凹疝形成,治疗中盆腔功能障碍的常用手术有阴道骶骨固定术、McCall后穹隆成形及高位骶韧带悬吊、骶棘韧带固定术、经阴道后路悬吊带术、全盆底重建术等,该文对这些手术方式的适应证、手术方法、并发症及防治进行综述。     

Perineal descent and levator ani hernia: a dynamic magnetic resonance imaging study

PURPOSE: Patients with symptomatic pelvic organ prolapse often have multifocal pelvic floor defects that are not always evident of physical examination. In this study, dynamic magnetic resonance imaging of symptomatic patients with pelvic floor prolapse demonstrated unsuspected levator ani hernia. This study was designed to identify any specific symptoms and/or physical findings associated with these hernias.METHODS: Eighty consecutive patients with pelvic organ prolapse, fecal and/or urinary incontinence, or chronic constipation received standardized questionnaires, physical examination, and dynamic magnetic resonance imaging. Fishers exact test was used to compare symptoms and examination findings between patients with or without levator ani hernia.RESULTS: Twelve patients (15 percent) were found to have unilateral (n = 8) or bilateral (n = 4) levator ani hernias on dynamic magnetic resonance imaging. No one specific symptom was directly associated with the presence of a levator ani hernia. Furthermore, levator ani hernias were not found more frequently in patients with previous pelvic floor surgery. Perineal descent on physical examination was associated with the finding of a levator ani hernia in nine patients (P = 0.02). Although not statistically significant, there was a trend toward a lower incidence of levator ani hernia in females using estrogen replacement therapy (P = 0.06).CONCLUSIONS: Patients with symptomatic pelvic organ prolapse and perineal descent on physical examination may have a levator ani hernia. Although the significance of levator ani hernia needs to be determined, the recurrence rate after the surgical management of pelvic organ prolapse remains unacceptably high, and ongoing investigation of all associated abnormalities is warranted.Data were obtained from the Johns Hopkins Pelvic Floor Database. Poster presentation at The American Society of Colon and Rectal Surgery Meeting, Boston, Massachusetts, June 24 to 29, 2000.     

Prolift全盆底修补系统在老年女性全盆底重建术中的应用

目的通过对Prolift全盆底修补系统在老年女性盆腔器官脱垂治疗中的应用及近期疗效的评估,探讨治疗盆腔器官脱垂的手术方式。方法选取2009年1月至2010年12月间南京市妇幼保健院妇科收治的因盆腔器官脱垂行盆底修复重建手术的老年女性患者共43例。其中采用Prolift全盆底修补系统行全盆底重建手术24例（A组）,传统的阴道前后壁修补手术19例（B组）。比较2组患者的一般资料、围手术期和随访情况,并进行统计学分析。结果 2组患者的年龄、体质量、孕产次、阴道壁脱垂程度差异无显著性（P〉0.05）。2组患者的手术时间、术中出血量、尿管留置天数、术后残余尿和住院时间比较,差异无显著性（P〉0.05）。2组术后随访率均为100%。A、B组术后复发各为0和3例,A组复发率明显低于B组（P〈0.05）;A组发生性生活不适者3例,略高于B组的1例,但无显著性差异（P〉0.05）;A组补片侵蚀2例（8.33%）,2组均未发生直肠、输尿管等周围脏器及明显血管神经损伤。结论 Prolift用于阴道前后壁脱垂患者的全盆底重建手术,手术安全可行,近期疗效明显优于传统的阴道前后壁修补术。     

Dynamic pelvic magnetic resonance imaging and cystocolpoproctography alter surgical management of pelvic floor disorders

PURPOSE: Pelvic organ prolapse results in a spectrum of progressively disabling disorders. Despite attempts to standardize the clinical examination, a variety of imaging techniques are used. The purpose of this study was to evaluate dynamic pelvic magnetic resonance imaging and dynamic cystocolpoproctography in the surgical management of females with complex pelvic floor disorders. METHODS: Twenty-two patients were identified from The Johns Hopkins Pelvic Floor Disorders Center database who had symptoms of complex pelvic organ prolapse and underwent dynamic magnetic resonance, dynamic cystocolpoproctography, and subsequent multidisciplinary review and operative repair. RESULTS: The mean age of the study group was 58 ± 13 years, and all patients were Caucasian. Constipation (95.5 percent), urinary incontinence (77.3 percent), complaints of incomplete fecal evacuation (59.1 percent), and bulging vaginal tissues (54.4 percent) were the most common complaints on presentation. All patients had multiple complaints with a median number of 4 symptoms (range, 2–8). Physical examination, dynamic magnetic resonance imaging, and dynamic cystocolpoproctography were concordant for rectocele, enterocele, cystocele, and perineal descent in only 41 percent of patients. Dynamic imaging lead to changes in the initial operative plan in 41 percent of patients. Dynamic magnetic resonance was the only modality that identified levator ani hernias. Dynamic cystocolpoproctography identified sigmoidoceles and internal rectal prolapse more often than physical examination or dynamic magnetic resonance. CONCLUSIONS: Levator ani hernias are often missed by physical examination and traditional fluoroscopic imaging. Dynamic magnetic resonance and cystocolpoproctography are complementary studies to the physical examination that may alter the surgical management of females with complex pelvic floor disorders.Presented at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000.No reprints are available.     

Female pelvic floor dysfunction--an imaging perspective

Female pelvic floor dysfunction encompasses a range of morbidities, including urinary incontinence, female pelvic organ prolapse, anal incontinence and obstructed defecation. Patients often present with symptoms covered by several specialties including gastroenterology, colorectal surgery, urology and gynecology. Imaging can therefore bring clinicians from multiple specialties together by revealing that we frequently deal with different aspects of one underlying problem or pathophysiological process. This article provides an interdisciplinary imaging perspective on the pelvic floor. Modern pelvic floor imaging comprises defecation proctography, translabial and endorectal ultrasound, and static and dynamic MRI. This Perspectives focuses on the potential use of translabial ultrasound, including 3D and 4D applications, for diagnosis of pelvic floor disorders. Over the next decade, pelvic floor imaging will most likely be integrated into mainstream diagnostics in obstetrics and gynecology and colorectal surgery. Using imaging to facilitate communication between different specialties has the potential to greatly improve the multidisciplinary management of complex pelvic floor disorders.     

Laparoscopy for pelvic floor disorders

Surgical treatment of pelvic floor disorders has significantly evolved during the last decade, with increasing understanding of anatomy, pathophysiology and the minimally-invasive ‘revolution’ of laparoscopic surgery. Laparoscopic pelvic floor repair requires a thorough knowledge of pelvic floor anatomy and its supportive components before repair of defective anatomy is possible. Several surgical procedures have been introduced and applied to treat rectal prolapse syndromes. Transabdominal procedures include a variety of rectopexies with the use of sutures or prosthesis and with or without resection of redundant sigmoid colon. Unfortunately there is lack of one generally accepted standard treatment technique. This article will focus on recent advances in the management of pelvic floor disorders affecting defecation, with a brief overview of contemporary concepts in pelvic floor anatomy and different laparoscopic treatment options.     

Dynamic MR imaging of outlet obstruction

The outlet obstruction syndrome encompasses all pelvic floor abnormalities which are responsible for an incomplete evacuation of fecal contents from the rectum. It has been estimated that outlet obstruction may be observed in half of constipated patients. A detailed clinical examination still represents the cornerstone of the diagnosis of these patients. However, there is general agreement that a reliable evaluation of the different pelvic floor abnormalities and the treatment decision highly depend on the imaging assessment. Traditionally, conventional defecography has played an important role in the radiological assessment of these patients but the technique is limited by its projectional nature and its inability to detect soft-tissue structures. Dynamic pelvic MR imaging using either closed-configuration or open-configuration MR systems is a rapidly evolving technique which has been gaining increased interest over the last years. The free selection of imaging planes, the good temporal resolution, and the excellent soft-tissue contrast have transformed this method into the preferred imaging modality in the evaluation of patients with pelvic floor dysfunction including rectocele, enterocele, internal rectal prolapse, and anismus.     

Anatomical considerations in TNM staging and therapeutical procedures for low rectal cancer

BACKGROUND: Separation of the mesoderm-derived muscular structures and the endoderm-derived structures of the hindgut and reclassification of their involvement based on their embryological origin may be of clinical importance in providing anatomical support for a more standardized perineal resection during abdominoperineal resection. The aim of this study was to utilize magnetic resonance images and histological studies of fetal and neonatal specimens to redefine the T3/T4 distinction by reassessment of the intersphincteric plane and the pelvic diaphragm as they pertain to cancer infiltration and as part of the embryological development of the pelvic floor muscles and their connective tissue compartments. MATERIALS AND METHODS: Pelvic floor anatomy was studied in seven newborn children and 120 embryos and fetuses. Anatomical data were completed by magnetic resonance imaging in 82 patients with T3 and T4 rectal cancers (64 T3, 18 T4; 35 women and 47 men) undergoing neoadjuvant chemoradiation for locally advanced (T3 or T4) rectal cancers. RESULTS: Clear demarcation between mesodermal and endodermal structures of the pelvic floor, which is equally evident in plastinated sections and magnetic resonance images, is already visible in early fetal stages. There is a constitutive overlap between the endoderm- and the ectoderm-derived components of the pelvic floor. CONCLUSION: Our data suggest that the current classification of rectal cancer staging is confusing, where the routinely used TNM classification system unnecessarily differentiates between embryologically identical muscular structures. Tumor spread along the musculature of the hindgut beyond the dentate line could possibly explain the occasional involvement of lymph nodes outside the conventional mesorectum.     

Dynamic magnetic resonance imaging evaluation of the structural and functional results of postanal repair for neuropathic fecal incontinence

PURPOSE: The aim of this study was to determine whether dynamic magnetic resonance imaging of the pelvic floor can discriminate between patients who improve after postanal repair for neurogenic fecal incontinence and those who remain symptomatic. METHODS: Pelvic floor measurements obtained during dynamic magnetic resonance imaging in eight females whose anal incontinence had improved after postanal repair were compared with those from nine females who remained symptomatic. All subjects also underwent standard anorectal physiology testing. RESULTS: There was no significant difference between groups with respect to any measurement of anterior or middle pelvic floor compartments. Additionally, there was no difference in posterior pelvic floor configuration when symptomatic patients were compared with those who had improved. However, dynamic magnetic resonance measurements revealed patients who remained symptomatic had significantly greater posterior pelvic floor weakness. Anorectal physiology was unable to differentiate between groups. CONCLUSIONS: There is no difference in static pelvic floor measurements when subjects remaining symptomatic after postanal repair are compared with those who have improved. In contrast, dynamic measurements may be able to predict failure in those who demonstrate excessive posterior pelvic floor mobility.     

Rectal prolapse and anal incontinence treated with a modified Roscoe Graham operation

The results of abdominal mobilization of the rectum and repair of the pelvic floor behind the anorectal junction are reported in 23 patients with rectal prolapse, being accompanied by some form of anal incontinence in 12. Within 20 months, on the average, three patients had recurrent prolapse. Two thirds of the patients with incontinence for solid and/or fluid feces were cured for prolapse as well as incontinence. Seven became constipated, while 14 were fully satisfied. Seven of eight patients with a highly reduced tone of the external sphincter before surgery had a marked improvement after surgery. The results do not differ greatly from those after the suspension operation or repair of the pelvic floor in front of the rectum, despite being more physiologic, but suggest that simultaneous suspension and abdominal repair of the pelvic floor may avoid the need for a secondary postanal repair from below in patients with persistent incontinence after suspension surgery. A controlled, randomized trial is advocated.