直肠内注入模拟粪便的动态MRI对女性盆底痉挛综合征的诊断价值

目的 利用动态MRI研究直肠内模拟粪便注入前、后女性盆底痉挛综合征(SPFS)患者的肛直肠形态、功能性病变, 并对多盆腔器官脱垂进行评价, 明确注入球囊后的动态MRI在SPFS患者中的诊断优势。 方法 对53例临床诊断为SPFS的女性患者行动态MRI检查, 使用自行设计高顺应性球囊模拟大便, 测量患者直肠内球囊注入前、后力排相盆底的相关数据。 结果 盆底动态MRI结果显示, 53例女性SPFS患者中, 伴发多盆腔器官脱垂者24例。直肠内造影剂注入前、后力排相的肛直角变化, 差异无统计学意义(χ2=0.603, P > 0.05);相比直肠内模拟粪便注入后的盆底动态MRI, 未注入的力排相分别有18.0%(9/50)膀胱脱垂、6.1%(3/49)子宫或阴道穹窿脱垂、32.7%(17/52)直肠前膨出及14.6%(7/48)会阴体下降诊断为阴性。直肠内模拟粪便注入前、后力排相观察多盆腔器官脱垂变化, 差异均有明显统计学意义。 结论 直肠内注入模拟粪便的盆底动态MRI为女性SPFS患者提供了更全面的诊断, 为术前正确诊断盆腔多部位缺陷及术后正确评价治疗效果提供了客观依据。     

静动态MRI在盆腔器官脱垂术前与术后中的应用

目的：探讨静动态 MRI 在盆腔器官脱垂(POP)术前诊断、术后疗效评价中的价值。方法经盆腔器官脱垂量化分度法(POP-Q)诊断为 POP 的患者29例,对照组为年龄、产次和体质量与之匹配的无症状志愿者12例,行静态和动态盆底 MRI 检查,观察盆底结构形态学变化,测量 POP 患者术前、术后及对照组动态 MRI 图像上各指标：膀胱下缘到耻尾线(PCL)的垂直距离(B-PCL)、子宫颈到 PCL 的垂直距离(U-PCL)、Douglas 窝到 PCL 的垂直距离(D-PCL)、耻骨直肠肌裂孔线(H 线)、盆底肌下降距离(M 线)、肛提肌裂孔面积(LHS)、肛提肌板角度(LPA)、髂尾肌角度(ICA)、尿道倾斜角(UA)。结果POP 患者术前 MRI 上诊断膀胱膨出19例,子宫脱垂28例,直肠膨出4例,Douglas 窝疝14例,盆底松弛29例,发现肛提肌缺陷27例,耻骨宫颈筋膜缺陷24例。POP 患者术前 B-PCL、U-PCL、D-PCL、H 线、M 线、LHS、LPA、ICA 及 UA 等测量值均大于对照组,其差异均有非常显著意义(P <0.01);21例 POP 术后患者中,MRI 发现9例盆腔器官位置恢复正常,12例仍有脱垂;8例网片植入患者术后 MRI 显示网片无移位;POP患者术后 B-PCL、U-PCL、D-PCL、UA 测量值较术前缩小,其差异有统计学意义(P <0.05)。结论静动态 MRI 可全面评价 POP术前、术后盆底形态和功能改变,检出隐匿的脱垂和术后残存。     

MRI对女性盆底功能失调肛提肌裂孔解剖及形态的研究

目的 探讨正常女性与盆底功能失调患者力排相MRI肛提肌裂孔形态及解剖结构的变化.方法 选择23名女性健康志愿者(对照组)和35例盆底功能失调患者(试验组),采用MRI三维稳态进动快速成像序列采集静息和力排相盆腔横断、冠状和矢状面影像,观测肛提肌裂孔的解剖和形态,比较力排相试验组与对照组肛提肌裂孔面积和解剖结构的变化.结果 静息相两组间肛提肌裂孔面积比较差异无统计学意义(P＞0.05),力排相试验组肛提肌裂孔面积[(35.9 ±13.1)cm2]和面积增大百分比[(64.7±22.5)％]均显著大于对照组[(21.7±4.9)cm2和(11.3±6.4)％](P＜0.01).静息相两组受试者肛提肌裂孔解剖结构由前至后均分别为尿道、阴道和肛管,力排相试验组肛提肌裂孔出现膀胱10例(31.3％)、子宫12例(37.5％)、直肠黏膜21例(65.6％)和腹膜脂肪8例(25.0％),而对照组仅发现2例(9.5％)肛提肌裂孔内出现直肠黏膜,经x2检验差异均有统计学意义(P＜0.01或0.05).结论 女性盆底功能失调患者力排相常出现多个盆腔器官向肛提肌裂孔脱垂,并导致肛提肌裂孔异常膨大.     

静动态MRI及DTI对盆腔器官脱垂患者肛提肌形态和功能的评估

目的 探讨静动态MRI及扩散张量成像(DTI)评估盆腔器官脱垂(POP)患者肛提肌形态和功能变化的价值.方法 经盆腔器官脱垂量化分度法(POP-Q)诊断为POP的中老年女性患者41例,对照组为年龄和产次与之相匹配的健康志愿者30名,静态MRI评估肛提肌形态的改变,动态MRI评估肛提肌功能的异常并记录代表支撑功能5个测量值的变化,DTI评估肛提肌各向异性分数值的变化.应用独立样本t检验分别进行两组间各测量指标的比较.结果 静息状态下12例(29.3％)和最大用力时41例(100％) POP患者肛提肌裂孔明显增大呈“O”型,静息状态下29例(70.7％)髂尾肌呈“漏斗”状,最大用力时34例(82.9％)髂尾肌呈“盆”状,22例(53.7％)出现肛提肌萎缩或断裂.POP患者静息时的H线、M线和盆隔裂孔宽度均明显增大(H线:t=-7.897,P=0.000;M线:t=-12.305,P=0.000;盆隔裂孔宽度:t-5.320,P=0.000),最大用力时提肌板角(LPA)、H线、M线和盆隔裂孔宽度及最大用力与静息时各指标差值均明显增大(最大用力时LPA:t=-3.837,P=0.000;H线:t=-10.485,P=0.000;M线:t=-11.521,P=0.000;盆隔裂孔宽度:t=-9.618,P=0.000;LPA差值:t=-4.880,P=0.000;H线差值:t=-2.494,P=0.015;M线差值:t=-4.111,P=0.000;盆隔裂孔宽度差值:t=-5.151,P=0.000),各向异性分数值明显减小(左:t=-4.853,P=0.012;右:t=-6.297,P=0.000).结论 POP患者存在肛提肌缺陷、支撑能力下降和盆底松弛,静动态MRI及DTI能够客观地评估POP患者肛提肌形态和功能的变化.     

MR排便造影在后盆腔障碍性疾病中的评估价值

后盆腔障碍疾病是以肛直肠解剖和功能异常为主的一类盆底功能障碍性疾病,伴有便秘、便失禁等临床症状。MR排便造影是一种动态MR成像方法,可对后盆腔结构形态和运动功能异常情况直观显示,能够鉴别后盆腔障碍性疾病的类型并认识其发病原因,如直肠膨出、肠疝、盆腔器官脱垂和直肠套叠、脱垂等,同时对便失禁早期的肛直肠形态学和功能学异常改变的诊断有重要提示价值。     

经会阴三维超声观察未育女性盆膈裂孔的临床应用

目的 应用盆底三维超声观察未育正常女性盆膈裂孔的形态、结构、大小,为研究盆底功能障碍性疾病,提供影像学依据.方法 对100例正常未育女性进行盆底三维超声检查,获得盆膈裂孔声像图,观察其形态、结构,测量盆膈裂孔前后径、左右径、面积及耻骨直肠肌厚度.结果 所有检查者都能清晰显示盆膈裂孔图像,正常盆膈裂孔呈菱形,左右对称,结构完整,裂孔从前到后依次排列尿道、阴道、直肠.盆膈裂孔前后径、左右径、面积分别为(4.5±0.5)cm,(3.3±0.3)cm,(10.8±1.3)cm2,耻骨直肠肌厚度(0.88±0.1)cm.结论 三维超声是观察女性盆膈裂孔的一种有效的影像学方法,对盆底功能障碍性疾病的三维超声研究,有着重要意义.     

盆底功能性疾病影像学

盆底功能性疾病表现为一系列的盆腔器官功能紊乱．临床表现为多种症状并存．主要有排便功能障碍、尿失禁、性功能障碍及腔门失禁等，与之相应的病因主要为肛直肠功能性病变（包括直肠黏膜脱垂或套叠、直肠膨出和耻骨直肠肌痉挛综合征等)、膀胱膨出或脱垂、子宫阴道脱垂和盐底疝等。影像学检查对上述病变的诊断有独特的价值，笔者重点阐述     

正常女性盆底磁共振成像应用

目的利用动态MRI来评估正常女性的盆腔脏器及盆底肌肉在静息状态与盆腔最大用力排便时的运动情况以及形态的变化。使其一定程度上为盆底功能性疾病的影像学诊断拟定相对正常的影像学标准。方法本研究对20例志愿者进行盆腔动态MRI检查,用于观测前、中、后盆腔脏器的位置、运动范围和盆底肌肉形态及运动程度。结果对本组志愿者以耻尾线(PCL线)为参考线,测量盆腔脏器最大用力排便时平均下降距离,子宫颈为(21.37±5.8)mm,膀胱颈为(9.51±2.6)mm,肛直肠连接为(-14.75±5.73)mm。而肛提肌形态变化不明显。结论动态MRI是研究女性盆底解剖与形态学的有效方法。正常女性盆腔动态MRI与静息状态相比,力排时盆腔器官在一定范围内运动,形态学变化不明显。     

女性盆腔器官脱垂病人肛提肌的MRI评价

盆腔器官脱垂是指由于盆底支持结构薄弱而导致盆腔脏器脱离正常的解剖位置。肛提肌是盆底支持结构中的重要组成部分,其结构损伤及功能障碍是盆腔器官脱垂的重要致病原因,因此对肛提肌的解剖结构进行详细描述成为盆腔器官脱垂研究的关键。动态MRI、扩散张量成像和纤维束示踪技术以及三维有限元分析等MRI技术能够提供肛提肌形态、运动、功能、微观结构以及生物力学等方面的信息,对于探索盆腔器官脱垂发病机制、完善其临床诊断和治疗具有重要的价值。     

女性盆底脱垂MRI诊断进展

盆底由坚韧的肌肉、筋膜和韧带承托,象似一张吊床借助骨性结构维持盆腔器官的正常位置,当盆底支持组织张力减低,盆腔器官发生向下移位,即盆底器官脱垂.盆底器官脱垂在女性中是比较常见的疾病,据Nygaard等报道在老年女性中Ⅱ.脱垂最常见,可达62.9%的发生率[1].有一半已生育的妇女到晚年都会发生不同程度的盆底器官脱垂,严重的可影响其社会活动和生活质量.     

Magnetic resonance imaging in evaluating functional disorders of female pelvic floor

PURPOSE: To evaluate the diagnostic capabilities of MRI in the study of functional diseases of the female pelvic floor. MATERIALS AND METHODS: Ten healthy volunteers and 30 patients with clinically suspected pelvic floor deficiency, with or without pelvic organ prolapse, were evaluated by a high field strength magnet operating at 1.5 T. In each case SSFSE sequences (TR/TE:25720/67) in axial, coronal and sagittal planes, both at rest and during Valsalva's manoeuvre, were performed. Based on the MRI findings using fixed and mobile anatomical landmarks, the functional disease of the pelvic floor was diagnosed and quantified based on the identification and grading of visceral prolapse. The MRI findings were compared with the clinical findings in all cases and with the surgical data in the 7 patients who had undergone surgery. RESULTS: The MR image quality was adequate in all cases. In the group of symptomatic women MRI diagnosed: urethral hypermobility syndrome: 22 cases; isolated abnormalities of the anterior compartment: 8 cases of cystocele (low grade: 2, middle grade: 2, severe: 4); isolated abnormalities of the middle compartment: 6 cases of hysterocele (low grade: 2, middle grade: 4); isolated abnormalities of the posterior compartment: 5 cases of low-grade rectocele; 2 cases of enterocele (1 low grade, 1 middle grade); multi-compartment abnormalities: 11 cases; joint prolapse of anterior and middle compartment: 5 cases; joint prolapse of posterior and middle compartment: 3 cases; joint prolapse of anterior, middle and posterior compartment: 3 cases. The values of both fixed and mobile landmarks were significantly higher in the symptomatic group compared with the healthy volunteers. MRI confirmed the pelvic examination findings in all cases; in particular MRI findings were in total agreement with the clinical severity of prolapse, as defined by the Baden-Walker classification. In 7 cases MRI detected additional alterations (4 cases of hysterocele and 3 of enterocele) that had been missed at clinical evaluation. DISCUSSION AND CONCLUSIONS: In our experience MRI made an important contribution to the diagnosis and grading of functional disorders of the female pelvic floor and pelvic organ prolapse. The ability to simultaneously demonstrate both muscular and ligamentous structures and pelvic viscera, without using X-rays or contrast agents, is the main reason for the good results achieved by MRI and for its widespread use in this disorder. Furthermore the use of fast, breath-hold sequences can provide high-quality images both at rest and during Valsalva's manoeuvre. In conclusion MRI proved to be an accurate imaging tool that is more sensitive than clinical pelvic evaluation in diagnosing and grading functional disorders of the female pelvic floor and pelvic visceral prolapse.     

经会阴三维超声观察便秘产妇产后盆底结构及功能改变

 目的 经会阴盆底三维超声动态观察便秘产妇的肛提肌裂孔解剖形态及功能改变。方法 选取2014-01至2016-12在妇产科定期行产后复查的女性120例(产后组),其中有便秘症状48例(便秘产妇),无便秘症状72例(无便秘产妇),同期选取未育的无便秘症状健康妇女100例(对照组)。所有妇女均进行经会阴盆底三维超声检查,观察并测量、比较各组妇女的盆底形态结构及特征,测量各组妇女在静息状态、缩肛动作和Valsalva动作3种状态下的肛提肌裂孔面积、周长及耻骨直肠肌厚度。结果 产后妇女盆底组织结构疏松,对照组妇女肛提肌裂孔结构完整紧凑。在静息状态、缩肛动作及Valsalva动作3种状态下,产后组妇女的肛提肌裂孔面积、周长及耻骨直肠肌厚度均明显大于对照组妇女(P<0.05)。产后组便秘产妇在各种状态下的肛提肌裂孔面积及周长均明显大于非便秘产妇(P<0.05);在缩肛动作时,便秘产妇的耻骨直肠肌厚度明显薄于非便秘产妇(t=2.41,P<0.05),其余状态下的耻骨直肠肌厚度两者间比较,差异均无统计学意义(P＞0.05)。结论 产后妇女盆底解剖结构发生重塑,经会阴三维超声能有效观察产后女性尤其便秘产妇盆底解剖结构与功能的变化。     

Assessment of pelvic floor dysfunctions using dynamic magnetic resonance imaging

Purpose

The purpose of this study was to assess pelvic floor dysfunction using dynamic MRI.

Material and methods

A prospective study was carried out on 21 consecutive patients presented during February 2013 to June 2013 with pelvic pain, difficulty in defecation, constipation or organ prolapse. Pelvic floor was imaged using T2-weighted and fast imaging employing steady-state acquisition sequences. Pubococcygeal line was used as the line of reference which further allowed measurement of width and vertical descent of levator hiatus. Anorectal angle was measured to assess relaxation and contraction of puborectalis muscle. Grading of prolapse was classified as mild, moderate and severe. All data were recorded both in resting and during straining phase.

Results

A total of 21 patients were studied, with a mean age of 37.3 (9.4) years with 15 (71.4%) females and 6 (21%) males. Dynamic MR revealed cystocele and rectocele in 7 (33.3%) patients, each. Three (14.28%) patients had enteroceles and spastic pelvic syndrome, each. Only one patient (4.76%) had descending perineal syndrome. Intussusception was observed in 10 (47.6%) patients with commonest type being intra rectal seen in 7 (33.3%) patients.

Conclusion

Dynamic MRI is an ideal, non invasive technique which does not require patient preparation for evaluation of pelvic floor. It acts as one stop shop for diagnosing single or multiple pelvic compartment involvement in patients with pelvic floor dysfunction.     

Dynamic magnetic resonance imaging; reliability of assessment and correlation with clinical findings of pelvic organ prolapse

Introduction

Pelvic floor dysfunction and prolapse affect about 50% of women past middle age. Failure to recognize the complex set of pelvic floor defects in individuals leads to most postsurgical failures. Diagnosis and grading of pelvic floor dysfunction is primarily done by physical examination. Imaging does not have yet an established role in the investigation of prolapse, yet it is expected to play a role in preoperative planning identifying soft tissue abnormalities which will help avoiding recurrence.

Aim of the work

This is a prospective study targeted at defining the role of MRI in assessment of pelvic floor prolapse in females.

Methods

Dynamic and static MRI was performed in 40 female patients complaining of pelvic organ prolapse and/or stress urinary incontinence or fecal incontinence. Full history was taken and clinical examination performed and findings compared with MRI results.

Results

Good concordance was found between dynamic MRI and clinical examination in all three compartments, it was 82.5% in the anterior compartment, 80% in the posterior compartment, 85% in enteroceles and 65.0% in the middle compartment.

Conclusion

Dynamic MRI is expected to be a promising imaging tool and to play a larger role in the preoperative planning of pelvic organ prolapse in the near future.     

Computed tomography evaluation of pelvic organ prolapse. Techniques and applications

OBJECTIVES: Pelvic organ prolapse is a common debilitating condition affecting women. Cross-sectional imaging with magnetic resonance imaging (MRI) depicts pelvic floor anatomy as well as organ prolapse and can complement or replace fluoroscopy. Occasionally, patients cannot tolerate MRI, but multiplanar visualization of pelvic floor soft tissue anatomy and organ prolapse is clinically desired. The objective of this study was to determine if computed tomography (CT) is a potential diagnostic technique in these specific situations for demonstrating organ prolapse and the pelvic floor. METHODS: Seven women (mean age: 63.5 years) with clinical pelvic organ prolapse were referred for CT of the pelvis from the gynecologic and surgical clinics from November 1998 to September 2001. The CT technique included the following: insufflation of rectal air, positive oral contrast, supine position with knees flexed, and imaging at rest and straining with a single-detector scan in 5 cases (slice thickness of 3 mm, table speed of 5 mm/s, 2-mm reconstruction interval) and a multidetector scan in 1 case (detector collimation of 1 mm, slice thickness of 1.25 mm, 1-mm reconstruction interval). Axial and 3-dimensional images were interpreted. RESULTS: Computed tomography demonstrated prolapse in 5 of 7 patients. At CT, cystocele was present in 2 of 7 patients, vault or cervical prolapse was present in 4 of 7, enterocele was present in 3 of 7, rectocele was present in 2 of 7, and levator abnormalities were present in 4 of 7. Surgery was performed in 3 of the 5 patients with positive CT findings, and prolapse was confirmed. Surgery was also performed in 1 patient with negative CT findings, and global prolapse was detected. CONCLUSIONS: Demonstration of pelvic organ prolapse and muscular pelvic floor abnormalities is feasible with CT if the patient strains adequately. In patients who cannot tolerate MRI, CT may be useful as an alternative diagnostic tool.     

盆底MRI在女性压力性尿失禁诊疗中的应用价值

目的 探讨盆底MRI在女性压力性尿失禁(SUI)诊疗中的应用价值。方法 前瞻性收集2017年1月至2019年1月首都医科大学附属北京朝阳医院的SUI组和对照组受试者,部分SUI患者行尿道中段悬吊带术(TVT)治疗。受试者均行盆底动态MRI检查(静息相及力排相),对SUI组尿道、膀胱颈功能及盆腔器官脱垂进行定性、定量诊断,分析SUI组TVT术后尿道移动角度、膀胱颈及尿道开放、盆底器官脱垂程度变化。采用独立样本t检验(正态分布)或秩和检验(偏态分布)比较对照组和SUI组患者计量资料的差异,采用χ2检验比较计数资料的差异。结果 对照组25例,SUI组33例,31例行TVT治疗,其中12例于术后3~ 6个月复查盆底MRI,纳入术后观察。力排相下,SUI组较对照组,功能尿道长度、尿道移动角度、H线、M线、膀胱漏斗征、尿道开放和膀胱脱垂的差异有统计学意义(P<0.05)。膀胱漏斗征及尿道开放征术前、后的差异有统计学意义(P<0.05)。TVT术后SUI患者的膀胱脱垂程度减小,子宫脱垂程度增大,但差异无统计学意义(P>0.05);TVT术后SUI患者的尿道长度增加,尿道移动角度减小,但差异无统计学意义(P>0.05)。结论 盆底MRI能准确评估SUI盆底功能;TVT术后对尿道支持结构薄弱及盆底器官脱垂无明显改善。     

Imaging of the posterior pelvic floor

Disorders of the posterior pelvic floor are relatively common. The role of imaging in this field is increasing, especially in constipation, prolapse and anal incontinence, and currently imaging is an integral part of the investigation of these pelvic floor disorders. Evacuation proctography provides both structural and functional information for rectal voiding and prolapse. Dynamic MRI may be a valuable alternative as the pelvic floor muscles are visualised, and it is currently under evaluation. Endoluminal imaging is important in the management of anal incontinence. Both endosonography and endoanal MRI can be used for detection of anal sphincter defects. Endoanal MRI has the advantage of simultaneously evaluating external sphincter atrophy, which is an important predictive factor for the outcome of sphincter repair. Many aspects of constipation and prolapse remain incompletely understood and treatment is partly empirical; however, imaging has a central role in management to place patients into treatment-defined groups.     

盆底三维超声判断压力性尿失禁患者盆底功能损伤和疗效的价值

目的探讨盆底三维超声在压力性尿失禁患者盆底功能损伤和疗效判断中的应用价值。方法选取40例产后压力性尿失禁患者纳入本次实验作为观察组,另选择同期产后40例正常产妇纳入本次实验作为对照组,观察组产后接受盆底康复治疗,2组均接受盆底三维超声检查,统计并比较2组盆底功能(盆底裂孔面积、膀胱尿道后角以及膀胱颈至耻骨联合下缘的距离)。结果观察组康复治疗前静息状态及Valsalva动作下的盆底裂孔面积、膀胱尿道后角均大于对照组,膀胱颈至耻骨联合下缘距离均小于对照组(P<0.05);观察组康复治疗后静息状态及Valsalva动作下的盆底裂孔面积、膀胱尿道后角均小于治疗前,膀胱颈至耻骨联合下缘距离均大于治疗前(P<0.05);观察组康复治疗后静息状态及Valsalva动作下的盆底裂孔面积、膀胱尿道后角、膀胱颈至耻骨联合下缘距离与对照组比较,差异无统计学意义(P>0.05)。结论对产后压力性尿失禁患者实施盆底三维超声检查,可以准确判断患者的盆底功能损伤情况,并可作为评价盆底康复治疗效果的重要参考依据。