超声技术评估肛提肌结构与功能研究进展

肛提肌损伤是盆底功能障碍性疾病发生的重要因素。近年来,妇产科超声成像及诊断技术不断进步。本文主要对二维超声、常规三维超声、超声断层成像技术在肛提肌结构与功能评估方面的研究进展进行综述。     

自由解剖切面联合容积对比成像评估未育女性肛提肌裂孔

目的联合应用自由解剖切面(Omniview)与容积对比成像(VCI)技术观察和测量未育女性肛提肌裂孔。方法对60例年轻未育女性于静息状态下行经会阴盆底三维超声检查,脱机分析图像数据。由2名医师应用Omniview联合VCI(Omniview-VCI)模式测量肛提肌裂孔的前后径、左右径及面积。并由其中1名医师应用三维重建渲染(Render)模式测量肛提肌裂孔各测量值。统计分析两种成像模式下各测量值的差异并评价观察者内及观察者间测量结果的一致性。结果两种成像模式下肛提肌裂孔各测值差异均无统计学意义(P均0.05)。一致性分析结果显示,观察者内和观察者间肛提肌裂孔各测值的相关系数均0.8。结论 Omniview-VCI技术是评估女性肛提肌裂孔方便可靠的影像学方法。     

经阴道三维超声及其断层成像技术对剖宫产瘢痕妊娠的鉴别诊断

目的探讨经阴道三维超声及其断层成像技术对剖宫产瘢痕妊娠(CSP)的鉴别诊断价值。方法将58例清宫或宫/腹腔镜术后病理证实为CSP的患者纳入研究,了解其超声检查方法,分析其二维、经阴道三维超声及断层成像的声像图特征。所有超声检查均与病理诊断对照。结果 58例CSP患者中,经腹超声检查诊断7例、误诊4例(误诊率36.4%);经阴道二维超声诊断19例,误诊6例(误诊率24.0%);经阴道三维超声及断层成像诊断21例,误诊1例(误诊率4.5%);经阴道三维超声及断层成像诊断CSP的误诊率显著低于其他两种超声诊断方式(P0.05)。经腹及经阴道二维、三维超声诊断CSP的声像图特征:瘢痕处孕囊突入型35例(60.34%)、瘢痕处孕囊型17例(29.31%)、瘢痕处混合回声包块型6例(10.34%)。结论经阴道三维超声及断层成像技术能较清楚地显示孕囊或包块与剖宫产瘢痕空间位置关系,有利于寻找胚胎着床位置,为CSP的诊断和鉴别诊断提供重要信息,从而降低误诊率。     

经会阴三维超声评价女性盆底肌肉形态及功能

目的应用经会阴三维超声测量年轻未育女性的耻骨内脏肌宽度及肛提肌裂孔大小,探讨女性盆底的形态及功能。方法对100例18～31岁年轻未育女性在安静状态下、最大瓦氏动作及提肛动作时采集盆底经会阴三维超声图像,脱机分析,分别测量肛提肌裂孔的前后径、左右径、面积及耻骨内脏肌的宽度,并通过计算组内相关系数评估观察者之间的一致性。结果肛提肌裂孔呈菱形,两侧耻骨内脏肌基本对称,呈带状高回声,在肛直肠角后方形成U型襻。安静状态下肛提肌裂孔面积(11.15±1.70)cm2,最大瓦氏动作时增大至(14.35±2.43)cm2,而提肛动作时缩小至(9.20±1.46)cm2。两名观察者测量安静状态及提肛动作时的肛提肌裂孔大小及不同状态下耻骨内脏肌宽度一致性较好,但在最大瓦氏动作时测量肛提肌裂孔大小的一致性稍差。结论经会阴三维超声能直观观察盆底耻骨内脏肌的宽度及肛提肌裂孔的动态变化。     

经会阴超声结合经阴道超声在诊断肛周不同来源性感染中的价值

目的：探讨经会阴超声结合经阴道超声在诊断肛周不同来源性感染中的价值。方法：择取我院2020年2月至2021年7月疑似肛周疾病患者70例,男性患者仅给予经会阴超声诊断,女性患者给予经会阴超声+经阴道超声诊断,评估其诊断价值。结果：1)60例肛腺源感染患者中,术前超声诊断脓肿符合率为100.00%、主瘘管为94.92%、支管为83.33%、内口为86.67%、外口为100.00%。2)10例非肛腺源感染患者中,术前超声诊断和术后病理完全符合,包含会阴尿道瘘2例、肛周表皮样囊肿3例、藏毛囊肿伴感染3例、肛周化脓性汗腺炎1例、血栓性外痔1例。结论：针对肛周不同来源性感染,经会阴超声、经阴道超声联合诊断可对炎症予以分型,评估其炎症病变程度,还具有无痛和成本低等优势,诊断价值较高,值得推广应用。     

盆底超声评价女性肛提肌的研究进展

肛提肌是盆底肌肉的主要组成部分,其形态及功能异常是造成女性盆底功能障碍性疾病的主要原因。近年来盆底超声技术飞速发展,已被广泛应用于肛提肌损伤的研究中。本文对女性肛提肌的正常形态、超声成像以及肛提肌损伤超声诊断的研究现状进行综述。     

断层超声显像技术评价125I粒子治疗肝恶性肿瘤

目的探讨断层超声显像技术在125I粒子治疗肝恶性肿瘤中的应用价值。方法对14例肝癌患者的21个病灶植入125I粒子前,采用PhilipsiU22超声诊断仪、三维容积成像技术和Qlab软件对病灶进行超声断层显像检查,模拟粒子空间排布及计算所需粒子数。结果断层超声显像技术比CT断层图像制定的放射粒子治疗计划计算的粒子数更接近实际植入数,绘制的粒子分布图便于术中操作,肿瘤局部控制率为84.63%。结论超声断层显像能科学、合理地绘制粒子分布图,简化术中操作,在125I粒子治疗肝恶性肿瘤中有一定的临床应用价值。     

经会阴及经阴道超声诊断对肛周不同来源性感染的意义

目的:探讨经会阴及经阴道超声诊断对肛周不同来源性感染的意义。方法:选择可疑肛周疾病患者80例，男性采用经会阴超声诊断，女性采用经会阴超声结合经阴道超声诊断，详细检查所有脓肿、窦道及瘘管，非腺源性病变评估病变范围、可能性质，并将检查结果与手术结果进行对比分析。结果:1)80例手术患者中检出腺源性感染67例，非腺源性感染13例。2)67例腺源性感染患者肛瘘诊断结果:经术后确诊脓肿20例，主瘘管67例，支管18例，内口67例，外口67例。经超声诊断脓肿20例，符合率100%;主瘘管64例，符合率95.52%;支管15例，符合率83.33%;内口60例，符合率89.55%;外口67例，符合率100%。3)13例非腺源性感染病变中会阴尿道瘘、肛周表皮样囊肿、藏毛窦囊肿合并感染、肛周化脓性汗腺炎、血栓性外痔，均和手术病理检查结果相一致。结论:经会阴及经阴道超声在诊断肛周不同来源性感染中的价值显著，经会阴及阴道超声可进一步明确肛周腺源性炎症性疾病的范围及分型，通过鉴别腺源性感染、非腺源性感染类型为临床诊断提供重要参考价值，以便于及时开展治疗工作。     

经阴道三维超声在宫腔粘连术前的诊断价值

目的分析经阴道三维超声在宫腔粘连术前的诊断价值。方法选取2016年7月至2017年7月医院收治的宫腔粘连患者80例,术前分别采用经阴道二维超声与经阴道三维超声进行检查,对两种技术检查情况进行统计分析。结果以宫腔镜及病理诊断结果作为标准,在宫腔粘连程度诊断方面,与经阴道二维超声诊断准确率75.0%相比,经阴道三维超声诊断准确率95.0%显著提高(P0.05),且在轻度宫腔粘连诊断准确率方面,经阴道三维超声诊断91.8%显著高于经阴道二维超声诊断率69.4%(P0.05);在宫腔粘连分型方面,与经阴道二维超声诊断准确率85.0%相比,经阴道三维超声诊断准确率95.0%显著提高(P0.05)。结论对宫腔粘连疾病患者进行经阴道三维超声成像技术诊断能够提供更全面、直观地信息,在粘连程度、分型方面均具有较高的准确率,能够为宫腔粘连的诊断与治疗提供科学依据,值得临床应用与推广。     

经阴道实时三维超声成像诊断宫腔内病变

目的评价经阴道实时三维超声诊断宫腔内病变的临床价值。方法应用经阴道实时三维超声容积探头,对397例因不规则阴道出血、不孕、腹痛及白带异常等妇科住院患者进行术前检查。结果397例中共检出子宫内膜息肉183例,子宫内膜肥厚157例,子宫粘膜下肌瘤45例,子宫内膜癌12例,经手术证实诊断符合率分别为96％、98％、98％、92％。结论经阴道实时三维超声可对子宫内膜和官腔进行立体成像,能准确定位宫腔内病灶的位置,及其与宫壁和内膜的关系,与其他诊断方法相比具有其独特的优越性。     

Validity and reproducibility of the digital detection of levator trauma

Levator ani muscle trauma is a common consequence of vaginal childbirth and detectable on digital vaginal palpation. To ascertain validity and reproducibility of this test, we saw 110 women for an interview, prolapse staging, digital vaginal palpation by two blinded examiners and four-dimensional translabial ultrasound. The mean age was 55.5 years (range 17-85) and the median parity was 2 (range 0-8). Three patients could not be assessed, leaving 107 datasets representing 214 assessments of a right or left puborectalis muscle. Levator defects were found in 21 women (20%) with nine bilateral defects. There was agreement between assessors in 173/214 (81%), k=0.411, signifying moderate agreement. Agreement with an independent blinded review of tomographic ultrasound data was k=0.495. Even after substantial training, the agreement between assessors using digital palpation for the diagnosis of levator trauma remains only moderate. There seems to be a substantial learning curve. Palpatory detection of major levator trauma is less repeatable than identification by ultrasound.     

Diagnosing levator avulsions after first delivery by tomographic ultrasound: reliability between observers from different centers

Introduction and hypothesis

To evaluate the interobserver reliability of diagnosing levator avulsions between observers from different centers using tomographic ultrasound imaging (TUI) in women after their first delivery.

Methods

Transperineal ultrasound volume datasets of 40 women 6 months after their first delivery were analyzed by five observers from four different centers. Levator avulsions were diagnosed using TUI and datasets were assessed as optimal or suboptimal image quality and optimal or suboptimal pelvic floor contraction. Cohen’s kappa was used to evaluate the interobserver reliability of diagnosing levator avulsions for the total group, the group with optimal and suboptimal image quality, and the group with optimal and suboptimal pelvic floor contraction. Consensus on the presence or absence of avulsions was scored according to the number of observers who diagnosed an avulsion (0?=?consensus on the absence of avulsion, 1–4?=?avulsion diagnosed by 1 to 4 observers, 5?=?consensus on the presence of avulsion).

Results

For the total group, the interobserver reliability varied widely, with kappa values ranging from ?0.07 to 0.72. Analyzes in the subgroups showed comparable results. Of the women who potentially have an avulsion (avulsion diagnosed by at least one observer), consensus on the presence of an avulsion was reached in 0.0 to 20.0 %. Of the women who potentially have no avulsion (no avulsion diagnosed by at least one observer), consensus on the absence of an avulsion was reached in 46.7 to 85.7 %.

Conclusions

Diagnosing levator avulsions using TUI in women 6 months after their first delivery is strongly observer-dependent and therefore not generalizable.     

Is the levator–urethra gap helpful for diagnosing avulsion?

Introduction and hypothesis

Levator avulsion is a risk factor for female pelvic organ prolapse (POP) and recurrence after POP surgery. Imaging diagnosis requires the observation of an abnormal muscle insertion on tomographic ultrasound imaging (TUI). This study was designed to compare the diagnostic performance of the qualitative diagnosis (visual qualitative assessment) to measurement of the distance between muscle insertion and urethra [levator–urethra gap; (LUG)].

Methods

This was a retrospective analysis of data obtained in a tertiary urogynecological unit. All patients presented with symptoms of pelvic floor dysfunction and underwent 4D translabial pelvic floor ultrasound (US), supine, and after voiding. Avulsion was defined qualitatively as abnormal muscle insertion and quantitatively as LUG ≥25 mm on at least three consecutive central axial plane slices, with one examiner using both methods. We examined the correlation between both methods and validated them against clinical prolapse, significant organ descent on US, and hiatal ballooning.

Results

Between January and July 2013, 233 patients were seen, of whom 202 had complete volume data sets. The qualitative method diagnosed avulsion in 22 % and the quantitative method in 24.3 %. Agreement was good, with a kappa of 0.79 (0.70–0.87). Avulsion diagnosed by either method was associated with clinical and sonographic prolapse and hiatal ballooning, with odds ratios nonsignificantly higher for the quantitative method.

Conclusion

Qualitative analysis of slices on TUI and a method using LUG measurement show good agreement for the diagnosis of avulsion. The LUG method is at least equally as valid in its capacity to predict significant prolapse on clinical examination and US, as well as ballooning of the levator hiatus.

     

女性盆底肌磁共振弥散张量成像价值分析

目的探讨磁共振弥散张量成像(DTI)在女性盆底肌成像应用中的可行性。方法筛选35名无孕育史、无盆底疾病的年轻志愿者(对照组)和35名初产妇(研究组),分别行盆底肌常规磁共振成像(MRI)扫描和DTI扫描,测量肛提肌和肛门括约肌复合体的部分各向异性分数(FA)值,计算其平均值。并使用计算机软件描绘肛提肌和肛门括约肌复合体的三维纤维示踪图。结果对照组35名志愿者肛提肌平均FA值是(0.41±0.02),研究组35名初产妇肛提肌平均FA值是(0.34±0.03),差异有统计学意义(P0.05);对照组肛门括约肌复合体平均FA值为(0.70±0.03),研究组为(0.65±0.03),差异有统计学意义(P0.05)。DTI三维失踪成像可清晰显示初产妇肛提肌、肛门括约肌的肌肉形态改变。结论 DTI可以对女性盆底肌进行量化分析和三维形态学观察,有利于女性盆底肌肉损伤的早期诊断,值得临床推广。     

Levator defects can be detected by 2D translabial ultrasound

Introduction and hypothesis  Childbirth-related morphological abnormalities or defects of the puborectalis muscle (“avulsion”) can be diagnosed by magnetic resonance imaging and three-dimensional (3D) ultrasound, but neither method is universally available. In this study, we tested validity and reproducibility of a new method for diagnosing levator avulsion by 2D translabial ultrasound. Methods  Seventy-five women were examined for major morphological abnormalities of the puborectalis muscle by palpation, 2D and 3D ultrasound (US). For 2D US, we used an oblique parasagittal translabial approach. The operator using 2D US was blinded against all other findings. Results  Agreement between observers for diagnosis of avulsion by 2D US was 87% (Cohen’s kappa 0.56, CI 0.33–0.80). Agreement between tomographic 3D US and 2D US was 87% (kappa 0.61, CI 0.45–0.77). Conclusions  Defects of the puborectalis muscle can be diagnosed with 2D US. The finding of a discontinuity between the hyperechogenic muscle and the pelvic sidewall is moderately reproducible and agrees moderately well with palpation and 3D US.     

Digital rectal examination in the evaluation of rectovaginal septal defects

Introduction and hypothesis

The objective was to evaluate the diagnostic potential of digital rectal examination in the identification of a true rectocele.

Methods

This is a retrospective observational study utilising 187 archived data sets of women presenting with lower urinary tract symptoms and/or pelvic organ prolapse between August 2012 and November 2013. Evaluation included a standardised interview, ICS-POPQ, rectal examination and 4D translabial ultrasound. The main outcome measure was the diagnosis of rectocele by digital rectal palpation on Valsalva manoeuvre. This diagnosis correlated with the sonographic diagnosis of rectocele to determine agreement between digital examination and ultrasound findings.

Results

Complete data sets were available for 180 participants. On imaging, the mean position of the rectal ampulla was 11.07 (?36.3 to 44.3) mm below the symphysis pubis; 42.8% (77) had a rectocele of a depth of ≥10 mm. On palpation, a rectocele was detected in 60 women (33%). Agreement between palpation and imaging was observed in 77%; the kappa was 0.52 (CI 0.39–0.65). On receiver operator characteristic analysis, the area under the curve was 0.854 for the relationship between rectocele pocket depth and the detection of rectocele on palpation.

Conclusion

Moderate agreement was found between digital rectal examination for rectocele and translabial ultrasound findings of a “true rectocele”. Digital rectal examination may be used to identify these defects in clinical practice. Extending the clinical examination of prolapse to include rectal examination to palpate defects in the rectovaginal septum may reduce the need for defecatory proctograms for the assessment of obstructive defecation and may help triage patients in the management of posterior compartment prolapse.

     

The assessment of levator trauma: a comparison between palpation and 4D pelvic floor ultrasound

AIMS: Major morphological abnormalities of the pubovisceral muscle are observed in 10-20% of women symptomatic of pelvic floor disorders. Such defects arise in childbirth and are associated with prolapse. While they are clearly evident on 3D ultrasound and MR imaging, such defects can be difficult to detect clinically. We intended to compare findings on palpation with the results of ultrasound imaging. MATERIAL AND METHODS: Fifty-five women were recruited in a prospective observational study and assessed by interview, vaginal examination by a trained pelvic floor physiotherapist, and 3D/4D pelvic floor ultrasound. The vaginal examination involved digital assessment of muscle strength (modified Oxford grading) and morphological abnormalities. The ultrasound examination involved acquisition of volume datasets taken at rest, on Valsalva and pelvic floor muscle contraction. Assessments were undertaken supine and after voiding. Ultrasound operator and physiotherapist were blind to each other's findings. RESULTS: A comparison of 3D ultrasound and palpation was possible in 54 cases. Average Oxford grading was weakly associated with reduction in hiatal dimensions on contraction (r = -0.32, P = 0.024). A marked increase in hiatal dimensions detected on palpation was associated with increased hiatal area on Valsalva (P = 0.027). Defects were observed in 7/54 (13%) on ultrasound and in 10/55 (18%) on palpation. There was poor agreement between the methods, with only two defects picked up equally by both methods. CONCLUSIONS: Palpation of the pubovisceral muscle correlates poorly with 3D/4D pelvic floor ultrasound imaging for the assessment of muscular defects.     

Does levator avulsion cause distension of the genital hiatus and perineal body?

Introduction and hypothesis

Levator avulsion is associated with prolapse and prolapse recurrence after reconstructive surgery. We set out to determine whether clinical measurement of the genital hiatus and the perineal body (gh + pb) on maximum Valsalva can predict levator avulsion.

Methods

A total of 295 women attending a tertiary referral service underwent 4D translabial ultrasound imaging and clinical examination using the International Continence Society (ICS) Pelvic Organ Prolapse Quantification system (POP-Q). Analysis of ultrasound data sets for levator avulsion was performed using tomographic ultrasound imaging. The predictive performance of gh + pb for avulsion was tested using receiver-operating characteristic curves.

Results

Optimal sensitivity [70 %, 95 % confidence interval (CI) 59–79 %] and specificity (70 %, 95 % CI 66–72 %) were achieved with a cut-off of 8.5 cm for gh + pb.

Conclusions

A gh + pb measurement ≥ 8.5 cm may help to identify women with levator avulsion who are at increased risk of prolapse recurrence.     

女性盆底松弛综合征患者肛提肌裂隙的动态三维超声研究

目的探讨动态三维超声对盆底松弛综合征患者治疗前后肛提肌裂隙形态结构改变方面的评估价值。方法2011年10月到2012年9月间于南京市中医院便秘专病门诊筛选出盆底松弛综合征所致便秘的40例女性患者,填写克里夫兰便秘评分（CCS评分）量表,并在Valsalva动作时进行动态三维超声检查,测量患者肛提肌裂隙的前后径和左右径。经1个疗程（2周）的生物反馈和针灸治疗后,再次填写治疗后CCS评分量表并复查Valsalva动作时的动态三维超声。结果最终有25例盆底松弛综合征女性患者接受治疗前、后的动态三维超声检查并完成CCS评分量表。与治疗前相比,治疗后Valsalva动作时动态三维超声所测得的肛提肌裂隙纵轴[（5．13±0．82）cm比（4．89±0．89）cm,P〈O．01]、横轴[（4．86±0．74）cm比（4．62±0．75）cm,P〈0．01]和面积[（19．92±6．33）cm。比（18．16±6．42）cm2．P〈0．01]均明显减小,CCS评分亦明显下降[（15．80±3．42）比（9．52±2．50）,P〈0．01）。结论使用动态三维超声可以为女性盆底松弛综合征肛提肌裂隙的测定提供一种简单、无创并有效的影像学检测方法。     

Impact of levator trauma on pelvic floor muscle function

Introduction and hypothesis

Levator trauma is common after vaginal delivery, either as macrotrauma, i.e., levator avulsion, or microtrauma, i.e., irreversible overdistension of the levator hiatus. The effect of microtrauma on muscle function is unknown. We tested the hypothesis that levator trauma is associated with reduced contractile function of the levator ani.

Methods

Pregnant nulliparous women were recruited and seen before and after childbirth. All underwent an interview, a clinical examination including pelvic floor muscle (PFM) assessment using the Modified Oxford scale (MOS) [as an optional component] and translabial ultrasound. Sonographic and clinical parameters of PFM function were assessed before and after childbirth.

Results

Out of 560 women, 446 returned at a median of 5 months after childbirth and 433 were suitable for analysis. There was a significant reduction in all measures of PFM function except for MOS. Change in MOS was associated with delivery mode [analysis of variance (ANOVA) P?=?0.006). Forty-seven (15 %) vaginally parous women were diagnosed with levator avulsion, which was associated with a reduction in PFM contractility on sonographic parameters and MOS. However, only clinical assessment reached statistical significance. Sixty-five of 312 (21 %) women were diagnosed with microtrauma. We found no evidence of impairment in PFM contractility on ultrasound, but there was a statistically significant reduction in MOS.

Conclusions

Both levator avulsion (macrotrauma) and irreversible overdistension (microtrauma) are associated with reduced contractile function. This effect is more easily detected by palpation than by sonographic indices of levator function.