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中华消化病与影像杂志(电子版) ›› 2022, Vol. 12 ›› Issue (06) : 334 -341. doi: 10.3877/cma.j.issn.2095-2015.2022.06.003

论著

经会阴及经肛门三维超声技术对功能性肛门直肠疾病的评估
薛雅红1, 刘飞1, 凌艳1, 王小峰1,()   
  1. 1. 210022 南京中医药大学附属南京中医院肛肠科
  • 收稿日期:2022-02-10 出版日期:2022-12-01
  • 通信作者: 王小峰
  • 基金资助:
    南京市卫生局重点项目(ZKX19035)

Evaluation of functional anorectal disorder by transperineal and three-dimensional endoanal ultrasound

Yahong Xue1, Fei Liu1, Yan Ling1, Xiaofeng Wang1,()   

  1. 1. Anorectal Department, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing 210022, China
  • Received:2022-02-10 Published:2022-12-01
  • Corresponding author: Xiaofeng Wang
引用本文:

薛雅红, 刘飞, 凌艳, 王小峰. 经会阴及经肛门三维超声技术对功能性肛门直肠疾病的评估[J]. 中华消化病与影像杂志(电子版), 2022, 12(06): 334-341.

Yahong Xue, Fei Liu, Yan Ling, Xiaofeng Wang. Evaluation of functional anorectal disorder by transperineal and three-dimensional endoanal ultrasound[J]. Chinese Journal of Digestion and Medical Imageology(Electronic Edition), 2022, 12(06): 334-341.

目的

评估经会阴超声(TPUS)及三维肛管直肠腔内超声(3D-EAUS)技术对功能性肛门直肠疾病的临床诊断价值。

方法

回顾性分析2019年1月至2021年3月南京市中医院肛肠科收治的功能性肛门直肠疾病患者138例,其中功能性排便障碍96例,大便失禁14例,功能性肛门直肠痛28例。TPUS测量膀胱颈移动度(BND)、膀胱尿道后角(RVA)、肛直角、直肠前突等指标;3D-EAUS评估肛门括约肌完整性、测量耻骨直肠肌角。

结果

TPUS:80例女性功能性排便障碍患者中,最大Valsalva时10例(12.5%)BND>25 mm,23例(28.75%)RVA>140°,发现直肠前突45例(56.25%),直肠黏膜内套叠43例(53.75%),肠疝1例(1.25%);22例女性功能性肛门直肠痛患者中,最大Valsalva时2例(9.1%)BND>25 mm,4例(18.2%)RVA>140°,发现直肠前突11例(50%),直肠黏膜内套叠13例(59.1%);女性功能性排便障碍及功能性肛门直肠痛患者肛直角在静息状态和最大Valsalva时比较,差异均无统计学意义(P>0.05)。3D-EAUS:16例男性功能性排便障碍患者静息及最大Valsalva时耻骨直肠肌角差异有统计学意义[(88.84±3.80)°比(87.54±3.47)°,P<0.05]。14例大便失禁患者中,5例括约肌重度缺损(评分:10~13分),累及内外括约肌,均是产伤引起的会阴撕裂;1例中度缺损(评分:6分);3例轻度缺损(评分:3~4分)。功能性排便障碍女性患者中有41例最大Valsalva时的肛直角和耻骨直肠肌角均明显小于静息状态,差异比较有显著统计学意义(P<0.01)。

结论

TPUS及3D-EAUS技术能准确评估功能性肛门直肠疾病患者盆底形态学特征,并能发现其他伴随的盆底功能障碍,评估具有整体性。

Objective

To evaluate the diagnostic value of transperineal ultrasound(TPUS)and three-dimensional endoanal ultrasound(3D-EAUS)for functional anorectal disorder(FAD).

Methods

A total of 138 patients with FAD admitted to the Anorectal Department of Nanjing Hospital of Traditional Chinese Medicine from January 2019 to March 2021 were retrospectively analyzed, including 96 cases of functional defecation disorder(FDD), 14 cases of fecal incontinence(FI)and 28 cases of functional anorectal pain(FARP). Bladder neck descent(BND), retrovesical angle(RVA), anorectal angle(ARA), rectocele(RC)were measured by TPUS.Assessment of sphincter integrity and measurement of puborectalis angle were taken using 3D-EAUS.

Results

TPUS: In 80 female patients with FDD, 10(12.5%)patients had BND>25 mm at the maximum Valsalva, 23(28.75%)patients had RVA>140°, 45(56.25%)patients had RC, 43(53.75%)patients had rectal intussusception(RI)and 1(1.25%)patient had enterocele.Among 22 female patients with FARP, 2(9.1%)patients had BND>25 mm at the maximum Valsalva, 4(18.2%)patients had RVA>140°, 11(50%)patients had RC and 13(59.1%)patients had RI.No significant differences were observed in ARA between the resting state and the maximum Valsalva in female patients with FDD and FARP(P>0.05).3D-EAUS: There was a significant difference in the puborectalis angle between the resting state and the maximum Valsalva in 16 male patients with FDD [(88.84±3.80)°vs.(87.54±3.47)°, P<0.05]. In 14 cases of FI, 5 cases had severe sphincter defect(score: 10 to13 points), involving the internal and external sphincter, all of which were perineal laceration caused by birth injury, 1 case of moderate defect(score: 6 points), and 3 cases of mild defect(score: 3 to 4 points). In 41 female patients with FDD, both the ARA and puborectalis angle at the maximum Valsalva were significantly smaller than those at the resting state(P<0.01).

Conclusion

The TPUS and 3D-EAUS can accurately assess the morphological features of the pelvic floor in FAD patients, and detect other accompanying pelvic floor disorders.The assessment is integral.

表1 138例功能性肛门直肠疾病患者的一般资料
图1 经会阴超声盆底解矢状面显像注:PR耻骨直肠肌,R直肠,A肛管,V阴道,U尿道,P耻骨联合,B膀胱
图2 经肛门三维超声显示肛管三层面解剖注:2A外括约肌的皮下部;2B外括约肌的浅部、联合纵肌、内括约肌环;2C"U"形耻骨直肠肌、外括约肌深部及内括约肌环
图3 经会阴超声下检测指标注:R直肠,A肛管,P耻骨联合,B膀胱,V阴道,SB小肠,EC肠疝;a线:耻骨联合下缘水平线;虚线:直肠前突轮廓
表2 腔内超声肛门括约肌缺损评分(0~16分)[21]
图4 耻骨直肠肌角的测量注:PR耻骨直肠肌,IAS内括约肌,EAS外括约肌
表3 女性功能性肛门直肠疾病患者经会阴超声下表现
表4 FDD及FARP患者耻骨直肠肌角变化(±s)
图5 41例女性功能性排便障碍患者肛直角、耻骨直肠肌角变化
图6 女性功能性排便障碍患者肛直角、耻骨直肠肌角变化注:肛直角静息125°,最大Valsalva115°;耻骨直肠肌角静息95°,最大Valsalva 83°
图7 肛管后侧内括约肌缺损(120°),前侧内括约肌回缩增厚(箭头所指)
图8 肛管前侧外括约肌缺损(110°)
表5 大便失禁患者超声下括约肌缺损评估
1
Rao SSBharucha AEChiarioni G,et al.Functional Anorectal Disorders[J].Gastroenterology2016:S0016-5085(16)00175-X.
2
Davis KKumar D.Posterior pelvic floor compartment disorders[J].Best Pract Res Clin Obstet Gynaecol200519(6):941-958.
3
Drossman DAHasler WL.Rome IV-Functional GI Disorders:Disorders of Gut-Brain Interaction[J].Gastroenterology2016150(6):1257-1261.
4
Schmulson MJDrossman DA.What Is New in Rome IV[J].J Neurogastroenterol Motil.201723(2):151-163.
5
Luber KMBoero SChoe JY.The demographics of pelvic floor disorders:current observations and future projections[J].Am J Obstet Gynecol2001184:1496-503.
6
Grossi UDi Tanna GLHeinrich H,et al.Systematic review with meta-analysis:defecography should be a first-line diagnostic modality in patients with refractory constipation[J].Aliment Pharmacol Ther201848(11/12):1186-1201.
7
Jeong HYYang SJCho DH,et al.Comparison of 3-Dimensional Pelvic Floor Ultrasonography and Defecography for Assessment of Posterior Pelvic Floor Disorders[J].Ann Coloproctol202036(4):256-263.
8
Hainsworth AJSolanki DHamad A,et al.Integrated total pelvic floor ultrasound in pelvic floor defaecatory dysfunction[J].Colorectal Dis201719(1):O54-O65.
9
Vitton VVignally PBarthet M,et al.Dynamic anal endosonography and MRI defecography in diagnosis of pelvic floor disorders:comparison with conventional defecography[J].Dis Colon Rectum201154(11):1398-404.
10
AIUM/IUGA Practice Parameter for the Performance of Urogynecological Ultrasound Examinations:Developed in Collaboration with the ACR,the AUGS,the AUA,and the SRU[J].J Ultrasound Med201938(4):851-864.
11
Viscardi ARatto CParello A.Dynamic transperineal ultrasound in the workup of men with obstructed defecation:a pilot study[J].Dis Colon Rectum201255(9):976-982.
12
Stafford REAshton-Miller JAConstantinou CE,et al.A new method to quantify male pelvic floor displacement from 2D transperineal ultrasound images[J].Urology201381(3):685-689.
13
Kam HAYagel SEisenberg VH.Ultrasonography in Pelvic Floor Dysfunction[J].Obstet Gynecol Clin North Am201946(4):715-732.
14
Regadas FSMurad-Regadas SMLima DM,et al.Anal canal anatomy showed by three-dimensional anorectal ultrasonography[J].Surg Endosc200721(12):2207-2211.
15
Unger CAWeinstein MMPretorius DH.Pelvic floor imaging[J].Obstet Gynecol Clin North Am201138(1):23-43.
16
Dietz HP.The role of two-and three-dimensional dynamic ultrasonography in pelvic organ prolapse[J].J Minim Invasive Gynecol201017(3):282-294.
17
Chantarasorn VDietz HP.Diagnosis of cystocele type by clinical examination and pelvic floor ultrasound[J].Ultrasound Obstet Gynecol201239(6):710-714.
18
Wieczorek APStankiewicz ASantoro GA,et al.Pelvic floor disorders:role of new ultrasonographic techniques[J].World J Urol201129(5):615-623.
19
Santoro GAWieczorek APDietz HP,et al.State of the art:an integrated approach to pelvic floor ultrasonography[J].Ultrasound Obstet Gynecol201137(4):381-396.
20
Dietz HPBeer-Gabel M.Ultrasound in the investigation of posterior compartment vaginal prolapse and obstructed defecation[J].Ultrasound Obstet Gynecol201240(1):14-27.
21
Stark MBohe MValentin L.Effect of vaginal delivery on endosonographic anal sphincter morphology[J].Eur J Obstet Gynecol Reprod Biol2007130:193-201.
22
Murad-Regadas SMRegadas FSRodrigues LV,et al.A novel three-dimensional dynamic anorectal ultrasonography technique(echodefecography)to assess obstructed defecation,a comparison with defecography[J].Surg Endosc200822(4):974-979.
23
薛雅红,丁义江,江滨,等.盆底失弛缓综合征患者肛管形态学特征及其与功能的相关性研究[J].中华胃肠外科杂志201922(5):457-463.
24
Beer-Gabel MCarter D.Comparison of dynamic transperineal ultrasound and defecography for the evaluation of pelvic floor disorders[J].Int J Colorectal Dis201530(6):835-41.
25
Matthews CAWhitehead WETownsend MK,et al.Risk factors for urinary,fecal,or dual incontinence in the Nurses′ Health Study[J].Obstet Gynecol2013122(3):539-545.
26
Bliss DZHarms SGarrard JM,et al.Prevalence of incontinence by race and ethnicity of older people admitted to nursing homes[J].J Am Med Dir Assoc201314(6):451.e1-e7.
27
Palit SThin NKnowles CH,et al.Diagnostic disagreement between tests of evacuatory function:a prospective study of 100 constipated patients[J].Neurogastroenterol Motil201628(10):1589-1598.
28
Tirumanisetty PPrichard DFletcher JG,et al.Normal values for assessment of anal sphincter morphology,anorectal motion,and pelvic organ prolapse with MRI in healthy women[J].Neurogastroenterol Motil201830(7):e13314.
29
Steensma ABOom DMBurger CW,et al.Assessment of posterior compartment prolapse:a comparison of evacuation proctography and 3D transperineal ultrasound[J].Colorectal Dis201012(6):533-539.
30
Regadas FSHaas EMAbbas MA,et al.Prospective multicenter trial comparing echodefecography with defecography in the assessment of anorectal dysfunction in patients with obstructed defecation[J].Dis Colon Rectum201154(6):686-692.
31
van Gruting IMA, Stankiewicz A, Kluivers K, et al.Accuracy of Four Imaging Techniques for Diagnosis of Posterior Pelvic Floor Disorders[J].Obstet Gynecol2017130(5):1017-1024.
32
Albuquerque APereira E.Current applications of transperineal ultrasound in gastroenterology[J].World J Radiol20168(4):370-377.
33
陆继红,李茜,朱红,等.超声测量膀胱尿道后角对诊断压力性尿失禁的临床价值[J].中华妇产科杂志201045(5):338-341.
34
薛雅红,丁曙晴,丁义江.动态经会阴超声评估女性慢性肛门痛盆底形态学特征[J].中华超声影像学杂志.201625(11):984-989.
35
Xue YHDing SQDing YJ,et al.Role of three-dimensional endoanal ultrasound in assessing the anal sphincter morphology of female patients with chronic proctalgia[J].World J Gastroenterol201723(21):3900-3906.
36
De Leeuw JWVierhout MEStruijk PC,et al.Anal sphincter damage after vaginal delivery:functional outcome and risk factors for fecal incontinence[J].Acta Obstet Gynecol Scand200180(9):830-834.
37
Etienney Ide Parades V.Three-dimensional endoanal ultrasonography in daily proctological practice[J].Clin Res Hepatol Gastroenterol201135(4):260-270.
38
Volløyhaug ITaithongchai AArendsen L,et al.Is endoanal,introital or transperineal ultrasound diagnosis of sphincter defects more strongly associated with anal incontinence? [J].Int Urogynecol J202031(7):1471-1478.
39
Taithongchai Avan Gruting IMAVolløyhaug I,et al.Comparing the diagnostic accuracy of 3 ultrasound modalities for diagnosing obstetric anal sphincter injuries[J].Am J Obstet Gynecol2019221(2):134.e1-134.e9.
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