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Objective@#To evaluate the diagnostic value of three-dimensional endoanal ultrasound (3D-EAUS) for dyssynergic defecation (DD).@*Methods@#A case-control study was performed to retrospectively collectclinical data of 46 DD patients, including 16 males and 30 females with median age of 51 (20 to 70) years, at Nanjing Hospital of Chinese Medicine from February 2012 to April 2015.All the patients met the diagnostic criteria of functional constipation of Rome III. The paradoxical contraction of puborectalis (PR) muscle was found by both rectal examination and anorectal manometry. In the same period,45 healthy volunteers, including 22 males and 23 females with median age of 48 (21 to 72) years, without pelvic operation history, and with normal defecation in recent 6 months, were enrolled as the control group. No significant differences were observed in age and gender between two groups (both P>0.05). Cleveland constipation score of DD group was higher than that of control group [15(8-24) vs. 5(1-9), t=15.720, P<0.001]. 3D-EAUS examination was performed in all the subjects. Thickness and length of internal anal sphincter (IAS) (anterior side and posterior side), thickness of PR muscle, length of external anal sphincter (EAS) plus PR muscle, and puborectalis angle were measured and compared by using student t test between two groups. Correlation between these ultrasound parameters and anorectal manometry was examined by Pearson correlation analysis.@*Results@#Both male and female in the DD group had the greater thickness of IAS, as compared to those in the control group [male: (1.7±0.5) mm vs.(1.5±0.2) mm, t=2.516, P=0.016; female: (1.9±0.4) mm vs.(1.6±0.5) mm, t=2.034,P=0.047]. No significant differences between the two groups were observed with respect to the posterior length of IAS, length of EAS plus PR muscle, and thickness of PR muscle (all P>0.05). Compared to the control group, male in the DD group had smaller puborectalis angle during straining [(87.0±3.6)° vs. (90.5±1.8)°,t=3.502,P=0.002];female in the DD group had smaller puborectalis angle both in resting and straining [resting:(86.5±3.8)° vs. (90.1±2.1)°,t=4.047, P<0.001;straining: (84.1±4.5)° vs. (90.2±2.3)°, t=5.938, P<0.001]. Correlation analysis showed that anterior length of IAS was positively correlated with anal resting pressure (r=0.321, P=0.030); the length of EAS plus PR muscle was positively correlated with anal squeeze pressure (r=0.415, P=0.004). There were no correlations between the thickness and the posterior length of IAS and the anal resting pressure, or between the thickness of PR muscle and the anal squeeze pressure (all P>0.05).@*Conclusions@#The 3D-EAUS can accurately assess the morphological features of anal canal in DD patients. There is a certain positive correlation between 3D-EAUS and anorectal manometry.
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Resumen El objetivo de este trabajo fue determinar los efectos del antecedente de abuso sexual y emocional, rumiación, ansiedad y depresión sobre la contracción paradójica del puborrectal. Se realizó un estudio de campo con diseño transversal en 118 pacientes. Los resultados de los análisis de regresión demuestran que el antecedente de abuso sexual predice contracción paradójica del puborrectal, depresión y rumiación, además de ejercer efecto indirecto sobre depresión y ansiedad a través de rumiación. El antecedente de abuso emocional predice mayor ansiedad y menor depresión. La rumiación predice ansiedad y depresión. Se sugiere aplicar estos resultados en la práctica y explorar en estudios ulteriores las interrogantes derivadas de este trabajo.
Abstract The objective of this research was to determine the effects of sexual and emotional abuse history, rumination, anxiety, and depression on the paradoxical contraction of the puborectalis muscle. A cross-sectional study was carried out in 118 patients. The results of regression analyses show that a history of sexual abuse predicts paradoxical contraction of the puborectalis muscle, depression, and rumination, besides having an indirect effect on depression and anxiety through rumination. A history of emotional abuse predicts greater anxiety and less depression. The article suggests that these results must be applied in practice and that subsequent studies should explore the questions deriving from this research.
Resumo O objetivo deste trabalho foi determinar os efeitos do antecedente de abuso sexual e emocional, ruminação, ansiedade e depressão sobre a contração paradoxal do puborretal. Realizou-se um estudo de campo com desenho transversal em 118 pacientes. Os resultados das análises de regressão demonstram que o antecedente de abuso sexual prevê a contração paradoxal do puborretal, depressão e ruminação, além de exercer efeito indireto sobre depressão e ansiedade através da ruminação. O antecedente de abuso emocional prevê maior ansiedade e menor depressão. A ruminação prevê ansiedade e depressão. Sugere-se aplicar esses resultados na prática e explorar as interrogantes derivadas deste trabalho em estudos posteriores.
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Objective To explore the effects of pregnancy and delivery on the anal sphincter complex (ASC) with 3D-US imaging technique.Methods Transperineal 3D-US images were obtained in 131 women,including 15 nulliparous women (nulliparous group),31 women in middle pregnancy (middle pregnancy group),31 women in late pregnancy (late pregnancy group),24 underwent cesarean section (cesarean section group) and 30 underwent natural childbirth (natural childbirth group).In the resting and anal shrinking state,external anal sphincter (EAS) thickness was measured at 3,6,9 and 12 o'clock positions at distal plane,internal anal sphincter (IAS) thickness was measured at the same four positions at proximal,middle and distal planes,and at the 4 and 8 o'clock positions,the bilateral puborectails muscle (PRM) at middle plane were measured.Results In resting state,at 12 and 9 o'clock positions on the proximal plane,and 3 and 9 o'clock positions on middle plane,the thickness of IAS of cesarean section group was thicker than those in nulliparous group and natural childbirth group (all P＜0.05).On the distal plane,the thickness of EAS at 4 positions of caesarean section group and the natural childbirth group was thinner than those in the late pregnancy group (all P＜0.05).In anal shrinking state,the thickness of IAS at 12 and 9 o'clock positions on the proximal plane,and the thickness of EAS 12 o'clock position on the distal plane,which later pregnancy and cesarean section group were thicker than those in natural children group (all P＜0.05).In resting and anal shrinking state,the thickness of left and right PRM in natural childbirth group were thinner than those in late pregnancy group and cesarean section group (all P＜0.05).In resting and anal shrinking state of nulliparous group,anal shrinking state of middle pregnancy group,and resting state of late pregnancy group,the thickness of left PRM was thicker than those of right PRM (all P＜0.05).Conclusion ASC changes occur in varying degrees in women in middle pregnancy and [ate pregnancy,also in women after cesarean section and natural childbirth.ASC thickening is a protective mechanism for women during pregnancy.
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Objective To discuss the relativity of dyschesia with the change of puborectalismuscle.Methods 68 patients with dyschesia were compared with 68 healthy volunteers at lithotomy position undergoing 3D ultrasonography on resting,contracting and maximum exertion phase respectively.Three dimensionally reconstructed images were reconstructed and pubo-rectal angle and the thickness of puborectalis muscle at 6 o'clock position were measured.Results The pubo-rectal angle of the study group and control group had no significant differences at either resting [(86 ± 8) ° vs.(86 ± 8)°] or contracting phases [(88 ± 9) ° vs.(86 ± 7) °] (t =-0.145,t =0.434,P ＞ 0.05).While at maximum exertion the differences were significant [(80 ± 6) °vs.(95 ± 5) °,t =-5.397,P ＜ 0.05].The d-value of pubo-rectal angle between maximum and resting exertion statistically different [(6 ± 3) °,(-9 ± 7) °,t =5.551,P ＜ 0.05].The thickness of puborectalis muscle between the two groups differed statistically significant only at maximum exertion phase [(4.60 ± 0.60) mm vs.(3.97 ± 0.32) mm,t =6.872,P ＜ 0.05].The d-value of the thickness of puborectalis muscle between maximum and resting exertion were statistically different (t =-11.474,P ＜ 0.05).Conclusions The pubo-rectal angle of the study group is smaller at maximum exertion than the control group.The thickness of puborectalis muscle at six o'clock (lithotomy position) in study group is larger at maximum exertion than the control group.And the severity of constipation changed with the variation of angle.
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BACKGROUND/AIMS: External anal sphincter (EAS) and puborectalis muscle (PRM) play important role in anal continence function. Based on length-tension measurement, we recently reported that the human EAS muscle operates at short sarcomere length under physiological conditions. Goal of our study was to determine if PRM also operates at the short sarcomere length. METHODS: Length-tension relationship of the PRM muscle was studied in vivo in 10 healthy nullipara women. Length was altered by vaginal distension using custom-designed probes of 5, 10, 15, 20, 25 and 30 mm diameters as well as by distending a polyethylene bag with different volumes of water. Probes were equipped with a reverse perfuse sleeve sensor to measure vaginal pressure (surrogate of PRM tension). PRM electromyogram (EMG) was recorded using wire electrodes. Three-dimensional ultra-sound images were obtained to determine effect of vaginal distension on PRM length. RESULTS: Ultrasound images demonstrate distension volume dependent increase in PRM length. Rest and squeeze pressures of vaginal bag increased with the increase in bag volume. Similarly, the change in vaginal pressure, which represents the PRM contraction increased with the increase in the probe size. Increase in probe size was not associated with an increase in EMG activity (a marker of neural drive) of the PRM. CONCLUSIONS: Probe size dependent increase in PRM contraction pressure, in the presence of constant EMG (neural input) proves that the human PRM operates at short sarcomere length. Surgically adjusting the PRM length may represent a novel strategy to improve treat anal continence and possibly other pelvic floor disorders.
Subject(s)
Female , Humans , Anal Canal , Electrodes , Fecal Incontinence , Muscles , Pelvic Floor Disorders , Polyethylene , Sarcomeres , Ultrasonography , WaterABSTRACT
Objective To investigate the measurement standards and clinical application of observing anatomical morphologies and contractile function of puborectalis muscle on pelvic floor parasagittal plane by endoluminal two-dimensional ultrasonography.Methods The thickness and thickening rate of puborectalis muscle of 78 young nulliparous women were measured on pelvic floor parasagittal plane at three levelsurethral level (anterior),vaginal level (central) and rectal level (posterior),both at rest and during contraction.And the thickening rates of these parts during contraction were compared with each other.Interclass correlation coefficients were calculated to evaluate the consistency of the datas.Results At rest,thickness of anterior part of the left was (9.23 ± 0.20)mm,and that of the right was (8.99 ± 0.20)mm.During contraction,thickness of anterior parts of bilateral puborectalis muscle were significantly thicker than that of central or posterior parts (P ＜0.05).The interclass coefficients were more than 0.93 and 0.83.Conclusions The endoluminal two-dimensional ultrasonography can be used to observe morphologies and contractile function dynamically of puborectalis on pelvic floor parasagittal plane.It is simple,reproducible and worthy of clinical promotion.