A practical ligament-based diagnostic system for cure of pelvic symptoms and prolapse.

The Integral Theory Paradigm (ITP) has a 25-year track record of successfully treating bladder/bowel/pain symptoms caused by laxity in specific ligaments, even when the prolapse is minimal. The ITP-based treatment involves ligament support and can be nonsurgical or daycare surgical. An accurate diagnostic protocol is required. The Integral Theory Diagnostic system is performed in an outpatient setting. It a step-by-step "how to" resource for clinicians who wish to learn a practical anatomical diagnostic method which can quickly and accurately identify a ligament cause for bladder/bowel/pain symptoms, and therefore, potentially cure them. The structured ITP diagnosis flow chart uses symptoms to diagnose anatomical defects. It comprises 4 related steps. The ITP is holistic, and bladder, bowel, pain symptoms co-occur. The first step, therefore, is to establish all possible symptoms for transfer to the Diagnostic Algorithm which is the second step. Because patients complain of one main symptom, other symptoms must be located by direct questioning, using the Diagnostic Algorithm as an aide memoire, or a questionnaire to locate bladder, bowel, pain symptoms. Second step: symptoms are placed into 3 anatomical zones: anterior zone, pubourethral ligament (PUL) [stress urinary incontinence (SUI)]; middle zone, cardinal ligament (CL) (transverse defect cystocele); posterior zone, uterosacral ligament (USL) (uterine prolapse and enterocele). The third step is a vaginal examination to confirm the ligament damage (prolapses) in the three zones predicted by the algorithm. The fourth step is "simulated operations" (mechanical support of specific ligaments per vaginam) to validate the particular ligament indicated by the diagnostic algorithm, is indeed causing that symptom. For SUI, a hemostat test at midurethra supports PUL vaginally to stop urine loss on coughing; the lower blade of a bivalve speculum gently inserted into the vagina can relieve urge and pain.

A brief physiology and pathophysiology of the anorectum based on the Integral Theory paradigm.

The remit of this review is confined to the experimental scientific works and surgeries based on the Integral Theory paradigm. The video abstract summarizes the anorectal function, how ligaments cause dysfunction and cure of fecal incontinence and obstructed defecation by ligament repair. Anorectal function is reflex and binary, with cortical and peripheral components. The same three oppositely acting reflex muscle forces which open and close the bladder, contract against the pubourethral (PUL) and uterosacral (USL) ligaments: (I) to close the anorectum for continence when the puborectalis muscle (PRM) contracts forwards; (II) to open the anorectum prior to evacuation when the PRM relaxes; (III) to stretch the rectum in opposite directions to support the anorectal stretch receptors "N" to prevent premature activation of the defecation reflex, (fecal urgency). Weak or loose PULs or USLs may cause dysfunction of closure, of evacuation, and inability to control the defecation reflex (fecal urgency). Repair of the PUL and USL can improve or cure these dysfunctions. The perineal body (PB) acts as an anatomical support for the distal vagina, anorectum and external anal sphincter (EAS). It serves as an anchoring point for the forward action of the pubococcygeus muscle (PCM), which tensions the anterior rectal wall during closure and defecation. Bladder and bowel dysfunction have a similar pathogenesis, ligament laxity, mainly pubourethral and uterosacral, with added PB damage for anorectal dysfunction. PB damage can cause obstructive defecation and descending perineal syndrome (DPS). Repair of damaged PUL and USL can restore the closure and evacuation functions of both bladder an anorectum. DPS can be cured by repair of the PB's suspensory ligaments, deep transversus perinei.

Acupuncture Versus Biofeedback for Treatment of Functional Anorectal Pain.

BACKGROUND/AIMS: Functional anorectal pain is one of several types of functional anorectal disorders. In this study, we compared the effectiveness of acupuncture (intervention) and biofeedback (control) as treatment for patients with functional anorectal pain. MATERIALS AND METHODS: This prospective, single-center, randomized, and comparative study examined 68 patients with functional anorectal pain who were recruited from June 2017 to January 2019 at the Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine. Patients were randomly assigned to receive acupuncture or biofeedback. Patients in the acupuncture group received acupuncture at Zhongliao (BL33), Xialiao (BL34), Ganshu (BL18), Shenshu (BL23), and Dachangshu (BL25). Patients in the biofeedback group received pelvic floor biofeedback therapy, consisting of Kegel pelvic floor muscle training and electrical stimulation. Patients in both groups received 20 treatments over 4 weeks. The primary outcome was pain score on a visual analog scale, and the secondary outcomes were results from the MOS 36-item short-form health survey (SF-36) quality of life questionnaire, the self-rating depression scale, and the self-rating anxiety scale. RESULTS: Visual analog scale pain scores significantly decreased in both of the groups with treatment (both P < .01). The final visual analog scale score was significantly lower in patients with pelvic floor dyssynergia who were treated with biofeedback (1.40 ± 0.97 vs. 5.30 ± 1.70) (P < .05). The 2 groups had similar decreases in self-rating depression scale and self-rating anxiety scale scores. Intriguingly, the acupuncture group had better mental health outcomes (P <.05). CONCLUSION: Both acupuncture and biofeedback therapy reduced the pain of patients with functional anorectal pain. Biofeedback provided more relief in patients with pelvic floor dyssynergia, and acupuncture provided greater improvements in mental health status.

[Symptom distribution of female pelvic floor dysfunction patients with constipation as chief complaint].

OBJECTIVE: To observe the multiple symptom distribution, severity and quality of life of female pelvic floor dysfunction(FPFD) patients with constipation as chief complaint. METHODS: One hundred FPFD patients with constipation as chief complaint from Speciaty Outpatient Clinic, Pelvic Floor Center of Nanjing Municipal Hospital of Traditional Chinese Medicine between September 2015 and February 2017 were retrospectively enrolled in this study. A comprehensive medical history questionnaire survey and systematical evaluation of severity and quality of life of these patients with constipation was conducted. Constipation scoring system scale (CSS) and patient-assessment of constipation quality of life questionnaire (PAC-QOL) were applied to evaluate the constipation. Other scales included: (1)pain visual analogue scale (VAS) and short form-36 questionnaire (SF-36): if combined with chronic functional anal rectal pain; (2) international consultation on incontinence questionnaire-short form (ICIQ-SF) and urinary incontinence quality of life questionnaires (I-QOL):if combined with urinary incontinence; (3) fecal incontinence severity score scale (Wexner-FIS) and fecal incontinence quality of life questionnaire (FI-QOL):if combined with fecal incontinence. RESULTS: The mean age of 100 FPFD patients was (57.9±13.9) (24-89) years and the mean disease course was (7.0±8.2)(0.5-40.0) years. Seventy-five cases (75%) were complicated with anal pain, 70 with urinary incontinence, 37 with rectocele, 19 with nocturia, 11 with urinary frequency, 10 with defecation incontinence. Complication with only one symptom was observed in 20 cases (20%), and with two or more symptoms was observed in 80 cases (80%). Pelvic floor relaxation syndrome patients were dominant (58 cases, 58%). The severity of constipation (CSS) was 6-22 (13.89±3.79) points and the quality of life (PAC-QOL) was 45-133 (87.13±18.57) points in FPFD patients. VAS and SF-36 of patients combined with chronic functional anal rectal pain were 1-8 (3.0±1.9) points and 14.4-137.0(71.5±31.4) points respectively. ICIQ-SF and I-QOL of patients combined with urinary incontinence were 1-17 (6.1±3.6) points and 52-110 (90.0±15.8) points respectively. Wexner-FIS and FI-QOL of patients combined with fecal incontinence were 1-11 (4.4±3.0) points and 52-116 (83.4±23.3) points respectively. CONCLUSIONS: The symptoms of FPFD patients with constipation as chief complaint are complex. They are mainly complicated with anal diseases, then urinary incontinence, and mostly with more than 2 symptoms. Their quality of life is poor.

[Pelvic floor biofeedback therapy in pelvic floor diseases].

Pelvic floor biofeedback therapy is safe and effective in chronic constipation, urinary incontinence, fecal incontinence and pelvic floor pain whereas the heterogeneous indication affects the efficacy evaluation and technical communication. The best indications are as follows: (1) Pelvic floor myogenic dysfunction without severe pelvic organ prolapse and severe neurogenic defect; (2) Patients have good mental cognition and treatment adherence who fulfill the training with the therapist. The training protocol is conducted at hospital or at home, and is as follows: (1) To help patients to target the pelvic floor muscles; (2) To improve the type I( muscle tonic contraction variability; (3) To improve the pelvic floor type I( and type II( muscles activity coordination; (4) To enhance the pelvic floor muscle strength and rectum defecation awareness. The biofeedback efficacy is evaluated with different symptoms, questionnaire score, patient satisfaction recognition and long-term outcomes. Pelvic floor biofeedback therapy will be highlighted and extended to the primary care in near future following the pragmatic randomized controlled clinical trials, collection and analysis of big data.

Role of three-dimensional endoanal ultrasound in assessing the anal sphincter morphology of female patients with chronic proctalgia.

AIM: To assess the role of three-dimensional endoanal ultrasound (3D-EAUS) for morphological assessment of the anal sphincter of female patients with chronic proctalgia (CP). METHODS: In this unmatched case control study, 30 consecutive female patients with CP and 25 normal women (control group) were enrolled. 3D-EAUS was performed in all subjects. Thickness and length of internal anal sphincter (IAS), thickness of puborectalis muscle (PR), length of the external anal sphincter (EAS) plus PR, and puborectalis angle were measured and compared between the two groups. RESULTS: Patients with CP had significantly shorter IAS length and greater PR thickness, as compared to those in normal individuals (26.28 ± 3.59 mm vs 28.87 ± 4.84 mm, P < 0.05 and 9.67 ± 1.57 mm vs 8.85 ± 0.97 mm, P < 0.05, respectively). No significant between-group differences were observed with respect to IAS thickness and the EAS plus PR length (P > 0.05). Puborectalis angle in the CP group was significantly decreased, both in resting (88.23° ± 1.81° vs 89.94° ± 2.07° in control group, P < 0.05) and straining (88.47° ± 3.32° vs 90.72° ± 1.87° in control group, P < 0.05) phases, which suggest the presence of paradoxical contraction of PR in patients with CP. In the CP group, no significant difference in puborectalis angle was observed between the resting and straining phases (88.23° ± 1.81° vs 88.47° ± 3.32° respectively, P > 0.05). CONCLUSION: The association of greater PR thickness and paradoxical contraction of PR with CP suggest their potential value as markers of CP.

[Research on the Angle and Effective Depth of Deep Acupuncture at Baliao Points by Three-dimensional Reconstruction of Computed Tomography].

OBJECTIVE: To explore the needle insertion parameters of deep acupuncture at Baliao points for clinic and teaching. METHODS: A retrospective analysis of 100 cases of prone pelvic CT from January to June 2016 in Nanjing Hospital was carried out. The 3 D images were scanned with continuous 5 mm slice thickness. The optimum needle angle is defined as the angle of the needle along the central axis of sacral anterior and posterior hole, and the angle between the needle body and the skin surface and the center line of the body was observed. The effect needle depth is defined as the thickness of the sacral back soft tissue plus 1/2 sacral depth, to observe the best needle angle of deep acupuncture parameters of Baliao points. RESULTS: For deep acupuncture at Baliao, the oblique thorn method should be used with the needle-point toward the inner bottom. The best insertion angle between needle body and skin surface is: Shangliao(BL 31) (61.04±12.15)°ï¼Œ Ciliao(BL 32) (57.57±10.01)°ï¼Œ Zhongliao(BL 33) (58.25±8.69)°ï¼Œ Xialiao(BL 34) (54.39±10.94)°. The optimum angle of insertion between the needle body and the posterior midline of the human body is: BL 31 (24.54±6.21)°ï¼Œ BL 32 (18.58±7.76)°ï¼Œ BL 33 (17.36±7.90)°ï¼Œ BL 34 (30.73±9.45)°. The effective insertion depth show a decreasing trend: BL 31 (58.16±12.43) mm, BL 32 (44.57±11.55) mm, BL 33 (33.96±10.74) mm, BL 34 (31.13±10.94) mm. The effective depth is positively correlated with BMI, and has no correlation with gender and weight. CONCLUSIONS: The study of the parameters of needle insertion should be taken into account both clinical efficacy and safety, and CT three-dimensional reconstruction can accurately, rationally and scientifically perform acupoint anatomical measurements.

[Value of anorectal manometry in defecation disorders and its clinical interpretation].

Bowel dysfunction affected by functional factors, mechanical factors or surgical damage may lead to constipation, fecal incontinence and other overlapped symptoms, which is only the tip of the iceberg. Anorectal manometry can provide combined dysfunction information of four subtypes, including sphincter dysfunction, dyssynergic defecation, sensory disability and insufficient rectal expel force, which are underlying pathophysiology of defecation dysfunction. Anorectal manometry can be helpful in optimizing protocol or predicting success in pelvic floor dyssynergic syndrome of defecation, fecal incontinence or anorectal pain, stoma closure and pediatric intractable constipation. Interpretation of manometry parameter or data must consider the age, sex, symptoms, digital rectal examination, pelvic floor radiology(ultrasound, MR and defecography), physiology (pelvic floor sEMG and evoked potential testing) and psychology, in order to perform comprehensive assessment.

[Efficacy analysis of acupuncture with biofeedback in the treatment of patients with functional anorectal pain].

OBJECTIVE: To observe the short- and long-term efficacy of acupuncture combined with biofeedback in the treatment of functional anorectal pain (FARP). METHODS: Clinical data of 142 patients who met the functional gastrointestinal disorders and functional anorectal pain based on criteria of Rome III( undergoing acupuncture with biofeedback therapy from August 2010 to November 2015 in Pelvic Floor Center of The Third Affiliated Hospital of Nanjing University of Chinese Medicine were retrospectively analyzed. Telephone and outpatient clinic recheck were used as standard follow-up. The clinical effect of short-term and long-term data collected from the disease-based database was evaluated with visual analogue pain scale (VAS) (0-10 points), short form health survey questionnaire (SF-36) (0-148 points). The overall satisfaction and effectiveness (VAS was >30%) were evaluated at the end of treatment (short-term) and during follow-up (long-term). RESULTS: The effective follow-up data were obtained from 71.1%(101/142) of patients and the median follow-up time was 28(3-67) months. The VAS of 101 cases was 6.09±1.78, 1.99±1.89 and 3.55±2.60 before treatment, at the end of treatment and during follow-up respectively. Though the VAS during follow-up was higher than that at the end of treatment, but still significantly lower than that before treatment(P<0.05). The SF-36 score of 31 patients was 82.0±16.9, 94.0±15.1 and 88.1±15.3 before treatment, at the end of treatment and during follow-up respectively. Though the SF-36 score during follow-up was lower compared to at the end of treatment, but still significantly higher compared to before treatment (P<0.05). The effective rates were 85.9%(122/142) at the end of treatment and 75.2%(76/101) during follow-up, and the satisfactory rates were 92.3%(131/142) and 84.2%(85/101), respectively. CONCLUSION: Acupuncture with biofeedback has significant short-term and long-term efficacy in treating functional anorectal pain, and its degree of satisfaction is high.

[Variation of Locations of Baliao Acupoints in 290 Volunteer Subjects Analyzed by Using Computed Tomography-aided Three-dimensional Reconstruction Technique].

OBJECTIVE: To observe the variation of sacral vertebrates and foramen involving the bilateral Shangliao (BL 31), Ciliao (BL 32), Zhongliao (BL 33) and Xialiao (BL 34, Baliao acupoints), so as to provide an anatomic basis of acupoint needling in clinical practice. METHODS: A total of 290 patients[161 men and 129 women, mean age and standard devia-tion, (63.6±13.3)years old and (59.5±13.3) years old, respectively] with intact pelvic structure were recruited in the present study. Computed tomography (CT) scans of intact pelves were taken using a SOMATOM Definition AS 128 and the acquired signals were imported into Siemens Syngo Inspace platform for 3 D reconstruction, followed by identification, classification and analysis of the variation of sacral foramen (Baliao acupoint). RESULTS: The total variation rate of posterior sacral foramen (Baliao acupoint) was 20.34%(59/290). The detected three types of variation were sacral vertebrae number variation (4 sacral vertebraes, 6 sacral vertebraes), fusion variant (lumbosacral fusion, sacrococcygeal fusion, lumbosacral & sacrococcygeal fusion, and lumbosacral fusion & S 4 variation) and mixed type. CONCLUSIONS: Variations of sacral vertebrae including the number and fusion exist in the human body, suggesting an increase of the difficulty of acupoint needling. Since posterior iliac spine does not change generally, it is recommended to be used as a reference point for locating the Baliao acupoint.

[Development of Researches on the Underlying Mechanism of Acupuncture Stimulation of Baliao-points for Improving Outlet Obstruction Constipation].

Outlet obstruction constipation (OOC) is a common clinical problem affecting many people's daily life quality nowadays. Acupuncture therapy is effective in easing OOC to reduce patients' sufferings by stimulation of Baliao-points i. e., bilateral Shangliao (BL 31), Ciliao (BL 32), Zhongliao (BL 33) and Xialiao (BL 34), which has been confirmed repeatedly in clinical practice. In the present paper, the authors reviewed development of studies on the underlying mechanisms of acupuncture stimulation of Baliao-points for OOC from: 1) lowering the sensitivity of intraganglionic laminar nerve endings (rIGLEs) to rectal mechanical distension during defecation, 2) raising the level of circulating cholecystokinin (CCK) to improve the sensory threshold of the rectum, 3) lowering the excitability of γ-motor neurons in the spinal anterior horns controlling the slow contraction of the rectal sphincter muscle, 4) inhibiting the excitability of sympathetic output from the spinal lateral horns, 5) easing the tonic contraction of the pelvic muscles to reduce the release of 5-hydroxy tryptamine (5-HT), histamine, and other related chemical mediators due to local ischemia. Moreover, further study on the mechanism of acupuncture stimulation of Baliao-points underlying improving OOC may help up find more specific and effective therapeutic targets and provide more reliable experimental foundation and theoretical basis.

[Thinking on current treatment situation of acupuncture foe functional defecation disorders].

In order to optimize acupuncture treatment protocol for functional defecation disorders, literature during past 20 years is reviewed, and factors which influences acupuncture therapeutic effect are analyzed from aspects of acupoint, acupuncture technique, etc. As for the selection of acupoint, more attention should be paid on the use of Baliao, especially Zhongliao (BL 33) and Xialiao (BL 34); when Baliao is deeply needled, it is essential to acquire scientific technique. The relationship between acupuncture parameter (including electroacupuncture waveform and frequency), acupuncture techniques (including reinforcing and reducing technique, quantity of stimulation, etc. ) and acupuncture efficacy is complicated, and the scientific values of present research conclusion are in need, of further improvement. The diagnosis and treatment awareness on types of functional defecation should be strengthened, and the mental health of the constipation patients should be concerned. The combination of acupuncture and biofeedback training can have a synergistic effect, which is benefit to achieve a better long-term effect. Based on this, acupuncture treatment protocol for functional defecation disorders can be optimized to further improve the efficacy.

[Pay attention to the functional protection during operation for benign anal diseases].

Benign anorectal diseases are common. Hemorrhoids, anal fissure and anal fistula are the top three of colorectal surgery for benign anrorectal clinical practice. Postoperative fecal incontinence or stool seepage has not yet got enough attention by specialists. This article elaborates on the clinical status, evaluation process, functional protection and treatment strategies etc. Following the continence protection principle requires specialists to focus on not only the disease itself but the patient-centered quality of life.

[Comparison of two-dimensional ultrasound and three-dimensional endoanal ultrasound in the diagnosis of perianal fistula].

OBJECTIVE: To compare the accuracy of two-dimensional endoanal ultrasound (2D-EAUS) and three-dimensional endoanal ultrasound (3D-EAUS) in the diagnosis of perianal fistulas. METHODS: Image data of 47 perianal fistula patients undergoing surgery in our department between January 2012 and December 2012 were collected. All the patients underwent 2D-EAUS and 3D-EAUS, and the results were compared to intraoperative findings (gold standard) by kappa concordance test. RESULTS: Both 2D-EAUS and 3D-EAUS showed good concordance with intraoperative findings in internal opening (kappa: 0.776 vs. 0.636). 3D-EAUS had better concordance with intraoperative finding in the diagnosis of intersphincteric, high transsphincteric and suprasphincteric fistulas as compared to 2D-EAUS (kappa: 0.810 vs. 0.592, kappa: 0.863 vs. 0.548, kappa: 1.000 vs. 0.672). 3D-EAUS showed better concordance with intraoperative findings in secondary tract compared to 2D-EAUS(kappa: 0.659 vs. 0.535). Both 2D-EAUS and 3D-EAUS had good concordance with intraoperative findings in complicated abscesses (kappa: 0.881 vs. 0.816). CONCLUSION: 3D-EAUS can show the relationship of fistula with anal sphincter, especially in diagnosing high fistula and fistula with secondary tracts, and has a higher diagnostic accuracy than 2D-EAUS.

[Observation on effect characteristics of electroacupuncture for different types of functional constipation].

OBJECTIVE: To explore the differences of electroacupuncture (EA) on onset time and symptom improvement for treatment of different types of functional constipation. METHODS: Thirty-eight cases of constipation were selected, including 9 cases of constipation-predominant irritable bowel syndrome (IBS-C), 10 cases of slow transit constipation (STC), 10 cases of pelvic floor dyssynergia (PFD) and 9 cases of inadequate defecatory propulsion (IDP). The electroacupuncture was applied at Tianshu (ST 25), Fujie (SP 14), Shenshu (BL 23), Dachangshu (BL 25) and so on in abdominal and lumbosacral area, 5 times per week, 10 times as a treatment course. The onset time, score of clinical symptoms of constipation and improvement of every symptom in each group were compared. RESULTS: (1) The onset time was (1.78 +/- 0.83) days in IBS-C type, (3.11 +/- 1.90) days in IDP type, (4.10 +/- 1.85) days in STC type and (4.30 +/- 2.00) days in PFD type, indicating statistical differences between IBS-C type and STC type, IBS-C type and PFD type (both P < 0.05). (2) Compared before the treatment, the total scores of symptoms on the onset day in each group were all improved (P < 0.05, P < 0.01), and score of IBS-C type was superior to the rest 3 types (P < 0.05, P < 0.01). (3) EA improved desire to defecate or frequency of defecation in each type (P < 0.05, P < 0.01), in which both were improved in STC type and PFD type, and the improvement of defecation frequency was more significant in STC type (P < 0.01). EA relieved unsmooth defecation or pendant-expansion feeling in each type (all P < 0.05), in which both were improved in IBS-C type (both P < 0.05). EA relieved abdominal distension and pain in IBS-C type, STC type and PFD type (all P < 0.05), while its effects were not obvious on defecation difficulty, defecation time and defecation texture (all P > 0.05). CONCLUSION: The electroacupuncture for treatment of 4 types of constipation is characterized by rapid onset; the improved symptoms are not identical in the electroacupuncture treatment plan for each type of defecation; the main improvement of symptoms are lied on desire to defecate and frequency of defecation, unsmooth defecation or pendant-expansion feeling and abdominal distension and pain. Meanwhile the improvements of defecation texture, defecation difficulty and defecation time were not signi-ficant.

[Dynamic three-dimensional ultrasound study on levator ani muscle fissures for female pelvic floor relaxation syndrome].

OBJECTIVE: To explore the value of dynamic three-dimensional ultrasound in detecting the levator ani muscle fissures morphological changes of female pelvic floor relaxation syndrome after biofeedback and acupuncture treatments. METHODS: Forty female constipation patients with pelvic floor relaxation syndrome were screened from the Constipation Designed Disease Clinic in our hospital between October 2011 and September 2012. Cleveland Constipation Score (CCS) scale was used. Anteroposterior and transverse diameters of the levator ani muscle fissures were measured by dynamic three-dimensional ultrasound in Valsalva maneuver. After a course (10 days) of biofeedback and acupuncture treatments, CCS scale was filled, and dynamic three-dimensional ultrasound was performed in Valsalva maneuver as well. Associated data before and after treatment were compared. RESULTS: Twenty-five patients completed the trial. As compared to pre-treatment, the longitudinal axes of levator ani muscle fissure [(4.89±0.89) cm vs. (5.13±0.82) cm, P<0.01], the horizontal axes of the levator ani muscle fissure [(4.62±0.75) cm vs. (4.86±0.74) cm, P<0.01], and the area of the levator ani muscle fissure [(18.16±6.42) cm(2) vs. (19.92±6.33) cm(2), P<0.01] decreased significantly after treatment, while CCS scale (9.52±2.50 vs. 15.80±3.42, P<0.01) declined significantly as well. CONCLUSIONS: The dynamic three-dimensional ultrasound is an effective, simple and non-invasive method for the determination of levator ani muscle fissure in female patients with pelvic floor relaxation syndrome.

[Study on the measurement and locating of Baliao points (eight sacral foramina)].

OBJECTIVE: To seek the problems of position, measuring and locating methods of Baliao points (posterior sacral foramina) in modern researches. METHODS: Using Baliao (eight sacral foramina), Shangliao(BL 31), Ciliao(BL 32), Zhongliao(BL 33), Xialiao(BL 34), Dihoukong (posterior sacral foramina), Dikong (sacral foramina) and Digu(sacrum) as the key words, literature in the database of the CNKI from 1957 to 2012 were re trieved and analyzed. RESULTS: Problems were found in the past researches including limited numbers of relative literature, disunity of the measurement targets, complicated terms of indices, disunity of the starting and ending point of measurement, unclear weight of indices, deviation of results, lacking of combination with clinical practice and variety of locating methods. CONCLUSION: Position of Baliao points (eight sacral foramina) are clear. However, the locating methods are blurred and vary a lot. Study on living body has more significance for measurement and researches. Factors of gender, body weight, height and childbearing should also be taken into consideration. Therefore, it is necessary to find a more accurate and easier way of locating.

[A multi-center, randomized, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in the treatment of anal fissure].

OBJECTIVE: To evaluate the clinical efficacy and safety of glyceryl trinitrate (GTN) ointment in the treatment of anal fissure. METHODS: In this multi-center, randomized, double-blind and placebo-controlled trial, 240 chronic anal fissure patients from 7 clinical centers were randomized to receive eight-week treatment with GTN ointment (treatment group) or vaseline ointment (control group) respectively. Healing rate, visual analogue score (VAS), maximum anal resting pressure (MARP) and adverse reactions were recorded and compared. RESULTS: A total of 221 patients (92.1%) finished the trial, including 114 patients in treatment group (95.0%, 114/120) and 107 in control group (89.2%, 107/120). At the endpoint of treatment (56 d), 90 patients in treatment group (78.9%, 90/114) healed completely compared to 31 patients in control group (29.0%, 31/107), and decrease rates of VAS in the two groups were (94.8±15.7)% and (61.2±35.7)% respectively, both differences were statistically significant (P<0.01). MARP after first administration was (20.2±18.5) mm Hg in treatment group (n=12) and (7.1±14.7) mm Hg in control group (n=6), which was not significantly different (P=0.152). Adverse reaction incidence was higher in treatment group (42.1% vs. 9.3%, P<0.05), while these adverse reactions were mainly headache and fullness in head, which were self-limiting. CONCLUSION: GTN ointment can effectively promote healing and relieve pain in anal fissure with safety and tolerance.

[Dynamic three-dimensional ultrasound in the diagnosis of pelvic floor dyssynergia].

OBJECTIVE: To explore the feasibility of dynamic three-dimensional ultrasound measurement in the diagnosis of pelvic floor dyssynergia(PFD). METHODS: Thirty female patients with PFD received dynamic three-dimensional ultrasound. The differences in angle α measured by transperineal three-dimensional ultrasound, and angle ß, angle γ, and H line as measured by transanorectal three-dimensional ultrasound were compared between resting state and Valsalva maneuver. In addition, the detective rate of PFD by different parameters was analyzed. RESULTS: In 30 patients, rectocele was found in 13 cases(43.3%), rectal internal mucous intussusception in 14 cases(46.7%), uterine prolapse in 11 cases(36.7%), and bladder prolapse in 1 case(3.3%). Compared with the resting state, α, ß and H decreased obviously, but γ increased apparently in Valsalva maneuver, and differences of these parameters were statistically significant(all P<0.01). Detective rates of PFD for parameters of α, ß, γ and H were 93.3%(28/30), 96.7%(29/30), 96.7%(29/30) and 86.7%(26/30), respectively. CONCLUSION: Measurements of α, ß, γ and H can provide feasible indicators for clinical diagnosis of PFD.