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Cowley D, Stafford RE, Worman RS, Hodges PW. Pelvic floor muscle length changes with breathing in males: A preliminary report. Respir Physiol Neurobiol 2023; 316:104117. [PMID: 37516287 DOI: 10.1016/j.resp.2023.104117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 07/31/2023]
Abstract
The study aimed to identify whether pelvic floor muscles modulate length with breathing, and if any length changes induced by breathing relate to abdominal cavity displacement and intra-abdominal pressure. To investigate these relationships, displacement of pelvic landmarks that related to pelvic floor muscle length using transperineal ultrasound imaging, breath volume, intra-abdominal pressure, abdominal and ribcage displacement, and abdominal and anal sphincter muscle electromyography were measured during quiet breathing and breathing with increased dead-space in ten healthy men. Pelvic floor muscle landmark displacement modulated with ribcage motion during breathing. This relationship was stronger for: i) motion of the urethrovesical junction (puborectalis muscle length change) than the mid-urethra landmark (striated urethral sphincter muscle length change), and ii) dead-space breathing in standing than dead-space breathing in supine or quiet breathing in standing. In most (but not all) participants, the urethrovesical junction descended during inspiration and elevated during expiration. Striated urethral sphincter length changes during the respiratory cycle was independent of intra-abdominal pressure. In summary, breathing involves pelvic floor muscle length changes and is consistent with the role of these muscles during respiration to aid maintenance of continence, lung ventilation and/or provision of support to the abdominal cavity. Clinicians who train pelvic floor muscles need to be aware that length change of pelvic floor muscles is expected with breathing.
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Affiliation(s)
- David Cowley
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia
| | - Ryan E Stafford
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia
| | - Rachel S Worman
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia
| | - Paul W Hodges
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia.
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Cernat C, Das S, Hendriks GAGM, Noort FVD, Manzini C, van der Vaart CH, de Korte CL. Tissue Characterization of Puborectalis Muscle From 3-D Ultrasound. Ultrasound Med Biol 2023; 49:527-538. [PMID: 36376156 DOI: 10.1016/j.ultrasmedbio.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 09/27/2022] [Accepted: 10/03/2022] [Indexed: 06/16/2023]
Abstract
Pelvic floor (PF) muscles have the role of preventing pelvic organ descent. The puborectalis muscle (PRM), which is one of the female PF muscles, can be damaged during child delivery. This damage can potentially cause irreversible muscle trauma and even lead to an avulsion, which is disconnection of the muscle from its insertion point, the pubic bone. Ultrasound imaging allows diagnosis of such trauma based on comparison of geometric features of a damaged muscle with the geometric features of a healthy muscle. Although avulsion, which is considered severe damage, can be diagnosed, microdamage within the muscle itself leading to structural changes cannot be diagnosed by visual inspection through imaging only. Therefore, we developed a quantitative ultrasound tissue characterization method to obtain information on the state of the tissue of the PRM and the presence of microdamage in avulsed PRMs. The muscle was segmented as the region of interest (ROI) and further subdivided into six regions of interest (sub-ROIs). Mean echogenicity, entropy and shape parameter of the statistical distribution of gray values were analyzed on two of these sub-ROIs nearest to the bone. The regions nearest to the bones are also the most likely regions to exhibit damage in case of disconnection or avulsion. This analysis was performed for both the muscle at rest and the muscle in contraction. We found that, for PRMs with unilateral avulsion compared with undamaged PRMs, the mean echogenicity (p = 0.02) and shape parameter (p < 0.01) were higher, whereas the entropy was lower (p < 0.01). This method might be applicable to quantification of PRM damage within the muscle.
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Affiliation(s)
- Catalin Cernat
- Medical Ultrasound Imaging Center (MUSIC), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Shreya Das
- Medical Ultrasound Imaging Center (MUSIC), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gijs A G M Hendriks
- Medical Ultrasound Imaging Center (MUSIC), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frieda van den Noort
- Robotics and Mechatronics, Technical Medical Center, University of Twente, Enschede, The Netherlands
| | - Claudia Manzini
- Department of Reproductive Medicine and Gynecology, University Medical Center, Utrecht, The Netherlands
| | - C Huub van der Vaart
- Department of Reproductive Medicine and Gynecology, University Medical Center, Utrecht, The Netherlands
| | - Chris L de Korte
- Medical Ultrasound Imaging Center (MUSIC), Radboud University Medical Center, Nijmegen, The Netherlands; Physics of Fluids, Technical Medical Centre, University of Twente, Enschede, The Netherlands.
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Alketbi MSG, Meyer J, Robert-Yap J, Scarpa R, Gialamas E, Abbassi Z, Balaphas A, Buchs N, Roche B, Ris F. Levator ani and puborectalis muscle rupture: diagnosis and repair for perineal instability. Tech Coloproctol 2021; 25:923-933. [PMID: 33745102 DOI: 10.1007/s10151-020-02392-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 12/20/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Puborectalis muscle rupture usually arises from peri-partum perineal trauma and may result in anterior, middle compartment prolapses, posterior compartment prolapse which includes rectocele and rectal prolapse, with or without associated anal sphincter damage. Patients with puborectalis muscle and levator ani rupture may present some form of incontinence or evacuation disorder, sexual dysfunction or pelvic organ descent. However, the literature on this subject is scarce. The aim of our study was to evaluate management and treatment of functional disorders associated with puborectalis and/or pubococcygei rupture at the level of the insertion in the pubis in a cohort of patients referred to a tertiary care coloproctology center. METHODS We conducted a prospective cohort study of patients with levator ani and puborectalis muscle avulsion in the Proctology and Pelvic Floor Unit, Division of Digestive Surgery of the University Hospitals of Geneva from January 2001 to November 2018. Clinical examination, anoscopy and ultrasound were performed on a routine basis. Rupture of the levator ani muscle was diagnosed by clinical examination and ultrasound. A Wexner incontinence score was completed before and 6 months after surgery. Levator ani muscle repair was performed using a transvaginal approach. RESULTS Fifty-two female patients (median age 56 ± 11.69 SD years, range 38-86 years) were included in the study. Thirty-one patients (59.6%) had anal incontinence, 25 (48.1%) urinary incontinence, 28 (53.9%) dyschezia (obstructive defecation or excessive straining to defecate), 20 (38.5%) dyspareunia, 17 (32.7%) colpophony, and 13 (25.0%) impaired sensation during sexual intercourse. Deviation of the anus on the side opposite the lesion was observed in 50 patients (96.2%), confirmed with clinical examination and both endoanal and perineal ultrasound. Out of these 52 patients, levator ani rupture (including puborectalis rupture) were categorized into right sided, 43 (82.69%), left sided, 7 (13.46%) and bilateral, 2 (3.85%). Levator ani muscle repair was performed in all patients, associated with posterior repair and levatorplasty in 26 patients (50%) and with sphincteroplasty in 34 patients (63.4%). Four patients (7.7%) experienced postoperative complications: significant postoperative pain (n = 3; 5.77%), urinary retention (n = 2; 3.85%), hematoma (n = 1; 1.92%), and perineal abscess (n = 1; 1.92%). Forty-one patients (78.8%) had full restoration of normal puborectalis muscle function (Wexner score: 0/20) after surgery, and overall, all patients had an improvement in the Wexner score and in sexual function. Dyschezia was reported by 28 patients (53.9%) preoperatively, resolved in 18 (64.3%) and improved by 50% or more in 10 (35.71%). CONCLUSIONS Diagnosis of levator ani and puborectalis muscle rupture requires careful history taking, clinical examination, endoanal and perineal ultrasound. Surgical repair improved anal continence as well as sexual function in all patients. Transvaginal levator ani repair seems to be well tolerated with good short-term results.
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Affiliation(s)
- M S Gh Alketbi
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland.
| | - J Meyer
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - J Robert-Yap
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - R Scarpa
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - E Gialamas
- Division of Digestive Surgery, Neuchâtel Hospital, Neuchâtel, Switzerland
| | - Z Abbassi
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - A Balaphas
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - N Buchs
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - B Roche
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - F Ris
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
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Das S, Hansen HHG, Hendriks GAGM, van den Noort F, Manzini C, van der Vaart CH, de Korte CL. 3D Ultrasound Strain Imaging of Puborectalis Muscle. Ultrasound Med Biol 2021; 47:569-581. [PMID: 33358339 DOI: 10.1016/j.ultrasmedbio.2020.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 11/09/2020] [Accepted: 11/17/2020] [Indexed: 05/15/2023]
Abstract
The female pelvic floor (PF) muscles provide support to the pelvic organs. During delivery, some of these muscles have to stretch up to three times their original length to allow passage of the baby, leading frequently to damage and consequently later-life PF dysfunction (PFD). Three-dimensional (3D) ultrasound (US) imaging can be used to image these muscles and to diagnose the damage by assessing quantitative, geometric and functional information of the muscles through strain imaging. In this study we developed 3D US strain imaging of the PF muscles and explored its application to the puborectalis muscle (PRM), which is one of the major PF muscles.
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Affiliation(s)
- Shreya Das
- Medical Ultrasound Imaging Center, Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Hendrik H G Hansen
- Medical Ultrasound Imaging Center, Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gijs A G M Hendriks
- Medical Ultrasound Imaging Center, Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frieda van den Noort
- Robotics and Mechatronics, Faculty of Electrical Engineering, Mathematics and Computer Science, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Claudia Manzini
- Department of Reproductive Medicine and Gynecology, University Medical Center, Utrecht, The Netherlands
| | - C Huub van der Vaart
- Department of Reproductive Medicine and Gynecology, University Medical Center, Utrecht, The Netherlands
| | - Chris L de Korte
- Medical Ultrasound Imaging Center, Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands; Physics of Fluids, MIRA, University of Twente, Enschede, The Netherlands
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Jarboe M, Ladino-Torres M, Wild L, Spremo D, Elkins S, Ladouceur R, Nagy D, Ehrlich P, Ralls M. Imaged-guided and muscle sparing laparoscopic anorectoplasty using real-time magnetic resonance imaging. Pediatr Surg Int 2020; 36:1255-1260. [PMID: 32638078 DOI: 10.1007/s00383-020-04700-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2020] [Indexed: 11/25/2022]
Abstract
A challenge when repairing imperforate anus is positioning the neo-rectum into the center of the sphincter muscle complex (SMC) with limited muscle injury and scarring. Unfortunately, the path through the components of the SMC are often non-linear. We have used MRI to delineate the complex and guide the needle through the center using standard MRI-guidance (Raschbaum GR et al. J Pediatr Surg 45:220-223, 2010; Thomas TT et al. J Pediatr Surg 35:927-930, 2000). However, asynchronous scanning requires multiple, time-consuming scans to advance the needle in stepwise fashion. Asynchronous scanning also prevents visualizing the needle as it is advanced. We recently integrated software into the MRI operative suite that allows placement of the needle with real-time MRI. We report the feasibility and utility of real-time MRI-assisted laparoscopic assisted anorectoplasty (RT MRI-LAARP). Needle guidance was performed with Siemens Espree 1.5 T MRI with T1 Flash RT Sequence. After needle placement, laparoscopic mobilization, fistula takedown and pull-through was performed using the needle to guide dilation to create a tract to pull-through the neo-rectum. Charts of patients who underwent RT MRI-LAARP were reviewed. Demographics, anatomy, number of needle passes, OR duration and complications are reported. There were five children that underwent RT MRI-LAARP; one was a redo secondary to a retracted rectovestibular fistula. Operative time ranged from 187-505 min. Average hospital stay was 4.0 ± 1.0 days. There were no intraoperative complications although one patient had temporary urinary retention post-op. Muscle sparring laparoscopic anorectoplasty using real-time MRI is feasible and facilitates needle placement through the SMC.
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Affiliation(s)
- Marcus Jarboe
- Section of Pediatric Surgery, Department of Surgery, Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, SPC 4211, Ann Arbor, MI, 48109-4211, USA.,Department of Pediatric and Interventional Radiology, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Maria Ladino-Torres
- Department of Pediatric and Interventional Radiology, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Laurie Wild
- Section of Pediatric Surgery, Department of Surgery, Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, SPC 4211, Ann Arbor, MI, 48109-4211, USA
| | - Dragan Spremo
- Department of Pediatric and Interventional Radiology, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Samual Elkins
- Department of Pediatric and Interventional Radiology, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Robert Ladouceur
- Department of Pediatric and Interventional Radiology, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Dave Nagy
- Department of Pediatric and Interventional Radiology, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - Peter Ehrlich
- Section of Pediatric Surgery, Department of Surgery, Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, SPC 4211, Ann Arbor, MI, 48109-4211, USA
| | - Matthew Ralls
- Section of Pediatric Surgery, Department of Surgery, Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, SPC 4211, Ann Arbor, MI, 48109-4211, USA.
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Wei W, Li RX, Shang XJ, Peng X. An improved surgical procedure for treatment of puborectalis syndrome. Shijie Huaren Xiaohua Zazhi 2015; 23:343-347. [DOI: 10.11569/wcjd.v23.i2.343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy of an improved surgical procedure for treatment of puborectalis syndrome.
METHODS: This prospective randomized study included 54 patients suffering from puborectalis syndrome. They were randomized into two groups: a control group which included 27 patients who underwent partial division of puborectalis and an observation group which included 27 patients who received an improved surgical procedure (partial division of puborectalis plus rectal serosal gomphosis and lateral internal sphincterotomy). The total effective rate and recurrence rate were compared for the two groups.
RESULTS: After one year and a half, the total effective rate in the observation group was 92.6%, significantly higher than that in the control group (59.3%, P < 0.05). The recurrence rate in the observation group was 3.8%, significantly lower than that in control group (36%, P < 0.05).
CONCLUSION: The improved surgery has low recurrence rate and high safety.
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Kawamoto A, Inoue Y, Okigami M, Okugawa Y, Hiro J, Toiyama Y, Tanaka K, Uchida K, Mohri Y, Kusunoki M. Puborectal sling interposition combined with seton drainage for pouch-vaginal fistula after rectal cancer surgery with colonic J pouch-anal reconstruction: report of a case. Int Surg 2014; 99:710-3. [PMID: 25437575 DOI: 10.9738/INTSURG-D-13-00187.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The management of postoperative rectovaginal fistula (RVF) after rectal cancer surgery is difficult and requires reconstruction of the anastomotic site and fistula. Though various surgical procedures have been reported for the repair of RVFs, the results of surgical repair are often unsatisfactory, and failure of the initial repair leads to difficulty in the later operations. Furthermore, it has been reported that cases associated with local infection result in low success rates. We report a case of an 80-year-old woman with a recurrent colonic J pouch-vaginal fistula after anoabdominal rectal resection with partial internal sphincteric resection, who achieved a good outcome following a repair using a puborectal sling interposition combined with seton drainage. It may be a useful option for RVF management in repair of such pouch-vaginal fistula after coloanal anastomosis with intersphincteric resection.
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