anatomia diagnostica (pp tshare)

Prof. Filippo Pucciani

CLINICA CHIRURGICA GENERALE E DISCIPLINE CHIRURGICHEUniversità degli Studi di Firenze

Testo - Articoli

• Riabilitazione uro-ginecologica - II edizione Paolo di Benedetto – Edizioni Minerva Medica

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• Pucciani F. et al. Multimodal rehabilitation of faecal incontinence: experience of an italian centre devoted to faecal disorder rehabilitation. Tech Coloproctol 2003; 7: 139-147.

• Pucciani F. et al.: Pelvic floor dyssynergia and bimodal rehabilitation: results of combined pelviperineal kinesitherapy and biofeedback training. Int J Colorect Dis 1998; 13: 124-130.

Continence - Defecation

Storage and evacuation of gas and stool

Somatovisceral integrated activity

Faecal continence Defecation

FAECAL CONTINENCE - DEFAECATION

• Pelvic floor muscles • Anal sphincters• Neural integrity (AN – PN)• Sensory and motor activity of the rectum • Anal sensation• Colonic motility• Faecal consistence

Coordinate interaction

PelviDistretto posteriore

ANATOMIARetto


Anatomia del retto

PerineoPiano superficiale

Female perineum

Muscoli perineali -Sfintere anale esterno

Perineal musclesStraining perineal reflex

Perineal muscle contraction on straining postulates a reflex relationship that we callthe "straining-perineal reflex." We suggest that this reflex, which results in perineal muscle contraction, supports the perineum against the increased intra-abdominal pressure inducedby straining and the tendency of the perineum to descend.

Shafik A, El-Sibai O, Shafik AA, Ahmed I. Effect of straining on perineal muscles and their role in perineal support: Identification of the straining-perineal reflex. J Surg Res 2003; 112: 162-167.

Post-defecation reflex?

Somatic element

Post-defecation reflex

As soon as the contents have passed there is a sharp contraction of the sphincters and levator ani muscles so that the pelvic floor is elevated to its original position, the canal closed and the valve mechanism restored. This is called the post-defecation reflex.

Parks AG, Porter NH, Hardcastle J. The syndrome of descending perineum. Proc R Soc Med 1966; 59: 477-482.

Somatic element Visceral element

Joined longitudinal muscle

?+

Joined Longitudinal MuscleCorrugator ani

Puborectalis muscle+

Longitudinal muscle of the rectum

Lunnis S. Anatomy and function of the anal longitudinal muscle. Br J Surg 1992;; 79: 882-884.

PERINEAL BODY

“Perineal body is the site along which the tendineus fibres of perineal musclesfrom the two sides decussate with each other across the midline”

Shafik A, Ahmed I, Shafik AA, El-Ghamrawy TA, El-Sibai O. Surgical anatomy of the perineal muscles and their role in perineal disorders. Anat Sci Int 2005; 80: 167-171.

PERINEAL BODYObstetric trauma

• Endoanal sonography for obstetric traumaMartinez HM et al. Endoanal sonography in assessment of fecal incontinence following obstetric trauma. Ultrasound Obstet Gynecol 2003; 22: 616-621

• Perineal body thickness/sphincter defectsOberwalder M, Wexner SD et al. Anal ultrasound and endosonographic measurement of perineal body thickness: a new evaluation for fecal incontinence in females. Surg Endosc 2004; 18: 650-654.

• Perineorraphy: surgical approximation of bilateral extension of perineal body instead

of levator ani

Soga H, Nagata I et al. A histotopographic study of the perineal body in elderly women: the surgical applicability of novel histological findings. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18: 1423-1430.

Rectovaginal septum

“The rectovaginal septum (fascia) attaches to the pelvic sidewall along a well defined line. It extends from perineal body toward the arcus tendineus fasciae pelvis with which it converges approximately midway between the pubis (3.75 cm) and the ischial spine (4.8 cm).”

Leffler KS et al: Attachment of the rectovaginal septum to the pelvic sidewall. Am J Obstet Gynecol 2001; 185: 41-43.

“The rectovaginal septum is formed of a network of collagen, elastic fibres, smooth muscle cells, nerve fibres emerging from the autonomic inferior hypogastric plexus, and variable numbers of small vessels.”

Stecco C et al: Histotopographic study of the rectovaginal septum. Ital J Anat Embryol 2005; 110: 247-254.

• Rectovaginal endometriosis

• Rectocele

• Enterocele

• Rectovaginal fistula

Urethra

Vaginal coil

Rectovaginal septum

Anorectum

Rectovaginal septum

Pathologies

Pelvic MNR

Enterocele

Enterocele

Rectal prolapse

http://radiographics.rsnajnls.org/cgi/content/full/22/4/817/F7A

Coccyx – Anococcygeal ligament

Coccygodynia

Anococcygeal ligament Postanal spaces

DefecographyCoccygeal trauma - Dyssynergia

Coccygeal

trauma

Dyssynergia

Perineo Piano profondo

Diaframma pelvico

Pelvic diaphragm

PAVIMENTO PELVICOProiezioni corticali


Fascia pelvicaStrutture comuni uro-gine-proctologiche

- F.P. Parietale Arco tendineo del m. elevatore dell’ano

- F.P. Viscerale Lamina sacro-retto-genito-pubica

Lamina sacro-retto-genito-pubicaCroce di Richard

Leg . Pubo-uretraliLeg . Uretro-pelvici

Leg . Cardinali

Leg . Sacro-uterini

Strutture supporto utero-vagina


S.J. Lewis, K.W. Heaton. Stool Form Scale as a Useful Guide to Intestinal Transit Time Scandinavian Journal of Gastroenterology 1997; 32 (9): 920 – 924.

Faecal consistenceStool form scale


Stool form

“Several studies have already shown that the stool form scaleis strongly correlated with whole-gut transit time by scintigraphyor radio-opaque markers”

Choung RS, Locke GR 3rd, Zinsmeister AR, Schleck CD, Talley NJ. Epidemiology of slow and fast colonic transit using a scale of stool form in a community.Aliment Pharmacol Ther. 2007; 26:1043-50.

Faecal impaction Overflow incontinenceType 1

Type 2


http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Choung%20RS%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Locke%20GR%203rd%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Zinsmeister%20AR%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Schleck%20CD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Talley%20NJ%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

ANATOMIARetto


SFINTERI ANALISchema


Three loops theory


SNPPlessi sacrale e coccigeo


Pullen AH, Tucker D, Martin JE. Morphological and morphometric characterization of Onuf’s nucleus in spinal cord in man.J Anat 1997; 191: 201-213.

Onufrowicz 1889 nucleus X Cranial origin distal part S1

Caudal end proximal part S3

Onuf ’s nucleus


Nervo pudendo


Supraspinal control of anal sphincterPubMed

Vitton V, Grimaud JC, Bouvier M, Abysique A.Supraspinal control of external anal sphincter motility: effects of vesical distension in humans and cats..Neurogastroenterol Motil. 2006 Nov;18(11):1031-40.

Nout YS, Leedy GM, Beattie MS, Bresnahan JC.

Alterations in eliminative and sexual reflexes after spinal cord injury: defecatory function and development of spasticity in pelvic floor musculature. Prog Brain Res. 2006;152:359-72. Review.

Pierce LM, Reyes M, Thor KB, Dolber PC, Bremer RE, Kuehl TJ, Coates KW. Immunohistochemical evidence for the interaction between levator ani and pudendal motor neurons in the coordination of pelvic floor and visceral activity in the squirrel monkey. Am J Obstet Gynecol. 2005 May;192(5):1506-15.

Abysique A, Orsoni P, Bouvier M.

Evidence for supraspinal nervous control of external anal sphincter motility in the cat. Brain Res. 1998 Jun 8;795(1-2):147-56.

MacDonagh R, Sun WM, Thomas DG, Smallwood R, Read NW.

Anorectal function in patients with complete supraconal spinal cord lesions. Gut. 1992 Nov;33(11):1532-8.

Weber J, Beuret-Blanquart F, Ducrotte P, Touchais JY, Denis P.

External anal sphincter function in spinal patients. Electromyographic and manometric study. Dis Colon Rectum. 1991 May;34(5):409-15.

Holstege G, Tan J.

Supraspinal control of motoneurons innervating the striated muscles of the pelvic floor including urethral and anal sphincters in the cat. Brain. 1987 Oct;110 ( Pt 5):1323-44.

Weber J, Denis P, Mihout B, Muller JM, Blanquart F, Galmiche JP, Simon P, Pasquis P.

Effect of brain-stem lesion on colonic and anorectal motility. Study of three patients. Dig Dis Sci. 1985 May;30(5):419-25.

Pudendal nerve

Tonic EAS activity Voluntary EAS inhibitionCutaneous-anal reflex


http://www.ncbi.nlm.nih.gov/sites/?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17040414&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Colonic motilityManometry

HAPCSegmenting activity* - LAPC

*

Bassotti G et Al. Normal aspects of colorectal motility and abnormalities in slow transit constipation.World J Gastroenterol 2005; 11: 2691-96


Rectal motor complexes

• “The temporal association with motor events in the proximal colon suggests that PRMA is triggered by the arrival of stool or gas in the rectum. Because most cycles are either segmental or are propagated retrogradely, PRMA may serve as an intrinsic braking mechanism that prevents untimely flow of colonic contents, particularly during sleep. Rao SS, Welcher K. Periodic rectal motor activity: the intrinsic colonic gatekeeper? Am J Gastroenterol 1996; 91: 890-897.

• “The onset of rectal contractions was accompanied by increasing resting pressure and contractile activity of the anal canal, such that pressure in the anal canal was always greater than pressure in the rectum.

Ferrara A et al. Relationship between anal canal tone and rectal motor activity. Dis Colon Rectum 1993; 36: 337-342.

PRMA: Periodic Rectal Motor Activity

Disorders of defecationAnorectal investigations

• Anorectal manometry

• Neuro-physiologic tests(EMG, pudendo-anal reflexes, PNTML, PN-SsEP)

• Anal endosonography

• MNR

• Defecography

Functional Morphologic

ENDOSCOPY

ENDOSCOPIAColoproctologia

• Anoscopia• Rettoscopia• Retto-sigmoidoscopia• Pan-coloscopia

Indicazioni specifiche per ogni tecnica strumentale


MALATTIA EMORROIDARIARettoscopia


Test Veri Falsi positivo positivi positivi

Test Veri Falsi negativo negativi negativi

Rapporto esito test diagnostico / malattia

Sensibilità: veri positivi su tutti i malatiSpecificità: veri negativi su tutti i saniValore predittivo positivo: veri positivi / tutti i positivi al testValore predittivo negativo: veri negativi / tutti i negativi al test


Clinical usefulness of assessing anorectal physiology

1. To provide new information that could influence the management of patients with disorders of defecation.

2. To identify the patients who may most benefit from this assessment.Rao SS, Patel RS: How useful are manometric tests of anorectal function in the management of defecation disorders? Am J Gastroenterol 1997; 92: 469-475.


Anorectal manometry

“To assess patients prior to and to facilitate biofeedback training of the evacuation and continence mechanism”.

Rao SSC, Azpiroz F, Diamant N, Enck P, Tougas G, Wald A: Minimum standards of anorectal manometry. Neurogastroenterol Motil 2002; 14: 553-559.


Manometria anorettaleAmbulatorio - Strumentazione


Anorectal manometry

• Anal resting pressure• Maximal voluntary contraction• Recto-Anal Inhibitory Reflex• Rectal sensations• Rectal compliance

• Sensibility: 92.2%• Specificity: 86.6%• Positive predictive factor: 0.90• Negative predictive factor: 0.64

Sun WM et al.: Utility of a combined test of anorectal manometry, electromyography, and sensation in determining the mechanism of “idiopathic” faecal incontinence. Gut; 1992; 33: 807-813.


Manometria anorettale stazionariaFasi di registrazione

• ARP : Anal Resting Pressure

• MVC: Maximal voluntary contraction

• RAIR: Recto Anal Inhibitory Reflex

• RECTAL SENSATIONS• COMPLIANCE


Manometria anorettaleARP

LD A LS P



LD A LS PProf. Filippo Pucciani


LD A LS P


Manometria anorettaleVolume vettore


Manometria anorettaleMVC


Manometria anorettaleMVC

LD A LS P


Manometria anorettaleRAIR


Sampling reflex


Sampling reflex

IAS

EAS

Sampling reflex

RAIR

RAER

Manometria anorettaleRAIR


Manometria anorettaleCompliance rettale – Rectal sensations

LD A LS P

+CRST: Conscious Rectal Sensitivity Threshold

CS: Constant Sensation

MTV: Maximal Tolerated Volume


Manometria anorettaleCompliance rettale


Faecal continenceNeural pathways – Reflexes latency

PNTML

PA reflex

Pn-SsEP

Pudendalnerve


Faecal incontinenceNeuro-physiologic tests

Clinical indications

1. Symptomatic patients with low ARP with no obvious explanation.

2. Incontinent patient with a negative workup.

3. Abnormal workup without ano-rectal anatomical explanation.

4. Faecal incontinence in patients affected by neurological diseases.

Tests

A. Anal electromyography.

B. Pudendo-anal reflex (PA).

C. Pudendal nerve terminal motor latency (PNTML).

D. Pudendal nerve somato-sensorial evoked potentials (PN-SsEP).

Cole J., Gottesman L.: Anal electrophysiological and pudendal nerve evoked potentials. In: Practical guide to anorectal testing. Igaku-Shoin Eds. New York 1995;207-220.

Faecal incontinenceNeuro-physiologic tests

Test Stimulation Measurement Diagnosis

PA reflex Afferent nerve stimulation

Latency of sacral reflex

Polyneuropathies

Pelvic floor neuropathies

PNTML * Efferent nerve stimulation

Latency of terminal motor fibres stimulation

Pudendal nerve stretch injuries(obstetric trauma, descending perineum syndrome)

PN-SsPE Mixed nerve stimulation

Amplitude of scalp response

Myelopathies

Cole J., Gottesman L.: Anal electrophysiological and pudendal nerve evoked potentials. In: Practical guide to anorectal testing. Igaku-Shoin Eds. New York 1995; 207-220.

Anatomia pelviRMN


MNR - DefecographyNormal subjects

Pelvic MNRDPS - Hysterectomy


MNR


MNR Faecal incontinence


DISTENSION RECTOCELEDefecography


Pelvic floor dyssynergiaRectal Intussusception + Anterior distension rectocele

70%


Endosonografia anale con sonda rotante


Endosonografia anale con sonda rotante Incontinenza fecale


anatomia diagnostica (pp tshare)

Documents

perineal support

perineal disorders

perineal bodyperineal

anal longitudinal muscle

reflex relationship

anal ultrasound

straining postulates

effect of straining