pelvic floor syndrome
Introduction
Introduction to pelvic floor syndrome Pelvic floor syndrome refers to several syndromes caused by neuromuscular abnormalities such as rectum, levator ani muscle and anal and external sphincter. basic knowledge The proportion of sickness: 0.004% - 0.006% Susceptible people: no special people Mode of infection: non-infectious Complications: rectal prolapse
Cause
Causes of pelvic floor syndrome
(1) Causes of the disease
Abnormalities in pelvic floor function are caused by abnormalities of nerves and/or muscles. Under pathological conditions, stool control and/or defecation dysfunction, clinical symptoms of constipation or fecal incontinence The level of lesions is not consistent, may be located in the pelvic floor, may also be in the central nervous system, and some may have local anatomic abnormalities, such as rectal prolapse; some patients alternate between defecation difficulties and fecal incontinence at different stages, but Commonality is anorectal pelvic floor dysfunction, the common causes are as follows:
1. Outlet obstructed constipation This group of patients showed that it is extremely difficult to pass the anal canal. The defecation is laborious, the cause and mechanism are not very clear, and it may be a group of multi-source dysfunction.
(1) Anal fistula (spasm): The difficulty of defecation in this group of patients is due to the pelvic floor striated muscle, mainly the puborectal muscle and the external anal sphincter can not relax, sometimes the activity of the puborectalis muscle is enhanced during defecation, and the coordinated movement is lost. As a result, the perineum is not complete, causing difficulty in defecation, incomplete bowel movements, pain in the anus, patients often abuse lubricants, enema, and have fecal leaks and rectal pain.
(2) adult megacolon (adult megacolon): due to the lack of certain ganglion cells at the anorectal junction, the feces reach the rectum is not easy to cause anorectal inhibition and reflex, it is difficult to initiate defecation, clinically difficult to identify.
(3) anorectal anorectal sensation (impaired anorectal sensation): due to long-term excessive exertion of defecation damage to the perineal nerve (dominated external anal sphincter and urethral sphincter and puborectalis muscle), resulting in rectal filling and expansion, intentional retardation, sensory threshold, And with the external anal sphincter and rectal pubic muscle to the reaction of rectal filling and expansion, causing difficulty in defecation, and some with fecal incontinence.
(4) descending perineum syndrome (descending perineum syndrome): caused by weakened muscles of the pelvic floor muscles, may be caused by aging or nerve damage, easy to damage the phrenic nerve (S3 and S4) that governs the puborectalis muscle during childbirth, Once the pelvic floor muscles are weakened, any force can cause the perineum to drop significantly, causing the rectum to expand. Excessive rectal mucosa protrudes into the rectum, often with poor bowel movements, often with a sense of convenience, frequent defecation, anal rest and contraction The narrow pressure is high; the pelvic floor repeatedly drops rapidly and pulls the perineal nerve that innervates the external anal sphincter, leading to progressive nerve damage, and fecal incontinence can occur later.
2. Rectoceele rectenocele rectalle anterior rectal wall into the posterior wall of the vagina, can be asymptomatic, but most of the performance is difficult to defecation, but also some complain of anal pain, fecal leakage, anal bleeding, etc., may There are other symptoms such as vaginal prolapse, urinary incontinence, physical examination or defecation angiography can be found in the rectal vaginal septum relaxation, there are 3 cases of low, medium and high, the lower part is located above the levator ani muscle, originating from the trauma during childbirth, to the anus Relaxation in the sphincter region (such as fecal incontinence, sphincter angioplasty), high in more common in the perineal decline, vaginal proximal bulging, mostly intestinal bulging, genital prolapse, the most common rectal bulging The typical patient needs to hold the vagina by hand when defecation, such as the appearance of slag-like feces, the need to finger out, or the faecal angiography to show a segment of the rectum that does not empty, or its length exceeds 3cm, etc., it is rectal swelling Caused by.
3. Rectal prolapse can be manifested as anterior mucosal prolapse, excessive force can cause rectal intussusception, rectal intussusception or prolapsed top tightly inserted into the pelvic floor and trauma, causing solitary solitary ulcer ( Solitary rectal ulcer syndrome), can cause bleeding, pain in the anus, defecation disorder, etc., it is likely that the functional outlet is blocked first, due to forced defecation, secondary rectal prolapse, rectal prolapse and perineal sag will be repeatedly pulled and damaged The genital nerve causes incontinence.
4. Chronic anal pain syndromes mainly include levator syndrome, proctalgia fugax, coccygodynia, and descending perineum syndrome (DPS). ), chronic idiopathic anal pain, in which the cause of spastic anal pain is levator ani muscle, tail muscle tendon, hereditary anal sphincter myopathy may also be related to pain, in addition, sigmoid contraction may also At work, the tailbone pain may be functional and the cause is unclear.
(1) levator ani muscle syndrome: levator syndrome (levator syndrome) is related to levator ani muscle spasm, and can not find obvious causes, showing pain in the anorectal area, the degree is not heavy, it is dull pain or pressure When the sitting position is aggravated, it disappears when standing or lying, so it occurs mostly during the daytime. It can also be expressed as a persistent burning sensation. The patient often describes it as sitting on the ball. The pain can be radiated to the buttocks. Diagnosis can trigger pain, long-distance driving, female childbirth, genitourinary surgery may increase the pain, some patients are related to mental stress, no positive findings, sometimes may touch the tension of the levator ani muscle, or even the band, should pay attention Exclude other organic causes.
(2) spastic anal pain: proctalgia anal pain (proctalgia fugax), also known as transient anal pain, is a variant of levator ani muscle syndrome, levator ani muscle, rectal anal ischemia or Caused by rectal fistula, may also be related to psychological factors, mostly female, mostly professional women, often accompanied by excessive anxiety or neurotic tendency, manifested as episodes of severe pain, colic, burning, stinging, After the episodes or unpleasant sexual intercourse, especially during the night, the patient is awakened, the pain is persistent, no radiation, and lasts for a few seconds to several minutes. The rectal examination can touch the levator ani muscle. Or a rectal examination to detect the junction of the straight-sigmoid colon (difficult to pass).
(3) Coccygeal pain: coccygodynia is characterized by lower tibia, pain in the perineum, anal canal, thigh and coccyx area, persistent pain, burning or cramping pain, may be accompanied by tenderness in the appendix area, levator Tendons, often due to defecation, sitting position, tail bone trauma induced, most of the episodes during the day, most patients with mental stress or depression, psychological treatment has a certain effect.
(4) descending perineum syndrome (DPS): perineal descending syndrome is caused by various causes of pelvic floor muscle degeneration, dysfunction, in the quiet state or forced defecation when the perineum falls more than the normal range of Pelvic floor disease, in obesity, advanced age, vulvar nerve injury caused by childbirth, stenosis after anal surgery, etc., the pelvic floor muscle group tension is reduced, the rectal mucosa prolapses due to excessive force, and the rectal anterior wall mucosa falls into the anal canal and is not easy to reset. And stimulate the patient to have a sense of falling, so that the patient is more forced to defecate, causing a vicious circle, causing the perineum to continue to decline, and forming a perineal descent syndrome, the patient has a feeling of defecation, anal bulge, difficulty in defecation and pain in the perineum, in defecation or When walking, there is a mass in the anus. When the patient performs simulated bowel movements, the perineum is swollen. The anal sphincter is lowered. If the anus is used, the distal end of the anoscope is blocked by the rectal mucosa.
(5) chronic idiopathic anal pain (chronic idiopathic anal pain): more common in women, mainly in the middle of the anal canal persistent burning burning, like the ball in the anal canal, or intermittent, can be unilateral, to the abdomen, Thigh, tibia and vaginal radiation may be accompanied by pelvic floor or spinal surgery, spinal angiography or perineal decline, more than sitting position, can occur at any time, often in the latter half of the day, sometimes relieved when the position is taken.
5. Idiopathic faecal incontinence, also known as neurogenic fecal incontinence, is caused by the progressive damage of the pelvic floor striated muscle and the external anal sphincter and the internal sphincter dysfunction, most patients with anal resting pressure And narrowing pressure drop, anal external sphincter myoelectric abnormalities, suggesting that neuropathy is the basis, in some patients, the rectal internal pressure is significantly increased, exceeding the anal internal pressure and causing fecal leakage, many anorectal angles of patients with fecal incontinence become dull, such as There is no significant decrease in resting pressure and constriction pressure in the anus, and there may be no fecal incontinence; if the anal sphincter is insufficiency, as long as the anorectal angle is still normal, it is usually still able to form a shape.
(two) pathogenesis
The anorectal area and the pelvic floor have complex anatomical structures, including both striated muscle and smooth muscle.
1. Rectum, levator ani muscle, puborectal muscle and their phrenic nerve.
2. Anal external sphincter and perineal nerve.
3. Anal internal sphincter (smooth muscle) and endogenous and autonomic nerves, these muscle groups are highly coordinated in the control of defecation and defecation, the central nervous system, peripheral nervous system and enteric nervous system participate in the regulation, gastrointestinal hormones may also A certain role, factors related to stool control and defecation.
(1) related factors of stool control: the reason why stool can be controlled is due to the anal canal high pressure belt, the narrowing pressure of the anal external sphincter, the role of the "valve" of the anorectal angle, in addition, the compliance of the rectal wall and the anus Rectal inhibition reflex also plays a regulatory role in stool control. The formed stool itself also has the function of restraining stool. The factors of stool control are:
1 anal tube high pressure belt: about 4cm long, the anal canal is at high pressure at rest, mainly caused by the continuous contraction of the anal sphincter, the anal sphincter contraction, to prevent leakage of intestinal contents, between the anal canal and the rectal pressure The pressure difference is an important condition for restraining stools for a long time.
2 The narrowing pressure of the external anal sphincter: If the bowel movement cannot be defecate immediately, the external rectal sphincter and the pelvic rectal muscle of the pelvic floor contract, producing a narrowing pressure, which is 2 to 3 times higher than the resting pressure, and strengthens the control stool. However, the duration is short, often no more than 1 min. Therefore, if the intra-rectal pressure is significantly increased, the intestinal contents of the proximal anal can leak.
3 The role of anal rectal angle "valve": When resting in the left lateral position, this angle is 102 ° ± 18 °, when sitting at 109 ° ± 17 °, when the pelvic floor muscles contract, the pelvic floor is raised, the angle changes Small, played the role of "valve".
4 anorectal inhibition of reflex: under normal circumstances, when the feces enter the rectum, it will cause anorectal inhibition and reflex, that is, anal sphincter relaxation, anal external sphincter contraction, the latter to prevent the discharge of rectal contents, have the effect of restraining stool, such as not Immediately defecation, the anal sphincter no longer relaxes.
5 rectal wall compliance: when the content of the rectum is increased, the rectum can passively adapt to the tension, and the pressure in the cavity is still very low. This relaxation of the rectal wall can effectively prevent the pressure in the cavity from exceeding the internal pressure of the anus and play a role in stool control. However, if you continue to increase the rectal contents, it will increase the rectal internal pressure, usually the maximum tolerated capacity is 200 ~ 300ml.
6 The role of fecal formation in the colon: discharge molding is more difficult than water sample, which is also one of the mechanism of fecal control, and the water sample can enter the rectum in large quantities, overcome the control mechanism of the stool, easily cause incontinence, under normal circumstances The above control mechanism is perfect, and no fecal incontinence occurs.
(2) Related factors of defecation: The main factors related to the initiation of defecation are:
1 colon peristalsis: can push the contents of the intestine to the distal colon. When the content of the sigmoid colon reaches a certain amount, the contraction occurs, the feces enter the rectum, the rectum is dilated, causing rectal anal inhibition, due to anal sphincter relaxation, local dilatation, rectum The contents can enter the proximal end of the anal canal, so that the receptors of the local mucosa perceive the contents of the intestine as liquid, solid or gas, and enter the defecation state if conditions permit.
2 During defecation, the internal and external anal sphincter and puborectal muscles were loose, the pelvic floor descended, forming a funnel, the anorectal angle became larger, the increased intra-abdominal pressure directly applied to the feces, and the whole left colon collapsed to empty the feces. The end of defecation, the anal external sphincter and the puborectal muscle alternately contract, in order to end the reflex, this reflex can promote the recovery of the anal sphincter muscle tension and close the anal canal.
3 After eating, the rectal volume is reduced, and the tension of the rectal wall is increased. This reflection is conducive to rectal emptying.
Prevention
Pelvic floor syndrome prevention
Prevention and effective treatment of the etiology of the pelvic floor syndrome. The most prominent advantage of laver is that it is rich in abnormally soft crude fiber. The crude fiber is the "scavenger" in the human intestine, and the crude fiber material of laver is difficult to be digested by the human gastrointestinal tract. After eating, the peristalsis can be increased. The stool is smooth. Regular consumption of seaweed soup can also remove harmful substances accumulated in the intestines and keep the intestines healthy, which is conducive to prevention.
Complication
Pelvic floor syndrome complications Complications rectal prolapse
Because the stool is dry, the defecation is laborious and inexhaustible, often accompanied by rectal prolapse.
Symptom
Symptoms of pelvic floor syndrome common symptoms constipation, acute anal relaxation, rectal prolapse, weakness
The most common symptoms are constipation, fecal incontinence, pelvic floor pressure, pain, urgency and weight, poor bowel movements and rectal prolapse. Constipation is the most ambiguous symptom. Most patients have 3 times/d to 3 times. / Week, if you ask carefully, you will be prompted difficulty in bowel movements, laborious, uncomfortable or inconvenient, unable to start defecation.
If there is a quarter of the time in the bowel movement, it will indicate the pelvic floor dysfunction, the pelvic floor pressure, the stool can not be difficult or difficult, and the blockage also indicates the pelvic floor dysfunction. Please note that about 50% of normal people occasionally have bowel movements. Thoroughly, 10% of these symptoms can occur frequently. Long-term forced defecation and bloody stools often suggest rectal prolapse, and there may be associated rectal solitary ulcers, except for tumors and inflammatory bowel disease.
50% of fecal incontinence will not proactively complain of this symptom, unless detailed inquiry, these patients have a long history of fecal exertion, childbirth is an important factor in the pelvic floor injury, to understand the production, perineal incision or genital tear, pull Surgery, extended labor, and delivery of overweight are important risk factors.
Examine
Examination of pelvic floor syndrome
The use of pressure measuring instruments to detect rectal pressure has certain help in the diagnosis of pelvic floor syndrome, generally including anus length, anal canal resting pressure, rectal narrowing pressure and defecation pressure measurement, but it should be noted that although the gastrointestinal pressure is measured Diagnosis of esophagus, small intestine and Oddi sphincter dysmotility and adult megacolon is very important, but in some cases there is still a big gap between the results of rectal manometry and the clinical situation of patients with pelvic floor syndrome, so the rectal pressure should be treated with caution. The result of the measurement.
85% of the patients with anal pain caused by defecation during the defecation process, the anal canal ultrasound can detect the anal sphincter becomes shorter and thicker (the puborectalis muscle becomes shorter and thicker more significant), and the same change is only seen in 35% of the normal population Ultrasonic examination of the anal canal has a certain significance for the diagnosis of pelvic floor muscle coordination disorder and anal fistula.
The anterior angle of the anus, the distance between the anus, the distance between the intestine and the length and depth of the puborectalis muscle are measured by defecation angiography. If the puborectal muscle is not loose and/or contracted, the rectal angle does not increase. Reduced, visible pubic rectal indentation and deepening of the impression, the rectal ampulla can be diagnosed with pelvic floor syndrome.
Diagnosis
Diagnosis and diagnosis of pelvic floor syndrome
Diagnostic criteria
1. Clinical manifestations.
2. Physical examination of the perineal scars, anal examination refers to anal relaxation and narrowing of the anus. When the abdominal force simulates defecation, the perineum moves more than 2cm. When the bowel movement occurs, the rectum prolapses outside the anus or touches the prolapse in the anus. Rectum.
3. Auxiliary inspection.
Differential diagnosis
Acute pelvic inflammatory disease is acute disease, lower abdominal pain, high body temperature, fast heart rate, such as concurrent sepsis, body temperature can reach 40 ° C, such as abscess formation in the pelvic cavity, it is a persistent relaxation type of hyperthermia, if there is peritonitis, the digestive system appears Symptoms such as nausea, vomiting, diarrhea, etc., if abscess formation, may have lower abdominal mass and local irritation; bladder stimulation symptoms, such as frequent urination, dysuria, may occur in the adjacent rectum. There is diarrhea, and it is difficult to feel heavy and relieve bowel movements.
