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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
________________________________________________
• 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
Prof. Filippo Pucciani
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
Coccyx – Anococcygeal ligament
Coccygodynia
Anococcygeal ligament Postanal spaces
DefecographyCoccygeal trauma - Dyssynergia
Coccygeal
trauma
Dyssynergia
Perineo Piano profondo
Diaframma pelvico
Pelvic diaphragm
PAVIMENTO PELVICOProiezioni corticali
Prof. Filippo Pucciani
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
Prof. Filippo Pucciani
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
Prof. Filippo Pucciani
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
Prof. Filippo Pucciani
ANATOMIARetto
Prof. Filippo Pucciani
SFINTERI ANALISchema
Prof. Filippo Pucciani
Three loops theory
Prof. Filippo Pucciani
SNPPlessi sacrale e coccigeo
Prof. Filippo Pucciani
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
Prof. Filippo Pucciani
Nervo pudendo
Prof. Filippo Pucciani
Nervo pudendo
Prof. Filippo Pucciani
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
Prof. Filippo Pucciani
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
Prof. Filippo Pucciani
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
Prof. Filippo Pucciani
MALATTIA EMORROIDARIARettoscopia
Prof. Filippo Pucciani
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
Prof. Filippo Pucciani
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.
Prof. Filippo Pucciani
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.
Prof. Filippo Pucciani
Manometria anorettaleAmbulatorio - Strumentazione
Prof. Filippo Pucciani
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.
Prof. Filippo Pucciani
Manometria anorettale stazionariaFasi di registrazione
• ARP : Anal Resting Pressure
• MVC: Maximal voluntary contraction
• RAIR: Recto Anal Inhibitory Reflex
• RECTAL SENSATIONS• COMPLIANCE
Prof. Filippo Pucciani
Manometria anorettaleARP
LD A LS P
Prof. Filippo Pucciani
Manometria anorettaleARP
LD A LS PProf. Filippo Pucciani
Manometria anorettaleARP
LD A LS P
Prof. Filippo Pucciani
Manometria anorettaleVolume vettore
Prof. Filippo Pucciani
Manometria anorettaleMVC
LD A LS PProf. Filippo Pucciani
Manometria anorettaleMVC
LD A LS P
Prof. Filippo Pucciani
Manometria anorettaleRAIR
LD A LS PProf. Filippo Pucciani
Sampling reflex
Prof. Filippo Pucciani
Sampling reflex
IAS
EAS
Sampling reflex
RAIR
RAER
Manometria anorettaleRAIR
LD A LS PProf. Filippo Pucciani
Manometria anorettaleCompliance rettale – Rectal sensations
LD A LS P
+CRST: Conscious Rectal Sensitivity Threshold
CS: Constant Sensation
MTV: Maximal Tolerated Volume
Prof. Filippo Pucciani
Manometria anorettaleCompliance rettale
Prof. Filippo Pucciani
Faecal continenceNeural pathways – Reflexes latency
PNTML
PA reflex
Pn-SsEP
Pudendalnerve
Prof. Filippo Pucciani
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
Prof. Filippo Pucciani
MNR - DefecographyNormal subjects
Pelvic MNRDPS - Hysterectomy
Prof. Filippo Pucciani
MNR
Prof. Filippo Pucciani
MNR Faecal incontinence
Prof. Filippo Pucciani
DISTENSION RECTOCELEDefecography
Prof. Filippo Pucciani
Pelvic floor dyssynergiaRectal Intussusception + Anterior distension rectocele
70%
Prof. Filippo Pucciani
Endosonografia anale con sonda rotante
Prof. Filippo Pucciani
Endosonografia anale con sonda rotante Incontinenza fecale
Prof. Filippo Pucciani