Anatomia - Diagnostica (PPTshare)

CLINICA CHIRURGICA GENERALE E DISCIPLINE CHIRURGICHE
Università degli Studi di Firenze
Prof. Filippo Pucciani

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
Faecal continence Defecation
Storage and evacuation of gas and stool
Somatovisceral integrated activity

FAECAL CONTINENCE - DEFAECATION
Coordinate interaction
• Pelvic floor muscles

• Anal sphincters
• Neural integrity (AN – PN)
• Sensory and motor activity of the rectum
• Anal sensation
• Colonic motility
• Faecal consistence
Pelvi
Distretto posteriore
ANATOMIA
Retto

Anatomia del retto
Perineo
Piano superficiale
Female perineum
Muscoli perineali -Sfintere anale esterno
Perineal muscles
Straining perineal reflex
Perineal muscle contraction on straining postulates a reflex relationship that we call

the "straining-perineal reflex." We suggest that this reflex, which results in perineal muscle
contraction, supports the perineum against the increased intra-abdominal pressure induced
by 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.
Somatic element
Post-defecation reflex?
Post-defecation reflex
Somatic element
+ Visceral element ?
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 Joined longitudinal muscle
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.
Joined Longitudinal Muscle
Corrugator 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 muscles
from 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 BODY
Obstetric trauma
• Endoanal sonography for obstetric trauma

Martinez HM et al. Endoanal sonography in assessment of fecal incontinence following obstetric trauma. Ultrasound
Obstet Gynecol 2003; 22: 616-621
• Perineal body thickness/sphincter defects

Oberwalder 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 septum
Pelvic MNR
Pathologies
Urethra
• Rectovaginal endometriosis
• Rectocele
Vaginal
coil
• Enterocele
Rectovaginal
septum • Rectovaginal fistula
Anorectum
Enterocele
Enterocele
Rectal prolapse
Coccyx – Anococcygeal ligament
Coccygodynia
Anococcygeal ligament Postanal spaces

Defecography
Coccygeal trauma - Dyssynergia
Coccygea
l
trauma
Dyssynergia
Perineo
Piano profondo
Diaframma
pelvico
Pelvic diaphragm
PAVIMENTO PELVICO
Proiezioni corticali

Fascia pelvica
Strutture 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-pubica
Croce di Richard
Leg . Pubo-uretrali
Leg . Uretro-pelvici
Leg . Cardinali
Leg . Sacro-uterini
Strutture supporto utero-vagina

Faecal consistence
Stool form scale
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. Prof. Filippo Pucciani
Stool form
“Several studies have already shown that the stool form scale
is strongly correlated with whole-gut transit time by scintigraphy
or 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.
Type 1
Faecal impaction Overflow incontinence

Type 2

ANATOMIA
Retto

SFINTERI ANALI
Schema

Three loops theory

SNP
Plessi sacrale e coccigeo

Onuf ’s nucleus
Cranial origin distal part S1
Onufrowicz 1889 nucleus X

Caudal end proximal part S3
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.
Nervo pudendo

Nervo pudendo

Supraspinal control of anal sphincter
PubMed
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.
Tonic EAS activity

Pudendal nerve Voluntary EAS inhibition
Cutaneous-anal reflex
Colonic motility
Manometry
Segmenting activity* - LAPC HAPC
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
PRMA: Periodic Rectal Motor Activity
• “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.
Disorders of defecation
Anorectal investigations
ENDOSCOPY
Functional Morphologic
• Anorectal manometry • Anal endosonography
• Neuro-physiologic tests • MNR

(EMG, pudendo-anal reflexes, PNTML, PN-SsEP)
• Defecography
ENDOSCOPIA
Coloproctologia
• Anoscopia
• Rettoscopia
• Retto-sigmoidoscopia
• Pan-coloscopia
Indicazioni specifiche per ogni tecnica strumentale

MALATTIA EMORROIDARIA
Rettoscopia

Rapporto esito test diagnostico / malattia
Test Veri Falsi

positivo positivi positivi
Test Veri Falsi

negativo negativi negativi
Sensibilità: veri positivi su tutti i malati

Specificità: veri negativi su tutti i sani
Valore predittivo positivo: veri positivi / tutti i positivi al test
Valore 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 anorettale
Ambulatorio - Strumentazione

Anorectal manometry
• Sensibility: 92.2%
• Specificity: 86.6%
• Positive predictive factor: 0.90
• Negative predictive factor: 0.64
• Anal resting pressure

• Maximal voluntary contraction
• Recto-Anal Inhibitory Reflex
• Rectal sensations
• Rectal compliance
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 stazionaria
Fasi di registrazione
• ARP : Anal Resting Pressure

• MVC: Maximal voluntary contraction
• RAIR: Recto Anal Inhibitory Reflex
• RECTAL SENSATIONS
• COMPLIANCE
ARP
LD A LS P
Prof. Filippo
Pucciani
ARP
LD A LS P
ARP
LD A LS P
Volume vettore

MVC
LD A LS P
MVC
LD A LS P
RAIR
LD A LS P
Sampling reflex

Sampling reflex
Sampling reflex
IAS RAIR
EAS RAER
RAIR
LD A LS P
Compliance rettale – Rectal sensations
CRST: Conscious Rectal

Sensitivity Threshold
+ CS: Constant Sensation

MTV: Maximal Tolerated Volume
LD A LS P
Compliance rettale

Faecal continence
Neural pathways – Reflexes latency
Pn-SsEP
PNTML
Pudendal
nerve
PA reflex
Faecal incontinence
Neuro-physiologic tests
Clinical indications Tests
1. Symptomatic patients with low ARP A. Anal electromyography.

with no obvious explanation.
B. Pudendo-anal reflex (PA).
2. Incontinent patient with a negative
workup. C. Pudendal nerve terminal
motor latency (PNTML).
3. Abnormal workup without ano-
rectal anatomical explanation. D. Pudendal nerve somato-
sensorial evoked potentials
4. Faecal incontinence in patients (PN-SsEP).
affected by neurological diseases.
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 incontinence
Neuro-physiologic tests
Test Stimulation Measurement Diagnosis
Afferent nerve Latency of sacral Polyneuropathies

PA reflex stimulation reflex Pelvic floor
neuropathies
Latency of Pudendal nerve

Efferent nerve
PNTML * stimulation
terminal motor stretch injuries
fibres stimulation (obstetric trauma, descending
perineum syndrome)
Mixed nerve Amplitude of scalp

PN-SsPE stimulation 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 pelvi
RMN

MNR - Defecography
Normal subjects
Pelvic MNR
DPS - Hysterectomy

MNR

MNR
Faecal incontinence

DISTENSION RECTOCELE
Defecography

Pelvic floor dyssynergia
Rectal Intussusception + Anterior distension rectocele
70%

Endosonografia anale con sonda rotante

Endosonografia anale con sonda rotante
Incontinenza fecale

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CLINICA CHIRURGICA GENERALE E DISCIPLINE CHIRURGICHE

Università degli Studi di Firenze

Prof. Filippo Pucciani

• Riabilitazione uro-ginecologica - II edizione

• Pucciani F. et al. Multimodal rehabilitation of faecal incontinence:

• Pucciani F. et al.: Pelvic floor dyssynergia and bimodal rehabilitation:

Faecal continence Defecation

Storage and evacuation of gas and stool

Somatovisceral integrated activity

• Pelvic floor muscles

Prof. Filippo Pucciani

Perineal muscle contraction on straining postulates a reflex relationship that we call

Parks AG, Porter NH, Hardcastle J. The syndrome of

“Perineal body is the site along which

• Endoanal sonography for obstetric trauma

• Perineal body thickness/sphincter defects

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

“The rectovaginal septum (fascia) attaches to the pelvic sidewall along a

“The rectovaginal septum is formed of a network of collagen, elastic fibres,

Anococcygeal ligament Postanal spaces

Prof. Filippo Pucciani

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

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

Prof. Filippo Pucciani

Faecal impaction Overflow incontinence

Prof. Filippo Pucciani

Prof. Filippo Pucciani

Prof. Filippo Pucciani

Prof. Filippo Pucciani

Prof. Filippo Pucciani

Onufrowicz 1889 nucleus X

Prof. Filippo Pucciani

Prof. Filippo Pucciani

Tonic EAS activity

Segmenting activity* - LAPC HAPC

Prof. Filippo Pucciani

• Anorectal manometry • Anal endosonography

• Neuro-physiologic tests • MNR

Indicazioni specifiche per ogni tecnica strumentale

Prof. Filippo Pucciani

Test Veri Falsi

Test Veri Falsi

Sensibilità: veri positivi su tutti i malati

1. To provide new information that could

2. To identify the patients who may most

“To assess patients prior to and to facilitate

Rao SSC, Azpiroz F, Diamant N, Enck P, Tougas G, Wald A: Minimum

Prof. Filippo Pucciani

Prof. Filippo Pucciani

• Anal resting pressure

Prof. Filippo Pucciani

• ARP : Anal Resting Pressure

Prof. Filippo Pucciani

Prof. Filippo Pucciani

CRST: Conscious Rectal

+ CS: Constant Sensation

Prof. Filippo Pucciani

Clinical indications Tests

1. Symptomatic patients with low ARP A. Anal electromyography.

Test Stimulation Measurement Diagnosis

Afferent nerve Latency of sacral Polyneuropathies

Latency of Pudendal nerve

Mixed nerve Amplitude of scalp