NGHIEN CUUKHOAHOC
i SCIENTIFIC RES
OANH GIADACOieM SATRIJC TRANG KlSU
TUI (J BENH NHAN R 6 | LOAN GHliC N A N G
SAN CHAU BANG CONG HUaNG T l i OQNG
Evaluation of rectocele in patients with pelvic floor dysfunction by dynamic magnetic resonance imaging
Objectives: Rectocele is a bulge or a prolapse of the anterior rectal wall into the posterior vaginal wall. It is relatively common with diversified and nonspecific symptoms. Clinical examination is easily confused and/or sometimes omitted the prolapse of other pelvic organs. Imaging to assess the pelvic floor dysfunction is an important and useful diagnostic test, especially dynamic MR.
Methods: Our study was cross-sectional descriptive. Patients with pelvic floor dysfunction were undergone clinical examinations and then were Indicated to have dynamic MR scanning at Ho Chi Minh City Medical University by anorectic doctor, urologist and gynecologist.
Results: 1.863 patients were evaluated from January 2008 to June 2012. Most of them are women, middle-aged and used to give birth. The rate of rectocele with its depth from 2 to 4 cm was 77.9%, mainly with the shape of "finger". The depth of more than 2 cm with the shape of "bag" has the high risk of stagnancy The factor of age and being used to give birth have a significant relation with rectocele (p<0.001). The rate of rectocele in the group of anismus was 64.2%. The combination of the prolapse of more than one pelvic chamber accounted for 77.4%) (p<0.001).
Conclusions: Dynamic MR of the pelvic floor helps to diagnose in details the characteristics of the rectocele and other pelvic organ prolapse, helping clinicians to choose the appropriate treatments.
* Bp mon Chan 3oan hinh anh.
D^i hoc Y Duac Thanh pho Ho i
Chi Minh I
DI^N QUANG VilT NAIH So 15 - 4 / 2014
NGHIEN c u l l KHOA HOC
I. DAT V A N D £
Sa tryc trang kilu till (STTKT) duac dinh nghTa la tinh trang thoat vj cua thanh truac true trang vao thanh sau Sm dgo Bpnh rIt pho bien a nu' giai vai tan s u i t b$nh thay doi tCF 20-80% I'^i. Tuy nhien, chi 20-70%
trong so nay c6 bleu hien trieu chifng lam s^ng nhu cam giac c6 khoi phong vung chau, dau vting chSu, dai tipn khong h i t phan, phai dQng tay trp giijp khi dai tien
"•"1... Nguyen nhan sinh b$nh d i n nay van chua r5 rang, thuang la do sy ket hpp cua nhieu yeu t l nguy ca nhu tao bon, benh co that ca mu tryc trang, ton thuang mac 3m dgo true trang bam sinh hay mac phai vi Ian tuoi, tien su co ph^u thuat viing ch§u va do qua trinh sinh de. Quyet d|nh d i l u trj va lya chpn phuang phap phlu thugt cho STTKT can dua v^o benh su, tham kham lam sang va danh gia d6ng hpc tong phan N l u chi dya vao tham kham bang tay thi de nhim l l n STTKT vai sa cac c l u triic khac nhu bang quang, t u cung hay rupt non..
hogc bo sot c h i n doan trong nhQ'ng truang hpp co sa dong thai nhieu tang vung chau.
Nam 1991, Ian d i u tien cac tac gia Yang, Kruyt va cpng sy '^-^i da LFng dung s y phat trien cac chuli xung nhanh trong cpng huang tiy de t i l n hanh khao sat dpng hpc s^n chgu. Vai hinh anh ro net, dp phan giai cao va benh nhan khong bj anh huang cua tia X, phuang tien nay d3 d i n thay the cho X quang d^ng hpc t i n g phan trong c h i n doan cac roi loan phCrc tap cua san chau.
Trong nghien CLFU nay, chung toi khao sat dac diem hinh anh cua STTKT tren nhang benh nhan cd cac bieu hien r l i loan chO'c nang san chau bang ky thuat chup cpng huang ILF d$ng.
II. D 6 | T U - O N G V A P H U - O N G P H A P N G H I E N CLPU
Doi tygng nghien cuu la nhung bpnh nhan nu, co cac bilu hien r l i loan chiFC nang san chau noi chung, dup'c chi djnh chyp cpng huang tLF bai cac bac sT chuyen khoa tiet nieu, phy khoa hoac hau mon tryc trang. Chung toi loai bo nhu'ng truang hap benh nhan khong hap tac t i t hoac phat hien co khoi u viing chau, u tnic trang, benh Hirschprungs.
Phuang phap nghien CLFU la mo ta c i t ngang, trong khoang thai gian 4,5 nam, tLF thang 01/2008 d i n
th^ng 06/2012, tai Benh vien Dai hpc Y Dup-c Thanh p h i Ho Chi Minh.
Cach thipc tien hanh: Bam gel siSu sim vao tryc trang t?o cam giac mac dai tipn. Dat benh nhan nam ir t u t h i FOWLER vcfi cudn thu tin hi#u byng q u i n ngang vung chUu. Sil dung may cpng huang tCF kin AVENTO 1.5T vai cac chuli xung T2 HASTE va TRUFISP, ghi hinh san ch$u a m | t cat ngang, dpc va doc giua qua cac thi nghi, thot, r$n t i n g phan va lam nghiem phip Valsalva.
TiSu chuan chan doan sa cac khoang ch$u vIn con nhieu tranh cai do nhung nghien CLFU danh giS dpng hpc trSn nguai binh thuang co ca m l u qua nho, chua dai dien duyc cho dan so. Chiing t6i lya chpn theo phIn Ian tac gi^ s u dung duang mu-cut 13m mic
Mot so djnh nghTa va tieu chuan danh gia s^n chiu'^'^O'ii'^^'is'
- San chau dup'c chia thanh cac khoang: trudc, giija, sau va tui cung Douglas; cac khoang lln lypt chua cac t^ng tuang irng la bang quang, t u cung/tiln het tuyen, hau mon-tryc trang va tui cung. Tui cung co the chiFa rupt non, dai trang ch$u hong hay mQ phuc mac
- Gdc hau mon-tryc trang: la goc tao bai tryc cua I n g hgu m6n va duang t i l p tuyen vai thanh sau dogn xa cua true trang. Giao diem cua hai duang nay chinh la ch5 noi hau mon-tryc trang.
- Dyd'ng mu-cyt: dud'ng n6i ba dud'i khap mu din khap giQ-a hai xuang cut c u l l cung.
- Sa cac ca quan san ch§u: Danh gia khoang c^ch trgn du6'ng vuong g6c n l i tLF cho thap nhIt cua c^c tang chau den d y a n g mu-cut. D6 sa san ch§u sau chia ra 4 muc' binh thuang: 0-<2 cm, dp 1: 2-<4 cm, dp II:
4-<6 cm, dp III: >6 cm. Dp sa cCia cac c l u triic khac chia thanh 3 miFc: dp I: <3 cm, do II: 3-<6 cm, dp III: >6 cm.
- Sa tryc trang kieu tui: thanh true trSng phing ra truac >0,5 cm so vai v\ tri binh thuang. Tui nay c6 th^
dupe phan loai dua vao dp sSu cua tui (d6 I: < 2 cm, dp II: 2-4 cm, dp III: >4 cm) hay xep loai hinh thai tiii sa theo tac gia Marti (logi i: kieu hinh ngon tay, logi II: kilu hinh tui, loai III: tui sa kem l6ng hoac sa tn/e trang).
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- Long tryc trang-hau mon: la sy phat trien nep gap >0,3 cm 15m vao thanh tryc trang khi ran. N i p g i p nay cd the la niem mac hay toan bp thanh tryc trang.
PhSn bipt long tryc-truc trang khi k h l i long con nam trong tryc trang, l i n g tryc trang-hau mon khi k h l i long n l m trong vCing I n g hau mon va gpi la sa true trang khi khoi long sa h i n ra ngoai.
- Bpnh CO t h i t ca mu true trang duac chan doan dya vao cac yeu t6 gai ^ sau:
+ Goc hau mon-tryc trang giam it ho^e tang it trong thi ran so vai thi nghi.
+ Co hinh anh I n 16m phia thanh sau tryc trang ciia ca mu tryc trang hoac ca that h|u mon trong thi r$n.
•^ T i n g gel it han 2/3 lupng gel ban d i u trong khoang 60 giay.
+ B I day ca mu true trang trong thi ran Ian han trong thi nghi.
Cac trieu c h i f n g lam sang chia 5 nhom:
1. Roi logn dgi tien vai dai tien <3 ngay/lan hoac dai tipn kho, ran nhilu, thai gian d^i tien lau, khdng h i t phan sau dgi tien, phai dung tay trp giup khi dai tien.
2. Roi logn di tieu: tieu son, tieu khong kiem seat.
3. Cam giac dau/trin nang hoac co khoi chen ep a vung ehgu/hau mon.
4. 0 6 khoi sa sinh due, sa tryc trang ra ben ngoai.
5. Giao hp'p dau.
Chung toi t i l n h^nh kham bpnh nhan va ghi nh$n cac y l u t l : trieu chLFng lam sang, so Ian sinh con, tien SLF cat tLF cung, dac diem STTKT (dp sau tui, hinh thai, it dpng gel trong tui sau tong phan), dp sa cac t?ng trong eac khoang chau va b$nh co t h I t ca mu tryc trang.
So lieu d u a c x u ly b I n g phan mem STATA. Dung cac phep thiF so sanh gia trj trung binh. danh gia anh hyang cCia yeu to t u l i , sinh con vdi STTKT; eac kieu phan do ciJa STTKT va miFc d6 u gel; moi lien quan cua STTKT vai bfinh ly co that ca mu tryc trang, s y ket hp'p vai sa eac tang chau khac Phep kiem co y nghTa thong kg khi p<0,05.
III. K^T QUA
Nghien CLFU cua chung toi duac tien hanh tren 1.683 bpnh nhan vai do tuoi tu' 14 den 9 1 , tuoi trung binh la 48 ± 15. Lira tuoi 30-60 chiem ti le kha cao, nhilu nhIt la nhom 40-49 tu6i (25,0%).
Bieu do 1. Bieu dd phan phdi benh nhan theo tudi (dwang dwt net)
S6 benh nhan dS tu'ng sinh con la 1.456 (86,5%) vai s6 con tu 1-14, nhom cd 2-3 con chilm ti le gan 60,0%. Co 50 truang hpp (3,0%) da c i t tLF cung.
Trieu chu'ng lam sang vai b i l u hien roi logn dai ti^n chilm tl le nhieu nhlt.
121S
1
TCI TC2 TC3 TC4 506Bieu do 2. Phan bo cac lo^i tri$u chOng lam sang Ti ie sa tryc trang kieu tui la 77,9%, kich thuac tiii trung binh la 2,8 cm, chilm nhieu nhat la loai STTKT CO kich thyac a miFc dp II va hinh thai Marti 1. Ti le cac till sa CO kich thyac nho trong nhom Marti I la cao nhat va till sa cd kich thuac Ian dp III trong nhom Marti III la cao nhat.
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NGHIEN CUtJ KHOA HOC
Kiem dinh tinh khuynh huang cho thIy kich thuac tui cang Ian thi kha nang u' dong gel trong tiii cang tang va nguy ca LP gel a STTKT loai hinh thai Marti II la cao nhlt, ke den la loai Marti III, nguy ca thap nhat la Marti!
(p<0,001).
Bang 1. Phan do theo kich thwac va hinh thai Marti cua sa tri/c trang kiiu tui Phan dp kich thipo'C
Phan do hinh thai Marti 1 Marti II Marti III
D p i Tan so
288 12 24
Ti le % 36,5
3.8 11.5
D o i i T i n so
462 278 162
Ti le % 58,6 88,5 77,9
Do III Tan so
39 24 22
Ti 1$ % 4,9 7,6 10,6
Co moi hen quan c6 y nghTa thing ke giua STTKT vo'i cac yeu t l tuli, so con vp'i OR l l n luat la 0,98 (p<0,001) va 0,92 (p<0,003). Tuy nhien, khi xem xet dong thai tac dpng cua hai yeu t l nay thi chi eo yeu t l tuoi mdfi thyc sy eo lien quan vai STTKT (p<0,001)
Tuang ty, khi xet tac dpng cua yeu to tuoi va y l u to da tLPng sinh con (khong xet tai s i con) vdi STTKT, chung toi nhan thay ca hai yeu to nay d i u co m l i lien quan co y nghTa thing ke Nguy ca hinh thanh STTKT a phy nu" da tO'ng sinh eon cao gap 2,64 l l n so vai nguai chua tCrng sinh con (p<0.001).
Co 165/1683 (9,8%) truang hap co d i u hieu gai y c h i n doan benh co thIt ca mu true trang. Trong s6 nay.
CO 64,2% truang hpp co STTKT.
Ti le CO STTKT kem bat thuang tCFng khoang chau
nhu sa bang quang, tiF cung, san chau sau va tiii cung Douglas l l n lupt la 69,2%; 54,0%; 95,4% va 19,4%.
Bang duai trinh bay ti le co STTKT k i t hap sa cac khoang san chau.
Bang 2.
So iLfffng l^hoang chau 0 1 2 3 4
Tan so 53 283 261 540 174
Ti If % 4 21,6 19,9 41.2 13,3
Hinh 1. STTKTcfp//Mart// Hinh 2. STTKT do It Marti III va sa bang quang
BKNqUANGVIETNAIVI S6 1 5 - 4 / 2 0 1 4
NGHIEN CUU KHOA HOC
IV. BAN LUAN
CJ nuac ta, truac day viec c h i n doan va d i l u tn cac r l i loan chipc nang vung chau duac thyc hien rieng biet a tCFng chuyen khoa. Trong do, STTKT chii y l u dupe chan doan dya vao ky thuat chup X quang dpng t i n g phan vai l i l u chieu tuang duang va lieu chieu co quan sinh due eho mpt Ian khao sat kha c a o ' " ' . Tuy nhien, ky thuat nay chi thyc hien dan gian vai thulc can quang bam vao true trang nen khong khao sat dupe cac khoang chau a phia truac, gay anh huang d i n k i t qua dieu tn. TLF khi chuyen khoa san chau hpc phat trien, viec ung dyng e6ng huang tLF dpng da d i n thay t h i cho X quang. Vai nghign CLFU nho trong nuac cQng da cho thay duac vai tr6 cCia c6ng huang ILF trong chan doan eac benh ly san ch$u (^s.i6.i7)
Tuang t u vai eac nghien CLFU truac day, k i t qua eua chiing toi thyc hi§n tren benh nhan co cac bieu hien r l i loan chu-c nang san ch$u co ti le STTKT kha cao, t$p trung nhieu a tuoi trung nien va nguy ca cao g I p 2,7 Ian d nhCrng ngyai da tirng sinh con (kh6ng ke so l l n sinh).
Vi tuoi va s i Ian sinh con lidn quan co y nghTa thing ke nen khi xet d i n g thai 2 yeu to nay vai nguy ca hinh thanh STTKT thi k i t qua cho thIy tuoi mai co lien quan thyc sy. Tuy nhien, dSy Igi la tuang quan nghich nhe va khong dang ke, vai so tuoi tang them 1 thi nguy ca CO tui sa lai giam di 1,02 Ian. D i l u nay co the duac giai thich bai tinh khong dong nhat cua m l u nghien CLFU, m l u dup'c lay tren nhom dan so co nhieu bieu hien roi loan san ch$u noi chung.
Ben cgnh do, s u phoi hpp STTKT kem sa nhieu khoang chau chiem ti le cao, giong nhu cac nghien CLFU truac day cung da dup'c chifng minh i^-^.'o isi
Cac k i t qua la minh chirng ro rang, chung minh cho thuylt toan ven t h i n g nhat cua san chgu, cung nhu anh huang cua yeu to tuoi tac va sang chan trong qua trinh sinh de, gay ton thuang eau true lien k i t nang da vCing ch§u.
Ti le benh nhan STTKT co bieu hien trieu chirng lam sang thay doi rIt da dang 23-70% va cung co the hoan toan khong co trieu chung. Trong nghien CLFU cua chung toi, cd 56% benh nhan STTKT co cam giac eo khli chen ep vung chau, tao bon, dai tten kho hay di ngoai khong het phan phai dung tay trp giup, d i l u nay phu hap vai ket qua nghien ciru eiia tac gia Yoshioka*^"
va Johansson'^"* la 59 - 70,7%.
Tl le STTKT a nhom benh nhan eo d i u hieu benh ly CO thIt ca mu tryc trang ciia chung toi la 64,2%, tuang t y vai tac gia Siproudhis'^^' va Johansson'^"' la 62 - 7 1 % . Sy CO that cua ca mu tryc trang gay t i c nghen duang ra ciia phan, giam kha nang tong phSn va gay dai tien kho, tang nguy ca hinh thanh STTKT
Tham kham lam sang c6 the c h i n doan dupe STTKT nhung dp sau va hinh thai cua tiii, s u iF dong sau thi ran t i n g phan va cac b i t thuang khac di kem cua san chau thi chi co the thay dupe tren hinh anh dpng. Danh gia toan dien va xem xet them cac bieu hien lam sang giiip di d i n quyet dinh dieu trj p h l u thuat diing dan. Ket qua ciia chiing toi eho thay, eac tui sa CO dp sau Ian > 2 em vcfi hinh thai c l tui hep hoac co kem l i n g (Marti II va III) thi nguy ca LF dong trong tiir tang, tuang t y vai nhan djnh ciia cac nghien CLFU tru'ac (3ayi'''"'oi.
Han c h i trong nghien cuu nay la khong co nhom chiFng (khong c6 bieu hien cac r l i loan san chau) va chua CO s u ket hpp vai bac sT lam sang de so sanh.
V K^T LUAN
STTKT la benh pho b i l n vai lam sang khong dac hieu va thuang c6 kem theo sa cae tang khac cua vung chau. Vi vay chan doan benh ly vung san chau c i n chinh xac va toan dien. Cpng huang ILF dpng san chau thyc s y la phuang tien hieu qua khong the thilu de danh gia toan bp vung chau, tLF do vach ra k l hoach d i l u tri phu hap va hieu qua.
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T A I LIEU THAM K H A O
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Results of rectocele repair, a prospective study. Dis Colon Rectum, 38:764-8.
2. Saries JC, Amaud A, Sielezneff I, Olivier S (1989). Endo-rectal repair of rectocele. Int J Colorectal Dis, 4:167-71.
3 Halligan 3. Bertram CI (1995). Is Barium trapping in rectoceles significant? Dis Colon Rectum, 38:764-8.
T. Van Dam JH, Ginai AZ, Gosselink MJ (1997).
Role of defecography in predicting clinical outcome of rectocele repair Dis Colon Rectum, 40:201-7.
5. Yang A, Mostwin JL, Rosenshein NB, Zerhounl EA (1991). Pelvic floor descent in women: dynamic evaluation with fast MR imaging and cinematic display Radiologyl79:25-33.
6. Kruyt RH, Delemarre JB, Doornbos J, Vogel HJ (1991). Normal anorectum: dynamic MR imaging anatomy Radiology, 179:159-163.
7. Andrew Yang, Jacek L Mostwin, Neil B.
Rosenshein (1991). Pelvic Floor Descent in Women:
Dynamic Evaluation with Fast MR Imaging and Cinematic Display. Radiology, 179(1): 25-33.
8. Jeremiah C Healy, Stephen Halligan, Rodney H. Reznek (1997). Dynamic MR Imaging Compared with Evacuation Proctography when Evaluating Anorectal Configuration and Pelvic Floor Movement. AJR, 169:
775-779.
a. Fustus E.Roos, Dominik Weishaupt, Simon Wildermuth (2002). Experience of 4 Years with Open MR Defecography: Pictorial Review of Anorectal Anatomy and Disease. RadioGraphics. 22: 817-832.
10. Julie R.Fielding (2002). Practical MR Imaging of Female Pelvic Floor Weakness RadioGraphics 22:295-304
11. Lamb GM, De Jode MG, Guold SW (2000).
Upright dynamic MR defeacating proctography in an open configuration MR system. The British Journal of
Radiology 73:152-155.
12. Zoran L Barbaric, Alan K. Marumoto (2001).
MRI of the Perineum and Pelvic Floor. Topic in Magnetic Resonance Imaging 12:83-92.
13. Chu WC, Tam YH, Lam WW (2007). Dynamic MR assessment of the anorectal angle and puborectalis muscle in pediatric patients with anismus: Technique and feasibility J Magn Reson Imaging 25:1067-72.
14. Reginald Goal, Gerrit Kemerink (1990).
Radiation Dose in Defecography. Radiology 176:137- 39.
15. Nguyin Thi Thuy Llnh, Vo Tin DCrc, Ph^m Ngoc Hoa (2008). Vai tro cua cong hwang twd^ng vung san chau trong chin doan roi loan sw thoit phan. Tap chi Yhoc Vietnam, 349:85-89.
16. Nguyin Thi ThOy Linh, Vd Tin Dwc, Pham Ngoc Hoa (2009). Cong hwdng tw ddng trong danh gii cac benh ly vung san chau. Tap chi Y hQC TPHCM, 13:292-297.
17. Nguyin Trung Vinh (2010). Nh$n xetbwdcdku phiu thu$t phuc hdi ban sau ca nang hau mdn trong diiu tri hoi chung sa san chau. Tap chi Yhoc TPHCM, 14:263-268.
18. Smith AR (1994). Role of connective tissue and muscle in pelvic floor dysfunction. Curr Opin Obstet Gynecol, 6:317-19.
19. Siproudhis L, Dautreme S. (1993). Dyschezia and rectocele-a marriage of convenience? Physiologic evaluation of the rectocele in a group of 52 women complaining of difficulty in evacuation. Dis Colon Rectum, 36:1030-6.
20. Johansson C. Nilsson BY (1992). Association between rectocele paradoxical sphincter response. Dis Colon Rectum, 35:503-9.
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Physiologic and anatomic assessment of patients with rectocele. Dis Colon Rectum, 34:704-8.
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TOM T A T
D^t van de; Sa true trang kiiu tui (STTKT) la si/phdng hoac sa thanh trwac trwc trang vao thanh sau am d^o.
Benh kha pho biin vai cac biiu hien lam sang da dang, khong dac hieu. Tham kh^m lam sang di chin doan nhim va / ho$c bo sot sa cac tang khac cua vung chau. Hinh anh hoc danh gia chirc nang dong cua san chau la mot phuKrng tien khdng thi thiiu trong chan doan, dac biet la cong hwang tw.
Phifong phap nghien ciru: Md ta cit ngang. Cac benh nhan co biiu hien roi loan chwc nang san chau dwac kham va chi dinh chup cong hw&ng tu- dong tai Benh vien Dai hoc Y Dwac Thanh phd Hd Chi Minh, bai nhung bac sT chuyen khoa hau mdn trwc trang, tiit nieu va phu khoa.
Kit qua: Co 1.683 benh nhan dwac nghien cuv tir thang 1-2008 den thang 6-2012. trong dd chu yiu la nw, tuoi trung nien va da tCmg sinh con. Vile STTKT vai do sau tui 2-4 cm la 77,9%, kiiu hinh thai dang ngon tay chiem da so. Kich thwac >2cmva hinh thai kiiu tui co nguy ca w dong cao. Yiu to tudi va da tOng sinh con co lien quan vdv STTKT va co y' nghia thSng ke (p<0,001). 77 te STTKT trong nhom benh ly co that ca mu trwc trang la 64,2%. Sw kit hap sa nhiiu han mot khoang chau vai STTKT la 74,4%> (p<0,001).
Ket luan: Chup cpng hw&ng tir dong san chau giup chan doan chinh xac cung nhw danh gia chi tiit d$c diem cua STTKT va sa cac tang ch$u, giup bac sT lam sang dinh hwdng Iwa chon phwang phap diiu tn thich hap.
NGUCl T H A M D ! N H : PGS.TS Lam Khanh
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