| ObjectiveThis study is divided into four groups of healthy women,female patients with rectal prolapse,healthy men and male patients with rectal prolapse,using magnetic resonance imaging data to reconstruct pelvic floor tissue(including levator ani muscle and bony pelvis)with healthy adults and patients with rectal prolapse.Through the observation of the two-dimensional magnetic resonance images,as well as to measure and analyze the parameters of levator ani muscle about supporting functions and bony pelvis morphological characteristics on the three-dimensional model.In order to use magnetic resonance data to reflect the space structure and relations about bony pelvis and levaor ani muscle on healthy adults and patients with rectal prolapse,to evaluate the function and change on the pelvic floor tissue,to explore the pathogenesis and clinical manifestations of rectal prolapse,to provide references for clinical diagnosis,treatments and curative effect evaluation on patients with rectal prolapse.Methods1.The research objects are recruited 12 healthy women and 11 healthy male volunteers,as well as 11 female patients and 9 male patients with rectal prolapse diagnosed in Guang,an men Hospital,Chinese academy of traditional Chinese medicine during the November 2015 to February 2017.Routine MRI scanning and 3-dimensional T2 SPACE axis positioning sequence scanning up to the sacral promontory and down to 1 cm under the perineal area respectively for 4 groups.Savethe original data in Dicom format.2.Analysis the original data on MRI,levator hiatus shape,iliococcygeus form and damage or break defect on levator ani muscle.3-dimensional T2 SPACE original data was electronically transferred into a software called Mimics 19.0 for production of 3D models of levator ani muscle and bony pelvis.The model exported by STL format.3.To observe the morphological features of levator ani muscle and bony pelvis on reconstructed 3-dimensional models,to measure the width,length of levator hiatus(LHW,LHL),levator symphysis gap(LSG-L,LSG-R),levator plate angle(LPA),levator muscle volume(LUOL),width of the iliococcygeus(ICW-L,ICW-R),and iliococcygeal angle(ICA-L,ICA-R)were measured to assess the levator ani morphology;while the pubococcygeal line(PCL),interspinous diameter(IS),intertuberous diameter(IT)and angle of the pubic arch(PAA)were measured on the 3-dimensinal models to characterize the bony pelvis morphology.4.The parameters of levator ani muscle and bony pelvis on Healthy women and female patients with rectal prolapse in 2-dimensional images and 3-dimensional models were compared to analyze the pelvic floor change features on female patients with rectal prolapse.5.The parameters of levator ani muscle and bony pelvis on Healthy women and healthy men in 2-dimensional images and 3-dimensional models were compared to analyze the features of female and male pelvic floor tissue morphology.6.The parameters of levator ani muscle and bony pelvis on Healthy men and male patients with rectal prolapse in 2-dimensional images and 3-dimensional models were compared to analyze the pelvic floor change features on female patients with rectal prolapse,in order to help explaining the etiology and pathogenesis on patients with rectal prolapse.7.To observe and compare the distribution of TCM syndrome pattern on female and male patients with rectal prolapse,the theoretical guidance of traditional Chinese medicine is highlighted,and the modern concept of 3-dimensional reconstruction is combined with the emphasis on interdisciplinary and complementary advantages to enrich the etiology and pathogenesis theory of rectal prolapse.Results1.The 3-dimensional reconstruction on healthy female pelvic floor tissue(1)General conditions:12 healthy female volunteers,average age was 53.31±4.39,the average Body Mass Index was 23.32±1.45kg/m2,the mean number of vaginal delivery was 2.26±0.56 times.(2)Analysis of two-dimensional images features:12 cases of healthy women levator hiatus shape were with 8 cases of "V",2 cases of”O",1 case 'of "U",1 case of irregular shape;10 cases of iliococcygeus form were "vault",2 cases "horizontar",and damage or break defect on levator ani muscle were 2 cases on the left side injury,2 cases on the right injury,8 cases of no damage.(3)Analysis of 3-dimensional models features:measurement results about Parameters of levator ani muscle:LHW 36.67±5.32mm,LHL 59.32±4.11mm,LSG-L 23.32±2.87mm,LSG-R 24.83±2.67mm,LPA 43.31 ±3.79°,LVOL 24.89±5.88mm3,ICW-L 36.32±4.67mm,ICW-R 38.77±4.99mm,ICA-L 33.86±5.21°,ICA-R 36.21 ±4.880.(4)Analysis of 3-dimensional models features:measurement results about Parameters of bony pelvis:PCL 103.35±8.32mm,IS 110.32±7.33mm,IT 122.56±8.56mm,PAA 92.22±7.33°.2.The 3-dimensional reconstruction on female patients pelvic floor tissue with rectal prolapse(1)General conditions:11 female patients with rectal prolapse,average age was 56.11 ±5.75,the average Body Mass Index was 24.21 ±2.33kg/m2,the mean number of vaginal delivery was 2.10±0.74 times.There was no statistical significance on age,BMI and the mean number of vaginal delivery between the healthy and the female patients with rectal prolapse.(2)Distribution of TCM syndrome pattern:collapse from qi deficiency,the most common(6 cases,54.55%),followed by deficiency of qi and blood,unconsolidation of kidney-qi,36.36%and 9.09%respectively(4 cases and 1 cases),and syndrome of dampness-heat diffusing downward did not see.(3)Analysis of two-dimensional images features:11 cases of female patients with rectal prolapse levator hiatus shape were with 7 cases of "O",2 case of "U",2 case of irregular shape;2 cases of iliococcygeus form were "vault",1 cases "horizontal",8 cases "Funnel",and damage or break defect on levator ani muscle were 5 cases on the left side injury,4 cases on the right injury,2 cases on both sides.(4)Analysis of 3-dimensional models features:measurement results about parameters of levator ani muscle:LHW 42.01±4.12mm,LHL 66.22±7.33mm,LSG-L 30.00±6.54mm,LSG-R 29.55±5.36mm,LPA 50.12±8.33°,LVOL 23.11 ±4.26cm3,ICW-L 39.56±3.11mm,ICW-R 38.91 ±2.57mm,ICA-L 35.97±4.91°,ICA-R 36.36±5.57°.There was no statistically significant difference between deficiency of qi and blood and collapse from qi deficiency about parameters of levator ani muscle on female patients.LHW?LHL?LSG-L?LSG-R?LPA increased in female patients with rectal prolapse than healthy women,the differences were statistically significant;LVOL decreased and ICW-L?ICW-R?ICA-L?ICA-R increased in female patients with rectal prolapse than healthy womenA,there was no statistically significant difference.(5)Analysis of 3-dimensional models features:measurement results about Parameters of bony pelvis:PCL 108.77±6.89mm,is 109.89±7.74mm,IT 123.08±7.55mm,PAA 92.75±8.21°.There was no statistically significant difference between deficiency of qi and blood and collapse from qi deficiency about parameters of bony pelvis on female patients.Compared with healthy women,IS decreased,PCL?IT and PAA increased,there was no statistically significant difference;PCL line was only statistically significant difference.3.The 3-dimensional reconstruction on healthy male pelvic floor tissue(1)General conditions:11 healthy male volunteers,average age was 54.56±3.11,the average Body Mass Index was 23.64±1.72kg/m2.There was no statistical significance on age,BMI between the male and the female.(2)Analysis of two-dimensional images features:11 cases of healthy men levator hiatus shape were with 8 cases of "V";11 cases of iliococcygeus form were "vault";and damage or break defect on levator ani muscle were no person.(3)Analysis of 3-dimensional models features:measurement results about Parameters of levator ani muscle:LHW 30.51 ±3.99mm,LHL 51.57±5.54mm,LSG-L 19.11 ±3.53mm,LSG-R 20.18±4.21mm,LPA 39.19±4.43°,LVOL 43.21 ±7.39cm3,ICW-L 51.03±5,89mm,ICW-R 50.56±3.21mm,ICA-L 38.52±4.89°,ICA-R 38.05±5.29°.LHW?LHL?LSG-L?LSG-R?LPA decreased in the male than the female,the differences were statistically significant;LVOL?ICW-L?ICW-R?ICA-L?ICA-R increased in the male than the female,the differences were statistically significant.(4)Analysis of 3-dimensional models features:measurement results about Parameters of bony pelvis:PCL 80.36±6.26mm,IS 103.83±5.42mm,IT 96.47±6.33mm,PAA 76.31 ±5.370.Compared with the healthy female,PCL?IS?IT and PAA decreased,the differences were statistically significant.4.The 3-dimensional reconstruction on male patients pelvic floor tissue with rectal prolapse(1)General conditions:9 male patients with rectal prolapse,average age was 52.79±2.58,the average Body Mass Index was 23.80±2.03kg/m2.There was no statistical significance on age and BMI between the healthy male and the male patients with rectal prolapse.(2)Distribution of TCM syndrome pattern:similar to female rectal prolapse,collapse from qi deficiency,the most common(6 cases,66.67%),followed by unconsolidation of kidney-qi(3 cases,33.33%),deficiency of qi and blood and syndrome of dampness-heat diffusing downward did not see.(3)Analysis of two-dimensional images features:9 cases of male patients with rectal prolapse levator hiatus shape were with 7 cases of "Vn" 2 case of "U";6 cases of iliococcygeus form were "vault",2 cases "horizontal",1 case "Funnel",and damage or break defect on levator ani muscle were 2 cases on the left side injury,2 cases on the right injury,6 cases on both sides.(4)Analysis of 3-dimensional models features:measurement results about Parameters of levator ani muscle:LHW 37.96±4.59mm,LHL 61.55±7.01mm,LSG-L 24.75±4.13mm,LSG-R 27.92±5.43mm,LPA 46.74±5.26°,LVOL 31.94±6.28mm3,ICW-L 53.72±6.71mm,ICW-R 51.86±3.47mm,ICA-L 39.51±3.91°,ICA-R 38.20±4.70°.There was no statistically significant difference between unconsolidation of kidney-qi and collapse from qi deficiency about parameters of levator ani muscle on male patients.LHW?LHL?LSG-L?LSG-R?LPA increased in male patients with rectal prolapse than healthy men,the differences were statistically significant;LVOL decreased and ICW-L?ICW-R?ICA-L?ICA-R increased in male patients with rectal prolapse than healthy men,only the difference of LVOL was statistically significant.(5)Analysis of 3-dimensional models features:measurement results about parameters of bony pelvis:PCL 95.41 ±8.57mm,IS 105.32±6.19mm,IT 126.88±5.71mm,PAA 77.01 ±4.70°.There was no statistically significant difference between unconsolidation of kidney-qi and collapse from qi deficiency about parameters of bony pelvis on male patients.Compared with healthy men,IS?PCL?IT and PAA increased,there was no statistically significant difference with IS and PAA;PCL and IT were of statistically significant difference.Conclusions1.Using MRI volume scan data obtained 3-dimensional reconstruction,guarantee the continuity and integrity of the 3-dimensional models,can reflect the pelvic floor tissue structure and relations of the healthy and the patients with rectal prolapse.The 3-dimensional models of pelvic floor tissue can observe the 3-dimensional anatomic structures and morphological characteristics of levator ani muscle and bony pelvis.2.The reconstruction 3-dimensional models were the basis of 3-dimensional finite element analysis,through the analysis of mechanics of the pelvic floor tissue,get the mechanical change of the structure and morphology change processes under different mechanical effect,can evaluate mechanical characteristics of pelvic floor support system using 3-dimensional digital models instead of living tissue,providing a new thought and way to the research of rectal prolapse.3.Distribution of TCM syndrome pattern on female and male patients with rectal prolapse:the most common was collapse from qi deficiency,followed by deficiency of qi and blood,unconsolidation of kidney-qi.4.The change of levator hiatus shape,size and fracture defect of levator ani muscle could be one of the factors which lead to rectal prolapse,not all patients with rectal prolapse were with change of the shape and size of levator hiatus or the damage and fracture defect of levator ani muscle.Compared with the change of iliococcygeus form,change of the shape of puborectalis and pubococcygeus were more likely to cause the disease of rectal prolapse.5.Sex differences of levator ani muscle and bony pelvis were accompanied by functional differences.In order to meet the production,The proportion of female bony pelvis is more with volume than the male.And male muscles were stronger,structure were relatively bulky.While female were relatively thin,muscles were more mild,pelvis were more lighter.6.Compared with the change of interspinous diameter and intertuberous diameter,the pubococcygeal line is likely to be one of the reasons for rectal prolapse.7.Due to pregnancy and childbirth physiological processes,the female were more likely to cause damage or fracture defects with levator ani muscle,which can lead to abdominal cavity pressure interruption along levator ani muscle transmission,make the pressure to focus on the weak of levator ani muscle,and the pelvic floor support system build new mechanics balance.When a new equilibrium was damaged over time,pelvic floor support system will completely lose force balance,and the abdominal pressure make the increasing of levator hiatus,leading to the occurrence of rectal prolapse.The study help us to learn the theoretical basis of the mechanism of rectal prolapse from the perspective of pelvic floor mechanics balance. |
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