女性压力性尿失禁的MRI研究
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摘要
目的：
压力性尿失禁(SUI)属于盆底功能障碍性疾病(PFD),绝大多数见于女性。关于SUI的发病机制有诸多理论,主要包括压力传导理论、“吊床”假说、盆底整体理论等,这些理论均认为SUI发生直接或间接地与尿道周围支持结构薄弱有关。尿道支持韧带及肛提肌共同作用以维持控尿,同时尿道的活动度与尿道支持韧带及肛提肌密切相关,而目前对于尿道支持韧带组成仍然存在争议。MRI具有多方位、高软组织分辨率的成像优势,可直接显示尿道支持结构,从而利于评价尿道支持韧带的形态学改变。利用MRI技术观察正常的尿道支持韧带的组成、形态及走行,进而与SUI患者的尿道支持韧带的形态学变化进行对照研究；同时采用动态MRI成像技术观察、比较正常健康女性和SUI患者的肛提肌的功能状态及尿道活动度的变化,以评价MRI在SUI诊断中的作用。另外,通过对进行经闭孔尿道吊带术(TOT)治疗的SUI患者术前及术后1周的MRI检查结果的对比分析,以明确MRI对SUI患者术后尿道支持韧带及尿道活动度改变的评价作用,即MRI对手术短期疗效的评价作用。
材料与方法：
本研究利用MRI检查技术,对28例健康女性志愿者和16例SUI患者(其中7例伴有盆腔脏器脱垂)行静息及屏气用力状态下的盆腔MRI研究,采用常规轴位、矢状位、冠状位扫描。静息状态下的MRI用于观察正常健康女性及SUI患者尿道支持韧带的形态学表现；屏气用力状态下的MRI用于观察用力前后肛提肌及尿道活动度变化情况；同时测量二种状态下H线、M线、盆膈裂孔横径、尿道长度、尿道倾斜角、尿道膀胱后角、耻骨后间隙、膀胱尿道连接部至耻尾线距离及提肌板角,并对测量结果组间进行统计学分析。研究中测量数据距离单位为毫米(mm),角度单位为度(°),数据满足正态性分布,用均数±标准差进行描述；组间用配对t检验和两组独立样本t检验进行比较；非正态性资料用中位数M、第25百分位数P25和第75百分位数P75进行统计描述；组间比较用两组独立样本秩和检验。所有假设检验的检验水准为a=0.05。
结果：
1、正常人静息状态下尿道支持结构MRI表现
尿道的四组支持韧带包括尿道周围韧带、尿道旁韧带、耻骨尿道韧带和尿道下韧带,其在T1WI和T2WI上均表现为偏低信号,以T2WI更为显著,形态总体呈细条状,边缘锐利,围绕尿道分别呈“弧形”及“斜线”样走行。尿道周围韧带两端起自耻骨直肠肌的内侧面,经尿道的腹侧走行；尿道旁韧带为一对连接尿道侧壁和尿道周围韧带的斜线样结构：耻骨尿道韧带由尿道腹侧发出止于耻骨后方,呈悬带样；尿道下韧带为尿道背侧吊带样结构,向前侧方延伸与盆侧壁盆筋膜腱弓相连。尿道的支持韧带是固定尿道,防止尿失禁的重要结构。肛提肌主要由耻骨直肠肌、耻骨尾骨肌及髂骨尾骨肌构成,在T2WI像上均呈中等信号,包绕在尿道、阴道及直肠两侧,横断面白上由至下分别呈“扇形”、“V”、“U”形,三对肌肉之间没有明确分界。肛提肌能主动收缩对抗腹压增高,参与维持脏器的正常功能及位置。
2、正常人屏气用力状态下尿道支持结构的MRI改变
屏气用力状态下的MRI显示正常健康女性用力前后尿道支持韧带及肛提肌各组成部分形态无明显变化,盆膈裂孔横径平均增大2mm H线、M线用力后可有轻度增大分别为52.7mm、11.0mm(用力后H线<6cm、M线<2cm),提肌板用力前后与耻尾线基本平行,尿道倾斜角、尿道膀胱后角用力后轻度增大,分别为7.0°、4.0°,尿道长度平均缩短2.00mm。
3、SUI患者尿道支持结构的静态及屏气用力状态下的MRI改变
静息状态下SUI患者尿道的四组支持韧带有不同程度的形态学改变,总体上表现为韧带的松弛或断裂,其中尿道周围韧带常呈“波浪状”改变；尿道旁韧带表现为短缩；耻骨尿道韧带表现为与耻骨后盆筋膜腱弓分离；尿道下韧带表现为与盆侧壁的盆筋膜腱弓分离；屏气用力状态下上述改变仍存在,无显著性变化。SUI患者的肛提肌在静息状态下其形态学表现与正常人相近,但在屏气用力状态下肛提肌的形态变化比较明显,表现为耻骨直肠肌及耻骨尾骨肌向外后方膨隆,致使盆膈裂孔呈“O”形增大,髂骨尾骨肌呈“盘状”加深,伴有盆腔脏器脱垂(POP)者上述表现更为显著。屏气用力状态下H线>6cm、M线>2cm,提肌板向尾侧倾斜平均20°；尿道倾斜角增大,甚至呈水平位；尿道膀胱后角增大、消失；尿道长度平均缩短4.80mmm。
4、SUI患者术前与TOT术后1周MRI检查结果比较
静态及屏气用力状态下MRI上尿道的四组支持韧带及肛提肌形态未见改变；通过测量显示尿道的活动度较术前略有减小,经统计学分析后表明其差异无统计学意义。
结论：
1、MRI可以较好的显示尿道的四组支持韧带及肛提肌形态学特征,并可客观评价肛提肌的功能性状态及尿道活动度,从而对SUI患者术前诊断提供影像学依据。
2、MRI可以反映TOT手术后的SUI患者尿道周围支持结构及尿道活动度的变化情况,对手术近期疗效的评价有一定作用,若增加病例数及延长随访观察时间,有望对手术治疗效果作出客观影像学评价。
Objective:Stress urinary incontinence (SUI) is due to pelvic floor disfunction, most found in women. On the pathogenesis of SUI have many theories, including the pressure transmission theory, "hammock" hypothesis,and the integral theory. These theories consider that SUI occurs because of the urethra supporting structure defects. Urethral support ligaments and the ani levator muscles control urine, urethral mobility connects with urethral support ligaments and the levator ani muscles. The composition of the urethral support ligaments is still controversial. MRI can show the urethral support structures well. Using dynamic MRI we observe the composition, morphology and courses of the urethral support ligaments and ani levator muscles, and then compare with the patients with SUI. In addition, the SUI patients who accepeted TOT treatment before and. after operation 1 week had given MRI examination to understand the value of MRI in evaluating postoperative effect. Materials and Methods:28 healthy volunteers and 16 SUI patients in which 7 cases with POP accepted static and dynamic pelvic MRI examination. Static MRI observes urethral ligaments, dynamic MRI observes urethral activity and morphological changes of levator ani muscle, and under two states measure H line, M line, diameter of pelvic diaphragm, urethral length, urethral tilt angle, posterior urethrovesical angle, retropubic space, the distance from urethrovesical junction to the PCL and levator plate angle. The measurement results of groups were statistically analyzed. The datas according with normality using mean±standard deviation descriptions, between two groups using paired t test and two independent sample t test. Non-normal data using the M, P25 and P75 for the statistical description, between two groups using two independent sample rank sum test. All hypothesis testing standards were a= 0.05.
Results:1. Normal static MRI performance of urethral support structures The urethral support ligaments in T2WI are slightly low signal. Periurethral ligament originating from the inner side of puborectalis, running close to the ventral urethra; paraurethral ligament connecting the lateral wall of urethra to the periurethral ligament; pubourethral ligament originating from the ventral urethra to the posterior aspect of the pubic bone, was suspended with sample; suburethral ligament lying dorsal urethra hammock-like structure, connecting the urethra and pelvic arcus tendinous fasciae. The urethral support ligaments fix urethra and prevent SUI. Ani levator muscles compose of puborectalis, pubococcygeus and iliococcygeal muscle, in T2WI muscles showed a moderate signal. Levator ani muscle contraction can resist the increased abdominal pressure and maintain normal organ function and location.
2. Normal dynamic MRI changes of urethral support structures Healthy women ani levator muscles had no significant morphological changes, diameter of pelvic diaphragm, the H line, M line, posterior urethrovesical angle, retropubic space and the distance from bladder neck to the PCL increased slightly after force, urethral tilt angle, after force increase lightly. Levator plate always parallel to PCL.
3. Urethral support structures in static and dynamic MRI in patients with SUI SUI patients urethral support ligament changes, including laxity or rupture.Morphological changes of the levator ani is obviously, diameter of pelvic diaphragm increases, diaphragmatic hiatus was "O" shape in SUI with POP. H line> 6cm, M line> 2cm, levator plate caudal tilt average 20°. In SUI patients after force urethral length shorten, most or all of the urethra below the inferior edge of symphysis pubis; urethral inclination angle and posterior urethrovesical angle increase.
4. SUI patients before and after TOT 1 week MRI imaging examination results The modality of urethra support ligaments did not change, postoperative urethral activity improved, but the difference was not statistically significant. Conclusion: 1. MRI can better show the morphology of four urethral support ligaments and levator ani muscles,and can objectively evaluate the functionality status of the levator ani and urethral activity degree, and thus supply imaging evidence for preoperative diagnosis of SUI.
2. MRI can reflect the changes of urethral support structure and urethral activity of post-operative patients with SUI. MRI has a role in evaluation of curative effect of surgery. By increasing the number of cases and extending follow-up observation period, MRI is expected to give an objective image evaluation in surgical effect.
压力性尿失禁(SUI)属于盆底功能障碍性疾病(PFD),绝大多数见于女性。关于SUI的发病机制有诸多理论,主要包括压力传导理论、“吊床”假说、盆底整体理论等,这些理论均认为SUI发生直接或间接地与尿道周围支持结构薄弱有关。尿道支持韧带及肛提肌共同作用以维持控尿,同时尿道的活动度与尿道支持韧带及肛提肌密切相关,而目前对于尿道支持韧带组成仍然存在争议。MRI具有多方位、高软组织分辨率的成像优势,可直接显示尿道支持结构,从而利于评价尿道支持韧带的形态学改变。利用MRI技术观察正常的尿道支持韧带的组成、形态及走行,进而与SUI患者的尿道支持韧带的形态学变化进行对照研究；同时采用动态MRI成像技术观察、比较正常健康女性和SUI患者的肛提肌的功能状态及尿道活动度的变化,以评价MRI在SUI诊断中的作用。另外,通过对进行经闭孔尿道吊带术(TOT)治疗的SUI患者术前及术后1周的MRI检查结果的对比分析,以明确MRI对SUI患者术后尿道支持韧带及尿道活动度改变的评价作用,即MRI对手术短期疗效的评价作用。
材料与方法：
本研究利用MRI检查技术,对28例健康女性志愿者和16例SUI患者(其中7例伴有盆腔脏器脱垂)行静息及屏气用力状态下的盆腔MRI研究,采用常规轴位、矢状位、冠状位扫描。静息状态下的MRI用于观察正常健康女性及SUI患者尿道支持韧带的形态学表现；屏气用力状态下的MRI用于观察用力前后肛提肌及尿道活动度变化情况；同时测量二种状态下H线、M线、盆膈裂孔横径、尿道长度、尿道倾斜角、尿道膀胱后角、耻骨后间隙、膀胱尿道连接部至耻尾线距离及提肌板角,并对测量结果组间进行统计学分析。研究中测量数据距离单位为毫米(mm),角度单位为度(°),数据满足正态性分布,用均数±标准差进行描述；组间用配对t检验和两组独立样本t检验进行比较；非正态性资料用中位数M、第25百分位数P25和第75百分位数P75进行统计描述；组间比较用两组独立样本秩和检验。所有假设检验的检验水准为a=0.05。
结果：
1、正常人静息状态下尿道支持结构MRI表现
尿道的四组支持韧带包括尿道周围韧带、尿道旁韧带、耻骨尿道韧带和尿道下韧带,其在T1WI和T2WI上均表现为偏低信号,以T2WI更为显著,形态总体呈细条状,边缘锐利,围绕尿道分别呈“弧形”及“斜线”样走行。尿道周围韧带两端起自耻骨直肠肌的内侧面,经尿道的腹侧走行；尿道旁韧带为一对连接尿道侧壁和尿道周围韧带的斜线样结构：耻骨尿道韧带由尿道腹侧发出止于耻骨后方,呈悬带样；尿道下韧带为尿道背侧吊带样结构,向前侧方延伸与盆侧壁盆筋膜腱弓相连。尿道的支持韧带是固定尿道,防止尿失禁的重要结构。肛提肌主要由耻骨直肠肌、耻骨尾骨肌及髂骨尾骨肌构成,在T2WI像上均呈中等信号,包绕在尿道、阴道及直肠两侧,横断面白上由至下分别呈“扇形”、“V”、“U”形,三对肌肉之间没有明确分界。肛提肌能主动收缩对抗腹压增高,参与维持脏器的正常功能及位置。
2、正常人屏气用力状态下尿道支持结构的MRI改变
屏气用力状态下的MRI显示正常健康女性用力前后尿道支持韧带及肛提肌各组成部分形态无明显变化,盆膈裂孔横径平均增大2mm H线、M线用力后可有轻度增大分别为52.7mm、11.0mm(用力后H线<6cm、M线<2cm),提肌板用力前后与耻尾线基本平行,尿道倾斜角、尿道膀胱后角用力后轻度增大,分别为7.0°、4.0°,尿道长度平均缩短2.00mm。
3、SUI患者尿道支持结构的静态及屏气用力状态下的MRI改变
静息状态下SUI患者尿道的四组支持韧带有不同程度的形态学改变,总体上表现为韧带的松弛或断裂,其中尿道周围韧带常呈“波浪状”改变；尿道旁韧带表现为短缩；耻骨尿道韧带表现为与耻骨后盆筋膜腱弓分离；尿道下韧带表现为与盆侧壁的盆筋膜腱弓分离；屏气用力状态下上述改变仍存在,无显著性变化。SUI患者的肛提肌在静息状态下其形态学表现与正常人相近,但在屏气用力状态下肛提肌的形态变化比较明显,表现为耻骨直肠肌及耻骨尾骨肌向外后方膨隆,致使盆膈裂孔呈“O”形增大,髂骨尾骨肌呈“盘状”加深,伴有盆腔脏器脱垂(POP)者上述表现更为显著。屏气用力状态下H线>6cm、M线>2cm,提肌板向尾侧倾斜平均20°；尿道倾斜角增大,甚至呈水平位；尿道膀胱后角增大、消失；尿道长度平均缩短4.80mmm。
4、SUI患者术前与TOT术后1周MRI检查结果比较
静态及屏气用力状态下MRI上尿道的四组支持韧带及肛提肌形态未见改变；通过测量显示尿道的活动度较术前略有减小,经统计学分析后表明其差异无统计学意义。
结论：
1、MRI可以较好的显示尿道的四组支持韧带及肛提肌形态学特征,并可客观评价肛提肌的功能性状态及尿道活动度,从而对SUI患者术前诊断提供影像学依据。
2、MRI可以反映TOT手术后的SUI患者尿道周围支持结构及尿道活动度的变化情况,对手术近期疗效的评价有一定作用,若增加病例数及延长随访观察时间,有望对手术治疗效果作出客观影像学评价。
Objective:Stress urinary incontinence (SUI) is due to pelvic floor disfunction, most found in women. On the pathogenesis of SUI have many theories, including the pressure transmission theory, "hammock" hypothesis,and the integral theory. These theories consider that SUI occurs because of the urethra supporting structure defects. Urethral support ligaments and the ani levator muscles control urine, urethral mobility connects with urethral support ligaments and the levator ani muscles. The composition of the urethral support ligaments is still controversial. MRI can show the urethral support structures well. Using dynamic MRI we observe the composition, morphology and courses of the urethral support ligaments and ani levator muscles, and then compare with the patients with SUI. In addition, the SUI patients who accepeted TOT treatment before and. after operation 1 week had given MRI examination to understand the value of MRI in evaluating postoperative effect. Materials and Methods:28 healthy volunteers and 16 SUI patients in which 7 cases with POP accepted static and dynamic pelvic MRI examination. Static MRI observes urethral ligaments, dynamic MRI observes urethral activity and morphological changes of levator ani muscle, and under two states measure H line, M line, diameter of pelvic diaphragm, urethral length, urethral tilt angle, posterior urethrovesical angle, retropubic space, the distance from urethrovesical junction to the PCL and levator plate angle. The measurement results of groups were statistically analyzed. The datas according with normality using mean±standard deviation descriptions, between two groups using paired t test and two independent sample t test. Non-normal data using the M, P25 and P75 for the statistical description, between two groups using two independent sample rank sum test. All hypothesis testing standards were a= 0.05.
Results:1. Normal static MRI performance of urethral support structures The urethral support ligaments in T2WI are slightly low signal. Periurethral ligament originating from the inner side of puborectalis, running close to the ventral urethra; paraurethral ligament connecting the lateral wall of urethra to the periurethral ligament; pubourethral ligament originating from the ventral urethra to the posterior aspect of the pubic bone, was suspended with sample; suburethral ligament lying dorsal urethra hammock-like structure, connecting the urethra and pelvic arcus tendinous fasciae. The urethral support ligaments fix urethra and prevent SUI. Ani levator muscles compose of puborectalis, pubococcygeus and iliococcygeal muscle, in T2WI muscles showed a moderate signal. Levator ani muscle contraction can resist the increased abdominal pressure and maintain normal organ function and location.
2. Normal dynamic MRI changes of urethral support structures Healthy women ani levator muscles had no significant morphological changes, diameter of pelvic diaphragm, the H line, M line, posterior urethrovesical angle, retropubic space and the distance from bladder neck to the PCL increased slightly after force, urethral tilt angle, after force increase lightly. Levator plate always parallel to PCL.
3. Urethral support structures in static and dynamic MRI in patients with SUI SUI patients urethral support ligament changes, including laxity or rupture.Morphological changes of the levator ani is obviously, diameter of pelvic diaphragm increases, diaphragmatic hiatus was "O" shape in SUI with POP. H line> 6cm, M line> 2cm, levator plate caudal tilt average 20°. In SUI patients after force urethral length shorten, most or all of the urethra below the inferior edge of symphysis pubis; urethral inclination angle and posterior urethrovesical angle increase.
4. SUI patients before and after TOT 1 week MRI imaging examination results The modality of urethra support ligaments did not change, postoperative urethral activity improved, but the difference was not statistically significant. Conclusion: 1. MRI can better show the morphology of four urethral support ligaments and levator ani muscles,and can objectively evaluate the functionality status of the levator ani and urethral activity degree, and thus supply imaging evidence for preoperative diagnosis of SUI.
2. MRI can reflect the changes of urethral support structure and urethral activity of post-operative patients with SUI. MRI has a role in evaluation of curative effect of surgery. By increasing the number of cases and extending follow-up observation period, MRI is expected to give an objective image evaluation in surgical effect.
引文
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[10]Hunskaar S, Arnold EP, Burgio K, et al. Epidemiology and natural history of urinary incontinence[M]. UK:Health Publications,1999:199.
[11]Yang A, Mostwin JL, Rosenshein NB, et al. Pelvic floor descent in women Dynamic evaluation with fast MRI imaging and cinematic display[J]. Radiology, 1991,179(1):25-33.
[12]王毅,龚水根,张伟国等.正常女性盆底解剖、形态的动态MRI研究[J].中国医学影像技术,2003,19(12)：1171-1174.
[13]Kruyt RH, Delemarre JBVM, Doornbos J, et al. Normal anorectum:Dynamic MRI imaging anatomy[J]. Radiology,1991,179(1):159-163.
[14]Lienemann A, Anthuber C, Baron A, et al. Dynamic MRI colpocystorectography assessing pelvic floor descent[J]. European Radiology,1997,7(8):1309-1317.
[15]Goh V, Halligan S, Kaplan G, et al. Dynamic MRI imaging of the pelvic floor in asymptomatic subjects[J]. AJR,2000,174(3):661-666.
[16]Healy JC, Halligan S, Reznek RH, et al. Patterns of prolapse in women with symptoms of pelvic floor weakness Assessment with MRI imaging[J]. Radiology,1997,203(1):77-81.
[17]Pannu HK, Kaufman HS, Cundiff GW. Dynamic MRI Imaging of Pelvic Organ Prolapse:Spectrum of Abnormalities [J]. RadioGraphics,2000,20:1567-1582.
[18]El Sayed RF, El Mashed SM, Farag A, et al. Pelvic floor dysfunction:assessment with combined analysis of static and dynamic MRI imaging findings[J]. Radiology,2008,248(2):518-530.
[19]Mondot L S, Novellas M, Senni T P, et al. Pelvic prolapse:Static and dynamic MRI[J]. Abdominal Imaging,2007,32(6):775-783.
[20]Broekhuis S R, Futterer J J, Hendriks J C M, et al. Symptoms of pelvic floor dysfunction are poorly correlated with findings on clinical examination and dynamic MRI imaging of the pelvic floor[J]. Int Urogynecol J,2009,20: 1169-1174.
[21]Lienemann A, Sprenger D, Janssen U, et al. Assessment of pelvic organ descent by use of functional Cine-MRI:Which reference line should be used? Neurourol Urodyn,2004,23(1):33-37.
[22]Comiter CV, Vasavada SP, Barbaric ZL, et al. Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging[J]. Urology,1999,3: 454-457.
[23]Pelsang RD, Bonney WW. Voiding cystourethrography in female stress in continence[J].AJR Am J Roentgenol,1996,166:561-565.
[24]Jeong K K, Yong J, Kim M, et al. The urethra and its supporting structures in women with stress urinary incontinence:MRI imaging using an endovaginal coil[J]. AJR,2003,180 (4):1037-1044.
[25]DeLancey JOL.Structural support of the urethra as it relates to stress urinary incontinence:the hammock hypothesis[J]. Am J Obstet Gynecol,1994,170(6): 1713-20;discussion 1720-3.
[26]Petros PE, Ulmsten UI.An integral theory of female urinary incontinence. Experimental and clinical considerations[J]. Acta Obstet Gynecol Scand Suppl, 1990,153:7-31.
[27]Singh K, Jakab M, Reid WM, et al. Three-dimensional assessment of levator ani morphologic features in different grades of prolapse[J]. Am J Obstet Gynecol, 2003,188:910-915.
[28]Critchley HOD, Dixon JS, Gosling JA. Comparative study of the periurethral and perianal parts of the human levator ani muscle[J]. Urol Int,1980,35: 226-232.
[29]Wall LL. The muscles of the pelvic floor[J]. Clin Obstet Gynecol,1993,36: 910-925.
[30]DeLancey JOL. The anatomy of the pelvic floor[J]. Curr Opiri Obstet Gynecol, 1994,6:313-316.
[1]Stoker J, Halligan S, Bartram CI. Pelvic floor imaging. Radiology[J],2001,218: 621-641.
[2]Fitzpatrick M, O'HerlihyC. The effects of labour and delivery on the pelvic floor[J]. Best Pract Res Clin Obstet Gynaecol,2001,15:63-79.
[3]Stoker J, Bartram CI, Halligan S. Imaging of the posterior pelvic floor[J]. Eur Radiol,2002,12:779-788.
[4]Pannu HK. Magnetic resonance imaging of pelvic organ prolapse (Review) [J]. Abdom Imaging,2002,27:660-673.
[5]Hodroff MA, Stolpen AH, Denson MA, et al. Dynamic magnetic resonance imaging of the female pelvis:the relationship with the pelvic organ prolapse quantification staging system[J].J Urol,2002,167:1353-1355.
[6]Fletcher JG, Busse RF, Riederer SJ, et al. Magnetic resonance imaging of anatomic and dynamic defects of the pelvic floor in defecatory disorders[J]. Am J Gastroenterol,2003,98:399-411.
[7]Tan IL, Stoker J, Zwamborn AW, et al. Female pelvic floor: endovaginal MRI imaging of normal anatomy[J]. Radiology,1998,206:777-783.
[8]Hilfiker PR, Debatin JF, Schwizer W, et al. MRI defecography:depiction of anorectal anatomy and pathology[J]. J Comput Assist Tomogr,1998,22:749-755.
[9]Wber AM, Abrams P, Brubaker L, et al. The Standardization of Terminology for Researchers in Female Pelvic Floor Disorders[J]. Int Urogunecol J Pelvic Floor Dysfunct,2001,12(3):178-186.
[10]Bustami FM. A reappraisal of the anatomy of the levator ani muscle in man[J]. Acta Morphol Neerl Scand,1988,26:255-268.
[11]Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation.Ⅷ.Levator hiatus and tunnel:anotomy and functoin[J]. Dis Colon Rectum,1979,22(11):539-549.
[12]崔龙，邰浩清,姜文芳.肛管直肠角形成和维持的解剖机制及其临床应用[J],中华小儿外科杂志,2000，21(5)：298-301.
[13]Garavoglia M, Borghi F, Levi AC. Arrangement of the Anal Striated Musculature[J]. Dis Colon Rectum,1993,36(1):10-15.
[14]Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. IX. Single loop continence:a new theory of the mechanism of analc ontinence[J]. Dis Colon Rectum,1980,23(1):37-43.
[15]Bo K, Lilleas F, Talseth T, et al. Dynamic MRI of the Pelvic Floor Muscles in an Upright Sitting Position[J]. Neurourol Urodyn,2001,20(2):167-174.
[16]Kegel AH. Stress Incontinence and Genital Relaxation; a Nonsurgical Method of Incresing the Tone of Sphincters and Their Supporting Structures[J].Clin Symp, 1952,4(2):35-51.
[17]Rociu E, Stoker J, Eijkemans MJ, et al. Normal anal sphincter anatomy and age-and sex-related variaitons at highspaital-resolution edoanal MRI imaging[J]. Radiology,2000,217:395-401.
[18]Fucini C, Elbetti C, Messerini L. Anatomic plane of separation between external anal sphincter and puborectalis muscle:clinical implications[J]. Dis Colon Rectum,1999,42(3):374-37.
[19]Bollard RC, Gardiner A, Lindow S, et al. Normal female anal sphincter difficulties in interpertation explained[J]. Dis Colon Rectum,2002,45(2): 171-175.
[20]Shaft A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation[J]. Dis Colon Rectum,1987,30(12):970-982.
[21]Schmeiser G, Putz R. The anatomy and function of the pelvic floor[J]. Radiology, 2000,40(5):429-436.
[22]Bremmer S, Melgren A, Holmstrom B, et al. Pelvic anatomy and pathology is Influenced by disetntion of the rectum:defacoperitoneography before and after rectal Filling with contrast medium[J]. Dis Colon Rectum,1997,40:1477-1483.
[23]Macura KJ, Genadry R, Borman TL, et al. Evaluation of the female urethra with intraurethral magnetic reasonance imaging[J]. J Magn Reson Imaging,2004,20: 153-159.
[24]Rud T, Andersson KE, Asmussen M, et al. Factors maintaining intraurethral pressure in women[J]. Invest Urol,1980,17:343-347.
[25]Goh V, Halligan S, Kaplan G, et al. Dynamic MRI imaging of the pelvic floor in asymptomatic subjects[J]. Am J Roentgenol,2000,174:661-666.
[26]Piloni V, Bassotti G, Fioravanti P, et al. Dynamic imaging of the normal pelvic floor[J]. Int J Colorectal Dis,1997,12:246-253.
[27]Myers DL, Arya LA, Verma A, et al. Pelvic anatomy for obstetrics and gynecology residents:an experimental study using clay models[J]. Obstet Gynecol,2001,97:321-324.
[28]Barbaric ZL, Marumoto AK, Raz S. Magnetic resonance imaging of the perineum and pelvic floor[J]. Top Magn Reson Imaging,2001,12:83-92.
[29]熊坤林,龚水根,张伟国.正常肛提肌用力前后SCT、MRI形态变化研究[J].放射学实践,2007,22(5)：496-499.
[30]Rania F, Medhat M, Sahar M, et al. Anatomy of the urethal supporting ligments defined by dissection, histology, and MRI of female cadavers and MRI of healthy nulliparous women[J]. AJR,2007,189:1145-1157.
[31]Healy JC, Halligan S, Reznek RH,et al. Dynamic MRI imaging compared with evacuation proctography when evaluating anorectal configuration and pelvic floor movement[J]. Am J Roentgenol,1997,169:775-779.
[32]Gousse AE, Barbaric ZL, Safir MH, et al. Dynamic half Fourier acquisition single shot spin-echo magnetic resonance imaging for evaluating the female pelvis[J]. J Urol,2000,164:1606-1613.
[33]Unterweger M, Marincek B, Gotstein-Aalame N, et al. Ultrafast MRI imaging of the pelvic floor[J].Am J Roentgenol,2001,176:959-963.
[34]Quick HH, Serfaty JM, Pannu HK,et al. Endourethral MRI[J]. Magn Reson Med, 2001,45:138-146.
[2]崔龙.肛提肌的形态学及其功能意义和临床应用[J].南京中医药大学学报,2007,17(4)：242-244.
[3]熊坤林,龚水根,张伟国.正常肛提肌用力前后SCT、MRI形态变化研究[J].放射学实践,2007,22(5)：496-499.
[4]Klutke CG, Sigel CL. Functional female pelvic anatomy. Urol Clin North Am, 1995,22:487-498.
[5]Klutke C, Golomb J, Barbaric Z, et al. The anatomy of stress incontinence: magnetic resonance imaging of the female bladder neck and urethra[J]. J Urol 1990,143:563-566.
[6]Tan IL, Stoker J, Zwamborn AW, et al. Female pelvic floor endovaginal MRI imaging of normal anatomy[J]. Radiology,1998,206(3):777-783.
[7]El Sayed RF, Morsy MM, El Mashed SM, et al. Anatomy of the urethal supporting ligments defined by dissection histology and MRI of female cadavers and MRI of healthy nulliparous women[J]. AJR,2007,189:1145-1157.
[8]Fothergill WE. Pathology and the operative treatment of displacements of the pelvic viscera[J]. J Obstet Gynaecol Br Emp,1907,13:410-419.
[9]Paramore RH. The supports in chief of the female pelvic viscera[J]. J Obstet Gynaecol Br Emp,1908,30:391-409.
[10]Hunskaar S, Arnold EP, Burgio K, et al. Epidemiology and natural history of urinary incontinence[M]. UK:Health Publications,1999:199.
[11]Yang A, Mostwin JL, Rosenshein NB, et al. Pelvic floor descent in women Dynamic evaluation with fast MRI imaging and cinematic display[J]. Radiology, 1991,179(1):25-33.
[12]王毅,龚水根,张伟国等.正常女性盆底解剖、形态的动态MRI研究[J].中国医学影像技术,2003,19(12)：1171-1174.
[13]Kruyt RH, Delemarre JBVM, Doornbos J, et al. Normal anorectum:Dynamic MRI imaging anatomy[J]. Radiology,1991,179(1):159-163.
[14]Lienemann A, Anthuber C, Baron A, et al. Dynamic MRI colpocystorectography assessing pelvic floor descent[J]. European Radiology,1997,7(8):1309-1317.
[15]Goh V, Halligan S, Kaplan G, et al. Dynamic MRI imaging of the pelvic floor in asymptomatic subjects[J]. AJR,2000,174(3):661-666.
[16]Healy JC, Halligan S, Reznek RH, et al. Patterns of prolapse in women with symptoms of pelvic floor weakness Assessment with MRI imaging[J]. Radiology,1997,203(1):77-81.
[17]Pannu HK, Kaufman HS, Cundiff GW. Dynamic MRI Imaging of Pelvic Organ Prolapse:Spectrum of Abnormalities [J]. RadioGraphics,2000,20:1567-1582.
[18]El Sayed RF, El Mashed SM, Farag A, et al. Pelvic floor dysfunction:assessment with combined analysis of static and dynamic MRI imaging findings[J]. Radiology,2008,248(2):518-530.
[19]Mondot L S, Novellas M, Senni T P, et al. Pelvic prolapse:Static and dynamic MRI[J]. Abdominal Imaging,2007,32(6):775-783.
[20]Broekhuis S R, Futterer J J, Hendriks J C M, et al. Symptoms of pelvic floor dysfunction are poorly correlated with findings on clinical examination and dynamic MRI imaging of the pelvic floor[J]. Int Urogynecol J,2009,20: 1169-1174.
[21]Lienemann A, Sprenger D, Janssen U, et al. Assessment of pelvic organ descent by use of functional Cine-MRI:Which reference line should be used? Neurourol Urodyn,2004,23(1):33-37.
[22]Comiter CV, Vasavada SP, Barbaric ZL, et al. Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging[J]. Urology,1999,3: 454-457.
[23]Pelsang RD, Bonney WW. Voiding cystourethrography in female stress in continence[J].AJR Am J Roentgenol,1996,166:561-565.
[24]Jeong K K, Yong J, Kim M, et al. The urethra and its supporting structures in women with stress urinary incontinence:MRI imaging using an endovaginal coil[J]. AJR,2003,180 (4):1037-1044.
[25]DeLancey JOL.Structural support of the urethra as it relates to stress urinary incontinence:the hammock hypothesis[J]. Am J Obstet Gynecol,1994,170(6): 1713-20;discussion 1720-3.
[26]Petros PE, Ulmsten UI.An integral theory of female urinary incontinence. Experimental and clinical considerations[J]. Acta Obstet Gynecol Scand Suppl, 1990,153:7-31.
[27]Singh K, Jakab M, Reid WM, et al. Three-dimensional assessment of levator ani morphologic features in different grades of prolapse[J]. Am J Obstet Gynecol, 2003,188:910-915.
[28]Critchley HOD, Dixon JS, Gosling JA. Comparative study of the periurethral and perianal parts of the human levator ani muscle[J]. Urol Int,1980,35: 226-232.
[29]Wall LL. The muscles of the pelvic floor[J]. Clin Obstet Gynecol,1993,36: 910-925.
[30]DeLancey JOL. The anatomy of the pelvic floor[J]. Curr Opiri Obstet Gynecol, 1994,6:313-316.
[1]Stoker J, Halligan S, Bartram CI. Pelvic floor imaging. Radiology[J],2001,218: 621-641.
[2]Fitzpatrick M, O'HerlihyC. The effects of labour and delivery on the pelvic floor[J]. Best Pract Res Clin Obstet Gynaecol,2001,15:63-79.
[3]Stoker J, Bartram CI, Halligan S. Imaging of the posterior pelvic floor[J]. Eur Radiol,2002,12:779-788.
[4]Pannu HK. Magnetic resonance imaging of pelvic organ prolapse (Review) [J]. Abdom Imaging,2002,27:660-673.
[5]Hodroff MA, Stolpen AH, Denson MA, et al. Dynamic magnetic resonance imaging of the female pelvis:the relationship with the pelvic organ prolapse quantification staging system[J].J Urol,2002,167:1353-1355.
[6]Fletcher JG, Busse RF, Riederer SJ, et al. Magnetic resonance imaging of anatomic and dynamic defects of the pelvic floor in defecatory disorders[J]. Am J Gastroenterol,2003,98:399-411.
[7]Tan IL, Stoker J, Zwamborn AW, et al. Female pelvic floor: endovaginal MRI imaging of normal anatomy[J]. Radiology,1998,206:777-783.
[8]Hilfiker PR, Debatin JF, Schwizer W, et al. MRI defecography:depiction of anorectal anatomy and pathology[J]. J Comput Assist Tomogr,1998,22:749-755.
[9]Wber AM, Abrams P, Brubaker L, et al. The Standardization of Terminology for Researchers in Female Pelvic Floor Disorders[J]. Int Urogunecol J Pelvic Floor Dysfunct,2001,12(3):178-186.
[10]Bustami FM. A reappraisal of the anatomy of the levator ani muscle in man[J]. Acta Morphol Neerl Scand,1988,26:255-268.
[11]Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation.Ⅷ.Levator hiatus and tunnel:anotomy and functoin[J]. Dis Colon Rectum,1979,22(11):539-549.
[12]崔龙，邰浩清,姜文芳.肛管直肠角形成和维持的解剖机制及其临床应用[J],中华小儿外科杂志,2000，21(5)：298-301.
[13]Garavoglia M, Borghi F, Levi AC. Arrangement of the Anal Striated Musculature[J]. Dis Colon Rectum,1993,36(1):10-15.
[14]Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. IX. Single loop continence:a new theory of the mechanism of analc ontinence[J]. Dis Colon Rectum,1980,23(1):37-43.
[15]Bo K, Lilleas F, Talseth T, et al. Dynamic MRI of the Pelvic Floor Muscles in an Upright Sitting Position[J]. Neurourol Urodyn,2001,20(2):167-174.
[16]Kegel AH. Stress Incontinence and Genital Relaxation; a Nonsurgical Method of Incresing the Tone of Sphincters and Their Supporting Structures[J].Clin Symp, 1952,4(2):35-51.
[17]Rociu E, Stoker J, Eijkemans MJ, et al. Normal anal sphincter anatomy and age-and sex-related variaitons at highspaital-resolution edoanal MRI imaging[J]. Radiology,2000,217:395-401.
[18]Fucini C, Elbetti C, Messerini L. Anatomic plane of separation between external anal sphincter and puborectalis muscle:clinical implications[J]. Dis Colon Rectum,1999,42(3):374-37.
[19]Bollard RC, Gardiner A, Lindow S, et al. Normal female anal sphincter difficulties in interpertation explained[J]. Dis Colon Rectum,2002,45(2): 171-175.
[20]Shaft A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation[J]. Dis Colon Rectum,1987,30(12):970-982.
[21]Schmeiser G, Putz R. The anatomy and function of the pelvic floor[J]. Radiology, 2000,40(5):429-436.
[22]Bremmer S, Melgren A, Holmstrom B, et al. Pelvic anatomy and pathology is Influenced by disetntion of the rectum:defacoperitoneography before and after rectal Filling with contrast medium[J]. Dis Colon Rectum,1997,40:1477-1483.
[23]Macura KJ, Genadry R, Borman TL, et al. Evaluation of the female urethra with intraurethral magnetic reasonance imaging[J]. J Magn Reson Imaging,2004,20: 153-159.
[24]Rud T, Andersson KE, Asmussen M, et al. Factors maintaining intraurethral pressure in women[J]. Invest Urol,1980,17:343-347.
[25]Goh V, Halligan S, Kaplan G, et al. Dynamic MRI imaging of the pelvic floor in asymptomatic subjects[J]. Am J Roentgenol,2000,174:661-666.
[26]Piloni V, Bassotti G, Fioravanti P, et al. Dynamic imaging of the normal pelvic floor[J]. Int J Colorectal Dis,1997,12:246-253.
[27]Myers DL, Arya LA, Verma A, et al. Pelvic anatomy for obstetrics and gynecology residents:an experimental study using clay models[J]. Obstet Gynecol,2001,97:321-324.
[28]Barbaric ZL, Marumoto AK, Raz S. Magnetic resonance imaging of the perineum and pelvic floor[J]. Top Magn Reson Imaging,2001,12:83-92.
[29]熊坤林,龚水根,张伟国.正常肛提肌用力前后SCT、MRI形态变化研究[J].放射学实践,2007,22(5)：496-499.
[30]Rania F, Medhat M, Sahar M, et al. Anatomy of the urethal supporting ligments defined by dissection, histology, and MRI of female cadavers and MRI of healthy nulliparous women[J]. AJR,2007,189:1145-1157.
[31]Healy JC, Halligan S, Reznek RH,et al. Dynamic MRI imaging compared with evacuation proctography when evaluating anorectal configuration and pelvic floor movement[J]. Am J Roentgenol,1997,169:775-779.
[32]Gousse AE, Barbaric ZL, Safir MH, et al. Dynamic half Fourier acquisition single shot spin-echo magnetic resonance imaging for evaluating the female pelvis[J]. J Urol,2000,164:1606-1613.
[33]Unterweger M, Marincek B, Gotstein-Aalame N, et al. Ultrafast MRI imaging of the pelvic floor[J].Am J Roentgenol,2001,176:959-963.
[34]Quick HH, Serfaty JM, Pannu HK,et al. Endourethral MRI[J]. Magn Reson Med, 2001,45:138-146.