RU2464933C2 - Method of diagnosing pain syndrome in patients with chronic pelvic pain syndrome - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to urology and can be applied for diagnostics of pain syndrome in patients with syndrome of chronic pelvic pain syndrome (CPPS). Examination is performed in "B" mode with application of duplex scanning of arteries and veins of levator ani by means of transrectal sensor with frequency 7.5-7.8 MHz, which is introduced into patient's rectum after cleansing enema and emptying urinary bladder in position of patient lying on left side with bent to abdomen legs. Gel-filled condom, on which gel is applied as well, is put on transrectal sensor. Plane is scanning is transversal, long axis of transrectal sensor being oriented along long axis of patient's body. If Vps indices in arteries of levator ani increase by 0.46 cm/sec and Pi indices increase by 1.35 c.u., with unchanged indices Ved, Ri and D. If in veins of levator ani indices Vps, Ved and Pi increase by 0.9 cm/sec, 1.11 cm/sec and 0.62 c.u. respectively, indices Ri and D reduce by 0.12 c.u. and 0.14 mm respectively, pain syndrome in patients with chronic pelvic pain syndrome is diagnosed.

EFFECT: method makes it possible to increase diagnostics accuracy due to ultrasonic examination of state of levator ani, lifting anus in patients.

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Description

The invention relates to medicine, namely to urology, and can be used for the diagnosis of pain in patients with chronic pelvic pain syndrome (CTSB).

Syndrome of chronic pelvic pain in men takes first place in prevalence among diseases of the male genital area and one of the first places among male diseases in general. According to the modern classification of diseases, CFS is a synonym for III In the category of chronic prostatitis. The diagnosis is made in the presence of subjective symptoms of prostatitis and in the absence of laboratory signs of inflammation of the prostate - prostatodynia. The most common cause of pelvic pain is pathology of the prostate gland, at the same time, this symptom may be due to other causes, in particular pathology in the muscles that raise the pelvic floor (pelvic floor levator muscles). It remains relevant to create effective methods for diagnosing pain in patients with chronic pelvic pain syndrome.

A known method for the diagnosis of pain in patients with chronic pelvic pain by assessing the condition of the muscles, which consists in conducting electroneuromyography (ENMG), which allows you to objectively register the processes of muscle contraction. Irritation is created by an electric current using an electrode mounted on the motor point of the muscle whose contractile properties are to be determined (Klyzhina E.A. Electromyographic criteria for diagnosing urination disorders in women // Youth - Barnaul: Materials of a scientific and practical conference. - Barnaul, 2004. - S. 173-174). The movement of the muscle is recorded mechanically.

However, the known method is not accurate enough, because the pelvic floor levator muscles are located very deep from the skin, so it is impossible to conduct a study using a technically known method.

The closest technical result achieved is a method for diagnosing changes in the muscles of the pelvic floor by transabdominal ultrasound in B-mode using a convex sensor with a frequency of 3.5 to 5.0 MHz (Coloproctology, No. 1, 2002, scientific and practical medical journal Association of Coloproctologists of Russia, Moscow, Editor-in-Chief - G.I. Vorobyov, Registration Certificate pi No. 77-14097, p.3-5). The known method allows you to give information in the form of two-dimensional gray-scale tomographic images of anatomical structures in real time, which allows us to evaluate their morphological state. The study is possible with a fairly good preparation of patients: a full bladder as a kind of acoustic window that improves visualization. In order to identify a pathological focus in the small pelvis (as a possible cause of SCTD) and to locate the muscles-levators of the pelvic floor, the prostate, several sections are performed in both the longitudinal and transverse cavities.

Ultrasound examination (through the anterior abdominal wall) in a known manner allows to identify reliably fluid in the small pelvis, abscesses, prostate size, thickness of the pelvic floor levator muscles, structure, echogenicity, and sometimes - vascularization of the CDC (color Doppler mapping) and EDC (energy Doppler mapping) regimen ), but without specifying speed indicators (too low speed in the vessels of the pelvic floor levator muscles). Therefore, the conclusion: "vascularization is reduced, increased, moderate ..." is subjective.

The disadvantage of this method is the inaccuracy in the diagnosis due to the scattering of the ultrasound beam in depth, therefore, the data appear to be “blurry”, inaccurate, and some characteristics cannot be determined (vessel diameter, speed indicators in the arterial and venous channels). In addition, the individual characteristics of the patient that impair visualization are not taken into account: overweight, flatulence, dense skin, developed abdominal press, etc.

The authors propose a method for diagnosing pain in patients with chronic pelvic pain syndrome by ultrasound using Doppler mapping, which allows more accurate and quick examination of the pelvic floor levator muscles that raise the anus, blood flow (arterial and venous) in them (scanning depth at Ultrasound is directly proportional to the accuracy of diagnosis) and to clarify the condition of the pelvic organs.

The technical result of the proposed method is to increase the accuracy of diagnosis by ultrasound examination of the state of the muscles-levators of the pelvic floor, raising the anus in patients.

The technical result is achieved by the fact that the study is carried out in "B" mode using a duplex scan of the arteries and veins of the pelvic floor levator muscles using a transrectal sensor with a frequency of 7.5-7.8 MHz, which is injected into the rectum of the patient after a cleansing enema and bladder emptying when the patient is lying on his left side with legs bent to the stomach; a condom filled with gel is put on the transrectal sensor, on which the gel is also applied; the scanning plane is transverse, and the long axis of the transrectal sensor is oriented along the long axis of the patient’s body and with an increase in the arteries of the pelvic floor levator muscles Vps by 0.46 cm / sec and Pi by 1.35 cu, while the Ved indices remain unchanged, Ri and D, as well as with an increase in the veins of the muscles of the pelvic floor levator, Vps by 0.9 cm / sec, Ved by 1.11 cm / sec and Pi by 0.62 cu, a decrease in Ri by 0.12 y, e and 0.14 mm D are diagnosed with pain in patients with chronic pelvic pain syndrome.

To confirm the technical result, a table is presented.

The method is as follows. In the study, any ultrasound scanner is used that has a linear or biplane transrectal sensor 7.5-7.8 MHz with the Doppler effect. Studies are carried out in the "B" mode using duplex scanning of blood vessels (arteries and veins of the muscles of the levator of the pelvic floor).

Before the examination, the patient undergoes one cleansing enema, the bladder is empty. The patient lies on his left side, bending and bringing his legs to the stomach (in this position, the anus becomes easily accessible). A special condom is put on a transrectal probe filled with gel for ultrasound examinations, on which a gel is also placed. The sensor is carefully inserted into the rectum, taking into account its physiological bends. Scanning plane - the transverse, long axis of the sensor is oriented perpendicular to the long axis of the patient’s body. Pelvic floor levator muscles are wide ribbon cords, going from the anal sphincter upward fan-shaped. When the anus is retracted, when straining, the pelvic floor levator muscles contract, thicken, which serves as a guide when they are found and examined.

In the "B" mode, the right and left muscles are visualized - the pelvic floor levators: isoechogenic, homogeneous, with clear, even contours of the elongated shape of the "tape". At the sphincter level, 10 mm and 20 mm measure their thickness. Using the Doppler effect and duplex scanning, vascularization in the muscles-levators of the pelvic floor, diameter of arteries and veins, and linear velocity of blood flow are recorded. The following parameters are taken into account:

Vps, cm / sec - peak systolic velocity (the highest linear velocity of the movement of individual blood particles in the stream at the time of its maximum acceleration into systole);

Ved, cm / sec - final diastolic velocity (its indicators, as a rule, do not have independent values and are used to calculate indices);

Ri, e.e. - resistance index (the ratio of the difference between peak systolic and final diastolic to peak systolic);

Pi, e.e. - pulsatory index (the ratio of the difference between the peak systolic and early diastolic velocity or final diastolic velocity to the average blood flow velocity);

D, mm is the diameter of the vessels.

The main significance of the indices is to quantify peripheral vascular resistance.

Given the data of the control group, the pelvic floor levator muscles are isoechoic, the echostructure is uniform, the contours are clear, even. The linear velocity of blood flow - in the arteries: Vps, cm / sec - 14.4 ± 0.45; Ved, cm / s - 3.5 ± 0.23; Ri, у.e.- 0.73 ± 0.02; Pi, e.e. - 1.95 ± 0.11; d, mm - 1.3 ± 0.04; in the veins: Vps, cm / sec - 4.54 ± 0.2; Ved, cm / sec - 1.96 ± 0.12; Ri, e.e. - 0.55 ± 0.02; Pi, у.e.- 0.52 ± 0.05; d, mm - 2.23 ± 0.04.

Clinical example.

Patient S., 27 years old, a military man, turned to a urologist with complaints of pulling sensations in the lower abdomen, in the perineum, sometimes accompanied by painful sensations in the testicles. An erection is weak, during the “prolonged” sexual intercourse, pain in the rectum sometimes occurs.

Beginning of sexual activity from the age of 15. Sexual contacts are regular, but partners are intermittent, unmarried. The frequency of sexual intercourse 2-3 times a week. There is premature ejaculation. A method of protection is the use of condoms.

The onset of the disease does not connect with anything, it does not carry out communication with emotional and psychological stresses. The first symptoms arose about six months ago (I drew attention to the “flaccid penis” before sexual intercourse). He has no bad habits; he has been actively skiing since childhood. Chronic diseases do not suffer.

Normosthenic physique, physically developed correctly. The skin is clean, the lymph nodes are not enlarged. Hemodynamic parameters are satisfactory. There are no comments on organs and systems. Hair growth - according to the male type, the external genitalia are developed correctly. The prostate gland, on palpation, is not enlarged, painless, the contours are even, the middle groove is not smooth, the penis is without features, the anus is closed, there are no prolapsed hemorrhoids. Pelvic floor levator muscles are tense, painful on the left.

A laboratory examination was carried out. A study of peripheral blood and biochemical analyzes did not provide additional information about a possible cause of the disease. PSA was within normal limits. No urinary tract infections detected. Sigmoidoscopy - without features.

Examination with a gray-scale transabdominal sensor revealed an unexpanded prostate gland with unchanged echostructure. Pelvic floor levator muscles were heterogeneous cords. Vascularization could not be detected. No additional formations were found in the pelvis.

Then TRUSI was carried out using the proposed technique with the aim of clarifying the state of the levator muscles of the pelvic floor and prostate. For research, a 7.8 MHz transrectal sensor of the U3 scanner was used. The following data were obtained: the contours of the pelvic floor levator muscles were clear, even, the thickness at three levels seemed less than in the patients of the control group, the echostructure was heterogeneous, and the echogenicity on the left was reduced. Duplex scanning specified the parameters in the arterial and venous channels and revealed the following: in the arteries - Vps increased on the left by 0.46 cm / sec; on the right at 0.10 cm / sec; Ved is - 0.03 cm / sec; Ri is 0.02 cu; Pi increased by 1.35 cu; in veins - Vps increased by 0.9 cm / sec; Ved increased by 1.11 cm / sec; Ri decreased by 0.12 cu; Pi increased by 0.62 cu A clear increase in Vps in the arteries and veins of the pelvic floor levator muscles, as well as an increase in Pi, indicates an increase in peripheral resistance caused by muscle spasm. The following conclusions were drawn: in this patient, a possible morphological substrate of pelvic pain may be a spasm of the muscles-levators of the pelvic floor and a violation of their blood flow.

Against the background of physiotherapeutic treatment (laser) in combination with rheoprotectants and fasting and dietary therapy, as well as the normalization of lifestyle after two weeks, the condition improved, the pain syndrome stopped.

A dynamic examination with a rectal sensor using duplex scanning made it possible to assess the condition of the pelvic floor levator muscles: the indicators returned to normal (taking into account the data of the control group). After a month and a half, positive dynamics continued.

An ultrasound study was conducted in 20 volunteers in the control group, all were somatically healthy, the average age was 20.1 years. Patients with chronic pelvic pain were examined 14. The average age is 38.1 years. A clinical study included: an anamnesis, in which emphasis was placed on previously transmitted or recurring urinary tract infections, examination and palpation of the external genital organs, perineum, inguinal region, lower abdomen and digital rectal examination of the prostate and pelvic floor levator muscles. Of the instrumental methods of examination used: sigmoidoscopy, laboratory and bacteriological studies of prostatic juice. Ultrasound of the prostate and pelvic floor levator muscles. The average duration of CPSD disease was 4.7 years; all patients were repeatedly treated by a urologist with a diagnosis of chronic prostatitis with a short-term effect or without it. In a finger study, all patients noted their tension and pain, in 4 people, trigger points were found along the edge of the coccyx. To determine the pathological process that occurs in the muscles-levators of the pelvic floor, ultrasound diagnostics was used, followed by a comparison of the results (table).

In the arteries:

- Vps with SCHT increases by 0.46 cm / sec.

- Ved practically does not change 0.03 cm / sec.

- Ri also practically does not change 0.02 cu

- Pi increases by 1.35 cu

- D remains at the level of indicators of the control group.

In the veins:

- Vps with SCHT increases by 0.9 cm / sec.

- Ved increases by 1.11 cm / sec.

- Ri decreases by 0.12 cu

- Pi increases by 0.62 cu

- D decreases by 0.14 mm.

Thus, the claimed method allows to diagnose pain in patients with chronic pelvic pain syndrome by ultrasound examination of blood flow in the muscles-levators of the pelvic floor, which makes it possible to objectify muscle spasm.

The inventive method has high accuracy, painlessness, safety, non-invasiveness, the possibility of repeated repetition for the purpose of dynamic observation, a short time to complete the study, low cost, reliable identification of structural changes in the muscles-levators of the pelvic floor, allows you to specify the speed indicators of blood flow in the muscles-levators of the pelvic floor bottom, which is important for understanding the pathological processes in them and indirectly in the pelvic organs and can be used by ul doctors ultrasound diagnostics in a medical institution of any profile in the diagnosis of pain in patients with CPS.

A method for the diagnosis of pain in patients with chronic pelvic pain syndrome

Table Indicators Arteries Veins control group SKHTB difference control group SKHTB difference Vps, cm / s 14.4 ± 0.5 14.86 ± 0.9 +0.46 4.54 ± 0.2 5.44 ± 0.8 +0.9 Ved, cm / s 3.5 ± 0.2 3.53 ± 0.3 +0.03 1.96 ± 0.1 3.07 ± 0.5 +1.11 RI, у.e. 0.73 ± 0.02 0.75 ± 0.01 +0.02 0.55 ± 0.02 0.43 ± 0.3 -0.12 Pi, e.e. 1.95 ± 0.1 3.3 ± 0.8 +1.35 0.52 ± 0.05 1.14 ± 0.03 +0.62 d mm 1.3 ± 0.04 1.3 ± 0.1 0 2.23 ± 0.04 2.09 ± 0.09 -0.14

Claims (1)

A method for the diagnosis of pain in patients with chronic pelvic pain syndrome by ultrasound, characterized in that the study is carried out in "B" mode using duplex scanning of arteries and veins of the pelvic floor levator muscles using a transrectal sensor with a frequency of 7.5-7, 8 MHz, which is introduced into the rectum of the patient after a cleansing enema and emptying of the bladder when the patient is lying on his left side with legs bent to the stomach; a condom filled with gel is put on the transrectal sensor, on which the gel is also applied; the scan plane is transverse, and the long axis of the transrectal sensor is oriented along the long axis of the patient’s body and with an increase in the arteries of the pelvic floor levator muscles Vps by 0.46 cm / s, and Pi by 1.35 cu, with the indicators unchanged Ved, Ri and D, as well as with an increase in the veins of the muscles of the pelvic floor levator, Vps by 0.9 cm / s, Ved by 1.11 cm / s, and Pi by 0.62 cu, a decrease in Ri at 0.12 cu and 0.14 mm D are diagnosed with pain in patients with chronic pelvic pain syndrome.