Pavimento Pelvico (Patologie)
Il pavimento pelvico corrisponde alla zona genito-urinaria-anale ed è costituito da tessuto muscolare e connettivale.
Partecipa alle funzioni urinaria, fecale, sessuale, riproduttiva, della statica pelvica, biomeccanica del cingolo pelvico.
I sintomi causati dalla disfunzione del pavimento pelvico modificano spesso la qualità di vita di chi ne è afflitto, peggiorando notevolmente più aspetti della vita quotidiana.
Anatomia del pavimento pelvico
Il pavimento pelvico rappresenta la chiusura inferiore del bacino e corrisponde all’area genito-urinaria anale. In tale zona al di sotto di pelle e mucose, è presente tessuto muscolare, così come nella restante parte del corpo umano. Il pavimento pelvico è costituito oltre che di muscoli, organizzati in tre diversi strati più o meno profondi nel bacino, anche da tessuto connettivo (legamenti e fascie).
I visceri pelvici (vescica e uretra, utero e canale vaginale nella donna, retto e canale anale) sono poggiati sui muscoli e sul connettivo che compongono il pavimento pelvico, che può essere pertanto paragonato ad un’amaca.
Inoltre uretra e canale anale nella loro parte finale “attraversano” il pavimento pelvico, che determina quindi intorno ad essi fibre muscolari ad andamento circolare, cioè gli sfinteri, rispettivamente uretrale e anale.
Anche il canale vaginale nella sua parte finale è circondato ad anello dalle fibre del pavimento pelvico. Il pavimento pelvico si estende dal pube (in avanti) al coccige e al sacro (all’indietro), mentre lateralmente si attacca in parte direttamente alle ossa del bacino, in parte si inserisce su altri muscoli o strutture connettive. Da questi punti di origine, quasi tutte le fibre muscolari prendono contatto con una grossa formazione tendinea facilmente individuabile dall’esterno, situata tra l’ano e la vagina nella donna e tra l’ano e la base del pene nell’uomo, chiamata centro tendineo del perineo.
Funzioni del pavimento pelvico
Funzione urinaria e pavimento pelvico
Le funzione urinaria è svolta dalle alte (reni e ureteri) e dalle basse (vescica e uretra).
La vescica è il “serbatoio” dell’urina, mentre l’uretra è un condotto tubulare in continuità con la vescica e che sbocca all’esterno.
Il pavimento pelvico circondando l’uretra con le sue fibre muscolari, costituisce lo sfintere uretrale interno e lo sfintere uretrale esterno; il primo involontario mentre il secondo è sottoposto al controllo volontario del soggetto e ci permette di trattenere l’urina spostando a piacimento e in condizioni socialmente accettabili la minzione.
L’urina, filtrata dai reni, prosegue attraverso gli ureteri e raggiunge la vescica. All’interno di questa sono presenti piccole cellule sensistive (recettori) che informano il cervello, sullo stato di riempimento vescicale. Quando l’individuo decide di mingere, la vescica si contrae, gli sfinteri uretrali si rilassano e l’urina defluisce all’esterno attraverso l’uretra. E’ considerato normale un intervallo di 3-4 ore tra una minzione e l’altra.
Funzione fecale e pavimento pelvico
La funzione fecale è svolta fondamentalmente dal tratto terminale del tubo digerente. Il materiale fecale, prodotto dall’attività digestiva, arriva nel sigma (il serbatoio delle feci), da qui circa un paio di volte al giorno queste sostanze passano nella porzione superiore del retto (l’ampolla rettale) e questo fenomeno viene percepito dal soggetto più o meno intensamente a seconda di quanto materiale giunge o è già presente nell’ampolla.
Il riempimento dell’ampolla rettale provoca il rilasciamento dello sfintere anale interno (involontario) consentendo quindi al materiale fecale di passare nella parte inferiore del retto (il canale anale). Qui le cellule sensitive (recettori) presenti consentono il riconoscimento della natura del materiale (solida o gassosa). La contrazione od il rilasciamento dello sfintere anale esterno (volontario) e del puborettale (parzialmente volontario) apre o chiude l’ano, consentendo od impedendo così alle feci di uscire.
https://www.traditionrolex.com/45
Quando il soggetto decide di defecare al rilasciamento dei muscoli della continenza si associa un aumento della pressione addominale (realizzato dai muscoli della parete addominale e dal diaframma respiratorio, che vengono a costituire il “torchio addominale”).
La continenza delle feci è quindi assicurata dal sistema sfinteriale, dal muscolo puborettale, dalle proprietà elastiche del retto, che si adatta al contenuto fecale, dalla consistenza delle feci.
Viene considerato normale un numero di evacuazioni comprese tra 2 volte al giorno e 2 volte alla settimana.
Funzione sessuale e pavimento pelvico
La sessualità è una funzione complessa e coinvolge l’aspetto fisico-biologico e quello psico-relazionale.
In entrambi i sessi i diversi eventi della funzione sessuale vengono distinti in quattro fasi: desiderio, eccitazione, orgasmo, risoluzione / soddisfazione.
I muscoli del pavimento pelvico sono coinvolti nella funzione sessuale femminile: essi, circondando il canale vaginale, permettono la penetrazione vaginale, lasciandosi distendere durante tale momento.
Inoltre sono coinvolti nella fase dell’orgasmo con l’attivazione riflessa di contrazioni ritmiche ripetute.
Nella funzione sessuale maschile la porzione muscolare del pavimento pelvico partecipa al meccanismo di erezione e di eiaculazione attraverso l’attività contrattile.
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Funzione riproduttiva e pavimento pelvico
Il ruolo del pavimento pelvico nella funzione riproduttiva è relativo al parto.
Durante tale evento i muscoli di questa zona si lasciano distendere per permettere la fuoriuscita del feto. Inoltre essi sono parte attiva nel promuovere la fuoriuscita del neonato attraverso una buona capacità contrattile.
E’ pertanto utile che in occasione di questo importante evento, i muscoli del pavimento pelvico possiedano una buona capacità elastica.
Funzione statica e pavimento pelvico
Consiste nella capacità di mantenere in sede degli organi della bassa pelvi (vescica e uretra, utero e canale vaginale, retto e canale anale) ripetto sia alla forza di gravità, sia agli aumenti di pressione intraddominale che si verificano normalmente durante le attività quotidiane (tossire, flettere il busto per raccogliere un oggetto, sedersi, alzarsi, ecc.).
La funzione relativa alla statica pelvica viene realizzata dal pavimento pelvico, sia con la porzione muscolare, sia con quella connettivale. La prima, più esterna, costituisce il sistema di sostegno e può essere paragonata alla funzione svolta dall’acqua quando fa galleggiare una nave. I muscoli del pavimento pelvico sono infatti posti al di sotto dei visceri e li fanno “galleggiare”.
Funzione biomeccanica e pavimento pelvico
Il pavimento pelvico appartiene al cingolo pelvico, costuito da diverse strutture biomeccaniche: ossa del bacino, muscoli, legamenti. Questi elementi cooperano insieme per assicurare stabilità al corpo, insieme alle strutture muscolo scheletriche del tronco, come la colonna vertebrale.
Ad esempio, ogni volta che un arto superiore o inferiore si muove (es.: camminare, afferrare un oggetto, ecc.), le strutture biomeccaniche del cingolo pelvico e/o del tronco si attivano per fare da “contrappeso” alla parte che si muove. Così il movimento diventa armonico, preciso e funzionale. Ne deriva che in alcune condizioni funzionali, come afferrare un oggetto con le mani, si contraggano anche i muscoli del cingolo pelvico, compreso il pavimento pelvico.
Quali sono i disturbi
Il prolasso degli organi pelvici consiste nella discesa verso il basso di uno o più organi della pelvi. A seconda dell’organo disceso, il prolasso viene chiamato
- cistocele (vescica);
- isterocele (utero);
- rettocele (retto);
- enterocele (anse intestinali).
Il prolasso degli organi pelvici è un patologia tipicamente femminile.
I sintomi avvertiti dalla paziente sono: senso di protrusione vaginale (la paziente percepisce al tatto una “pallina” che protrude dal canale vaginale verso l’esterno), senso di peso in zona genito-anale e/o al basso ventre; questi sintomi possono accentuarsi nelle ore serali e in occasione di lavori pesanti. Talvolta può essere presente difficoltà alla defecazione (la paziente percepisce il bisogno di defecare, ma non riesce ad espellere le feci in modo soddisfacente).
Le cause del prolasso sono identificabili in alcuni fattori di rischio: gravidanza e parto, sovrappeso, sport ad alto impatto, stipsi, tosse e starnuti frequenti. Il coinvolgimento del pavimento pelvico riguarda sia la porzione muscolare di sostegno, spesso ipovalida, sia la porzione connettivale di sospensione, il cui danno determina lo spostamento verso il basso del viscere prolassato.
Disturbi del comparto anteriore
Essi vengono distinti in disturbi della fase di riempimento vescicale, della fase di svuotamento vescicale e della fase post-minzione.
Disturbi della fase di riempimento
Incontinenza urinaria
che viene definita come la perdita involontaria di urina. Ne soffrono in Italia circa 3 milioni di individui, per la maggior parte donne.
Vengono distinte tre forme:
- l’incontinenza urinaria da sforzo o da stress, che si verifica durante uno sforzo intenso come tossire, starnutire, soffiarsi il naso, sollevare un peso, oppure lieve, come camminare o fare le scale. E’ tipica dei soggetti di sesso femminile e si presenta frequentemente nel periodo post partum e nella menopausa.
- l’incontinenza urinaria da urgenza, presente in concomitanza di un impellente ed improcrastinabile bisogno di mingere e tale da impedire al soggetto di raggiungere la toilette in tempo utile.
- l’incontinenza urinaria mista, dove sono presenti i sintomi di entrambe le forme.
Appartengono ai disturbi della fase di svuotamento anche l’urgenza urinaria (improvviso irresistibile desiderio di urinare, difficile da procrastinare), l’aumento della frequenza urinaria, “pollachiuria”, è riferita dal paziente come lo svuotamento
minzionale quotidiano troppo frequente (frequenza normale è al massimo di 7), la nicturia (necessità di svegliarsi una o più volte durante la notte per mingere).
Disturbi della fase di svuotamento
Sono collegati alle difficoltà riferite dal soggetto nel momento della minzione: quando è difficile iniziarla, oppure il manifestarsi di flusso urinario debole e/o intermittente durante tale momento od infine la necessità di utilizzare la forza dell’addome per spingere fuori l’urina.
Disturbi post minzionali
I disturbi che si verificano dopo la minzione sono : il senso di incompleto svuotamento vescicale e del gocciolamento post minzionale (perdita involontaria di urina immediatamente successiva al termine della minzione, solitamente dopo aver lasciato la toilette).
Disturbi del comparto medio
Disfunzioni sessuali
Le disfunzioni sessuali colpiscono entrambi i sessi e consistono nella difficoltà o impossibilità ad avere rapporti sessuali, nella mancata soddisfazione durante questi e/o nel dolore che ad essi si può accompagnare.
Il pavimento pelvico può essere causa o conseguenza di queste, oppure essere uno degli elementi che mantiene questa complessa disfunzione in quanto i muscoli del pavimento pelvico sono coinvolti nella penetrazione vaginale, nella fase dell’orgasmo
e nel meccanismo di erezione e di eiaculazione.
Disturbi del comparto posteriore
L’incontinenza ai gas e/o alle feci
È la perdita involontaria di gas e/o feci solide o liquide.
E’ un sintomo altamente invalidante per la qualità di vita ed è probabilmente più frequente di quanto si possa ipotizzare
Sindrome da defecazione ostruita
Disturbo della defecazione caratterizzato da prolungato ponzamento, sensazione di incompleta evacuazione e necessita di ricorrere a digitazioni o clisteri per evacuare.
In Italia ne è affetta circa 1 donna su 4-5 sopra i 40 anni.
È considerato normale un numero di evacuazioni comprese tra 2 al giorno e 2 alla settimana.
La stipsi può dipendere da una ridotta capacità contrattile dell’intestino e/o dalla presenza di un ostruzione meccanica o funzionale.
L’ostruzione meccanica solitamente è legata alla presenza di un prolasso rettale interno od esterno, di un rettocele anteriore e/o dall’invaginazione del retto in se stesso (intussuscezione retto-rettale).
L’ostruzione funzionale è legata al mancato od incompleto rilasciamento dei muscoli della continenza in presenza di una dissinergia muscolare del pavimento pelvico
o del fascio pubo-rettale che circonda e chiude il canale anale.
Malattia emorroidaria
La malattia emorroidaria caratterizzata da sanguinamento, bruciore, dolore, gonfiore a livello del canale anale è sostenuta quasi sempre oltre che dalla dilatazione dei vasi venosi che compongono il plesso emorroidario anche dalla presenza di un prolasso della mucosa o talvolta di tutta la parete del retto.
Cosa causa le disfunzioni del pavimento pelvico?
Alla base delle disfunzioni del Pavimento Pelvico vi è un allungamento ed assottigliamento delle fibre muscolari e del connettivo che lo compongono oltre che la riduzione dell’innervazione di queste strutture.
Gravidanze, parto naturale, l’aumento cronico della pressione addominale ( stitici, obesi , bronchitici cronici ecc. ), le modificazioni ormonali della menopausa, interventi chirurgici sulla pelvi oltre che il prolasso congenito degli organi pelvici contribuiscono al logoramento delle strutture del pavimento pelvico ed alla conseguente perdita delle funzioni che esso svolge.
Nella maggior parte dei casi le alterazioni anatomiche sono molteplici e non sempre localizzate in un singolo comparto. Per questo motivo spesso le manifestazioni cliniche delle patologie del pavimento pelvico possono essere molteplici e soltanto una completa valutazione clinica può evidenziare le eventuali alterazioni multi fattoriali alla loro base.
La perdita della funzione di sostegno da parte delle strutture del Pavimento Pelvico provoca il PROLASSO DEGLI ORGANI PELVICI (POP). La perdita del sostegno provoca la perdita della posizione abituale degli organi pelvici con ripercussioni importanti sulla loro funzione.
Le principali alterazioni anatomiche alla base delle patologie del pavimento pelvico sono:
- ISTEROCELE / COLPOCELE
- CISTOCELE
- RETTOCELE
- ENTEROCELE / SIGMOIDOCELE
- PROLASSO DEL RETTO
L’ISTEROCELE O PROLASSO DELL’UTERO è caratterizzato dalla perdita di domicilio dell’utero che venendo a mancare il sostegno da parte delle strutture del pavimento pelvico scivola verso l’esterno.
Tipicamente, il prolasso viene definito di 1° grado quando la cervice scende al di sotto del livello della spina ischiatica (terzo medio della vagina), di 2° grado quando la cervice scende fino all’introitus (ostio vaginale), ma non lo supera, e di 3° grado quando la cervice si impegna attraverso l’introitus (prolasso esterno).
Il sintomo più frequente è un senso di pesantezza o di pressione nella regione vaginale. Una massa visibile può protrudere attraverso l’orificio vaginale. Questa sintomatologia è presente quasi sempre quando la paziente mantiene la stazione eretta, mentre si verifica raramente quando la paziente è supina.
Il prolasso congiunto di utero e vagina prende il nome di PROCIDENZA
IL COLPOCELE è costituito dal prolasso della cupola vaginale nelle donne che hanno subito un isterectomia e presenta più o meno le stesse caratteristiche dell’Isterocele.
ISTEROCELE e COLPOCELE sono spesso associati ad INCONTINENZA URINARIA, DISFUNZIONI SESSUALI e talvolta anche a DOLORE PELVICO CRONICO.
IL CISTOCELE è un’erniazione della vescica urinaria attraverso la parete anteriore della vagina solitamente legata alla perdita di consistenza della parete vaginale anteriore e di sostegno da parte del connettivo pubocervicale.
Come per l’Isterocele anche il Cistocele viene definito di 1° grado quando la parete vescicale è ancora contenuta nel canale vaginale; di 2° grado quando la parete vescicale affiora dall’ostio vaginale ed infine, di 3° grado quando la parete vescicale sporge al di fuori dell’ostio vaginale.
Il Cistocele causa spesso INCONTINENZA URINARIA caratterizzata da una difficoltà alla minzione tale da costringere la donna ad urinare in posizione semi seduta fino a dover riposizionare manualmente il prolasso per urinare; altre volte invece è presente una perdita involontaria di urina con urgenza minzionale, aumento del numero di minzioni quotidiane (pollachiuria) e notturne ( nicturia). A queste talvolta si associano anche DISFUNZIONI SESSUALI come dolore durante i rapporti (dispareunia) o impossibilità a raggiungere l’orgasmo.
IL RETTOCELE è una protrusione del retto all’interno del lume vaginale come conseguenza dell’indebolimento della parete muscolare del retto,della fascia perirettale e dei muscoli che compongono i setto retto-vaginale.
Esistono vari tipi di classificazione del Rettocele le più diffuse sono:
La classificazione HWS (Half Way System) di Baden e Walker che identificano 5 gradi a seconda della protrusione della parete vaginale posteriore rispetto alle caruncole imenali. Si definisce quindi di Grado 0 quando non vi sono modificazioni della parete vaginale posteriore neppure durante la manovra del ponza mento; di Grado 1 quando vi è una protrusione della parete vaginale posteriore che non raggiunge le caruncole imenali; di Grado 2 quando la protrusione raggiunge le caruncole ma non le supera; di Grado 3 quando la parete vaginale posteriore oltrepassa le caruncole ed infine Grado 4 quando vi è una completa eversione vaginale.
La classificazione Mellgren è invece molto usata soprattutto dai radiologi ed in base alla profondità della tasca del rettocele lo classifica in 1° grado se minore 2 cm, 2° grado se compreso tra 2 e 4 cm ed infine 3° grado se maggiore di 4 cm.
I sintomi del rettocele sono legati principalmente alla difficoltà evacuativa (SINDROME DA DEFECAZIONE OSTRUITA) anche se non sono infrequenti CISTITI ricorrenti e DISFUNZIONI SESSUALI.
L’ENTEROCELE è un’erniazione del peritoneo e dell’intestino tenue a livello dello scavo pelvico di Douglas tra il retto e la vagina. Ad erniare può essere anche il sigma in casi di ptosi (eccessiva lunghezza) e prende il nome di SIMOIDOCELE.
La sintomatologia di questa condizione è solitamente legata all’occupazione di spazio e si caratterizza con un senso di peso pelvico e talvolta con sensazione di ingombro vaginale soprattutto durante la defecazione. Talvolta l’Enterocele può essere collegato ad una SINDROME DA DEFECAZIONE OSTRUITA.
IL PROLASSO RETTALE è caratterizzato da una patologica discesa dell’intestino retto dentro se stesso. Il retto scivolando ( invaginandosi) dentro il suo stesso lume può non impegnarsi nel canale anale configurando un prolasso retto-rettale, oppure può entrare nel canale anale creando un prolasso retto-anale. Questa condizione è generalmente associata ad una SINDROME DA DEFECAZIONE OSTRUITA per l’impossibilità delle feci di fuoriuscire durante l’atto defecatorio a causa dell’ostruzione del lume rettale da parte della parete prolassata.
Possiamo classificare i Prolassi Rettali in 2 categorie a seconda se a prolassare è l’intera parete del retto (Prolasso a tutto spessore o completo) o la sola parete mucosa (prolasso mucoso). Quest’ultimo è di solito associato alla MALATTIA EMORROIDARIA.
Inoltre possiamo suddividere i Prolassi Rettali in interni ed esterni se i tratto prolassante fuoriesce o meno dall’orifizio anale.
I sintomi principali del Prolasso Rettale sono legati alla presenza della MALATTIA EMORROIDARIA e della SINDROME DA DEFECAZIONE OSTRUITA oltre che talvolta anche di RAGADI ANALI ed INCONTINENZA ANALE.
Diagnosi dei disturbi del pavimento pelvico
La caratteristica multifattorialità delle patologie del pavimento pelvico ha portato alla necessità dello sviluppo di apposite tecniche diagnostiche per riuscire ad identificare le varie alterazioni che sono alla base di una disfunzione del pavimento pelvico.
La valutazione clinica da parte dello specialista è il primo step diagnostico per le patologie del pavimento pelvico e solo dopo uno scrupoloso esame obiettivo che preveda anche un esplorazione rettale e/o vaginale ed una eventuale anoscopia sarà possibile indicare al paziente il corretto percorso diagnostico da seguire.
Gli strumenti diagnostici per identificare un disturbo del pavimento pelvico sono:
- MANOMETRIA ANO-RETTALE PANCOLONSCOPIA o Retto-Sigmoido-Colon-Scopia
- DEFECOGRAFIA o meglio PERINEOGRAFIA
- TEMPI DI TRANSITO INTESTINALI
- ECOGRAFIA PELVICA, TRANSVAGINALE e TRANSPERINEALE
- ECOGRAFIA TRANSRETTALE
- URODINAMICA
- ELETTROMIOGRAFIA ANALE e TEMPO DI LATENZA DEL NERVO PUDENDO
Manometria ano-rettale
Il Servizio di MANOMETRIA ANO-RETTALE è seguito dalla Dott. Fabio Goffredo, Medico Chirurgo Specialista in Gastroenterologia ed Endoscopia digestiva
La Manometria Anorettale è un’indagine che viene eseguita ormai da oltre 30 anni per
raccogliere informazioni sulla fisiopatologia dell’ultimo tratto dell’intestino e della muscolatura del pavimento pelvico, in relazione alla continenza ed alla evacuazione del contenuto intestinale.
Questo esame si propone di esaminare gli aspetti motori e sensitivi che presiedono ai meccanismi di evacuazione e contenimento delle feci.
L’apparato di registrazione prevede quindi l’uso di rilevatori dei valori pressori esistenti nell’ampolla rettale e nel canale anale oltre che di stimolatori dei recettori della sensibilità viscerale della parete rettale.
L’esame, condotto con un’apposita strumentazione provvista di un sistema di perfusione ad acqua o ad aria, un unità di acquisizione dati computerizzata e specifici cateteri di materiale plastico.
L’esame ha una durata di circa 20-30 minuti non prevede nessun tipo di sedazione od anestesia e quindi il paziente può riprendere immediatamente le normali attività quotidiane e lavorative.
Pancolonscopia o Retto-Sigmoido-Colon-Scopia
È un esame che consente lo studio della mucosa del colon e del retto oltre che se necessario degli unltimi centimetri dell’ileo distale. Questo esame che si esegue introducendo un particolare strumento a fibre ottiche (colonscopio) dall’ano fino ad arrivare alla valvola ileocecale o se necessario risalire nell’ileo distale, permette di evidenziare eventuali patologie del colon-retto come polipi, diverticoli, infiammazioni o tumori.
L’utilizzo di un sistema a visione diretta consente anche di poter eseguire biopsie della mucosa oltre che di asportare polipi o aree di mucosa patologica oltre che iniettare medicamenti.
Per eseguire l’esame è necessaria la pulizia intestinale che si esegue assumendo delle soluzioni lassative. L’esame solitamente nei centri qualificati viene condotto sotto sedazione, un particolare tipo di anestesia che consente di non accorgersi dei fastidi che l’esame può arrecare ma che viene rapidamente eliminata e consente al paziente di ritornare a casa poco tempo dopo la fine della procedura.
La pan colonscopia ha un importante valore preventivo per il tumore del colon retto perche questo si sviluppa con un lungo processo di degenerazione delle cellule della mucosa che inizia con una lesione benigna, il polipo, e termina con una neoplasia maligna. L’eradicazione dei polipi eventualmente presenti interrompe perciò questo percorso degenerativo impedendo la formazione di una lesione neoplastica. Per tale motivo le linee guida internazionali consigliano l’esecuzione di una pancolonscopia al raggiungimento dei 50 anni e la sua ripetizione periodica ogni 5-8 anni. Nei casi di familiarità per cancro del colon-retto la prima pan colonscopia andrebbe eseguita al raggiungimento del 40° anno.
Defecografia o meglio perineografia
La defecografia è lo studio radiologico contrasto grafico dinamico della fase evacuativa e permette di visualizzare la presenza di modificazioni dell’anatomia normale del retto durante l’evacuazione. La Perineografia è un evoluzione della defecografia che consente lo studio dinamico di tutte le strutture del pavimento pelvico sempre durante l’evacuazione.
Questi esami si possono eseguire sotto visione RX (radiologica tradizionale) o più recentemente utilizzando la Risonanza Magnetica (RMN Perineografia).
L’esame defecografico è semplice ed indolore e necessita unicamente di una preparazione con un clistere 3 ore prima dell’indagine per standardizzare l’esame con una quantità fissa e nota di contrasto e per evitare che feci formate creino degli artefatti. Nella Perineografia il contrasto viene somministrato anche per via orale, vaginale e vescicale così da poter valutare nella sua interezza le modificazioni anatomiche di tutti gli organi che sono in sinergia con il pavimento pelvico.
Tempi di transito intestinali
Lo studio dei tempi di transito intestinale permette di evidenziare la durata del transito intestinale oro-anale, che generalmente varia da 2 a 5 giorni in soggetti con assunzione adeguata di scorie e di liquidi.
L’esame viene condotto facendo assumere marcatori radiopachi di forme diverse (solitamente 10 al giorno) e valutando poi tramite una semplice radiografia dell’addome la progressione di questi ultimi nel tratto digerente. Questo studio consente di identificare la persistenza ed il numero di marcatori ed eventualmente la zona di accumulo consentendo di discriminare una stipsi da rallentato transito da una probabile stipsi da ostruita defecazione.
Ecografia pelvica, transvaginale e transperineale
Queste metodiche consentono lo studio ecografico del comparto anteriore del pavimento pelvico femminile garantendo un ottima dell’uretra, del collo vescicale e delle strutture anatomiche contigue. Questi esami consentono, inoltre, di eseguire uno studio funzionale delle variazioni dinamiche dell’uretra rispetto alla sinfisi pubica durante l’aumento della pressione addominale in modo da ottenere una più accurata valutazione dei pazienti con incontinenza urinaria.
Ecografia transrettale
Questa metodica diagnostica nata per lo studio della prostata e nella stadiazione del cancro del retto medio-basso, riveste oggi un ruolo molto importante nella valutazione dell’anatomia delle strutture del pavimento pelvico oltre che nello studio delle patologie proctologiche (fistole, ascessi).
Se eseguito con una particolare sonda rotante questo esame fornisce una scansione radiale a 360° che consente di ottenere immagini assai dettagliate degli sfinteri e della parete rettale.
La combinazione dell’ultrasonografia con una diagnostica endoluminale che consente il contatto del trasduttore con la parete del viscere da studiare ha rivoluzionato lo studio morfologico delle strutture del pavimento pelvico, soprattutto degli sfinteri e della parete rettale, consentendo uno studio dinamico tridimensionale che garantisce enormi potenzialità di inquadramento fisiopatologico.
Urodinamica
L’Urodinamica è una metodica di valutazione oggettiva della funzione delle vie urinarie inferiori (vescica,uretra) e superiori (rene) mediante la misurazione di tempi, volumi, pressioni, attività elettrica.
Questa metodica solitamente prevede lo studio della funzione delle sole vie urinarie inferiori comprendendo con queste anche il pavimento pelvico.
L’Urodinamica è un esame fondamentale per diagnosticare le disfunzioni del basso apparato urinario, rappresentate generalmente da problemi di riempimento o di svuotamento o entrambe della vescica, mediante la riproduzione, durante l’esame, dei sintomi lamentati dal paziente.
In pratica si va ad indagare come il paziente riempie e svuota la vescica, se percepisce normalmente a dati volumi e pressioni, le sensazioni di riempimento e gli stimoli , se è capace di procrastinare la minzione, se non perde urina con gli aumenti della pressione addominale (colpi di tosse), se la sua capacità di svuotare la vescica è valida (non rimane urina in vescica).
Elettromiografia anale e tempo di latenza del nervo pudendo
L’elettromiografia anale studia l’attività elettrica dello sfintere anale esterno e del muscolo pubo-rettale, registrandone i potenziali a riposo, durante la contrazione e durante il ponzamento.
Lo studio della latenza del nervo pudendo permette di rilevare il tempo trascorso dall’applicazione di uno stimolo al nervo e la risposta motoria dello sfintere esterno.
Entrambi i 2 esami sono molto utili nello studio dei deficit sfinteriali come nei casi di incontinenza fecale.