盆底功能障碍背景下直肠内脱垂的分级标准及诊疗策略

doi:10.12280/gjfckx.20251137

摘要/Abstract

摘要：

盆底功能障碍（pelvic floor dysfunction，PFD）是一类以尿失禁、排便功能障碍和盆腔器官脱垂为主要表现的临床综合征，严重影响患者生活质量，其中直肠内脱垂（internal rectal prolapse，IRP）作为PFD的重要组成部分，其分级与盆底支持结构的完整性密切相关。现有证据表明，PFD所引起的盆底支持结构退化与肛提肌功能障碍是IRP发生发展的关键驱动因素。IRP分级与盆底损伤程度显著相关，高级别IRP（Ⅲ~Ⅳ级）多伴随严重的盆底解剖与功能异常。动态磁共振排粪造影（dynamic magnetic resonance defecography，DMRD）及高分辨率肛肠测压（high-resolution anorectal manometry，HR-ARM）是实现客观分级与功能评估的关键工具。治疗上，低分级IRP对盆底肌训练（pelvic floor muscle training，PFMT）反应良好，而高分级IRP常需手术干预。目前该领域仍缺乏统一的分级标准与前瞻性队列研究的支持，未来应致力于构建多中心协作、整合影像组学与人工智能技术的标准化分级体系，以推动精准诊疗。

关键词: 盆底疾病, 直肠脱垂, 诊断, 分级标准, 盆底肌训练

Abstract:

Pelvic floor dysfunction (PFD) is a clinical syndrome mainly characterized by urinary incontinence, defecation dysfunction, and pelvic organ prolapse, which significantly affects the quality of patients' life. Internal rectal prolapse (IRP), as an important component of PFD, is closely related to the integrity of the pelvic floor support structure in terms of its grading. Current evidence shows that the degeneration of the pelvic floor support structures and the dysfunction of the levator ani muscle caused by PFD are the key driving factors for the occurrence and development of IRP. The grading of IRP is significantly correlated with the degree of pelvic floor injury. High-grade IRP (Grades Ⅲ-Ⅳ) is often accompanied by severe pelvic floor anatomical and functional abnormalities. Dynamic magnetic resonance defecography (DMRD) and high-resolution anorectal manometry (HR-ARM) are the key tools for objective grading and functional evaluation. In terms of treatment, low-grade IRP responds well to pelvic floor muscle training (PFMT), while high-grade IRP often requires surgical intervention. Currently, there is still a lack of a unified grading standard and support from prospective cohort studies in this field. In the future, efforts should be made to construct a standardized grading system through multi-center collaboration, integrating radiomics and artificial intelligence technologies to promote precision diagnosis and treatment.

Key words: Pelvic floor disorders, Prolapse of rectum, Diagnosis, Standardized criteria, Pelvic floor muscle training

刘飞虎, 管忠安. 盆底功能障碍背景下直肠内脱垂的分级标准及诊疗策略[J]. 国际妇产科学杂志, 2026, 53(1): 48-53.

LIU Fei-hu, GUAN Zhong-an. Standardized Criteria and Management Strategies for Internal Rectal Prolapse in the Context of Pelvic Floor Dysfunction[J]. Journal of International Obstetrics and Gynecology, 2026, 53(1): 48-53.

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参考文献 30

[1]	Kołodyńska G, Zalewski M, Rożek-Piechura K. Urinary incontinence in postmenopausal women - causes, symptoms, treatment[J]. Prz Menopauzalny, 2019, 18(1):46-50. doi: 10.5114/pm.2019.84157. pmid: 31114458
[2]	Weintraub AY, Glinter H, Marcus-Braun N. Narrative review of the epidemiology, diagnosis and pathophysiology of pelvic organ prolapse[J]. Int Braz J Urol, 2020, 46(1):5-14. doi: 10.1590/S1677-5538.IBJU.2018.0581. pmid: 31851453
[3]	Blomquist JL, Carroll M, Muñoz A, et al. Pelvic floor muscle strength and the incidence of pelvic floor disorders after vaginal and cesarean delivery[J]. Am J Obstet Gynecol, 2020, 222(1):62.e1-62.e8. doi: 10.1016/j.ajog.2019.08.003.
[4]	O'Connor A, Byrne CM, Heywood N, et al. Anal sphincter function in rectal intussusception and high and low "take-off" external rectal prolapse-A prospective observational study[J]. Colorectal Dis, 2024, 26(12):2069-2079. doi: 10.1111/codi.17191. pmid: 39370561
[5]	Neshatian L, Triadafilopoulos G, Wallace S, et al. Increased Grades of Rectal Intussusception: Role of Decline in Pelvic Floor Integrity and Association With Dyssynergic Defecation[J]. Am J Gastroenterol, 2024, 119(5):946-956. doi: 10.14309/ajg.0000000000002605.
[6]	Revels JW, Mansoori B, Fadl S, et al. MR Defecating Proctography with Emphasis on Posterior Compartment Disorders[J]. Radiographics, 2023, 43(1):e220119. doi: 10.1148/rg.220119.
[7]	Duran P, Boscolo Sesillo F, Cook M, et al. Proregenerative extracellular matrix hydrogel mitigates pathological alterations of pelvic skeletal muscles after birth injury[J]. Sci Transl Med, 2023, 15(707):eabj3138. doi: 10.1126/scitranslmed.abj3138.
[8]	Zabriskie HA, Drummond MJ, Nygaard IE, et al. Older maternal age at first delivery as a risk factor for pelvic organ prolapse: what we know[J]. Am J Obstet Gynecol, 2025, 232(6):499-505. doi: 10.1016/j.ajog.2025.03.006.
[9]	Subramaniam N, Dietz HP. Is posterior compartment prolapse associated with anal incontinence?[J]. Ultrasound Obstet Gynecol, 2023, 61(5):642-648. doi: 10.1002/uog.26145.
[10]	Neshatian L, Liu A, Gurland B, et al. Sarcopenia Is an Independent Risk Factor for the Decline in Anal Sphincter Function and Increased Levator Laxity in Women[J]. Am J Gastroenterol, 2025 May 16. doi: 10.14309/ajg.0000000000003544.
[11]	DeLancey JO, Mastrovito S, Masteling M, et al. A unified pelvic floor conceptual model for studying morphological changes with prolapse, age, and parity[J]. Am J Obstet Gynecol, 2024, 230(5):476-484.e2. doi: 10.1016/j.ajog.2023.11.1247.
[12]	Dietz HP, Shek KL, Low GK. All or nothing? A second look at partial levator avulsion[J]. Ultrasound Obstet Gynecol, 2022, 60(5):693-697. doi: 10.1002/uog.26034.
[13]	卢任华. 排粪造影的检查方法及临床应用[J]. 中国实用外科杂志, 1993, 13(12):708-711.
[14]	沈辉, 王卫星, 田冰, 等. 出口梗阻型便秘影像学诊断[J]. 中国实用外科杂志, 2013, 33(11):925-929.
[15]	Cariou de Vergie L, Venara A, Duchalais E, et al. Internal rectal prolapse: Definition, assessment and management in 2016[J]. J Visc Surg, 2017, 154(1):21-28. doi: 10.1016/j.jviscsurg.2016.10.004. pmid: 27865742
[16]	Deb B, Sharma M, Fletcher JG, et al. Inadequate Rectal Pressure and Insufficient Relaxation and Abdominopelvic Coordination in Defecatory Disorders[J]. Gastroenterology, 2022, 162(4):1111-1122.e2. doi: 10.1053/j.gastro.2021.12.257.
[17]	Wallace SL, Kim Y, Lai E, et al. Postoperative complications and pelvic organ prolapse recurrence following combined pelvic organ prolapse and rectal prolapse surgery compared with pelvic organ prolapse only surgery[J]. Am J Obstet Gynecol, 2022, 227(2):317.e1-317.e12. doi: 10.1016/j.ajog.2022.05.050.
[18]	Zhang C, Li X, Xie B, et al. A novel pelvic magnetic resonance imaging measurement for pelvic organ prolapse evaluation[J]. Am J Obstet Gynecol, 2025, 232(4):383.e1-383.e8. doi: 10.1016/j.ajog.2024.10.007.
[19]	Lamichhane R, Gautam M, Fletcher JG, et al. Inadequate Propulsion and Pelvic Floor Relaxation in Dyssynergic Defecation: Insights From Synchronous Proctomanometry[J]. Gastroenterology, 2025, 169(5):942-957.e9. doi: 10.1053/j.gastro.2025.04.013. pmid: 40315962
[20]	van Gruting IM, Stankiewicz A, Thakar R, et al. Imaging modalities for the detection of posterior pelvic floor disorders in women with obstructed defaecation syndrome[J]. Cochrane Database Syst Rev, 2021, 9(9):CD011482. doi: 10.1002/14651858.CD011482.pub2.
[21]	Chamié LP, Ribeiro D, Caiado A, et al. Translabial US and Dynamic MR Imaging of the Pelvic Floor: Normal Anatomy and Dysfunction[J]. Radiographics, 2018, 38(1):287-308. doi: 10.1148/rg.2018170055. pmid: 29320316
[22]	Duran P, Zelus EI, Burnett LA, et al. Repeated birth injuries lead to long-term pelvic floor muscle dysfunction in the preclinical rat model[J]. Am J Obstet Gynecol, 2025, 232(2):198.e1-198.e23. doi: 10.1016/j.ajog.2024.08.036.
[23]	Gillor M, Shek KL, Dietz HP. How comparable is clinical grading of obstetric anal sphincter injury with that determined by four-dimensional translabial ultrasound?[J]. Ultrasound Obstet Gynecol, 2020, 56(4):618-623. doi: 10.1002/uog.22011. pmid: 32149422
[24]	Blackett JW, Gautam M, Mishra R, et al. Comparison of Anorectal Manometry, Rectal Balloon Expulsion Test, and Defecography for Diagnosing Defecatory Disorders[J]. Gastroenterology, 2022, 163(6):1582-1592.e2. doi: 10.1053/j.gastro.2022.08.034. pmid: 35995074
[25]	Beamish NF, Davenport MH, Ali MU, et al. Impact of postpartum exercise on pelvic floor disorders and diastasis recti abdominis: a systematic review and meta-analysis[J]. Br J Sports Med, 2025, 59(8):562-575. doi: 10.1136/bjsports-2024-108619.
[26]	Pennycuff JF, Borazjani A, Wang H, et al. Commercially Available Home Pelvic Training Devices for the Treatment of Pelvic Floor Disorders: A Systematic Review and Meta-analysis[J]. Obstet Gynecol, 2022, 140(2):275-292. doi: 10.1097/AOG.0000000000004860. pmid: 35852280
[27]	Herrle F, Sandra-Petrescu F, Rothenhoefer S, et al. Laparoscopic Resection Rectopexy Versus Delorme's Procedure In Full-thickness Rectal Prolapse: A Randomized Multicenter Trial (DELORES-RCT)[J]. Ann Surg, 2025, 282(6):939-945. doi: 10.1097/SLA.0000000000006708.
[28]	Wu J, Yao H, Yu L, et al. A novel 3D printed type II silk fibroin/polycaprolactone mesh for the treatment of pelvic organ prolapse[J]. Biomater Sci, 2023, 11(21):7203-7215. doi: 10.1039/d3bm01158e.
[29]	Sung VW, Jeppson P, Madsen A. Nonoperative Management of Pelvic Organ Prolapse[J]. Obstet Gynecol, 2023, 141(4):724-736. doi: 10.1097/AOG.0000000000005121. pmid: 36897185
[30]	Kahn B, Varner RE, Murphy M, et al. Transvaginal Mesh Compared With Native Tissue Repair for Pelvic Organ Prolapse[J]. Obstet Gynecol, 2022, 139(6):975-985. doi: 10.1097/AOG.0000000000004794. pmid: 35675593

分级	影像学特征	临床表现
Ⅰ级	直肠黏膜轻度、局灶性内陷（深度<3 mm），肠壁肌层完整。	通常无临床意义，常见于无症状人群或偶发排便不畅。
Ⅱ级	黏膜环周性脱垂或套叠（套叠深度≥3 mm），但仅限于黏膜层，未延伸至肌层。	可出现明显的临床症状，如排便梗阻感、肛门坠胀等。
Ⅲ级	直肠全层壁套叠，进入肛管上段。	症状严重且典型，与IRP的相关性极高。强烈的排便梗阻感，常需手法辅助。
Ⅳ级	套叠的直肠壁持续下降，可达肛管下段或肛门外缘（需与外部脱垂鉴别）	最严重的表现形式，症状极其严重，几乎必然发展为完全性直肠脱垂，必须进行临床干预。

分级	影像学特征	临床表现
Ⅰ级	直肠黏膜轻度、局灶性内陷（深度<3 mm），肠壁肌层完整。	通常无临床意义，常见于无症状人群或偶发排便不畅。
Ⅱ级	黏膜环周性脱垂或套叠（套叠深度≥3 mm），但仅限于黏膜层，未延伸至肌层。	可出现明显的临床症状，如排便梗阻感、肛门坠胀等。
Ⅲ级	直肠全层壁套叠，进入肛管上段。	症状严重且典型，与IRP的相关性极高。强烈的排便梗阻感，常需手法辅助。
Ⅳ级	套叠的直肠壁持续下降，可达肛管下段或肛门外缘（需与外部脱垂鉴别）	最严重的表现形式，症状极其严重，几乎必然发展为完全性直肠脱垂，必须进行临床干预。