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REVIEW ARTICLE J Surg Ultrasound 2015;2:59-64 JSU Journal of Surgical Ultrasound 골반저질환에서회음부초음파검사의유용성 대장항문외과의영역 서울양병원대장항문외과 신현근 Transperineal Ultrasonography for Pelvic Floor Disorders in the Aspect of Colorectal Surgeon Hyeon-Keun Shin Division of Colorectal Surgery, Department of Surgery, Seoul Yang Hospital, Seoul, Korea Received July 9, 2015 Revised October 23, 2015 Accepted October 27, 2015 Correspondence to: Hyeon-Keun Shin Division of Colorectal Surgery, Department of Surgery, Seoul Yang Hospital, Seoul, Korea Tel: +82-2-480-8007 Fax: +82-2-480-8119 E-mail: shkmd@lycos.co.kr Ultrasonography has recently been used in the diagnosis of pelvic floor disorders and is replacing conventional radiological methods. Transperineal ultrasonography can be used as an important diagnostic method for pelvic floor disorders to demonstrate the anatomy of the pelvic floor. This is a minimally invasive procedure providing an extensive perineal view. Pelvic floor organ (including the bladder, uterus, anus and rectum) position, movement, and prolapse can be observed as a real-time imaging and may be used in diagnosis of obstructive defecation syndrome including rectocele, rectal intussusception, enterocele, and NRPR. Imaging of these real movements can lead to a better understanding of the disorders and favorable results can be expected after treatment. Other advantages include low costs and high availability. Finally, transperineal ultrasonography can be helpful in the diagnosis of anorectal or pelvic floor disorders. Keywords: Pelvic floor disorders, ODS, Transperineal ultrasonography 서론 대장항문외과에서진료하게되는변비등의증상을호소하는환자들중에는골반저질환과연관된복잡한경우도드물지않고, 이러한골반저질환들은임상적으로진단하기에쉽지않은질환이며, 골반저구조물에대한해부학적, 생리학적기능들도아직확실하게이해되고있지않다. 특히골반저질환으로호소하는환자들의증상과의사의임상적진찰소견이일치하지않을때도있다.(1) 임상적진료시외래에서직장수지검사등을시행하여어느정 도필요한정보를얻을수있으나충분하다고할수없고, 이러한이유로방사선검사가시행되고있다. 골반저질환에대한방사선검사로배변조영술 (defecography) 과 MRI (dynamic MR imaging) 검사가있다. 이중배변조영술 (defecography) 이대표적이며흔히사용되는검사이지만직장외다른골반구조물들을모두관찰하기어렵고특수한장비와시설이필요하며검사시방사선에노출될가능성등의여러가지한계점들을가지고있다.(2) MRI 검사는검사의편의성부분이나고가의장비로인한문제등으로인해흔히사용되고있지는않다.(3) 이러한단점들을극 Journal of Surgical Ultrasound is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright c 2015 by The Korean Surgical Ultrasound Society ISSN 2288-9140

J Surg Ultrasound Vol. 2, No. 2, 2015 복하고자시작된것이역동적항문직장초음파 (dynamic anorectal ultrasonography, DAUS) 이며여기에는회음부초음파 (transperineal ultrasound, TPUS), 경질초음파 (endovaginal ultrasonography, EVUS), 경항문초음파 (endoanal ultrasonography, EAUS) 가있다.(4,5) 사실회음부초음파검사 (TPUS) 는 1995년요실금환자에서방광경부 (bladder neck) 를관찰하는데처음으로사용되었다.(6) 회음부초음파검사의장점으로는검사가쉽고, 방사선노출의위험이없으며검사시골반구조물들의움직임을직접관찰할수있다는것이다.(7) 특히배변장애를호소하는환자를진료할때배변과유사한상황 - 안정시및힘주기 (straining)- 에서골반내전, 중, 후방구획 (anterior, middle, posterior pelvic compartment) 을각각관찰할수있다.(8) 이스라엘의 Beer-Gabel et al.(4), 브라질의 Kleinübing et al.(9), 스위스의 Roche et al. (10), 그리고이탈리아의 Piloni (11) 는각각회음부후방과골반저에대한회음부초음파를이용한효과적인검사법을보고하였다. 이러한장점들은그동안모호하게받아들여졌던골반저질환에대한진료를좀더구체적으로진행할수있게되고치료-특히수술적-에이르기까지도움이될수있다고생각된다. 물론초음파검사소견이항상임상소견이나환자증상과일치하지는않으며, 해부학적교정이반드시기능의개선으로연결되지는않는다.(12) 하지만골반수술의목표는가능한환자의증상을해결하고해부학적결함과기능을교정하는것이므로회음부초음파검사를이용하여골반저에대한통합적진료를하는것이도움이될것이다. 현재까지고가의장비를이용한 3D 초음파검사등이소개되고좋은반응을얻고있기도하지만일선진료현장에서이러한장비를모두갖추기는무리가있을수있고따라서일반적인 2D 초음파장비를이용한회음부초음파검사에대하여설명하고자한다. 배변장애나골반통증를호소하는환자에서직장류 (rectocele), 직장중첩 (rectoanal intussusception), 치골직장근이완부전증 (non-relaxing puborectalis syndrome) 등의이상소견을관찰할수있다. 2. 장비회음부초음파검사를위해선일반적인 2D 초음파검사장비로도충분하다. 일반적으로 3.5-7 MHz의 curved transducer 를사용한다 (Fig. 1). 3. 검사방법검사전에관장이반드시필요하지는않으며, 필요한경우방광은적당히차있는것이다른구조물과의감별에도움이된다. 다만방광이너무차있으면장기의탈출 (prolapsed) 이방해되어검사가올바르지않을수도있다. 환자를앙와위에서양측무릎을약간굽힌쇄석위를취하게한다. Curved transducer 를사용하여 mid-sagittal view 를얻는다. Probe 표면에초음파검사용젤을바른후외과용글러브 (powderless) 를덧씌운후젤을추가로덧바른다. 이렇게함으로써검사시보다선명한영상을얻을수있다 (Fig. 2). 회음부에 probe 를가볍게밀착시키면서골반구조물을확인한다 (Fig. 3). 전방, 중간, 후방구획의구조물을볼때마다약간씩 probe 의각도를달리하여원하는구조물의이미지를확인한다. 본 론 1. 검사목적회음부초음파검사를시행하면방광, 요도, 질및자궁, 항문과직장에대한전체모양을관찰할수있다. 또한안정시, 발살바동작 (Valsalva maneuver) 혹은힘쓰기 (straining) 동작중의골반저구조물의역동적인 (dynamic) 움직임이나변화를실시간으로 (real-time) 직접관찰할수있다. Fig. 1. 2-dimensional Ultrasound Machine. 60

Hyeon-Keun Shin: Transperineal Ultrasonography for the Pelvic Floor Disorders in the Aspect of Colorectal Surgeon Fig. 2. Transducer preparing with gel and powderless glove. Fig. 3. (A) Transducer placement on perineum, reprinted from Dietz.(13) (B) Transducer placement and imaging of pelvic floor organ. 4. 정상구조물 하나의 화면에 보여야 올바른 검사이다(Fig. 4). 안정 앞쪽으로 치골결합(symphysis pubis)이 관찰되며 차 (resting)시와 발살바 동작(Valsalva maneuver) 혹은 힘 례로 요도, 질, 항문관과 직장이 보이고 그 뒤로 항문거근 쓰기(straining) 동작시 치골결합과 항문거근판 사이의 판(levator plate)이 관찰된다. 치골결합과 항문거근판이 거리를 측정하여 거근틈(levatoe hiatus)의 전-후(AP) 거 61

J Surg Ultrasound Vol. 2, No. 2, 2015 Fig. 4. Normal sagittal view of pelvic floor. Fig. 5. Movement of anorectum, at rest& during straining. (A) At rest, (B) During straining. 리를 알 수 있다(Fig. 5). 또한 이 둘의 연결선을 기준선으 로 하여 이보다 아래로 내려오는 경우를 탈출(prolapsed) 소견으로 판단할 수 있다. 5. 적응질환 직장류: 배변시 직장 전벽이 질쪽으로 돌출되는 것을 말하며, 돌출되는 정도가 10 mm 이상이면 초음파에서 직 장류로 진단할 수 있다(Fig. 6, 7). 하지만 현재까지 돌출 되는 정도와 증상이 일치하는지는 입증된 결과가 없다. 직장탈-직장중첩증: 직장벽이 직장관내로 밀려내려오 는 상태이며 폐쇄성 변비나 불완전 배변감등의 증상을 일 으키며, 경회음부 초음파에서 관찰할 수 있다(Fig. 8). 62 Fig. 6. Anterior rectocele in female patient. Anterior rectocele: white arrow, R: rectum.

Hyeon-Keun Shin: Transperineal Ultrasonography for the Pelvic Floor Disorders in the Aspect of Colorectal Surgeon Fig. 7. Rectocele depth measurement using TPUS : schematic sagittal view of the rectum during maximal straining (Bladder and urethra not shown). V-axis passes through the anterior aspect of the anal canal at right angles to the X-axis. W-axis is a line drawn at right angles to the V-axis through the most anterior part of the rectocele. X-axis passes through the center of the body of the pubis. Point E: the most anterior part of the rectocele, Point F: junction of the V and W axes, D4: the measured depth of the rectocele during maximal straining, RVS: Rectovaginal septum. Fig. 8. Rectal intussusceptions (A) Resting, (B) Straining. White arrow: intussusception. 결론 회음부초음파검사를시행함으로써배변장애나골반저질환이의심되는환자에서골반구조물의움직임이나변화를직접관찰하는것이가능하고, 이것을환자에게직접보여주면서질환에대하여설명할수있다는점은, 모호한증상의호소혹은충분하지못한검사로인해서올바른진단에적절히이르지못하는문제점들을해결할수있고, 진료및치료시에환자와의관계에큰신뢰를형성할수 있으며치료시환자의적극적인동참을유도할수있고, 이는치료후의결과및환자의만족감에도좋은영향을미칠수있다고생각된다. 회음부초음파검사는검사방법이어렵지않으며방사선노출의위험이없고고가의장비나시설이필요하지도않으며일반적인 2D초음파장비를이용하기때문에비용적인문제나검사의편의성에있어서도장점이있으므로변실금이나배변장애, 골반저질환에대한진료영역에서적극적으로시행해볼수있는검사방법이라고생각한다. 하지만회음부검사로인해서환자 63

J Surg Ultrasound Vol. 2, No. 2, 2015 가느낄수있는민망함혹은불쾌한기분등과관련하여오해나법적인문제등의소지가있을수있으므로, 이에대하여검사전에충분히환자에게검사목적및방법을설명하고동의를얻어야할것이며, 검사중반드시간호사를동반함으로써만일에생길수있는불미스러운문제점들에대한주의도필요하다. REFERENCES 1. Maglinte DD, Kelvin FM, Fitzgerald K, Hale DS, Benson JT. Association of compartment defects in pelvic floor dysfunction. AJR Am J Roentgenol 1999;172:439-44. 2. Goei R, Kemerink G. Radiation dose in defecography. Radiology 1990;176:137-9. 3. Kruger J, Heap X, Dietz HP. OC259: a comparison of magnetic resonance imaging and 4D ultrasound in the assessment of the levator hiatus. Ultrasound Obstet Gynecol 2007;30:A447. 4. Beer-Gabel M, Teshler M, Barzilai N, Lurie Y, Malnick S, Bass D, et al. Dynamic transperineal ultrasound in the diagnosis of pelvic floor disorders: pilot study. Dis Colon Rectum 2002;45:239-45; discussion 245-8. 5. Brusciano L, Limongelli P, Pescatori M, Napolitano V, Gagliardi G, Maffettone V, et al. Ultrasonographic patterns in patients with obstructed defaecation. Int J Colorectal Dis 2007;22:969-77. 6. Schaer GN, Koechli OR, Schuessler B, Haller U. Perineal ultrasound for evaluating the bladder neck in urinary stress incontinence. Obstet Gynecol 1995;85: 220-4. 7. Pescatori M, Regadas FSP, Regadas SMM, Zbar AP. Imaging Atlas of the Pelvic Floor and Anorectal Diseases. Milano: Springer-Verlag; 2008. 8. Beer-Gabel M, Frudinger A, Zbar A. Dynamic transperineal ultrasound and transvaginal sonography. In: Wexner SD, Zbar AP, Pescatori M, editors. Complex anorectal disorders: investigation and management. London: Springer; 2005. pp.246-58. 9. Kleinübing H Jr, Jannini JF, Malafaia O, Brenner S, Pinho TM. Transperineal ultrasonography: new method to image the anorectal region. Dis Colon Rectum 2000;43:1572-4. 10. Roche B, Deléaval J, Fransioli A, Marti MC. Comparison of transanal and external perineal ultrasonography. Eur Radiol 2001;11:1165-70. 11. Piloni V. Dynamic imaging of pelvic floor with transperineal sonography. Tech Coloproctol 2001;5:103-5. 12. Santoro GA, Wieczorek AP, Dietz HP, Mellgren A, Sultan AH, Shobeiri SA, et al. State of the art: an integrated approach to pelvic floor ultrasonography. Ultrasound Obstet Gynecol 2011;37:381-96. 13. Dietz HP. Pelvic floor ultrasound: a review. Am J Obstet Gynecol 2010;202:321-34. 64