Role of dynamic magnetic resonance imaging in management of obstructed defecation case series

Magnetic resonance defecography assessment of obstructed defecation syndrome in patients with chronic constipation in a tertiary care hospital

BACKGROUND

Obstructed defecation syndrome (ODS) is a subtype of constipation that is considered one of the major pelvic floor dysfunctions affecting the aging population, particularly women over 50 seeking medical care. The condition is characterized by the urge to defecate but an impaired ability to expel the fecal bolus. ODS is associated with various anorectal abnormalities, which are not always apparent during a standard physical examination, requiring specialized imaging techniques for proper diagnosis.

AIM

To study the distribution of causes of ODS in patients with chronic constipation by magnetic resonance defecography (MRD).

METHODS

This observational study evaluated the causes of ODS in 57 patients with chronic constipation who presented to Bangabandhu Sheikh Mujib Medical University between July 2020 and June 2021. After obtaining institutional review board approval and informed consent, patients underwent history taking, physical exams, and relevant investigations. ODS was diagnosed using Rome III criteria, with colonoscopy ruling out organic causes. Standard MRD was performed in different phases, and images were analyzed by expert radiologists and reported in a standardized format.

RESULTS

Pelvic floor descent and anorectal junction descent were the most frequent findings, each present in 94.7% of cases. Rectocele was observed in 78.9% of patients, while vaginal or uterine prolapse was seen in 59.4% of females. Less common abnormalities included paradoxical contraction (7%), and there were no cases of sigmoidocele. Functional measurements showed significant differences in pelvic floor dynamics between rest and defecation, particularly in the H-line, M-line, and descent of pelvic organs (P < 0.05).

CONCLUSION

Pelvic floor descent and anorectal descent were the most common findings in patients suffering from ODS, followed by rectocele. Younger females (< 30 years) were most affected.

Assessment of Different Pubococcygeal Lines for the Quantitative Diagnosis of Pelvic Organ Prolapse Using Magnetic Resonance Defecography

INTRODUCTION AND HYPOTHESIS

The objective was to elucidate the clinical utility of two reference lines, the pubosacrococcygeal joint line (PCLjnt) and pubococcygeal joint line (PCLcc), in the quantitative diagnosis of pelvic organ prolapse (POP) and pelvic floor laxity.

METHODS

A retrospective analysis of magnetic resonance defecography (MRD) in patients with stage II or above POP was conducted. POP and pelvic floor relaxation were quantitatively assessed using both PCLjnt and PCLcc as reference lines. Further research, point-to-point correlation analysis was performed between the pelvic organ prolapse quantification (POP-Q) system and MRD to investigate the discrepancies between the two reference lines.

RESULTS

There was no significant statistical difference in the degree of cystocele and H line between the PCLjnt and PCLcc groups (p > 0.05). Nevertheless, significant differences in the degree of uterine prolapse and M-line between the two groups were observed (p = 0.00). Both the PCLjnt and PCLcc reference lines demonstrated better correlation with POP-Q, and the PCLcc exhibited slightly higher correlation coefficients than the PCLjnt.

CONCLUSIONS

The results revealed significant moderate correlations between both reference lines and key POP-Q landmarks. Both PCLjnt and PCLcc can be utilized for interpreting MRD images and diagnosing POP for anterior wall and uterine prolapse.

Sexual Dimorphism in the Architectural Design of Rat and Human Pelvic Floor Muscles

Skeletal muscle architecture is a strong predictor of in vivo functional capacity and is evaluated in fixed tissues, accommodating the study of human muscles from cadaveric donors. Previous studies evaluating the pelvic floor muscles (PFMs) demonstrated that the rat is the most appropriate small animal model for the study of female PFM architecture, but the rat's suitability for the study of male PFMs is undetermined. We aimed to determine (1) whether PFM architecture exhibits sexual dimorphism in rats or humans, and (2) if the rat is also a suitable animal model for the study of male human PFMs. PFMs were fixed in situ and harvested en bloc from male and female cadaveric donors and 3-month-old male and female Sprague-Dawley rats. Three architectural parameters influenced by species size were used to compare male versus female PFMs within species, while four size-independent measures compared species within sex. All comparisons were made with two-way analysis of variances and Tukey's multiple comparisons tests post hoc. Sarcomere length (rats and humans, p = 0.016 and = 0.002) and normalized fiber length (rats, p < 0.001) were significantly larger in male PFMs. Three of the size-independent measures exhibited similar species trends in both sexes, while the size-independent sarcomere length measure (Ls/Lso) differed between male rats and humans (p < 0.001). Thus, sexual dimorphism is present in rat and human PFM architecture, and the male rat is suitable for studies of human male PFMs.

Clinical value of MR defecography: What additional knowledge is provided by the radiologist to the surgeon?

PURPOSE

To evaluate the clinical value of MR defecography in supporting surgical decision-making and management strategies in a consecutive series of patients.

MATERIAL AND METHODS

A consecutive series of patients with clinical suspicion of pelvic disorders who underwent MR defecography at a single university hospital from January 2021 to June 2024 were included. MR defecography was performed at rest (axial/sagittal and coronal T2-weighted sequences), during squeezing, straining, and evacuation (dynamic sagittal T2-weighted sequences). An expert surgeon assessed his satisfaction about the diagnostic information given by the prospective radiological report as: 1: insufficient, 2: sufficient, 3: good, 4: excellent. For patients who underwent surgery, the same surgeon assessed the usefulness of the MR defecography, using a score from 1 to 4 (1: discordant findings, useless exam; 2: concordant findings without new information; 3: concordant findings, useful new information; 4: concordant findings, extremely useful new information).

RESULTS

A total of 218 patients (age 27 - 79, mean 60 ± 11; 193 females and 25 males) entered the analysis. For 211 of them (97 %), the radiologist was able to evaluate the images and determine an MR defecography-based diagnosis; in 7 patients (3 %), a diagnosis was not provided due to exam interruption for low patient's compliance. In 195/211 patients (92 %), the radiological diagnosis matched the clinical suspect that prompted the examination. The satisfaction about the diagnostic information given by the radiological report of the 211 exams was assessed by the surgeon as follows: excellent (n = 99, 47 %), good (n = 48, 23 %), sufficient (n = 35, 16 %), and insufficient (n = 29, 14 %). Out of 211 patients, 73 (34.6 %) underwent surgery. MR defecography provided concordant findings with relevant additional information in 63 (86.3 %), concordant findings with additional information in 3 (4.1 %), concordant findings without additional information in 4 (5.5 %), and discordant findings in 3 (4.1 %).

CONCLUSIONS

The diagnostic information prospectively provided by MR defecography resulted to be good or excellent in 70 % of the patients, adding clinical value in the preoperative surgical setting in 86 % of those patients who underwent surgery.

Comparison of Dynamic Magnetic Resonance Defecography With Clinical Examination in Diagnosing Pelvic Floor Dysfunction: An Observational Study

BACKGROUND

Pelvic floor dysfunction (PFD) is frequently reported in both sexes. Dynamic magnetic resonance defecography (DMRD) is the preferred modality, mainly due to its superiority and complementary role in clinical examination. However, studies from the perspective of Indian patients are scarce and mostly restricted to females. Thus, we assessed the diagnostic performance of DMRD in patients with PFD and correlated the findings with those on clinical examination.

MATERIALS AND METHODS

This prospective, observational study involved 57 adult patients of either sex, presenting with pelvic floor symptoms (PFS) and diagnosed with PFD. Initially, the patients underwent clinical examination, and diagnosis was recorded. Subsequently, the patients were subjected to DMRD. The findings were correlated with the Pearson "r" correlation coefficient.

RESULTS

A significantly greater proportion of patients had involvement of multiple compartments (36 vs. 12, p<0.001), cystocele (23 vs. 8, p=0.002), and rectal prolapse (25 vs. 14, p=0.030) on DMRD than clinical examination, while there was no significant difference regarding uterine prolapse (p=0.789). Grading of cystocele and rectal prolapse as well as diagnosis of enterocele/peritoneocele, rectocele, and intussusception could be done only with DMRD. DMRD had a strong and significant correlation with clinical examination regarding cystocele (r=0.943, p=0.003), uterine prolapse (r=0.972, p=0.001), and rectal prolapse (r=0.951, p=0.001).

CONCLUSIONS

DMRD demonstrated significantly better performance in the diagnosis of multiple compartment involvement, cystocele, and rectal prolapse. DMRD and clinical examination were significantly correlated regarding the diagnosis of cystocele, uterine prolapse, and rectal prolapse. Thus, DMRD provides information, in addition to the clinical examination, and should be used in symptomatic patients.

[Dynamic magnetic resonance imaging of the pelvic floor: clinical application]

BACKGROUND

Dynamic magnetic resonance imaging (MRI) of the pelvic floor plays a key role in imaging complex pelvic floor dysfunction. The simultaneous detection of multiple findings in a complex anatomic setting renders correct analysis and clinical interpretation challenging.

OBJECTIVES

The most important aspects (anatomy of the pelvic floor, three compartment model, morphological and functional analysis, reporting) for a successful clinical use of dynamic MRI of the pelvic floor are summarized.

MATERIALS AND METHODS

Review of the scientific literature on dynamic pelvic MR imaging with special consideration of the joint recommendations provided by the expert panel of ESUR/ESGAR in 2016.

RESULTS

The pelvic floor is a complex anatomic structure, mainly formed by the levator ani muscle, the urethral support system and the endopelvic fascia. Firstly, morphological changes of these structures are analysed on the static sequences. Secondly, the functional analysis using the three compartment model is performed on the dynamic sequences during squeezing, straining and defecation. Pelvic organ mobility, pelvic organ prolapse, the anorectal angle and pelvic floor relaxation are measured and graded. The diagnosis of cystoceles, enteroceles, rectoceles, the uterovaginal as well as anorectal decent, intussusceptions and dyssynergic defecation should be reported using a structured report form.

CONCLUSIONS

A comprehensive analysis of all morphological and functional findings during dynamic MRI of the pelvic floor can provide information missed by other imaging modalities and hence alter therapeutic strategies.

Diagnostic Value of Dynamic Magnetic Resonance Imaging (dMRI) of the Pelvic Floor in Genital Prolapses

Pelvic organ prolapse is a chronic disease resulting from a weakening of the musculoskeletal apparatus of the pelvic organs. For the diagnosis of this pathology, it is insufficient to conduct only a clinical examination. An effective diagnostic tool is the method of dynamic magnetic resonance imaging (MRI) of the pelvic floor, which allows a comprehensive assessment of the anatomical and functional characteristics of the walls of the pelvis and pelvic organs. The aim of the study was to analyze the literature data on the possibilities and limitations of using dynamic MRI in pelvic organ prolapse. The widespread use of the dynamic MRI method is due to the high quality of the resulting image, good reproducibility, and the maximum ability to display the characteristics of the pelvic floor. Dynamic MRI of the small pelvis allows a comprehensive assessment of the anatomical and functional features of the pelvis, excluding the effect of ionizing radiation on the body. The method is characterized by good visualization with high resolution and excellent soft tissue contrast. The method allows for assessing the state of the evacuation function of visualized structures in dynamics. Simultaneous imaging of all three parts of the pelvic floor using dynamic MRI makes it possible to assess multicompartment disorders. The anatomical characteristics of the state of the pelvic organs in the norm and in the event of prolapse are considered. The technique for performing the method and the procedure for analyzing the resulting images are described. The possibilities of diagnosing a multicomponent lesion are considered, while it is noted that dynamic MRI of the pelvic organs provides visualization and functional analysis of all three parts of the pelvis and often allows the choice and correction of tactics for the surgical treatment of pelvic organ prolapse. It is noted that dynamic MRI is characterized by a high resolution of the obtained images, and the advantage of the method is the ability to detect functional changes accompanying the pathology of the pelvic floor.

Role of endoanal ultrasound in the assessment of perianal fistula in correlation with MRI fistulography

Background

Perianal fistula is a considered as chronic recurrent inflammatory condition that requires proper surgical treatment and may require repeated intervention. Therefore, adequate pre-operative radiological diagnosis plays a critical role.

In this study, we aimed at comparing the role of endoanal ultrasonography with MRI fistulography in evaluating the primary fistula's tract, internal opening, secondary extensions, and complications of the perianal fistula.

Results

The study was carried over 108 males (90%) and 12 females (10%) presenting with clinically diagnosed perianal fistula. Ultrasound was found superior to MRI in the localization of the internal opening with estimated K value (0.44), P value (0.001). Regarding the type of fistula, ultrasound was found in agreement with MRI in 112 cases (93.3%) with estimated K value of about (0.7). Ultrasound was found equally effective as MRI in the detection of complication with estimated agreement K value of about 1. Regarding assessment of the secondary extensions, the agreement between the two modalities was about 50% with estimated k value of about 0.65. Conversely, MRI was found superior to ultrasound in the characterization of the fibrotic tracts.

Conclusions

Both EAUS and MRI have a crucial role in the evaluation and detection of perianal fistulas. EAUS was preferable to MRI in the localization of the internal opening; ,conversely, in the evaluation of extra-sphincteric fistulas and fibrotic tracts characterization MRI was preferable to EAUS.

ACR Appropriateness Criteria® Pelvic Floor Dysfunction in Females

Pelvic floor disorders including pelvic organ prolapse (POP), urinary dysfunction, defecatory dysfunction, and complications after pelvic floor surgery are relatively common in the female population. Imaging tests are obtained when the initial clinical evaluation is thought to be incomplete or inconclusive or demonstrates findings that are discordant with patients' symptoms. An integrated imaging approach is optimal to evaluate the complex anatomy and dynamic functionality of the pelvic floor. Fluoroscopic cystocolpoproctography (CCP) and MR defecography are considered the initial imaging tests of choice for evaluation of POP. Fluoroscopic voiding cystourethrography is considered the initial imaging test for patients with urinary dysfunction. Fluoroscopic CCP and MR defecography are considered the initial imaging test for patients with defecatory dysfunction, whereas ultrasound pelvis transrectal is a complementary test in patients requiring evaluation for anal sphincter defects. MRI pelvis without and with intravenous contrast, MRI pelvis with dynamic maneuvers, and MR defecography are considered the initial imaging tests in patients with suspected complications of prior pelvic floor surgical repair. Transperineal ultrasound is emerging as an important imaging tool, in particular for screening of pelvic floor dysfunction and for evaluation of midurethral slings, vaginal mesh, and complications related to prior pelvic floor surgical repair. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Relation between pelvic floor neurophysiological abnormalities and erectile dysfunction in patients with obstructed defecation

Background

Obstructed defecation is a common pelvic floor medical problem among adult population. Pelvic floor disorders were reported to be associated with sexual dysfunction including erectile dysfunction among male patients. The aim was to determine the relation between pelvic floor neurophysiological abnormalities and erectile dysfunction in male patients with obstructed defecation.

Methods

This cross-sectional study included 65 married male patients with obstructed defecation and a control group consisted of 15 apparently healthy married males. Assessment of obstructed defecation severity was done by using modified obstructed defecation score, time of toileting and Patient Assessment of Constipation-Quality of Life questionnaire. Assessment of erectile functions was done using erectile function domain of International Index of Erectile Function questionnaire and Erectile Dysfunction-Effect on Quality of Life Questionnaire. Anal manometry and dynamic pelvis magnetic resonance imaging were done. Electrophysiological studies included pudendal nerve motor conduction study and needle electromyography of external anal sphincter, puborectalis and bulbocavernosus muscles.

Results

There were 32 patients (49.2%) who had erectile dysfunction. The maximum straining anal pressure was significantly higher among patients with erectile dysfunction. Pudendal nerve terminal motor latency was significantly delayed and the percentage of bilateral pudendal neuropathy was significantly higher among patients with erectile dysfunction. The percentage of electromyography evidence of denervation with chronic reinnervation in the external anal sphincter and bulbocavernosus muscles were significantly higher among patients with erectile dysfunction. Regression analysis detected three co-variables to be associated with significantly increasing the likelihood of development of erectile dysfunction. These were maximum straining anal pressure (odd ratio = 1.122), right pudendal nerve terminal motor latency (odd ratio = 3.755) and left pudendal nerve terminal motor latency (odd ratio = 3.770).

Conclusions

Erectile dysfunction is prevalent among patients with obstructed defecation. It is associated with characteristic pelvic floor electrophysiological abnormalities. Pelvic floor neurophysiological changes vary from minimal to severe neuromuscular abnormalities that usually accompanying erectile dysfunction. Pudendal neuropathy and increased maximum straining anal pressure are essential risk factors for increasing the likelihood of development of erectile dysfunction in patients with obstructed defecation.

Obstructed Defecation Symptom Severity and Degree of Rectal Hypermobility and Folding Detected by Dynamic Ultrasound

ABSTRACT

We used dynamic pelvic floor ultrasound to investigate the relationship between obstructed defecation symptom (ODS) severity and the degree of rectal hypermobility/folding. In this retrospective study, women who presented with ODS from October 2017 to January 2019 and underwent an interview, pelvic examination, and pelvic floor ultrasound were recruited. Patients were diagnosed with abdominal constipation, dyssynergia, or pelvic constipation. Pelvic constipation patients were categorized based on their reported frequency of incomplete emptying of stool (<50% or ≥50% of bowel movements) representing mild and severe ODS, respectively. Using dynamic ultrasound, rectal hypermobility was quantified via rectovaginal septum length at rest and Valsalva and its compression ratio, where shorter lengths and larger compression ratios are indicative of increased rectal hypermobility. One hundred twenty-one patients (41 with abdominal constipation, 7 with dyssynergia, and 73 with pelvic constipation) were included. Compression ratios were higher in women with severe versus mild ODS (17.36 ± 16.89 vs 36.38 ± 25.82, P = 0.0039). The risk of having severe symptoms was 4 times greater (odds ratio = 4.2, 95% confidence interval = 1.4 to 12.6, P = 0.01) among those with a high compression ratio (≥20%) after controlling for age, body mass index, and levator plate descent angle. Incomplete emptying was weakly, positively, linearly correlated with rectal hypermobility/folding (r = -0.2724, -0.3767 to 0.3922, and P = 0.0197, 0.0010, 0.0006, respectively). Women with more severe ODS experienced more rectal hypermobility/folding as measured via dynamic ultrasound-a cheaper, effective alternative to magnetic resonance defecography for evaluation of obstructed defecation.

The Effect of Biofeedback Therapy Combined with Comprehensive Nursing Intervention on the Quality of Life of Patients with Functional Constipation Based on Dynamic Magnetic Resonance Defecation

In order to study the quality of life of patients with functional constipation based on dynamic magnetic resonance defecation, the biofeedback therapy combined with comprehensive nursing intervention was used to diagnose and treat the patients, so as to explore its clinical efficacy and its impact on patients' quality of life. The obstructed defecation surgical treatment carries frequent recurrences, and dynamic magnetic resonance imaging defecography evaluated and elucidated the underlying anatomic features. This research selected 80 patients who came to our hospital for treatment of functional constipation and evaluated and recorded various clinical indicators before and after treatment in the form of questionnaire survey. The results showed that the clinical symptom scores of patients with functional constipation before and after treatment were greatly different (P < 0.05). Thus, the biofeedback therapy combined with comprehensive nursing intervention showed a good clinical effect in the treatment of patients with functional constipation and significantly improved the quality of life of patients, showing high clinical application and promotion value. A convenient diagnostic procedure is represented by the dynamic magnetic resonance imaging in females, especially pelvic floor organs dynamic imaging during defecation.

MR defecography review

Pelvic floor dysfunction is a relatively common but often complex condition, presenting with a variety of clinical symptoms, especially when it involves multiple compartments. Clinical exam alone is often inadequate and requires a complementary imaging study. Magnetic resonance defecography (MRD) is an excellent noninvasive diagnostic study with its multiplanar capability, lack of ionizing radiation and excellent soft tissue resolution. It can identify both anatomic and functional abnormalities in the pelvic floor and specifically excels in its ability to simultaneously detect multicompartmental pathology and help with vital pre-operative assessment. This manuscript reviews the relevant anatomical landmarks, describes the optimal technique, highlights an approach to the interpretation of MRD, and provides an overview of the various pelvic floor disorders in the different anatomical compartments.

Comparison of magnetic resonance defecography grading with POP-Q staging and Baden-Walker grading in the evaluation of female pelvic organ prolapse

PURPOSE

The physical examination and pelvic imaging with MRI are often used in the pre-operative evaluation of pelvic organ prolapse. The objective of this study was to compare grading of prolapse on defecography phase of dynamic magnetic resonance imaging (dMRI) with physical examination (PE) grading using both the Pelvic Organ Prolapse Quantification (POP-Q) staging and Baden-Walker (BW) grading systems in the evaluation of pelvic organ prolapse (POP).

METHODS

We retrospectively reviewed the charts of 170 patients who underwent dMRI at our institution. BW grading and POP-Q staging were collected for anterior, apical, and posterior compartments, along with absolute dMRI values and overall grading of dMRI. For the overall grading/staging from dMRI, BW, and POP-Q, Spearman rho (ρ) was used to assess the correlation. The correlations between dMRI grading and POP-Q staging were compared to the correlations between dMRI grading and BW grading using Fisher's Z transformation.

RESULTS

A total of 54 patients were included. dMRI grading was not significantly correlated with BW grading for anterior, apical, and posterior compartment prolapse (p > 0.15). However, overall dMRI grading demonstrated a significant (p = 0.025) and positive correlation (ρ = 0.305) with the POP-Q staging system. dMRI grading for anterior compartment prolapse also demonstrated a positive correlation (p = 0.001, ρ = 0.436) with the POP-Q staging derived from measurement locations Aa and Ba. The overall dMRI grade is better correlated with POP-Q stage than with BW grade (p = 0.024).

CONCLUSION

Overall and anterior compartment grading from dMRI demonstrated a significant and positive correlation with the overall POP-Q staging and anterior compartment POP-Q staging, respectively. The overall dMRI grade is better correlated with POP-Q staging than with BW grading.

Statistical shape modeling of the pelvic floor to evaluate women with obstructed defecation symptoms

Obstructed defecation (OD) is common and may be related to compromised pelvic floor integrity. Magnetic resonance (MR) defecography and statistical shape modeling were used to define pelvic floor shape variations, hypothesizing that State (rest vs peak evacuation) and Group (control vs case) would significantly influence shape. 16 women underwent MR defecography (9 cases vs 7 controls). Midsagittal, 2D pelvic floors were segmented and aligned by corresponding points. Principal component scores were compared using a Two-Way Mixed MANOVA. Three modes described differences between State (p < 0.001) and Group (p = 0.023). The pelvic floor shape differed significantly between women with and without OD and during evacuation.

MR defecography in ano-rectal dysfunction: a clinical-radiological correlation study

Background

The aim of this work is to assess the diagnostic accuracy of MR defecography in ano-rectal dysfunction [ARD] for proper treatment planning.

Results

MR defecography was done to 30 patients with ARD for detection of its functional and structural causes. Increased perineal descent was detected in 70% of cases, rectocele in 46.7%, rectal intussusception in 40%, cystocele in 26.7%, uterine prolapse in 27.7%, enterocele in 13.3%, and paradoxical puborectalis contraction in 30%.

Conclusion

MR defecography is an essential diagnostic tool for optimum management of ano-rectal dysfunction patients.

RETRACTED ARTICLE: Evaluation of obstructed defecation syndrome (ODS) using magnetic resonance defecography (MRD)

Background

Obstructed defecation syndrome is associated with varying combinations of a host of ano-rectal abnormalities, and no physical examination can demonstrate these abnormalities. The present study was aimed to evaluate the spectrum of various pelvic floor abnormalities in obstructed defecation syndrome (ODS).

Results

Of the total 302 patients imaged with age range of 18–72 years (mean age 54 years), 218 were females, and 84 were males. Ano-rectal junction descent was the commonest abnormality observed in 273 (90.3%) patients followed by rectocele (232) (76.8%), rectal intussusception (93) (30.7%), and cystocele (92) (30.4%). Cervical descent was observed in 78 (35.7%) of female patients. Spastic perineum was seen in 27 (8.9%) patients.

Conclusion

MRD serves as single stop shop for demonstrating and grading a gamut of pelvic organ abnormalities underpinning ODS which in turn helps in choosing the best treatment plan for the patient.

Integrated MR Analytical Approach and Reporting of Pelvic Floor Dysfunction: Current Implications and New Horizons

Reporting MR imaging of pelvic floor dysfunction can be made easy if radiologists understand the aim of each MR sequence and what to report in each set of MR images. For an MR imaging report that is critical in decision making for patient management, it is of paramount importance to the radiologist to know what to look for and where to look for it. This article presents a new term, integrated MR analytical approach. A reporting template is included in which all MR findings are presented in a schematic form that can be easily interpreted by clinicians from different subspecialties.

Use of Dynamic MRI of the Pelvic Floor in the Assessment of Anterior Compartment Disorders

PURPOSE OF REVIEW

Approximately 25% of women in the USA suffer from pelvic floor disorders. Disorders of the anterior compartment of the pelvic floor, in particular, can cause symptoms such as incomplete urinary voiding, urinary incontinence, pelvic organ prolapse, dyspareunia, and pelvic pain, potentially negatively impacting a woman's quality of life. In some clinical situations, clinical exam alone may be insufficient, especially when patient's symptoms are in excess of their pelvic exam findings. In many of these patients, dynamic magnetic resonance imaging (dMRI) of the pelvic floor can be a valuable imaging tool allowing for comprehensive assessment of the entire pelvic anatomy and its function.

RECENT FINDINGS

Traditionally, evaluation of the anterior compartment has been primarily through clinical examination with occasional use of urodynamic testing and ultrasound. In recent years, dMRI has continued to gain popularity due to its improved imaging quality, reproducibility, and ability to display the entire pelvic floor. Emerging evidence has also shown utility of dMRI in the postoperative setting. In spite of advances, there remains an ongoing discussion in contemporary literature regarding the accuracy of dMRI and its correlation with clinical examination and with patient symptoms. Dynamic pelvic MRI is a helpful adjunct to physical examination and urodynamic testing, particularly when a patient's symptoms are in excess of the physical examination findings. Evaluation with dMRI can guide preoperative and postoperative surgical management in many patients, especially in the setting of multicompartmental disorders. This review will summarize relevant pelvic floor anatomy and discuss the clinical application, imaging technique, imaging interpretation, and limitations of dMRI.

Five-year outcome after pelvic floor reconstructive surgery: evaluation using dynamic magnetic resonance imaging compared to clinical examination and quality-of-life questionnaire

Background Dynamic magnetic resonance imaging (dMRI) captures the entire pelvis during Valsalva maneuver and helps diagnosing pelvic floor changes after reconstructive surgery. Purpose To evaluate therapeutic outcome five years after reconstructive surgery using clinical examination, dMRI, and quality-of-life (QOL) questionnaire. Material and Methods Clinical examination, dMRI, and QOL questionnaire were conducted before surgery and in the follow-ups at 12 weeks, one year, and five years in women with pelvic organ prolapse (POP) stage ≥2. dMRI was performed at 1.5-T using a predefined protocol including sagittal T2-weighted (T2W) sequence at rest and sagittal T2W true-FISP sequence at maximum strain for metric POP measurements (reference points = bladder, cervix, pouch, rectum). Pelvic organ mobility (POM) was defined as the difference of the metric measurement at maximum strain and at rest. Results Twenty-six women with 104 MRI examinations were available for analysis. dMRI results mostly differ to clinical examination regarding the overall five-year outcome and the posterior compartment in particular. dMRI diagnosed substantially more patients with recurrent or de novo POP in the posterior compartment (n = 17) compared to clinical examination (n = 4). POM after five years aligns to preoperative status except for the bladder. POM reflects best the QOL results regarding defecation disorders. Conclusion A tendency for recurrent and de novo POP was seen in all diagnostic modalities applied. dMRI objectively visualizes the interaction of the pelvic organs and the pelvic floor after reconstructive surgery and POM correlated best with the women's personal impression on pelvic floor complaints.

Improved Detection of Pelvic Organ Prolapse: Comparative Utility of Defecography Phase Sequence to Nondefecography Valsalva Maneuvers in Dynamic Pelvic Floor Magnetic Resonance Imaging

PURPOSE

To evaluate the utility of a defecography phase (DP) sequence in dynamic pelvic floor MRI (DPMRI), in comparison to DPMRI utilizing only non-defecography Valsalva maneuvers (VM).

MATERIALS AND METHODS

Inclusion criteria identified 237 female patients with symptoms and/or physical exam findings of pelvic floor prolapse. All DPMRI exams were obtained following insertion of ultrasound gel into the rectum and vagina. Steady-state free-precession sequences in sagittal plane were acquired in the resting state, followed by dynamic cine acquisitions during VM and DP. In all phases, two experienced radiologists performed blinded review using the H-line, M-line, Organ prolapse (HMO) system. The presence of a rectocele, enterocele and inferior descent of the anorectal junction, bladder base, and vaginal vault were recorded in all patients using the pubococcygeal line as a fixed landmark.

RESULTS

DPMRI with DP detected significantly more number of patients than VM (p<0.0001) with vaginal prolapse (231/237, 97.5% vs. 177/237, 74.7%), anorectal prolapse (227/237, 95.8% vs. 197/237, 83.1%), cystocele (197/237, 83.1% vs. 108/237, 45.6%), and rectocele (154/237, 65% vs. 93/237, 39.2%). The median cycstocele (3.2cm vs. 1cm), vaginal prolapse (3cm vs. 1.5cm), anorectal prolapse (5.4cm vs. 4.2cm), H-line (8cm vs. 7.2cm) and M-line (5.3cm vs. 3.9cm) were significantly higher with DP than VM (p<0.0001).

CONCLUSIONS

Addition of DP to DPMRI demonstrates a greater degree of pelvic floor instability as compared to imaging performed during VM alone. Pelvic floor structures may show mild descent or appear normal during VM, with marked prolapse on subsequent DP images.

Magnetic resonance defecography versus clinical examination and fluoroscopy: a systematic review and meta-analysis

BACKGROUND

Magnetic resonance defecography (MRD) allows for dynamic visualisation of the pelvic floor compartments when assessing for pelvic floor dysfunction. Additional benefits over traditional techniques are largely unknown. The aim of this study was to compare detection and miss rates of pelvic floor abnormalities with MRD versus clinical examination and traditional fluoroscopic techniques.

METHODS

A systematic review and meta-analysis was conducted in accordance with recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were accessed. Studies were included if they reported detection rates of at least one outcome of interest with MRD versus EITHER clinical examination AND/OR fluoroscopic techniques within the same cohort of patients.

RESULTS

Twenty-eight studies were included: 14 studies compared clinical examination to MRD, and 16 compared fluoroscopic techniques to MRD. Detection and miss rates with MRD were not significantly different from clinical examination findings for any outcome except enterocele, where MRD had a higher detection rate (37.16% with MRD vs 25.08%; OR 2.23, 95% CI 1.21-4.11, p = 0.010) and lower miss rates (1.20 vs 37.35%; OR 0.05, 95% CI 0.01-0.20, p = 0.0001) compared to clinical examination. However, compared to fluoroscopy, MRD had a lower detection rate for rectoceles (61.84 vs 73.68%; OR 0.48 95% CI 0.30-0.76, p = 0.002) rectoanal intussusception (37.91 vs 57.14%; OR 0.32, 95% CI 0.16-0.66, p = 0.002) and perineal descent (52.29 vs 74.51%; OR 0.36, 95% CI 0.17-0.74, p = 0.006). Miss rates of MRD were also higher compared to fluoroscopy for rectoceles (15.96 vs 0%; OR 15.74, 95% CI 5.34-46.40, p < 0.00001), intussusception (36.11 vs 3.70%; OR 10.52, 95% CI 3.25-34.03, p = 0.0001) and perineal descent (32.11 vs 0.92%; OR 12.30, 95% CI 3.38-44.76, p = 0.0001).

CONCLUSIONS

MRD has a role in the assessment of pelvic floor dysfunction. However, clinicians need to be mindful of the risk of underdiagnosis and consider the use of additional imaging.

[Assessment before surgical treatment for pelvic organ prolapse: Clinical practice guidelines]

INTRODUCTION

The issue addressed in this chapter of recommendations is: What is the clinical and para-clinical assessment to achieve in women with genital prolapse and for whom surgical treatment has been decided. What are the clinical elements of the examination that must be taken into account as a risk factor of failure or relapse after surgery, in order to anticipate and evaluate possible surgical difficulties, and to move towards a preferred surgical technique?

MATERIAL AND METHODS

This work is based on a systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane Database of Systemactic Reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement [AP]).

RESULTS

It suits first of all to describe prolapse, by clinical examination, helped, if needed, by a supplement of imagery if clinical examination data are insufficient or in case of discrepancy between the functional signs and clinical anomalies found, or in case of doubt in associated pathology. It suits to look relapse risk factors (high grade prolapse) and postoperative complications risk factors (risk factors for prothetic exposure, surgical approach difficulties, pelvic pain syndrome with hypersensitivity) to inform the patient and guide the therapeutic choice. Urinary functional disorders associated with prolapse (urinary incontinence, overactive bladder, dysuria, urinary tract infection, upper urinary tract impact) will be search and evaluated by interview and clinical examination and by a flowmeter with measurement of the post voiding residue, a urinalysis, and renal-bladder ultrasound. In the presence of voiding disorders, it is appropriate to do their clinical and urodynamic evaluation. In the absence of any spontaneous or hidden urinary sign, there is so far no reason to recommend systematically urodynamic assessment. Anorectal symptoms associated with prolapse (irritable bowel syndrome, obstruction of defecation, fecal incontinence) should be search and evaluated. Before prolapse surgery, it is essential not to ignore gynecologic pathology.

CONCLUSION

Before proposing a surgical cure of genital prolapse of women, it suits to achieve a clinical and paraclinical assessment to describe prolapse (anatomical structures involved, grade), to look for recurrence, difficulties approach and postoperative complications risk factors, and to appreciate the impact or the symptoms associated with prolapse (urinary, anorectal, gynecological, pelvic-perineal pain) to guide their evaluation and their treatment. © 2016 Published by Elsevier Masson SAS.

Magnetic resonance imaging of pelvic floor dysfunction - joint recommendations of the ESUR and ESGAR Pelvic Floor Working Group

OBJECTIVE

To develop recommendations that can be used as guidance for standardized approach regarding indications, patient preparation, sequences acquisition, interpretation and reporting of magnetic resonance imaging (MRI) for diagnosis and grading of pelvic floor dysfunction (PFD).

METHODS

The technique included critical literature between 1993 and 2013 and expert consensus about MRI protocols by the pelvic floor-imaging working group of the European Society of Urogenital Radiology (ESUR) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) from one Egyptian and seven European institutions. Data collection and analysis were achieved in 5 consecutive steps. Eighty-two items were scored to be eligible for further analysis and scaling. Agreement of at least 80 % was defined as consensus finding.

RESULTS

Consensus was reached for 88 % of 82 items. Recommended reporting template should include two main sections for measurements and grading. The pubococcygeal line (PCL) is recommended as the reference line to measure pelvic organ prolapse. The recommended grading scheme is the "Rule of three" for Pelvic Organ Prolapse (POP), while a rectocele and ARJ descent each has its specific grading system.

CONCLUSION

This literature review and expert consensus recommendations can be used as guidance for MR imaging and reporting of PFD.

KEY POINTS

• These recommendations highlight the most important prerequisites to obtain a diagnostic PFD-MRI. • Static, dynamic and evacuation sequences should be generally performed for PFD evaluation. • The recommendations were constructed through consensus among 13 radiologists from 8 institutions.

Comparison of dynamic magnetic resonance defaecography with rectal contrast and conventional defaecography for posterior pelvic floor compartment prolapse

AIM

This study compared the diagnostic capabilities of dynamic magnetic resonance defaecography (D-MRI) with conventional defaecography (CD, reference standard) in patients with symptoms of prolapse of the posterior compartment of the pelvic floor.

METHOD

Forty-five consecutive patients underwent CD and D-MRI. Outcome measures were the presence or absence of rectocele, enterocele, intussusception, rectal prolapse and the descent of the anorectal junction on straining, measured in millimetres. Cohen's Kappa, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and the positive and negative likelihood ratio of D-MRI were compared with CD. Cohen's Kappa and Pearson's correlation coefficient were calculated and regression analysis was performed to determine inter-observer agreement.

RESULTS

Forty-one patients were available for analysis. D-MRI underreported rectocele formation with a difference in prevalence (CD 77.8% vs D-MRI 55.6%), mean protrusion (26.4 vs 22.7 mm, P = 0.039) and 11 false negative results, giving a low sensitivity of 0.62 and a NPV of 0.31. For the diagnosis of enterocele, D-MRI was inferior to CD, with five false negative results, giving a low sensitivity of 0.17 and high specificity (1.0) and PPV (1.0). Nine false positive intussusceptions were seen on D-MRI with only two missed.

CONCLUSION

The accuracy of D-MRI for diagnosing rectocele and enterocele is less than that of CD. D-MRI, however, appears superior to CD in identifying intussusception. D-MRI and CD are complementary imaging techniques in the evaluation of patients with symptoms of prolapse of the posterior compartment.

ACR Appropriateness Criteria pelvic floor dysfunction

Pelvic floor dysfunction is a common and potentially complex condition. Imaging can complement physical examination by revealing clinically occult abnormalities and clarifying the nature of the pelvic floor defects present. Imaging can add value in preoperative management for patients with a complex clinical presentation, and in postoperative management of patients suspected to have recurrent pelvic floor dysfunction or a surgical complication. Imaging findings are only clinically relevant if the patient is symptomatic. Several imaging modalities have a potential role in evaluating patients; the choice of modality depends on the patient's symptoms, the clinical information desired, and the usefulness of the test. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions; they are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals, and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Magnetic resonance imaging of pelvic floor disorders

Physical examination alone is often inadequate for evaluation of pelvic floor dysfunction. Magnetic resonance imaging (MRI) is a robust modality that can provide high-quality anatomic and functional evaluation of the pelvic floor. Although lack of standardized technique and radiologist inexperience may be relative deterrents in universal acceptance of pelvic floor MRI, the role of MRI is increasing as it is technically feasible on most magnets and offers some advantages over the traditional fluoroscopic defecography. This review focuses on the technical and interpretational aspects of anatomic and functional pelvic floor MRI.

Comparison between dynamic cystocolpoproctography and dynamic pelvic floor MRI: pros and cons: which is the "functional" examination for anorectal and pelvic floor dysfunction?

"Functional" imaging of anorectal and pelvic floor dysfunction has assumed an important role in the diagnosis and management of these disorders. Although defecography has been widely practiced for decades to evaluate the dynamics of rectal emptying, debate concerning its clinical relevance, how it should be done and interpreted continues. Due to the recognition of the association of defecatory disorders with pelvic organ prolapse in women, the need to evaluate the pelvic floor as a unit has arisen. To meet this need, defecography has been extended to include not only evaluation of defecation disorders but also the rest of the pelvic floor by opacifying the small bowel, vagina, and the urinary bladder. The term "dynamic cystocolpoproctography" (DCP) has been appropriately applied to this examination. Rectal emptying performed with DCP provides the maximum stress to the pelvic floor resulting in complete levator ani relaxation. In addition to diagnosing defecatory disorders, this method of examination demonstrates maximum pelvic organ descent and provides organ-specific quantification of organ prolapse, information that is only inferred by means of physical examination. It has been found to be of clinical value in patients with defecation disorders and the diagnosis of associated prolapse in other compartments that are frequently unrecognized by history taking and the limitations of physical examination. Pelvic floor anatomy is complex and DCP does not show the anatomical details pelvic magnetic resonance imaging (MRI) provides. Technical advances allowing acquisition of dynamic rapid MRI sequences has been applied to pelvic floor imaging. Early reports have shown that pelvic MRI may be a useful tool in pre-operative planning of these disorders and may lead to a change in surgical therapy. Predictions of hypothetical increase cancer incidence and deaths in patients exposed to radiation, the emergence of pelvic floor MRI in addition to questions relating to the clinical significance of DCP findings have added to these controversies. This review analyses the pros and cons between DCP and dynamic pelvic floor MRI, addresses imaging and interpretive controversies, and their relevance to clinical management.

Role of conventional radiology and MRi defecography of pelvic floor hernias

Background

Purpose of the study is to define the role of conventional radiology and MRI in the evaluation of pelvic floor hernias in female pelvic floor disorders.

Methods

A MEDLINE and PubMed search was performed for journals before March 2013 with MeSH major terms 'MR Defecography' and 'pelvic floor hernias'.

Results

The prevalence of pelvic floor hernias at conventional radiology was higher if compared with that at MRI. Concerning the hernia content, there were significantly more enteroceles and sigmoidoceles on conventional radiology than on MRI, whereas, in relation to the hernia development modalities, the prevalence of elytroceles, edroceles, and Douglas' hernias at conventional radiology was significantly higher than that at MRI.

Conclusions

MRI shows lower sensitivity than conventional radiology in the detection of pelvic floor hernias development. The less-invasive MRI may have a role in a better evaluation of the entire pelvic anatomy and pelvic organ interaction especially in patients with multicompartmental defects, planned for surgery.

[Anorectal diagnostics for proctological diseases]

The majority of proctological diseases can be defined by a structured evaluation of the symptoms and a physical examination. Magnetic resonance imaging (MRI) and anal endosonography can detect complex anal fistulas with a high accuracy but MRI should be preferred because of its objective visualization. Functional anorectal disorders are multifactorial and show morphological and functional irregularities in different compartments of the pelvic floor which is why MR defecography is now one of the most important methods in diagnostic algorithms. Interpreting the results of anal endosonography, anal manometry and neurophysiological testing is highly demanding because of large interindividual variability. Scores are used for objective measurement of symptom severity and quality of life. In clinical practice, well validated scores evaluated in large patient groups with predetermined circumstances are needed. Bringing together morphological results with scores based on subjective perception is required to optimize diagnostics and therapy evaluation in proctology.

Dynamic MRI defecography vs. entero-colpo-cysto-defecography in the evaluation of midline pelvic floor hernias in female pelvic floor disorders

PURPOSE

The aim of this study was to compare the diagnostic efficacy of dynamic MR defecography (MR-D) with entero-colpo-cysto-defecography (ECCD) in the assessment of midline pelvic floor hernias (MPH) in female pelvic floor disorders.

METHODS

From August 2004 to August 2010, 3,006 female patients who required ECCD for the evaluation of pelvic floor disorders were enrolled in this study. All the 1,160 patients with ECCD findings of MPH were asked to undergo MR-D; 1,142 accepted to undergo MR-D and constituted the object of analysis. This study was approved by the Institutional Ethical Committee. All the patients gave their written informed consent to take part in the study.

RESULTS

Overall, the prevalence of MPH at ECCD was higher if compared with that at MR-D. Concerning the hernia content, there were significantly more enteroceles and sigmoidoceles on ECCD than on MR-D, whereas, in relation to the hernia development modalities, the prevalence of elytroceles, edroceles, and Douglas' hernias at ECCD was significantly higher than that at MR-D. In spite of a 100% specificity, the sensibility of MR-D in the detection of an omentocele, sigmoidocele, and enterocele was, respectively, 95%, 82%, and 65%, showing an inferior diagnostic capacity if compared with that of ECCD.

CONCLUSION

MR-D shows lower sensitivity than ECCD in the detection of MPH development. The less-invasive MR-D may have a role in a better evaluation of the entire pelvic anatomy and pelvic organ interaction especially in patients with multicompartmental defects, planned for surgery.

What is necessary to diagnose constipation?

Constipation is a common ailment with multiple symptoms and diverse etiology. Understanding the pathophysiology is important to guide optimal management. During the past few years, there have been remarkable developments in the diagnosis of constipation and defecation disorders. Several innovative manometric, neurophysiologic, and radiologic techniques have been discovered, which have improved the accuracy of identifying the neuromuscular mechanisms of chronic constipation. These include use of digital rectal examination, Bristol stool scale, colonic scintigraphy, wireless motility capsule for assessment of colonic and whole gut transit, high resolution anorectal manometry, and colonic manometry. These tests provide a better definition of the underlying mechanism(s), which in turn can lead to improved management of this condition. In this review, we summarize the recent advances in diagnostic testing with a particular emphasis on when and why to test, and discuss the utility of diagnostic tests for chronic constipation.