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Schrum CJ, Dickinson MM, Shah ED, Speicher MR, Strohbehn K. Utilization of Rectal Examinations Before Magnetic Resonance Defecography Studies. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024; 30:153-160. [PMID: 37737745 DOI: 10.1097/spv.0000000000001404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
IMPORTANCE More information is needed to guide referring subspecialists on the appropriate patient evaluation before magnetic resonance defecography (MRD). OBJECTIVES This study aimed to evaluate how often health care providers perform digital rectal examination (DRE) before ordering MRD to investigate causes of bowel and pelvic floor complaints. STUDY DESIGN We conducted a retrospective cohort review, including MRD performed on female patients at an integrated health care system from 2016 through 2020. The primary outcome was the presence or absence of documented rectal examination in the year before defecography by the referring provider or 6 months prior by a primary care physician or pelvic floor physical therapist. We hypothesized that the overall rate of rectal examination would be high and unaffected by the referring provider's subspecialty. RESULTS Three hundred-four defecography tests were performed, with 209 patients (68.8%) referred by gastroenterology providers and 95 (31.2%) from other specialties. Gastroenterologists performed DRE in 32.8% of patients, in contrast to 84.4% of patients referred by other specialties ( P < 0.001). When comparing subspecialties that most commonly refer patients for MRD (gastroenterology, colorectal surgery and urogynecology), there was a statistically significant difference between gastroenterologists and colorectal surgeons ( P < 0.001) as well as urogynecologists ( P < 0.001) but no difference in the rate of rectal examination between colorectal surgeons and urogynecologists ( P = 1.00). CONCLUSIONS At our single integrated health system, the rate of DRE before MRD testing varied significantly by specialty. Our findings highlight the need for better understanding of DRE utility in the algorithms for evaluation of bowel and pelvic floor disorders.
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Affiliation(s)
- Colby J Schrum
- From the Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | - Eric D Shah
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Mark R Speicher
- American Association of Colleges of Osteopathic Medicine, Bethesda, MD
| | - Kris Strohbehn
- From the Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Thanaracthanon P, Sasiwimonphan K, Sunthornram A, Harisinghani MG, Chulroek T. Diagnostic performance of dynamic MR defecography in assessment of dyssynergic defecation. Abdom Radiol (NY) 2023; 48:3458-3468. [PMID: 37542178 DOI: 10.1007/s00261-023-04010-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 08/06/2023]
Abstract
PURPOSE To assess diagnostic performance of MR defecographic findings in diagnosis of dyssynergic defecation (DD). METHODS This retrospective study included 46 patients with chronic constipation who met the Rome IV criteria for diagnosis of present or absent DD and underwent MRI between Jan 2015 and June 2020. Patients were divided into DD group (n = 24) and non-DD group (n = 22). Nine parameters were analyzed by two radiologists: anorectal angle (ARA) and M line at rest, defecation, and change between 2 phases; anal canal width; prominent puborectalis muscle; abnormal evacuation. Receiver operating characteristic (ROC) curves were plotted to extract the optimal cut-offs and area under the curve (AUC). Multivariate analysis was performed. RESULTS Seven findings showed statistically significant difference between DD and non-DD groups. M line at defecation had highest odds ratio, followed by ARA change, ARA at defecation, M line change, prominent puborectalis muscle, abnormal evacuation and anal canal width, respectively. ARA change and prominent puborectalis muscle had highest specificity (95.5% and 100%, respectively). The optimal cut-offs of ARA at defecation, ARA change, M line at defecation, M line change and anal canal width were 122°, 1.5°, 3.25 cm, 1.9 cm and 8.5 mm, respectively. Multivariate logistic regression revealed two significant findings in differentiating between DD and non-DD, including M line at defecation (OR 23.31, 95% CI 3.10-175.32) and ARA at defecation (OR 13.63, 95% CI 1.94-95.53) with sensitivity, specificity, PPV, NPV and AUC of 79.2%, 95.5%, 95%, 80.8% and 0.87(95% CI 0.78-0.97), respectively. CONCLUSION MR defecography has high diagnostic performance in diagnosis of DD. Although M line and ARA at defecation are two significant findings on multivariate analysis, ARA change less than 1.5 degrees and prominent puborectalis muscle have good specificity in DD diagnosis.
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Affiliation(s)
- Pimpapon Thanaracthanon
- Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Radiology, King Chulalongkorn Memorial Hospital, 1873 Rama 4 Road, Pathumwan, Bangkok, 10330, Thailand
| | - Kewalee Sasiwimonphan
- Department of Radiology, King Chulalongkorn Memorial Hospital, 1873 Rama 4 Road, Pathumwan, Bangkok, 10330, Thailand
| | - Angkana Sunthornram
- Department of Radiology, King Chulalongkorn Memorial Hospital, 1873 Rama 4 Road, Pathumwan, Bangkok, 10330, Thailand
| | - Mukesh G Harisinghani
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA, 02114, USA
| | - Thitinan Chulroek
- Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
- Department of Radiology, King Chulalongkorn Memorial Hospital, 1873 Rama 4 Road, Pathumwan, Bangkok, 10330, Thailand.
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Pääkkö E, Mäkelä‐Kaikkonen J, Laukkanen H, Ohtonen P, Laitakari K, Rautio T, Oikarinen H. X-ray video defaecography is superior to magnetic resonance defaecography in the imaging of defaecation disorders. Colorectal Dis 2022; 24:747-753. [PMID: 35119795 PMCID: PMC9307008 DOI: 10.1111/codi.16081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/30/2021] [Accepted: 01/12/2022] [Indexed: 02/08/2023]
Abstract
AIM The aim of this work was to study the technical success and diagnostic capability of magnetic resonance defaecography (MRD) compared with video defaecography (VD). METHOD Sixty four women with defaecation disorders underwent both MRD and x-ray VD over 1 year. The assessment by two radiologists in consensus was retrospective and blinded. The technical success of straining and evacuation was evaluated subjectively. The presence of enterocele, intussusception, rectocele and dyssynergic defaecation was analysed according to established criteria, with VD as the standard of reference. RESULTS It was found that 62/64 (96.9%) VD studies were technically fully diagnostic compared with 29/64 (45.3%) for MRD. The number of partially diagnostic studies was 1/64 (1.6%) for VD versus 21/64 (32.8%) for MRD, with 1/64 (1.6%) (VD) and 14/64 (21.9%) (MRD) being nondiagnostic. Thirty enteroceles were observed by VD compared with seven in MRD with moderate agreement (κ = 0.41). Altogether 53 intussusceptions were observed by VD compared with 27 by MRD with poor agreement (κ = -0.10 and κ = 0.02 in recto-rectal and recto-anal intussusception, respectively). Moderate agreement (κ = 0.47) was observed in diagnosing rectocele, with 47 cases by VD and 29 by MRD. Dyssynergic defaecation was observed in three patients by VD and in 11 patients by MRD, with slight agreement (κ = 0.14). CONCLUSION The technical success and diagnostic capabilities of VD are better than those of MRD. VD remains the method of choice in the imaging of defaecation disorders.
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Affiliation(s)
- Eija Pääkkö
- Department of Diagnostic RadiologyOulu University HospitalOuluFinland
| | - Johanna Mäkelä‐Kaikkonen
- Division of GastroenterologyDepartment of SurgeryOulu University HospitalOuluFinland,Medical Research Center OuluCenter of Surgical ResearchUniversity of OuluOuluFinland
| | - Hannele Laukkanen
- Department of Diagnostic RadiologyOulu University HospitalOuluFinland
| | - Pasi Ohtonen
- Division of Operative CareOulu University HospitalOuluFinland,The Research Unit of Surgery, Anesthesia and Intensive CareUniversity of OuluOuluFinland
| | - Kirsi Laitakari
- Division of GastroenterologyDepartment of SurgeryOulu University HospitalOuluFinland,Medical Research Center OuluCenter of Surgical ResearchUniversity of OuluOuluFinland
| | - Tero Rautio
- Division of GastroenterologyDepartment of SurgeryOulu University HospitalOuluFinland,Medical Research Center OuluCenter of Surgical ResearchUniversity of OuluOuluFinland
| | - Heljä Oikarinen
- Department of Diagnostic RadiologyOulu University HospitalOuluFinland
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Lukies M, Harisis G, Jarema A, Scicchitano M, MacLaurin W. Defecating proctography: A pictorial essay. Radiography (Lond) 2022; 28:628-633. [PMID: 35569315 DOI: 10.1016/j.radi.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/11/2022] [Accepted: 04/23/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To provide an illustrative description of the technique and spectrum of findings in defecating proctography. KEY FINDINGS Important findings on defecating proctography include rectocoele, enterocoele, sigmoidocoele, cystocoele, intussusception, rectal prolapse, descending perineum, incomplete emptying, anismus, and faecal incontinence. This review article illustrates these key findings with examples. CONCLUSION Defecating proctography is a well-established and cost-effective method of assessing disordered defecation. In conjunction with clinical information and other diagnostic tests, findings on defecating proctography can guide appropriate multidisciplinary management and may lead to improvement in embarrassing and debilitating symptoms in many patients. IMPLICATIONS FOR PRACTICE This review article provides a suggested technique and covers the spectrum of findings on defecating proctography.
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Affiliation(s)
- M Lukies
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia.
| | - G Harisis
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia
| | - A Jarema
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia
| | - M Scicchitano
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia
| | - W MacLaurin
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia
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Zhang H, Wang Z, Xiao X, Wang J, Zhou B. Dynamic magnetic resonance imaging evaluation before and after operation for pelvic organ prolapse. Abdom Radiol (NY) 2022; 47:848-857. [PMID: 34870730 DOI: 10.1007/s00261-021-03361-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/18/2021] [Accepted: 11/22/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE This study aimed to explore the value of dynamic magnetic resonance imaging (MRI) before and after operation for pelvic organ prolapse (POP). METHODS Twenty-nine patients with POP (POP group) before and one month after surgery and 12 healthy women (control group) underwent static and dynamic MRI at rest and during straining (Valsalva maneuver). The preoperative MRI images of the POP and control groups were analyzed, and various measurements were recorded. Differences in measurements were compared between the POP and control groups; similarly, changes in measurements before and after operation were compared. RESULTS In the POP group, MRI detected 29 anterior vaginal prolapses, 27 uterine prolapses, 1 rectoceles, and 14 pouch of Douglas hernias. In addition, 27 levator ani muscle defect and 15 pubocervical fascial defect cases were observed. The bladder-pubococcygeal line (B-PCL), uterus-pubococcygeal line (U-PCL), Douglas pouch-pubococcygeal line, the length of the hiatus, the descent of the levator plate, levator hiatus size, levator plate angle, iliococcygeus angle, and urethral inclination angle (UA) were larger in the POP group than in the control group. The pelvic organs' positions returned to normal postoperatively in 9 of 21 cases. The B-PCL, U-PCL, and UA were smaller post-surgery than pre-surgery. CONCLUSIONS Static and dynamic MRI can comprehensively evaluate morphological and functional changes of the pelvic floor postoperatively.
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Affiliation(s)
- Hongbo Zhang
- Department of Radiology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Zeyan Wang
- Department of Radiology, Zhongshan City People's Hospital, Zhongshan, China
| | - Xuehong Xiao
- Department of Radiology, Zhongshan City People's Hospital, Zhongshan, China
| | - Jing Wang
- Department of Radiology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Beibei Zhou
- Department of Radiology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China.
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Routzong MR, Abramowitch SD, Chang C, Goldberg RP, Rostaminia G. Obstructed Defecation Symptom Severity and Degree of Rectal Hypermobility and Folding Detected by Dynamic Ultrasound. Ultrasound Q 2021; 37:229-236. [PMID: 34478420 DOI: 10.1097/ruq.0000000000000565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Megan R Routzong
- Translational Biomechanics Laboratory, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Steven D Abramowitch
- Translational Biomechanics Laboratory, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Cecilia Chang
- NorthShore University HealthSystem Research Institute, Evanston
| | | | - Ghazaleh Rostaminia
- Division of Urogynecology, University of Chicago Pritzker School of Medicine, NorthShore University HealthSystem, Skokie, IL
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Spinelli A, Laurenti V, Carrano FM, Gonzalez-Díaz E, Borycka-Kiciak K. Diagnosis and Treatment of Obstetric Anal Sphincter Injuries: New Evidence and Perspectives. J Clin Med 2021; 10:jcm10153261. [PMID: 34362045 PMCID: PMC8347477 DOI: 10.3390/jcm10153261] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022] Open
Abstract
Perineal injury during childbirth is a common event with important morbidity associated in particular with third-and-fourth degree perineal tears (also referred to as obstetric anal sphincter injuries—OASIS). Early diagnosis of these damages is mandatory to define a prompt therapeutic strategy and thus avoid the development of late-onset consequences, such as faecal incontinence. For this purpose, various diagnostic exams can be performed after a thorough clinical examination. The management of OASIS includes several measures and should be individualized according to the timing and features of the clinical presentation.
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Affiliation(s)
- Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
- Correspondence:
| | - Virginia Laurenti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Francesco Maria Carrano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Enrique Gonzalez-Díaz
- Pelvic Floor Unit, Department of Obstetrics and Gynaecology, Complejo Asistencial Universitario de León (CAULE), C/Altos de Nava S/N, 24080 León, Spain;
- Department of Obstetrics and Gynaecology, Complejo Asistencial Universitario de León (CAULE), C/Altos de Nava S/N, 24080 León, Spain
| | - Katarzyna Borycka-Kiciak
- Department of Colorectal, General and Oncological Surgery, Centre of Postgraduate Medical Education, 80, Ceglowska Street, 01810 Warsaw, Poland;
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Clinical applications of pelvic floor imaging: opinion statement endorsed by the society of abdominal radiology (SAR), American Urological Association (AUA), and American Urogynecologic Society (AUGS). Abdom Radiol (NY) 2021; 46:1451-1464. [PMID: 33772614 DOI: 10.1007/s00261-021-03017-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/21/2021] [Accepted: 02/25/2021] [Indexed: 10/21/2022]
Abstract
Pelvic floor dysfunction is prevalent, with multifactorial causes and variable clinical presentations. Accurate diagnosis and assessment of the involved structures commonly requires a multidisciplinary approach. Imaging is often complementary to clinical assessment, and the most commonly used modalities for pelvic floor imaging include fluoroscopic defecography, magnetic resonance defecography, and pelvic floor ultrasound. This collaboration opinion paper was developed by representatives from multiple specialties involved in care of patients with pelvic floor dysfunction (radiologists, urogynecologists, urologists, and colorectal surgeons). Here, we discuss the utility of imaging techniques in various clinical scenarios, highlighting the perspectives of referring physicians. The final draft was endorsed by the Society of Abdominal Radiology (SAR), American Urogynecologic Society (AUGS), and the American Urological Association (AUA).
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Abstract
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.
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Khatri G, Kumar NM, Xi Y, Smith W, Bacsu C, Bailey AA, Zimmern PE, Pedrosa I. Defecation versus pre- and post-defecation Valsalva maneuvers for dynamic MR assessment of pelvic floor dysfunction. Abdom Radiol (NY) 2021; 46:1362-1372. [PMID: 31494706 DOI: 10.1007/s00261-019-02208-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To compare prevalence and severity of multi-compartment pelvic floor dysfunction between supine magnetic resonance defecography with defecation (MRD) and supine dynamic MRI during Valsalva, both with and without rectal distention. METHODS This was an IRB-approved, HIPAA-compliant retrospective review of consecutive patients referred for MR Defecography. MRD protocol included imaging at rest, during pre-defecation Valsalva (Pre-DV), defecation (Def), and post-defecation Valsalva (Post-DV). The Post-DV images were performed after complete evacuation either during the defecation acquisition or, in cases where patient was unable to defecate during the examination, in a conventional toilet. Size of cystocele, vaginal prolapse, anorectal (AR) descent, and enterocele were measured on all acquisitions relative to the pubococcygeal line. Rectocele size was recorded in anteroposterior dimension. The presence or absence of rectal intussusception (RI) was documented. The prevalence, absolute size, and grades of prolapse, rectocele, and RI were compared between the acquisitions using pair-wise ANOVA, Friedman, Dunn pair-wise, and Cochran-Mantel-Haenszel tests. RESULTS 30 patients were included in the final analysis. Higher prevalence of cystocele, vaginal prolapse, enterocele, AR descent grade 2 or higher, rectocele grade 2 or higher, and RI were seen on Def compared to Post-DV and Pre-DV. Cystocele, vaginal prolapse, enterocele, AR descent, and rectocele sizes were significantly larger on Def compared to Post-DV by 0.7-1.95 cm (p ≤ 0.007). Prolapse in all compartments and rectocele size were significantly larger on Def compared to Pre-DV (p < 0.0001). Cystocele, vaginal prolapse, and enterocele sizes were significantly larger on Post-DV compared to Pre-DV (p < 0.0001). There were significant differences in grading of all types of prolapse and rectocele between the various acquisitions of MRD (p < 0.0001). Cystocele, AR descent, and rectocele grades were significantly higher on Def compared to Post-DV (p range ≤ 0.0002). Grading of all types of prolapse and rectocele was significantly higher on Def compared to Pre-DV (p < 0.0001). Cystocele, vaginal prolapse, and enterocele grades were all significantly higher on Post-DV compared to Pre-DV (p ≤ 0.0007). CONCLUSION Defecation images during supine MRD elicit higher prevalence and size of prolapse of all pelvic compartments in comparison to both pre- and post-defecation Valsalva images. Post-defecation Valsalva images show larger size of anterior and middle compartment prolapse than pre-defecation Valsalva images. Functional evaluation of pelvic floor dysfunction with MRI should include image acquisition during defecation. If Valsalva images are acquired, these should be performed after the defecation acquisition and without rectal distention.
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Flusberg M, Xi Y, Jambhekar K, Bahrami S, Chernyak V, Lalwani N, Lockhart M, Ram R, Fielding JR, El Sayed RF, Khatri G. Variability in utilization and techniques of pelvic floor imaging: findings of the SAR pelvic floor dysfunction disease-focused panel. Abdom Radiol (NY) 2021; 46:1294-1301. [PMID: 33585965 DOI: 10.1007/s00261-021-02957-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/11/2021] [Accepted: 01/15/2021] [Indexed: 11/26/2022]
Abstract
Pelvic floor disorders are common and can negatively impact quality of life. Imaging of patients with pelvic floor disorders has been extremely heterogeneous between institutions due in part to variations in clinical expectations, technical considerations, and radiologist experience. In order to assess variations in utilization and technique of pelvic floor imaging across practices, the society of abdominal radiology (SAR) disease-focused panel on pelvic floor dysfunction developed and administered an online survey to radiologists including the SAR membership. Results of the survey were compared with published recommendations for pelvic floor imaging to identify areas in need of further standardization. MRI was the most commonly reported imaging technique for pelvic floor imaging followed by fluoroscopic defecography. Ultrasound was only used by a small minority of responding radiologists. The survey responses demonstrated variability in imaging utilization, patient referral patterns, imaging protocols, patient education, and interpretation and reporting of pelvic floor imaging examinations. This survey highlighted inconsistencies in technique between institutions as well as potential gaps in knowledge that should be addressed to standardize evaluation of patients with pelvic floor dysfunction.
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Affiliation(s)
- Milana Flusberg
- Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA.
| | - Yin Xi
- University of Texas Southwestern Medical Center, Dallas, USA
| | - Kedar Jambhekar
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Simin Bahrami
- University of California Los Angeles, Los Angeles, CA, USA
| | | | - Neeraj Lalwani
- Wake Forest University Baptist Medical Center, Winston-Salem, USA
| | - Mark Lockhart
- University of Alabama Medical Center, Birmingham, USA
| | - Roopa Ram
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Gaurav Khatri
- University of Texas Southwestern Medical Center, Dallas, USA
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Lalwani N, Khatri G, El Sayed RF, Ram R, Jambhekar K, Chernyak V, Kamath A, Lewis S, Flusberg M, Scholz F, Arif-Tiwari H, Palmer SL, Lockhart ME, Fielding JR. MR defecography technique: recommendations of the society of abdominal radiology's disease-focused panel on pelvic floor imaging. Abdom Radiol (NY) 2021; 46:1351-1361. [PMID: 31385010 DOI: 10.1007/s00261-019-02160-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE To develop recommendations for magnetic resonance (MR) defecography technique based on consensus of expert radiologists on the disease-focused panel of the Society of Abdominal Radiology (SAR). METHODS An extensive questionnaire was sent to a group of 20 experts from the disease-focused panel of the SAR. The questionnaire encompassed details of technique and MRI protocol used for evaluating pelvic floor disorders. 75% agreement on questionnaire responses was defined as consensus. RESULTS The expert panel reached consensus for 70% of the items and provided the basis of these recommendations for MR defecography technique. There was unanimous agreement that patients should receive coaching and explanation of commands used during MR defecography, the rectum should be distended with contrast agent, and that sagittal T2-weighted images should include the entire pelvis within the field of view. The panel also agreed unanimously that IV contrast should not be used for MR defecography. Additional areas of consensus ranged in agreement from 75 to 92%. CONCLUSION We provide a set of consensus recommendations for MR defecography technique based on a survey of expert radiologists in the SAR pelvic floor dysfunction disease-focused panel. These recommendations can be used to develop a standardized imaging protocol.
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Affiliation(s)
- Neeraj Lalwani
- Wake Forest University Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Gaurav Khatri
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Roopa Ram
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kedar Jambhekar
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Victoria Chernyak
- Albert Einstein College of Medicine, Montefiore Medical Center, The Bronx, NY, USA
| | - Amita Kamath
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sara Lewis
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Milana Flusberg
- Department of Radiology, Westchester Medical Center, Valhalla, NY, USA
| | | | | | - Suzanne L Palmer
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mark E Lockhart
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Julia R Fielding
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
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Qu E, Wu J, Zhang M, Wu L, Zhang T, Xu J, Zhang X. The ultrasound diagnostic criteria for diastasis recti and its correlation with pelvic floor dysfunction in early postpartum women. Quant Imaging Med Surg 2021; 11:706-713. [PMID: 33532270 DOI: 10.21037/qims-20-596] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background There has been a long-standing controversy about diastasis recti diagnostic criteria and its relation to pelvic floor dysfunction (PFD). This study aimed to establish ultrasound diagnostic criteria for diastasis recti and investigate the correlation between it and PFD in early postpartum females. Methods The inter-rectus distance (IRD) was measured at 3 locations in 116 healthy nulliparous females and 108 postpartum females. At the same time, they remained relaxed and then maintained a head-lift posture. The measurement for the 90th percentile was used to define the normal IRD in the nulliparous group. Afterward, the 108 postpartum females underwent an ultrasonographic examination of pelvic floor function. The correlations of these values with the IRD were then examined. Results We established the following ultrasonographic diagnostic criteria for diastasis recti: an IRD of >2 mm at 3 cm below the umbilicus, >20 mm at the umbilicus, and >14 mm at 3 cm above the umbilicus. The IRD was positively correlated with body mass index (BMI) in the nulliparous group (r=0.286, P<0.01) and with age in the postpartum group (r=0.230, P<0.05). The IRD was not relative to either the PFD ultrasound results or the clinical symptoms. Conclusions We established a set of ultrasonographic diagnostic criteria for diastasis recti at 3 locations along the umbilicus. There is no clear correlation between diastasis recti and PFD in early postpartum females.
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Affiliation(s)
- Enze Qu
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jiawei Wu
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Man Zhang
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lili Wu
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ting Zhang
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jing Xu
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xinling Zhang
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Sakala MD, Shampain KL, Wasnik AP. Advances in MR Imaging of the Female Pelvis. Magn Reson Imaging Clin N Am 2020; 28:415-431. [PMID: 32624159 DOI: 10.1016/j.mric.2020.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This article focuses on advanced MR imaging techniques of the female pelvis and clinical applications for benign and malignant disease. General and abbreviated protocols for female pelvic MR imaging are reviewed. Diffusion-weighted imaging, dynamic contrast-enhanced MR imaging, and susceptibility-weighted imaging are discussed in the context of adnexal mass characterization using the ADNEx-MR scoring system, evaluation of endometriosis, local staging of cervical and endometrial cancers, assessment of nodal and peritoneal metastasis, and potential detection of leiomyosarcoma. MR defecography is also discussed regarding evaluation of multicompartmental pelvic floor disorders.
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Affiliation(s)
- Michelle D Sakala
- Department of Radiology, Division of Abdominal Imaging, University of Michigan-Michigan Medicine, University Hospital B1 D502D, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Kimberly L Shampain
- Department of Radiology, Division of Abdominal Imaging, University of Michigan-Michigan Medicine, University Hospital B1 D502D, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Ashish P Wasnik
- Department of Radiology, Division of Abdominal Imaging, University of Michigan-Michigan Medicine, University Hospital B1 D502D, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Kumar NM, Khatri G, Christie AL, Sims R, Pedrosa I, Zimmern PE. Supine magnetic resonance defecography for evaluation of anterior compartment prolapse: Comparison with upright voiding cystourethrogram. Eur J Radiol 2019; 117:95-101. [PMID: 31307659 DOI: 10.1016/j.ejrad.2019.05.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To compare utility of supine Magnetic Resonance Defecography (MRD) with upright Voiding Cystourethrogram (VCUG) for evaluation of cystocele and urethral hypermobility (UHM). METHODS This was an IRB-approved, HIPAA-compliant, retrospective study of 51 consecutive patients with symptomatic pelvic organ prolapse (POP) and lower urinary tract symptoms who underwent both upright VCUG and supine MRD. Cystocele height was defined in centimeters with reference to the inferior edge of the pubic bone on VCUG and the pubococcygeal line on MRD. Urethral angle at rest (UAR) and during straining (UAS) was measured in degrees between the urethral axis and a vertical line at the external meatus. Pairedt-test and simple linear regression were applied to compare VCUG and MRD data sets. p < 0.05 was considered significant. RESULTS The mean cystocele extent was 1.58 cm lower (more inferior to the reference point) (95% CI for the mean difference: 1.21, 1.94;p < 0.0001) on MRD (-2.73 ± 1.99 cm) than on VCUG (-1.16 ± 1.75 cm). Mean UAS on MRD (72.29 ± 26.45) was 31.8 degrees higher compared to that on VCUG (40.45 ± 21.41), (95% CI for mean difference in UAS: 37.57, 26.11; p < 0.0001). Mean UAS-UAR on MRD (74.30 ± 28.50) was 58.6 degrees higher compared to that on VCUG (15.70 ± 11.27) (95% CI for mean difference in UAS-UAR 65.94, 51.26; p < 0.0001). Cystocele size was upgraded in 22 (43.3%) patients on MRD compared to VCUG. Five (9.8%) patients demonstrated UHM on VCUG; 48 (94.1%) patients demonstrated UHM on MRD. The differences between VCUG and MRD scores persisted across the range of VCUG measurements. Cystocele size was significantly larger in POP (+) patients than in POP (-) patients on MRD (p = 0.005) but not on VCUG (p = 0.06). CONCLUSIONS Supine MRD demonstrates significantly higher prevalence and degree of cystocele and UHM than upright VCUG, and alters the grade of bladder prolapse in a significant portion of the patient population. Cystocele size on MRD correlates with clinical presence of prolapse symptoms.
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Affiliation(s)
- Neil M Kumar
- Department of Radiology, University of Texas Southwestern Medical Center, 2201 Inwood Road, Dallas, TX 75390-9085, United States.
| | - Gaurav Khatri
- Department of Radiology, University of Texas Southwestern Medical Center, 2201 Inwood Road, Dallas, TX 75390-9085, United States.
| | - Alana L Christie
- Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8851, United States.
| | - Robert Sims
- Department of Radiology, University of Texas Southwestern Medical Center, 2201 Inwood Road, Dallas, TX 75390-9085, United States.
| | - Ivan Pedrosa
- Department of Radiology, University of Texas Southwestern Medical Center, 2201 Inwood Road, Dallas, TX 75390-9085, United States; Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8851, United States; Department of Urology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8851, United States.
| | - Philippe E Zimmern
- Department of Urology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8851, United States.
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16
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Salvador JC, Coutinho MP, Venâncio JM, Viamonte B. Dynamic magnetic resonance imaging of the female pelvic floor-a pictorial review. Insights Imaging 2019; 10:4. [PMID: 30689115 PMCID: PMC6352388 DOI: 10.1186/s13244-019-0687-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 01/03/2019] [Indexed: 11/13/2022] Open
Abstract
Pelvic floor dysfunctions represent a range of functional disorders that frequently occur in adult women, carrying a significant burden on the quality of life, and its incidence tends to increase attending to the expected aging of the population. Pelvic floor dysfunctions can manifest as incontinence, constipation, and prolapsed pelvic organs. Since pelvic floor weakness is frequently generalized and clinically underdiagnosed, imaging evaluation is of major importance, especially prior to surgical correction. Given some interobserver variability of soft-tissue measurements, MR defecography allows a noninvasive, radiation-free, multiplanar dynamic evaluation of the three pelvic compartments simultaneously and with high spatial and temporal resolution. Both static/anatomic and dynamic/functional findings are important, since pelvic disorders can manifest as whole pelvic floor weakness/dysfunction or as an isolated or single compartment disorder. Imaging has a preponderant role in accessing pelvic floor disorders, and dynamic MR defecography presents as a reliable option, being able to evaluate the entire pelvic floor for optimal patient management before surgery. The purpose of this article is to address the female pelvic anatomy and explain the appropriate MR Defecography protocol, along with all the anatomic points, lines, angles, and measurements needed for a correct interpretation, to later focus on the different disorders of the female pelvic floor, illustrated with MR defecography images, highlighting the role of this technique in accessing these pathologic conditions.
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Affiliation(s)
- João Cunha Salvador
- Department of Radiology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Rua Prof. Lima Basto, Lisboa, Portugal.
| | - Mónica Portela Coutinho
- Department of Radiology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Rua Prof. Lima Basto, Lisboa, Portugal
| | - José Marques Venâncio
- Department of Radiology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Rua Prof. Lima Basto, Lisboa, Portugal
| | - Bárbara Viamonte
- Department of Radiology, Hospital Universitário de São João, Centro Hospitalar São João, Porto, Portugal
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17
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Kim NY, Kim DH, Pickhardt PJ, Carchman EH, Wald A, Robbins JB. Defecography: An Overview of Technique, Interpretation, and Impact on Patient Care. Gastroenterol Clin North Am 2018; 47:553-568. [PMID: 30115437 DOI: 10.1016/j.gtc.2018.04.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Pelvic floor and defecatory dysfunction are common in the female patient population. When combined with physical examination, barium defecography allows for accurate and expanded assessment of the underlying pathology and helps to guide future intervention. Understanding the imaging findings of barium defecography in the spectrum of pathology of the anorectum and pelvic floor allows one to appropriately triage and treat patients presenting with defecatory dysfunction.
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Affiliation(s)
- Nathan Y Kim
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - David H Kim
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - Evie H Carchman
- Department of Surgery, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - Arnold Wald
- Department of Medicine, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - Jessica B Robbins
- Department of Radiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Madison, WI 53792, USA.
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18
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Kobi M, Flusberg M, Paroder V, Chernyak V. Practical guide to dynamic pelvic floor MRI. J Magn Reson Imaging 2018; 47:1155-1170. [PMID: 29575371 DOI: 10.1002/jmri.25998] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 02/13/2018] [Indexed: 01/23/2023] Open
Abstract
Pelvic floor dysfunction encompasses a spectrum of functional disorders that result from impairment of the ligaments, fasciae, and muscles supporting the pelvic organs. It is a prevalent disorder that carries a lifetime risk over 10% for undergoing a surgical repair. Pelvic floor weakness presents as a wide range of symptoms, including pain, pelvic pressure or bulging, urinary and fecal incontinence, constipation, and sexual dysfunction. A correct diagnosis by clinical examination alone can be challenging, particularly in cases involving multiple compartments. Magnetic resonance imaging (MRI) allows noninvasive, radiation-free, high soft-tissue resolution evaluation of all three pelvic compartments, and has proved a reliable technique for accurate diagnosis of pelvic floor dysfunction. MR defecography with steady-state sequences allows detailed anatomic and functional evaluation of the pelvic floor. This article provides an overview of normal anatomy and function of the pelvic floor and discusses a practical approach to the evaluation of imaging findings of pelvic floor relaxation, pelvic organ prolapse, fecal incontinence, and obstructed defecation. LEVEL OF EVIDENCE 5 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1155-1170.
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Affiliation(s)
- Mariya Kobi
- Department of Radiology, Montefiore Medical Center, Bronx, New York, USA
| | - Milana Flusberg
- Department of Radiology, Montefiore Medical Center, Bronx, New York, USA
| | - Viktoriya Paroder
- Department of Radiology, Memorial Sloan Kettering Center, New York, New York, USA
| | - Victoria Chernyak
- Department of Radiology, Montefiore Medical Center, Bronx, New York, USA
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19
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Han W, Wang Y, Qi S, Li T, Cao J, Zheng T, Su Y. Observation of the effect of physical rehabilitation therapy combined with the medication on pelvic floor dysfunction. Exp Ther Med 2017; 15:1211-1216. [PMID: 29399117 PMCID: PMC5774529 DOI: 10.3892/etm.2017.5583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/18/2017] [Indexed: 12/13/2022] Open
Abstract
We observed the effects of physical rehabilitation therapy combined with medication on pelvic floor dysfunction (PFD). We collected the medical records of 84 maternal patients with PFD who received treatment at the Affiliated Hospital of Hebei University between May 2015 and October 2016. These patients were randomly divided into two groups, the control group (n=42) and observation group (n=42). In the control group, patients received conventional physical rehabilitation therapy while in observation group, patients received the shixiao powder combined with siwu decoction in addition to the physical rehabilitation. The therapeutic effects were compared between the two groups. The total effective rate of the observation group was 97.6%, which was significantly higher than 78.6% in the control group (P<0.05). In observation group, the index scores of pelvic floor function under rest state, such as electromyo-graphy amplitude, contraction force, coordinate strength and urine flow rate, were significantly higher than those in control group (P<0.05). The rate of Grade II perineal muscle strength in the observation group was 7.32%, which was significantly lower than 47.62% in control group (P<0.05). In observation group, the rates of Grade III and Grade IV muscle strength were respectively 43.91 and 29.26%, which were significantly higher than those in control group (P<0.05). Before the administration of treatment, there were no significant differences in the comparison of the urinary incontinence and sexual life quality of patients between the two groups (P>0.05). In observation group, after treatment, the rehabilitation effects of urinary incontinence and sexual life quality at 3 months post-delivery were significantly better than those in control group (P<0.05). Before treatment, there were no significant differences in the comparison of levels of C-reactive protein (CRP) and interleukin-10 (IL-10) between the two groups (P>0.05), however, after treatment, the levels of CRP and IL-10 of patients in observation group were significantly lower than those in control group (P<0.05). In the observation group, the incidence rate of complications (7.14%) were significantly lower than that in control group (23.81%; P<0.05). Therefore, physical rehabilitation therapy combined with the shixiao powder and siwu decoction exhibits significant efficacy in the treatment of PFD by effectively improving the pelvic floor functions, increasing perineal muscle strength, and decreasing expression levels of inflammatory factors, which can significantly ameliorate life quality and reduce the incidence rate of complications. Thus, this treatment method shows great application value in clinical practice.
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Affiliation(s)
- Wei Han
- Maternity and Child Care Among Perinatal Care Clinic, Tangshan, Hebei 063000, P.R. China
| | - Yongmei Wang
- Department of Gynecology and Obstetrics, The Fourth Hospital of Hebei Medical University (Tumor Hospital of Hebei) Shijiazhuang, Hebei 050011, P.R. China
| | - Shengbo Qi
- Hospital of Gastrointestinal Surgery, Weifang, Shandong 261042, P.R. China
| | - Tingting Li
- Department of Thoracic Surgery, Affiliated Hospital of Hebei University, Baoding, Hebei 071000, P.R. China
| | - Jiang Cao
- Hospital of Gastrointestinal Surgery, Weifang, Shandong 261042, P.R. China
| | - Tinghua Zheng
- Maternity and Child Care Department of Obstetrics and Gynecology, Tangshan, Hebei 063000, P.R. China
| | - Yan Su
- Maternal and Child Health Care Medicine, Tangshan, Hebei 063000, P.R. China
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20
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Khatri G, de Leon AD, Lockhart ME. MR Imaging of the Pelvic Floor. Magn Reson Imaging Clin N Am 2017; 25:457-480. [DOI: 10.1016/j.mric.2017.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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21
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Gómez Londoño M, Castaño Botero JC, Saldarriaga Hernández EC. Trastornos de la contracción de los músculos del piso pélvico femenino. UROLOGÍA COLOMBIANA 2015. [DOI: 10.1016/j.uroco.2015.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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