MR imaging of the pelvic floor: defecography

Chronic Pelvic Pain: Role of Imaging in the Diagnosis and Management

Chronic pelvic pain (CPP) in women is not uncommon, and it may be difficult to identify the exact cause difficult to manage. It is major health problem for women that affects the quality of their daily lives. The etiology of chronic pelvic pain may be of gynecological or non-gynecological origin and associated with several predisposing and precipitating factors. Psychological and social factors also contribute to the syndrome of CPP and must be evaluated before managing these patients. Due to multifactorial etiology, CPP needs a multidisciplinary approach for diagnosis and management. A detailed history and physical examination supported by appropriate laboratory tests and imaging are the keys to diagnosis. In this paper, the role of imaging in diagnosis and management of CPP is reviewed. Imaging findings should be correlated with detailed clinical examination findings as there are imaging findings that may be unrelated and not the cause of CPP in a particular patient, imaging findings should be correlated with the clinical circumstances.

Barium Defecating Proctography and Dynamic Magnetic Resonance Proctography: Their Role and Patient's Perception

Objectives:

The objectives of the study were to compare the imaging findings and patient’s perception of barium defecating proctography and dynamic magnetic resonance (MR) proctography in patients with pelvic floor disorders.

Material and Methods:

This is a prospective study conducted on patients with pelvic floor disorders who consented to undergo both barium proctography and dynamic MR proctography. Imaging findings of both the procedures were compared. Inter-observer agreement (IOA) for key imaging features was assessed. Patient’s perception of these procedures was assessed using a short questionnaire and a visual analog scale.

Results:

Forty patients (M: F =19:21) with a mean age of 43.65 years and range of 21–75 years were included for final analysis. Mean patient experience score was significantly better for MR imaging (MRI) (p < 0.001). However, patients perceived significantly higher difficulty in rectal evacuation during MRI studies (p = 0.003). While significantly higher number of rectoceles (p = 0.014) were diagnosed on MRI, a greater number of pelvic floor descent (p = 0.02) and intra-rectal intussusception (p = 0.011) were diagnosed on barium proctography. The IOA for barium proctography was substantial for identifying rectoceles, rectal prolapse and for determining M line, p < 0.001. There was excellent IOA for MRI interpretation of cystoceles, peritoneoceles, and uterine prolapse and substantial to excellent IOA for determining anal canal length and anorectal angle, p < 0.001. The mean study time for the barium and MRI study was 12 minutes and 15 minutes, respectively.

Conclusion:

Barium proctography was more sensitive than MRI for detecting pelvic floor descent and intrarectal intussusception. Although patients perceived better rectal emptying with barium proctography, the overall patient experience was better for dynamic MRI proctography.

Five-Month Follow-Up Assessing Defecography and Urodynamics after Laparoscopic Nerve-Sparing Colorectal Resection for Endometriosis

Introduction

Large resections may be necessary in cytoreductive surgery for endometriosis, which present risk of urinary and bowel complications. Presentation of Case. A 29-year-old woman underwent multidisciplinary laparoscopy for endometriosis in a private practice setting for acyclic pelvic pain and cyclic abdominal distension with changes in bowel habits and frequent sensation of incomplete defecation. After surgery, urodynamics remained normal and bowel function improved subjectively and objectively per dynamic magnetic resonance defecography (DMRD). The five-month follow-up found improvements in pain scores, bowel function, and health-related quality of life (assessed by the full versions of the Short Form 36 and Endometriosis Health Profile 30 scales). Discussion. Animus may contribute to the bowel symptoms in women with endometriosis. DMRD provides additional objective parameters for comparing pre- and postoperative functions.

Conclusion

A nerve-sparing segmental rectosigmoidectomy for endometriosis carefully executed by a multidisciplinary team can preserve the function of different pelvic organs.

Advances in imaging diagnosis of rectocele

Rectocele is one of the common manifestations of outlet obstructive constipation. There are several imaging methods for evaluating rectocele including conventional defecography, dynamic nuclear magnetic resonance imaging (MRI) defecography and pelvic floor ultrasonography. These diagnostic techniques can identify the degree of rectocele and provide evidence for treatment. Defecography is still considered the gold standard for evaluating rectocele and guiding the operation, but it exposes patients to radiation. MRI defecography has the advantages of multi-dimensional imaging, excellent soft-tissue contrast and no radiation, and has broad prospects in the future, but it is expensive nowadays and has an unphysiological defecation way. Pelvic floor ultrasonography, especially endoanal and transperineal techniques, is able to identify all dysfunctions of the posterior pelvic floor compartment without radiation, but needs further studies.

MRI for pelvic floor dysfunction: can the strain phase be eliminated?

PURPOSE

The purpose of the study was to determine if the strain phase of an MR defecography (MRD) protocol is redundant and can be eliminated without a loss of diagnostic information.

MATERIALS AND METHODS

Institutional review board approval was obtained and the requirement for informed consent was waived. A retrospective single-center review of 80 MRD examinations (68 female, 12 male, mean age 55 years old) was conducted. Two radiologists blinded to patient information evaluated in consensus the strain and evacuation phases separately and in a random order. Each phase was assessed for the presence and degree of posterior compartment descent, cystocele, urethral hypermobility, uterovaginal prolapse, rectocele, rectal intussusception, and enterocele. The degree of pelvic floor descent was compared using a paired t test and McNemar's test was used to compare the proportion of abnormal findings.

RESULTS

The evacuation phase identified all abnormalities identified on the strain phase and also identified both additional and more pronounced abnormalities, including an additional 34 cystoceles, 20 cases of urethral hypermobility, 13 uterovaginal prolapses, 36 rectoceles, 5 rectal intussusceptions, and 6 enteroceles (all p < 0.02). The mean posterior compartment descent was 24.1 mm greater on the evacuation phase than the strain phase (p < 0.0001).

CONCLUSION

The strain phase is redundant and we propose that it can be eliminated from a routine MRD protocol. This will help streamline the examination, simplify patient instructions, and reduce both imaging and reporting time.

Modeling the contraction of the pelvic floor muscles

We performed numerical simulation of voluntary contraction of the pelvic floor muscles to evaluate the resulting displacements of the organs and muscles. Structures were segmented in Magnetic Resonance (MR) images. Different material properties and constitutive models were attributed. The Finite Element Method was applied, and displacements were compared with dynamic MRI findings. Numerical simulation showed muscle magnitude displacement ranging from 0 to 7.9 mm, more evident in the posterior area. Accordingly, the anorectum moved more than the uterus and bladder. Dynamic MRI showed less 0.2 mm and 4.1 mm muscle dislocation in the anterior and cranial directions, respectively. Applications of this model include evaluating muscle impairment, subject-specific mesh implant planning, or effectiveness of rehabilitation.

The value of fluoroscopic defecography in the diagnostic and therapeutic management of defecation disorders in children

BACKGROUND

Defecography is a study to assess anorectal function during evacuation.

OBJECTIVE

To investigate the value of fluoroscopic defecography in directing diagnostic and therapeutic management in children with defecation disorders.

MATERIALS AND METHODS

We reviewed all fluoroscopic defecography studies performed (2003-2009) in children with defecation problems and normal anorectal motility studies. Results were classified into three groups: (1) normal pelvic floor function; (2) pelvic floor dyssynergia, including incomplete relaxation of pelvic musculature, inconsistent change in anorectal angle and incomplete voluntary evacuation; (3) structural abnormality, including excessive pelvic floor descent with an intra-rectal intussusception, rectocele or rectal prolapse.

RESULTS

We included 18 patients (13 boys, median age 9.1 years). Indication for fluoroscopic defecography was chronic constipation in 56%, fecal incontinence in 22% and rectal prolapse in 22%. Defecography showed pelvic floor dyssynergia in 9 children (50%), a structural abnormality in 4 (22%) and normal pelvic floor function in 5 (28%). In 12 children (67%) the outcome of fluoroscopic defecography directly influenced therapeutic management. After defecography 4 children (22%) were referred for anorectal biofeedback treatment, 4 children (22%) for surgery, 2 children (11%) for additional MR defecography, and 1 child to the psychology department, and medication was changed in 1 child. In 6 children (33%) the result did not change the management. In 9 children (75%) the change of management was successful.

CONCLUSIONS

Fluoroscopic defecography can be a useful tool in understanding the pathophysiology and it may provide information that impacts management of children with refractory defecation disorders.

Optimal management of constipation associated with irritable bowel syndrome

Irritable bowel syndrome (IBS) is a common chronic functional disorder of the gastrointestinal tract, meanly characterized by recurrent abdominal pain or discomfort and altered bowel habit. It is a complex disorder involving biological, environmental, and psychosocial factors. The diagnosis is achieved according to the Rome III criteria provided that organic causes have been excluded. Although IBS does not constitute a life-threatening condition, it has a remarkable prevalence and profoundly reduces the quality of life with burdening socioeconomic costs. One of the principal concerns about IBS is the lack of effective therapeutic options. Up to 40% of patients are not satisfied with any available medications, especially those suffering from chronic constipation. A correct management of IBS with constipation should evolve through a global approach focused on the patient, starting with careful history taking in order to assess the presence of organic diseases that might trigger the disorder. Therefore, the second step is to examine lifestyle, dietary habits, and psychological status. On these bases, a step-up management of disease is recommended: from fiber and bulking agents, to osmotic laxative drugs, to new molecules like lubiprostone and linaclotide. Although new promising tools for relief of bowel-movement-related symptoms are being discovered, a dedicated doctor-patient relationship still seems to be the key for success.

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.

Surgical management of fecal incontinence

The surgical approach to treating fecal incontinence is complex. After optimal medical management has failed, surgery remains the best option for restoring function. Patient factors, such as prior surgery, anatomic derangements, and degree of incontinence, help inform the astute surgeon regarding the most appropriate option. Many varied approaches to surgical management are available, ranging from more conservative approaches, such as anal canal bulking agents and neuromodulation, to more aggressive approaches, including sphincter repair, anal cerclage techniques, and muscle transposition. Efficacy and morbidity of these approaches also range widely, and this article presents the data and operative considerations for these approaches.