Quantifying the effects of five rehabilitation training methods on the ability of elderly men to control bowel movements: a finite element analysis study

Purpose

The study aims to develop a finite element model of the pelvic floor and thighs of elderly men to quantitatively assess the impact of different pelvic floor muscle trainings and the urinary and defecation control ability.

Methods

A finite element model of the pelvic floor and thighs of elderly men was constructed based on MRI and CT. Material properties of pelvic floor tissues were assigned through literature review, and the relative changes in waistline, retrovesical angle (RVA) and anorectad angulation (ARA) to quantitatively verify the effectiveness of the model. By changing the material properties of muscles, the study analyzed the muscle strengthening or impairment effects of the five types of rehabilitation training for four types of urination and defecation dysfunction. The changes in four outcome indicators, including the retrovesical angle, anorectad angulation, stress, and strain, were compared.

Results

This study indicates that ARA and RVA approached their normal ranges as material properties changed, indicating an enhancement in the urinary and defecation control ability, particularly through targeted exercises for the levator ani muscle, external anal sphincter, and pelvic floor muscles. This study also emphasizes the effectiveness of personalized rehabilitation programs including biofeedback, exercise training, electrical stimulation, magnetic stimulation, and vibration training and advocates for providing optimized rehabilitation training methods for elderly patients.

Discussion

Based on the results of computational biomechanics, this study provides foundational scientific insights and practical recommendations for rehabilitation training of the elderly's urinary and defecation control ability, thereby improving their quality of life. In addition, this study also provides new perspectives and potential applications of finite element analysis in elderly men, particularly in evaluating and designing targeted rehabilitation training.

Evolution of the human birth canal

It seems puzzling why humans have evolved such a small and rigid birth canal that entails a relatively complex process of labor compared with the birth canal of our closest relatives, the great apes. This study reviewed insights into the evolution of the human birth canal from recent theoretical and empirical studies and discussed connections to obstetrics, gynecology, and orthopedics. Originating from the evolution of bipedality and the large human brain million years ago, the evolution of the human birth canal has been characterized by complex trade-off dynamics among multiple biological, environmental, and sociocultural factors. The long-held notion that a wider pelvis has not evolved because it would be disadvantageous for bipedal locomotion has not yet been empirically verified. However, recent clinical and biomechanical studies suggest that a larger birth canal would compromise pelvic floor stability and increase the risk of incontinence and pelvic organ prolapse. Several mammals have neonates that are equally large or even larger than human neonates compared to the size of the maternal birth canal. In these species, the pubic symphysis opens widely to allow successful delivery. Biomechanical and developmental constraints imposed by bipedality have hindered this evolutionary solution in humans and led to the comparatively rigid pelvic girdle in pregnant women. Mathematical models have shown why the evolutionary compromise to these antagonistic selective factors inevitably involves a certain rate of fetopelvic disproportion. In addition, these models predict that cesarean deliveries have disrupted the evolutionary equilibrium and led to new and ongoing evolutionary changes. Different forms of assisted birth have existed since the stone age and have become an integral part of human reproduction. Paradoxically, by buffering selection, they may also have hindered the evolution of a larger birth canal. Many of the biological, environmental, and sociocultural factors that have influenced the evolution of the human birth canal vary globally and are subject to ongoing transitions. These differences may have contributed to the global variation in the form of the birth canal and the difficulty of labor, and they likely continue to change human reproductive anatomy.

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.

Static and Dynamic Magnetic Resonance Imaging in Female Pelvic Floor Dysfunction: Correlation With Pelvic Organ Prolapse Quantification

BACKGROUND

Pelvic organ prolapse (POP) is clinically assessed and staged commonly by the pelvic organ prolapse quantification (POP-Q) system. Dynamic magnetic resonance imaging (MRI) of the pelvic floor is an emerging modality for anatomical and functional assessment of the pelvic floor and staging of POP. The purpose of this study was to correlate the dynamic MRI findings with POP-Q examination for the staging of POP in each pelvic compartment by comparing various anatomic points.

METHODS

A prospective observational study of the comparative cross-sectional design was conducted among patients who underwent MRI of the pelvic floor and POP-Q at our institute. A total of 50 patients were included. Anatomical landmarks in the three compartments were analyzed in relation to standard reference lines on dynamic MRI and compared with POP-Q measurements.

RESULTS

Most of our patients had multicompartment disease (70%). When compared to POP-Q, MRI has a strong correlation for quantification of anterior (0.723) and middle (0.525) compartments and a weak correlation (0.232) for posterior compartment prolapse.

CONCLUSION

POP-Q examination is based on the various points within the vaginal canal, and all the points do not represent a true anatomic landmark. MRI, on the other hand, is based on a true anatomical plane and gives detailed information about various structures in all three compartments. Thus, MRI also helps bridge the gap between various referring specialties in treating pelvic floor disorders.

Time-Synchronized MRI-Assessment of Respiratory Apparatus Subsystems-A Feasibility Study

The thorax (TH), the thoracic diaphragm (TD), and the abdominal wall (AW) are three sub-systems of the respiratory apparatus whose displacement motion has been well studied with the use of magnetic resonance imaging (MRI). Another sub-system, which has however received less research attention with respect to breathing, is the pelvic floor (PF). In particular, there is no study that has investigated the displacement of all four sub-systems simultaneously. Addressing this issue, it was the purpose of this feasibility study to establish a data acquisition paradigm for time-synchronous quantitative analysis of dynamic MRI data from these four major contributors to respiration and phonation (TH, TD, AW, and PF). Three healthy females were asked to breathe in and out forcefully while being recorded in a 1.5-Tesla whole body MR-scanner. Spanning a sequence of 15.12 seconds, 40 MRI data frames were acquired. Each data frame contained two slices, simultaneously documenting the mid-sagittal (TH, TD, PF) and transversal (AW) planes. The displacement motion of the four anatomical structures of interest was documented using kymographic analysis, resulting in time-varying calibrated structure displacement data. After computing the fundamental frequency of the cyclical breathing motion, the phase offsets of the TH, PF, and AW with respect to the TD were computed. Data analysis revealed three fundamentally different displacement patterns. Total structure displacement was in the range of 0.94 cm (TH) to 4.27 cm (TD). Phase delays of up to 90∘ (i.e., a quarter of a breathing cycle) between different structures were found. Motion offsets in the range of -28.30∘ to 14.90∘ were computed for the PF with respect to the TD. The diversity of results in only three investigated participants suggests a variety of possible breathing strategies, warranting further research.

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.

Consensus Definitions and Interpretation Templates for Magnetic Resonance Imaging of Defecatory Pelvic Floor Disorders: Proceedings of the Consensus Meeting of the Pelvic Floor Disorders Consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdominal Radiology, the International Continence Society, the American Urogynecologic Society, the International Urogynecological Association, and the Society of Gynecologic Surgeons

The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, radiologists, physiotherapists, and other advanced care practitioners. Specialists from these fields are all dedicated to the diagnosis and management of patients with pelvic floor conditions, but they approach, evaluate, and treat such patients with their own unique perspectives given the differences in their respective training. The PFDC was formed to bridge gaps and enable collaboration between these specialties. The goal of the PFDC is to develop and evaluate educational programs, create clinical guidelines and algorithms, and promote high quality of care in this unique patient population. The recommendations included in this article represent the work of the PFDC Working Group on Magnetic Resonance Imaging of Pelvic Floor Disorders (members listed alphabetically in Table 1). The objective was to generate inclusive, rather than prescriptive, guidance for all practitioners, irrespective of discipline, involved in the evaluation and treatment of patients with pelvic floor disorders.

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.

Total uterine prolapse complicated with vesicovaginal fistula: A case report

RATIONALE

Vesicovaginal fistula (VVF) most commonly occurs due to iatrogenic injury during surgery or obstructed labor. We report a rare case of a patient with severe pelvic organ prolapse who developed VVF even though pessary had not been used.

PATIENT CONCERNS

A 63-year-old postmenopausal woman, para 3 (all spontaneous vaginal deliveries), complained of vaginal bulging sensation and involuntary urinary leakage for 3 years.

DIAGNOSIS

Stage IV uterine prolapse with VVF.

INTERVENTIONS

She underwent transvaginal VVF repair combined with total vaginal hysterectomy and sacrospinous ligament fixation. The postoperative course was uncomplicated.

OUTCOMES

The patient remained free of complications during the 1-year follow-up.

LESSONS

This case illustrates the point that patients with pelvic organ prolapse (POP) should be treated promptly and careful follow-up should be conducted. Clinicians should be aware of the symptoms of VVF to ensure its early diagnosis and treatment.

Biomechanical trade-offs in the pelvic floor constrain the evolution of the human birth canal

Compared with most other primates, humans are characterized by a tight fit between the maternal birth canal and the fetal head, leading to a relatively high risk of neonatal and maternal mortality and morbidities. Obstetric selection is thought to favor a spacious birth canal, whereas the source for opposing selection is frequently assumed to relate to bipedal locomotion. Another, yet underinvestigated, hypothesis is that a more expansive birth canal suspends the soft tissue of the pelvic floor across a larger area, which is disadvantageous for continence and support of the weight of the inner organs and fetus. To test this "pelvic floor hypothesis," we generated a finite element model of the human female pelvic floor and varied its radial size and thickness while keeping all else constant. This allowed us to study the effect of pelvic geometry on pelvic floor deflection (i.e., the amount of bending from the original position) and tissue stresses and stretches. Deflection grew disproportionately fast with increasing radial size, and stresses and stretches also increased. By contrast, an increase in thickness increased pelvic floor stiffness (i.e., the resistance to deformation), which reduced deflection but was unable to fully compensate for the effect of increasing radial size. Moreover, larger thicknesses increase the intra-abdominal pressure necessary for childbirth. Our results support the pelvic floor hypothesis and evince functional trade-offs affecting not only the size of the birth canal but also the thickness and stiffness of the pelvic floor.

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)

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).

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.

Magnetic resonance imaging to evaluate anterior pelvic prolapse: H line is the key

INTRODUCTION

The aim of the study is to compare clinical staging of anterior pelvic prolapse with magnetic resonance imaging (MRI) staging, using the pubococcygeal line (PCL), the midpubic line (MPL), and the H line as reference lines. Moreover, we aim to analyze interrater reliability of each reference line.

MATERIAL AND METHODS

Forty-two women with pelvic organ prolapse (POP) symptoms were studied using the pelvic organ prolapse quantification on physical examination. Two different observers calculated anterior POP using the three MRI reference lines, retrospectively. Agreement between MRI and clinical staging was estimated using Pearson correlation for the quantitative measurements and kappa index for the stages. Interrater reliability was estimated using the intraclass correlation coefficient (ICC).

RESULTS

Correlation between physical examination and the H line was high by both observers (r = 0.86 and r = 0.76, p < 0.01). The correlation was lower using MPL (r = 0.76 and r = 0.65, p < 0.01). The results of comparing MRI staging and physical examination were: κ = 0.618 and κ = 0.602 for the H line, κ = 0.273 and κ = 0.267 for MPL and κ = -0.105 and κ = -0.140 for PCL. The results of interrater reliability were: ICC of 0.968 for the H line, ICC of 0.788 for MPL, and ICC of 0.737 for PCL.

CONCLUSION

Anterior POP staging using MRI H line as a reference presents a better agreement with clinical staging than PCL or MPL. The H line has better interrater reliability. The H line could replace the current lines.

Development of Upright Computed Tomography With Area Detector for Whole-Body Scans: Phantom Study, Efficacy on Workflow, Effect of Gravity on Human Body, and Potential Clinical Impact

OBJECTIVES

Multiple human systems are greatly affected by gravity, and many disease symptoms are altered by posture. However, the overall anatomical structure and pathophysiology of the human body while standing has not been thoroughly analyzed due to the limitations of various upright imaging modalities, such as low spatial resolution, low contrast resolution, limited scan range, or long examination time. Recently, we developed an upright computed tomography (CT), which enables whole-torso cross-sectional scanning with 3-dimensional acquisition within 15 seconds. The purpose of this study was to evaluate the performance, workflow efficacy, effects of gravity on a large circulation system and the pelvic floor, and potential clinical impact of upright CT.

MATERIALS AND METHODS

We compared noise characteristics, spatial resolution, and CT numbers in a phantom between supine and upright CT. Thirty-two asymptomatic volunteers (48.4 ± 11.5 years) prospectively underwent both CT examinations with the same scanning protocols on the same day. We conducted a questionnaire survey among these volunteers who underwent the upright CT examination to determine their opinions regarding the stability of using the pole throughout the acquisition (closed question), as well as safety and comfortability throughout each examination (both used 5-point scales). The total access time (sum of entry time and exit time) and gravity effects on a large circulation system and the pelvic floor were evaluated using the Wilcoxon signed-rank test and the Mann-Whitney U test. For a large circulation system, the areas of the vena cava and aorta were evaluated at 3 points (superior vena cava or ascending aorta, at the level of the diaphragm, and inferior vena cava or abdominal aorta). For the pelvic floor, distances were evaluated from the bladder neck to the pubococcygeal line and the anorectal junction to the pubococcygeal line. We also examined the usefulness of the upright CT in patients with functional diseases of spondylolisthesis, pelvic floor prolapse, and inguinal hernia.

RESULTS

Noise characteristics, spatial resolution, and CT numbers on upright CT were comparable to those of supine CT. In the volunteer study, all volunteers answered yes regarding the stability of using the pole, and most reported feeling safe (average rating of 4.2) and comfortable (average rating of 3.8) throughout the upright CT examination. The total access time for the upright CT was significantly reduced by 56% in comparison with that of supine CT (upright: 41 ± 9 seconds vs supine: 91 ± 15 seconds, P < 0.001). In the upright position, the area of superior vena cava was 80% smaller than that of the supine position (upright: 39.9 ± 17.4 mm vs supine: 195.4 ± 52.2 mm, P < 0.001), the area at the level of the diaphragm was similar (upright: 428.3 ± 87.9 mm vs supine: 426.1 ± 82.0 mm, P = 0.866), and the area of inferior vena cava was 37% larger (upright: 346.6 ± 96.9 mm vs supine: 252.5 ± 93.1 mm, P < 0.001), whereas the areas of aortas did not significantly differ among the 3 levels. The bladder neck and anorectal junction significantly descended (9.4 ± 6.0 mm and 8.0 ± 5.6 mm, respectively, both P < 0.001) in the standing position, relative to their levels in the supine position. This tendency of the bladder neck to descend was more prominent in women than in men (12.2 ± 5.2 mm in women vs 6.7 ± 5.6 mm in men, P = 0.006). In 3 patients, upright CT revealed lumbar foraminal stenosis, bladder prolapse, and inguinal hernia; moreover, it clarified the grade or clinical significance of the disease in a manner that was not apparent on conventional CT.

CONCLUSIONS

Upright CT was comparable to supine CT in physical characteristics, and it significantly reduced the access time for examination. Upright CT was useful in clarifying the effect of gravity on the human body: gravity differentially affected the volume and shape of the vena cava, depending on body position. The pelvic floor descended significantly in the standing position, compared with its location in the supine position, and the descent of the bladder neck was more prominent in women than in men. Upright CT could potentially aid in objective diagnosis and determination of the grade or clinical significance of common functional diseases.

Recent Advances in Computed Tomography and MR Imaging

Numerous advanced MR imaging and computed tomographic techniques have been developed and implemented in clinical practice over the past several years resulting in increased diagnostic accuracy and improved patient care. In this article, the authors highlight recent and emerging imaging techniques in functional and structural MR imaging, perfusion and vascular imaging, standardization of imaging practices, and selected applications of artificial intelligence in clinical practice.

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.

MAGNETIC RESONANCE IMAGING OF PELVIC FLOOR DYSFUNCTION, REVIEW

Pelvic floor dysfunction is an important medical and social problem in the female population. The impact of pelvic floor disorders (PFD) is likely to grow as the prevalence of these disorders increases with an aging population. Pregnancy and delivery are considered major risk factors in the development of POP and stress urinary incontinence. Pelvic floor dysfunction may involve pelvic organ prolapse and/or pelvic floor relaxation. Organ prolapse can include any combination of the following: urethra (urethrocele), bladder (cystocele), or both (cystourethrocele), vaginal vault and cervix (vaginal vault prolapse), uterus (uterineprolapse), rectum (rectocele), sigmoid colon (sigmoidocele),and small bowel (enterocele).Given the paucity of understanding of PFD pathophysiology ,multicompartmental pathology, the high rate of recurrence and repeat surgery imaging plays a major role in its clinical management.The magnetic resonance imaging (MRI) allows noninvasive, radiation-free, rapid, high-resolution evaluation the multicompartment defects in one examination.Findings reported at MR imaging of the pelvic floor are valuable for selecting candidates for surgical treatment and for indicating the most appropriate surgical approach.

MR defecography in the assessment of anatomic and functional abnormalities in stress urinary incontinence before and after pelvic reconstruction

PURPOSE

Magnetic resonance defecography (MRD) was used to evaluate anatomic and functional pelvic floor disorders in women with stress urinary incontinence (SUI) before and after midurethral sling (MUS) intervention.

METHOD

We performed MRD in both SUI patients and continent controls. Static MR was used to describe the anatomic abnormalities in levator ani muscle and periurethral ligaments (PUL). Dynamic MR was used to depict the function of the urethra and pelvic floor. We compared the MRD parameters between the SUI patients and continent controls before surgery. For SUI patients, dynamic MR images evaluated the functional changes of the urethra and pelvic floor after surgery.

RESULTS

In SUI group, 75.8 % have PUL defects, 65.7 % discontinuity or complete loss of pubococcygeal muscle, as compared to the continent groups (p < 0.01). There was no significant difference between the perimenopausal volunteers and SUI patients in the puborectalis defection (p > 0.05). The dynamic MR showed the urethral hypermobility, functional urethra shortening, bladder neck funneling, urethra opening and cystocele were significantly associated with SUI patients (p < 0.01). Postoperative MR indicated that SUI patients after MUS had a lower risk of bladder funneling and urethral opening at the defection phase (p < 0.01), but no significant difference in urethral hypermobility or pelvic floor prolapse was seen (p>0.05).

CONCLUSIONS

MRD with high-resolution and defecation phases provides a detailed anatomic and functional evaluation of the pelvic floor in female SUI before and after pelvic reconstruction.

MRI comparative study of levator ani muscle changes in nulliparous and multiparous females

Background

Pelvic floor dysfunction is known to be among the principal factors influencing public health, regarding frequency, cost and effect on women’s quality of life. Radiographic assessment of the pelvic floor function and anatomy plays a vital role in the recognition of pelvic floor defects. The aim of this study is to detect the postpartum-related levator ani muscle changes thus defining the relationship between the vaginal deliveries and the etiology of pelvic floor dysfunction in order to provide guidelines to decrease the incidence of pelvic floor injuries during parturition and guide the treatment plan.

Results

There was a significant difference in the puborectalis muscle thickness between the case and control groups in the right puborectalis (P value ≤ 0.001) and in the left puborectalis (P value (≤ 0.001) as well as significant midpoint thickness (P value = 0.03) with 46.2% puborectalis muscle injury in the case group compared with none in the control group.

Conclusion

Pelvic floor MRI is highly recommended as it is a contrast-free modality that allows for both anatomical and functional analysis. Its incorporation in the routine postpartum assessment will allow early detection of abnormalities even in asymptomatic cases thus ensuring proper management and preventing the development of pelvic floor dysfunction predisposed to by repeated vaginal deliveries.

MR defecography detects pelvic floor dysfunction in participants with chronic complete spinal cord injury

STUDY DESIGN

A prospective single arm study.

OBJECTIVES

Previously we have demonstrated that magnetic resonance (MR) defecography is feasible in participants with complete spinal cord injury (SCI). The main aim of this study is to evaluate whether MR defecography can provide objective parameters correlating with the clinical manifestations of neurogenic bowel dysfunction (NBD) in participants with SCI.

SETTING

A monocentric study in a comprehensive care university hospital Spinal Cord Injury Center.

METHODS

Previously published MR defecography parameters (anorectal angle (ARA), hiatal descent (M-line) and hiatal width (H-line)) of twenty participants with SCI were now compared to a standardized clinical assessment of NBD. Descriptive statistics, correlations and t-tests for independent samples were calculated.

RESULTS

The significantly higher values for the ARA at rest and M-line at rest in participants with SCI correlated with the clinical assessment of bowel incontinence. Furthermore, in nearly half of the investigated SCI cohort the normally positive difference between ARA, M-line and H-line at rest and during defecation became negative suggesting pelvic floor dyssynergia as a potential mechanism underlying constipation in people with complete SCI. In fact, these participants showed a more severe clinical presentation of NBD according to the total NBD score.

CONCLUSIONS

MR defecography provides objective parameters correlating with clinical signs of NBD, such as constipation and bowel incontinence. Therefore, MR defecography can support pathophysiology-based decision-making with respect to specific therapeutic interventions, which should help to improve the management of NBD.

Quantitative evaluation of age-related changes to pelvic floor muscles in magnetic resonance images from 369 patients

AIM

This study aimed to establish and validate a quantitative evaluation method for pelvic floor muscles using magnetic resonance images (MRI) and to examine the morphological change of pelvic floor muscles with aging.

METHODS

Data from 369 consecutive patients (163 men, 206 women; median age 58 years; range 17-92 years) who underwent coronal T2-weighted pelvic MRI at Osaka General Hospital between January 2016 and December 2016 were retrospectively examined. MRI of the levator ani muscle was evaluated. The MRI image blinded the patient information and was evaluated by a radiology specialist with 22 years of experience. In coronal T2-weighted MRI of the pelvis, the levator ani muscle was evaluated using the slice; it showed the most upward and downward convexity. We measured the thickness of the levator ani muscle, and the distance at the most convex part from a straight line connecting the origin and insertion of the levator ani muscle on both the left and right sides. Upward and downward convexity was recorded in positive and negative values, respectively.

RESULTS

The levator ani muscle was able to be evaluated quantitatively in all cases. Both men and women showed thinning (men: mean 3.316 mm, r = -0.388, P < 0.0001; women: mean 3.947 mm, r = -0.359, P < 0.0001) and concavity (men: mean 1.412 mm, r = -0.362, P < 0.0001; women: mean 4.979 mm, r = -0.630, P < 0.0001) of the levator ani muscle with aging.

CONCLUSIONS

A quantitative evaluation method for pelvic floor muscles using MRI was established. Aging was associated with morphological changes in the pelvic floor muscles in both men and women. Geriatr Gerontol Int 2019; 19: 834-837.

MRI anatomy and pathology of the anal canal

The normal function of the anal sphincter complex is crucial for quality of life, as it is the mechanism by which fecal continence is maintained. Additionally, the anal sphincter complex is an integral part of the coordinated effort of defecation. As imaging plays an important role in assessment of pathologic conditions involving the anal region, understanding the normal anatomy of the anal sphincter complex is important for correct image interpretation and accurate diagnosis. This review discusses the anatomy and function of the anal sphincter complex, important technical considerations for MRI, and various inflammatory, infectious, and neoplastic processes, as well as pathologic structural conditions that affect the anal region. Level of Evidence: 5 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2019;50:1018-1032.

Transurethral high-intensity ultrasound for treatment of stress urinary incontinence (SUI): simulation studies with patient-specific models

BACKGROUND

Stress urinary incontinence (SUI) is prevalent in adult women, attributed to weakened endopelvic supporting tissues, and typically treated using drugs and invasive surgical procedures. The objective of this in silico study is to explore transurethral high-intensity ultrasound for delivery of precise thermal therapy to the endopelvic tissues adjacent to the mid-urethra, to induce thermal remodeling as a potential minimally invasive treatment alternative.

METHODS

3D acoustic (Rayleigh-Sommerfeld) and biothermal (Pennes bioheat) models of the ultrasound applicator and surrounding tissues were devised. Parametric studies over transducer configuration [frequency, radius-of-curvature (ROC)] and treatment settings (power, duration) were performed, and select cases on patient-specific models were used for further evaluation. Transient temperature and thermal dose distributions were calculated, and temperature and dose metrics reported.

RESULTS

Configurations using a 5-MHz curvilinear transducer (3.5 × 10 mm, 28 mm ROC) with single 90 s sonication can create heated zones with 11 mm penetration (>50 °C) while sparing the inner 1.8 mm (<45 °C) radial depth of the urethral mucosa. Sequential and discrete applicator rotations can sweep out bilateral coagulation volumes (1.4 W power, 15° rotations, 600 s total time), produce large volumetric (1124 mm³ above 60 EM43 °C) and wide angular (∼50.5° per lateral sweep) coverage, with up to 15.6 mm thermal penetration and at least 1.6 mm radial urethral protection (<5 EM43 °C).

CONCLUSION

Transurethral applicators with curvilinear ultrasound transducers can deliver spatially selective temperature elevations to lateral mid-urethral targets as a possible means to tighten the endopelvic fascia and adjacent tissues.

How to define pathologic pelvic floor descent in MR defecography during defecation?

OBJECTIVES

To assess the extents of pelvic floor descent both during the maximal straining phase and the defecation phase in healthy volunteers and in patients with pelvic floor disorders, studied with MR defecography (MRD), and to define specific threshold values for pelvic floor descent during the defecation phase.

MATERIAL AND METHODS

Twenty-two patients (mean age 51 ± 19.4) with obstructed defecation and 20 healthy volunteers (mean age 33.4 ± 11.5) underwent 3.0T MRD in supine position using midsagittal T2-weighted images. Two radiologists performed measurements in reference to PCL-lines in straining and during defecation. In order to identify cutoff values of pelvic floor measurements for diagnosis of pathologic pelvic floor descent [anterior, middle, and posterior compartments (AC, MC, PC)], receiver-operating characteristic (ROC) curves were plotted.

RESULTS

Pelvic floor descent of all three compartments was significantly larger during defecation than at straining in patients and healthy volunteers (p < 0.002). When grading pelvic floor descent in the straining phase, only two healthy volunteers showed moderate PC descent (10%), which is considered pathologic. However, when applying the grading system during defecation, PC descent was overestimated with 50% of the healthy volunteers (10 of 20) showing moderate PC descent. The AUC for PC measurements during defecation was 0.77 (p = 0.003) and suggests a cutoff value of 45 mm below the PCL to identify patients with pathologic PC descent. With the adapted cutoff, only 15% of healthy volunteers show pathologic PC descent during defecation.

CONCLUSION

MRD measurements during straining and defecation can be used to differentiate patients with pelvic floor dysfunction from healthy volunteers. However, different cutoff values should be used during straining and during defecation to define normal or pathologic PC descent.

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.

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.

Dynamic Pelvic Magnetic Resonance Imaging Evaluation of Pelvic Organ Prolapse Compared to Physical Examination Findings

OBJECTIVE

To compare dynamic magnetic resonance imaging (dMRI) defecography phase findings with physical examination (PE) grading in the evaluation of pelvic organ prolapse (POP).

METHODS

We retrospectively reviewed 274 consecutive patients who underwent dMRI with defecography. Baden-Walker grading of POP, absolute dMRI values, and grading by dMRI were collected for anterior, apical, and posterior compartments. Anatomically significant POP on PE was defined as Baden-Walker Grade ≥3 and on dMRI by dMRI Grade ≥2. A Spearman's Rank correlation was performed between absolute dMRI values and respective POP grades.

RESULTS

A total of 178 female patients were included. Anatomically insignificant and significant cystoceles had a 26.4% (19/72) and 84.6% (66/78) agreement respectively. Anatomically insignificant and significant apical prolapse had a 2.0% (2/100) and 62.9% (17/27) agreement respectively. Anatomically insignificant and significant posterior prolapse had a 49.5% (51/103) and 78.7% (59/75) agreement respectively. PE detected only 30% (9/30) of total dMRI detected enteroceles and misdiagnosed 10% (3/30) of these patients with a rectocele.

CONCLUSION

The dMRI defecography phase correlated well for anatomically significant prolapse in anterior and posterior compartments. dMRI was superior to PE for enterocele detection and was better able to distinguish an enterocele from a rectocele. Thus, dMRI may have the greatest diagnostic value in cases where the presence of an enterocele is unclear in apical and/or posterior compartments.

Clinical functional evaluation of female's pelvic floor: integrative review

Abstract Introduction: The effectiveness of pelvic floor muscle training (PFMT) depends on the correct prescription of intensity, repetition and endurance of muscle contractions, which are provided by an adequate assessment of pelvic floor muscle. Objective: Verify the techniques, resources and strategies used for clinical functional evaluation of female pelvic floor (PF) described in literature. Methods: It’s an integrative review of published studies and books from 2010 until December 2015. Relevant articles with complete description of PF evaluation were found through the use of Scielo, LILACS, PubMed and Medline databases. Results: 34 articles that fulfilled all the criteria were selected. Conclusion: The most used techniques, resources and strategies were: anamnesis, physical examination, measurement of pelvic floor muscle activity using Modified Oxford Scale or perineometry, and use of questionnaires to analyze patient's perspective of their own symptoms. Thus, we could use the parameters obtained in the evaluation to plan an ideal PFMT for each patient, so the physiotherapist would have a good database to analyze the evolution and define the end of therapy.

Pelvic MRI: Is Endovaginal or Rectal Filling Needed?

Magnetic resonance imaging is the optimal modality for pelvic imaging. It is based on T2-weighted magnetic resonance (MR) sequences allowing uterine and vaginal cavity assessment as well as rectal evaluation. Anatomical depiction of these structures may benefit from distension, and conditions either developing inside the lumen of cavities or coming from the outside may then be better delineated and localized. The need for distension, either rectal or vaginal, and the way to conduct it are matters of debate, depending on indication for which the MR examination is being conducted. In this review, we discuss advantages and potential drawbacks of this technique, based on literature and our experience, in the evaluation of various gynecological and rectal diseases.

Practical guide to dynamic pelvic floor MRI

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.

Diagnostic Evaluation of Chronic Pelvic Pain

Chronic pelvic pain can result from various intra- and extra-pelvic etiologies. Although patient history and physical examination may narrow the differential diagnosis, frequently, the different etiologies have overlapping presentations. Imaging examinations such as US and/or MR imaging may help delineate the cause of pain, particularly when related to intra-pelvic organs, pelvic floor dysfunction or prolapse, synthetic material such as pelvic mesh or slings, and in some cases of neuropathic pain. Etiologies of neuropathic pain can also be assessed with non-imaging tests such as nerve conduction studies, electromyography, and testing of sacral reflexes.

Recent Advances in Understanding Pelvic-Floor Tissue of Women With and Without Pelvic Organ Prolapse: Considerations for Physical Therapists

Pelvic organ prolapse is a fairly common condition that imposes significant symptoms, diminished quality of life, social burden, financial expense, and surgical risk on women. As evidence supporting the benefit of pelvic-floor muscle training in nonsurgical management of pelvic organ prolapse grows, physical therapists are becoming a provider of choice interacting with women affected by pelvic organ prolapse. This perspective article will review recent research on tissue characteristics of 3 key components of pelvic organ support: skeletal muscle, ligament, and vaginal wall. This information will be summarized as implications for physical therapists. An improved understanding of pelvic-floor tissue in women with and without pelvic organ prolapse will provide a more comprehensive appreciation of the interaction of multiple systems in the disorder.

Long-term intermittent pharmacological therapy of uterine fibroids - a possibility to avoid hysterectomy and its negative consequences

Uterine fibroids are found in almost 20-40% of women of reproductive age. For each woman an individualised treatment method should be applied because the hysterectomy procedure is not a good option in every case. The uterus is an organ necessary not only in reproduction. Its removal may result in: pelvic floor dysfunction and stress urinary incontinence, negative impair on life quality, depressive disorders, increased risk of cardiovascular and neurodegenerative diseases, and higher incidence of neoplastic disease. According to the last scientific reports, selective progesterone receptor modulators are the effective therapeutic option in uterine fibroids in women of reproductive age because progesterone is an important factor in their pathogenesis. Ulipristal acetate (UPA) is a progesterone receptor antagonist. It inhibits cell proliferation and angiogenesis in uterine fibroids and also reduces collagen deposits in extracellular matrix. Significant data concerning ulipristal acetate efficacy have been provided by scientific research, especially from the consecutive PEARL studies. Oral ulipristal acetate effectively and safely controls bleeding and pain in patients with symptomatic fibroids. It reduces fibroid volume and restores quality of life. The results of UPA long-term intermittent treatment are largely maintained during the off-treatment periods.

Age, Gender and Women's Health and the Patient

Patients with functional gastrointestinal disorders (FGIDs) often experience distress, reduced quality of life, a perceived lack of validation, and an unsatisfactory experience with health care providers. A health care provider can provide the patient with a framework in which to understand and legitimize their symptoms, remove self-doubt or blame, and identify factors that contribute to symptoms that the patient can influence or control. This framework is implemented with the consideration of important factors that impact FGIDs, such as gender, age, society, and the patient's perspective. Although the majority of FGIDs, including globus, rumination syndrome, IBS, bloating, constipation, functional abdominal pain, sphincter of Oddi dyskinesia, pelvic floor dysfunction, and extra-intestinal manifestations, are more prevalent in women than men, functional chest pain, dyspepsia, vomiting, and anorectal pain do not appear to vary by gender. Studies suggest sex differences in somatic but not visceral pain perception, motility, and central processing of visceral pain; although further research is required in autonomic nervous system dysfunction, genetics and immunologic/microbiome. Gender differences in response to psychological treatments, antidepressants, fiber, probiotics, and anticholinergics have not been adequately studied. However, a greater clinical response to 5-HT3 antagonists but not 5-HT4 agonists has been reported in women compared with men.

MR Imaging in Diagnosis of Pelvic Floor Descent: Supine versus Sitting Position

Introduction. Functional disorders of the pelvic floor represent have a significant impact on the quality of life. The advent of open-configuration systems allowed for the evaluation of defecation with MR imaging in sitting position. The purpose of the present study is to compare the results of static and dynamic pelvic MR performed in supine position versus sitting position, using a new MR prototype machine, in the diagnosis of pelvic floor descent. Materials and Methods. Thirty-one patients with pelvic floor disorders were enrolled, and underwent MR Defecography in supine position with 1.5 T closed magnet (MAGNETOM Symphony, Siemens, Germany) and in sitting position with a 0.25-Tesla open magnet system (G-Scan ESAOTE, Italy). Results. In rest and squeezing phases, positions of bladder, vagina, and ARJ were significantly different when the patient was imaged in supine versus sitting position. In the defecation phase, a significant difference for the bladder and vagina position was detected between the two exams whereas a significant difference for the ARJ was not found. A statistically significant difference exists when the pelvic floor descent is evaluated in sitting versus supine position. Conclusion. Our results show that MR Defecography in sitting position may represent a useful tool to correctly diagnose and grade the pelvic organ descent.