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Duca I, Boja R, Dumitrascu DL. Assessment of defecation disorders using high-resolution MRI-defecography. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023; 167:357-361. [PMID: 35582728 DOI: 10.5507/bp.2022.023] [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: 03/05/2022] [Accepted: 05/03/2022] [Indexed: 11/23/2022] Open
Abstract
AIMS The aim of this retrospective study was to try to find correlations between different diagnoses established by clinical examination, anorectal manometry and MRI-defecography and, the association with psychiatric disorders. METHODS 44 patients (median age 53.81 years) presenting with intestinal motility disorders and who underwent clinical, biological and psychiatric examination, dynamic defecographic-MRI (resting, squeezing, straining, defecation and evacuation phases), anorectal manometry, colonoscopy. MRI was performed using the 1,5 T. RESULTS MRI-defecography revealed the following changes: anismus (16), rectocele (12), pelvic floor dysfunction (6), peritoneocele (2), cervical-cystic-ptosis (1), rectal prolapse (6), and in 1 case the examination was normal. Hypertonic anal sphincter (16) and lack of defecation reflex (12) at anorectal manometry correlated with anismus in all patients at MRI-defecography. Lack of inhibitor anal reflex (6) was associated with rectocele (4), cervix-cysto-ptosis (1) and peritoneocele (2). Anxiety (11), depression (6) and anxiety-depressive disorders (10) were found in 27/44, somatization disorders in 9/44 and no psychiatric changes in 8/44 cases. CONCLUSION As multiparous women are at risk for outlet obstruction constipation, MRI-defecography is suggested in this category. There is good correlation between diagnosis using anorectal manometry and MRI-defecography in patients with terminal constipation and anismus. Lower defecation dysfunction is often associated with psychiatric disorders.
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Affiliation(s)
- Ioana Duca
- 2nd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy Cluj-Napoca, Romania
| | | | - Dan Lucian Dumitrascu
- 2nd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy Cluj-Napoca, Romania
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Kämpfer C, Pieper CC. [Dynamic magnetic resonance imaging of the pelvic floor: clinical application]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:799-807. [PMID: 37783986 DOI: 10.1007/s00117-023-01223-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Dynamic magnetic resonance imaging (MRI) of the pelvic floor plays a key role in imaging complex pelvic floor dysfunction. The simultaneous detection of multiple findings in a complex anatomic setting renders correct analysis and clinical interpretation challenging. OBJECTIVES The most important aspects (anatomy of the pelvic floor, three compartment model, morphological and functional analysis, reporting) for a successful clinical use of dynamic MRI of the pelvic floor are summarized. MATERIALS AND METHODS Review of the scientific literature on dynamic pelvic MR imaging with special consideration of the joint recommendations provided by the expert panel of ESUR/ESGAR in 2016. RESULTS The pelvic floor is a complex anatomic structure, mainly formed by the levator ani muscle, the urethral support system and the endopelvic fascia. Firstly, morphological changes of these structures are analysed on the static sequences. Secondly, the functional analysis using the three compartment model is performed on the dynamic sequences during squeezing, straining and defecation. Pelvic organ mobility, pelvic organ prolapse, the anorectal angle and pelvic floor relaxation are measured and graded. The diagnosis of cystoceles, enteroceles, rectoceles, the uterovaginal as well as anorectal decent, intussusceptions and dyssynergic defecation should be reported using a structured report form. CONCLUSIONS A comprehensive analysis of all morphological and functional findings during dynamic MRI of the pelvic floor can provide information missed by other imaging modalities and hence alter therapeutic strategies.
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Affiliation(s)
- C Kämpfer
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland.
| | - C C Pieper
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
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Dohmen J, Pieper CC, Kalff JC, Vilz T. [Imaging of the pelvic floor (MR defecography) : The surgeon's perspective]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:827-834. [PMID: 37831101 DOI: 10.1007/s00117-023-01213-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Magnetic resonance defecography (MRD) plays a central role in diagnosing pelvic floor functional disorders by visualizing the entire pelvic floor along with pelvic organs and providing functional assessment of the defecation process. A shared understanding between radiology and surgery regarding indications and interpretation of findings is crucial for optimal utilization of MRD. OBJECTIVES This review aims to explain the indications for MRD from a surgical perspective and elucidate the significance of radiological findings for treatment. It intends to clarify for which symptoms MRD is appropriate and which criteria should be followed for standardized results. This is prerequisite to develop interdisciplinary therapeutic approaches. MATERIALS AND METHODS A comprehensive literature search was conducted, including current consensus guidelines. RESULTS MRD can provide relevant findings in the diagnosis of fecal incontinence and obstructed defecation syndrome, particularly in cases of pelvic floor descent, enterocele, intussusception, and pelvic floor dyssynergia. However, rectocele findings in MRD should be interpreted with caution in order to avoid overdiagnosis. CONCLUSION MRD findings should never be considered in isolation but rather in conjunction with patient history, clinical examination, and symptomatology since morphology and functional complaints may not always correlate, and there is wide variance of normal values. Interdisciplinary interpretation of MRD results involving radiology, surgery, gynecology, and urology, preferably in the context of pelvic floor conferences, is recommended.
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Affiliation(s)
- Jonas Dohmen
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
| | - Claus C Pieper
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Jörg C Kalff
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Tim Vilz
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
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4
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Kämpfer C, Pieper CC. [Dynamic magnetic resonance imaging of the pelvic floor: Technical aspects]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:793-798. [PMID: 37831100 DOI: 10.1007/s00117-023-01212-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Dynamic magnetic resonance imaging (MRI) of the pelvic floor plays a key role in imaging complex pelvic floor dysfunction. High-quality examination is crucial for diagnostic benefit but can be technically challenging. OBJECTIVES The most important technical aspects (patient selection, patient preparation, MRI technology, MRI scan protocol, success control) for obtaining a state-of-the-art dynamic MRI of the pelvic floor are summarized. MATERIALS AND METHODS Review of the scientific literature on dynamic pelvic MR imaging with special consideration of the joint recommendations provided by the expert panels of European Society of Urogenital Radiology/European Society of Gastrointestinal and Abdominal Radiology (ESUR/ESGAR) in 2016 and Society of Abdominal Radiology (SAR) in 2019. RESULTS Examination with at least 1.5 T and a surface coil after rectal instillation of ultrasound gel is clinical standard. Dynamic MRI in a closed magnet with the patient in supine position is the most widespread technique. No clinically significant pathologies of the pelvic floor are missed compared to the sitting position in an open magnet. The minimum scan protocol should encompass static, high-resolution T2-imaging (i.e., T2-TSE) in three planes and dynamic sequences with high temporal resolution in sagittal (and possibly axial) plane (i.e., steady-state or balanced steady-state free precession) during squeezing, straining and evacuation. Detailed patient instruction and practicing prior to the scan improve patients' compliance and hence diagnostic quality. CONCLUSIONS A technically flawless dynamic MRI of the pelvic floor according to these standards can provide information missed by other imaging modalities and hence alter therapeutic strategies.
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Affiliation(s)
- C Kämpfer
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland.
| | - C C Pieper
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
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Ghafoor S, Beintner-Skawran SM, Stöckli G, Betschart C, Reiner CS. Pelvic organ movements in asymptomatic nulliparous and symptomatic premenopausal women with pelvic organ prolapse in dynamic MRI: a feasibility study comparing midsagittal single-slice with multi-slice sequences. Abdom Radiol (NY) 2023; 48:2658-2671. [PMID: 37208547 PMCID: PMC10333376 DOI: 10.1007/s00261-023-03944-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/21/2023]
Abstract
PURPOSE To compare multi-slice (MS) MRI sequences of the pelvis acquired at rest and straining to dynamic midsagittal single-slice (SS) sequences for the assessment of pelvic organ prolapse (POP). METHODS This IRB-approved prospective single-center feasibility study included 23 premenopausal symptomatic patients with POP and 22 asymptomatic nulliparous volunteers. MRI of the pelvis at rest and straining was performed with midsagittal SS and MS sequences. Straining effort, visibility of organs and POP grade were scored on both. Organ points (bladder, cervix, anorectum) were measured. Differences between SS and MS sequences were compared with Wilcoxon test. RESULTS Straining effort was good in 84.4% on SS and in 64.4% on MS sequences (p = 0.003). Organ points were always visible on MS sequences, whereas the cervix was not fully visible in 31.1-33.3% on SS sequences. At rest, there were no statistically significant differences of organ point measurements between SS and MS sequences in symptomatic patients. At straining, positions of bladder, cervix, and anorectum were + 1.1 cm (± 1.8 cm), - 0.7 cm (± 2.9 cm), and + 0.7 cm (± 1.3 cm) on SS and + 0.4 mm (± 1.7 cm), - 1.4 cm (± 2.6 cm), and + 0.4 cm (± 1.3 cm) on MS sequences (p < 0.05). Only 2 cases of higher-grade POP were missed on MS sequences (both with poor straining effort). CONCLUSION MS sequences increase the visibility of organ points compared to SS sequences. Dynamic MS sequences can depict POP if images are acquired with sufficient straining effort. Further work is needed to optimize the depiction of the maximum straining effort with MS sequences.
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Affiliation(s)
- Soleen Ghafoor
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Stephan M Beintner-Skawran
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Gian Stöckli
- Department of Gynecology, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Cornelia Betschart
- Department of Gynecology, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Cäcilia S Reiner
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
- University of Zurich, Zurich, Switzerland.
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Kalev G, Marquardt C, Schmerer M, Ulrich A, Heyl W, Schiedeck T. Resection rectopexy as part of the multidisciplinary approach in the management of complex pelvic floor disorders. Innov Surg Sci 2023; 8:29-36. [PMID: 37842195 PMCID: PMC10576551 DOI: 10.1515/iss-2022-0027] [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: 11/06/2022] [Accepted: 05/22/2023] [Indexed: 10/17/2023] Open
Abstract
Objectives Pelvic floor disorders are frequently caused by an organ prolapse involving multiple pelvic floor compartments. In such cases, a multidisciplinary strategy for diagnostic work-up and therapy is required. Methods All patients who underwent transabdominal rectopexy/resection rectopexy alone or in combination with simultaneous gynecological pelvic floor reconstruction at our institution between 01/2006 and 12/2021 were included in this retrospective study. The study aimed to evaluate the functional outcome and postoperative complications. Results Two hundred and eighty seven patients were assigned to one of the following groups: PG1 - patient group one: after resection rectopexy (n=141); PG2 - after ventral rectopexy (n=8); PG3 - after combined resection rectopexy and sacro (cervico)colpopexy (n=62); PG4 - after combined resection rectopexy and trans-vaginal pelvic floor repair (n=76). The duration of follow-up was 14 months for PG1 (median, IQR 37 months), 11 months for PG2 (mean, SD 9 months), 7 months for PG 3 (median, IQR 33 months), and 12 months for PG 4 (median, IQR 51 Months). The surgical procedure resulted in improvement of symptoms related to obstructed defecation in 56.4 % (22/39) of the patients in PG1, 25 % in PG2 (1/4), 62.5 % (20/32) in PG3, and 71.8 % (28/39) in PG4. "De novo" constipation was reported by 2.4 % (2/141) of patients from PG1. Improvement in fecal incontinence symptoms was reported by 69 % (40/58) of patients in PG1, 100 % in PG2 (2/2), 93.1 % (27/29) in PG3, and 87.2 % (34/39) in PG4. The recurrence rate for external rectal prolapse was 7.1 % in PG1, 50 % in PG2 (1/2), 2.7 % in PG3, and 6.3 % in PG4. A significant difference in terms of severe morbidity (grade ≥ IIIb) and mortality could not be determined between the non-interdisciplinary (PG1 with PG2) and interdisciplinary surgery (PG3 with PG4) (p=0.88, p=0.499). Conclusions Based on our results, we can assume that combined surgery is as feasible as rectal surgery alone. In our study, combined interventions were effective and not associated with an increased risk of postoperative complications.
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Affiliation(s)
- Georgi Kalev
- Department of General, Visceral, Thoracic and Pediatric Surgery, Ludwigsburg Hospital, Ludwigsburg, Germany
| | - Christoph Marquardt
- Department of General, Visceral, Thoracic and Pediatric Surgery, Ludwigsburg Hospital, Ludwigsburg, Germany
| | - Marten Schmerer
- Department of General, Visceral, Thoracic and Pediatric Surgery, Ludwigsburg Hospital, Ludwigsburg, Germany
| | - Anja Ulrich
- Department of General, Visceral, Thoracic and Pediatric Surgery, Ludwigsburg Hospital, Ludwigsburg, Germany
| | - Wolfgang Heyl
- Department of Obstetrics and Gynecology, Ludwigsburg Hospital, Ludwigsburg, Germany
| | - Thomas Schiedeck
- Department of General, Visceral, Thoracic and Pediatric Surgery, Ludwigsburg Hospital, Ludwigsburg, Germany
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Dawkins A, Sobieh A, Myers C, Schambach B, Nair R. MRI defecography revisited. At-rest pelvic floor measurements with and without rectal gel. Is there a difference? Abdom Radiol (NY) 2023; 48:1237-1245. [PMID: 36809560 DOI: 10.1007/s00261-023-03849-6] [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: 12/26/2022] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE The authors sought to test if there was a difference in key pelvic floor measurements obtained during MR defecography at-rest, i.e., H-line, M-line and anorectal angle (ARA), before and after rectal gel administration. The authors also sought to determine if any observed differences would affect the interpretation of the defecography studies. METHODS Institutional Review Board approval was obtained. An abdominal fellow retrospectively reviewed the images of all patients who underwent MRI defecography at our institution from January 2018 through June 2021. The H-line, M-line and ARA values were remeasured on T2-weighted sagittal images, with and without rectal gel for each patient. RESULTS One hundred and eleven (111) studies were included in the analysis. 18% (N = 20) of patients satisfied the criterion for pelvic floor widening before gel administration based on H-line measurement. This increased to 27% (N = 30) after rectal gel (p = 0.08). 14.4% (N = 16) met the M-line measurement criterion for pelvic floor descent before gel administration. This increased to 38.7% after rectal gel (N = 43) (p < 0.001). 67.6% (N = 75) demonstrated an abnormal ARA prior to administration of rectal gel. This decreased to 58.6% (N = 65) after rectal gel administration (p = 0.07). The overall reporting discrepancies incurred by the presence or absence of rectal gel were 16.2%, 29.7% and 23.4% for H-line, M-line and ARA, respectively. CONCLUSION The instillation of gel during MR defecography can cause significant changes to the observed pelvic floor measurements at-rest. This in turn can influence the interpretation of defecography studies.
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Affiliation(s)
- Adrian Dawkins
- Department of Radiology, University of Kentucky, 800 Rose Street, Lexington, KY, 40536-0293, USA.
| | - Ahmed Sobieh
- Department of Radiology, University of Kentucky, 800 Rose Street, Lexington, KY, 40536-0293, USA
| | - Charles Myers
- Department of Radiology, University of Kentucky, 800 Rose Street, Lexington, KY, 40536-0293, USA
| | | | - Rashmi Nair
- Department of Radiology, University of Kentucky, 800 Rose Street, Lexington, KY, 40536-0293, USA
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The added value of conventional defecography and MRI defecography in clinical decision making on treatment for posterior compartment prolapse. Int Urogynecol J 2023; 34:507-515. [PMID: 35403883 PMCID: PMC9870817 DOI: 10.1007/s00192-022-05181-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/04/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Conventional defecography and MRI defecography can be requested as an additional test for diagnosing and differentiating the type of posterior compartment prolapse and/or obstructive defecation disorders. The objective of this study was to determine the added value of conventional defecography, conventional defecography and MRI defecography for clinical decision-making on treatment for patients with posterior compartment prolapse. METHODS Four gynecologists were asked to fill in their treatment plan per patient for 32 cases for three different steps. Step 1 consisted of information on the anamnesis and physical examination (POP-Q). Step 2 consisted of Step 1, including conventional defecography (group A) or MRI defecography (group B). In Step 3, all gynecologists received the information on Step 1 including both conventional defecography and MRI defecography. Data analysis solely focused on the assessment of changes in the gynecological treatment plan of the posterior compartment. RESULTS After Step 2 a change in treatment plan occurred in 37% and 48% of the women in groups A and B, respectively. Accordingly, after Step 3 (including all imaging data), a change in treatment plan occurred in 19% and 52% of the women in groups A and B, respectively. A change within the surgery group (when a different type of surgery was selected) was seen for a total of 11 cases in group A and 20 in group B in all steps combined. CONCLUSIONS Both conventional defecography and MRI defecography had an large effect on the treatment plan for patients with posterior compartment prolapse. The dedicated added value of the imaging modality individually cannot be concluded yet.
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Khatri G, Bhosale PR, Robbins JB, Akin EA, Ascher SM, Brook OR, Dassel M, Glanc P, Henrichsen TL, Learman LA, Sadowski EA, Saphier CJ, Wasnik AP, Maturen KE. ACR Appropriateness Criteria® Pelvic Floor Dysfunction in Females. J Am Coll Radiol 2022; 19:S137-S155. [PMID: 35550798 DOI: 10.1016/j.jacr.2022.02.016] [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: 02/17/2022] [Accepted: 02/19/2022] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Gaurav Khatri
- Division Chief, Body MRI; Associate Division Chief, Abdominal Imaging, UT Southwestern Medical Center, Dallas, Texas; Program Director, Body MRI Fellowship.
| | | | | | - Esma A Akin
- George Washington University Hospital, Washington, District of Columbia
| | - Susan M Ascher
- Georgetown University Hospital, Washington, District of Columbia
| | - Olga R Brook
- Section Chief of Abdominal Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mark Dassel
- Director Endometriosis and Chronic Pelvic Pain, Cleveland Clinic, Cleveland, Ohio; American College of Obstetricians and Gynecologists
| | - Phyllis Glanc
- University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Lee A Learman
- Dean, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; American College of Obstetricians and Gynecologists
| | - Elizabeth A Sadowski
- University of Wisconsin, Madison, Wisconsin; and ACR O-RADS MRI Education Subcommittee Chair
| | - Carl J Saphier
- Women's Ultrasound, LLC, Englewood, New Jersey; American College of Obstetricians and Gynecologists
| | - Ashish P Wasnik
- Division Chief, Abdominal Radiology, University of Michigan, Ann Arbor, Michigan
| | - Katherine E Maturen
- Associate Chair for Ambulatory Care and Specialty Chair, University of Michigan, Ann Arbor, Michigan
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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. Female Pelvic Med Reconstr Surg 2021; 27:e645-e656. [PMID: 34506350 DOI: 10.1097/spv.0000000000001111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Gurland BH, Khatri G, Ram R, Hull TL, Kocjancic E, Quiroz LH, El Sayed RF, Jambhekar KR, Chernyak V, Mohan Paspulati R, Sheth VR, Steiner AM, Kamath A, Shobeiri SA, Weinstein MM, Bordeianou L. 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. Dis Colon Rectum 2021; 64:1184-1197. [PMID: 34516442 DOI: 10.1097/dcr.0000000000002155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Brooke H Gurland
- Division of Colorectal Surgery, Stanford University, Palo Alto, California
| | - Gaurav Khatri
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Roopa Ram
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic Hospitals, Cleveland, Ohio
| | - Ervin Kocjancic
- Department of Urology, College of Medicine University of Illinois, Chicago, Illinois
| | - Lieschen H Quiroz
- Department of Obstetrics & Gynecology, University of Oklahoma, Oklahoma City, Oklahoma
| | - Rania F El Sayed
- Department of Radiology, Cairo University Pelvic Floor Centre of Excellency and Research Lab, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt
| | - Kedar R Jambhekar
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Victoria Chernyak
- Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, The Bronx, New York
| | - Raj Mohan Paspulati
- Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Vipul R Sheth
- Department of Radiology, Stanford University, Palo Alto, California
| | - Ari M Steiner
- Department of Radiology, Mount Sinai South Nassau Hospital, Oceanside, New York
| | - Amita Kamath
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - S Abbas Shobeiri
- Department of Obstetrics & Gynecology, University of Virginia, INOVA Women's Hospital, Falls Church, Virginia
| | - Milena M Weinstein
- Department of Obstetrics & Gynecology, Massachusetts General Hospital Pelvic Floor Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Liliana Bordeianou
- Department of Gastrointestinal Surgery, Massachusetts General Hospital Pelvic Floor Disorders Center, Harvard Medical School, Boston, Massachusetts
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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. AJR Am J Roentgenol 2021; 217:800-812. [PMID: 34505543 DOI: 10.2214/ajr.21.26488] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Gurland BH, Khatri G, Ram R, Hull TL, Kocjancic E, Quiroz LH, El Sayed RF, Jambhekar KR, Chernyak V, Paspulati RM, Sheth VR, Steiner AM, Kamath A, Shobeiri SA, Weinstein MM, Bordeianou L. 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. Int Urogynecol J 2021; 32:2561-2574. [PMID: 34505921 DOI: 10.1007/s00192-021-04955-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Brooke H Gurland
- Division of Colorectal Surgery, Stanford University, Palo Alto, CA, USA
| | - Gaurav Khatri
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Roopa Ram
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic Hospitals, Cleveland, OH, USA
| | - Ervin Kocjancic
- Department of Urology, College of Medicine University of Illinois, Chicago, IL, USA
| | - Lieschen H Quiroz
- Department of Obstetrics & Gynecology, University of Oklahoma, Oklahoma City, Ok, USA
| | - Rania F El Sayed
- Department of Radiology, Cairo University Pelvic Floor Centre of Excellency and Research Lab, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt
| | - Kedar R Jambhekar
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Victoria Chernyak
- Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, The Bronx, NY, USA
| | - Raj Mohan Paspulati
- Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Vipul R Sheth
- Department of Radiology, Stanford University, Palo Alto, CA, USA
| | - Ari M Steiner
- Department of Radiology, Mount Sinai South Nassau Hospital, Oceanside, NY, USA
| | - Amita Kamath
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - S Abbas Shobeiri
- Department of Obstetrics & Gynecology, University of Virginia, INOVA Women's Hospital, Falls Church, VA, USA
| | - Milena M Weinstein
- Department of Obstetrics & Gynecology, Massachusetts General Hospital Pelvic Floor Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Liliana Bordeianou
- Department of Gastrointestinal Surgery, Massachusetts General Hospital Pelvic Floor Disorders Center, Harvard Medical School, Boston, MA, USA. .,Massachusetts General Hospital Surgery, 55 Fruit St, GRB 425, Boston, MA, 02114, USA.
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Ciesielski P, Szczotko M, Kołodziejczak M. Surgical Treatment of Full-Thickness Rectal Prolapse (FTRP): a Case Series Analysis. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02439-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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The Effect of Biofeedback Therapy Combined with Comprehensive Nursing Intervention on the Quality of Life of Patients with Functional Constipation Based on Dynamic Magnetic Resonance Defecation. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:9947373. [PMID: 34094042 PMCID: PMC8137299 DOI: 10.1155/2021/9947373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/15/2021] [Accepted: 05/02/2021] [Indexed: 11/17/2022]
Abstract
In order to study the quality of life of patients with functional constipation based on dynamic magnetic resonance defecation, the biofeedback therapy combined with comprehensive nursing intervention was used to diagnose and treat the patients, so as to explore its clinical efficacy and its impact on patients' quality of life. The obstructed defecation surgical treatment carries frequent recurrences, and dynamic magnetic resonance imaging defecography evaluated and elucidated the underlying anatomic features. This research selected 80 patients who came to our hospital for treatment of functional constipation and evaluated and recorded various clinical indicators before and after treatment in the form of questionnaire survey. The results showed that the clinical symptom scores of patients with functional constipation before and after treatment were greatly different (P < 0.05). Thus, the biofeedback therapy combined with comprehensive nursing intervention showed a good clinical effect in the treatment of patients with functional constipation and significantly improved the quality of life of patients, showing high clinical application and promotion value. A convenient diagnostic procedure is represented by the dynamic magnetic resonance imaging in females, especially pelvic floor organs dynamic imaging during defecation.
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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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Steiner A, Marks R, Bahrami S, Arif-Tiwari H. How to develop and sustain a successful pelvic floor MRI practice. Abdom Radiol (NY) 2021; 46:1443-1450. [PMID: 31485786 DOI: 10.1007/s00261-019-02204-y] [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] [Indexed: 11/29/2022]
Abstract
PURPOSE Magnetic resonance imaging (MRI) of the pelvic floor has become a commonly requested diagnostic tool for pelvic floor assessment. We provide a practical guide for developing, growing, and troubleshooting a dedicated pelvic floor imaging service. METHODS The authors provide an organized approach to the development of a pelvic floor MRI program based on the experience of the SAR Pelvic Floor Disease Focused Panel in academic and private practice settings. Topics addressed include creating interest, staff education, patient preparation both before and after arrival to the imaging center, image acquisition, reporting, and troubleshooting. RESULTS Using the organization and approach in this guide, the challenge of growing this relatively complex imaging program can be simplified. Familiarity with best practices and established techniques used by successful programs will allow new sites to avoid early pitfalls and quickly develop a mature and autonomous workflow. CONCLUSIONS The development and growing of a pelvic floor MRI program presents its own set of challenges and unique workflow issues which can create anxiety in both patients and providers. We systematically present an approach to streamline the development of a successful pelvic floor MRI program.
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Affiliation(s)
- Ari Steiner
- Department of Radiology, Mount Sinai South Nassau Hospital, Oceanside, NY, USA.
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Robert Marks
- Department of Radiology, Naval Medical Center San Diego, San Diego, CA, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Simin Bahrami
- Division of Abdominal Imaging & Interventions, Department of Radiology, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Hina Arif-Tiwari
- Department of Medical Imaging, College of Medicine, University of Arizona, Tucson, AZ, USA
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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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Abdelzaher DG, Abdelatif M, Thabet WM, Elshafei AM, Shady MM. Role of static and dynamic MRI in evaluation of pelvic posterior compartment pathologies: prospective case series. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00165-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pelvic floor dysfunction affects the lifestyle of women worldwide; the aim of this study is to evaluate the role of static MRI and dynamic MR defecography in the diagnosis of the posterior compartment of pelvic floor dysfunction.
This prospective study included 50 female patients. All of them presented with pelvic floor dysfunction. Static and dynamic MRI were performed for all patients after injection of 120–150 ml of intrarectal gel and voiding 2 h before examination. Dynamic MRI was performed at rest, squeezing, straining phases, and during defecation.
Results
MR defecography can detect posterior compartment pathology with high sensitivity and specificity. We found anterior rectocele in 26 patients (52%). Rectocele incidence was analyzed and compared to postoperative reports, and the receiver operator curve (ROC) was calculated that showed area under the curve (AUC) of 0.998. The cut-off value of 1.95 cm gives a sensitivity of 96.4% and specificity of 100% during straining. The percentage of anismus was 26%, rectorectal intussusception 52%, anal prolapse types (rectoanal intussusception 14% and external prolapse 8%), and peritoneocele 34%.
Conclusion
MRI is a valuable imaging modality that can be used to diagnose pelvic floor disorders and does not involve the risk of exposure to ionizing radiation. It can direct the surgical procedure and thus improve the post-operative results and decrease the rate of recurrence due to missed pathology.
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Saraya S, Awad A, EL Bakry RE. MR defecography in ano-rectal dysfunction: a clinical-radiological correlation study. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00286-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The aim of this work is to assess the diagnostic accuracy of MR defecography in ano-rectal dysfunction [ARD] for proper treatment planning.
Results
MR defecography was done to 30 patients with ARD for detection of its functional and structural causes. Increased perineal descent was detected in 70% of cases, rectocele in 46.7%, rectal intussusception in 40%, cystocele in 26.7%, uterine prolapse in 27.7%, enterocele in 13.3%, and paradoxical puborectalis contraction in 30%.
Conclusion
MR defecography is an essential diagnostic tool for optimum management of ano-rectal dysfunction patients.
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Lakhoo J, Khatri G, Elsayed RF, Chernyak V, Olpin J, Steiner A, Tammisetti VS, Sundaram KM, Arora SS. MRI of the Male Pelvic Floor. Radiographics 2019; 39:2003-2022. [PMID: 31697623 DOI: 10.1148/rg.2019190064] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The pelvic floor is a complex structure that supports the pelvic organs and provides resting tone and voluntary control of the urethral and anal sphincters. Dysfunction of or injury to the pelvic floor can lead to gastrointestinal, urinary, and sexual dysfunction. The prevalence of pelvic floor disorders is much lower in men than in women, and because of this, the majority of the published literature pertaining to MRI of the pelvic floor is oriented toward evaluation of the female pelvic floor. The male pelvic floor has sex-specific differences in anatomy and pathophysiologic disorders. Despite these differences, static and dynamic MRI features of these disorders, specifically gastrointestinal disorders, are similar in both sexes. MRI and MR defecography can be used to evaluate anorectal disorders related to the pelvic floor. MRI can also be used after prostatectomy to help predict the risk of postsurgical incontinence, to evaluate postsurgical function by using dynamic voiding MR cystourethrography, and subsequently, to assess causes of incontinence treatment failure. Increased tone of the pelvic musculature in men secondary to chronic pain can lead to sexual dysfunction. This article reviews normal male pelvic floor anatomy and how it differs from the female pelvis; MRI techniques for imaging the male pelvis; and urinary, gastrointestinal, and sexual conditions related to abnormalities of pelvic floor structures in men.Online supplemental material is available for this article.©RSNA, 2019.
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Affiliation(s)
- Janesh Lakhoo
- From the Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave South, CCC1121, Nashville, TN 37232 (J.L., K.M.S., S.S.A.); Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (G.K.); Department of Radiology, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt (R.F.E.); Department of Radiology, Montefiore Medical Center, Bronx, NY (V.C.); Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah (J.O.); Department of Radiology, South Nassau Communities Hospital, Oceanside, NY (A.S.); and Department of Diagnostic and Interventional Radiology, University of Texas Health Science Center at Houston, Houston, Tex (V.S.T.)
| | - Gaurav Khatri
- From the Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave South, CCC1121, Nashville, TN 37232 (J.L., K.M.S., S.S.A.); Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (G.K.); Department of Radiology, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt (R.F.E.); Department of Radiology, Montefiore Medical Center, Bronx, NY (V.C.); Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah (J.O.); Department of Radiology, South Nassau Communities Hospital, Oceanside, NY (A.S.); and Department of Diagnostic and Interventional Radiology, University of Texas Health Science Center at Houston, Houston, Tex (V.S.T.)
| | - Rania F Elsayed
- From the Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave South, CCC1121, Nashville, TN 37232 (J.L., K.M.S., S.S.A.); Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (G.K.); Department of Radiology, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt (R.F.E.); Department of Radiology, Montefiore Medical Center, Bronx, NY (V.C.); Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah (J.O.); Department of Radiology, South Nassau Communities Hospital, Oceanside, NY (A.S.); and Department of Diagnostic and Interventional Radiology, University of Texas Health Science Center at Houston, Houston, Tex (V.S.T.)
| | - Victoria Chernyak
- From the Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave South, CCC1121, Nashville, TN 37232 (J.L., K.M.S., S.S.A.); Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (G.K.); Department of Radiology, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt (R.F.E.); Department of Radiology, Montefiore Medical Center, Bronx, NY (V.C.); Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah (J.O.); Department of Radiology, South Nassau Communities Hospital, Oceanside, NY (A.S.); and Department of Diagnostic and Interventional Radiology, University of Texas Health Science Center at Houston, Houston, Tex (V.S.T.)
| | - Jeffrey Olpin
- From the Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave South, CCC1121, Nashville, TN 37232 (J.L., K.M.S., S.S.A.); Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (G.K.); Department of Radiology, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt (R.F.E.); Department of Radiology, Montefiore Medical Center, Bronx, NY (V.C.); Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah (J.O.); Department of Radiology, South Nassau Communities Hospital, Oceanside, NY (A.S.); and Department of Diagnostic and Interventional Radiology, University of Texas Health Science Center at Houston, Houston, Tex (V.S.T.)
| | - Ari Steiner
- From the Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave South, CCC1121, Nashville, TN 37232 (J.L., K.M.S., S.S.A.); Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (G.K.); Department of Radiology, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt (R.F.E.); Department of Radiology, Montefiore Medical Center, Bronx, NY (V.C.); Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah (J.O.); Department of Radiology, South Nassau Communities Hospital, Oceanside, NY (A.S.); and Department of Diagnostic and Interventional Radiology, University of Texas Health Science Center at Houston, Houston, Tex (V.S.T.)
| | - Varaha S Tammisetti
- From the Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave South, CCC1121, Nashville, TN 37232 (J.L., K.M.S., S.S.A.); Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (G.K.); Department of Radiology, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt (R.F.E.); Department of Radiology, Montefiore Medical Center, Bronx, NY (V.C.); Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah (J.O.); Department of Radiology, South Nassau Communities Hospital, Oceanside, NY (A.S.); and Department of Diagnostic and Interventional Radiology, University of Texas Health Science Center at Houston, Houston, Tex (V.S.T.)
| | - Karthik M Sundaram
- From the Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave South, CCC1121, Nashville, TN 37232 (J.L., K.M.S., S.S.A.); Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (G.K.); Department of Radiology, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt (R.F.E.); Department of Radiology, Montefiore Medical Center, Bronx, NY (V.C.); Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah (J.O.); Department of Radiology, South Nassau Communities Hospital, Oceanside, NY (A.S.); and Department of Diagnostic and Interventional Radiology, University of Texas Health Science Center at Houston, Houston, Tex (V.S.T.)
| | - Sandeep S Arora
- From the Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave South, CCC1121, Nashville, TN 37232 (J.L., K.M.S., S.S.A.); Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (G.K.); Department of Radiology, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt (R.F.E.); Department of Radiology, Montefiore Medical Center, Bronx, NY (V.C.); Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah (J.O.); Department of Radiology, South Nassau Communities Hospital, Oceanside, NY (A.S.); and Department of Diagnostic and Interventional Radiology, University of Texas Health Science Center at Houston, Houston, Tex (V.S.T.)
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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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Wang XJ, Camilleri M. Personalized medicine in functional gastrointestinal disorders: Understanding pathogenesis to increase diagnostic and treatment efficacy. World J Gastroenterol 2019; 25:1185-1196. [PMID: 30886502 PMCID: PMC6421234 DOI: 10.3748/wjg.v25.i10.1185] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/04/2019] [Accepted: 02/23/2019] [Indexed: 02/06/2023] Open
Abstract
There is overwhelming evidence that functional gastrointestinal disorders (FGIDs) are associated with specific mechanisms that constitute important targets for personalized treatment. There are specific mechanisms in patients presenting with functional upper gastrointestinal symptoms (UGI Sx). Among patients with UGI Sx, approximately equal proportions (25%) of patients have delayed gastric emptying (GE), reduced gastric accommodation (GA), both impaired GE and GA, or neither, presumably due to increased gastric or duodenal sensitivity. Treatments targeted to the underlying pathophysiology utilize prokinetics, gastric relaxants, or central neuromodulators. Similarly, specific mechanisms in patients presenting with functional lower gastrointestinal symptoms, especially with diarrhea or constipation, are recognized, including at least 30% of patients with functional constipation pelvic floor dyssynergia and 5% has colonic inertia (with neural or interstitial cells of Cajal loss in myenteric plexus); 25% of patients with diarrhea-predominant irritable bowel syndrome (IBSD) has evidence of bile acid diarrhea; and, depending on ethnicity, a varying proportion of patients has disaccharidase deficiency, and less often sucrose-isomaltase deficiency. Among patients with predominant pain or bloating, the role of fermentable oligosaccharides, disaccharides, monosaccharides and polyols should be considered. Personalization is applied through pharmacogenomics related to drug pharmacokinetics, specifically the role of CYP2D6, 2C19 and 3A4 in the use of drugs for treatment of patients with FGIDs. Single mutations or multiple genetic variants are relatively rare, with limited impact to date on the understanding or treatment of FGIDs. The role of mucosal gene expression in FGIDs, particularly in IBS-D, is the subject of ongoing research. In summary, the time for personalization of FGIDs, based on deep phenotyping, is here; pharmacogenomics is relevant in the use of central neuromodulators. There is still unclear impact of the role of genetics in the management of FGIDs.
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Affiliation(s)
- Xiao Jing Wang
- Division of Gastroenterology and Hepatology, Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, MN 55905, United States
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, MN 55905, United States
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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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Abstract
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.
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Schawkat K, Pfister B, Parker H, Heinrich H, Barth BK, Weishaupt D, Fox M, Reiner CS. Dynamic MRI of the pelvic floor: comparison of performance in supine vs left lateral body position. Br J Radiol 2018; 91:20180393. [PMID: 30160176 DOI: 10.1259/bjr.20180393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE: To investigate the performance of MR-defecography (MRD) in lateral body position as an alternative to supine position. METHODS: 22 consecutive patients (16 females; mean age 51 ± 19.4) with obstructed defecation and 20 healthy volunteers (11 females; mean age 33.4 ± 11.5) underwent MRD in a closed-configuration 3T-MRI in supine and lateral position. MRD included T2 weighted images at rest and during defecation after filling the rectum with 250 ml water-based gel. Measurements were performed in reference to the pubococcygeal line and grade of evacuation was assessed. Image quality (IQ) was rated on a 5-point-scale (5 = excellent). RESULTS: In patients grades of middle and posterior compartment descent were similar in both body positions (p > 0.05). Grades of anterior compartment descent were significantly higher in lateral position (21/22 vs 17/22 patients with normal or small descent, p < 0.034). In volunteers grades of descent were similar for all compartments in supine and lateral position (p > 0.05). When attempting to defecate in supine position 6/22 (27%) patients showed no evacuation, while in lateral position only 3/22 (14%) were not able to evacuate. IQ in patients was equal at rest (4.4 ± 0.5 and 4.7 ± 0.6, p > 0.05) and slightly better in supine compared to the lateral position during defecation (4.5 ± 0.4 vs 3.9 ± 0.9, p < 0.017). IQ in volunteers was equal in supine and lateral position (p > 0.05). CONCLUSION: In lateral position, more patients were able to evacuate with similar grades of pelvic floor descent compared to supine position. MRD in lateral position may be a valuable alternative for patients unable to defecate in supine position. ADVANCES IN KNOWLEDGE: In lateral position, more patients were able to evacuate during MRD. MRD in lateral position may be an alternative for patients unable to defecate in supine position.
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Affiliation(s)
- Khoschy Schawkat
- 1 Institute of Diagnostic and Interventional Radiology, University Hospital Zurich , Zurich , Switzerland.,2 University Zurich , Zurich , Switzerland
| | - Bettina Pfister
- 1 Institute of Diagnostic and Interventional Radiology, University Hospital Zurich , Zurich , Switzerland.,2 University Zurich , Zurich , Switzerland
| | - Helen Parker
- 2 University Zurich , Zurich , Switzerland.,3 Department of Gastroenterology and Hepatology, University Hospital Zurich , Zurich , Switzerland.,4 Institute of Health and Society, Newcastle University , Newcastle upon Tyne , UK
| | - Henriette Heinrich
- 3 Department of Gastroenterology and Hepatology, University Hospital Zurich , Zurich , Switzerland.,5 Gastroenterology, Abdominal Center, St. Claraspital , Basel , Switzerland
| | - Borna K Barth
- 1 Institute of Diagnostic and Interventional Radiology, University Hospital Zurich , Zurich , Switzerland.,2 University Zurich , Zurich , Switzerland
| | - Dominik Weishaupt
- 6 Department of Radiology, Stadtspital Triemli , Zurich , Switzerland
| | - Mark Fox
- 3 Department of Gastroenterology and Hepatology, University Hospital Zurich , Zurich , Switzerland.,5 Gastroenterology, Abdominal Center, St. Claraspital , Basel , Switzerland
| | - Caecilia S Reiner
- 1 Institute of Diagnostic and Interventional Radiology, University Hospital Zurich , Zurich , Switzerland.,2 University Zurich , Zurich , Switzerland
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Arif-Tiwari H, Twiss CO, Lin FC, Funk JT, Vedantham S, Martin DR, Kalb BT. Improved Detection of Pelvic Organ Prolapse: Comparative Utility of Defecography Phase Sequence to Nondefecography Valsalva Maneuvers in Dynamic Pelvic Floor Magnetic Resonance Imaging. Curr Probl Diagn Radiol 2018; 48:342-347. [PMID: 30241870 DOI: 10.1067/j.cpradiol.2018.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/16/2018] [Accepted: 08/16/2018] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Hina Arif-Tiwari
- Department of Medical Imaging, University of Arizona, College of Medicine, Tucson, AZ; Department of Surgery, University of Arizona, Banner University Medicine, Tucson, AZ.
| | - Christian O Twiss
- Department of Surgery, Section of Urology, University of Arizona Medical Center, Tucson, AZ.
| | - Frank C Lin
- Division of Urology, Department of Surgery, University of Arizona, Banner University Medicine, Tucson, AZ.
| | - Joel T Funk
- Division of Urology, Department of Surgery, University of Arizona, Banner University Medicine, Tucson, AZ.
| | - Srinivasan Vedantham
- Department of Medical Imaging, University of Arizona, College of Medicine, Tucson, AZ.
| | - Diego R Martin
- College of Medicine, University of Arizona, Banner University Medicine, Tucson, AZ.
| | - Bobby T Kalb
- College of Medicine, University of Arizona, Tucson, AZ.
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Lin FC, Funk JT, Tiwari HA, Kalb BT, Twiss CO. Dynamic Pelvic Magnetic Resonance Imaging Evaluation of Pelvic Organ Prolapse Compared to Physical Examination Findings. Urology 2018; 119:49-54. [PMID: 29944912 DOI: 10.1016/j.urology.2018.05.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 05/17/2018] [Accepted: 05/22/2018] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Frank C Lin
- University of Arizona, College of Medicine, Division of Urology, Tucson, AZ.
| | - Joel T Funk
- University of Arizona, College of Medicine, Division of Urology, Tucson, AZ
| | - Hina Arif Tiwari
- University of Arizona, College of Medicine, Department of Medical Imaging, Tucson, AZ
| | - Bobby T Kalb
- University of Arizona, College of Medicine, Department of Medical Imaging, Tucson, AZ
| | - Christian O Twiss
- University of Arizona, College of Medicine, Division of Urology, Tucson, AZ
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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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Ramage L, Georgiou P, Qiu S, McLean P, Khan N, Kontnvounisios C, Tekkis P, Tan E. Can we correlate pelvic floor dysfunction severity on MR defecography with patient-reported symptom severity? Updates Surg 2017; 70:467-476. [PMID: 29255962 PMCID: PMC6244712 DOI: 10.1007/s13304-017-0506-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/02/2017] [Indexed: 12/15/2022]
Abstract
MR defecography (MRD) is an alternative to conventional defecography (CD) which allows for dynamic visualisation of the pelvic floor. The aim of this study was to assess whether MRI features indicative of pelvic floor dysfunction correlated with patient-reported symptom severity. MR proctograms were matched to a prospectively-maintained functional database. Univariate and multivariate analyses were performed using pre-treatment questionnaire responses to the Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ), Wexner Incontinence Score (WIS), and modified Obstructed Defecation Symptom (ODS) Score. 302 MRI proctograms were performed between January 2012 and April 2015. 170 patients were included. Patients with a rectocele > 2 cm (p = 0.003; OR 5.756) or MRD features suggestive of puborectalis syndrome (p = 0.025; OR 8.602) were more likely to report a higher ODS score on multivariate analysis. Lack of rectal evacuation was negatively associated with an abnormal WIS (p = 0.007; OR 0.228). Age > 50 (p = 0.027, OR 2.204) and a history of pelvic floor surgery (p = 0.042, OR 0.359) were correlated with an abnormal BBUSQ incontinence score. Lack of rectal evacuation (p = 0.027, OR 3.602) was associated with an abnormal BBUSQ constipation score. Age > 50 (p = 0.07, OR 0.156) and the presence of rectoanal intussusception (p = 0.010, OR 0.138) were associated with an abnormal BBUSQ evacuation score. Whilst MRD is a useful tool in aiding multidisciplinary decision making, overall, it is poorly correlated with patient-reported symptom severity, and treatment decisions should not rest solely on results.
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Affiliation(s)
- Lisa Ramage
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, Academic Surgery, 3rd Floor, Fulham Road, London, SW10 9NH, UK
| | - Panagiotis Georgiou
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, Academic Surgery, 3rd Floor, Fulham Road, London, SW10 9NH, UK
| | - Shengyang Qiu
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, Academic Surgery, 3rd Floor, Fulham Road, London, SW10 9NH, UK
| | - Paul McLean
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, Academic Surgery, 3rd Floor, Fulham Road, London, SW10 9NH, UK
| | - Nasir Khan
- Department of Radiology, Chelsea Westminster Hospital, London, UK.,Department of Radiology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Christos Kontnvounisios
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, Academic Surgery, 3rd Floor, Fulham Road, London, SW10 9NH, UK. .,Department of Colorectal Surgery, The Royal Marsden NHS Foundation Trust, London, UK.
| | - Paris Tekkis
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, Academic Surgery, 3rd Floor, Fulham Road, London, SW10 9NH, UK.,Department of Colorectal Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Emile Tan
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Republic of Singapore
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Camilleri M, Ford AC, Mawe GM, Dinning PG, Rao SS, Chey WD, Simrén M, Lembo A, Young-Fadok TM, Chang L. Chronic constipation. Nat Rev Dis Primers 2017; 3:17095. [PMID: 29239347 DOI: 10.1038/nrdp.2017.95] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic constipation is a prevalent condition that severely impacts the quality of life of those affected. Several types of primary chronic constipation, which show substantial overlap, have been described, including normal-transit constipation, rectal evacuation disorders and slow-transit constipation. Diagnosis of primary chronic constipation involves a multistep process initiated by the exclusion of 'alarm' features (for example, unintentional weight loss or rectal bleeding) that might indicate organic diseases (such as polyps or tumours) and a therapeutic trial with first-line treatments such as dietary changes, lifestyle modifications and over-the-counter laxatives. If symptoms do not improve, investigations to diagnose rectal evacuation disorders and slow-transit constipation are performed, such as digital rectal examination, anorectal structure and function testing (including the balloon expulsion test, anorectal manometry or defecography) or colonic transit tests (such as the radiopaque marker test, wireless motility capsule test, scintigraphy or colonic manometry). The mainstays of treatment are diet and lifestyle interventions, pharmacological therapy and, rarely, surgery. This Primer provides an introduction to the epidemiology, pathophysiological mechanisms, diagnosis, management and quality of life associated with the commonly encountered clinical problem of chronic constipation in adults unrelated to opioid abuse.
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Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Charlton Bldg., Rm. 8-110, Rochester, Minnesota 55905, USA
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds and Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Gary M Mawe
- Department of Neurological Sciences, The University of Vermont, Burlington, Vermont, USA
| | - Phil G Dinning
- Departments of Gastroenterology & Surgery, Flinders University, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Satish S Rao
- Division of Gastroenterology and Hepatology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - William D Chey
- Division of Gastroenterology, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Magnus Simrén
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anthony Lembo
- Digestive Disease Center, Beth Israel Deaconess Hospital, Boston, Massachusetts, USA
| | | | - Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Magnetic resonance defecography versus clinical examination and fluoroscopy: a systematic review and meta-analysis. Tech Coloproctol 2017; 21:915-927. [PMID: 29094218 DOI: 10.1007/s10151-017-1704-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/19/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Magnetic resonance defecography (MRD) allows for dynamic visualisation of the pelvic floor compartments when assessing for pelvic floor dysfunction. Additional benefits over traditional techniques are largely unknown. The aim of this study was to compare detection and miss rates of pelvic floor abnormalities with MRD versus clinical examination and traditional fluoroscopic techniques. METHODS A systematic review and meta-analysis was conducted in accordance with recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were accessed. Studies were included if they reported detection rates of at least one outcome of interest with MRD versus EITHER clinical examination AND/OR fluoroscopic techniques within the same cohort of patients. RESULTS Twenty-eight studies were included: 14 studies compared clinical examination to MRD, and 16 compared fluoroscopic techniques to MRD. Detection and miss rates with MRD were not significantly different from clinical examination findings for any outcome except enterocele, where MRD had a higher detection rate (37.16% with MRD vs 25.08%; OR 2.23, 95% CI 1.21-4.11, p = 0.010) and lower miss rates (1.20 vs 37.35%; OR 0.05, 95% CI 0.01-0.20, p = 0.0001) compared to clinical examination. However, compared to fluoroscopy, MRD had a lower detection rate for rectoceles (61.84 vs 73.68%; OR 0.48 95% CI 0.30-0.76, p = 0.002) rectoanal intussusception (37.91 vs 57.14%; OR 0.32, 95% CI 0.16-0.66, p = 0.002) and perineal descent (52.29 vs 74.51%; OR 0.36, 95% CI 0.17-0.74, p = 0.006). Miss rates of MRD were also higher compared to fluoroscopy for rectoceles (15.96 vs 0%; OR 15.74, 95% CI 5.34-46.40, p < 0.00001), intussusception (36.11 vs 3.70%; OR 10.52, 95% CI 3.25-34.03, p = 0.0001) and perineal descent (32.11 vs 0.92%; OR 12.30, 95% CI 3.38-44.76, p = 0.0001). CONCLUSIONS MRD has a role in the assessment of pelvic floor dysfunction. However, clinicians need to be mindful of the risk of underdiagnosis and consider the use of additional imaging.
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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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Khatri G, Khan A, Raval G, Chhabra A. Diagnostic Evaluation of Chronic Pelvic Pain. Phys Med Rehabil Clin N Am 2017; 28:477-500. [PMID: 28676360 DOI: 10.1016/j.pmr.2017.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Gaurav Khatri
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
| | - Ambereen Khan
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Gargi Raval
- Department of Physical Medicine and Rehabilitation, Dallas VA Medical Center, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; Department of Orthopedics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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Cariou de Vergie L, Venara A, Duchalais E, Frampas E, Lehur PA. Internal rectal prolapse: Definition, assessment and management in 2016. J Visc Surg 2016; 154:21-28. [PMID: 27865742 DOI: 10.1016/j.jviscsurg.2016.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Internal rectal prolapse (IRP) is a well-recognized pelvic floor disorder mainly seen during defecatory straining. The symptomatic expression of IRP is complex, encompassing fecal continence (56%) and/or evacuation disorders (85%). IRP cannot be characterized easily by clinical examination alone and the emergence of dynamic defecography (especially MRI) has allowed a better comprehension of its pathophysiology and led to the proposition of a severity score (Oxford score) that can guide management. Decision for surgical management should be multidisciplinary, discussed after a complete work-up, and only after medical treatment has failed. Information should be provided to the patient, outlining the goals of treatment, the potential complications and results. Stapled trans-anal rectal resection (STARR) has been considered as the gold standard for IRP treatment. However, inconsistent results (failure observed in up to 20% of cases, and fecal incontinence occurring in up to 25% of patients at one year) have led to a decrease in its indications. Laparoscopic ventral mesh rectopexy has substantial advantages in solving the functional problems due to IRP (efficacy on evacuation and resolution of continence symptoms in 65-92%, and 73-97% of patients, respectively) and is currently considered as the gold standard therapy for IRP once the decision to operate has been made.
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Affiliation(s)
- L Cariou de Vergie
- Clinique de chirurgie digestive et endocrinienne, Hôtel-Dieu, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France; Maternité, hôpital Mère-Enfant, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - A Venara
- Clinique de chirurgie générale et digestive, 49000 Angers, France
| | - E Duchalais
- Clinique de chirurgie digestive et endocrinienne, Hôtel-Dieu, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - E Frampas
- Radiologie centrale, Hôtel-Dieu, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - P A Lehur
- Clinique de chirurgie digestive et endocrinienne, Hôtel-Dieu, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France.
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Hassan HHM, Elnekiedy AM, Elshazly WG, Naguib NN. Modified MR defecography without rectal filling in obstructed defecation syndrome: Initial experience. Eur J Radiol 2016; 85:1673-81. [DOI: 10.1016/j.ejrad.2016.06.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/20/2016] [Accepted: 06/20/2016] [Indexed: 10/21/2022]
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Abstract
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.
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Descending perineum syndrome: a review of the presentation, diagnosis, and management. Int Urogynecol J 2016; 27:1149-56. [PMID: 26755058 DOI: 10.1007/s00192-015-2889-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 11/02/2015] [Indexed: 12/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Defecatory dysfunction is a relatively common and challenging problem among women and one that practicing pelvic reconstructive surgeons and gynecologists deal with frequently. A subset of defecatory dysfunction includes obstructed defecation, which can have multiple causes, one of which is descending perineum syndrome (DPS). METHODS A literature search was performed to identify the pathophysiology, diagnosis, and management of DPS. RESULTS Although DPS has been described in the literature for many decades, it is still uncommonly diagnosed and difficult to manage. A high index of suspicion combined with physical examination consistent with excess perineal descent, patient symptom assessment, and imaging in the form of defecography are required for the diagnosis to be accurately made. Primary management options of DPS include conservative measures consisting of bowel regimens and biofeedback. Although various surgical approaches have been described in limited case series, no compelling evidence can be demonstrated at this point to support surgical intervention. CONCLUSIONS Knowledge of DPS is essential for the practicing pelvic reconstructive surgeon to make a timely diagnosis, avoid harmful treatments, and initiate therapy early on.
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Khatri G, Bailey AA, Bacsu C, Christie AL, Kumar N, Pedrosa I, Zimmern P. Influence of rectal gel volume on defecation during dynamic pelvic floor magnetic resonance imaging. Clin Imaging 2015; 39:1027-31. [DOI: 10.1016/j.clinimag.2015.05.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 05/02/2015] [Accepted: 05/15/2015] [Indexed: 11/16/2022]
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Prospective Comparison between two different magnetic resonance defecography techniques for evaluating pelvic floor disorders: air-balloon versus gel for rectal filling. Eur Radiol 2015; 26:1783-91. [DOI: 10.1007/s00330-015-4016-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/18/2015] [Accepted: 09/07/2015] [Indexed: 10/23/2022]
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Steele SR, Varma MG, Prichard D, Bharucha AE, Vogler SA, Erdogan A, Rao SS, Lowry AC, Lange EO, Hall GM, Bleier JI, Senagore AJ, Maykel J, Chan SY, Paquette IM, Audett MC, Bastawrous A, Umamaheswaran P, Fleshman JW, Caton G, O’Brien BS, Nelson JM, Steiner A, Garely A, Noor N, Desrosiers L, Kelley R, Jacobson NS. The evolution of evaluation and management of urinary or fecal incontinence and pelvic organ prolapse. Curr Probl Surg 2015; 52:92-136. [DOI: 10.1067/j.cpsurg.2015.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 01/29/2015] [Indexed: 12/23/2022]
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Jodorkovsky D, Macura KJ, Gearhart SL, Dunbar KB, Stein EM, Clarke JO. High-resolution anorectal manometry and dynamic pelvic magnetic resonance imaging are complementary technologies. J Gastroenterol Hepatol 2015; 30:71-4. [PMID: 25088015 DOI: 10.1111/jgh.12697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2014] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Dynamic pelvic magnetic resonance imaging (DP-MRI) offers a comprehensive evaluation of pelvic organ structure in addition to functional information regarding evacuation. Opportunity to apply this technology can be limited due to regional lack of availability. Ideally, clues from standard anorectal testing could predict abnormalities on DP-MRI, leading to its efficient use. The aim of this study is to determine whether high-resolution anorectal manometry (HR-ARM) correlates with findings on DP-MRI. METHODS This is a retrospective study of HR-ARM performed on patients with constipation who also underwent DP-MRI. Studies were reviewed for significant findings including posterior pelvic organ prolapse, rectocele > 3 cm, rectal intussusception, and anorectal angle. Statistical analysis was performed using Pearson's correlation coefficient, Student's t-test, and Fisher's exact test. RESULTS Twenty-three patients undergoing HR-ARM (age range 25-78) also underwent DP-MRI. All were female; 76% were Caucasian. Twenty had significant structural findings: small pelvic prolapse (n = 2), moderate pelvic prolapse (n = 10), large pelvic prolapse (n = 9), rectocele (n = 8), or rectal intussusception (n = 3). Only intrarectal pressure on HR-ARM weakly correlated with size of rectocele (r = 0.46; P = 0.03) and degree of pelvic organ prolapse (r = 0.48; P = 0.02). The remainder of the HR-ARM parameters did not significantly correlate with DP-MRI findings. Patients with dyssynergy were not more likely to have rectoceles > 3 cm (44.4% versus 35.7%; P = 0.5) or large prolapses (44.4% versus 50%, P = 1.0), compared with those without dyssynergy, on HR-ARM. CONCLUSION We were unable to find a correlation between HR-ARM findings and structural pelvic defects on DP-MRI. Therefore, these two technologies provide complementary information in the evaluation of defecatory dysfunction.
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Affiliation(s)
- Daniela Jodorkovsky
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Review of the Diagnosis, Management and Treatment of Fecal Incontinence. Female Pelvic Med Reconstr Surg 2015; 21:8-17. [DOI: 10.1097/spv.0000000000000102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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ACR Appropriateness Criteria pelvic floor dysfunction. J Am Coll Radiol 2014; 12:134-42. [PMID: 25652300 DOI: 10.1016/j.jacr.2014.10.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 10/29/2014] [Indexed: 01/23/2023]
Abstract
Pelvic floor dysfunction is a common and potentially complex condition. Imaging can complement physical examination by revealing clinically occult abnormalities and clarifying the nature of the pelvic floor defects present. Imaging can add value in preoperative management for patients with a complex clinical presentation, and in postoperative management of patients suspected to have recurrent pelvic floor dysfunction or a surgical complication. Imaging findings are only clinically relevant if the patient is symptomatic. Several imaging modalities have a potential role in evaluating patients; the choice of modality depends on the patient's symptoms, the clinical information desired, and the usefulness of the test. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions; they are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals, and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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García del Salto L, de Miguel Criado J, Aguilera del Hoyo LF, Gutiérrez Velasco L, Fraga Rivas P, Manzano Paradela M, Díez Pérez de las Vacas MI, Marco Sanz AG, Fraile Moreno E. MR Imaging–based Assessment of the Female Pelvic Floor. Radiographics 2014; 34:1417-39. [DOI: 10.1148/rg.345140137] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Abstract
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.
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Affiliation(s)
- Gaurav Khatri
- From the Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX
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