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Wu L, Liu Y, Xu P, Yang M. Transperineal pelvic floor ultrasound in male. Int Urol Nephrol 2023; 55:3261-3268. [PMID: 37160487 DOI: 10.1007/s11255-023-03617-x] [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: 02/23/2023] [Accepted: 04/24/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION The pelvic floor (PF) is a highly complex structure which may be affected by various stimulating factors like decreased PF support. As ultrasound can dynamically observe the position and mobility of anatomical structures, However, there are very few studies on PF ultrasound in males. MATERIALS AND METHODS Twenty-one male patients with normal conditions underwent transperineal pelvic floor ultrasound (TPFU) examination. Ultrasound was performed in a supine lithotomy position. The probe was pressed on the sagittal plane of the perineum and adjusted till the anorectal angle, as well as bladder, were located and the median prostate and pubic symphysis were visible on the sagittal plane. TPFU was carried out to observe the patterns of pelvic floor movement during different phases, measure ultrasound parameters of the PF in men, and assess the potential applications and prospects of the male PF. RESULTS Two-dimensional male PF ultrasound can detect the bladder, prostate, male urethra, anus, rectum. Resting, Valsalva, and contraction phases of the PF are clearly shown, the pelvic organs in the Valsalva phase shift to the dorsal foot side, and shift to the cephalic ventral side when the levator ani muscle (LAM) contracts. Three-dimensional male PF ultrasound can visually show the shape and structure of the levator ani muscle hiatus. CONCLUSION It is a feasible examination tool for detecting PF disorders. However, there are still many fields to explore in the future.
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Affiliation(s)
- Lanying Wu
- Department of Ultrasound, Beijing Shijitan Hospital Affiliated to Capital Medical University, No. 10 Tieyi Road, Yangfangdian, Haidian District, Beijing, China
| | - Yong Liu
- Department of Ultrasound, Beijing Shijitan Hospital Affiliated to Capital Medical University, No. 10 Tieyi Road, Yangfangdian, Haidian District, Beijing, China
| | - Ping Xu
- Department of Ultrasound, Beijing Shijitan Hospital Affiliated to Capital Medical University, No. 10 Tieyi Road, Yangfangdian, Haidian District, Beijing, China
| | - Min Yang
- Department of Ultrasound, Beijing Shijitan Hospital Affiliated to Capital Medical University, No. 10 Tieyi Road, Yangfangdian, Haidian District, Beijing, China.
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Sarpietro G, Foti PV, Conte C, Matarazzo MG. Role of Magnetic Resonance Imaging in Pelvic Organ Prolapse Evaluation. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2074. [PMID: 38138177 PMCID: PMC10744532 DOI: 10.3390/medicina59122074] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/27/2023] [Accepted: 11/14/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: The primary method for assessing pelvic floor defects is through physical examination. Magnetic resonance imaging (MRI) is a radiological technique that is useful for identifying the underlying defects of pelvic floor structures that require surgery. The primary aim of this study was to find correspondence between the clinical and radiological staging of pelvic organ prolapse (POP) before and after vaginal surgery. A secondary endpoint was to investigate, through clinical and MRI findings, whether surgery influences continence mechanisms. Finally, we reported changes in the quality of life of women who underwent surgery for prolapse. Materials and Methods: Twenty-five women with prolapse stage ≥ 2 POP-Q were recruited in this prospective study. They underwent preoperative clinical examination, MRI at rest and under the Valsalva maneuver, and quality of life questionnaires. Three months after vaginal surgery, they repeated clinical and radiological evaluation. Results: Twenty women completed the study. Both clinical and MRI evaluations showed an improvement in prolapse and symptoms after surgery. There were some discrepancies between clinical and radiological staging. MRI parameters did not show differences between pre- and postoperative values at rest; under the Valsalva maneuver, instead, the measurements changed after surgery. Continence was not worsened by the widening of the vesicourethral angle. Patients reported an improvement in quality of life. Conclusions: MRI is an accurate and objective method for defining the stage of prolapse, but clinical evaluation alone is sufficient for staging prolapse before surgery and evaluating the result at follow-up. It is an accurate method for visualizing some pelvic structures that can be compromised because of pelvic organ prolapse. MRI showed that vaginal surgery does not affect continence mechanisms.
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Affiliation(s)
- Giuseppe Sarpietro
- Gynecological and Obstetrics Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
| | - Pietro Valerio Foti
- Radiodiagnostic and Radiotherapy Unit, University Hospital “Policlinico-San Marco”, 95123 Catania, Italy;
| | - Carmine Conte
- Department of Woman and Child Health and Public Health, Catholic University of the Sacred Heart, 00168 Rome, Italy;
| | - Maria Grazia Matarazzo
- Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, 95124 Catania, Italy;
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Brillantino A, Iacobellis F, Maglio M, Grillo M, Vicenzo L, Monaco L, Romano L, Renzi A. The Relevance of the Excessive Perineal Descent in the Obstructed Defecation Syndrome: A Prospective Study of 141 Patients. Dis Colon Rectum 2023; 66:1508-1515. [PMID: 36952567 DOI: 10.1097/dcr.0000000000002526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND Despite the widely accepted association between excessive straining and perineal descent, the clinical significance of perineal descent in patients with obstructed defecation syndrome is still unclear. OBJECTIVE This study aimed to evaluate the prevalence of pathological perineal descent in patients with obstructed defecation syndrome and the impact of perineal descent on symptoms severity. DESIGN This was a prospective multicenter uncontrolled study. SETTINGS The study involved 3 hospital pelvic-care centers and was conducted from January 2018 to January 2022. PATIENTS The study included 141 consecutive adult patients with an obstructed defecation syndrome score of 9 or more and no evidence of organic GI pathology. All the patients underwent dynamic pelvic MRI and, in case of suspected paradoxical puborectalis contraction, anal manometry. MAIN OUTCOME MEASURES Main outcome measures were the prevalence of excessive perineal descent and the correlation between perineal descent and obstructed defecation syndrome score. RESULTS One hundred twenty-eight patients (90.7%) completed magnetic resonance examination and were included in the analysis. Of these, 18 patients (14.1%) had a physiological perineal descent and 110 (85.9%) had an excessive perineal descent. Excessive perineal descent was found in 46.1% of patients (12/26) with MRI signs of paradoxical puborectalis contraction and in 96% of patients (98/102) with normal puborectalis relaxation. In this latter group of patients, a good correlation between obstructed defecation syndrome score and maximum perineal descent during straining was found (Spearman r test: 0.68; p < 0.0001). LIMITATIONS The study was limited by the small sample size and by the strong selection of the study population. CONCLUSIONS Excessive perineal descent is a common finding in patients with obstructed defecation syndrome and high symptoms score, occurring almost consistently in patients without paradoxical puborectalis contraction. In these patients, the maximum perineal descent seems to be well correlated with symptoms severity. See Video Abstract at http://links.lww.com/DCR/C135 . LA RELEVANCIA DEL DESCENSO PERINEAL EXCESIVO EN EL SNDROME DE DEFECACIN OBSTRUIDA UN ESTUDIO PROSPECTIVO DE PACIENTES ANTECEDENTES:A pesar de la asociación ampliamente aceptada entre el esfuerzo excesivo y el descenso perineal, la importancia clínica del descenso perineal en pacientes con síndrome de defecación obstruida aún no está clara.OBJETIVO:Evaluar la prevalencia del descenso perineal patológico en pacientes con síndrome de defecación obstruida y el impacto del descenso perineal en la severidad de los síntomas.DISEÑO:Este fue un estudio prospectivo multicéntrico no controladoENTORNO CLINICO:El estudio involucró a tres centros hospitalarios de atención pélvica y se llevó a cabo entre enero de 2018 y enero de 2022.PACIENTES:El estudio incluyó a 141 pacientes adultos consecutivos con puntuación del síndrome de defecación obstruida ≥ 9 y sin evidencia de patología gastrointestinal orgánica. A todas las pacientes se les realizó resonancia magnética pélvica dinámica y, en caso de sospecha de contracción puborrectal paradójica, manometría anal.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado fueron la prevalencia del descenso perineal excesivo y la correlación entre el descenso perineal y la puntuación del síndrome de defecación obstruida.RESULTADOS:Ciento veintiocho (90,7%) pacientes completaron el examen de resonancia magnética y fueron incluidos en el análisis. De estos, 18 (14,1%) presentaron descenso perineal fisiológico y 110 (85,9%) descenso perineal excesivo. Se encontró descenso perineal excesivo en el 46,1% (12/26) de los pacientes con signos de contracción puborrectal paradójica en la resonancia magnética y en el 96% (98/102) de los pacientes con relajación puborrectal normal. En estos últimos pacientes se encontró una buena correlación entre la puntuación del síndrome de defecación obstruida y el descenso perineal máximo durante el esfuerzo (prueba r de Spearman: 0,68; p < 0,0001).LIMITACIONES:El estudio estuvo limitado por el pequeño tamaño de la muestra y por la fuerte selección de la población de estudio.CONCLUSIONES:El descenso perineal excesivo es un hallazgo común en pacientes con síndrome de defecación obstruida y alto puntaje de síntomas, ocurriendo casi constantemente en pacientes sin contracción puborrectal paradójica. En estos últimos pacientes el descenso perineal máximo parece estar bien correlacionado con la severidad de los síntomas. Consulte Video Resumen en http://links.lww.com/DCRC135 . (Traducción- Dr. Francisco M. Abarca-Rendon ).
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Affiliation(s)
- Antonio Brillantino
- Surgery Department, "A. Cardarelli" Hospital, Via A. Cardarelli, Naples, Italy
| | - Francesca Iacobellis
- Radiology Department, "A. Cardarelli" Hospital, Via A. Cardarelli, Naples, Italy
| | - Mauro Maglio
- Surgery Department, "A. Cardarelli" Hospital, Via A. Cardarelli, Naples, Italy
| | - Maurizio Grillo
- Surgery Department, "A. Cardarelli" Hospital, Via A. Cardarelli, Naples, Italy
| | - Luciano Vicenzo
- Surgery Department, "A. Cardarelli" Hospital, Via A. Cardarelli, Naples, Italy
| | - Luigi Monaco
- Surgery Department, "Villa Esther" Hospital, Via Due Principati, Avellino, Italy
| | - Luigia Romano
- Radiology Department, "A. Cardarelli" Hospital, Via A. Cardarelli, Naples, Italy
| | - Adolfo Renzi
- Surgery Department, Ospedale Buonconsiglio Fatebenefratelli, Naples, Italy
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Hainsworth AJ, Premakumar YS, Griffin N, Solanki D, Morris SJ, Ferrari L, Emmanuel A, Taylor S, Schizas AMP, Williams AB. Pelvic floor imaging in asymptomatic subjects. Colorectal Dis 2023; 25:2001-2009. [PMID: 37574701 DOI: 10.1111/codi.16709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 06/08/2023] [Accepted: 06/15/2023] [Indexed: 08/15/2023]
Abstract
AIM The aim of this work was to determine the range of normal imaging features during total pelvic floor ultrasound (TPFUS) (transperineal, transvaginal, endovaginal and endoanal) and defaecation MRI (dMRI). METHOD Twenty asymptomatic female volunteers (mean age 36.5 years) were prospectively investigated with dMRI and TPFUS. Subjects were screened with symptom questionnaires (ICIQ-B, St Mark's faecal incontinence score, obstructed defaecation syndrome score, ICIQ-V, BSAQ). dMRI and TPFUS were performed and interpreted by blinded clinicians according to previously published methods. RESULTS The subjects comprised six parous and 14 nulliparous women, of whom three were postmenopausal. There were three with a rectocoele on both modalities and one with a rectocoele on dMRI only. There was one with intussusception on TPFUS. Two had an enterocoele on both modalities and one on TPFUS only. There were six with a cystocoele on both modalities, one on dMRI only and one on TPFUS only. On dMRI, there were 12 with functional features. Four also displayed functional features on TPFUS. Two displayed functional features on TPFUS only. CONCLUSION This study demonstrates the presence of abnormal findings on dMRI and TPFUS without symptoms. There was a high rate of functional features on dMRI. This series is not large enough to redefine normal parameters but is helpful for appreciating the wide range of findings seen in health.
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Affiliation(s)
- Alison J Hainsworth
- The Pelvic Floor Unit, Colorectal Department, St Thomas' Hospital, London, UK
| | | | - Nyree Griffin
- The Pelvic Floor Unit, Colorectal Department, St Thomas' Hospital, London, UK
| | - Deepa Solanki
- The Pelvic Floor Unit, Colorectal Department, St Thomas' Hospital, London, UK
| | - Samantha J Morris
- The Pelvic Floor Unit, Colorectal Department, St Thomas' Hospital, London, UK
| | - Linda Ferrari
- The Pelvic Floor Unit, Colorectal Department, St Thomas' Hospital, London, UK
| | - Anton Emmanuel
- Neuro-Gastroenterology Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Stuart Taylor
- Radiology Department, University College London Hospitals NHS Foundation Trust, London, UK
| | - Alexis M P Schizas
- The Pelvic Floor Unit, Colorectal Department, St Thomas' Hospital, London, UK
| | - Andrew B Williams
- The Pelvic Floor Unit, Colorectal Department, St Thomas' Hospital, London, UK
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Quantifying the physiologic motions of the pelvic viscera during evacuation in nulligravid asymptomatic women. Int Urogynecol J 2023; 34:535-543. [PMID: 35794274 DOI: 10.1007/s00192-022-05282-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/07/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Pelvic organ prolapse (POP) is often diagnosed during an in-office examination, which looks for motion of the vaginal wall while performing a strain maneuver. It is believed that the pelvic organs in adequately supported women are relatively stationary. This study was aimed at investigating the physiological displacements of pelvic organs using MR defecography. METHODS This prospective cohort study included 19 volunteers. Midsagittal slices representing rest and the maximum movement of the posterior vaginal fornix during three maneuvers were identified. Normalized axes for analysis were defined as the x' (line connecting the inferior-posterior-most point on the pubic symphysis to the anterior edge of the sacrococcygeal joint) and the y' (line orthogonal to the x axis that passed through the sacral promontory). The positions of the posterior vaginal fornix, mid-vagina, bladder neck, anorectal junction, and hymen were recorded. These subjects were then analyzed using the current radiological grading system of POP to determine any overlap between asymptomatic subjects and diagnostic ranges of POP. RESULTS Evacuation caused the most motion in the landmarks. The majority of the motion of the landmarks was along the y axis. The posterior vaginal fornix experienced significant descent (125% of the initial distance) without much anterior-posterior translation (7% of the initial distance) during defecation. All landmarks experienced similar trends. CONCLUSIONS We have shown that there is significant rotational motion of the pelvic organs around the pubic bone in adequately supported women. This motion when described using radiological grading is likely to be considered mild or moderate prolapse, which may contribute to overdiagnosis of POP.
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Ribeiro AM, Nammur LG, Mateus-Vasconcelos ECL, Ferreira CHJ, Muglia VF, de Oliveira HF. Pelvic floor muscles after prostate radiation therapy: morpho-functional assessment by magnetic resonance imaging, surface electromyography and digital anal palpation. Int Braz J Urol 2020; 47:120-130. [PMID: 33047917 PMCID: PMC7712707 DOI: 10.1590/s1677-5538.ibju.2019.0765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 02/12/2020] [Indexed: 11/21/2022] Open
Abstract
Aim: To evaluate the radiotherapy (RT) effect in the pelvic floor muscles (PFM) function in men with prostate cancer (PC). Materials and Methods: A cross-sectional study included three groups of patients with PC and RT indication: 1) Pre-RT group: evaluated before the beginning of RT; 2) Acute group: evaluated between six months and one year after RT; 3) Late Group: evaluated between two and a half years and four years post-RT. PFM assessment was divided into: a) functional assessment through the digital anal palpation (Modified Oxford Scale) and surface electromyography (sEMG) with anal probe; b) anatomical assessment by pelvic magnetic resonance imaging (MRI) with thickness measurements of levator ani muscle and pelvic specific parameters at rest and under Valsalva maneuver. We used Student t test, considering as significant p <0.05. Results: Thirty-three men were assessed: Pre-RT (n=12); Acute (n=10) and Late (n=11) groups. PFM functional assessment showed Late group with lower electromyographic activity, especially in the sustained contractions when compared to the Pre-RT (p=0.003) and Acute groups (p=0.006). There was no significant difference between groups in MRI. Conclusion: PFM functional assessment showed a decrease in sEMG activity in the Late group post-RT. Most of the sample (72.7%) did not know how to actively contract the PFM or had a weak voluntary contraction when assessed by digital anal palpation. Also, these patients presented higher prevalence of pelvic complaints. No changes were observed in the morpho-functional parameters evaluated by MRI, except the measurement of the membranous urethra length when comparing Pre-RT Group and Acute and Late Groups.
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Affiliation(s)
- Aline Moreira Ribeiro
- Departamento de Ciências da Saúde, Curso de Educação Física, Centro Mineiro do Ensino Superior, Campo Belo, MG, Brasil
| | - Larissa Guerra Nammur
- Faculdade de Fisioterapia e Educação Física, Universidade Federal de Uberlândia, Uberlândia, MG, Brasil
| | | | - Cristine Homsi Jorge Ferreira
- Departamento de Biomecânica, Medicina e Reabilitação do Sistema Locomotor, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Valdair Francisco Muglia
- Departamento de Clínica Médica, Divisão de Radiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Harley Francisco de Oliveira
- Departamento de Clínica Médica, Divisão de Radioterapia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
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Development of Upright Computed Tomography With Area Detector for Whole-Body Scans: Phantom Study, Efficacy on Workflow, Effect of Gravity on Human Body, and Potential Clinical Impact. Invest Radiol 2020; 55:73-83. [PMID: 31503082 PMCID: PMC6948833 DOI: 10.1097/rli.0000000000000603] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Multiple human systems are greatly affected by gravity, and many disease symptoms are altered by posture. However, the overall anatomical structure and pathophysiology of the human body while standing has not been thoroughly analyzed due to the limitations of various upright imaging modalities, such as low spatial resolution, low contrast resolution, limited scan range, or long examination time. Recently, we developed an upright computed tomography (CT), which enables whole-torso cross-sectional scanning with 3-dimensional acquisition within 15 seconds. The purpose of this study was to evaluate the performance, workflow efficacy, effects of gravity on a large circulation system and the pelvic floor, and potential clinical impact of upright CT. MATERIALS AND METHODS We compared noise characteristics, spatial resolution, and CT numbers in a phantom between supine and upright CT. Thirty-two asymptomatic volunteers (48.4 ± 11.5 years) prospectively underwent both CT examinations with the same scanning protocols on the same day. We conducted a questionnaire survey among these volunteers who underwent the upright CT examination to determine their opinions regarding the stability of using the pole throughout the acquisition (closed question), as well as safety and comfortability throughout each examination (both used 5-point scales). The total access time (sum of entry time and exit time) and gravity effects on a large circulation system and the pelvic floor were evaluated using the Wilcoxon signed-rank test and the Mann-Whitney U test. For a large circulation system, the areas of the vena cava and aorta were evaluated at 3 points (superior vena cava or ascending aorta, at the level of the diaphragm, and inferior vena cava or abdominal aorta). For the pelvic floor, distances were evaluated from the bladder neck to the pubococcygeal line and the anorectal junction to the pubococcygeal line. We also examined the usefulness of the upright CT in patients with functional diseases of spondylolisthesis, pelvic floor prolapse, and inguinal hernia. RESULTS Noise characteristics, spatial resolution, and CT numbers on upright CT were comparable to those of supine CT. In the volunteer study, all volunteers answered yes regarding the stability of using the pole, and most reported feeling safe (average rating of 4.2) and comfortable (average rating of 3.8) throughout the upright CT examination. The total access time for the upright CT was significantly reduced by 56% in comparison with that of supine CT (upright: 41 ± 9 seconds vs supine: 91 ± 15 seconds, P < 0.001). In the upright position, the area of superior vena cava was 80% smaller than that of the supine position (upright: 39.9 ± 17.4 mm vs supine: 195.4 ± 52.2 mm, P < 0.001), the area at the level of the diaphragm was similar (upright: 428.3 ± 87.9 mm vs supine: 426.1 ± 82.0 mm, P = 0.866), and the area of inferior vena cava was 37% larger (upright: 346.6 ± 96.9 mm vs supine: 252.5 ± 93.1 mm, P < 0.001), whereas the areas of aortas did not significantly differ among the 3 levels. The bladder neck and anorectal junction significantly descended (9.4 ± 6.0 mm and 8.0 ± 5.6 mm, respectively, both P < 0.001) in the standing position, relative to their levels in the supine position. This tendency of the bladder neck to descend was more prominent in women than in men (12.2 ± 5.2 mm in women vs 6.7 ± 5.6 mm in men, P = 0.006). In 3 patients, upright CT revealed lumbar foraminal stenosis, bladder prolapse, and inguinal hernia; moreover, it clarified the grade or clinical significance of the disease in a manner that was not apparent on conventional CT. CONCLUSIONS Upright CT was comparable to supine CT in physical characteristics, and it significantly reduced the access time for examination. Upright CT was useful in clarifying the effect of gravity on the human body: gravity differentially affected the volume and shape of the vena cava, depending on body position. The pelvic floor descended significantly in the standing position, compared with its location in the supine position, and the descent of the bladder neck was more prominent in women than in men. Upright CT could potentially aid in objective diagnosis and determination of the grade or clinical significance of common functional diseases.
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Pelvic floor morphology in the standing position using upright computed tomography: age and sex differences. Int Urogynecol J 2020; 31:2387-2393. [DOI: 10.1007/s00192-020-04335-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/08/2020] [Indexed: 12/14/2022]
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Serra J, Pohl D, Azpiroz F, Chiarioni G, Ducrotté P, Gourcerol G, Hungin APS, Layer P, Mendive JM, Pfeifer J, Rogler G, Scott SM, Simrén M, Whorwell P. European society of neurogastroenterology and motility guidelines on functional constipation in adults. Neurogastroenterol Motil 2020; 32:e13762. [PMID: 31756783 DOI: 10.1111/nmo.13762] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Chronic constipation is a common disorder with a reported prevalence ranging from 3% to 27% in the general population. Several management strategies, including diagnostic tests, empiric treatments, and specific treatments, have been developed. Our aim was to develop European guidelines for the clinical management of constipation. DESIGN After a thorough review of the literature by experts in relevant fields, including gastroenterologists, surgeons, general practitioners, radiologists, and experts in gastrointestinal motility testing from various European countries, a Delphi consensus process was used to produce statements and practical algorithms for the management of chronic constipation. KEY RESULTS Seventy-three final statements were agreed upon after the Delphi process. The level of evidence for most statements was low or very low. A high level of evidence was agreed only for anorectal manometry as a comprehensive evaluation of anorectal function and for treatment with osmotic laxatives, especially polyethylene glycol, the prokinetic drug prucalopride, secretagogues, such as linaclotide and lubiprostone and PAMORAs for the treatment of opioid-induced constipation. However, the level of agreement between the authors was good for most statements (80% or more of the authors). The greatest disagreement was related to the surgical management of constipation. CONCLUSIONS AND INFERENCES European guidelines on chronic constipation, with recommendations and algorithms, were developed by experts. Despite the high level of agreement between the different experts, the level of scientific evidence for most recommendations was low, highlighting the need for future research to increase the evidence and improve treatment outcomes in these patients.
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Affiliation(s)
- Jordi Serra
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain.,Motility and Functional Gut Disorders Unit, University Hospital Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, Autonomous University of Barcelona, Badalona, Spain
| | - Daniel Pohl
- Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland.,Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Fernando Azpiroz
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Giuseppe Chiarioni
- Division of Gastroenterology B, AOUI Verona, Verona, Italy.,UNC Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Philippe Ducrotté
- Department of Gastroenterology, UMR INSERM 1073, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Department of Physiology, UMR INSERM 1073 & CIC INSERM 1404, Rouen University Hospital, Rouen, France
| | - A Pali S Hungin
- General Practice, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Peter Layer
- Department of Medicine, Israelitic Hospital, Hamburg, Germany
| | - Juan-Manuel Mendive
- Sant Adrià de Besòs (Barcelona) Catalan Institut of Health (ICS), La Mina Primary Health Care Centre, Badalona, Spain
| | - Johann Pfeifer
- Department of Surgery, Division of General Surgery, Medical University of Graz, Graz, Austria
| | - Gerhard Rogler
- Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland.,Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - S Mark Scott
- Neurogastroenterology Group, Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts, UK.,The London School of Medicine & Dentistry, Queen Mary University London, London, UK
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Whorwell
- Division of Diabetes, Endocrinology & Gastroenterology, Neurogastroenterology Unit, Wythenshawe Hospital, University of Manchester, Manchester, UK
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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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Komemushi Y, Komemushi A, Morimoto K, Yoneda Y, Yoshimura R, Tanaka T, Katou T, Nakatani T. Quantitative evaluation of age-related changes to pelvic floor muscles in magnetic resonance images from 369 patients. Geriatr Gerontol Int 2019; 19:834-837. [PMID: 31270946 DOI: 10.1111/ggi.13726] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/17/2019] [Accepted: 06/04/2019] [Indexed: 11/28/2022]
Abstract
AIM This study aimed to establish and validate a quantitative evaluation method for pelvic floor muscles using magnetic resonance images (MRI) and to examine the morphological change of pelvic floor muscles with aging. METHODS Data from 369 consecutive patients (163 men, 206 women; median age 58 years; range 17-92 years) who underwent coronal T2-weighted pelvic MRI at Osaka General Hospital between January 2016 and December 2016 were retrospectively examined. MRI of the levator ani muscle was evaluated. The MRI image blinded the patient information and was evaluated by a radiology specialist with 22 years of experience. In coronal T2-weighted MRI of the pelvis, the levator ani muscle was evaluated using the slice; it showed the most upward and downward convexity. We measured the thickness of the levator ani muscle, and the distance at the most convex part from a straight line connecting the origin and insertion of the levator ani muscle on both the left and right sides. Upward and downward convexity was recorded in positive and negative values, respectively. RESULTS The levator ani muscle was able to be evaluated quantitatively in all cases. Both men and women showed thinning (men: mean 3.316 mm, r = -0.388, P < 0.0001; women: mean 3.947 mm, r = -0.359, P < 0.0001) and concavity (men: mean 1.412 mm, r = -0.362, P < 0.0001; women: mean 4.979 mm, r = -0.630, P < 0.0001) of the levator ani muscle with aging. CONCLUSIONS A quantitative evaluation method for pelvic floor muscles using MRI was established. Aging was associated with morphological changes in the pelvic floor muscles in both men and women. Geriatr Gerontol Int 2019; 19: 834-837.
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Affiliation(s)
| | - Atsushi Komemushi
- Department of Radiology, Kansai Medical University Medical Center, Osaka, Japan
| | - Kazuya Morimoto
- Department of Urology, Osaka General Hospital of West Japan Railway Company, Osaka, Japan
| | - Yukio Yoneda
- Department of Urology, Osaka General Hospital of West Japan Railway Company, Osaka, Japan
| | - Rikio Yoshimura
- Department of Urology, Osaka General Hospital of West Japan Railway Company, Osaka, Japan
| | - Tomoaki Tanaka
- Department of Urology, Osaka City University, Osaka, Japan
| | - Takeharu Katou
- Department of Radiology, Osaka General Hospital of West Japan Railway Company, Osaka, Japan
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12
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Grossi U, Di Tanna GL, Heinrich H, Taylor SA, Knowles CH, Scott SM. Systematic review with meta-analysis: defecography should be a first-line diagnostic modality in patients with refractory constipation. Aliment Pharmacol Ther 2018; 48:1186-1201. [PMID: 30417419 DOI: 10.1111/apt.15039] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/16/2018] [Accepted: 10/08/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Defecography is considered the reference standard for the assessment of pelvic floor anatomy and function in patients with a refractory evacuation disorder. However, the overlap of radiologically significant findings seen in patients with chronic constipation (CC) and healthy volunteers is poorly defined. AIM To systematically review rates of structural and functional abnormalities diagnosed by barium defecography and/or magnetic resonance imaging defecography (MRID) in patients with symptoms of CC and in healthy volunteers. METHODS Electronic searches of major databases were performed without date restrictions. RESULTS From a total of 1760 records identified, 175 full-text articles were assessed for eligibility. 63 studies were included providing data on outcomes of 7519 barium defecographies and 668 MRIDs in patients with CC, and 225 barium defecographies and 50 MRIDs in healthy volunteers. Pathological high-grade (Oxford III and IV) intussuscepta and large (>4 cm) rectoceles were diagnosed in 23.7% (95% CI: 16.8-31.4) and 15.9% (10.4-22.2) of patients, respectively. Enterocele and perineal descent were observed in 16.8% (12.7-21.4) and 44.4% (36.2-52.7) of patients, respectively. Barium defecography detected more intussuscepta than MRID (OR: 1.52 [1.12-2.14]; P = 0.009]). Normative data for both barium defecography and MRID structural and functional parameters were limited, particularly for MRID (only one eligible study). CONCLUSIONS Pathological structural abnormalities, as well as functional abnormalities, are common in patients with chronic constipation. Since structural abnormalities cannot be evaluated using nonimaging test modalities (balloon expulsion and anorectal manometry), defecography should be considered the first-line diagnostic test if resources allow.
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Affiliation(s)
- Ugo Grossi
- Centre for Trauma and Surgery, and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Proctology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gian Luca Di Tanna
- Department of Econometrics, Statistics and Applied Economics, Riskcenter - IREA, Universitat de Barcelona, Barcelona, Spain
| | - Henriette Heinrich
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Charles H Knowles
- Centre for Trauma and Surgery, and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - S Mark Scott
- Centre for Trauma and Surgery, and GI Physiology Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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13
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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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14
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Tirumanisetty P, Prichard D, Chakraborty S, Zinsmeister AR, Bharucha AE. Normal values for assessment of anal sphincter morphology, anorectal motion, and pelvic organ prolapse with MRI in healthy women. Neurogastroenterol Motil 2018; 30:e13314. [PMID: 29498141 PMCID: PMC6003834 DOI: 10.1111/nmo.13314] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/20/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoanal MRI and MR defecography are used to identify anal sphincter injury and disordered defecation. However, few studies have evaluated findings in asymptomatic healthy people. The effects of BMI and parity on rectoanal motion and evacuation are unknown. METHODS In 113 asymptomatic females (age 50 ± 17 years, Mean ± SD) without risk factors for anorectal trauma, anal sphincter appearance, anorectal motion, and pelvic organ prolapse were evaluated with MRI. The relationship between age, BMI, and parity and structural findings were evaluated with parametric and non-parametric tests. RESULTS The anal sphincters and puborectalis appeared normal in over 90% of women. During dynamic MRI, the anorectal angle was 100 ± 1º (Mean ± SEM) at rest, 70 ± 2° at squeeze, and 120 ± 2° during defecation. The change in anorectal angle during squeeze (r = -.25, P < .005), but not during evacuation (r = .13, P = .25) was associated with age. In the multivariable models, BMI (P < .01) and parity (P < .01) were, respectively, independently associated with the intersubject variation in the anorectal angle at rest and the angle change during squeeze. Ten percent or fewer women had had descent of the bladder base or uterus 4 cm or more below the pubococcygeal line or a rectocele measuring 4 cm or larger. Only 5% had a patulous anal canal. CONCLUSIONS In addition to age, BMI and parity also affect anorectal motion in asymptomatic women. These findings provide age-adjusted normal values for rectoanal anatomy and pelvic floor motion.
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Affiliation(s)
- Pratyusha Tirumanisetty
- Division of Gastroenterology and Hepatology, Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN
| | - David Prichard
- Division of Gastroenterology and Hepatology, Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Subhankar Chakraborty
- Division of Gastroenterology and Hepatology, Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN
| | | | - Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN
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15
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Abstract
Anal complaints are very common in the general population and are caused by a variety of disorders mostly benign in nature. The aim of this article is to provide the radiologist with a detailed description of the MRI anatomy and technique, and an overview of the various diseases most commonly presenting with anal pain, by descriptions and illustrative examples of MRI features of each entity.
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Affiliation(s)
- Ayşe Erden
- Department of Radiology, School of Medicine, Ankara University, Talatpaşa Bulvarı, Sıhhiye, 06100, Ankara, Turkey.
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16
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Carrington EV, Scott SM, Bharucha A, Mion F, Remes-Troche JM, Malcolm A, Heinrich H, Fox M, Rao SS. Expert consensus document: Advances in the evaluation of anorectal function. Nat Rev Gastroenterol Hepatol 2018; 15:309-323. [PMID: 29636555 PMCID: PMC6028941 DOI: 10.1038/nrgastro.2018.27] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.
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Affiliation(s)
- Emma V. Carrington
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - S. Mark Scott
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - Adil Bharucha
- Department of Gastroenterology and Hepatology, Mayo College of Medicine, Rochester, MN, USA
| | - François Mion
- Exploration Fonctionnelle Digestive, Hospital Edouard Herriot, Hospices Civils de Lyon, Lyon I University and Inserm 1032 LabTAU, Lyon, France
| | - Jose M. Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, México
| | - Allison Malcolm
- Division of Gastroenterology, Royal North Shore Hospital, and University of Sydney, Sydney, Australia
| | - Henriette Heinrich
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - Mark Fox
- Abdominal Center: Gastroenterology, St. Claraspital, Basel, Switzerland
- Clinic for Gastroenterology & Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Satish S. Rao
- Division of Gastroenterology and Hepatology, Augusta University, Augusta, Georgia
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17
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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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18
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Kahokehr AA, Selph JP, Belsante MJ, Bashir M, Sofue K, Tausch TJ, Brand TC, Lloyd JC, Goldsmith ZG, Walter JR, Peterson AC. Mechanism of Action of the Transobturator Sling for Post-Radical Prostatectomy Incontinence: A Multi-institutional Prospective Study Using Dynamic Magnetic Resonance Imaging. Urology 2018; 116:185-192. [PMID: 29567018 DOI: 10.1016/j.urology.2018.01.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/22/2018] [Accepted: 01/27/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare the length of the membranous (functional) urethra in male patients who underwent the male transobturator sling (TOS) for postradical prostatectomy urinary incontinence (PPI). The TOS is in established use for treatment of PPI; however, the precise mechanism of action is unknown. MATERIALS AND METHODS This is a prospective case-controlled study on men undergoing male TOS surgery from 2008 to 2014. The comparison arm included patients without incontinence after radical prostatectomy. All participants underwent dynamic magnetic resonance imaging (MRI) at baseline and this was repeated after TOS placement for those who underwent the procedure. Three standardized points were measured using MRI and compared in both groups in addition to clinical measures. RESULTS Thirty-nine patients were enrolled and 31 patients completed the protocols. The controls (N = 14) had a longer vesicourethral anastomosis to urethra measured at the penile bulb (functional urethral length) distance compared to the pre-TOS group at rest (1.92 cm controls vs 1.27 cm pre-TOS, P = .0018) and at Valsalva (2.13 cm controls vs 1.72 cm pre-TOS, P = .0371). Placement of the sling (N = 17) increased the functional urethral length distance at rest (1.92 cm control vs 1.53 cm post-TOS, P = .09) and at Valsalva (1.94 cm post-TOS vs 2.13 cm control, P = .61), so that the difference was no longer statistically significant. CONCLUSION We identified that one possible mechanism in improvement in stress urinary incontinence post-TOS placement is the lengthening of the vesicourethral anastomosis to bulbar-urethra distance. This is the first such study utilizing dynamics MRI in post prostatectomy controls, incontinent pre-TOS, and post-TOS to assess and show these findings.
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Affiliation(s)
- Arman A Kahokehr
- Division of Urology, Duke University Medical Center, Durham, NC.
| | - John P Selph
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Mustafa Bashir
- Center for Advanced Magnetic Resonance Development, Duke University Medical Center, Durham, NC
| | - Keitaro Sofue
- Center for Advanced Magnetic Resonance Development, Duke University Medical Center, Durham, NC
| | - Timothy J Tausch
- Department of Urology, Walter Reed National Military Medical Center, Bethesda, MD
| | - Timothy C Brand
- Division of Urology, Madigan Army Medical Center, Tacoma, WA
| | - Jessica C Lloyd
- Division of Urology, Duke University Medical Center, Durham, NC
| | | | - Jack R Walter
- Division of Urology, Madigan Army Medical Center, Tacoma, WA
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19
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Naganawa S, Maeda E, Hagiwara A, Amemiya S, Gonoi W, Hanaoka S, Yoshikawa T, Ohtomo K. Vaginal delivery-related changes in the pelvic organ position and vaginal cross-sectional area in the general population. Clin Imaging 2018; 50:86-90. [PMID: 29328961 DOI: 10.1016/j.clinimag.2017.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 12/05/2017] [Accepted: 12/11/2017] [Indexed: 11/20/2022]
Abstract
PURPOSE Evaluate the effect of vaginal delivery on pelvic organ positions and vaginal cross-sectional areas. METHODS MRI of 119 premenopausal women were grouped according to the number of deliveries. The distances from the three 3-reference points (bladder, uterus, and rectum) to two 2-lines (pubococcygeal-line (PCL) and midpubic-line (MPL)), length of H- and M-lines and vaginal cross-sectional area were compared between the groups. RESULTS With increasing parity, distance from the rectum to PCL tended to increase (nullipara vs. bipara; p<0.01). Vaginal cross-sectional area was larger in bipara and tripara than in nullipara (p<0.01). CONCLUSIONS Rectal position is more caudally located and vaginal cross-sectional area is larger in bipara than in nullipara.
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Affiliation(s)
- Shotaro Naganawa
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Eriko Maeda
- Department of Computational Diagnostic Radiology and Preventive Medicine, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Akifumi Hagiwara
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Shiori Amemiya
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Wataru Gonoi
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Shouhei Hanaoka
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Takeharu Yoshikawa
- Department of Computational Diagnostic Radiology and Preventive Medicine, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kuni Ohtomo
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Lockhart ME, Bates GW, Morgan DE, Beasley TM, Richter HE. Dynamic 3T pelvic floor magnetic resonance imaging in women progressing from the nulligravid to the primiparous state. Int Urogynecol J 2017; 29:735-744. [PMID: 28871385 DOI: 10.1007/s00192-017-3462-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/11/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to prospectively characterize dynamic pelvic 3-Tesla magnetic resonance imaging (dp3T MRI) findings in nulligravida women and characterize changes 6 months after delivery in the same woman. METHODS In this prospective study, nulligravida women seeking assisted reproductive technology for pregnancy were recruited. After physical examination by Pelvic Organ Prolapse Quantification (POP-Q), Brink assessment and measures including the Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire-7, pre-pregnancy dp3T MRI at rest, with strain, and evacuation were performed. Assessments were repeated ≥6 months postpartum. Analysis included Welch and paired t tests for continuous variables, Fisher's exact test for differences in categorical outcomes, and paired t tests for postpartum symptoms. RESULTS Nineteen subjects (mean ± SD age, 31 ± 5 years) completed baseline clinical and dp3T MRI studies, 15 delivered and 10 (30.5 ± 3 years) completed pre-pregnancy and post-delivery clinical and dp3T MRI assessments. There were no significant changes in scores of validated questionnaires (all p > 0.05) or on POP-Q measures post-delivery. Two (20%) subjects without pre-pregnancy levator tears had tears on MRI post-delivery. MRI measures of pelvic organ descent were increased post-delivery. Seventeen pelvic soft-tissue parameters increased by greater than 10% post-delivery, including 5 out of 70 (7.1%), 17 out of 110 (15.5%), and 50 out of 110 (45.5%) values exceeding thresholds at rest, strain, and evacuation respectively. CONCLUSIONS Dynamic pelvic 3T MRI detected levator tears and increased pelvic organ descent, which can be directly attributed to pregnancy and delivery.
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Affiliation(s)
- Mark E Lockhart
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - G Wright Bates
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Desiree E Morgan
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Timothy M Beasley
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA. .,Division Urogynecology and Pelvic Reconstructive Surgery, Department Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, 35249, USA.
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Al-Najar MS, Ghanem AF, AlRyalat SAS, Al-Ryalat NT, Alhajahjeh SO. The usefulness of MR defecography in the evaluation of pelvic floor dysfunction: our experience using 3T MRI. Abdom Radiol (NY) 2017; 42:2219-2224. [PMID: 28386692 DOI: 10.1007/s00261-017-1130-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess the usefulness of MR defecography in evaluating pelvic floor dysfunction, and to correlate several pelvic organ abnormalities with each other and with patients' symptoms and characteristics. METHODS MR defecographic examinations performed in 3T MRI machine of 95 patients (70 females, 25 males; mean age 48) were retrospectively reviewed. Pelvic organ abnormalities from all three compartments were recorded, including the anorectal junction descent, anterior rectocele, and cystocele. These were graded according to the known HMO system in relation to the pubococcygeal line. The correlation between these different abnormalities and their relation to patient symptoms and characteristics were evaluated. RESULTS Anorectal junction descent and anterior rectocele were most commonly observed, predominantly manifesting in female patients. Both were associated with abnormalities from all compartments. The middle compartment was the least affected, and its abnormality of uterine/vaginal descent tended to occur in association with the anterior compartment abnormality (cystocele). Anismus was low in incidence, and was not associated with other compartments abnormalities. Both enterocele/peritoneocele and intussusception were uncommon. CONCLUSION MR defecography is the modality of choice in assessing pelvic floor dysfunction, because it can neatly show various pelvic organ abnormalities from all compartments in a dynamic fashion, which are frequently coexistent. It can even show clinically silent or unsuspected abnormalities which can impact the management of patients.
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Affiliation(s)
- Mahasen S Al-Najar
- Radiology Department, The University of Jordan Hospital, Queen Rania Street, P. O. Box 13046, Amman, 11942, Jordan.
| | - Ahmed F Ghanem
- Radiology Department, The University of Jordan Hospital, Queen Rania Street, P. O. Box 13046, Amman, 11942, Jordan
| | | | - Nosaiba T Al-Ryalat
- Radiology Department, The University of Jordan Hospital, Queen Rania Street, P. O. Box 13046, Amman, 11942, Jordan
| | - Sultan O Alhajahjeh
- Radiology Department, The University of Jordan Hospital, Queen Rania Street, P. O. Box 13046, Amman, 11942, Jordan
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El Sayed RF, Alt CD, Maccioni F, Meissnitzer M, Masselli G, Manganaro L, Vinci V, Weishaupt D. Magnetic resonance imaging of pelvic floor dysfunction - joint recommendations of the ESUR and ESGAR Pelvic Floor Working Group. Eur Radiol 2017; 27:2067-2085. [PMID: 27488850 PMCID: PMC5374191 DOI: 10.1007/s00330-016-4471-7] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 05/03/2016] [Accepted: 05/11/2016] [Indexed: 12/05/2022]
Abstract
OBJECTIVE To develop recommendations that can be used as guidance for standardized approach regarding indications, patient preparation, sequences acquisition, interpretation and reporting of magnetic resonance imaging (MRI) for diagnosis and grading of pelvic floor dysfunction (PFD). METHODS The technique included critical literature between 1993 and 2013 and expert consensus about MRI protocols by the pelvic floor-imaging working group of the European Society of Urogenital Radiology (ESUR) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) from one Egyptian and seven European institutions. Data collection and analysis were achieved in 5 consecutive steps. Eighty-two items were scored to be eligible for further analysis and scaling. Agreement of at least 80 % was defined as consensus finding. RESULTS Consensus was reached for 88 % of 82 items. Recommended reporting template should include two main sections for measurements and grading. The pubococcygeal line (PCL) is recommended as the reference line to measure pelvic organ prolapse. The recommended grading scheme is the "Rule of three" for Pelvic Organ Prolapse (POP), while a rectocele and ARJ descent each has its specific grading system. CONCLUSION This literature review and expert consensus recommendations can be used as guidance for MR imaging and reporting of PFD. KEY POINTS • These recommendations highlight the most important prerequisites to obtain a diagnostic PFD-MRI. • Static, dynamic and evacuation sequences should be generally performed for PFD evaluation. • The recommendations were constructed through consensus among 13 radiologists from 8 institutions.
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Affiliation(s)
- Rania Farouk El Sayed
- Genitourinary & Pelvic Floor MR Imaging Unit, Department of Radiology, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt.
| | - Celine D Alt
- Department of Diagnostic and Interventional Radiology, University Dusseldorf, Medical Faculty, Duesseldorf, Germany
| | - Francesca Maccioni
- Department of Radiological Sciences, Oncology and Pathology Policlinico Umberto I Hospital, Sapienza University Rome, Viale Regina Elena, Rome, Italy
| | - Matthias Meissnitzer
- Department of Radiology, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Gabriele Masselli
- Department of Radiology Dea, Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | - Lucia Manganaro
- Department of Radiological Sciences, Policlinico Umberto I Hospital, Sapienza University of Rome, Viale Regina Elena, Rome, Italy
| | - Valeria Vinci
- Department of Radiological Sciences, Policlinico Umberto I Hospital, Sapienza University of Rome, Viale Regina Elena, Rome, Italy
| | - Dominik Weishaupt
- Institute of Radiology and Nuclear Medicine, Triemli Hospital Zurich, Zurich, Switzerland
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Magnetic Resonance Imaging of Female Pelvic Floor Dysfunction: A Review of Dynamic MRI Defecography. CURRENT RADIOLOGY REPORTS 2017. [DOI: 10.1007/s40134-017-0217-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTıVE: To compare the morphometric data relating to the muscular structures of the anal canal, in patients with chronic anal fissure and in control group, examined at a 3.0 Tesla MR system. SUBJECTS AND METHODS Forty-seven consecutive patients with chronic anal fissure and randomly selected 40 patients who had no claims for perianal disease during their life time were included in the study. T2-weighted sagittal, high-resolution (HR) T2-weighted, and contrast-enhanced fat-suppressed T1-weighted oblique axial and oblique coronal images were retrospectively analyzed by two observers in consensus. Thickness of sphincteric muscles, anal canal length, anorectal angle, thickness of anococcygeal ligament, depth of Minor triangle, width between subcutaneous sphincters, vascularity of posterior commissure, visibility of posterosuperior projection of external sphincter, and angle between the distal anal canal and posterosuperior projection of external sphincter (H angle) in patients and in controls were compared and analyzed using t test, Mann-Whitney U test, and Spearman correlation. RESULTS The patients with chronic anal fissure had longer anal canal (51.50 mm ± 0.91 vs. 44.11 mm ± 0.71; p = 0.000), thicker internal anal sphincter muscle at mid-anal level (4.18 ± 0.15 vs. 3.39 ± 0.07; p = 0.007), and wider space between subcutaneous external sphincters (11.39 ± 0.50 vs. 6.89 ± 0.22; p = 0.000). In patients, there was a positive correlation between H angle and external sphincter thickness at proximal (r = 0.347; p = 0.021), middle (r = 0427; p = 0.000), and distal (r = 0.518; p = 0.000)) levels of the anal canal. CONCLUSıON: 3.0 Tesla MR imaging provides detailed information about the morphometric changes in the anal sphincter muscles in patients with chronic anal fissure.
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van Iersel JJ, Formijne Jonkers HA, Verheijen PM, Broeders IAMJ, Heggelman BGF, Sreetharan V, Fütterer JJ, Somers I, van der Leest M, Consten ECJ. Comparison of dynamic magnetic resonance defaecography with rectal contrast and conventional defaecography for posterior pelvic floor compartment prolapse. Colorectal Dis 2017; 19:O46-O53. [PMID: 27870169 DOI: 10.1111/codi.13563] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 09/20/2016] [Indexed: 12/14/2022]
Abstract
AIM This study compared the diagnostic capabilities of dynamic magnetic resonance defaecography (D-MRI) with conventional defaecography (CD, reference standard) in patients with symptoms of prolapse of the posterior compartment of the pelvic floor. METHOD Forty-five consecutive patients underwent CD and D-MRI. Outcome measures were the presence or absence of rectocele, enterocele, intussusception, rectal prolapse and the descent of the anorectal junction on straining, measured in millimetres. Cohen's Kappa, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and the positive and negative likelihood ratio of D-MRI were compared with CD. Cohen's Kappa and Pearson's correlation coefficient were calculated and regression analysis was performed to determine inter-observer agreement. RESULTS Forty-one patients were available for analysis. D-MRI underreported rectocele formation with a difference in prevalence (CD 77.8% vs D-MRI 55.6%), mean protrusion (26.4 vs 22.7 mm, P = 0.039) and 11 false negative results, giving a low sensitivity of 0.62 and a NPV of 0.31. For the diagnosis of enterocele, D-MRI was inferior to CD, with five false negative results, giving a low sensitivity of 0.17 and high specificity (1.0) and PPV (1.0). Nine false positive intussusceptions were seen on D-MRI with only two missed. CONCLUSION The accuracy of D-MRI for diagnosing rectocele and enterocele is less than that of CD. D-MRI, however, appears superior to CD in identifying intussusception. D-MRI and CD are complementary imaging techniques in the evaluation of patients with symptoms of prolapse of the posterior compartment.
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Affiliation(s)
- J J van Iersel
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.,Institute of Technical Medicine, Twente University, Enschede, The Netherlands
| | | | - P M Verheijen
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - I A M J Broeders
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.,Institute of Technical Medicine, Twente University, Enschede, The Netherlands
| | - B G F Heggelman
- Department of Radiology, Meander Medical Centre, Amersfoort, The Netherlands
| | - V Sreetharan
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | - J J Fütterer
- Department of Radiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.,MIRA, Twente University, Enschede, The Netherlands
| | - I Somers
- Department of Radiology, Meander Medical Centre, Amersfoort, The Netherlands
| | - M van der Leest
- Department of Radiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - E C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
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Cimsit C, Yoldemir T, Akpinar IN. Prevalence of dynamic magnetic resonance imaging-identified pelvic organ prolapse in pre- and postmenopausal women without clinically evident pelvic organ descent. Acta Radiol 2016; 57:1418-1424. [PMID: 26041768 DOI: 10.1177/0284185115589123] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Dynamic magnetic resonance imaging (dMRI) is an imaging tool that can be used to evaluate and stage pelvic organ prolapse (POP). Greater understanding of the incidental detection of POP in asymptomatic patients is needed. Purpose To evaluate the prevalence of dMRI-detected POP in pre-and postmenopausal women who were imaged for reasons unrelated to pelvic floor dysfunction. Material and Methods A total of 227 women who had diagnoses that did not include POP underwent abdominal/pelvic dMRI. Patients with a positive gynecological examination for or a clinical history of POP ( n = 11), hysterectomy ( n = 4), or gynecologic-oncology surgery ( n = 2) were excluded, as well as patients who were unable to strain during MRI ( n = 11). A total of 199 patients without visible prolapse were enrolled in the study. An H-line, M-line, pubococcygeal line (PCL), and mid-pubic line (MPL) were used to detect and grade prolapse. Results The prevalence of dMRI-identified POP was higher in postmenopausal subjects. The PCL led to a greater frequency of prolapse detection than the MPL. The frequency of middle compartment descent was similar regardless of whether the PCL or MPL was used as a reference line. There was a higher incidence of prolapse in the posterior compartment. Using an H-line and PCL as references, the anterior and posterior compartments were found to significantly differ between pre- and postmenopausal subjects. The MRI parameters that were used to define POP were not correlated with parity, vaginal birth, BMI, or fetal birth weight. With respect to the MPL, age was correlated with both the presence of an elongated H-line and with descent. Conclusion Dynamic MRI identified incidental pelvic organ prolapse in asymptomatic patients. The prevalence of dMRI-detected POP was higher in postmenopausal women without visible prolapse. These findings suggest the need for further studies to identify how to modify the currently used dMRI thresholds for postmenopausal women.
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Affiliation(s)
- Canan Cimsit
- Department of Radiology, Marmara University Training and Research Hospital, Istanbul, Turkey
| | - Tevfik Yoldemir
- Department of Obstetrics and Gynaecology, Marmara University Training and Research Hospital, Istanbul, Turkey
| | - Ihsan Nuri Akpinar
- Department of Radiology, Marmara University Training and Research Hospital, Istanbul, Turkey
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Lone F, Sultan AH, Stankiewicz A, Thakar R. Interobserver agreement of multicompartment ultrasound in the assessment of pelvic floor anatomy. Br J Radiol 2016; 89:20150704. [PMID: 26800394 DOI: 10.1259/bjr.20150704] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess the interobserver agreement of pelvic floor anatomical measurements using multicompartment pelvic floor ultrasound. METHODS Females were recruited from the urogynaecology/gynaecology clinics between July and October 2009 and underwent multicompartment pelvic floor ultrasonography (PFUS) using two-dimensional (2D) transperineal ultrasound (TPUS), high-frequency 2D/three-dimensional (3D) endovaginal ultrasound (EVUS) using a biplane probe with linear and transverse arrays and a 360° rotational 3D-EVUS. PFUS measurements were independently analysed by two clinicians. RESULTS 158 females had PFUS assessment. Good-to-excellent interobserver agreement was observed for bladder-symphysis distance at rest and valsalva, urethral thickness, urethral length, urethral volume, levator hiatus area and width, anteroposterior diameter and anorectal angle. Lins Correlation was used to calculate the interobserver agreement and Bland-Altman plots were created to demonstrate the agreement between the researchers. There was also a good-to-excellent agreement between the two clinicians for the assessment of pelvic organ prolapse (POP) in the anterior, middle and posterior compartment. CONCLUSION Multicompartment PFUS is a reliable tool in the anatomical assessment of pelvic floor measurements and POP. ADVANCES IN KNOWLEDGE We found a good-to-excellent agreement between the two assessors in the assessment of pelvic floor measurements for all three pelvic floor compartments and suggest that multicompartment PFUS could be considered as a systematic integrated approach to assess the pelvic floor.
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Affiliation(s)
- Farah Lone
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London, UK
| | - Abdul H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London, UK
| | | | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London, UK
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Iacobellis F, Brillantino A, Renzi A, Monaco L, Serra N, Feragalli B, Iacomino A, Brunese L, Cappabianca S. MR Imaging in Diagnosis of Pelvic Floor Descent: Supine versus Sitting Position. Gastroenterol Res Pract 2016; 2016:6594152. [PMID: 26880893 PMCID: PMC4737448 DOI: 10.1155/2016/6594152] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/13/2015] [Indexed: 12/31/2022] Open
Abstract
Introduction. Functional disorders of the pelvic floor represent have a significant impact on the quality of life. The advent of open-configuration systems allowed for the evaluation of defecation with MR imaging in sitting position. The purpose of the present study is to compare the results of static and dynamic pelvic MR performed in supine position versus sitting position, using a new MR prototype machine, in the diagnosis of pelvic floor descent. Materials and Methods. Thirty-one patients with pelvic floor disorders were enrolled, and underwent MR Defecography in supine position with 1.5 T closed magnet (MAGNETOM Symphony, Siemens, Germany) and in sitting position with a 0.25-Tesla open magnet system (G-Scan ESAOTE, Italy). Results. In rest and squeezing phases, positions of bladder, vagina, and ARJ were significantly different when the patient was imaged in supine versus sitting position. In the defecation phase, a significant difference for the bladder and vagina position was detected between the two exams whereas a significant difference for the ARJ was not found. A statistically significant difference exists when the pelvic floor descent is evaluated in sitting versus supine position. Conclusion. Our results show that MR Defecography in sitting position may represent a useful tool to correctly diagnose and grade the pelvic organ descent.
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Affiliation(s)
- Francesca Iacobellis
- Department of Radiology, Second University of Naples, Piazza Miraglia 2, 80138 Napoli, Italy
| | - Antonio Brillantino
- “Villa delle Querce” Hospital, Via Battistello Caracciolo 48, 80136 Napoli, Italy
| | - Adolfo Renzi
- “Villa delle Querce” Hospital, Via Battistello Caracciolo 48, 80136 Napoli, Italy
| | - Luigi Monaco
- “Villa Esther” Hospital, Via Due Principati 169, 83100 Avellino, Italy
| | - Nicola Serra
- Department of Radiology, Second University of Naples, Piazza Miraglia 2, 80138 Napoli, Italy
| | - Beatrice Feragalli
- Department of Medical, Oral and Biotechnological Sciences, “G. D'Annunzio” University, Via dei Vestini, 66013 Chieti, Italy
| | - Aniello Iacomino
- Department of Radiology, Second University of Naples, Piazza Miraglia 2, 80138 Napoli, Italy
| | - Luca Brunese
- Department of Health Science, University of Molise, Viale Giovanni Paolo II 1, 86100 Campobasso, Italy
| | - Salvatore Cappabianca
- Department of Radiology, Second University of Naples, Piazza Miraglia 2, 80138 Napoli, Italy
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Macura KJ, Thompson RE, Bluemke DA, Genadry R. Magnetic resonance imaging in assessment of stress urinary incontinence in women: Parameters differentiating urethral hypermobility and intrinsic sphincter deficiency. World J Radiol 2015; 7:394-404. [PMID: 26644825 PMCID: PMC4663378 DOI: 10.4329/wjr.v7.i11.394] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/22/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To define the magnetic resonance imaging (MRI) parameters differentiating urethral hypermobility (UH) and intrinsic sphincter deficiency (ISD) in women with stress urinary incontinence (SUI).
METHODS: The static and dynamic MR images of 21 patients with SUI were correlated to urodynamic (UD) findings and compared to those of 10 continent controls. For the assessment of the urethra and integrity of the urethral support structures, we applied the high-resolution endocavitary MRI, such as intraurethral MRI, endovaginal or endorectal MRI. For the functional imaging of the urethral support, we performed dynamic MRI with the pelvic phased array coil. We assessed the following MRI parameters in both the patient and the volunteer groups: (1) urethral angle; (2) bladder neck descent; (3) status of the periurethral ligaments, (4) vaginal shape; (5) urethral sphincter integrity, length and muscle thickness at mid urethra; (6) bladder neck funneling; (7) status of the puborectalis muscle; (8) pubo-vaginal distance. UDs parameters were assessed in the patient study group as follows: (1) urethral mobility angle on Q-tip test; (2) Valsalva leak point pressure (VLPP) measured at 250 cc bladder volume; and (3) maximum urethral closure pressure (MUCP). The UH type of SUI was defined with the Q-tip test angle over 30 degrees, and VLPP pressure over 60 cm H2O. The ISD incontinence was defined with MUCP pressure below 20 cm H2O, and VLPP pressure less or equal to 60 cm H2O. We considered the associations between the MRI and clinical data and UDs using a variety of statistical tools to include linear regression, multivariate logistic regression and receiver operating characteristic (ROC) analysis. All statistical analyses were performed using STATA version 9.0 (StataCorp LP, College Station, TX).
RESULTS: In the incontinent group, 52% have history of vaginal delivery trauma as compared to none in control group (P < 0.001). There was no difference between the continent volunteers and incontinent patients in body habitus as assessed by the body mass index. Pubovaginal distance and periurethral ligament disruption are significantly associated with incontinence; periurethral ligament symmetricity reduces the odds of incontinence by 87%. Bladder neck funneling and length of the suprapubic urethral sphincter are significantly associated with the type of incontinence on UDs; funneling reduced the odds of pure UH by almost 95%; increasing suprapubic urethral sphincter length at rest is highly associated with UH. Both MRI variables result in a predictive model for UDs diagnosis (area under the ROC = 0.944).
CONCLUSION: MRI may play an important role in assessing the contribution of hypermobility and sphincteric dysfunction to the SUI in women when considering treatment options.
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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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Onal S, Lai-Yuen S, Bao P, Weitzenfeld A, Hogue D, Hart S. Quantitative assessment of new MRI-based measurements to differentiate low and high stages of pelvic organ prolapse using support vector machines. Int Urogynecol J 2014; 26:707-13. [PMID: 25429825 DOI: 10.1007/s00192-014-2582-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 11/10/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective of this study was to quantitatively assess the ability of new MRI-based measurements to differentiate low and high stages of pelvic organ prolapse. New measurements representing pelvic structural characteristics are proposed and analyzed using support vector machines (SVM). METHODS This retrospective study used data from 207 women with different types and stages of prolapse. Their demographic information, clinical history, and dynamic MRI data were obtained from the database. New MRI measurements were extracted and analyzed based on these reference lines: pubococcygeal line (PCL), mid-pubic line (MPL), true conjugate line (TCL), obstetric conjugate line (OCL), and diagonal conjugate line (DCL). A classification model using SVM was designed to assess the impact of the features (variables) in classifying prolapse into low or high stage. RESULTS The classification model using SVM can accurately identified anterior prolapse with very high accuracy (>0.90), and apical and posterior prolapse with good accuracy (0.80 - 0.90). Two newly proposed MRI-based features were found to be significant in the identification of anterior and posterior prolapse: the angle between TCL and MPL for anterior prolapse, and the angle between DCL and PCL for posterior prolapse. The overall accuracy of posterior prolapse identification increased from 47% to 80% when the newly proposed MRI-based features were taken into consideration. CONCLUSIONS The proposed MRI-based measurements are effective in differentiating low and high stages of pelvic organ prolapse, particularly for posterior prolapse.
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Affiliation(s)
- S Onal
- Department of Mechanical and Industrial Engineering, Southern Illinois University-Edwardsville, Edwardsville, IL, USA
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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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Pizzoferrato AC, Nyangoh Timoh K, Fritel X, Zareski E, Bader G, Fauconnier A. Dynamic Magnetic Resonance Imaging and pelvic floor disorders: how and when? Eur J Obstet Gynecol Reprod Biol 2014; 181:259-66. [PMID: 25212114 DOI: 10.1016/j.ejogrb.2014.07.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 07/11/2014] [Accepted: 07/20/2014] [Indexed: 11/29/2022]
Abstract
Pelvic Floor Disorders (PFD) are a major public health problem in the world and decrease seriously the patient's quality of life. In case of recurrence after surgery or complex prolapse, imaging techniques can be used. Dynamic MRI, introduced in the early 1990s, offers information of the four compartments of the pelvis with a high resolution and a direct visualization of muscles and fascias in multiple planes. But for a practical use, such an expensive exam should be well correlated to symptoms and clinical examination or change surgical approach. The aim of our review was to precise the evidence regarding techniques, and indication of dynamic MRI in the assessment of pelvic floor disorders in daily practice. The first part is a review of available studies on methods of carrying out the dynamic MRI. The second part consists on the comparison of dynamic MRI to other assessment methods in case of pelvic floor disorders. Results emphasize the lack of strong level studies about the interest of dynamic MRI in the diagnosis and surgical management of pelvic organ prolapse. Although dynamic MRI appears highly reproducible between examiners, especially for the anterior compartment, its correlation with the degree of prolapse or the symptoms appears low. The most interesting field of application seems the detection of levator ani (LA) avulsion with a higher risk of prolapse and recidive in case of LA defects. More prospective, randomized, comparative studies have to be done.
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Affiliation(s)
- Anne-Cécile Pizzoferrato
- Department of Gynaecology and Obstetrics, Intercommunal Hospital Center of Poissy-Saint-Germain-en-Laye, Poissy, France; Research Unit EA7285, Risk and Safety in Clinical Medicine for Women and Perinatal Health, Université Versailles St-Quentin, Montigny-le-Bretonneux, France.
| | - Krystel Nyangoh Timoh
- Department of Gynaecology and Obstetrics, Intercommunal Hospital Center of Poissy-Saint-Germain-en-Laye, Poissy, France
| | - Xavier Fritel
- Poitiers University, INSERM CIC1402, University Hospital of Poitiers, Poitiers, France
| | - Elise Zareski
- Department of Gynaecology and Obstetrics, Intercommunal Hospital Center of Poissy-Saint-Germain-en-Laye, Poissy, France
| | - Georges Bader
- Department of Gynaecology and Obstetrics, Intercommunal Hospital Center of Poissy-Saint-Germain-en-Laye, Poissy, France
| | - Arnaud Fauconnier
- Department of Gynaecology and Obstetrics, Intercommunal Hospital Center of Poissy-Saint-Germain-en-Laye, Poissy, France; Research Unit EA7285, Risk and Safety in Clinical Medicine for Women and Perinatal Health, Université Versailles St-Quentin, Montigny-le-Bretonneux, France
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Prevalence of pelvic organ prolapse detected at dynamic MRI in women without history of pelvic floor dysfunction: Comparison of two reference lines. Clin Radiol 2014; 69:e71-7. [DOI: 10.1016/j.crad.2013.09.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Revised: 09/09/2013] [Accepted: 09/20/2013] [Indexed: 11/23/2022]
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Onal S, Lai-Yuen S, Bao P, Weitzenfeld A, Greene K, Kedar R, Hart S. Assessment of a semiautomated pelvic floor measurement model for evaluating pelvic organ prolapse on MRI. Int Urogynecol J 2014; 25:767-73. [PMID: 24429795 DOI: 10.1007/s00192-013-2287-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 11/18/2013] [Indexed: 10/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective of this study was to assess the performance of a semiautomated pelvic floor measurement algorithmic model on dynamic magnetic resonance imaging (MRI) images compared with manual pelvic floor measurements for pelvic organ prolapse (POP) evaluation. METHODS We examined 15 MRIs along the midsagittal view. Five reference points used for pelvic floor measurements were identified both manually and using our semiautomated measurement model. The two processes were compared in terms of accuracy and precision. RESULTS The semiautomated pelvic floor measurement model provided highly consistent and accurate locations for all reference points on MRI. Results also showed that the model can identify the reference points faster than the manual-point identification process. CONCLUSION The semiautomated pelvic floor measurement model can be used to facilitate and improve the process of pelvic floor measurements on MRI. This will enable high throughput analysis of MRI data to improve the correlation analysis with clinical outcomes and potentially improve POP assessment.
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Affiliation(s)
- S Onal
- Department of Industrial & Management Systems Engineering, University of South Florida, 4202 East Fowler Avenue, ENB 118, Tampa, FL, 33620, USA,
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Abstract
Pelvic floor dysfunction is largely a complex problem of multiparous and postmenopausal women and is associated with pelvic floor or organ descent. Physical examination can underestimate the extent of the dysfunction and misdiagnose the disorders. Functional magnetic resonance (MR) imaging is emerging as a promising tool to evaluate the dynamics of the pelvic floor and use for surgical triage and operative planning. This article reviews the anatomy and pathology of pelvic floor dysfunction, typical imaging findings, and the current role of functional MR imaging.
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STEWARD MJ, TAYLOR SA, BRUNELL C. Advances in MRI assessment of pelvic floor structure and function: a review. IMAGING 2013. [DOI: 10.1259/imaging.20100059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Assessment of levator ani morphology and function in asymptomatic nulliparous women via static and dynamic magnetic resonance imaging. Int J Gynaecol Obstet 2013; 121:233-9. [PMID: 23518136 DOI: 10.1016/j.ijgo.2013.01.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 01/15/2013] [Accepted: 02/21/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate levator ani morphology and function in healthy nulliparous women using static and dynamic magnetic resonance imaging. METHODS Eighty asymptomatic, healthy nulliparous Chinese women (mean age, 25.3±3.5years) volunteered for the present study. Static T2-weighted fast spin-echo images were employed to evaluate levator ani morphology; dynamic T2-weighted fast imaging employing steady-state acquisition was used to evaluate its function. A 2 samples t test was employed to compare groups. RESULTS No morphologic abnormality was detected in the 80 healthy nulliparous women. However, 15% (12/80) of women had various degrees of pelvic organ descent below the pubococcygeal line. In these women, the width of the pubic portion of the levator ani was significantly reduced during straining, whereas the levator plate angle, the levator hiatus area, and the H and M line lengths were enlarged. These changes were associated with weakened levator ani function and pelvic floor laxity. CONCLUSION Functional abnormality of the levator ani muscle was noted in nulliparous women at static and dynamic magnetic resonance imaging. Further follow-up investigation is needed to confirm whether women with functional abnormality are more likely to develop a prolapse after vaginal birth.
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Campbell AM, Murphy J, Charlesworth PB, Bhan C, Jarvi K, Power N, Ward HC, Williams NS. Dynamic MRI (dMRI) as a guide to therapy in children and adolescents with persistent full thickness rectal prolapse: a single centre review. J Pediatr Surg 2013; 48:607-13. [PMID: 23480920 DOI: 10.1016/j.jpedsurg.2012.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 07/22/2012] [Accepted: 08/02/2012] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Full thickness rectal prolapse (FTRP) tends to be self-limiting in children and is usually managed expectantly. However, it may persist and therefore requires surgical correction. There is no consensus upon operative management, and no one procedure has uniformly good outcomes. The aim of this study was to determine whether pre-operative diagnostic dMRI findings might help identify the operative approach best suited to the anatomical abnormality of the individual child. METHODS A retrospective review of ten children with persistent FTRP who had been evaluated pre-operatively with dMRI between 2002 and 2010 was performed. In this preliminary work, MRI findings were not used to direct surgical management. Data collected included: age at presentation, underlying medical conditions, timing and findings of dMRI (specifically, descent of rectum from pubococcygeal (PC) line on straining), timing and type of surgery, surgical outcomes, and length of follow-up. RESULTS Ten children (two female) with a median age of 11 years 2 months (range 8-15 years) with FTRP refractory to conservative treatment underwent diagnostic pre-operative dMRI. Median perineal descent from PC line on straining during dMRI was 3.5 cm (range 1-4 cm). Three of the seven children with severe descent initially underwent a Delorme's procedure, and all required surgical revision. Five with severe descent and one with moderate descent achieved a cure following rectopexy. Two patients with mild descent underwent a Delorme's procedure. One achieved a cure, and the other developed recurrence. Of the ten patients, seven had no prolapse at the last clinic review, and three have persisting symptoms. Median follow-up was 3.5 years (range 1-6). CONCLUSION The findings from this small study favour rectal suspension techniques for surgical management of moderate to severe perineal descent on dMRI. Delorme's procedure should only be applied to those with mild descent. Pre-operative dMRI assessment may have a potential role in guiding surgical intervention for children. However, future prospective studies will be required to confirm this assertion.
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Maccioni F. Functional disorders of the ano-rectal compartment of the pelvic floor: clinical and diagnostic value of dynamic MRI. ACTA ACUST UNITED AC 2012; 38:930-51. [DOI: 10.1007/s00261-012-9955-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Farouk El Sayed R. The urogynecological side of pelvic floor MRI: the clinician’s needs and the radiologist’s role. ACTA ACUST UNITED AC 2012; 38:912-29. [DOI: 10.1007/s00261-012-9905-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Patients with congenital and acquired neurogenic bladder dysfunction due to central and peripheral nervous lesions are significantly limited in their daily lives. The neurogenic dysfunction of the bladder and lower urinary tract are often misinterpreted and later fed to a diagnosis. Without therapy severe complications, including renal damage, could be the consequence in the follow up. Therefore, dedicated diagnostics have to be done to recognize the different disorders and to determine the specific therapy. For these patients a lifelong bladder monitoring and neuro-urological management is necessary. This article describes techniques of neuro-urological testings and the interpretation in case of neurogenic disorders.
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Dynamic anal endosonography and MRI defecography in diagnosis of pelvic floor disorders: comparison with conventional defecography. Dis Colon Rectum 2011; 54:1398-404. [PMID: 21979185 DOI: 10.1097/dcr.0b013e31822e89bc] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pelvic floor disorders are frequent, especially in women. Surgeons need more information on the accuracy of available diagnostic techniques to make therapeutic decisions. OBJECTIVE This study aimed to compare the accuracy of dynamic anorectal endosonography and dynamic MRI defecography with conventional defecography as the criterion standard in the diagnosis of pelvic floor disorders. DESIGN We used a prospective crossover design in which patients underwent each procedure in random order within the same month. SETTING Investigations were conducted at a regional referral center in Marseille, France. PATIENTS Women with dyschezia who were undergoing diagnostic evaluation were eligible. INTERVENTION Dynamic anorectal endosonography, dynamic MRI, and conventional defecography were performed in all patients by 3 blinded operators. MAIN OUTCOME MEASURE The accuracy of dynamic anorectal endosonography and dynamic MRI in the diagnosis of pelvic floor disorders was assessed by calculating sensitivity, specificity, positive and negative predictive values, correlation coefficients, concordance rates, and the Cohen κ statistic, with conventional defecography used as the criterion standard. RESULTS The study comprised 56 women with a mean age of 50.7 (SD, 12.5) years. No significant differences were observed between dynamic anorectal endosonography and dynamic MRI in the number of patients with rectocele (P = .49), perineal descent (P = .11 when dynamic anorectal endosonography measured descent of the puborectalis muscle; P = .27 for bladder descent), or enterocele (P = .78); no differences were found between these techniques in sensitivity, specificity, or positive and negative predictive values. Diagnostic concordance with conventional defecography as the standard did not differ significantly between dynamic MRI and dynamic anorectal endosonography: Concordance rates for dynamic anorectal endosonography were 75% for rectocele, 64% for perineal descent, and 91% for enterocele (no rectal intussusception was found with dynamic anorectal endosonography); concordance rates for dynamic MRI were 82% for rectocele, 57% for perineal descent, 93% for enterocele, and 55% for rectal intussusception. Significantly more internal anal sphincter defects were found with dynamic anorectal endosonography than with dynamic MRI defecography: 21 patients (37.5%) vs 12 patients (21.4%); P = .02. Patient tolerance was significantly better for dynamic anorectal endosonography than for dynamic MRI (P = .002) or conventional defecography (P = .005). Most patients said they would choose dynamic anorectal endosonography (72.1%) rather than dynamic MRI (25.6%) or conventional defecography (2.3%) if follow-up were necessary (P < .001). CONCLUSION Dynamic anorectal endosonography and dynamic MRI defecography show equivalent diagnostic performance in assessing pelvic floor disorders. However, because of its better tolerance and availability, dynamic anorectal endosonography may be preferable as the initial imaging procedure after clinical examination in the evaluation of pelvic floor disorders.
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Pannu HK, Scatarige JC, Eng J. MRI diagnosis of pelvic organ prolapse compared with clinical examination. Acad Radiol 2011; 18:1245-51. [PMID: 21795069 DOI: 10.1016/j.acra.2011.05.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 05/02/2011] [Accepted: 05/03/2011] [Indexed: 11/30/2022]
Abstract
RATIONALE AND OBJECTIVES The aims of this study were to determine agreement between clinical examination and magnetic resonance imaging (MRI) (rectal contrast and noncontrast MRI) for pelvic organ prolapse using both the pubococcygeal line (PCL) and the midpubic line (MPL) and to assess the relationship between measurements performed relative to each line. MATERIALS AND METHODS Dynamic MRI exams in 88 women (with rectal contrast, n = 39; noncontrast, n = 49) were evaluated, followed by review of clinical exam notes. Agreement between clinical exam and MRI and the difference between PCL and MPL measurements were evaluated. RESULTS Agreement of rectal contrast MRI with clinical exam was 79% for PCL and 85% for MPL (P = .17) for cystoceles, 50% for PCL and 59% for MPL (P = .20) for vaginal prolapse, 56% for PCL for enteroceles, and 61% for rectoceles. Agreement of noncontrast MRI with clinical exam was 67% for PCL and 78% for MPL (P = .19) for cystoceles, 58% for PCL and 71% for MPL (P = .10) for vaginal prolapse, 65% for enteroceles, and 40% for rectoceles. The average difference between the PCL and the MPL was 3.12 ± 0.24 cm at the bladder base and 4.88 ± 0.37 cm at the vaginal apex. CONCLUSIONS Agreement of MRI with clinical exam was highest for cystoceles. There was no significant difference in agreement using the MPL or PCL, suggesting that either line can be used on MRI. The average differences between the PCL and MPL at the bladder base and vaginal apex were approximately 3 and 5 cm, respectively.
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Affiliation(s)
- Harpreet K Pannu
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Kruger JA, Heap SW, Murphy BA, Dietz HP. How best to measure the levator hiatus: evidence for the non-Euclidean nature of the 'plane of minimal dimensions'. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 36:755-758. [PMID: 20645397 DOI: 10.1002/uog.7750] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/13/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To clarify whether the 'plane of minimal dimensions' of the levator hiatus on three-dimensional (3D) ultrasound accurately represents the minimal anatomical transverse hiatal dimension during a Valsalva maneuver. METHODS In this retrospective study of 3D transperineal ultrasound and magnetic resonance (MR) imaging, datasets from 19 female participants were used to measure the transverse diameter of the levator hiatus using the plane of minimal dimensions on maximum Valsalva maneuver. The term 'apparent minimal transverse diameter' (aMTD) was used to define the transverse diameter measured using axial ultrasound and comparable axial or coronal MR images. Coronal MR images, using the plane of the vagina as a reference, were also obtained on maximum Valsalva. The transverse diameter measured between the caudal margin of the pubococcygeus/puborectalis on the MR coronal image is denoted by the term 'true minimal transverse diameter' (tMTD). Statistical comparisons between the aMTD and tMTD were made using Student's t-test. RESULTS No significant difference was demonstrated between the aMTD as measured by ultrasonography and MRI. However, there were significant differences found between the aMTD measured by both ultrasound and MRI and the tMTD measured on coronal MR images (both P < 0.01), with mean ( ± SD) values of 4.36 ± 0.85, 4.13 ± 1.09 and 3.23 ± 0.49 cm, respectively. CONCLUSION This study highlights the complexity and 3D nature of the levator hiatus and pelvic floor muscles. Investigators have previously assumed that the plane of minimal dimensions of the hiatus can be measured in a flat plane, however, the 3D nature of the hiatus means that the true levator hiatus occupies a warped (non-Euclidean) plane. Hiatal measurements on Valsalva may be subject to systematic error if performed in a single section, i.e. using a flat (Euclidean) plane.
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Affiliation(s)
- J A Kruger
- Auckland Bioengineering Institute, Auckland, New Zealand.
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Sutcliffe JR, King S, Hutson JM, Southwell B. What is new in radiology and pathology of motility disorders in children? Semin Pediatr Surg 2010; 19:81-5. [PMID: 20307844 DOI: 10.1053/j.sempedsurg.2009.11.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Disorders affecting colorectal motility lead to significant morbidity in children with surgical conditions. Etiology is frequently unknown, which in turn makes treatment empiric and compromises outcome. A thorough understanding of the normal mechanisms of control and the ability to recognize and manage defects is an important goal for clinicians. This article reviews recent advances made in the investigation of children with colorectal motility disorders, including the role of transit studies (marker studies and scintigraphy), options for assessing anatomy (ultrasound, contrast enema, and sectional imaging) and the use of manometry, both anorectal and colonic. Current concepts in microscopic evaluation are outlined.
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Affiliation(s)
- Jonathan R Sutcliffe
- Department of Paediatric Surgery, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom.
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MRI of the Urethra in Women With Lower Urinary Tract Symptoms: Spectrum of Findings at Static and Dynamic Imaging. AJR Am J Roentgenol 2009; 193:1708-15. [DOI: 10.2214/ajr.08.1547] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Lapray JF, Costa P, Delmas V, Haab F. Rôle de l’imagerie dans l’exploration des troubles de la statique pelvienne. Prog Urol 2009; 19:953-69. [DOI: 10.1016/j.purol.2009.09.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Accepted: 09/17/2009] [Indexed: 10/20/2022]
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Novellas S, Mondot L, Bafghi A, Fournol M, Baudin G, Coco L, Bongain A, Chevallier P. Évaluation de deux systèmes de cotation des prolapsus pelviens en IRM dynamique. ACTA ACUST UNITED AC 2009; 90:1717-24. [DOI: 10.1016/s0221-0363(09)73270-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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