Comparison of 3-Dimensional Pelvic Floor Ultrasonography and Defecography for Assessment of Posterior Pelvic Floor Disorders

Clinical value of transperineal ultrasound in evaluating the diagnostic grade of rectocele in Chinese women with obstructed defecation syndrome: An observational study

We aimed to evaluate the effectiveness of transperineal ultrasound (TPUS) in diagnosing rectocele, rectal intussusception (RI), enterocele, perineal descent (PD), and cystocele in Chinese women with obstructed defecation syndrome (ODS), and to determine the grading of rectocele via TPUS. Between January 2019 and December 2021, 107 obstructed defecation syndrome patients, with a mean age of 49.76 years, received TPUS and defecation proctography (DEP). Both methods were used to diagnose anorectal angle, rectocele, RI, enterocele, and PD, while cystocele and uterine prolapse were diagnosed only through TPUS. Agreement between DEP and TPUS diagnostic results was compared using Cohen kappa statistics. Seventy-six rectoceles were reported following DEP and 72 after TPUS. DEP detected 7 enteroceles, 6 of which were diagnosed simultaneously by TPUS. 43 patients presented dyssynergic defecation (DD) upon DEP, while 51 upon TPUS. DEP and TPUS detected PD in 13 and 11 patients respectively, and RI in 82 and 73, respectively. Rectocele (kappa = 0.738), RI (kappa = 0.711), DD (kappa = 0.774), enterocele (kappa = 0.847), and PD (kappa = 0.625) were obtained by Cohen kappa statistics, which indicated a good agreement between DEP and TPUS. The cutoff values for the diagnosis of moderate and severe rectocele with TPUS were 12.05 mm (AUC: 0.941) and 18.50 mm (AUC: 0.977), respectively. The DEP-determined and TPUS-determined anorectal angles were significantly correlated in the resting and Valsalva states (P < .01). Compared with DEP, while maintaining good agreement in detecting rectocele, RI, DD, enterocele, and PD, TPUS is a repeatable and noninvasive alternative. Threshold values of 12.05 mm and 18.50 mm on TPUS may diagnose moderate and severe rectocele, respectively.

Colonic pseudo-obstruction in a patient with dyssynergic defecation: A case report

Introduction and importance: Colonic pseudo-obstruction (CPO) is characterized by massive colonic dilatation of the large intestine without mechanical obstruction. In this study, we report our surgical experience in treating refractory CPO with increased anal sphincter tone, suggested as type IV dyssynergia.

Case presentation

A 48-year-old man with intellectual disability, depression, heart failure, and end-stage renal disease presented with acute exacerbation of CPO. He had a history of chronic constipation and abdominal distension. Colonic dilatation and defecation difficulty persisted despite medication and repeated colonoscopic decompression. Anal manometry results indicated type IV dyssynergia with increased rectal pressure. Hartmann′s operation was performed to resect the redundant megacolon and to avoid increased anal sphincter pressure during defecation. Hypoganglionosis was observed in the resected colon, which could worsen the chronic process of CPO.

Clinical discussion

Meticulous evaluation and careful management are required to treat CPO patients because the pathophysiology of CPO has not yet been clearly identified. Proper surgical treatment is needed for patients with refractory CPO.

Conclusion

CPO requires meticulous evaluation and careful management owing to the risk of bowel perforation. Precise evaluation to identify other factors affecting defecation problems accompanied by CPO is required to make appropriate treatment decisions.

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Colonic pseudo-obstruction is defined as massive colonic dilatation of the large intestine without mechanical obstruction.

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Dyssynergic defecation results from an abnormality for defecations and discordance for contraction of anal sphincter.

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Surgical resection is considered in patients with refractory colonic pseudo-obstruction and colonic aganglinosis.

Role of contrast-enhanced ultrasonography in MR-guided focused ultrasound ablation on uterus fibroids: lesion selection and assessment of ablative effects

OBJECTIVES

To determine whether contrast-enhanced ultrasonography (CEUS) can be used for selecting lesions and assessing the ablative effects of MRgFUS ablation on uterus fibroids, compared with MR imaging.

METHODS

This retrospective study was approved by the institutional review board of our hospital. From April 2018 to November 2019, a total of 44 symptomatic fibroids in 38 patients who underwent MRgFUS ablation were included. The association between pre-ablation characteristics on CEUS/MR imaging and the non-perfusion volume (NPV) after ablation was analyzed using multivariable linear regression analysis. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve values was compared between the CEUS and MR imaging regression models. NPV after ablation was compared between CEUS and enhanced MR imaging.

RESULTS

On CEUS, entangled branch vessels, fast-in, and fast-out patterns were significantly associated with NPV, with an AUC of 0.95 (95% CI; 0.88, 1.00). On MR imaging, hyper-intensity on T2-weighted images (T2WI), hyper-intense ring-like signal on T2WI images, and hyper-enhancement on contrast-enhanced T1WI images were correlated with NPV, with an AUC of 0.86 (95% CI; 0.70, 1.00). After ablation, no differences in NPV were noted between contrast-enhanced T1WI (84.13 ± 75.42 cm³) and CEUS (80.22 ± 76.49 cm³).

CONCLUSIONS

Some pre-ablation characteristics of uterine fibroids on CEUS were associated with NPV after MRgFUS. CEUS may contribute to the evaluation of ablative outcomes and patient selection, similar to MR imaging.

KEY POINTS

• Contrast-enhanced ultrasonography (CEUS) is effective for selecting the appropriate uterine fibroids before MR-guided focused ultrasound (MRgFUS) ablation and evaluating non-perfusion volumes (NPV) after ablation, as a potential alternative to MR imaging. • Before ablation, entangled branch vessels, fast-in, and fast-out patterns on CEUS were significantly associated with NPV after MRgFUS. • No significant differences in NPV were detected between contrast-enhanced T1WI and CEUS after ablation.

Three-Dimensional Pelvic Floor Ultrasound Assessment of Pelvic Organ Prolapse: Minimal Levator Hiatus and Levator Ani Deficiency Score

Purpose

The purpose of this study was to determine whether levator ani deficiency (LAD) scores and minimal levator hiatus (MLH) areas affect Pelvic Organ Prolapse Quantification (POP-Q) stage.

Methods

This study was a retrospective chart review of patients with pelvic organ prolapse (POP) at Seoul Songdo Hospital between August 2019 and August 2020. Three-dimensional (3D) pelvic floor ultrasound, preoperative anal manometry, and other physiological tests were performed in 78 patients with POP symptoms. We divided the patients into mild prolapse and severe prolapse groups based on the POP-Q. We examined the LAD and MLH areas. LAD scores were categorized as mild, moderate, or severe.

Results

There were 32 patients (41.0%) in the mild prolapse group (POP-Q stage I and II) and 46 (59.0%) in the severe prolapse group (POP-Q stage III and IV). The mean LAD score was significantly higher in severe prolapse group (13.33±2.49 vs. 8.19±2.92, P<0.001), and the rate of severe deficiency was also significantly higher in the severe prolapse group (29 [63.0%] vs. 2 [6.3%], P<0.001). The mean MLH was also significantly larger in the severe prolapse group (17.91±2.74 cm² vs. 14.95±2.60 cm², P<0.001). In addition, both MLH and LAD scores tended to increase at each stage.

Conclusion

There is a strong positive correlation between the POP-Q stage and the MLH and LAD scores that can be seen on 3D pelvic floor ultrasound. The findings of this study, by objectively demonstrating LAD and MLH in women with POP, are an important contribution to POP.