Dynamic MR colpocystorectography assessing pelvic-floor descent

Abstract

Magnetic resonance colpocystorectography (MR-CCRG) is presented in the evaluation of patients with pelvic-floor disorders. Five healthy volunteers and 44 female patients with isolated or combined visceral descent underwent dynamic MRI and dynamic fluoroscopy (DF). MR-CCRG was performed with the patient in a supine position using a True FISP sequence (1 image/1.2 s; in-plane resolution 1.02 mm) during pelvic floor contraction, relaxation, and straining maneuvers. Relevant organs, such as urethra, bladder, vagina, and rectum, were opacified by using a saline solution, Magnevist (Schering AG, Berlin, Germany), and sonography gel, respectively. The clinical evaluation and the intraoperative results (30 cases) were used as reference. MR-CCRG and DF were non-diagnostic in 3 cases each. Most patients had a combined type of visceral prolapse, the most frequent combination being a vaginal vault prolapse and a cystocele. The points of reference were sufficiently outlined by DF and MR-CCRG. In comparison with the clinical and intraoperative results, MR-CCRG proved to be especially beneficial in the diagnosis of different types of enteroceles including a uterovaginal prolapse. MR-CCRG showed an equal or higher sensitivity and specificity for all individual sites when compared with DF. Also, predominant herniation obscuring other concomitant prolapse could be verified in 8 cases. MR-CCRG is superior to DF and accurately depicts pelvic-floor descent and prolapse in women. The possibility of dynamic presentation (see enclosed CD-ROM) allows for a better understanding of the organ movements within a given topographic reference setting.

Influence of age, mode of delivery and parity on the prevalence of posterior pelvic floor dysfunctions

“…However, rectocele grade II or grade III, rectal intussusception, rectocele grade II or III associated with rectal intussusception and occult sphincter injury were more prevalent in group II (P = 0.0432; P = 0.0028; P = 0.0178; P = 0.0001, respectively). The groups did not differ significantly with regard to anismus, anismus associated with rectocele grade II or III, or entero/ sigmoidocele grade III ( (8,14,15,17,20,27) . Thus, while some reports have correlated pelvic floor abnormalities with obstetric trauma (4,10,12,23) , others have failed to identify an association between the incidence of such dysfunctions and vaginal delivery (17,20,27) .…”

“…Different techniques and imaging methods have been used to evaluate pelvic floor dysfunctions in the anterior, middle and posterior compartment (2,3,7,8,9,12,14,15,16,17,18,19,20,24,25,27) . Because of differences in measurement techniques and anatomical landmarks, some authors describe rectocele as a descent of the rectal ampulla, quantified by correlation with the inferoposterior margin of the symphysis pubis (8,12) , while others consider rectocele a herniation of the anterior rectal wall into the posterior vagina, the size of which determines the grade of rectocele (2,3,9,13,15,17,19,20,23,27,29) .…”

“…Because of differences in measurement techniques and anatomical landmarks, some authors describe rectocele as a descent of the rectal ampulla, quantified by correlation with the inferoposterior margin of the symphysis pubis (8,12) , while others consider rectocele a herniation of the anterior rectal wall into the posterior vagina, the size of which determines the grade of rectocele (2,3,9,13,15,17,19,20,23,27,29) . Using 3-DAUS, we identified isolated and associated posterior dysfunctions and determined rectocele size.…”

“…However, the relation between vaginal delivery, age (post-menopause) and posterior pelvic floor dysfunctions involving obstructed defecation syndrome (ODS) is still a matter of controversy (8,14,17,19,27) . Pelvic floor dysfunctions are best evaluated with dynamic techniques such as magnetic resonance (9,15) and ultrasonography using endorectal (2,18,19) or transperineal (3,7) probes to view the anal canal and pelvis anatomy. Thus, echodefecography, a 3-D dynamic anorectal ultrasonography technique recently developed by Murad-Regadas et al (19) , may be used to evaluate voiding disorders affecting the posterior compartment (rectocele, rectal intussusception, anismus)…”

Is dynamic two-dimensional anal ultrasonography useful in the assessment of anismus? A comparison with manometry

“…Once identified and quantified, anatomical and functional changes can be correlated with clinical symptoms and proctological findings (6) . Defecography, manometry, electromyography and, more recently, dynamic magnetic resonance scanning and dynamic anorectal ultrasonography, have all been used to diagnose patients with pelvic floor dysfunctions (1,2,3,4,5,6,7,8,9,11,12,13,14,15,16,17,18,19,20,21,22,23,24,26,27,28,29,30) . Advances in ultrasound technology includes the development of the three-dimensional (3D) anorectal transducer and allows to clearly visualize the anatomic configuration of the anal canal in multiplane images (27) but the twodimensional (2D) ultrasound can be useful in the diagnosis of anorectal disease (7,10,24) .…”