Dynamic Pelvic Magnetic Resonance Imaging Research Articles

70: Dynamic magnetic resonance imaging of pelvic anatomy following vaginal reconstructive surgery: A prospective study

To describe the impact of native tissue vaginal reconstruction, including vaginal vault suspension, on pelvic anatomy using dynamic magnetic resonance imaging (MRI). This IRB approved prospective cohort study investigated women undergoing intraperitoneal vaginal vault suspension for symptomatic pelvic organ prolapse (POP) with native tissue reconstruction. Enrolled participants underwent dynamic pelvic MRI preoperatively and 3 months postoperatively. Radiographic and anatomic measurements were compared. The H-line (or levator hiatus) was defined as the distance from the pubic symphysis to the posterior anal canal and the M-line (or muscular pelvic floor relaxation) was defined as the decent of the levator plate from the pubococcygeal line (PCL). The PCL represented the level of the pelvic floor and was measured from the inferior border of the pubic symphysis to the last coccygeal joint. Our primary outcome was to compare preoperative MRI measurements to those following surgical treatment. Secondary outcomes were evaluated via validated patient questionnaires pre- and post-operatively. A total of 17 participants were enrolled, 14 completed the study and were included in our analysis. The mean age was 62 years; all participants were white. The majority of participants had Stage III POP, as defined by the Pelvic Organ Prolapse Quantification (POP-Q) scale. Twelve participants (85.7%) underwent a concomitant hysterectomy and 5 participants (35.7%) received a concomitant midurethral sling procedure. There was a significant improvement in several radiographic measurements with straining and/or defecation following vaginal reconstruction, including the H-line, M-line, anorectal angle, and the extent of apical and anterior compartment prolapse. There was no difference regarding pubococcygeal line (PCL), anorectal decent, extent of enterocele, or posterior compartment prolapse. POP-Q measurements improved significantly in all compartments with the exception of perineal body and total vaginal length. Regarding validated questionnaires, PFDI-20 scores improved significantly (102 preop vs. 30 postop, p<0.001) following surgery. While PFIQ-7 scores also improved, this finding did not achieve significance (55 preop vs 24 postop, p=0.164). Native tissue reconstruction with intraperitoneal vaginal vault suspension for symptomatic pelvic organ prolapse not only improves pelvic anatomy and function as defined by POP-Q measurements and PFDI scores, but is also associated with significantly improved measurements on dynamic MRI at 3 months postoperatively.

Improved Detection of Pelvic Organ Prolapse: Comparative Utility of Defecography Phase Sequence to Nondefecography Valsalva Maneuvers in Dynamic Pelvic Floor Magnetic Resonance Imaging

To evaluate the utility of a defecography phase (DP) sequence in dynamic pelvic floor MRI (DPMRI), in comparison to DPMRI utilizing only non-defecography Valsalva maneuvers (VM). Inclusion criteria identified 237 female patients with symptoms and/or physical exam findings of pelvic floor prolapse. All DPMRI exams were obtained following insertion of ultrasound gel into the rectum and vagina. Steady-state free-precession sequences in sagittal plane were acquired in the resting state, followed by dynamic cine acquisitions during VM and DP. In all phases, two experienced radiologists performed blinded review using the H-line, M-line, Organ prolapse (HMO) system. The presence of a rectocele, enterocele and inferior descent of the anorectal junction, bladder base, and vaginal vault were recorded in all patients using the pubococcygeal line as a fixed landmark. DPMRI with DP detected significantly more number of patients than VM (p<0.0001) with vaginal prolapse (231/237, 97.5% vs. 177/237, 74.7%), anorectal prolapse (227/237, 95.8% vs. 197/237, 83.1%), cystocele (197/237, 83.1% vs. 108/237, 45.6%), and rectocele (154/237, 65% vs. 93/237, 39.2%). The median cycstocele (3.2cm vs. 1cm), vaginal prolapse (3cm vs. 1.5cm), anorectal prolapse (5.4cm vs. 4.2cm), H-line (8cm vs. 7.2cm) and M-line (5.3cm vs. 3.9cm) were significantly higher with DP than VM (p<0.0001). Addition of DP to DPMRI demonstrates a greater degree of pelvic floor instability as compared to imaging performed during VM alone. Pelvic floor structures may show mild descent or appear normal during VM, with marked prolapse on subsequent DP images.

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

ObjectiveTo compare dynamic magnetic resonance imaging (dMRI) defecography phase findings with physical examination (PE) grading in the evaluation of pelvic organ prolapse (POP). MethodsWe retrospectively reviewed 274 consecutive patients who underwent dMRI with defecography. Baden-Walker grading of POP, absolute dMRI values, and grading by dMRI were collected for anterior, apical, and posterior compartments. Anatomically significant POP on PE was defined as Baden-Walker Grade ≥3 and on dMRI by dMRI Grade ≥2. A Spearman's Rank correlation was performed between absolute dMRI values and respective POP grades. ResultsA total of 178 female patients were included. Anatomically insignificant and significant cystoceles had a 26.4% (19/72) and 84.6% (66/78) agreement respectively. Anatomically insignificant and significant apical prolapse had a 2.0% (2/100) and 62.9% (17/27) agreement respectively. Anatomically insignificant and significant posterior prolapse had a 49.5% (51/103) and 78.7% (59/75) agreement respectively. PE detected only 30% (9/30) of total dMRI detected enteroceles and misdiagnosed 10% (3/30) of these patients with a rectocele. ConclusionThe dMRI defecography phase correlated well for anatomically significant prolapse in anterior and posterior compartments. dMRI was superior to PE for enterocele detection and was better able to distinguish an enterocele from a rectocele. Thus, dMRI may have the greatest diagnostic value in cases where the presence of an enterocele is unclear in apical and/or posterior compartments.

Dynamic 3T pelvic floor magnetic resonance imaging in women progressing from the nulligravid to the primiparous state.

The objective was to prospectively characterize dynamic pelvic 3-Tesla magnetic resonance imaging (dp3T MRI) findings in nulligravida women and characterize changes 6months after delivery in the same woman. 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 ≥6months 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. Nineteen subjects (mean±SD age, 31±5years) completed baseline clinical and dp3T MRI studies, 15 delivered and 10 (30.5±3years) 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. Dynamic pelvic 3T MRI detected levator tears and increased pelvic organ descent, which can be directly attributed to pregnancy and delivery.

Dynamic Magnetic Resonance Imaging of the Pelvic Floor

Pelvic floor dysfunction is a widespread condition affecting up to 50% of elderly women. It markedly compromises the quality of life owing to various disabling symptoms such as pelvic pain, pelvic organ prolapse, and urinary and fecal incontinence. Although age and female sex are the main risk factors, others include multiparity, obesity, and connective tissue disorders. Pelvic floor dysfunction is frequently multicompartmental, and failure to diagnose it accurately often leads to treatment failure. Dynamic pelvic floor magnetic resonance imaging is a robust tool that enables simultaneous visualization of the 3 pelvic floor compartments and is indispensable for precise preoperative evaluation.

Comparison of High-Resolution Anorectal Manometry Parameters in Constipation vs Fecal Incontinence with Significant Rectal Descent by Dynamic Pelvic Magnetic Resonance Imaging

Introduction: Clinically undetected internal rectal prolapse or significant rectal descent can be demonstrated via MRI defecography (D-MRI). It is unknown if rectal prolapse is diagnosed more frequently using D-MRI in patients with fecal incontinence (FI) compared to patients with constipation (C). The purpose of our study is to retrospectively compare the diagnostic rate of rectal prolapse in patients with constipation with that for the patients with fecal incontinence, and compare the HR-ARM findings between the two patient populations. Methods: This is a retrospective study of rectal prolapse found in patients with fecal incontinence and constipation who underwent HR-ARM and DP-MRI. Statistical analysis was performed using one-tailed Student's t test with unequal variances. Results: The rate of rectal prolapse or significant rectal descent (>3 cm) found in FI patients was 86% 12/14, versus 31% 12/39 in C patients and 50% 2/4 in patients with both FI/C. FI patients with significant rectal descent had decreased mean (57.8 vs 84, p < 0.01) and maximum (61.7 vs 92, p < 0.01) resting sphincter pressure, decreased maximum squeeze sphincter pressure (98.75 vs 219.8, p < 0.01), decreased length of functional anal canal (hpz) (2.7 vs. 3.4, p=0.01), decreased residual anal pressure (46 vs. 75.6, p < 0.01) and decreased intrarectal pressure at rest (39.4 vs 73.3, p=0.01) compared to patients with C and similar MRI findings. Conclusion: A higher proportion of patients with fecal incontinence as a presenting symptom are found to have rectal prolapse on DP-MRI than patients with constipation. A pattern of decreased resting sphincter pressure, squeeze sphincter pressure, length of functional anal canal, residual anal pressure and intrarectal pressure may be more characteristic for patients with FI and DP-MRI findings of rectal descent.Table 1: HR-ARM Comparison of Patients with Constipation versus Fecal Incontinence with Significant DP-MRI Rectal Descent

Tu1778 High Resolution Anorectal Manometry Compared to Dynamic Pelvic Magnetic Resonance Imaging in Fecal Incontinence

Tu1778 High Resolution Anorectal Manometry Compared to Dynamic Pelvic Magnetic Resonance Imaging in Fecal Incontinence

Influence of rectal gel volume on defecation during dynamic pelvic floor magnetic resonance imaging

PurposeTo evaluate effects of altering rectal contrast volume on defecatory effort during magnetic resonance defecography (MRD). MethodsWe assessed defecation qualitatively and quantitatively as a function of rectal distention (group A: 180 cc, n=31; group B: 120 cc, n=31). Quantitative evaluation comprised measuring rectal area on midline sagittal images pre- and post-defecation. ResultsResting rectal area was significantly higher for group A than for group B (35.2 vs. 28.3 cm2, P<.0001). Post-defecation rectal area and change in area (pre- to post-defecation) were not significantly different. Subjective evaluation showed no significant difference. ConclusionDecreasing rectal gel volume from 180 to 120 cc did not compromise defecation performance during MRD.

High-resolution anorectal manometry and dynamic pelvic magnetic resonance imaging are complementary technologies

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. 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. 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. 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.

Análisis de nuestra experiencia mediante el uso de resonancia magnética dinámica pelviana en la evaluación del síndrome de defecación obstructiva

IntroductionThe aetiological diagnosis of obstructive defaecation syndrome (ODS) requires, among others, imaging tests. The purpose of this study is to descriptively analyse and compare the findings of dynamic pelvic magnetic resonance imaging (DPMRI) with the clinical examinations in patients with ODS. Material and methodsA prospective comparative study was made between the physical examination and the DPMRI, with a descriptive analysis of the results.A total of 30 patients were included (2 males and 28 females), with a median age of 60 (range 23-76) years, with symptoms of ODS. An anamnesis and detailed physical examination and a DPMRI were performed on all of them. Functional (anismus) and morphological changes (rectocele, enterocele, intussusception, etc.), were analysed. ResultsThe physical examination did not detect anomalies in 6 (20%) patients. A rectocele was diagnosed in 21 (70%) of the cases, and 2 (6.7%) a rectal mucosal prolapse. The DPMRI showed evidence of pelvic floor laxity in 22 (73.3%) cases, an enterocele in 4 (13.3%), a sigmoidocele in 2 (6.7%), intussusception in 8 (26.7%), rectal mucosal prolapse in 4 (13.3%), anismus in 3 (10%), and a cystocele in 4 (13.3%). The rectocele was the most frequent diagnosis, being given in 26 (86.6%) patients. ConclusionsMagnetic resonance imaging provides an overall pelvic assessment with good definition of the tissues, and does not use ionising radiation, is well tolerated, and provides us with complementary information to arrive at the diagnosis, and establish the best treatment for ODS. Larger studies comparing videodefaecography (VD), currently considered the Gold Standard technique, are needed to be able to demonstrate whether it is superior or not to DPMRI.

Assessment of Women With Defecatory Dysfunction and Manual Splinting Using Dynamic Pelvic Floor Magnetic Resonance Imaging

This study aimed to describe magnetic resonance imaging (MRI) findings in women with defecatory dysfunction who perform manual splinting. This is a retrospective study of 29 patients from a single urogynecology center who presented with complaints of defecatory dysfunction and who reported manual splinting to assist with bowel movements. Patients were scheduled for an MRI study with a novel "splinting" protocol to evaluate the effects of their manual splinting on the pelvic floor. The protocol involved asking patients to splint during the MRI, as they normally would when trying to defecate. The goal was to evaluate any change in pelvic anatomy and compensation for an anatomic defect that could potentially lead to their defecatory dysfunction. Magnetic resonance images of the pelvis were obtained at rest, with pelvic floor contraction, with Valsalva, and during manual splinting. These images were then reviewed by radiologists who evaluated various parameters, including anorectal angle, levator ani muscle integrity, and the presence of rectocele, cystocele, apical prolapse, and enterocele. The external and internal anal sphincters were also evaluated for continuity. From September 2008 to October 2010, 29 women reported defecatory dysfunction and the need for manual splinting. Their mean (SD) age was 55.2 (10.5) years. Magnetic resonance images showed a rectocele in 86.2% of the study group, cystocele in 75.9%, enterocele in 10.3%, and a defect of the levator ani muscles in 17.2%. Twenty-one (72.4%) women had more than 1 of these defects. In addition, 27.6% had an anorectal angle less than 90 degrees or greater than 105 degrees.Patients in the study group splinted in the vagina (58.6%), on the perineum (31.0%), or on the buttock (10.3%). In all but 1 woman (96.6%), splinting improved or completely corrected the identified defect(s) as evidenced with MRI. Among those who used vaginal splinting, 52.9% of defects were corrected and 47.1% were improved. Perineal splinting corrected 55.6% and improved 33.3% of cases and was ineffective in 11.1% of cases, whereas buttock splinting corrected 33.3% and improved 66.7% of cases. Most women in our study group who used manual splinting to assist in defecation are compensating for a pelvic floor defect that can be detected on MRI. Magnetic resonance imaging of the pelvis may help elucidate the etiology of the defecatory dysfunction in some women and may assist pelvic reconstructive surgeons in planning surgical correction of pelvic floor defects. Magnetic resonance imaging may also identify defects in the pelvic floor that are, at the present time, not amenable to surgical correction.

Magnetic resonance imaging of pelvic organ prolapse: comparing pubococcygeal and midpubic lines with clinical staging

The aim of the study was to determine which magnetic resonance imaging (MRI) reference line for staging pelvic organ prolapse, the pubococcygeal line (PCL) vs. the midpubic line (MPL), has the highest agreement with clinical staging. A retrospective study of women with pelvic floor complaints who underwent dynamic pelvic MRI from January 2004 to April 2007 was conducted. Two radiologists staged descent on MRI for each pelvic compartment (anterior, apical, posterior) by consensus, using PCL and MPL reference lines. Agreement between MRI and clinical staging was estimated using weighted kappas. Twenty women were included. Agreement between clinical and PCL staging was fair in the anterior (kappa = 0.29) and poor in the apical (kappa = 0.03) and posterior (kappa = 0.08) compartments. Agreement between clinical and MPL staging was fair in the anterior (kappa = 0.37), apical (kappa = 0.31), and posterior (kappa = 0.25) compartments. The MPL has higher agreement with clinical staging than the PCL. However, neither reference line has good agreement with clinical staging.

Functional Disorders: Rectoanal Intussusception

Rectoanal intussusception (RI) is a telescoping of the rectal wall during defecation. RI is an easily recognizable physiologic phenomenon on defecography. The management, however, is much more controversial. Two predominant hypotheses exist regarding the etiology of RI: RI as a primary disorder, and RI as a secondary phenomenon. The diagnosis may be suspected based on clinical symptoms of obstructive defecation. Diagnostic modalities include defecography as the gold standard. Dynamic pelvic magnetic resonance imaging (DPMRI) and transperineal ultrasound are attractive alternatives to defecography; however, their sensitivity is poor in comparison to the gold standard at this time. Management strategies including conservative measures such as biofeedback and surgical procedures including mucosal proctectomy (Delorme), rectopexy, and stapled transanal rectal resection (STARR) procedures have varied degrees of efficacy.

Transvaginal paravaginal repair of high-grade cystocele central and lateral defects with concomitant suburethral sling: Report of early results, outcomes, and patient satisfaction with a new technique

Baden-Walker classification grade III–IV (pelvic organ prolapse quantification [POP-Q] system stage III–IV) cystocele is associated with a constellation of abnormalities including urethral hypermobility, lateral defect, central defect, and concomitant vault and posterior wall prolapse. We describe a new transvaginal paravaginal technique to correct this group of abnormalities and report on our early results. We prospectively evaluated patients with high-grade cystocele who underwent repair with the new transvaginal paravaginal repair. Preoperative evaluation included history and physical examination, dynamic pelvic magnetic resonance imaging, urodynamics, and symptom questionnaire. All patients first underwent a distal urethral polypropylene sling surgery. After repair of the central defect of the cystocele, a paravaginal repair of the lateral defect was performed by using a circular 5 cm × 5 cm soft polypropylene mesh attached proximally to the sacrouterine/cardinal ligament, distally to the bladder neck, and laterally to the infralevator obturator fascia. Postoperative evaluation at 3-month intervals included history and physical examination using the POP-Q system, a voiding dysfunction and incontinence symptom questionnaire, the validated short form of the Urogenital Distress Inventory (UDI-6), a validated global quality-of-life question, and a postvoid residual. We performed the repair in 98 patients with a mean age of 65 years (range, 40 to 86 years). Of these, 26% underwent concomitant vaginal hysterectomy, 45% had enterocele repair, and 94% had rectocele repair. There were 2 complications, including transient ureteral obstruction due to bladder wall hematoma and 1 patient who presented with a recurrent enterocele requiring surgical repair. No patient experienced urinary retention. De novo stress urinary incontinence was seen in 3 patients; de novo urge incontinence was seen in 2 patients. Postoperative POP-Q scores showed 85% of patients with stage 0–I, 13% with stage II, and 2% with stage III anterior vaginal wall prolapse. Of patients with preoperative stress urinary incontinence, 70% reported never experiencing symptoms under any circumstances. Quality of life improved from 4.7 to 1 ( P <0.005). Transvaginal paravaginal repair of grade III–IV cystocele using soft polypropylene mesh fixed to the obturator fascia, sacrouterine ligaments, and bladder neck area provides excellent support of the central defect repair as well as repair of the lateral defect. The operation is safe, simple, and outpatient based, and provides excellent anatomic results with minimal complications. Concomitant distal polypropylene sling did not increase the rate of complications and did not compromise results of stress urinary incontinence surgery.

Review article: the management of pelvic floor disorders.

Anorectal disorders, such as faecal incontinence, defecation difficulty and conditions associated with anorectal pain, are commonly encountered in the practices of gastroenterologists, urogynaecologists and colorectal surgeons. The evaluation of these disorders has been very much improved by the development and wider availability of diagnostic tests, such as manometry, endo-anal ultrasound, static and dynamic pelvic magnetic resonance imaging and electromyography. After briefly reviewing the normal anatomy and physiology of the anorectum, the pathophysiology and diagnostic approaches to faecal incontinence, defecation disorders and functional anorectal pain are discussed. Until recently, the management of these disorders has been largely anecdotal. However, our therapeutic armamentarium has been expanded by pharmacological agents, such as nitrates, calcium channel blockers and botulinum toxin, as well as the development of novel techniques, such as sacral nerve stimulation. These and other pharmacological, behavioural and surgical approaches are reviewed with respect to the robustness of evidence to support their efficacy in patients with these disorders.

Value of express T2-weighted pelvic MRI in the preoperative evaluation of severe pelvic floor prolapse: a prospective study

ObjectivesTo report our prospective experience with extended-phase conjugate-symmetry rapid spin-echo sequence (EXPRESS) magnetic resonance imaging (MRI) of the female pelvis in the preoperative staging of severe pelvic floor prolapse (PFP). Severe PFP represents a significant diagnostic and reconstructive challenge for clinicians. Although the clinical utility of dynamic MRI has already been demonstrated, EXPRESS MRI has not been prospectively studied in the evaluation of PFP. MethodsBetween January 1999 and December 2001, 31 consecutive female patients with severe PFP were referred to our institution. Twenty of them underwent EXPRESS dynamic pelvic MRI. The physical examination, MRI, and intraoperative findings were statistically correlated. ResultsThe mean age of the 20 patients undergoing preoperative EXPRESS MRI was 67 years. The mean duration of prolapse was 6.1 years. All 20 patients underwent surgery for symptomatic PFP with or without associated voiding dysfunction. No postoperative complications or recurrent PFP had occurred at a median follow-up of 19 months. Significant correlations were found between the preoperative pelvic examination findings and operative findings of cystourethrocele and vaginal cuff prolapse, and significant correlations were found between MRI findings and operative findings of enterocele, cystourethrocele, vaginal cuff prolapse, and uterine prolapse. ConclusionsEXPRESS MRI can accurately stage PFP. The technique is rapid, precise, and noninvasive. Practitioners should consider obtaining dynamic, rapid-sequence sagittal pelvic MRI scans in cases of severe PFP when the diagnosis is not clear before surgery. More accurate preoperative information may ultimately result in improved long-term surgical outcomes and guide the refinement of surgical techniques.

Role of dynamic pelvic floor magnetic resonance imaging (MRI) in the assessment of patients with idiopathic combined faecal and urinary incontinence

The aetiology of combined urinary and faecal incontinence (UFI) are interrelated and remain poorly understood; affecting appropriate patient selection, thus accountmg for sub-optimal surgical outcome. A potential variable in this process is Global pelvic floor dysfunction (GPFD). The aim of this study was to prospectively assess whether use of phased array body coil MRI could identify global pelvic floor dysfunction in these patients with multisystem dysfunctional symptoms. Symptomatic parncipants were selected from patients presenting with complaints of combined urinary and faecal incontinence either in the colorectal or urology outpatient clinics. Patients who have had previous pelvic floor surgery were excluded from this study. All underwent standard urodynamics and anorectal physiology assessment. Voiding cystometry, coIonoscopy and endoanal ultrasound were also performed. A standardised protocol was used for the MRI imaging. Thirty individual parameters were measured using buih-in-sofiware (callipers, compass and densitometer). Statistical analysis was performed using SPSS software Nineteen consecutive patients were assessed. Patiems were age, sex and parity matched with asymptomatic controls (n= 11). The MRI procedure was tolerated well by all the participants. Results are shown in the table. Body coil MRI is a non-invasive, well-tolerated imaging modafity. The novel use of MR1 in these patients has demonstrated for the first time distinct anatomical features evident in the levator plate, Urethrovesical angle and anal sphincter complex in patients with GFPD. Our data suggests that body coil dynamic MR1 may have a potential role in identifying patients with global perineal muscle dysfunction, thus facilitating definitive surgical management.

Dynamic pelvic magnetic resonance imaging and cystocolpoproctography alter surgical management of pelvic floor disorders.

Pelvic organ prolapse results in a spectrum of progressively disabling disorders. Despite attempts to standardize the clinical examination, a variety of imaging techniques are used. The purpose of this study was to evaluate dynamic pelvic magnetic resonance imaging and dynamic cystocolpoproctography in the surgical management of females with complex pelvic floor disorders. Twenty-two patients were identified from The Johns Hopkins Pelvic Floor Disorders Center database who had symptoms of complex pelvic organ prolapse and underwent dynamic magnetic resonance, dynamic cystocolpoproctography, and subsequent multidisciplinary review and operative repair. The mean age of the study group was 58 +/- 13 years, and all patients were Caucasian. Constipation (95.5 percent), urinary incontinence (77.3 percent), complaints of incomplete fecal evacuation (59.1 percent), and bulging vaginal tissues (54.4 percent) were the most common complaints on presentation. All patients had multiple complaints with a median number of 4 symptoms (range, 2-8). Physical examination, dynamic magnetic resonance imaging, and dynamic cystocolpoproctography were concordant for rectocele, enterocele, cystocele, and perineal descent in only 41 percent of patients. Dynamic imaging lead to changes in the initial operative plan in 41 percent of patients. Dynamic magnetic resonance was the only modality that identified levator ani hernias. Dynamic cystocolpoproctography identified sigmoidoceles and internal rectal prolapse more often than physical examination or dynamic magnetic resonance. Levator ani hernias are often missed by physical examination and traditional fluoroscopic imaging. Dynamic magnetic resonance and cystocolpoproctography are complementary studies to the physical examination that may alter the surgical management of females with complex pelvic floor disorders.

A comparison between dynamic pelvic magnetic resonance imaging and videoproctography in patients with constipation

This study attempts to compare the diagnostic efficacy of dynamic pelvic magnetic resonance imaging with that of videoproctography for the presence of rectocele, sigmoidocele, and intussusception as well as the measurement of anorectal angle and perineal descent in constipated patients. Patients volunteering for the study and fulfilling the criteria for videoproctography to evaluate constipation were also scheduled for dynamic pelvic magnetic resonance imaging. Patients undergoing videoproctography were placed in the left lateral decubitus position, after which 50 ml of liquid barium paste was introduced into the rectum. After this, approximately 100 ml of thick barium paste similar to stool in consistency was injected into the rectum, and the patient was instructed to defecate while video images were taken. For dynamic pelvic magnetic resonance imaging, air, to be used as contrast, was allowed to accumulate in the rectum via examination with the patient in the prone position. A capsule was taped to the perineal skin immediately posterior to the anal orifice for marking. Sagittal and axial T1 images were obtained through the pelvis at 8-mm intervals with dynamic breathhold sagittal images of the anorectal region obtained at rest and during strain and squeeze maneuvers. Total acquisition time per maneuver was approximately 19 seconds. The tests were performed by different examiners blinded to the result of the other evaluation. The investigations were independently interpreted, findings compared, and patients questioned regarding their impression of dynamic pelvic magnetic resonance imaging and videoproctography. From June 1996 to April 1997, 22 patients (15 females) with a mean age of 68 (range, 21-85) years underwent both videoproctography and dynamic pelvic magnetic resonance imaging. Dynamic pelvic magnetic resonance imaging was only able to detect 1 of 12 (8.3 percent) anterior rectoceles and one of two (50 percent) posterior rectoceles identified by videoproctography. It failed to recognize any of the rectoanal intussusception (zero of four) but did show 9 of 12 (75 percent) sigmoidoceles. Significant discrepancy of measurement of the anorectal angle and perineal descent exists between the two studies, and dynamic pelvic magnetic resonance imaging was not able to detect any (0 of 11) of the patients with increased fixed perineal descent and only half (one of two) of the patients with increased dynamic perineal descent noted on videoproctography. All 22 patients preferred dynamic pelvic magnetic resonance imaging over videoproctography because of greater comfort. Occasionally, the increased cost of new technology can be justified by the enhanced diagnostic yield. The ability to avoid unnecessary surgery or, conversely, to continue to search for otherwise occult pathology that can be surgically corrected justifies routine application of these new tools. However, this study has shown that, despite a cost of approximately ten times more for dynamic pelvic magnetic resonance imaging than for videoproctography, no clinical changes were made. Thus, on the basis of this study, we cannot endorse the routine application of dynamic pelvic magnetic resonance imaging for the evaluation of constipated patients. In certain selected individuals, it may play a role, but further study is necessary to clarify its exact role.