MRI defecography. Anatomic and functional Cine-based evaluation of the pelvic floor dysfunction.

Transcription

1 MRI defecography. Anatomic and functional Cine-based evaluation of the pelvic floor dysfunction. Poster No.: C-2583 Congress: ECR 2015 Type: Scientific Exhibit Authors: J. A. SAAVEDRA ABRIL, J. Galicia-Alba, F. CABRERA FLORES, R. RAMIREZ-CARMONA, S. SAAVEDRA NAVARRO ; MEXICO, DF/MX, Mexico/MX, Mexico DF/MX Keywords: Defecography, MR, Pelvis, Pelvic floor dysfunction DOI: /ecr2015/C-2583 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 26

2 Aims and objectives The pelvic floor dysfunction is a major health social problem, whose symptoms are nonspecific and diagnosis is difficult. Since the early 60 s, fluoroscopy is used, this technique provides a lot of information in the diagnosis of this disease, but exposure to radiation and patient discomfort have made this method is less used in many institutions. MRI defecography is a technique that evaluates the pelvic floor movements and the anorectal region. The purpose of this electronic presentation is illustrate the advantages of dynamic MRI evaluation of pelvic floor disfunction.1 Methods and materials Historical reference about the imaging techniques used for the evaluation of the pelvic floor disfunction. Description of the normal anatomy and physiology of pelvic floor. X-ray defecography generalities. MRI advantages and indications for the study of pelvic floor diseases. Description of the study method technic. Pictorial review of pelvic floor pathology. Conclussions. Results HISTORICAL REFERENCE The dynamic fluoroscopy technique of evacuation was described by Walden en In 1964 Burhenne describes the X-ray technique. 2 Page 2 of 26

3 In 1991 Yang et al and Kruyt et. al were the first to describe the use of MRI, at the beginning with static images and then with de use of dynamic video 3,4 images. In 1993, Schreyer et. al made a comparison between healthy women and patients with pelvic floor dysfunction using MRI. 4 NORMAL ANATOMY The pelvic floor: Complex system that provides active and pasive support. It has been divided in to 3 compartments: - Anterior ( bladder/urethra) - Medium ( Vagina/utherus) - Posterior (anus/rectum) It gives support by two forms: - Ligaments, fascia and bones (pasive support) - Levator ani muscle (active support) 3 layers: - Superior (endopelvic fascia) - Middle (Pelvic diaphragm) - Inferior (urogenital diaphragm) NORMAL PHYSIOLOGY # The main difference between the pelvic floor muscles with others is that these ones stay in a state of contraction and they relax during defecation. # The initial movement during defecation is the descent of the anorectal union and the anal opening. Page 3 of 26

4 # The anal canal empties its content very fast. When the patient finishes evacuation, the anorectal angle closes, the muscular tone of the levator ani muscle decreases and the pelvic floor rises again (post defecation reflex). DEFECOGRAPHY WITH X-RAY TECHNIQUE Disadvantage: Pacient radiation exposure. It is used a mixture of mashed potatoes with barium of difficult introduction; which is annoying for patient. Advantages: It requires relatively little training. 6 Patient positioning is the most similar to the normal physiological situation. ADVANTAGES OF MRI There is no radiation exposure. This allows you to repeat any sequence as many times as necessary. The study time is similar to X-ray defecography. The patient preparation is less uncomfortable. The HMO system provides a standardized measurement of pelvic floor dysfunction and generates an objective interobserver agreement. INDICATIONS Ano rectal function disorders: Frequent indications for medical examination: - Constipation - Incomplete defecation - Anismus - Prolapse Page 4 of 26 5

5 Associate disorders: - Enterocele - Cystocele - Uterovaginal prolapse STUDY PROTOCOL Use of a laxative agent 24 hours before the procedure. Fasting is not necessary. The bladder may be partially empty. MRI 1.5 T close field GE MR 450. The rectum must be filled with ml of ultrasound gel; at our institution we have obtained good results without using gel mixtures with gadolinium 4 described by other authors. The patient must be in anterior supine position, with both knees flexed and with an adult diaper. The first step is to obtain simple static images to study the morphology of the pelvic floor in coronal, sagittal and axial T2 weighted images. The second step is to obtain fast dynamic sagittal sequences in T2 with video: - At rest. - Sustained contraction. - Valsalva. - During defecation. In some cases a series of images at post defecation phase are required to evaluate the possibility of intussusception. IMAGING FINDINGS HMO System: 6 Standardized evaluation of pelvic floor. H: Puborectalis hiatus line ( from the puborectalis muscle to the coccyx). Page 5 of 26

6 M: Line of descent of the pelvic floor, perpendicular to the pubococcygeal line to the back of H line ( anorectal junction). O: Organ prolapse. Pubococcygeal line 6,7,8,9,10 Straight line drawn from the lower part of the pubic bone to the last coccygeal articulation. It is the most important reference. The movement of the pelvic floor is measured perpendicular to this line with the M line. Other lines that are used for the objective differentiation of the the pelvic region 10 compartments are: The perineal line is passing through the posterior surface of the pubis. The middle pubic line passes through the center of the long axis of the pubis. Himen line which is parallel to the edge of the pubis and crosses the urethral meatus, which is localized with an oil marker. These lines are used as a recommendation of the International Continence Society for assessment of urogenital prolapse Anorectal angle 10 3,4,6,9,10,11 Formed by a line through the posterior wall of the rectum and another that follows the long axis of the anal canal with reference to anal rectal junction. At rest has a usual measure 95 to 96 range of 65 to 100 º. It is an indirect indicator of the activity of the rectus anal muscle. It is an acute angle near 75 during contraction; being notorious the impression of the puborectalis muscle which indicates activity of the levator ani muscle. It is obtuse angle in relaxation. PELVIC FLOOR PATHOLOGY Anterior rectocele: Page 6 of 26

7 Ventral bulging of the front wall of the rectus of mm. It is classified into three grades: 9,10 - Slight non significant: < than 2 cm - Moderate: between 2 and 4 cm - Severe: > than 4 cm or more. Intussusception and rectal prolapse Produce obstruction for the exit of the rectal content. Often associated with the solitary ulcer syndrome. It is divided into anorectal, intrarectal or external. It can be simple or complete depending on the extent from the wall. Enterocele 7,9,10 7,10 The perineal line passes through the posterior surface of the pubis. It is associated with symptoms of pressure and descent of the pelvic floor. Usually seen post-hysterectomy. Introduction of the peritoneum in the rectovaginal space. It may contain flanges or sigmoid colon. It is classified in 6 - Small: 3 cm - Mid: 3-6 cm - Big: more than 6 cm Perineal descent syndrome 10,11 Hypotonic pelvic floor. Frequent in elderly. Represents evacuation difficulty, incomplete emptying or incontinence. Caudal migration of the ano rectal junction > than 3.5 cm. Anorectal angle greater than 130 at rest and greater than 155 during Valsalva. Dyssynergic defecation (anismus) 9,11 Delayed onset of defecation of any amount or less than 1/3 the anal content within 60 seconds. Decrease in the anorectal angle during Valsalva. Page 7 of 26

8 Presence of paradoxical sphincter contractio or poor pelvic floor descent during Valsalva maneuver and defecation. Normal.dotm CT Scanner Lomas Altas false 18 pt 18 pt 0 0 false false false Normal.dotm CT Scanner Lomas Altas false 18 pt 18 pt 0 0 false false false Images for this section: Fig. 1: Normal Anatomy Page 8 of 26

9 Fig. 2: Normal Anatomy Page 9 of 26

10 Fig. 3: Rest Page 10 of 26

11 Fig. 4: Contraction Page 11 of 26

12 Fig. 5: Valsalva Page 12 of 26

13 Fig. 6: Evacuation Page 13 of 26

14 Table 1: Study Protocol Fig. 7: HMO System Reference Lines Page 14 of 26

15 Fig. 8: Measuring the anorectal angle in the dynamic phase Page 15 of 26

16 Fig. 9: Rectocele dynamic sequences Page 16 of 26

17 Fig. 10: Rectal prolapse and cystocele Page 17 of 26

18 Fig. 11: Grade III Rectal Prolapse Page 18 of 26

19 Fig. 12: Uterovaginal prolapse and cystocele are evaluated based on the pubococcygeal line during defecation. Page 19 of 26

20 Fig. 13: Enterocele Page 20 of 26

21 Fig. 14: Enterocele Page 21 of 26

22 Fig. 15: Peritoneocele 2 Page 22 of 26

23 Fig. 16: Peritoneocele and rectal prolapse senondary to pelvic mass complex Page 23 of 26

24 Fig. 17: Anismus Page 24 of 26

25 Conclusion CONCLUSIONS: MRI Defecography is better than X-ray Defecography by its multiplanar capacity, contrast in soft tissue, which are great advantages during the study of the anatomical and functional evaluation of pelvic floor. This method allows less discomfort in the preparation and patient positioning. No radiation exposure so sequences can be repeated several times. The position does not seem to be a limiting factor for the diagnosis of rectocele and prolapse. Personal information References Normal.dotm CT Scanner Lomas Altas false 18 pt 18 pt 0 0 false false false Stefan Lissne. The Pathophysiology, Diagnosis and Treatment of Constipation. Deutsches Ärzteblatt International. Dtsch Arztebl Int 2009; 106(46). Wallden L. Defecation block in cases of rectogenital pouch. Acta Chir Scand1952 (suppl 165): Yang A, Mostwin JL, Rosenshein NB, Zerhouni EA. Pelvic floor descent in women: dynamic evaluation with fast MR imaging and cinematic display. Radiology1991; 179: Andreas G Schreyer, Christian Paetzel, Alois Fürst. Dynamic magnetic resonance defecography in 10 asymptomatic volunteers World J Gastroenterol 2012 December 14; 18(46): Dean D. T. Maglinte, Clive I. Bartram, Douglass A. Hale. Functional Imaging of the Pelvic Floor. Radiology January 2012: Volume 258: Number 1. Lousine Boyadzhyan, Steven S. Raman, Shlomo Raz. Role of Static and Dynamic MR Imaging in Surgical Pelvic Floor Dysfunction. RadioGraphics 2008; 28: Page 25 of 26

26 7. Koenraad J. Mortele, Janice Fairhurst. Dynamic MR defecography of the posterior compartment: Indications, techniques and MRI features. European Journal of Radiology 61 (2007) Alfonso Reginelli, Graziella Di Grezia,Gianluca Gatta.,Role of conventional radiology and MRI defecography of pelvic floor hernias. Reginelli et al. BMC Surgery 2013, 13(Suppl 2):S53 9. Niccoló Faccioli, Alessio Comai, Paride Mainardi. Defecography: a practical approach. Diagn Interv Radiol 2010; 16: Marie#lle M. E. Lakeman & F. M. Zijta & J. Peringa. Dynamic magnetic resonance imaging to quantify pelvic organ prolapse: reliability of assessment and correlation with clinical findings and pelvic floor symptoms. Int Urogynecol J (2012) 23: C S Reiner, Tutuian, E Solopova. MR defecography in patients with dyssynergic defecation: spectrum of imaging findings and diagnostic value. The British Journal of Radiology, 84 (2011), Page 26 of 26