Pelvic Floor Disorders- Typically occur among women who have
given birth or have had a hysterectormy. General Pelvic pain,
Urinary Incontinence, Constipation Usually characterized by
abnormal pelvic organs displacement More than 300,000 surgeries
annually. PELVIC FLOOR
Slide 4
Ultrasound- Depict the anal sphincter complex and associated
pathologic changes in exquisite anatomic detail. Flouroscopy
Defecography- Is considered the Gold Standard for imaging Pelvic
Floor disorder. Is invasive and requires opacification of
Bladder,Vagina and Rectum. Uses Ionizing Radiation (Flouroscopy)
Fails to recognize associated abnormalities of the anterior and
middle pelvic compartments. DIAGNOSTIC MODALITIES
Pubococcygeal Line (PCL) - Pubococcygeal Line (PCL) - The
primary landmarks used to assess pelvic support. Prolapse Rule of
Three Organ below the PCL by 3 cm or less is mild Organ below the
PCL,between 3 and 6 cm is moderate Organ below the PCL by 6cm or
more are severe.
Slide 8
MR DEFECOGRAM Advantages : Elimination of ionizing radiation
Excellent depiction of surrounding soft tissues Allows assessment
of all three Compartments No Intravenous Contrast is needed Real
Time imaging Disadvantages : Claustro/Implants 30 minutes Exam Cost
Uncooperative patient
Slide 9
PATIENT PREPARATION Bowel cleansing enema cleansing 12-24 hours
prior to MRI Drink four cups of water (approx. 32 oz) over 30 min
prior MRI. - Distend Bladder(full bladder during exam). Provide
diapers, gown and have Radiologist explain the procedure. Inject
sonographic gel into vagina. - Opacify/Identify vagina (Female
Patients). Prepared and mixed gel with mashed potatoes. - Doped
with 1.5mL of gadolinium. Place patient in a right decubitus
position -200 ml of sonographic gel is put into the rectum
Slide 10
MR DEFECOGRAM Supplies: Diapers Bedpan Gloves Sonography Gel
60ml Syringes Barium Enema Bag KY Jelly (Lubricant) Blue Chuks
(Undercover) Towels
Slide 11
SSFSE/HASTE (T2) Fast,single shot (turbo spin echo) Relatively
motion insensitive Sagittal Scout for True Pelvis Performed at Rest
Use for PCL Baseline Artifacts in Bladder
Slide 12
SSFP (T2*) Fast, single shot(steady state) Relatively motion
insensitive Single Slice,multiple measurement Use for Cine
Evaluation (Real Time) No Cardiac or Respiratory Gating
Suceptibility Artifacts due to GRE
Slide 13
MR DEFECOGRAM PROTOCOL Protocol: Protocol: Axial T2 TSE T2
Haste Sagittal (Rest) T2* SSFP Cine Sagittal (Rest) T2* SSFP Cine
Sagittal (Contraction) T2* SSFP Cine Sagittal (Valsalva) T2* SSFP
Cine Coronal (Valsalva) T2* SSFP Cine Axial (Valsalva) T2* SSFP
Cine Sagiital (Evacuation) T2* SSFP Cine Coronal (Evacuation)
Slide 14
SSFP T2* Sagittal Cine 1.Pubic Symphysis 2.Rectum 3.Coccyx
THREE POINT POSITIONING 1 2 3
Slide 15
SSFP T2* Sagittal Cine Positioning SSFP T2* (Cine) Sag Rest PCL
in One Image
Slide 16
SSFP T2* Sagittal Cine Positioning SSFP T2* (Cine) Sag Rest
SSFP T2* (Cine) Sag Contraction
Slide 17
SSFP T2* Coronal Cine Positioning Need to be able to visualized
Anal Sphinter Sag SSFP CineSSFP T2* (Cine) Cor
Slide 18
SSFP T2* Axial Cine Positioning Sag SSFP CineSSFP T2* (Cine)
Axial
Slide 19
NORMAL ANATOMY MR DEFECOGRAM
Slide 20
Anterior Compartment Pathology MR DEFECOGRAM Cystocele- Occurs
when the supportive tissue between a woman's bladder wall weakens
and stretches, allowing the bladder to bulge into the vagina.
Middle Compartment Pathology MR DEFECOGRAM Vaginal Prolapse-
Occurs when pelvic floor muscles and ligaments stretch and weaken,
providing inadequate support for the uterus.
Middle Compartment Pathology MR DEFECOGRAM Enterocele - Occurs
when the small intestine descends into the lower pelvic cavity and
pushes at the top part of the vagina, creating a bulge.
Posterior Compartment Pathology MR DEFECOGRAM Rectocele Occurs
when there is a herniation of the rectum into the posterior vaginal
wall that results in a vaginal bulge.
PELVIC FLOOR Treatment: Mild Cases - Kegel exercise Moderate
Cases (Cystocele,Incotenience) Pessary may be used. Severe Cases
(Rectocele,Constipation)- Surgery may be necessary.
Slide 32
MR DEFECOGRAPHY LIMITATIONS Pitfalls/Drawbacks: No Bowel
cleansing/preparation. Inability to evacuate/defecate during
examination. Bend knees if needed. Suceptibility artifacts. HASTE
Cine (SSFSE) Implants
Slide 33
CONCLUSION MR Defecography: Provides an accurate and
comprehensive evaluation of the defecation process. It is superior
to fluoroscopic defecography, providing the ability to detect
associated abnormalities in the bladder and cervix/vagina.
Defecation phase imaging yields important additional information on
the presence and degree of pelvic floor abnormalities. The exam is
fast (approx. 30 minutes) and easily incorporates the defecation
phase in which 30% of abnormalities are missed.