Comparative Evaluation of Defecography phase to Non-

defecography Valsalva Maneuver in dynamic pelvic floor MRI

No Financial disclosures

Authors: Hina Arif1, Bobby Kalb1,Arash Meshksar1, Iva Petkovska1, Ferenc Pommersheim1, James Costello1, Joel Funk2 ,

Christian Twiss 2, Diego Martin1

Departments of Medical imaging 1 and Urology 2

University of Arizona, Tuscon, AZ.

•  Hidden women's health epidemic

•  50% middle aged & older are affected

•  Large health care cost: 30% reoperations

•  Unmet clinical need:

•  Paucity in understanding complex pelvic floor

dynamics

•  Limited pre operative evaluation: •  High recurrence rates •  Repeat surgery

PELVIC FLOOR DYSFUNCTION

To evaluate the utility of Defecography phase (DP) in

dynamic pelvic floor MRI, in comparison to non-

defecography Valsalva maneuver (VM).

PURPOSE

METHOD AND MATERIALS

All female patients who presented to pelvic floor clinic between Oct 2011- August 2015

Urinary: Sensation of incomplete emptying, urgency, incontinence,

nocturia, frequency

Fecal: incontinence, urgency, constipation

Vaginal prolapse or Dyspareunia

Findings of pelvic floor prolapse were demonstrated by Baden Walker system

PHYSICAL EXAMINATION

CLINICAL COMPLAINTS

INCLUSION CRITERIA

Study IRB-approved, HIPPA compliant

a) did not have a pelvic MRI performed, b) were of male gender, c) were unable to tolerate the gel administration or d) did not demonstrate expulsion of rectal

gel during defecography maneuvers.

EXCLUSION CRITERIA

MRI TECHNIQUE

MR Image acquisition:

• Fast imaging with steady-state free precession technique (True FISP)

• Mid sagittal acquisition was performed at rest, and during VM & DF

•  350-mm2 field of view, 256 × 208 matrix, partial Fourier acquisition of 7/8, 8-mm

section thickness, flip angle of 40°, acceleration factor of two Rest VM DF

Patient Preparation

• Insertion of ultrasound gel into rectum & vagina

• Instructions to strain (exert pressure against closed sphincter) and defecate

(expulsion of gel) during different phase of acquisition

•  Image review :

•  Image analysis was done in blinded

fashion by two radiologists with 13 & 5

years of experience in abdominal & pelvic

MRI

•  HMO system was employed for quantification

of pelvic floor descent

• Pubo-coccygeal line (PCL)

•  M-line

•  H-line

•  Presence of organ prolapse

•  Quantification of degree of organ prolapse

MR IMAGE ANALYSIS

Fielding J R Radiographics 2002;22:295-304

MR IMAGE ANALYSIS

Vertical distance of the

neck of urinary bladder

below the PCL

Cystocoele Ano-rectal junction prolapse Utero-vaginal Prolapse

•  M-line >2cm

• Rectum below the H-line

Descent from its position

on static images

RESULTS Statistics:

• Change in measurements of the PCL, H-line and M-line was calculated

between straining and defecation sequences.

• An unpaired t-test was used to compare the changes in measurements

between straining and defecation sequences for the PCL, H-line and M-

line, the degree of anorectal and vaginal prolapse, and the number of

patients with cystocele and rectocele.

• A p-value of < 0.05 was considered statistically significance.

Patient Demographics:

• The final study cohort consisted of 237 patients that met study

inclusion criteria (mean age 63 years, range 35-82 years).

RESULTS

Anorectal Prolapse

Cystourethrocele Vaginal vault prolapse

100%

71% 71%

86%

14%

43%

Defecography phase Valsalva maneuver

0

1

2

3

4

5

6

Cystocele Vaginal

prolapse Anorectal prolapse

Defecography phase Valsalva manoeuvre

Org

an

prol

apse

in

cm

Rectal descent = z = 2.80, p < 0.01 Cystocele descent = z = 5.70, p < 0.01 Vaginal vault descent = z = 4.14, p < 0.01

P <0.01

RESULTS

PCL H-line M-line

Resting phase

10.2 6.2 3.2

Valsalva manoeuvre

10.5 7.8 5.5

Defecography phase

7.8 13.4 7.6

RESULTS

•  Imaging of pelvic floor is complex; quantification and

assessment of pelvic floor prolapse remains challenging to the

radiologist and surgeons

•  Defecography phase in dynamic pelvic floor MR unmasks a

greater degree of instability involving either of the

compartments of pelvic floor

•  Better detection, and quantification of severity of cystocele,

vaginal prolapse and ano-rectal junction prolapse can be done

on DF in comparison to VM

DISCUSSION

CYSTOCELE GLOBAL PELVIC FLOOR PROLAPSE

Valsalva Maneuver Defecography Phase

ANO RECTAL PROLAPSE & RECTOCELE

Valsalva Maneuver Defecography Phase

Valsalva Maneuver Defecography Phase

UTERO-VAGINAL PROLAPSE

•  Pelvic floor structures may show mild instability or even

appear normal on the straining phase, with marked

prolapse subsequently revealed on DP imaging

CONCLUSION

•  Imaging in the Era of Comparative Effectiveness demands

evaluation pelvic floor dysfunction on the defecography

phase on dynamic pelvic floor MR examinations, which

currently and commonly based on assessment of pelvic

floor structures on only straining/Non-defecography

Valsalva Maneuver

•  Goh V, Halligan S, Kaplan G, et al. Dynamic MR imaging of the pelvic floor in asymptomatic subjects AJR Am J Roentgenol 2000; 174:661–66.

•  Hecht EM, Lee VS, Tanpitukpongse TP, et al. MRI of pelvic floor dysfunction: dynamic true fast imaging with steady-state precession versus HASTE. AJR Am J Roentgenol 2008; 191:352–358.

•  Lockhart ME, Fielding JR, Richter HE, et al. Reproducibility of dynamic MR imaging pelvic measurements: a multi-institutional study. Radiology 2008; 249:534-40.

•  Maglinte DD, Bartram CI, Hale DA, et al. Functional imaging of the pelvic floor. Radiology 2011; 258:23-39.

•  Mondot L, Novellas S, Senni M, et al. Pelvic prolapse: static and dynamic MRI. Abdom imaging 2007; 32:775-83.

•  Pannu HK, Kaufman HS, Cundiff GW, et al. Dynamic MR imaging of pelvic organ prolapse: spectrum of abnormalities. Radiographics 2000; 20:1567-82.

•  Pannu HK, Scatarige JC, et al. Comparison of supine magnetic resonance imaging with and without rectal contrast to fluoroscopic cystocolpoproctography for the diagnosis of pelvic organ prolapse. J Comput Assist Tomogr 2009; 33:125–130.

•  Roos JE, Weishaupt D, Wildermuth S, et al. Experience of 4 years with open MR defecography: pictorial review of anorectal anatomy and disease. Radiographics. 2002; 22:817-32.

•  Woodfield CA, Krishnamoorthy S, Hampton BS, et al. Imaging pelvic floor disorders: Trend toward comprehensive MRI. AJR Am J Roentgenol 2010; 194:1640-9.

•  Boyadzhyan L, Raman SS, Raz S. Role of static and dynamic MR imaging in surgical pelvic floor dysfunction. Radiographics 2008; 28:949-67.

•  Fielding JR. Practical MR imaging of female pelvic floor weakness. Radiographics 2002; 22:295-304.

•  Law YM, Fielding JR. MRI of pelvic floor dysfunction: Review. AJR Am J Roentgenol 2008; 191:S45-53.

•  Reiner CS, Weishaupt D. Dynamic pelvic floor imaging: MRI techniques and imaging parameters. Abdom Imaging 2012 Epub.

•  Bertschinger KM, Hetzer FH, Roos JE, et al. Dynamic MR imaging of the pelvic floor performed with patient sitting in an open-magnet unit versus with patient supine in a closed-magnet unit. Radiology 2002; 223:501–08.

•  Colaiacomo MC, Masselli G, Polettini E, et al. Dynamic MR imaging of the pelvic floor: a pictorial review. RadioGraphics 2009

•  El Sayed RF, El Mashed S, Farag A, et al. Pelvic floor dysfunction: Assessment with combined analysis of static and dynamic MR imaging findings. Radiology 2008; 248:518

•  Flusberg M, Sahni VA, Erturk SM, et al. Dynamic MR defecography: assessment of the usefulness of the defecation phase. AJR Am J Roentgenol 2011; 196:W394–W399.

REFERENCES