Magnetic Resonance Imaging Defecograhy technique

PRESENTATION CONTAINS ABOUT THE PROCEDURE OF MRI DEFECOGRAPHY, METHOD, PULSE SEQUENCES USED FOR THE PROCEDURE, IMAGE QUALITY IN DIFFERENT SEQUENCES INDICATIONS AND CONTRADICTION OF PROCEDURE

1. MR DEFECOGRAM PROCEDURE/ MR IMAGING OF PELVIS FLOOR  PRESENTED BY : YASHAWANT KUMAR YADAV M.Sc MIT 1 ST YEAR NAMS , BIR HOSPITAL

2. OUTLINES INTRODUCTION  BASIC ANATOMY OF PELVIS FLOOR  BASIC LINES IN PELVIS FLOOR INDICATIONS PATIENT PREPARATION PROTOCOL AND TECHNIQUES FINDINGS REFERENCES

3. Introduction  Functional disorders of the pelvic floor refer to a group of medical conditions that affect the ligaments, fasciae, and muscles that together support the pelvic organs. In  more than 15% of multiparous women this condition is common . the demand for services related to treatment of this conditions is estimated to rise 45% from 2000 to 2030 based on the aging of the population.  Since these pelvic dysfunctions manifest as organ prolapse and/or urinary and defecatory dysfunctions, carry a significant burden in the quality of life.

4. Pelvis floor Anatomy The pelvic floor is divided into three anatomic compartments: Anterior, Middle, and Posterior, connected by structures responsible for the pelvic support: craniocaudally, these are respectively the  Endopelvic fascia, The  pelvic diaphragm, and  The  urogenital diaphragm.

5. Contd ….. The pelvic supporting structures are formed by three layers (listed from cranial to caudal aspects): the endopelvic fascia, pelvic diaphragm, and urogenital diaphragm.

6. Contd.... F ollowing both the anatomic division of the pelvic floor into anterior, middle, and posterior compartments, and the medical specialization into urology, gynecology, and proctology. 1. Compartmentalization is used to organize various conditions. 2. This approach partly leads to common treatment failures in surgical procedures. 3. The reason for these failures is that the pelvic floor operates as a unified structure. 4. Pelvic  weakness frequently is generalized, affecting more than one compartment.

7. Contd …. All patients undergo colonoscopy prior to the MRD to exclude other colonic pathologies like colon neoplasms and polyps.

8. Contd …

9. Anatomical classification Female pelvis is divided in to 3 compartments

10. Male pelvis In men, the pelvis is divided into two functional compartments: anterior (genitourinary) and posterior (anorectal) From the cranial to caudal aspects, the supporting structures are formed by the pelvic diaphragm, urogenital diaphragm, and superficial perineal pouch.

11. Contd …… Considering that most of the endopelvic fascia is not visualized with imaging, the intact status of the fascia is inferred by the normal appearance of the pelvic organs.

12. Anterior compartment Stress urinary incontinence (SUI) is the most common type of urinary incontinence in women, commonly caused by a defect in the urethral support system . Other pathological causes have been attributed to urethral hypermobility, intrinsic sphincter deficiency, or urethral trauma (e.g., resulting from childbearing, surgical trauma, prolonged increased abdominal pressure). Women suffering from SUI often fear urinary leakage and are therefore impaired in their social or physical activities

13. Middle compartment Women affected by levator ani trauma (e.g., caused by vaginal childbirth) may suffer from non-specific complaints as abnormal emptying of the bladder, frequency and urgency, organ protrusion, pelvic pain, or pressure, as well as from dyspareunia and urinary or fecal incontinence.

14. Posterior Compartment The obstructed defecation syndrome (ODS) is the most frequent symptom related to the posterior compartment and may be sustained either by mechanical causes (e.g., rectal prolapse, rectal descent, rectal invagination, rectocele, enterocele) or by a functional disorder (puborectalis syndrome, dyssynergic defecation) Common symptoms of rectal prolapse include constipation, sensation of incomplete evacuation, fecal incontinence, and rectal ulceration with bleeding.

15. Contd ….. The first and most important line is the pubococcygeal line (PCL) , a straight line connecting the inferior border of the pubic symphysis to the last coccygeal joint, representing the plane of attachment of the pelvic floor muscles, used as reference for measuring organ prolapses and drawn in the midline sagittal plane.

16. H –line PCL (yellow line) drawn from the inferior aspect of the symphysis pubis to the last coccygeal joint. The H line (blue line,) is used to determine the anteroposterior diameter of the pelvic hiatus and extends from the inferior aspect of the pubic symphysis to the posterior rectal wall at the anorectal junction. Normal when it measures less than or equal to 5 cm.

17. M – line The M line (double-headed arrow) is a perpendicular line from the PCL to the posterior-most aspect of the H line. The M line is used to evaluate the caudal descent of the pelvic floor and is normal when it measures less than 2 cm

18. Ano rectal angle Indirect assessment of puborectalis muscle tone and strength. At rest, the angle should measure between 108° and 127°. During defecation, it should open and be wider, increasing by 15°–20°, compared with its width at rest The anorectal angle is formed between the posterior walls of the rectum and anal canal at the anorectal junction

19. INDICATIONS 1. Rectal Outlet Obstruction: where there is difficulty in stool passage due to functional or anatomical obstruction at the rectum or anal canal. 2. Rectocele : Helps in assessing the protrusion of the rectum into the vagina, particularly during defecation,  3. Recurrent Pelvic Organ Prolapse: Useful in evaluating the recurrence of prolapse of pelvic organs like the bladder, uterus, or rectum, especially after surgery. 4. Anismus ( Dyssynergic Defecation): Paradoxical contraction of the pelvic floor muscles during defecation instead of relaxation, causing difficulty in stool passage.

20. Contd.... 5. Enterocele and  Sigmoidocele : Identifies herniation of the small intestine (enterocele) or sigmoid colon ( sigmoidocele ) into the rectovaginal space, which can impact bowel function. 6. Pelvic Floor Dyssynergia: Evaluates the lack of coordination between pelvic floor muscles and anal sphincters during defecation. 7. Intussusception and Internal Rectal Prolapse:  8. Assessment Post-Surgery:  9. enteroceles, and spastic perineum 10. Obstructed defecation syndrome (ODS)

21. Enterocele Rectocele

22. Descending Perineum As the name suggests, it represents abnormal descent of one or all the three compartments of the pelvic floor due to poor muscle tone. Additional opacification of the vaginal vault by ultrasound jelly may be performed to obtain a tricompartmental MRD (urine in bladder is a natural contrast) which may better delineate the degree of descent.

23. Tri compartmental study .

24. PATIENT PREPARETION Patient is asked to have laxative for bowel clearance if possible …. Pt should well hydrated  MR basic preparation is needed like metallic object removal prior to study. Well written consent about the procedure is taken before the examination  Patient is well explained about the procedures and the different maneuver's for examination.

25. Risk factors include Female gender, pregnancy, multiparity, pelvic surgery, obesity, menopause, advanced age, connective tissue disorders, smoking, and any condition that may increase intraabdominal pressure, such as chronic pulmonary obstructive disease

26. Dynamic cystocolpodefecography It  remains a useful technic for functional assessment of the pelvic organs , being easily available, and respecting a physiological sitting position.

27. Dynamic cystocolpodefecography

28. MRI Defecography  MR defecography presents several advantages in regard to its alternative:  It  is less invasive, less time consuming, radiation-free and displays a simultaneous multiplanar dynamic evaluation of the three pelvic compartments, with high spatial and temporal resolution. MRI defecography  has been shown to be a superior method for evaluation of posterior compartment disorders and, regarding pelvic organ prolapses, has been proven to be reliable and with similar effectiveness as fluoroscopy.

29. Contd.... 1. Typically performed in a supine position, which does not mimic natural evacuation posture and ignores gravity's impact. 2. The advent of open-magnet units allows for more diverse positioning options. 3. Research shows improved and more detailed visualization of pelvic floor laxity in a sitting position. 4. Sitting position also enhances detection of rectal intussusception and offers better classification of various pelvic prolapses. 5. Despite these differences, both supine and sitting techniques demonstrate similar effectiveness in identifying clinically significant findings during pelvic floor assessments.

30. Contd... The American College of Radiology (ACR) released updated Appropriateness Criteria for Pelvic Floor Dysfunction. This publication highlights that: 1. Fluoroscopic cystocolpodefecography and MR defecography with rectal contrast opacification are both considered suitable methods. 2. These techniques receive equal ratings in terms of their effectiveness for evaluating disorders in various compartments of the pelvic floor. *with preference for MR defecography in assessing defecatory dysfunctions.

31. Contd.... In anal incontinence both,  Endorectal  ultrasound and pelvic MRI are preferred for assessing the anal sphincter,  But  it is indicated that MR defecography should be considered for evaluation of the entire pelvic floor in order to assess both the pelvic musculature and other possible associated abnormalities

32. Contd.... The European Society of Urogenital Radiology (ESUR) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) co-authored an article on imaging recommendations for pelvic floor dysfunction, detailing the following points: 1. They outlined specific indications where MR defecography is suitable. 2. There was a high level of consensus (85–92%) among the authors for using MR defecography to assess conditions like rectal outlet obstruction, rectocele, recurrent pelvic organ prolapse, and anismus . 3. For all other types of pelvic floor pathologies, the agreement amongst authors was at least moderate, ranging from 54% to 77%.

33. Basic preparation for protocol Patient should prepare with NPO 12 hour before the study day with clean bowel preparation …  Laxative should be recommended  for bowel clearance .  Patient should be explained about the procedure in details . 150-300 ml of ultrasound gel is prepared. Patient is asked to rotate in left or right side and anal opening is accessed . 50 ml irrigation syringes are used to inject the gel into the rectum.  Xylocangelly is used in the tip of irrigation syringe to prevent pain. Patient is been well explained and practiced about the procedure steps 

34. Protocol for defecography

35. General protocol 3 Planes Survey T2W COR THIN SECTION T2W_ SSH REST SAG BTFE_ BH REST SAG T2W _SSH SQUEEZ SAG BTFE_ BH SQUEEZ SAG T2W _SSH STRAIN SAG BTFE_ BH STRAIN SAG T2W _SSH DEFEC SAG BTFE_ BH DEFEC SAG T2W TSE SAG / AXIAL / COR

36. Contd …. Anal sphincter injuries can contribute to posterior compartment disorders. Therefore, referring surgeons and gastroenterologists may request concurrent endoanal evaluation during MRDP. High-contrast-resolution T2-weighted small field-of-view multiplanar MR images of the anal sphincter complex are acquired with an endorectal coil in place before the administration of rectal contrast medium.

37. Procedure US gel is introduced into the rectum by using a pediatric enema catheter 150-300ml. In keeping with consensus recommendations, vaginal gel is not routinely administered at our practice . If vaginal gel is used, the volumes can range between 5 and 60 mL, depending on patient comfort and institutional practice. Post-defecation Valsalva imaging is important, as it reveals a greater extent of Post-defecation Valsalva imaging is important, as it reveals a greater extent of

38. Sequences

39. Dynamic sequence acquisitions Rest phase

40. Squeeze phase Anal sphincters inward, so as to elevate the pelvic floor.

41. Strain phase

42. Defecation phase

43. CONTD…. Posterior compartment disorders that are demonstrable with MRDP include rectal intussusception (including extra-anal intussusception or rectal prolapse), rectocele, levator ani and perineal abnormalities, sphincter abnormalities, anterior and middle compartment disease, dyssynergia, and solitary rectal ulcer syndrome.

44. COTD... 1. Emphasizing the critical role of the evacuation phase in pelvic floor disorder assessments is crucial. 2. This phase is particularly effective for detecting and grading issues such as:    - Pelvic organ prolapses    - Pelvic floor descents    - Rectal intussusceptions 3. The evacuation phase demonstrates a higher sensitivity in identifying these conditions..

45. Case ….

46. case

47. Extra anal intussusception

48. Solitary rectal ulcer

49. Rectocele

50. Surgical evaluation / perspective

51. Pre and post operative case

52. Thank you !

53. REFERENCES Thapar RB, Patankar RV, Kamat RD, Thapar RR, Chemburkar V. MR defecography for obstructed defecation syndrome. Indian Journal of Radiology and Imaging. 2015 Jan;25(01):25–30. Revels JW, Mansoori B, Fadl S, Wang SS, Olson MC, Moran SK, et al. MR Defecating Proctography with Emphasis on Posterior Compartment Disorders. RadioGraphics . 2023 Jan 1;43(1):e220119. Salvador JC, Coutinho MP, Venâncio JM, Viamonte B. Dynamic magnetic resonance imaging of the female pelvic floor—a pictorial review. Insights Imaging. 2019 Dec;10(1):4. Maccioni F, Alt CD. MRI of the Pelvic Floor and MR Defecography. In: Hodler J, Kubik-Huch RA, Von Schulthess GK, editors. Diseases of the Abdomen and Pelvis 2018-2021 [Internet]. Cham: Springer International Publishing; 2018 [cited 2024 Jan 20]. p. 13–20. (IDKD Springer Series). Available from: http://link.springer.com/10.1007/978-3-319-75019-4_2 Parry AH, Wani AH. RETRACTED ARTICLE: Evaluation of obstructed defecation syndrome (ODS) using magnetic resonance defecography (MRD). Egypt J Radiol Nucl Med. 2020 Dec;51(1):78.