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Defecation versus pre- and post-defecation Valsalva maneuvers for dynamic MR assessment of pelvic floor dysfunction

  • Gaurav KhatriEmail author
  • Neil M. Kumar
  • Yin Xi
  • William Smith
  • Chasta Bacsu
  • April A. Bailey
  • Philippe E. Zimmern
  • Ivan Pedrosa
Special Section: Pelvic Floor
  • 17 Downloads

Abstract

Purpose

To compare prevalence and severity of multi-compartment pelvic floor dysfunction between supine magnetic resonance defecography with defecation (MRD) and supine dynamic MRI during Valsalva, both with and without rectal distention.

Methods

This was an IRB-approved, HIPAA-compliant retrospective review of consecutive patients referred for MR Defecography. MRD protocol included imaging at rest, during pre-defecation Valsalva (Pre-DV), defecation (Def), and post-defecation Valsalva (Post-DV). The Post-DV images were performed after complete evacuation either during the defecation acquisition or, in cases where patient was unable to defecate during the examination, in a conventional toilet. Size of cystocele, vaginal prolapse, anorectal (AR) descent, and enterocele were measured on all acquisitions relative to the pubococcygeal line. Rectocele size was recorded in anteroposterior dimension. The presence or absence of rectal intussusception (RI) was documented. The prevalence, absolute size, and grades of prolapse, rectocele, and RI were compared between the acquisitions using pair-wise ANOVA, Friedman, Dunn pair-wise, and Cochran–Mantel–Haenszel tests.

Results

30 patients were included in the final analysis. Higher prevalence of cystocele, vaginal prolapse, enterocele, AR descent grade 2 or higher, rectocele grade 2 or higher, and RI were seen on Def compared to Post-DV and Pre-DV. Cystocele, vaginal prolapse, enterocele, AR descent, and rectocele sizes were significantly larger on Def compared to Post-DV by 0.7−1.95 cm (p ≤ 0.007). Prolapse in all compartments and rectocele size were significantly larger on Def compared to Pre-DV (p < 0.0001). Cystocele, vaginal prolapse, and enterocele sizes were significantly larger on Post-DV compared to Pre-DV (p < 0.0001). There were significant differences in grading of all types of prolapse and rectocele between the various acquisitions of MRD (p < 0.0001). Cystocele, AR descent, and rectocele grades were significantly higher on Def compared to Post-DV (p range ≤ 0.0002). Grading of all types of prolapse and rectocele was significantly higher on Def compared to Pre-DV (p < 0.0001). Cystocele, vaginal prolapse, and enterocele grades were all significantly higher on Post-DV compared to Pre-DV (p  ≤ 0.0007).

Conclusion

Defecation images during supine MRD elicit higher prevalence and size of prolapse of all pelvic compartments in comparison to both pre- and post-defecation Valsalva images. Post-defecation Valsalva images show larger size of anterior and middle compartment prolapse than pre-defecation Valsalva images. Functional evaluation of pelvic floor dysfunction with MRI should include image acquisition during defecation. If Valsalva images are acquired, these should be performed after the defecation acquisition and without rectal distention.

Keywords

MR defecography Pelvic organ prolapse MR Valsalva Dynamic pelvic floor MRI Defecation Pelvic floor dysfunction 

Notes

Funding

None.

References

  1. 1.
    Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, Spino C, Whitehead WE, Wu J, Brody DJ, Pelvic Floor Disorders N (2008) Prevalence of symptomatic pelvic floor disorders in US women. JAMA 300 (11):1311-1316.  https://doi.org/10.1001/jama.300.11.1311 CrossRefGoogle Scholar
  2. 2.
    Weber AM, Abrams P, Brubaker L, Cundiff G, Davis G, Dmochowski RR, Fischer J, Hull T, Nygaard I, Weidner AC (2001) The standardization of terminology for researchers in female pelvic floor disorders. Int Urogynecol J Pelvic Floor Dysfunct 12 (3):178–186.  https://doi.org/10.1007/PL00004033 CrossRefGoogle Scholar
  3. 3.
    Clark AL, Gregory T, Smith VJ, Edwards R (2003) Epidemiologic evaluation of reoperation for surgically treated pelvic organ prolapse and urinary incontinence. American Journal of Obstetrics and Gynecology 189 (5):1261-1267.  https://doi.org/10.1067/S0002-9378(03)00829-9 CrossRefGoogle Scholar
  4. 4.
    Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL (1997) Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstetrics and gynecology 89 (4):501-506.  https://doi.org/10.1016/s0029-7844(97)00058-6 CrossRefGoogle Scholar
  5. 5.
    Maglinte DDT, Kelvin FM, Fitzgerald K, Hale DS, Benson TJ (1999) Association of compartment defects in pelvic floor dysfunction. AJR Am J Roentgenol 172 (2):439-444.  https://doi.org/10.2214/ajr.172.2.9930799 CrossRefGoogle Scholar
  6. 6.
    Kelvin FM, Hale DS, Maglinte DD, Patten BJ, Benson JT (1999) Female pelvic organ prolapse: diagnostic contribution of dynamic cystoproctography and comparison with physical examination. AJR Am J Roentgenol 173 (1):31-37.  https://doi.org/10.2214/ajr.173.1.10397095 CrossRefGoogle Scholar
  7. 7.
    Flusberg M, Sahni VA, Erturk SM, Mortele KJ (2011) Dynamic MR defecography: assessment of the usefulness of the defecation phase. AJR Am J Roentgenol 196 (4):W394-399.  https://doi.org/10.2214/ajr.10.4445 CrossRefGoogle Scholar
  8. 8.
    Arif-Tiwari H, Twiss CO, Lin FC, Funk JT, Vedantham S, Martin DR, Kalb BT (2019) Improved Detection of Pelvic Organ Prolapse: Comparative Utility of Defecography Phase Sequence to Nondefecography Valsalva Maneuvers in Dynamic Pelvic Floor Magnetic Resonance Imaging. Curr Probl Diagn Radiol 48 (4): 342-347.  https://doi.org/10.1067/j.cpradiol.2018.08.005 Google Scholar
  9. 9.
    Bhan SN, Mnatzakanian GN, Nisenbaum R, Lee AB, Colak E (2016) MRI for pelvic floor dysfunction: can the strain phase be eliminated? Abdom Radiol (NY) 41 (2):215-220.  https://doi.org/10.1007/s00261-015-0577-7 CrossRefGoogle Scholar
  10. 10.
    Hassan HH, Elnekiedy AM, Elshazly WG, Naguib NN (2016) Modified MR defecography without rectal filling in obstructed defecation syndrome: Initial experience. Eur J Radiol 85 (9):1673-1681.  https://doi.org/10.1016/j.ejrad.2016.06.014 CrossRefGoogle Scholar
  11. 11.
    Reiner CS, Weishaupt D (2013) Dynamic pelvic floor imaging: MRI techniques and imaging parameters. Abdom Imaging 38 (5):903-911.  https://doi.org/10.1007/s00261-012-9857-7 CrossRefGoogle Scholar
  12. 12.
    Kelvin FM, Maglinte DD, Hornback JA, Benson JT (1992) Pelvic prolapse: assessment with evacuation proctography (defecography). Radiology 184 (2):547-551.  https://doi.org/10.1148/radiology.184.2.1620863 CrossRefGoogle Scholar
  13. 13.
    Pannu HK, Javitt MC, Glanc P, Bhosale PR, Harisinghani MG, Khati NJ, Mitchell DG, Nyberg DA, Pandharipande PV, Shipp TD, Siegel CL, Simpson L, Wall DJ, Wong-You-Cheong JJ (2015) ACR Appropriateness Criteria pelvic floor dysfunction. Journal of the American College of Radiology : JACR 12 (2):134-142.  https://doi.org/10.1016/j.jacr.2014.10.021 CrossRefGoogle Scholar
  14. 14.
    Bertschinger KM, Hetzer FH, Roos JE, Treiber K, Marincek B, Hilfiker PR (2002) 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 223 (2):501-508.  https://doi.org/10.1148/radiol.2232010665 CrossRefGoogle Scholar
  15. 15.
    Dietz HP, Simpson JM (2008) Levator trauma is associated with pelvic organ prolapse. BJOG : an international journal of obstetrics and gynaecology 115 (8):979-984.  https://doi.org/10.1111/j.1471-0528.2008.01751.x CrossRefGoogle Scholar
  16. 16.
    Thomaz RP, Colla C, Darski C, Paiva LL (2018) Influence of pelvic floor muscle fatigue on stress urinary incontinence: a systematic review. Int Urogynecol J 29 (2):197-204.  https://doi.org/10.1007/s00192-017-3538-6 CrossRefGoogle Scholar
  17. 17.
    Tumbarello JA, Hsu Y, Lewicky-Gaupp C, Rohrer S, DeLancey JOL (2010) Do repetitive Valsalva maneuvers change maximum prolapse on dynamic MRI? International Urogynecology Journal 21 (10):1247-1251.  https://doi.org/10.1007/s00192-010-1178-1 CrossRefGoogle Scholar
  18. 18.
    Lockhart ME, Fielding JR, Richter HE, Brubaker L, Salomon CG, Ye W, Hakim CM, Wai CY, Stolpen AH, Weber AM (2008) Reproducibility of dynamic MR imaging pelvic measurements: a multi-institutional study. Radiology 249 (2):534-540.  https://doi.org/10.1148/radiol.2492072009 CrossRefGoogle Scholar
  19. 19.
    Lakeman MM, Zijta FM, Peringa J, Nederveen AJ, Stoker J, Roovers JP (2012) Dynamic magnetic resonance imaging to quantify pelvic organ prolapse: reliability of assessment and correlation with clinical findings and pelvic floor symptoms. Int Urogynecol J 23 (11):1547-1554.  https://doi.org/10.1007/s00192-012-1772-5 CrossRefGoogle Scholar
  20. 20.
    Hetzer FH, Andreisek G, Tsagari C, Sahrbacher U, Weishaupt D (2006) MR defecography in patients with fecal incontinence: imaging findings and their effect on surgical management. Radiology 240 (2):449-457.  https://doi.org/10.1148/radiol.2401050648 CrossRefGoogle Scholar
  21. 21.
    Attenberger UI, Morelli JN, Budjan J, Herold A, Kienle P, Kleine W, Hacker A, Baumann C, Heinzelbecker J, Schoenberg SO, Michaely HJ (2015) The value of dynamic magnetic resonance imaging in interdisciplinary treatment of pelvic floor dysfunction. Abdom Imaging 40 (7):2242-2247.  https://doi.org/10.1007/s00261-015-0476-y CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of RadiologyUniversity of Texas Southwestern Medical CenterDallasUSA
  2. 2.Department of RadiologyJohn Hopkins UniversityBaltimoreUSA
  3. 3.Department of UrologyUniversity of Texas Southwestern Medical CenterDallasUSA
  4. 4.High Plains Radiological AssociationAmarilloUSA

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