1. EDUARDO D CAMPUZANO BS,RT(R,MR,CT)
MR DEFECOGRAM
EDUARDO D CAMPUZANO
BS,RT(R,MR,CT)

2. OBJECTIVES
INDICATIONS
PREPARATIONS
PROTOCOL
FINDINGS
PITFALLS
SUMMARY

3. PELVIC FLOOR
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.

4. DIAGNOSTIC MODALITIES
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.

5. Pelvic Diaphragm ( Levator Ani & Coccygeous Muscle Grpups)
PELVIC FLOOR ANATOMY
Three Compartments:
Anterior Compartment – Bladder & Urethra
Middle Compartment – Uterus,Cervix & Vagina
Posterior Compartment – Ano-Rectum
Pelvic Diaphragm ( Levator Ani & Coccygeous Muscle Grpups)

6. PELVIC FLOOR ANATOMY

7. PELVIC FLOOR ANATOMY
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.

8. MR DEFECOGRAM Advantages : Disadvantages :
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

9. PATIENT PREPARATION
Bowel cleansing enema cleansing 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

10. MR DEFECOGRAM Supplies: Diapers Bedpan Gloves Sonography Gel
60ml Syringes
Barium Enema Bag
KY Jelly (Lubricant)
Blue Chuks (Undercover)
Towels

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

12. Suceptibility Artifacts due to GRE
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

13. MR DEFECOGRAM 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)

14. THREE POINT POSITIONING
SSFP T2* Sagittal Cine
THREE POINT POSITIONING 1 2 3
Pubic Symphysis
Rectum
Coccyx

15. SSFP T2* Sagittal Cine Positioning
SSFP T2* (Cine) Sag Rest
PCL in One Image

16. SSFP T2* Sagittal Cine Positioning
SSFP T2* (Cine) Sag Rest
SSFP T2* (Cine) Sag Contraction

17. SSFP T2* Coronal Cine Positioning
Sag SSFP Cine
SSFP T2* (Cine) Cor
Need to be able to visualized Anal Sphinter

18. SSFP T2* Axial Cine Positioning
Sag SSFP Cine
SSFP T2* (Cine) Axial

19. MR DEFECOGRAM
NORMAL ANATOMY

20. MR DEFECOGRAM Anterior Compartment Pathology
Cystocele- Occurs when the supportive tissue between a woman's bladder wall weakens and stretches, allowing the bladder to bulge into the vagina.

21. MR DEFECOGRAM
Anterior Compartment
Pathology
Cystocele

22. MR DEFECOGRAM Middle Compartment Pathology
Vaginal Prolapse- Occurs when pelvic floor muscles and ligaments stretch and weaken, providing inadequate support for the uterus.

23. MR DEFECOGRAM Middle Compartment Pathology Vaginal Prolapse REST
STRAIN
Vaginal Prolapse

24. MR DEFECOGRAM Middle Compartment Pathology
Enterocele - Occurs when the small intestine descends into the lower pelvic cavity and pushes at the top part of the vagina, creating a bulge.

25. MR DEFECOGRAM
Middle Compartment
Pathology
REST
STRAIN
Enterocele

26. Posterior Compartment
MR DEFECOGRAM
Posterior Compartment
Pathology
Rectocele – Occurs when there is a herniation of the rectum into the posterior vaginal wall that results in a vaginal bulge.

27. Posterior Compartment
MR DEFECOGRAM
Posterior Compartment
Pathology
Rectocele

28. Posterior Compartment
MR DEFECOGRAM
Posterior Compartment
REST
STRAIN
Anorectal Angle

29. Posterior Compartment
MR DEFECOGRAM
Posterior Compartment
Pathology
REST
STRAIN
Pelvic Dyssynergia

30. All Three Compartments Pathology
MR DEFECOGRAM
All Three Compartments Pathology

31. PELVIC FLOOR Treatment: Mild Cases - Kegel exercise
Moderate Cases (Cystocele,Incotenience) – Pessary may be used.
Severe Cases (Rectocele,Constipation)- Surgery may be necessary.

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

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.