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

OBJECTIVES INDICATIONS PREPARATIONS PROTOCOL FINDINGS PITFALLS SUMMARY

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.

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.

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)

PELVIC FLOOR ANATOMY

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.

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

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

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

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

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

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)

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

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

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

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

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

MR DEFECOGRAM NORMAL ANATOMY

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.

MR DEFECOGRAM Anterior Compartment Pathology Cystocele

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

MR DEFECOGRAM Middle Compartment Pathology Vaginal Prolapse REST STRAIN Vaginal Prolapse

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.

MR DEFECOGRAM Middle Compartment Pathology REST STRAIN Enterocele

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.

Posterior Compartment MR DEFECOGRAM Posterior Compartment Pathology Rectocele

Posterior Compartment MR DEFECOGRAM Posterior Compartment REST STRAIN Anorectal Angle

Posterior Compartment MR DEFECOGRAM Posterior Compartment Pathology REST STRAIN Pelvic Dyssynergia

All Three Compartments Pathology MR DEFECOGRAM All Three Compartments Pathology

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

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

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.