Lax Uterosacral Ligament and Urge Urinary Incontinence: MRI Findings in Symptomatic Patients Versus Healthy Volunteers.

INTRODUCTION AND HYPOTHESIS: The objective was to explore the association between urge urinary incontinence (UUI) and lax uterosacral ligaments (USL) using MRI. METHODS: Sixty-seven female participants were recruited prospectively: 41 continent volunteers (control group) and 26 patients with UUI. Static proton density- and T2-weighted turbo spin echo sequences of MR images were used. A radiologist employed a standardized grid system to record structural observations of the USLs on sequentially numbered axial MR images and then applied a four-point grading scale to assess ligament visibility. MR images were interpreted by a radiologist and a urologist, and then validated by an expert radiologist. RESULTS: The comparison between the mean length of uterosacral ligaments in the control and UUI groups was highly statistically significant (p < 0.001). The mean length of the right USL was 38 ± 11 mm, and the left USL was 35 ± 12 mm in the UUI group. In the control group, the mean length of the USL was 22 ± 9 mm on the right side and 18 ± 9 mm on the left side, along their craniocaudal extent. The highest inter-observer agreement was on the level of origin and insertion (image numbers), whereas the lowest agreement was on the anatomical site of origin and insertion of the USL in both the control and UUI groups. CONCLUSIONS: The average length of USLs in patients with UUI is significantly longer than that in healthy continent women, indicating laxity. Our findings support the relationship between the laxity of the USL and UUI symptoms and have therapeutic implications.

Solitary rectal ulcer syndrome (SRUS): observational case series findings on MR defecography.

OBJECTIVE: Radiological findings in solitary rectal ulcer syndrome (SRUS) are well described for evacuation proctography (EP) but sparse for magnetic resonance defecography (MRD). In order to rectify this, we describe the spectrum of MRD findings in patients with histologically proven SRUS. MATERIALS AND METHODS: MRD from twenty-eight patients (18 female; 10 males) with histologically confirmed SRUS were identified. MRD employed a 1.5-T magnet and a standardized technique with the rectal lumen filled with gel and imaged sagittally in the supine position, before, during, and after attempted rectal evacuation. A single radiologist observer with 5 years' experience in pelvic floor imaging made the anatomical and functional measurements. RESULTS: Sixteen patients (10 female) demonstrated internal rectal intussusception and 3 patients (11%) demonstrated complete external rectal prolapse. Anterior rectoceles were noted in 12 female patients (43%). Associated anterior and middle compartment weakness (evidenced by excessive descent) was observed in 18 patients (64%). Cystocele was found in 14 patients (50%) and uterine prolapse was noted in 7 patients (25%). Enterocoeles were detected in 5 patients (18%) and peritoneocoele in 5 patients (18%). None had sigmoidocoele. Sixteen patients (57%) demonstrated delayed voiding and 13 patients (46%) incomplete voiding, suggesting defecatory dyssynergia. CONCLUSION: MRD can identify and grade both rectal intussusception and dyssynergia in SRUS, and also depict associated anterior and/or middle compartment descent. Distinction between structural and functional findings has important therapeutic implications. KEY POINTS: MRD can identify and grade both rectal intussusception and dyssynergia in patients with SRUS. MRD is an acceptable substitute to evacuation proctography in assessing anorectal dysfunctions when attempting to avoid ionizing radiation. SRUS influences the pelvic floor globally. MRD depicts associated anterior and/or middle compartment prolapse.

Variability in utilization and techniques of pelvic floor imaging: findings of the SAR pelvic floor dysfunction disease-focused panel.

Pelvic floor disorders are common and can negatively impact quality of life. Imaging of patients with pelvic floor disorders has been extremely heterogeneous between institutions due in part to variations in clinical expectations, technical considerations, and radiologist experience. In order to assess variations in utilization and technique of pelvic floor imaging across practices, the society of abdominal radiology (SAR) disease-focused panel on pelvic floor dysfunction developed and administered an online survey to radiologists including the SAR membership. Results of the survey were compared with published recommendations for pelvic floor imaging to identify areas in need of further standardization. MRI was the most commonly reported imaging technique for pelvic floor imaging followed by fluoroscopic defecography. Ultrasound was only used by a small minority of responding radiologists. The survey responses demonstrated variability in imaging utilization, patient referral patterns, imaging protocols, patient education, and interpretation and reporting of pelvic floor imaging examinations. This survey highlighted inconsistencies in technique between institutions as well as potential gaps in knowledge that should be addressed to standardize evaluation of patients with pelvic floor dysfunction.

Multimodality imaging of pelvic floor anatomy.

The pelvic floor is composed of a network of muscles, ligaments, and fasciae, which provide active and passive support for the pelvic organs. Impairment of these pelvic floor elements can result in a variety of functional abnormalities and single or multicompartment organ prolapse. Knowledge of normal pelvic floor anatomy can aid the radiologist in understanding the complex nature of pelvic floor dysfunction and is important for comprehensive image interpretation. This article provides an overview of normal anatomy of the pelvic floor as seen on magnetic resonance imaging, ultrasound, and fluoroscopic studies performed in the evaluation of pelvic floor function.

Imaging and clinical assessment of functional defecatory disorders with emphasis on defecography.

Functional defecation disorders (FDD) encompass causes of constipation associated with anorectal dysfunction, which include dyssynergia or inadequate defecatory propulsion. FDD are frequently encountered in clinical practice and may affect up to 33-50% of patients with chronic constipation. The etiology of FDD is unclear, however, it has been defined as an acquired, but subliminal behavioral disorder. Pathophysiologic mechanisms may include discoordination of rectoanal muscles, paradoxical contraction or insufficient relaxation of puborectalis and/or anal sphincter during defecation, and sluggish colonic transit. A combination of comprehensive clinical assessment, digital rectal examination and a battery of physiologic tests are needed to make an accurate diagnosis of FDD. Defecography may play a crucial role in the evaluation of FDD, especially when a balloon expulsion test (BET) and/or anorectal manometry (ARM) are equivocal or demonstrate contradictory results. In this review, we provide a thorough overview of the epidemiology, pathophysiology, diagnostic criteria, clinical and imaging evaluation, and treatment options for FDD, with an emphasis on available diagnostic imaging tools such as defecography and conventional fluoroscopic methods.

MR defecography technique: recommendations of the society of abdominal radiology's disease-focused panel on pelvic floor imaging.

PURPOSE: To develop recommendations for magnetic resonance (MR) defecography technique based on consensus of expert radiologists on the disease-focused panel of the Society of Abdominal Radiology (SAR). METHODS: An extensive questionnaire was sent to a group of 20 experts from the disease-focused panel of the SAR. The questionnaire encompassed details of technique and MRI protocol used for evaluating pelvic floor disorders. 75% agreement on questionnaire responses was defined as consensus. RESULTS: The expert panel reached consensus for 70% of the items and provided the basis of these recommendations for MR defecography technique. There was unanimous agreement that patients should receive coaching and explanation of commands used during MR defecography, the rectum should be distended with contrast agent, and that sagittal T2-weighted images should include the entire pelvis within the field of view. The panel also agreed unanimously that IV contrast should not be used for MR defecography. Additional areas of consensus ranged in agreement from 75 to 92%. CONCLUSION: We provide a set of consensus recommendations for MR defecography technique based on a survey of expert radiologists in the SAR pelvic floor dysfunction disease-focused panel. These recommendations can be used to develop a standardized imaging protocol.

Magnetic Resonance Imaging of the Female Pelvic Floor: Anatomy Overview, Indications, and Imaging Protocols.

This article reviews different approaches for describing pelvic floor anatomy; "Classic 3-Compartment Approach", "Active and Passive Conceptual Approach" and "Multilayered System Approach". However, these approaches cannot explain pathogenesis of various dysfunctions. "Functional 3-Part Pelvic Supporting Systems Approach" a new, more function-based classification of the pelvic floor support system is introduced in which all structures that contribute to same function are grouped under 1 system. Indications for MR imaging of pelvic floor dysfunction, patients' preparation, static, dynamic and MR Defecography imaging protocols are detailed according to the concordance of experts in two recently published consensus papers.

Integrated MR Analytical Approach and Reporting of Pelvic Floor Dysfunction: Current Implications and New Horizons.

Reporting MR imaging of pelvic floor dysfunction can be made easy if radiologists understand the aim of each MR sequence and what to report in each set of MR images. For an MR imaging report that is critical in decision making for patient management, it is of paramount importance to the radiologist to know what to look for and where to look for it. This article presents a new term, integrated MR analytical approach. A reporting template is included in which all MR findings are presented in a schematic form that can be easily interpreted by clinicians from different subspecialties.

Changing dietary n-6:n-3 ratio using different oil sources affects performance, behavior, cytokines mRNA expression and meat fatty acid profile of broiler chickens.

Typical formulated broiler diets are deficient in n-3 poly-unsaturated fatty acids (PUFA) due to widening n-6:n-3 PUFA ratio which could greatly affect performance, immune system of birds and, more importantly, meat quality. This study was conducted to evaluate the effect of modifying dietary n-6:n-3 PUFA ratio from plant and animal oil sources on performance, behavior, cytokine mRNA expression, antioxidative status and meat fatty acid profile of broiler chickens. Birds (n = 420) were fed 7 diets enriched with different dietary oil sources and ratios as follows: sunflower oil in control diet (C); fish oil (FO); 1:1 ratio of sunflower oil to FO (C1FO1); 3:1 ratio of sunflower oil to fish oil (C3FO1); linseed oil (LO); 1:1 ratio of sunflower oil to linseed oil (C1LO1); 3:1 ratio of sunflower oil to linseed oil (C3LO1), resulting in dietary n-6:n-3 ratios of approximately 40:1, 1.5:1, 4:1, 8:1, 1:1, 2.5:1 and 5:1, respectively. The best final body weight, feed conversion ratio as well as protein efficiency ratio of broilers were recorded in the C1FO1 and C1LO1 groups. Compared with the control group, the dressing percentage and breast and thigh yield were highest in the C1FO1 and C1LO1 groups. Narrowing the dietary n-6:n-3 ratio increased (P < 0.05) n-3 PUFA content of breast meat. Moreover, the breast meat contents of eicosapentaenoic acid and docosahexaenoic acid increased (P < 0.05) with increasing dietary FO whereas α-linolenic acid content was higher with LO supplementation. Also, enriching the diets with n-3 PUFA from FO and LO clearly decreased (P < 0.05) serum total cholesterol, triglycerides and very low-density lipoproteins and enhanced antioxidative status. The feeding frequency was decreased (P < 0.05) in the C1FO1 and C1LO1 groups. Likewise, n-3 PUFA-enriched diets enhanced the frequency of preening, wing flapping and flightiness. Animal oil source addition, compared to plant oil, to broiler diets enhanced the relative mRNA expression of interferon gamma, interleukin-1 beta, interleukin-2 and interleukin-6 genes, especially at low n-6:n-3 ratios. This study has clearly shown that narrowing n-6:n-3 ratio through the addition of FO or LO improved performance and immune response of broilers and resulted in healthy chicken meat, enriched with long chain n-3 PUFA.

Magnetic resonance imaging of pelvic floor dysfunction - joint recommendations of the ESUR and ESGAR Pelvic Floor Working Group.

OBJECTIVE: To develop recommendations that can be used as guidance for standardized approach regarding indications, patient preparation, sequences acquisition, interpretation and reporting of magnetic resonance imaging (MRI) for diagnosis and grading of pelvic floor dysfunction (PFD). METHODS: The technique included critical literature between 1993 and 2013 and expert consensus about MRI protocols by the pelvic floor-imaging working group of the European Society of Urogenital Radiology (ESUR) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) from one Egyptian and seven European institutions. Data collection and analysis were achieved in 5 consecutive steps. Eighty-two items were scored to be eligible for further analysis and scaling. Agreement of at least 80 % was defined as consensus finding. RESULTS: Consensus was reached for 88 % of 82 items. Recommended reporting template should include two main sections for measurements and grading. The pubococcygeal line (PCL) is recommended as the reference line to measure pelvic organ prolapse. The recommended grading scheme is the "Rule of three" for Pelvic Organ Prolapse (POP), while a rectocele and ARJ descent each has its specific grading system. CONCLUSION: This literature review and expert consensus recommendations can be used as guidance for MR imaging and reporting of PFD. KEY POINTS: • These recommendations highlight the most important prerequisites to obtain a diagnostic PFD-MRI. • Static, dynamic and evacuation sequences should be generally performed for PFD evaluation. • The recommendations were constructed through consensus among 13 radiologists from 8 institutions.

Commentary on "MRI and CT of sacrocolpopexy".

OBJECTIVE: The purpose of this commentary is to highlight several aspects of two main perspectives on sacrocolpopexy: surgical-which includes selection of a route for reconstructive surgery, types of surgical meshes available, advantages and disadvantages of each type of mesh, and the associated postoperative complication-and radiologic, that is, the role of imaging in improving outcome. CONCLUSION: As new modalities and techniques related to sacrocolpopexy are developed, concepts of form and function change. With advances in imaging modalities, especially MRI and CT, and the postprocessing options available, the radiologist's role should extend beyond reporting imaging findings to sharing in the choice of the initial treatment plan.

The urogynecological side of pelvic floor MRI: the clinician's needs and the radiologist's role.

In pelvic floor dysfunction (PFD), magnetic resonance imaging of the pelvic floor supporting system from a functional point of view allows radiologists to recognize and classify the types of defects in each supporting structure (namely, the urethral supporting system, the vaginal supporting system, and the anal sphincter complex). Combined analysis of both the static and dynamic images of patients reporting stress urinary incontinence and pelvic organ prolapse has revealed a close relationship between certain anatomical defects in the pelvic organ support system and specific PFD. Because of the consistency and reproducibility of this relationship, radiologists can accurately identify and report the underlying structural defects, allowing clinicians to individually tailor surgical techniques for each patient. This is important because even those patients presenting with the same clinical symptoms may have different underlying structural derangement or abnormalities that may warrant a different treatment plan or approach. In view of the reported high rate of dysfunction recurrence after surgical treatment and clinicians' desire for a test that can pinpoint each patient's structural and anatomical defects, this approach provides the necessary scientific evidence on which best clinical practice can be based, and the data-reporting system used for analysis provides a tool for accurately planning reconstructive surgery, reducing the risk of surgical failure, dysfunction recurrence, and reoperation. With the improved radiological evidence made possible by combined image analysis, clinicians can now have the documentation that they need to plan more effective procedures and thus produce better outcomes. This review focuses on the MRI anatomy of the pelvic floor from a functional point of view and from the urogynecological side of floor dysfunction (UI and POP), adopting a problem-oriented approach. The first section of this article provides the basic essential anatomical information about the pelvic floor and briefly reviews the pathophysiology and clinical features of SUI and POP. The second portion details the vital role of the radiologist in obtaining accurate images for the clinician to use in planning reconstructive surgery. In addition, it includes case examples, illustrating how to report MRI findings systematically and comprehensively on both the static and dynamic images, using a recently developed integrated MRI analytical approach from a purely functional point of view that may enhance radiologists' interaction with clinicians and bridges the gap between radiology and surgery.

Activation of B cells by antigens on follicular dendritic cells.

A need for antigen-processing and presentation to B cells is not widely appreciated. However, cross-linking of multiple B cell receptors (BCRs) by T-independent antigens delivers a potent signal that induces antibody responses. Such BCR cross-linking also occurs in germinal centers where follicular dendritic cells (FDCs) present multimerized antigens as periodically arranged antigen-antibody complexes (ICs). Unlike T cells that recognize antigens as peptide-MHC complexes, optimal B cell-responses are induced by multimerized FDC-ICs that simultaneously engage multiple BCRs. FDC-FcgammaRIIB mediates IC-periodicity and FDC-BAFF, FDC-IL-6 and FDC-C4bBP are co-stimulators. Remarkably, specific antibody responses can be induced by FDC-ICs in the absence of T cells, opening up the exciting possibility that people with T cell insufficiencies may be immunized with T-dependent vaccines via FDC-ICs.

ADAM10 is essential for Notch2-dependent marginal zone B cell development and CD23 cleavage in vivo.

The proteolytic activity of a disintegrin and metalloproteinase 10 (ADAM10) regulates cell-fate decisions in Drosophila and mouse embryos. However, in utero lethality of ADAM10(-/-) mice has prevented examination of ADAM10 cleavage events in lymphocytes. To investigate their role in B cell development, we generated B cell-specific ADAM10 knockout mice. Intriguingly, deletion of ADAM10 prevented development of the entire marginal zone B cell (MZB) lineage. Additionally, cleavage of the low affinity IgE receptor, CD23, was profoundly impaired, but subsequent experiments demonstrated that ADAM10 regulates CD23 cleavage and MZB development by independent mechanisms. Development of MZBs is dependent on Notch2 signaling, which requires proteolysis of the Notch2 receptor by a previously unidentified proteinase. Further experiments revealed that Notch2 signaling is severely impaired in ADAM10-null B cells. Thus, ADAM10 critically regulates MZB development by initiating Notch2 signaling. This study identifies ADAM10 as the in vivo CD23 sheddase and an important regulator of B cell development. Moreover, it has important implications for the treatment of numerous CD23- and Notch-mediated pathologies, ranging from allergy to cancer.

IL-6 produced by immune complex-activated follicular dendritic cells promotes germinal center reactions, IgG responses and somatic hypermutation.

Reports that follicular dendritic cells (FDCs) produce IL-6 prompted the hypotheses that immune complexes (ICs) induce FDCs to produce IL-6 and that FDC-IL-6 promotes germinal center (GC) reactions, somatic hypermutation (SHM) and IgG production. FDCs were activated in vitro by addition of ICs and FDC-IL-6 production was determined. Wild-type (WT) and IL-6 knockout (KO) mice, as well as chimeras with WT and IL-6 KO cells, were immunized with (4-hydroxy-3-nitrophenyl)-acetyl (NP)-chicken gamma globulin (CGG) and used to study anti-(4-hydroxy-3-iodo-5-nitrophenyl) acetyl (NIP) responses, GC formation and SHM in the VH186.2 gene segment in Ig-gamma. FDC-IL-6 increased when FDCs encountered ICs. At low immunogen dose, 1 microg NP-CGG per mouse, the IgG anti-NIP response in IL-6 KO mice was low and immunohistochemistry revealed a reduction in both the number and size of GCs. The physiological relevance of FDC-IL-6 was apparent in the chimeric mice where total splenocytes from WT mice were unable to provide the IL-6 needed for normal IgG and GC responses in IL-6 KO animals with IL-6-defective FDCs. Moreover, the rate of mutation decreased from 18 to 8.9 mutations per 1000 bases (P < 0.001) in WT versus IL-6 KO mice. Addition of anti-IL-6 to GC reactions in vitro reduced antibody levels and SHM from 3.5 to 0.65 mutations per 1000 bases (P < 0.02). Thus, the absence of FDC-IL-6 correlated with a reduction in SHM that coincided with the reduction in GCs and specific anti-NIP. This is the first study to document that ICs induce FDC-IL-6 and that FDC-derived IL-6 is physiologically relevant in generating optimal GC reactions, SHM and IgG levels.