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.

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.

Anatomy of the urethral supporting ligaments defined by dissection, histology, and MRI of female cadavers and MRI of healthy nulliparous women.

OBJECTIVE: There has been no uniformity of opinion concerning the structures supporting the female urethra. Therefore, the aims of this prospective study were to define precisely the female urethral support structures at cadaveric anatomic dissection and histologic examination and to determine which of these structures can be detected on MRI of cadaveric specimens and of healthy volunteers. SUBJECTS AND METHODS: Dissection of seven formalin-preserved cadavers (age at death, 25-50 years; no parity history available) was performed by a professor of anatomy to explore the anatomy of the urethral supporting ligaments and was followed by MRI of the cadaveric specimens with ligamentous markers in place and then by histologic analysis of the dissected ligaments. MRI of 17 healthy nulliparous women (age range, 20-35 years; mean age, 25.5 years) was then performed using T2-weighted, dual turbo spin-echo, balanced fast-field echo, and STIR sequences. A standardized grid system that allowed us to record structural observations on sequentially numbered axial MR images was used by a radiologist who then applied a 4-point grading scale to assess ligament visibility. Three authors--one radiologist, one anatomist, and one urologist--then compared the appearance of each ligament seen in a cadaveric specimen with its appearance on MR images of the same cadaver and on MR images of volunteers. RESULTS: At cadaveric dissection we identified ventral and dorsal urethral ligaments. The ventral urethral ligaments included the pubourethral ligaments, which were found to consist of three separate components coursing anteroposterior from the bladder neck to the pubic bone; the periurethral ligament; and the paraurethral ligaments. Dorsal to the urethra, a slinglike ligament, which we believe should be named the "suburethral ligament," was identified. This ligament had a distinct plane of cleavage from the anterior vaginal wall. The MRI findings in the volunteers correlated with the MRI and gross anatomic findings in the cadavers. The proximal pubourethral, periurethral, paraurethral, and suburethral ligaments had visibility scores of 3 (moderately visible) or 4 (easily visible) on MRI in 47%, 65%, 47%, and 53% of volunteers, respectively. CONCLUSION: Our results present evidence that may help resolve previous controversies regarding the MR appearance of the ventral urethral ligaments and that better define the course of the ligament dorsal to the urethra, the suburethral ligament. We hope that this detailed anatomic information about the structures involved in continence may lead eventually to improvements in the treatments for women with stress urinary incontinence.