Habip Eser AKKAYA, Sena ÜNAL, Nuray ÜNSAL HALİLOĞLU, Ayşe ERDEN

MR defekografi ile pelvik taban yetmezliğinin değerlendirilmesi

Giriş: Bu çalışmanın amacı, pelvik taban yetmezliğinin MR defekografi bulgularını ortaya koymak ve görüntülerin elde edilmesi ve yorumlanmasında önemli noktaları vurgulamaktır. Gereç ve Yöntem: 2013-2016 yılları arasında ünitemizde MR defekografi görüntülemesi yapılan hastalar retrospektif olarak değerlendirildi. Pelvik kompartmanlardaki anormallikler araştırıldı ve derecelendirildi. Levator hiatus aksiyel çapı ve iliococcygeus açısı İstirahat ve ıkınma fazında ölçüldü ve ölçümler karşılaştırıldı. H çizgisi, M çizgisi ve ARA istirahat ölçümleri ıkınma ve defekasyon fazlarında ölçüldü ve ölçümler karşılaştırıldı. Bulgular: M ve H çizgisinin uzunluğu; istirahat ve ıkınma, istirahat ve defekasyon, ıkınma ve defekasyon fazlarında karşılaştırıldığında istatistiksel olarak anlamlı fark vardı. İstirahat ve ıkınma fazları arasında levator hiatusun transvers çapı ve iliococcygeus açılar arasında istatistiksel olarak anlamlı fark bulundu. Spastik pelvik taban sendromu olmayan hastalarda ARA istirahat ve ıkınma, istirahat ve defekasyon, ıkınma ve defekasyon fazlarında karşılaştırıldığında istatistiksel olarak anlamlı fark vardı. Spastik pelvik taban sendromlu hastalarda ARA istirahat ve ıkınma, istirahat ve defekasyon fazlarında karşılaştırıldığında istatistiksel olarak anlamlı fark bulundu. Ikınma ve defekasyon fazları arasında ise istatistiksel olarak anlamlı fark yoktu. Sonuç: MR defekografi, pelvik taban yetmezliği olan hastalarda pelvik kompartman anormallikleri hakkında ayrıntılı bilgi verir. Defekasyon fazında ilk alınan görüntüler arka kompartmanın değerlendirilmesinde başarılı iken, geç faz görüntüler ön ve orta kompartman anormalliklerinin daha doğru tespit edilebilmesini sağlar.

Anahtar Kelimeler:

MR defekografi, pelvik taban yetmezliği, spastik pelvik taban sendromu

Evaluation of pelvic floor dysfunction with magnetic resonance defecography

Introduction: The aim of this study is to reveal MR defecography findings of pelvic floor failure and to emphasize the important points of acquiring and interpreting images. Materials and Methods: Patients who underwent MR defecography imaging in our department between 2013 and 2016 were retrospectively evaluated. Abnormalities of pelvic compartments were investigated and were graded. Axial diameter of the levator hiatus and iliococcygeus angle were measured at rest and during straining and the measurements were compared. H line, M line and ARA were measured at rest, during straining and defecation and the measurements were compared. Results: There was statistically significant difference between rest and straining, rest and defecation, straining and defecation phases in terms of the length of M and H lines. Changes in the transverse diameter of levator hiatus and iliococcygeus angle between rest and straining phases were statistically significant. In patients without spastic pelvic floor syndrome there was statistically significant difference between rest and straining, rest and defecation, straining and defecation phases in terms of ARA. In patients with spastic pelvic floor syndrome, changes in ARA between rest and straining, rest and defecation phases were statistically significant. There was no statistically significant difference between straining and defecation phases in terms of ARA. Conclusion: MR defecography gives detailed information about pelvic compartment abnormalities in patients with pelvic floor failure. While early images of defecation are more useful for the assessment of the posterior compartment, late phase images would allow more accurate definition of anterior and middle compartment abnormalities.

Keywords:

MR defecography, pelvic floor dysfunction, spastic pelvic floor syndrome,

PDF

___

1. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans, B, Lee J, et al. An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J. 2010;21(1):5–26. https://doi.org/10.1007/s00192-009-0976-9
2. Remes-Troche JM, Rao SSC. Neurophysiological testing in anorectal disorders. Expert Rev Gastroenterol Hepatol. 2008;2(3):323–335. https://doi.org/10.1586/17474124.2.3.323
3. Silva ACA, Maglinte DD. Pelvic floor disorders: what’s the best test? Abdom Imaging. 2013;38(6):1391–1408. https://doi.org/10.1007/s00261-013-0039-z
4. Bitti GT, Argiolas GM, Ballicu N, Caddeo E, Cecconi M, Demurtas G, et al. Pelvic floor failure: MR imaging evaluation of anatomic and functional abnormalities. Radiographics. 2014;34(2):429–448. https://doi.org/10.1148/rg.342125050
5. García del Salto L, de Miguel Criado J, Aguilera del Hoyo LF, Velasco LG, Rivas PF, Paradela MM, et al. MR Imaging-based Assessment of the Female Pelvic Floor. Radiographics. 2014;34(5):1417–1439. https://doi.org/10.1148/rg.345140137
6. Law YM, Fielding JR. MRI of pelvic floor dysfunction. Am J Roentgenol.2008;191(6_supplement) :S45-S53. https://doi.org/10.2214/AJR.07.7096
7. Comiter CV, Vasavada SP, Barbaric ZL, Gousse AE, Raz S. Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging. Urology. 1999;54(3):454–457. https://doi.org/10.1016/S0090- 4295(99)00165-X
8. Lienemann A, Fischer T. Functional imaging of the pelvic floor. Eur J Radiol. 2003;47(2):117–122. https://doi.org/10.1016/S0720-048X(03)00164-5
9. Mortele KJ, Fairhurst J. Dynamic MR defecography of the posterior compartment: indications, techniques and MRI features. Eur J Radiol. 2007;61(3):462–472. https://doi.org/10.1016/j.ejrad.2006.11.020
10. El Sayed RF, Alt CD, Maccioni F, Meissnitzer M, Masselli G, Manganaro L, et al. Magnetic resonance imaging of pelvic floor dysfunction-joint recommendations of the ESUR and ESGAR Pelvic Floor Working Group. Eur Radiol. 2017;27(5):2067–2085. https://doi.org/10.1007/s00330-016-4471-7
11. Flusberg M, Sahni VA, Erturk SM, Mortele KJ. Dynamic MR defecography: assessment of the usefulness of the defecation phase. Am J Roentgenol. 2011;196(4):W394–W399. https://doi.org/10.2214/AJR.10.4445
12. Hetzer FH, Andreisek G, Tsagari C, Sahrbacher U, Weishaupt D. MR defecography in patients with fecal incontinence: imaging findings and their effect on surgical management. Radiology. 2006;240(2):449–457. https://doi.org/10.1148/radiol.2401050648
13. Bhan SN, Mnatzakanian GN, Nisenbaum R, Lee AB, Colak E. MRI for pelvic floor dysfunction: can the strain phase be eliminated? Abdom Radiol (NY). 2016;41(2):215–220. https://doi.org/10.1007/s00261-015-0577-7
14. Hassan HH, Elnekiedy AM, Elshazly WG, Naguib NN. Modified MR defecography without rectal filling in obstructed defecation syndrome: Initial experience. Eur J Radiol. 2016;85(9):1673–1681. https://doi.org/10.1016/j. ejrad.2016.06.014
15. Halligan S, Malouf A, Bartram CI, Marshall M, Hollings N, Kamm M. Predictive value of impaired evacuation at proctography in diagnosing anismus. Am J Roentgenol. 2001;177(3):633–636. https://doi.org/10.2214/ ajr.177.3.1770633
16. Jorge JM, Wexner SD, Ger GC, Nogueras J, Jagelman D. Cinedefecography and electromyography in the diagnosis of nonrelaxing puborectalis syndrome. Dis Colon Rectum. 1993;36(7):668–76. https://doi.org/10.1007/BF02238594
17. Kuijpers HC, Bleijenberg G. The spastic pelvic floor syndrome. A cause of constipation. Dis Colon Rectum. 1985;28(9):669–72. https://doi.org/10.1007/BF02553449
18. Reiner CS, Tutuian R, Solopova AE, Pohl D, Marincek B, Weishaupt D. MR defecography in patients with dyssynergic defecation: spectrum of imaging findings and diagnostic value. Br J Radiol. 2011;84(998):136–144. https://doi.org/10.1259/bjr/28989463