ARRS 2022 Abstracts


E1891. Peering at the Pelvis: MR Defecography Evaluation of Pelvic Floor Dysfunction
  1. Tucker Burr; Loyola University Medical Center
  2. Deanna Thorson; Loyola University Medical Center
  3. Ari Goldberg; Loyola University Medical Center
  4. Anugayathri Jawahar; Loyola University Medical Center
Pelvic floor disorders are incredibly prevalent, underdiagnosed, and can impose serious limits on activities of daily living. Although often managed clinically, there are important advantages to imaging, especially with dynamic magnetic resonance defecography (MRD). This exhibit is intended to provide guidance to the radiologist when interpreting MRD and assessing complex pelvic floor anatomy and function. A better understanding of MRD enables the radiologist to more accurately diagnose subtle findings of anatomical and/or functional abnormalities and therefore provide better guidance to the clinician when directing therapy.

Educational Goals / Teaching Points
Approximately a quarter of American women experience pelvic floor dysfunction. There is well established grading of pelvic floor dysfunction and pelvic organ prolapse (POP); however, knowledge of specific pelvic floor anatomy including ligaments, connective tissue, and musculature allows for more accurate diagnosis and explanation of clinical symptoms through functional pathology by dynamic MRI. In a space that is often difficult to conceptualize, this is illustrated with specific cases to provide context to anatomic features and functional changes.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Pelvic floor dysfunction can be evaluated and graded in the anterior, middle, and posterior compartments on MRD. This can be evaluated with the pubococcygeal line both at rest and with increased pelvic pressure using Kegel, Valsalva, and evacuation phases of imaging. An intricate web of connective tissue, ligaments, and musculature form three contiguous layers. From cranial to caudal, these layers are the endopelvic fascia, the pelvic diaphragm, and the urogenital diaphragm. Evaluating cases of incontinence, POP, and chronic pelvic pain with an understanding of potential sites of weakness allows for more accurate diagnosis. Functional evaluation with dynamic imaging is an important and unique aspect of MRD. Functional abnormality may be the only clinical symptom and the only sign of pathology. We review potential physiologic and anatomic derangements to watch for beyond POP and incomplete evacuation. Cases include: paradoxical puborectalis syndrome; open anal canal at rest with absent evacuation representing dyssynergia; and signs of endopelvic fascial defect. We highlight anatomic and functional abnormalities, how they correlate to clinical symptoms, and how this may lead to targeted therapy. The radiologist should be cognizant of MRD requiring a more complex imaging protocol including rectal gel and evacuation during the exam in a setting of possible pre-existing social stigma. Clear communication with the patient to set exam expectations is integral for optimizing image quality.

Pelvic floor dysfunction is an under-recognized group of disorders that can greatly affect patient well-being. Familiarity with pelvic floor anatomy, pathophysiology, and MRD examination can lead to more accurate diagnosis and improved patient care.