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1
Department of Radiology, Methodist Hospital of Indiana, 1701 N. Senate Blvd.,
Indianapolis, IN 46202.
2
Urogynecology Section, Methodist Hospital of Indiana, Indianapolis, IN
46202.
Received May 24, 1999;
accepted after revision June 25, 1999.
Supported in part by grants from Siemens Medical Systems and Clarian Health
Partners. (Methodist. Indiana University. Riley Hospital for Children.)
Abstract
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SUBJECTS AND METHODS. Ten patients underwent triphasic dynamic MR imaging and triphasic fluoroscopic cystocolpoproctography with identical amounts of contrast material to opacify the bladder, vagina, and rectum. The dynamic MR imaging procedure included cine-loop presentation. Each examination was analyzed to determine the presence and extent of prolapse of pelvic organs based on specific measurements.
RESULTS. Both dynamic MR imaging and fluoroscopic cystocolpoproctography revealed 10 rectoceles (mean extents, 2.85 and 2.45 cm, respectively). Nine cystoceles were revealed by both dynamic MR imaging (mean extent, 4.05 cm) and fluoroscopy (mean extent, 4.55 cm). Seven enteroceles were revealed, one of which was initially not seen on dynamic MR imaging. Two sigmoidoceles were revealed, one of which was not seen on fluoroscopy. The mean extent of the enteroceles and sigmoidoceles on dynamic MR imaging was 3.50 cm, and the mean extent on fluoroscopy was 4.25 cm. Nine of the 10 patients were able to defecate in the supine position on the MR imaging table. Patients were divided equally in their preference for dynamic MR imaging or fluoroscopic cystocolpoproctography.
CONCLUSION. Triphasic dynamic MR imaging and triphasic fluoroscopic cystocolpoproctography show similar detection rates for prolapse of pelvic organs. Although dynamic MR imaging underestimates the extent of cystoceles and enteroceles, it has the advantage of revealing all pelvic organs and the pelvic floor musculature in a multiplanar cine-loop presentation.
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Several studies have used dynamic MR imaging to assess female pelvic organ prolapse [7, 8, 9]. In these studies, contrast material was not used to opacify the pelvic organs, so their visualization, with the exception of the inherently delineated bladder and small bowel, was limited. Recently, Lienemann et al. [10] performed dynamic MR imaging of the pelvis after contrast opacification of the bladder, vagina, and rectum (i.e., dynamic MR cystocolpoproctography). They compared the MR findings with those of the dynamic fluoroscopic study and found MR imaging to be superior to fluoroscopy for the detection of organ prolapse. None of these authors used a triphasic approach [7, 8, 9, 10], in which the dynamic MR imaging and fluoroscopic examinations are divided into a cystographic, a proctographic, and a posttoilet phase to facilitate the recognition of prolapsed organs that may be obscured by other organs that remain unemptied.
MR imaging provides a multiplanar global evaluation of the pelvic contents, including the uterus and the pelvic floor muscle (i.e., the levator ani muscle) [8, 9, 10, 11, 12, 13, 14, 15, 16]. This global depiction of the pelvic contents cannot be obtained using fluoroscopy. A potential disadvantage of dynamic MR imaging is its less physiologic nature; the examination is usually performed with the patient in the supine position and may be limited to straining without subsequent rectal evacuation.
The purpose of this study was to compare dynamic MR cystocolpoproctography with fluoroscopic cystocolpoproctography for both the detection and measurement of the extent of pelvic organ prolapse. To our knowledge, prior studies comparing these two methods of examination have not been performed using both a triphasic approach and the incorporation of measurement of the extent of pelvic organ prolapse.
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The MR examination was performed in a similar manner to that described by Lienemann et al. [10], but with the important exception that the examination was separated into three phases: a cystographic phase, a proctographic phase, and a posttoilet phase. This triphasic approach mimicked the phases of dynamic fluoroscopic cystocolpoproctography [6]. To make the examinations as identical as possible, the amount of contrast material introduced into each of the pelvic organs was the same for both the MR imaging and the fluoroscopic examinations.
MR imaging was performed with the patient in the supine position with a 1.5-T superconductive unit and a circularly polarized (quadrature) body coil (Vision; Siemens, Erlangen, Germany). The patient was asked to empty her bladder on arrival at the department. Before the examination began, the patient was instructed about the voluntary maneuvers to be performed during imaging. Maneuvers consisted of progressive straining during the cystographic sequence; and a contraction of the pelvic floor muscles (squeezing) followed by relaxation, subsequent progressive straining, and rectal evacuation during the proctographic phase. The importance of rectal evacuation was emphasized to the patient; we explained that evacuation was essential to obtain complete information about the degree of prolapse. Waterproof padding was placed beneath the buttocks and thighs to limit patient embarrassment and to protect the table of the MR imaging unit.
The patient's bladder was catheterized with a 12-French catheter, and 50 ml of isotonic saline solution was instilled. MR images were obtained at rest in the axial, sagittal, and coronal planes. The pulse sequences used at rest included T2-weighted turbo spin-echo sequences (TR range/TE, 3300-3700/90; matrix size, 196 x 256; one acquisition; field of view, 270-350 mm; 5 mm thickness) in the axial, coronal, and sagittal planes. For the cystographic phase, the patient was asked to strain progressively while a dynamic series of images was obtained in the midsagittal plane using a true fast imaging in a steady-state free precession sequence (TR/TE, 6.32/3.00; flip angle, 70°; matrix size, 192 x 256; field of view, 250-330 mm; one image every 1.2 sec). The patient's bladder was then drained through the catheter. At that time, it was sometimes necessary to perform manual reduction of a large cystocele to promote bladder emptying [6]. The catheter was then withdrawn and the patient was asked to void in a bathroom before the proctographic phase of the examination.
The proctographic phase of the examination involved both vaginal and rectal opacification. The vagina and then the rectum were opacified with 20 ml and 200 ml, respectively, of sonographic transmission gel (Aquasonic 100; Parker Laboratories, Fairfield, NJ) introduced through a 26-French catheter. The patient was asked to perform the rest-squeeze-relax-strain-evacuate maneuver. During this process, a dynamic series of images was obtained in the midsagittal plane using a true fast imaging in a steady-state free precession sequence. The rest-squeeze-relax-strain-evacuate maneuver and the imaging were repeated so that imaging during complete rectal evacuation could be obtained. The patient was asked to strain while a brief dynamic series of images was obtained in the axial plane at the level of the pubic symphysis using the true fast imaging in a steady-state free precession sequence. The axial plane and pubic location were chosen to assess the presence of pelvic floor ballooning [9, 11].
The patient then went into the bathroom again and was asked to attempt further rectal evacuation. On return from the bathroom, the posttoilet phase was performed to evaluate for enterocele, sigmoidocele, or peritoneocele. Initially, a dynamic series of images in the midsagittal plane was obtained while the patient strained maximally. A second dynamic series was obtained in the coronal plane through the posterior pelvis to assess the extent of levator ani muscle descent [9, 11]. All the dynamic series were shown in cineloop presentation and recorded on videotape.
The technique of fluoroscopic dynamic cystocolpoproctography performed on a commode in the sitting position was similar to the technique previously described [6]. Several modifications were instituted for this study. First, a preliminary radiograph (36 x 43 cm) was obtained to identify the pubococcygeal line, which extends from the inferior margin of the pubic symphysis to the sacrococcygeal joint. Second, only 50 ml of contrast material was used to fill the bladder because cystocele size is not affected by introducing larger volumes of contrast material [6]. Third, a posttoilet image with maximal strain was routinely used because further rectal evacuation maximizes the visualization of enteroceles and sigmoidoceles [6, 17].
Preparation for the fluoroscopic examination required that the patient ingest 500 ml of barium suspension to opacify the small bowel. A preliminary radiograph was obtained, the bladder was catheterized, and 50 ml of diatrizoate sodium (Hypaque 50%; Winthrop Pharmaceuticals, New York, NY) was introduced. Two lateral radiographs of the bladder were obtained, one at rest and the other on maximal strain. Bladder drainage was performed, the catheter was withdrawn, and the patient was asked to void in the bathroom.
The vagina was opacified with 20 ml of a mixture of barium and a vaginal gel (Acigel; Ortho Pharmaceutical, Raritan, NJ). A folded gauze square was inserted in the introitus to limit the loss of barium. The rectum was filled with 200 ml of a thick barium paste (Anatrast; Lafayette Pharmacal, Lafayette, IN). Lateral radiographs were obtained at rest, on squeeze, and during and after evacuation. The postevacuation radiograph was obtained with the patient straining maximally, as was the posttoilet radiograph. The entire examination was recorded on videotape. Measurements of midline structures corrected for magnification were made possible by the incorporation of a midline radiopaque centimeter ruler within the commode. After completion of the dynamic fluoroscopic examination, each patient was asked whether she preferred the MR imaging or fluoroscopic examinations and to make comments about her choice.
Both the dynamic MR imaging and fluoroscopic cystocolpoproctograms were analyzed using specific measurements to determine the presence and extent of cystocele, vaginal vault prolapse, enterocele or sigmoidocele, and rectocele. Similar to past studies, the pubococcygeal line (Fig. 1A, Fig. 1B) was used as the reference point for defining each of the sites of prolapse, with the exception of rectocele [7, 8, 9, 10 11, 12, 13]. The pubococcygeal line is considered to represent the approximate line of attachment for the pelvic floor muscles and ligaments [13]; measurements of extent were obtained perpendicular to this line.
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A cystocele was defined as descent of the bladder base below the pubococcygeal line [10] (Fig. 1A, Fig. 1B). A cystocele was graded as small if the bladder base extended less than 3 cm below this line, moderate if this extension measured from 3 to 6 cm, and large if it extended 6 cm or more below this line [6]. Vaginal vault prolapse was defined as descent of the vaginal vault or any part of the remaining cervix below the pubococcygeal line [9, 10]. The degree of vaginal vault prolapse was graded as small if the vaginal vault or cervix extended less than 3 cm below this line, moderate if the extension measured from 3 to 6 cm below this line, and large if it extended 6 cm or more below this line.
An enterocele or sigmoidocele was defined as descent of the small bowel or sigmoid colon below the pubococcygeal line [9, 10] (Fig. 2A, Fig. 2B). Enteroceles or sigmoidoceles were graded as small if they extended less than 3 cm below the pubococcygeal line, moderate if they extended from 3 to 6 cm below this line, and large if they extended 6 cm or more below this line. A peritoneocele was defined as herniation of the peritoneal cul-de-sac with or without contained small bowel or sigmoid colon [18], and was measured in the same manner as enterocele and sigmoidocele. A rectocele was defined as any rectal protrusion anterior to a line extended upward through the anal canal [19] (Fig. 3A, Fig. 3B). Rectoceles were graded as small if they measured less than 2 cm in extent, moderate if they measured from 2 to 4 cm in extent, and large if they measured 4 cm or more in extent [19].
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We compared the mean difference in extent of pelvic organ prolapse on dynamic MR cystocolpoproctography and on fluoroscopic cystocolpoproctography using the paired t test.
We used dynamic MR cystocolpoproctography to obtain information about the state of the levator muscle (levator ani). Two parameters were analyzed: first, the presence or absence of pelvic floor ballooning in the axial plane at the level of the pubic symphysis [9, 11] (Fig. 4A, Fig. 4B); and second, the presence or absence of levator muscle descent in the coronal plane through the posterior pelvis [9, 11].
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Table 2 shows the mean extent of prolapse of pelvic organs and the difference in extent of prolapse shown by the two methods of examination. The mean difference in extent of cystocele is statistically significant (p = 0.03), as is the difference in extent of rectocele (p = 0.02). The mean differences in extent of vaginal vault prolapse (p = 0.19) and enterocele combined with sigmoidocele (p = 0.45) were not significant.
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All patients showed evidence of pelvic floor ballooning (Fig. 4A, Fig. 4B) and levator muscle descent. Patients were divided equally in their preference for the type of examination. Specifically, equal numbers of patients found the proctographic commode or the MR imaging table to be more comfortable than the other. Only one patient mentioned that the MR imaging unit was claustrophobic. Both the MR imaging and the fluoroscopic examination required a total of 1 hr to complete.
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This study compared two imaging techniques typically used to complement physical examination: dynamic fluoroscopic cystocolpoproctography and dynamic MR cystocolpoproctography. The patients in this study were referred for radiologic evaluation by urogynecologists. Of 10 patients, nine were referred to our institution after developing recurrent symptoms after prior surgery for pelvic organ prolapse. All patients had undergone hysterectomy, a procedure that encourages the formation of enteroceles [21]. The two techniques revealed concordant findings for the majority of patients for both the presence and grade of severity of prolapsed organs. Grading systems were not used in most previous reports that compared dynamic MR imaging with fluoroscopic examination [10, 13, 14, 15]. Grading serves to further show the concordance of the findings with the two techniques.
Both examinations were in complete agreement on the presence of both rectoceles and cystoceles; disagreement in the grading occurred for only one of these 19 sites of prolapse. One enterocele was missed on dynamic MR imaging as a result of insufficient bladder emptying. After more effectively draining the bladder, this patient was reexamined using MR imaging, and a large peritoneocele was revealed (Fig. 6A, Fig. 6B). The fluoroscopic examination failed to reveal one moderate-sized sigmoidocele, which probably reflects the failure to achieve sufficient retrograde filling of the sigmoid colon at the time of rectal opacification. Disagreement occurred concerning the presence of vaginal vault prolapse in one patient in whom metal clip artifacts obscured the vaginal vault on the dynamic MR imaging study.
Compared with the fluoroscopic examination, dynamic MR imaging results underestimated the extent of prolapse for sites other than rectoceles by approximately 10-15% (Table 2). The underestimates may be caused by examining patients in the supine position. The supine position has less gravitational influence than sitting; this influence is known to exacerbate pelvic floor weakness. This aspect was summarized by two of the 10 patients who expressed the belief that the fluoroscopic examination was the better study because their prolapse was only a problem when standing or sitting. Rectoceles are more likely affected by rectal evacuation than by gravitational forces; this may explain why they did not appear larger on the upright fluoroscopic examination. With the advent of open-configuration MR imaging units, pelvic floor imaging can be performed with the patient seated upright in the center of the MR imaging unit so that the examination is more physiologic [12, 22].
Nine patients were able to successfully evacuate during one of the two dynamic imaging sequences while performing the rest-squeeze-relax-strain-evacuate maneuver in the proctographic phase (Figs. 3A, Figs. 3B, 5A, 5B, and 7A, 7B, 7C). The normal defecatory response is associated with inhibition of pelvic floor muscular activity [23], allowing pelvic organ prolapse to be fully evident. MR imaging may be inadequate for the recognition of disorders of anorectal function such as anismus and rectal intussusception. Such disorders are shown when a patient defecates while seated within an open-configuration MR imaging unit [22]. They may also be shown in the supine position provided the patient is able to defecate, as exemplified by the first patient in our study who was considered to have anismus on both MR imaging and fluoroscopic examination.
For all patients, both the MR imaging and the fluoroscopic examinations were carried out using the same amount of contrast material in each of the opacified pelvic organs. Additionally, both examinations were performed in three phases. The initial cystographic phase was followed by bladder emptying through a catheter and further voiding in the bathroom. Without sufficient emptying, a cystocele may prevent the recognition of an enterocele, peritoneocele, or rectocele [17]. With dynamic MR imaging, bladder opacification is unnecessary, but bladder emptying is important and may require catheterization [17] (Fig. 6A, Fig. 6B). After the proctographic phase, a posttoilet phase with the patient straining maximally was routinely performed. This phase assists in the recognition of enteroceles and sigmoidoceles because the increased rectal emptying that many patients achieve in the privacy of the bathroom facilitates the descent of the small bowel or sigmoid colon in the posterior peritoneal cul-de-sac [17] (Fig. 7A, Fig. 7B, Fig. 7C). Forty-three percent of radiographically detected enteroceles are only seen on postevacuation radiographs [6]. On MR imaging, the posttoilet phase may also show a peritoneocele (Figs. 2A, Figs. 2B, 6A, 6B, and 7A, 7B, 7C). The relationship of the herniated small bowel to the peritoneal herniation appears to be variable; the enterocele may float within the peritoneocele (Fig. 2A) or sink to the bottom of the cul-de-sac (Fig. 7C). Seven of the eight patients with a peritoneocele visible on dynamic MR examination had an associated enterocele. This finding is in contrast to that of prior reports in which only 40% of peritoneoceles contained a herniated small bowel [18, 24]. It is possible that this difference in enterocele rate reflects our routine use of the posttoilet phase. Recognition of a peritoneocele is important because it predisposes to enterocele formation and suggests the need for operative closure of the cul-de-sac if surgery is undertaken.
In the study by Lienemann et al. [10], dynamic MR imaging and fluoroscopic imaging were limited to a single phase in which straining and evacuation of all opacified pelvic organs were performed simultaneously. Their fluoroscopic examination did not involve opacification of the small bowel. These methodologic differences may explain why their study found that the fluoroscopic examination was inferior to MR imaging. In particular, their study found that the cystocele was the predominant prolapsed organ visualized on fluoroscopic examination whereas enterocele was the predominant prolapsed organ on MR imaging [10]. Use of a triphasic approach, although more time-consuming, facilitates both bladder and rectal emptying and improves the recognition of enteroceles. Non-opacification of the small bowel during the fluoroscopic examination is a recognized factor in the failure to identify enteroceles [1]. This latter consideration is an important benefit of MR imaging because the small bowel possesses inherent contrast delineation from peritoneal fat; consequently, patients can avoid the unpalatability and delay incurred by barium ingestion. Literature studies conflict regarding the sensitivity of MR imaging compared with that of fluoroscopic examination for detecting pelvic organ prolapse. Although Lienemann et al. found MR imaging to be superior, more recent studies have concluded that MR imaging is either less sensitive [14] or of equivalent diagnostic benefit [15].
During the performance of this study, several technical issues surfaced. On fluoroscopic examination, the pubococcygeal line was often difficult to identify. This problem was caused by the lack of clarity of the inferior margin of the pubic symphysis on lateral radiographs, which may have affected the anterior point of the pubococcygeal line by 1 cm in some patients. During MR imaging, the presence of residual stool or air introduced with the sonography gel sometimes produced artifacts in the lower rectum that compromised visualization of the extent of a rectocele. However, there were always some clean images that made this determination possible. In both examinations, leakage of vaginal contrast material outside the introitus sometimes caused difficulty in identifying the vaginal apex. In one patient, a surgical clip in the vaginal vault prevented assessment of vault prolapse on the MR imaging study.
Justifiable concern exists that rectal evacuation on the MR imaging table may be poorly tolerated by the patient or may contaminate the MR imaging unit. The evacuated rectal contents were always confined to the waterproof absorbent padding placed beneath the patient. This padding was removed immediately after the proctographic phase. As a result, the MR imaging unit was never contaminated. Rapid removal of the padding minimized any discomfort associated with evacuated gel in the perirectal area. Cleansing of the MR imaging table between patients required approximately 2 min. Optimal performance of the MR imaging examination depended on a sensitive and cooperative approach by the radiologic technologist, radiologist, and nurse. As with the fluoroscopic examination, thoroughly explaining the procedure to the patient beforehand is important. It is also necessary to maintain verbal contact and provide verbal reassurance while the patient is inside the MR imaging unit to facilitate their cooperation and to minimize embarrassment. The MR imaging examination was remarkably well tolerated in this group of patients. This is in part because the patients understood that maximum information about their prolapse was required to plan future treatment.
There is some overlap on fluoroscopy between findings in asymptomatic volunteers and patients with prolapse, and there is a need to more fully define this overlap on MR imaging [9]. Yang et al. [7] found that in volunteers without symptoms of prolapse or incontinence, the bladder base did not descend more than 1 cm below the pubococcygeal line. Additionally, the vaginal cuff or cervix remained more than 1 cm above the pubococcygeal line. However, using these data as reference points in 10 asymptomatic volunteers, Healy et al. [9] showed the presence of uterocervical prolapse in four subjects and cystocele or rectocele in two subjects. These data suggest that the pubococcygeal line is too high to serve as a reference point. These data also highlight the need to explore other reference points for defining pelvic organ prolapse (Lienemann A, personal communication). More recently, a grading system for organ prolapse based on the relationship between the pelvic organs and the puborectalis muscle was proposed [16].
In our opinion, the overriding benefit of dynamic MR imaging is the depiction of the pelvic contents in the cine-loop presentation as seen on videotape. In this study, static images were used for obtaining measurements of the prolapse. The videotape shows the prolapsed organs and provides a multiplanar dynamic representation of the process and sequence of both organ descent and emptying. Pelvic organs do not empty simultaneously. Videotape analysis shows that the rectum and vagina empty first, followed by the emptying of the residual undrained bladder. Only when these organs have partially emptied can maximal small-bowel or peritoneal descent occur (Figs. 6A, Figs. 6B and 7A, 7B, 7C). Importantly, changes in the position of the levator muscle that occur in association with organ prolapse (Fig. 4A, Fig. 4B) are dynamically recorded in the cine-loop. Such information cannot be obtained from the fluoroscopic examination.
All patients with prolapse were found to have ballooning of the puborectalis muscle when a dynamic sequence was obtained in the axial plane at the level of the pubic symphysis [9, 11] (Fig. 4A, Fig. 4B). Asymptomatic volunteers do not show this expansile weakness [9], a manifestation of the increased size of the urogenital hiatus within the damaged levator muscle. Weakness of the levator muscle posteriorly was evident in all patients when a straining sequence was performed through the posterior pelvis in the coronal plane. The association of a damaged levator muscle and pelvic organ prolapse is well recognized, and increased prolapse is accompanied by progressive enlargement of the urogenital hiatus [25]. MR imaging can be used to measure the thickness of the levator muscle (Pannu HK, et al., presented at the American Roentgen Ray Society meeting, May 1999) and may be used to assess the position and size of this muscle. The use of MR imaging to analyze pelvic floor musculature is rapidly growing and has contributed considerably to our understanding of pelvic floor dysfunction [8, 9, 11, 12, 26, 27]. Because pelvic floor MR imaging is still evolving, the clinical benefit of viewing the damaged levator muscle remains to be fully clarified.
In conclusion, this study found that dynamic MR imaging and dynamic fluoroscopic cystocolpoproctography have similar detection rates for prolapse of pelvic organs. We found that both examinations grade the degree of prolapse similarly, although dynamic MR imaging underestimates the extent of cystoceles, enteroceles, and vaginal vault prolapse. The fluoroscopic study underestimates the extent of rectoceles. We emphasize that these preliminary conclusions apply only if both examinations are performed in the triphasic manner. The advantages of dynamic MR imaging are considerable. They include multiplanar cine-loop global visualization of pelvic organs and pelvic floor musculature, absence of ionizing radiation, and timesaving. MR imaging permits direct measurement without correction for magnification. In this study, patient preference was equally divided between the two types of examination. We are enthusiastic advocates of fluoroscopic cystocolpoproctography [1, 6, 17, 19, 20, 28, 29, 30], but we are reevaluating this advocacy in light of the benefits of dynamic MR imaging.
Acknowledgments
We thank Fran Shaul for expert secretarial assistance, Tom Courtney and Jan
Thompson for technical assistance with MR imaging, Lifen Zhou for statistical
assistance, and Andreas Lienemann for his inspiration and advice.
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