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Chapter 10 Imaging of the Pelvic Floor
Fig. 10.5. Position of the anorectal junction related to the pubococcygeal line in MRI and videoproctography in 20 patients with complex pelvic floor disorders at rest and at maximal straining
during defecation
147
Fig. 10.6. Anorectal angle at rest and during defecation in 20 patients in videoproctography and
dynamic MRI
148
Alois Fürst, Lilli Hutzel, Klaus Guenther, Andreas Schreyer, Christian Paetzel
only because data vary significantly, but also because findings of patients and asymptomatic volunteers tend to overlap (Kruyt et al. 1991; Healy et al. 1997a,b; Stoker et al.
2001).
Anterior rectoceles often present with symptoms of incomplete defecation and are
often observed along with a descent of the pelvic floor (Schoenenberger et al. 1998).
But rectoceles are also found in asymptomatic patients. Therefore, some authors assume that symptoms depend on the size of rectoceles (Lienemann et al. 1997).Because
of different approaches in the attempt to measure the expansion of a rectocele, there
are still no well-defined normal values available. Delemarre et al. (1994) used videoproctography and MRI to examine 38 patients in the prone position without rectal filling and without defecation. He concluded that videoproctography is superior to MRI
in the diagnosis of rectoceles. Lienemann et al.(1997) defined a rectocele as a protrusion of the anterior rectal wall of more than 30 mm according to Yoshioka. He found
that, in comparison to clinical examination, MRI was superior to colpocystoproctography in detecting rectoceles. In his study,patients were examined in the supine position (MRI) with rectal filling during maximal straining but without defecation. In
contrast, Healy et al. (1997b) rated videoproctography superior to MRI. He defined an
expansion of more than 20 mm (according to Yoshioka) as pathological. In addition,
he found that a rectocele less than 13 mm measured by videoproctography was missed
with the MRI technique. MRI examination again was performed without defecation;
the anal canal was marked with a plastic tube.
10
Fig. 10.7. Position of the anorectal junction related to the pubococcygeal line in MRI in patients
(n=20) and healthy volunteers (n=10) at rest and at maximal straining during defecation. The
difference was not statistically significant, but standard deviation was higher in the patient
group
Chapter 10 Imaging of the Pelvic Floor
In our own series, sizes of the rectoceles were approximately equal in both procedures: 27 mm (14–59 mm) in videoproctography vs 23 mm (10–40 mm) in MRI. According to our observations,the horizontal position does not seem to be a disadvantage since a rectocele was found in eight out of ten healthy volunteers in MRI, with an
average size of 26 mm. This is in part in accordance with data from the literature
(Lienemann et al. 1997; Hilfiker et al. 1998), where the incidence of a rectocele in
asymptomatic volunteers is about 80%, although these are described as small rectoceles. Our own data show that in standardized conditions videoproctography as well as
MRI yield reproducible and comparable data (Figs. 10.7, 10.8).
Incidence and degree of a cystocele and a uterocervical prolapse is usually related
to the number of vaginal deliveries, preceding hysterectomy and with chronic constipation leading to increased straining maneuvers (Vanbeckevoort et al. 1999; Fürst et
al. 2000). Besides clinical examination, imaging techniques make quantification of
findings possible (Lienemann et al. 1997). Yang et al. (1991), Lienemann et al. (1997),
Vanbeckevoort et al. (1999) and Healy et al.(1997a) used normal values for the descent
of the bladder base and uterocervical junction during straining in relation to the pubococcygeal line. These values were raised partly in healthy volunteers and partly determined at random (Rentsch et al.2001; Hutzel et al.2002a,b).
In our routine practice we do not contrast the urinary bladder or the vagina, because of an excellent visualization by natural contrast.The mean values of the descent
of the bladder base and uterocervical junction did not differ significantly in patients
as compared to healthy volunteers in our own studies (Figs.10.9, 10.10).In contrast,the
maximal values were substantially higher in patients than in healthy females.Interest-
149
Fig. 10.8. Anorectal angle at rest and at maximal straining during defecation in patients (n=20)
and healthy volunteers (n=10) in dynamic MRI
150
Alois Fürst, Lilli Hutzel, Klaus Guenther, Andreas Schreyer, Christian Paetzel
10
Fig. 10.9. Position of the bladder base related to the pubococcygeal line in patients (n=20) and
healthy volunteers (n=10)
ingly,six out of ten completely asymptomatic healthy female volunteers without a history of previous delivery or surgery were found to have a cystocele, and in three out of
ten vaginal prolapse was diagnosed (Fürst et al. 2000; Rentsch et al. 2001; Hutzel et al.
2002a,b) (Table 10.2).
In the studies of Lienemann and Sprenger, 20 and 39 healthy females were examined with dynamic MRI of the pelvic floor including defecation.A cystocele or vaginal
prolapse was seen in none of the cases.Since Lienemann’s examination and evaluation
technique are mainly comparable to our proceedings, the discrepancy of results is
hard to explain in this context.
An enterocele is defined as a herniation of peritoneum into the rectovaginal space,
which may contain small bowel loops or sigmoid colon. They are often accompanied
by severe defecation disorders and a sensation of pressure as well as downward movement of the pelvic floor. The prevalence of enteroceles in women lies between
18%–37%; they often occur after hysterectomy.
Lienemann et al.(2000) examined 55 patients and 11 asymptomatic volunteers with
colpocystoproctography and dynamic MRI without administration of contrast medium into the peritoneum or small bowel.The MRI held a clear advantage since the peritoneum and the contents of the enterocele were easily identified. He concluded that
MRI may replace colpocystoproctography in the diagnosis of enteroceles. Since contrasting the small bowel or peritoneum is not necessary for the clear identification of
pelvic organs and structures, we conclude that MRI is superior to colpocystoproctography in the diagnostics of enteroceles.
Chapter 10 Imaging of the Pelvic Floor
Fig. 10.10. Position of the uterocervical junction or vaginal vault related to the pubococcygeal
line in 18 patients and 10 healthy volunteers in dynamic MRI
151
Table 10.2. Anorectal junction, anorectal angle, bladder base, uterovaginal junction and rectoceles at rest and during straining in patients (n=20) and in healthy individuals (n=10)
20 patients (18 female) 10 healthy volunteers P-value
dynamic MRI dynamic MRI
Anorectal junction (mm) –11.6 (±19.5) rest –5.3 (±9.9) rest NS
–40.2 (± 23.3) straining –29.9 (±10.3) straining NS
Anorectal angle (°) 119.0 (±14.8) rest 93.0 (±4.8) rest NS
relative movement (°) 117.1 (±21.87) straining 108.7 (±14.7) straining NS
–1.9° +15.7 0.002
Bladder base (mm) +19.8 (±14.4) rest +23.0 (±4.6) rest NS
–11.7 (±24.4) straining –8.1 (±11.1) straining NS
Uterovaginal junction +34.8 (±18.9) rest +43.1 (±7.8) rest NS
(mm) +4.5 (±26.3) straining +7.9 (±16.5) straining NS
Rectoceles (size in mm) 23.0 (±9.2) 26.0 (±6.7) NS
10
152
Alois Fürst, Lilli Hutzel, Klaus Guenther, Andreas Schreyer, Christian Paetzel
10.11 Conclusion
Comparing videoproctography and dynamic MRI of the pelvic floor, defecation is essential when performing MRI, because pathological findings may only become evident towards the end of the defecation process. The anorectal junction and the anorectal angle are influenced by the horizontal position of the patients in the MRI. Still,MRI
is a valid tool to evaluate the posterior compartment in combined pelvic floor disorders, provided that patient preparation, examination technique and evaluation are
standardized.Rectoceles can be easily identified in MRI. In the diagnosis of cystoceles,
enteroceles or a uterovaginal prolapse, MRI is superior to conventional defecography
despite similar invasiveness. Since the pelvic organs of healthy volunteers show a relatively high mobility, presently suggested normal values for the position of pelvic organs in relation to the pubococcygeal line have to be redefined. It is necessary to evaluate normal values under standardized investigation conditions.
References
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imaging of the pelvic floor performed with patient sitting in an open-magnet unit versus
with patient supine in a closed-magnet unit. Radiology 223: 501–508
Broadhead DA, Chapple CL, Faulkner K (1995) The impact of digital imaging on patient doses
during barium studies. Br J Radiol 68: 992–996
Delemarre JBVM, Kruyt RH, Doornbos J,Buyze-Westerweel M, Trimbos JB (1994) Anterior rec-
tocele: assessment with radiographic defecography, dynamic magnetic resonance imaging,
and physical examination.Dis Colon Rectum 37 :249–259
Fürst A,Hutzel L, Rentsch M, Beham A,Spatz H, Jauch K-W (2000) Koloproktologische Erkran-
kungen des Beckenbodens. Radiologe 40: 446–450
Goei R, Kemerink G (1990) Radiation dose in defecography.Radiology 176 :137–139
Goodrich MA, Webb MJ, King BF, Bampton AEH,Campeau NG, Riederer SJ (1993) Magnetic res-
onance imaging of pelvic floor relaxation: dynamic analysis and evaluation of patients before
and after surgical repair.Obstet Gynecol 82: 883–891
Gufler H, Laubenberger J, de Gregorio G, Dohnicht S, Langer M (1999) Pelvic floor descent: dy-
namic MR imaging using a half-Fourier RARE sequence. J Magn Reson Imaging 9 :378–383
Hare C,Halligan S, Bartram CI et al (2001) Dose reduction in evacuation proctology.Eur Radiol
11: 432–434
Healy JC, Halligan S, Reznek RH, Watson S, Bartram CI, Kamm MA, Phillips RKS,Armstrong P
(1997a) Magnetic resonance imaging of the pelvic floor in patients with obstructed defaeca-
tion. Br J Surg 84 : 1555–1558
Healy JC, Halligan S, Reznek RH,Watson S, Bartram CI, Phillips RKS,Armstrong P (1997b) Dy-
namic MR imaging compared with evacuation proctography when evaluating anorectal con-
figuration and pelvic floor movement.AJR 169: 775–779
Herold A,Müller-Lobeck H, Jost W-H, Duschka L, Leder D (1999) Diagnostik des Rektums und
Beckenbodens bei chronischer Obstipation. Zentralbl Chir 124:784–795
Hilfiker PR,Debatin JF, Schwizer W, Schoenberger W, Fried M, Marincek B (1998) MR defecogra-
phy: depiction of anorectal anatomy and pathology. J Comput Assist Tomogr 22 :749–755
Hutzel L,Paetzel C, Spatz H,Fürst A (2002a) Dynamisches MRT und konventionelle Defäkogra-
phie: Möglichkeiten und Grenzen.Visceralchirurgie 37 :23–29
Hutzel L, Spatz H, Paetzel C, Fürst A (2002b) Stellenwert der dynamischen Beckenboden-MRT
und der konventionellen Defäkographie bei komplexen Beckenbodenstörungen. Gynäkol
Prax 26: 201–210
Kruyt RH, Delemarre JBVM,Doornbos J,Vogel H (1991) Normal anorectum: dynamic MR imag-
ing anatomy. Radiology 179 : 159–163
Lienemann A,Anthuber C, Baron A, Kohz P, Reiser M (1997) Dynamic MR colpocystorectogra-
phy assessing pelvic-floor descent.Eur Radiol 7: 1309–1317
Chapter 10 Imaging of the Pelvic Floor
Lienemann A, Anthuber C, Baron A, Reiser M (2000) Diagnosing enteroceles using dynamic
magnetic resonance imaging. Dis Colon Rectum 43: 205–213
Paetzel C, Strotzer M, Fürst A, Rentsch M, Lenhart M, Feuerbach S (2001) Dynamische MR-
Defäkographie zur Diagnostik kombinierter Beckenbodenstörungen in der Proktologie.
Fortschr Röntgenstr 173 :410–415
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onance imaging defecography – a new diagnostic alternative in the assessment of pelvic floor
disorders in proctology.Dis Colon Rectum 44: 999–1007
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Stoker J,Halligan S, Bartram CI (2001) Pelvic floor imaging. Radiology 218: 621–641
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153
Chapter 11
Chapter 11 Diagnostic Methods to Detect Female Urinary
Diagnostic Methods
to Detect Female Urinary Incontinence
Heinz Koelbl,Gert Naumann
155
11
Contents
11.1 Assessment of Genuine Stress Incontinence . . . . . . . . 157
11.2 Basic Investigations . . . . . . . . . . . . . . . . . . . . . . 157
11.3 Urodynamics . . . . . . . . . . . . . . . . . . . . . . . . . 158
11.3.1 Uroflowmetry . . . . . . . . . . . . . . . . . . . . . . . . . 158
11.3.2 Cystometry . . . . . . . . . . . . . . . . . . . . . . . . . . 159
11.3.3 Urethral Pressure Measurements . . . . . . . . . . . . . . 159
11.3.4 Valsalva Leak Point Pressure . . . . . . . . . . . . . . . . . 161
11.3.5 Videourodynamics . . . . . . . . . . . . . . . . . . . . . . 161
11.3.6 Ambulatory Urodynamic Monitoring . . . . . . . . . . . . 161
11.4 Electromyography . . . . . . . . . . . . . . . . . . . . . . 162
11.5 Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . 162
11.5.1 Sonographic Urethrocystography . . . . . . . . . . . . . . 162
11.5.2 Perineal Ultrasound . . . . . . . . . . . . . . . . . . . . . 163
11.5.3 Introital Ultrasound . . . . . . . . . . . . . . . . . . . . . 163
11.5.4 Intraurethral Ultrasound . . . . . . . . . . . . . . . . . . . 164
11.5.5 Three-Dimensional Ultrasound . . . . . . . . . . . . . . . 164
11.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 164
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
11
156
Heinz Koelbl, Gert Naumann
The International Continence Society defines stress incontinence as a symptom, a
sign, and a condition (Bates et al. 1979). The symptom is the patient’s complaint of involuntary loss of urine with physical exercise.The sign is the observation of urine loss
from the urethra immediately upon increasing intraabdominal pressure (e.g., while
coughing). The condition, genuine stress incontinence,is the socially unacceptable involuntary loss of urine that occurs when intravesical pressure exceeds maximum urethral pressure in the absence of detrusor activity.
The maintenance of urinary continence involves the interplay of several complex
mechanisms. Not only is normal central nervous system function and a normal bladder wall required, but anatomic and functional integrity of the urethra and vesical
neck are necessary (Asmussen and Miller 1983).The bladder neck consists of intrinsic
and extrinsic elements. The intrinsic component reveals a passive closure due to an
interplay between abundant elastic connective tissue and bladder neck smooth muscle. The bladder neck is suspended by ligaments attached to the pubic bone and the levator ani fascia representing the extrinsic component.
The neurologic integrity of the anatomic components maintaining continence is
extremely important. Intact innervation of the periurethral striated muscles and pelvic floor musculature by the pelvic efferent nerves and pudendal nerve, respectively,
serve to modulate resting tone and reflex increases in urethral pressure with stress.
Voluntary increases in urethral pressure by the muscles of the perineal membrane are
elicited via upper motor neuron pathways (pyramidal tracts), initiated from the cerebral cortex (Ostergard 1985). Interruption or damage to innervation of these various
structures can cause dysfunction at any level.
Various theories on how bladder storage and urethral competence are maintained
have been established until now.One theory developed by Enhoerning follows the concept of pressure transmission, which is based on the observations that intraurethral
pressure rises simultaneously with intra-abdominal pressure during a cough.Another
concept of the urethrovesical competence mechanism, according to Ulmsten and Petros, is that the vagina itself along with other supporting structures, i.e., ligaments,
muscles and their connective tissue insertions are responsible for maintaining the pelvic floor aspect of continence. The authors advocate three closure mechanisms. The
first is established by a contraction of the anterior pubococcygeus muscle closing the
urethra. The second mechanism is the bladder neck closure, by its elongation backwards and downwards against the immobilized proximal urethra. The third mechanism is mediated by a different group of pelvic floor muscles, which are voluntary.
These many facets of possible defects and factors contributing to the closure mechanism of the urethrovesical unit,which may cause the onset of genuine stress incontinence (GSI), warrant a complex investigative approach. Moreover, and as demonstrated in multiple studies the causes for GSI are complex, especially following anti-incontinence surgery. All diagnostic methods complement each other and may not be regarded as conclusive each one alone. Thus a multimodal approach to identifying urinary incontinence and the type of GSI is mandatory.All investigative procedures have
brought a new understanding into the onset of GSI caused by a single or multiple defects. However, despite the innovations within the last decades all the procedures have
their distinct limits. Thus,all investigative tools form a puzzle and help to confirm GSI
primarily based on the patient’s symptoms,resulting in a distinct detection of its pathomorphological and/or dysfunctional origin.
The evaluation of the subtype and severity of the urinary incontinence are the main
goals in assessing incontinence.All patients should be informed of the spectrum of investigation and treatment options.
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