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Chapter 11 • Anorectal Disorders in Inflammatory Bowel Disease 151
12
Imaging in Rectal Prolapse and Other
Dynamic Pelvic Floor Disorders
Marı´a del Rocı´o Iniguez-Rodrı´guez
DEP A R T M EN T O F RAD I O L O GY , A B C M E D I CA L C E N T E R , ME XI C O CI TY , M E XI C O
12.1 Introduction
In recent years, a variety of imaging techniques have been used for the evaluation of
defecatory disorders and pelvic organ prolapse, including defecography,
1–5
magnetic
resonance (MR) imaging (for the assessment of organ prolapse),
6–8
and ultrasonography
(for the assessment of urinar y and fecal incontinence).
9
Defecography evaluates in real time the morphology of the rectum and anal canal.
Because of its ability in structural and functional evaluation it is primarily performed
in the work-up of patients with morphologic and functional disorders of the recto-anal
region and in evacuation disorders involving the pelvic floor.
2–5,10–14
Recently, MR defecography has gained increasing interest because of its accuracy
in morph ologic and functional assessment, as well as the benefit of avoiding radiation
exposure for the patient.
7,15–17
With the advent of an open-configuration MR imaging
system, MR defecography with the patient in a vertical position has become
possible.
7,15–17
In this technique, a high-quality multiplanar soft-ti ssue contrast of MRI is used to
visualize the pelvic organs and the supporting soft-tissue structures without the radiation
burden of conventional fluoroscopic defecography.
15
Transabdominal, transvaginal, endoanal, transperineal, and 3D techniques can be
used to evaluate the pelvic floor sonographically. Ultrasound evaluation of the pelvic floor
has the advantage of being readily ava ilable and being relatively easy to perform, without
the use of ionizing radiation.
7
12.2 Defecography
Conventional defecography (video defecography) enables the evaluation of the anatomy
of the pelvic floor and the dynamics of rectal emptying and provides important information about anorectal and pelvic-floor functions.
1
The major indications to perform a defecography are constipation, incomplete evacuation or incontinence (often associated with rectal bleeding), mucous discharge,
Anorectal Disorders. https://doi.org/10.1016/B978-0-12-815346-8.00012-6
© 2019 Elsevier Inc. All rights reserved.
153
perineal pain or discomfort, and as a follow-up examination of patients who have
undergone surgery to the pelvic region.
5
The procedure was first described by Wallden in 1953,2and dramatically improved our
knowledge of evacuation dysfunctions. Mahieu et al. in 1980 developed a modified
technique that included opacifications with contrast media of the other pelvic landmarks
and this has now has become the current standard techniqu e.
3,4
Using this protocol five
quantitative morphologic signs have been identified as normal findings: (1) increase of
anorectal angle (ARA), (2) obliteration of the impression of the puborectalis sling, (3) wide
aperture of the anal canal, (4) evacuation of the rectal contents, and (5) good resistance of the
pelvic floor.
4
12.2.1 Technique
The technique of defecography relies on fluoroscopic screening, a specialized commode,
a recording device, contrast medium, and a means for injecting contrast medium into the
rectum.
3,9,10
Physiologic conditions during defecography are simulated by injecting a thick barium
paste into the rectum.
10
Barium paste is obtained by mixing equal proportions of potato
starch and barium solution with water. Barium paste must have the consistency of normal
stool. Finally, in a female patient, the vagina is opacified with a commercially available
barium sulfate paste for oral use.
5
The patient is then instructed to sit in the lateral
position on a commode made of radiolucent materials, thereby allowing both lateral
radiographs. Disposable plastic bags collect the excreted barium paste.
10
12.2.2 Parameters
The ARA is measured between the longitudinal axis of the anal canal and the posterior
rectal lines, parallel to the longitudinal axis of the rectum. At rest, its average value is
95–96 degrees (physiologic range, 65–100degrees) without noticeable differences between
men and woman.
11–13
The ARA is an indirect indicator of puborectal muscle activity.
During muscle contraction, the ARA becomes more acute, while during a defecatory
maneuver it relaxes becoming more obtuse.
14
The second important parameter to evaluate is movement of the anorectal junction
(ARJ) during straining. The line drawn between the ischial tuberosities is called the bisischiatic line and can used as a fixed bony landmark. Another fixed reference point is
represented by the tip of the coccyx, defined by measuring the vert ical distance between
the pubococcygeal line (PCL) and the ARJ. The PCL is drawn from the inferior aspect of the
pubis to the tip of the coccyx and is considered to represent the approximate line of
attachment of the pelvic-floor muscle. The distance from the PCL to the ARJ is measured
on images obtained when the patient is at rest and at maximal pelvic strain to assess the
position of the pelvic floor. The craniocaudal migration of ARJ indirectly represents the
elevation and descent of the pelvic floor.
5,11,14
154 ANORECTAL DISORDERS
12.2.3 Normal Findings
In the resting phase the impression of the puborectal sling is visible on the posterior wall
of the caudal rectum and the ARA is about 90 degrees. During voluntary contraction of the
pelvic floor (squeezing), the ARA decreases to about 75 degrees and the ARJ migrates cranially. The puborectal impression becomes more evident because of the contraction of the
levator ani. While the patient is asked to strain, the ARA increases with partial to complete
loss of puborectal impression and the pelvic floor descends. The degree of caudal migration of ARJ is considered normal when less than 3.5cm relative to the resting position.
During evacuation, wide opening of the anal canal and funneling of the anorectum is
seen with near to complete loss of puborectal sling impression. The ARA increases with the
relaxation of anal sphincter and puborectalis muscle. At the end of evacuation, the rectum
is completely empty and its walls collapse.
14
12.3 MR Defecography
MR imaging is already used in the evaluation of anorectal diseases.
17
With the advent of
open-configuration MR systems, which enable image acquisition in a vertical patient
position, MR defecography with the patient in the sitting position has become possible.
MR imaging provides a multiplanar global evaluation of the pelvis contents including
the uterus and the pelvic-floor muscles. This global depiction of the pelvic contents cannot be obtained using fluoroscopy.
15
12.3.1 Technique
There is a considerable variation in the literature regarding the optimal method of performing MR imaging in a patient with pelvic-floor dysfunction. Imaging has been performed with patients in the supine and upright positions. A magnet that has been
developed for interventional purposes allows upright imaging
15,18,19
; however, this mag-
net is not universally available.
Before imaging, patient preparation involves drinking 600 mL of water over 30 min to
opacify and better distend the small bowel, and thereby improve visualization. Maintaining a small amount of urine in the bladder improves visualization of the bladder and anterior vaginal wall prolapsed. The examination is performed with a torso phased-array coil
wrapped around the pelvis in a closed-magnet MR system.
15
For MR defecography, ultrasound gel or mashed potatoes dropped with gadopentetate dimeglumine are frequently
used for rectal filling.
18,20,21
12.3.2 Parameters and Normal Findings
The dynamic proces s of defecog raphy is demonstrated by using multiphase sagittal
gradient-echo images. Analyses during straining or defecation show an increase
Chapter 12 • Imaging in Rectal Prolapse and Other Dynamic Pelvic Floor Disorders 155
in the ARA, widening and opening of the anal canal, functioning of the pubo rectal
muscle, as well as positioning of the pelvic floor and descent of the perineum.
The ARA is defined, in accordance with conventional defecography, as the angle
betwee n the two lines that intersect at the ARJ; these lines are formed along the
poster ior b order of the distal part of the rectum and along the central axis of the anal
canal.
7,17
The “HMO” system is used to grade pelvic-floor laxity and organ descent and includes
evaluation of the “H-line,” “M-line,” and organ specific prolapse. The H-line is a measure
of the width of the pelvic-floor hiatus in the anteroposterior dimension and is measured
from the inferior tip of the pubic symphysis to the posterior circular fibers of the ARJ. Normal H-line at rest is 6 cm. The M-line is drawn perpendicularly down from the PCL to the
posterior extent of the H line at the posterior aspect of the ARJ. It represents the degree of
pelvic-floor descent. The M-line at rest is typically 2 cm. The “O” in the HMO system
represents organ-specific prolapse.
22
12.4 Ultrasound
In patients with urinary incontinence or retention, pre and postvoid bladder volumes can
be calculated using transabdominal ultrasound.
23
Endonanal ultrasound can be used to
evaluate the integrity of the internal anal sphincter (IAS) and the external anal sphincter
(EAS) muscles in patients with fecal incontinence. The mucosa and submucosa of the anal
canal are usually hyperechoic. The normal IAS is uniformly hypoechoic and is 2–3 mm
in thickness. The normal EAS is more heterogeneous in echotexture and is of variable
thickness.
24,25
More recently sonographic evaluation of pelvic organ prolapse has been
described with the use of 4D ultrasound.
26
12.5 Pathologic Condition
12.5.1 Intussusception and Rectal Prolapse
Rectal intussusception is a concentric invagination of the entire rectal wall during the
straining maneuver. The location can be anterior or posterior and can even affect the rectum circumferentially.
17
It may be classified as intrarectal (intussusceptions may remain
internal), intraanal (extend into the anal canal), or total rectal prolapsed (where the rectum passes through the canal). Therefore the widely used clinical term, rectal prolapse,
corresponds anatomically to an extra-rectal intussusception (
Fig. 12.1).
14,27
At defecography, the presence of transverse or oblique in-folding of the rectal wall of more than 3 mm
thickness represents intussusceptions. Minor degrees on in-folding of less than 3-mm
thickness represent mucosal prolapse.
17,27
Patients may experience incomplete defecation due to severe outlet obstruction. Most
patients with external rectal prolapse have associated incontinence.
14
156 ANORECTAL DISORDERS
12.5.2 Rectocele
Rectocele is an anterior bulge of the rectal wall that results from weakness in the rectovaginal fascia and it is less frequently posterior or lateral. Rectoceles are more frequently
found in women, usually resulting from obstetrics injury.
17
On the midsagittal image of
the dynamic MR examination or in defecography rectocele it is identified by a rectal bulge
of more than 2 cm, which is the distance measured between the anal canal and the tip of
the rectocele. Because an anterior rectal bulge of up to 2 cm may also occur in women
without defecatory dysfunction, the patient’s clinical symptoms, such as a feeling of
incomplete defecation, should be considered in determining the significance of these
findings.
17,28
Several authors describe a grading system for rectocele,
1,17
grade 1 are outpouchings
of <2 cm in anteroposterior diameter (not clinically significant), grade II are outpouchings
of between 2 and 4 cm, and grade III are outpouchings with an anteroposterior diameter
of !4 cm.
1,15
12.5.3 Enterocele and Sigmoidocele
Enterocele is a herniation of a peritoneal sac that is located downward and along the ventral rectal wall into the cul-de-sac or pouch of Douglas. At defecography, separation of the
opacified vagina and the upper rectum during straining or defecation suggests an enterocele.
10,17
This enlarged rectogenital fossa may contain small intestines, oment al fat, or
sigmoid colon (
Fig. 12.2).
12.5.4 Descending Perineum Syndrome
In descending perineum syndrome (pelvic-floor descent), the muscle tone of the pelvic
floor is diminished, there is an anterior wall prolapse of the rectum during excessive
straining, which is associated with pudendal nerve damage. For the diagnosis, at rest
FIG. 12.1 Rectal prolapse in a 59-year-old woman. (A, B) Lateral radiograph of the rectum on completion of forced
evacuation shows annular folding passing through anal orifice (external rectal prolapse).
Chapter 12 • Imaging in Rectal Prolapse and Other Dynamic Pelvic Floor Disorders 157
(fixed descent), the distance in centimeters between the ARJ and the PCL is measured, and
perineal descent at rest is considered when the ARJ and PCL distance is superior to 6 cm.
For perineal descent on straining (dynamic descent), the difference in centimeters
between the ARJ position at straining and at rest was noted. Perineal descent on straining
was defined as a difference of >3.5 cm between the two position.
1,10,17
This syndrome is
often associated with perineal discomfort and pain and a feeling of incomplete evacuation, leading to increased straining during defecation.
17
12.5.5 Spastic Pelvic Floor Syndrome
It is also known as spastic pelvic syndrome. This condition is due to an inappropriate contraction of the pelvic floor during defecation. The puborectalis muscle maintains continuous activity while at rest, it pulls the rectum anteriorly to maintain the ARA at about
90 degrees. During normal defecation the patient strains causing pelvic floor descent,
an increase in the ARA, and reflex inhibition. Characteristic findings of defecography
include a lack of pelvic floor descent and paradoxical contraction of the puborectalis muscle. The internal and external sphincters are relaxed with subsequent exp ulsion of the
fecal bolus. Another less specific feature is an aberrantly deep impression of the puborectalis sling on the po sterior rectal wall at rest. This is caused by the presence of a hypertrophic puborectalis muscle.
14,29
12.6 Summary
Several imaging techniques have greatly increased our knowledge of evacuation disorders.
There are a variety of options for imaging these patients including ultrasound, fluoroscopy
(A)
Rectocele
~30.8 mm
(B)
FIG. 12.2 Rectocele in a 40-year-old woman with obstructed defecation. (A, B) Lateral radiograph of rectum during
evacuation (A) and at the end of evacuation (B), reveals a 3 cm anterior rectocele (arrows). The anterior rectal wall
protrudes over the expected position and the vaginal lumen is dislocated anteriorly. The vertical line is along the long
axis of the expected location of anterior wall of anal canal. A cystocele is also evident (head arrows).
158 ANORECTAL DISORDERS
(defecography), and MRI examinations (MR defecography). Defecography remains a
widely availabl e and cost-effective procedure of choice for the assessment of anorectal
dysfunction and MRI is the newest technique to be used, offering several advantages over
the more traditional methods.
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160 ANORECTAL DISORDERS
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