OBJECTIVE: Utilize magnetic resonance defecography (MRD) to analyze the primary pelvic floor dysfunctions in patients with stress urinary incontinence (SUI) associated with pelvic organ prolapse (POP), and in SUI patients with asymptomatic POP.
METHODS: We performed MRD in both SUI and POP subjects. As a primary analysis, the functional MR parameters were compared between the isolated POP and POP combined SUI groups. As a secondary analysis, the functional MR data were compared between the POP combined SUI and the SUI with asymptomatic POP (isolated SUI) groups.
RESULTS: MRD noted the main characteristics of SUI combined moderate or severe POP, including the shorter closed urethra length (1.87 cm vs. 2.50 cm, p < 0.001), more prevalent urethral hypermobility (112.31° vs. 85.67°, p = 0.003), bladder neck funneling (48.28% vs. 20.51%, p = 0.020), lower position of vesicourethral junction (2.11 cm vs. 1.67 cm, p = 0.030), and more severe prolapse of the posterior bladder wall (6.26 cm vs. 4.35 cm, p = 0.008). The isolated SUI patients showed the shortest length of the closed urethra (1.56 cm vs. 1.87 cm, p = 0.029), a larger vesicourethral angle (153.80° vs. 107.58°, p < 0.001), the more positive bladder funneling (84.85% vs. 48.28%, p = 0.002) and a special urethral opening sign (45.45% vs. 3.45%, p < 0.001).
CONCLUSIONS: Patients with SUI accompanying POP primarily exhibit excessive urethral mobility and a shortened urethral closure. SUI patients with asymptomatic POP mainly show dysfunction of the urethra and bladder neck, characterized by the opening of the urethra and bladder neck and a shortened urethral closure.

In this case-control study, we aimed to evaluate how muscle volume affects pelvic floor function by analyzing the levator ani muscle (LAM) using volumetric segmentation in addition to standard magnetic resonance (MR) defecography assessments.
We enrolled 85 patients with varying degrees of pelvic floor dysfunction (PFD) and 85 age- and gender-matched controls in this retrospective study. All patients had MR defecography images, while all controls had pelvic MR images obtained for other reasons. Group comparisons were performed using independent samples t-tests and Mann-Whitney U tests. The receiver operating curve (ROC) was constructed to establish a cut-off value for a normal LAM volume. Interrater reliability was assessed by calculating the intraclass correlation coefficient. A P value of less than 0.05 was considered statistically significant.
Volumetric measurements revealed that the control group had higher LAM volumes, and the ROC curve analysis indicated a cut-off value of 38934.3 mm3 with a sensitivity of 0.812 and specificity of 0.8 for PFD assessment using LAM volumetric measurement. Gender did not significantly affect LAM volume in the control group.
Alongside the useful structural and functional information acquired from MR defecography images, volumetric analysis, and three-dimensional reconstructions of LAM may help to improve the accuracy of the diagnosis.

BACKGROUND: Magnetic resonance defecography (MRD) plays a central role in diagnosing pelvic floor functional disorders by visualizing the entire pelvic floor along with pelvic organs and providing functional assessment of the defecation process. A shared understanding between radiology and surgery regarding indications and interpretation of findings is crucial for optimal utilization of MRD.
OBJECTIVE: This review aims to explain the indications for MRD from a surgical perspective and elucidate the significance of radiological findings for treatment. It intends to clarify for which symptoms MRD is appropriate and which criteria should be followed for standardized results. This is prerequisite to develop interdisciplinary therapeutic approaches.
METHODS: A comprehensive literature search was conducted, including current consensus guidelines.
RESULTS: MRD can provide relevant findings in the diagnosis of fecal incontinence and obstructed defecation syndrome, particularly in cases of pelvic floor descent, enterocele, intussusception, and pelvic floor dyssynergia. However, rectocele findings in MRD should be interpreted with caution in order to avoid overdiagnosis.
CONCLUSIONS: MRD findings should never be considered in isolation but rather in conjunction with patient history, clinical examination, and symptomatology since morphology and functional complaints may not always correlate, and there is wide variance of normal values. Interdisciplinary interpretation of MRD results involving radiology, surgery, gynecology, and urology, preferably in the context of pelvic floor conferences, is recommended.
UNASSIGNED: HINTERGRUND: Die Magnetresonanz-Defäkographie (MRD) hat durch die Darstellung des gesamten Beckenbodens mitsamt den Beckenorganen und als funktionelle Untersuchung des Stuhlentleerungsakts eine zentrale Rolle in der Diagnostik der Beckenbodenfunktionsstörungen. Ein gemeinsames Verständnis zwischen Radiologie und Chirurgie über Indikation und Befunderhebung ist von immenser Bedeutung, um die MRD bestmöglich einzusetzen.
UNASSIGNED: Diese Übersichtsarbeit soll die Indikationen der MRD aus chirurgischer Sicht erläutern und darlegen, welche Bedeutung die radiologischen Befunde für die Behandlung haben. Es soll verdeutlicht werden, bei welchen Symptomen die MRD sinnvoll ist und welchen Kriterien Durchführung und Befundung folgen sollten, um standardisierte Befunde zu erhalten. Dies ist Voraussetzung, um interdisziplinäre Therapiekonzepte entwickeln zu können.
METHODS: Es erfolgte eine umfassende Literaturrecherche unter Einbezug aktueller Consensus-Guidelines.
UNASSIGNED: Die MRD kann in der Diagnostik der Stuhlinkontinenz und Stuhlentleerungsstörung relevante Befunde liefern und ist insbesondere beim Beckenbodendeszensus, der Enterozele, der Intussuszeption und der Beckenbodendyssynergie das Diagnostikum der Wahl. Rektozelenbefunde in der MRD sollten zurückhaltend interpretiert werden, um Überdiagnosen zu vermeiden.
CONCLUSIONS: MRD-Befunde können nie isoliert, sondern nur in Zusammenschau mit Anamnese, Untersuchung und Leidensdruck bewertet werden, da Morphologie und funktionellen Beschwerden nicht immer korrelieren und die Varianz der Normwerte groß ist. Die Interpretation der MRD sollte interdisziplinär (Radiologie, Chirurgie, Gynäkologie, Urologie) und idealerweise im Rahmen von Beckenbodenkonferenzen erfolgen.

BACKGROUND: Dynamic magnetic resonance imaging (MRI) of the pelvic floor plays a key role in imaging complex pelvic floor dysfunction. The simultaneous detection of multiple findings in a complex anatomic setting renders correct analysis and clinical interpretation challenging.
OBJECTIVE: The most important aspects (anatomy of the pelvic floor, three compartment model, morphological and functional analysis, reporting) for a successful clinical use of dynamic MRI of the pelvic floor are summarized.
METHODS: Review of the scientific literature on dynamic pelvic MR imaging with special consideration of the joint recommendations provided by the expert panel of ESUR/ESGAR in 2016.
RESULTS: The pelvic floor is a complex anatomic structure, mainly formed by the levator ani muscle, the urethral support system and the endopelvic fascia. Firstly, morphological changes of these structures are analysed on the static sequences. Secondly, the functional analysis using the three compartment model is performed on the dynamic sequences during squeezing, straining and defecation. Pelvic organ mobility, pelvic organ prolapse, the anorectal angle and pelvic floor relaxation are measured and graded. The diagnosis of cystoceles, enteroceles, rectoceles, the uterovaginal as well as anorectal decent, intussusceptions and dyssynergic defecation should be reported using a structured report form.
CONCLUSIONS: A comprehensive analysis of all morphological and functional findings during dynamic MRI of the pelvic floor can provide information missed by other imaging modalities and hence alter therapeutic strategies.
UNASSIGNED: HINTERGRUND: Die dynamische Magnetresonanztomographie (MRT) des Beckenbodens hat sich als maßgebliche Bildgebung bei komplexer Beckenbodendysfunktion etabliert. Die Analyse und klinische Interpretation sind aufgrund der Vielzahl möglicher, simultan erfasster Befunde und der komplexen Anatomie herausfordernd.
UNASSIGNED: Die wichtigsten Aspekte (Anatomie des Beckenbodens, 3‑Kompartimente-Modell, morphologische und funktionelle Analyse, Befundbericht) zur erfolgreichen klinischen Anwendung der dynamischen Beckenboden-MRT werden dargestellt.
METHODS: Recherche und Zusammenfassung der wissenschaftlichen Literatur zur dynamischen Beckenboden-MRT unter besonderer Berücksichtigung der Expertenempfehlungen der ESUR/ESGAR (European Society of Urogenital Radiology/European Society of Gastrointestinal and Abdominal Radiology) von 2016.
UNASSIGNED: Der Levator-ani-Komplex, der urethrale Stützapparat und die endopelvine Faszie stellen die zentralen Bestandteile des Beckenbodens dar. Diese werden bezüglich typischer Strukturveränderungen in den statischen Sequenzen zunächst morphologisch evaluiert. Im 3‑Kompartimente-Modell folgt die funktionelle Analyse der dynamischen Sequenzen mit Bestimmung der Beckenorganmobilität und des Beckenorganprolapses (zur pubokokzygealen Linie), des anorektalen Winkels sowie der Beckenbodenrelaxation (durch H‑ und M‑Linie) unter Belastung. Zystozelen, Enterozelen, Peritoneozelen, Rektozelen, uterovaginaler und anorektaler Deszensus werden quantifiziert und graduiert sowie assoziierte Pathologien (hypermobile Urethra, Intussuszeption, dyssynergische Defäkation) evaluiert. Die strukturierte Befunddokumentation ist ratsam.
CONCLUSIONS: Die umfassende qualitative und quantitative Analyse der Befunde in der dynamischen Beckenboden-MRT kann gegenüber anderen Bildgebungsmodalitäten therapierelevante Zusatzinformationen liefern und somit die (interdisziplinäre) Behandlung der Beckenbodendysfunktion verbessern.

Due to the complexity of pelvic floor dysfunctions and the frequent interdisciplinary findings, dynamic magnetic resonance imaging (MRI) can provide valuable (additional) information for the clinical examination in other disciplines through a comprehensive morphological and functional representation of the pelvic floor. It has therefore largely replaced conventional defecography under fluoroscopy in clinical practice. In order to increase the effectiveness and communication between radiology and the other specialist disciplines, recommendations for the standardized implementation and results of dynamic MRI were published by the European Society for Urogenital radiology (ESUR) in 2016 and based on these the Society for Abdominal Radiology (SAR) published simplified recommendations in 2019 for routine clinical use.
UNASSIGNED: Aufgrund der Komplexität von Beckenbodendysfunktionen und der häufig fachübergreifenden Befunde kann die dynamische Magnetresonanztomographie (MRT) durch eine umfassende morphologische und funktionelle Darstellung des Beckenbodens wertvolle (Zusatz‑)Informationen zur klinischen Untersuchung anderer Fachdisziplinen liefern und hat damit die konventionelle Defäkographie unter Durchleuchtung weitgehend aus dem klinischen Alltag verdrängt. Zur Steigerung der Effektivität und der Kommunikation zwischen Radiologie und anderen Fachdisziplinen wurden 2016 Empfehlungen zur standardisierten Durchführung und Befundung der dynamischen MRT von der European Society of Urogenital Radiology (ESUR) herausgegeben, und die Society for Abdominal Radiology (SAR) hat 2019 auf dieser Grundlage vereinfachte Empfehlungen für den klinischen Alltag veröffentlicht.

BACKGROUND: There are little data evaluating the performance of the 3-dimensional high-definition anorectal manometry (3D-HDAM) system in the diagnosis of dyssynergic defecation. Physical properties of the thicker, rigid, 3D-HDAM probe may have implications on the measurements of anorectal pressures.
OBJECTIVE: Our aim was to compare 3D-HDAM to balloon expulsion test and magnetic resonance (MR) defecography.
METHODS: Consecutive constipated patients referred for anorectal function testing at the Calgary Gut Motility Centre (Calgary, Canada) between 2014 and 2019 were assessed. All patients underwent anorectal manometry with the 3D-HDAM probe, and a subset underwent BET or MR defecography. Anorectal manometric variables were compared between patients who had normal and abnormal BET.
RESULTS: Over the study period, 81 patients underwent both 3D-HDAM and BET for symptoms of constipation. 52 patients expelled the balloon within 3 minutes. Patients with abnormal BET had significantly lower rectoanal pressure differential (RAPD) (-61 vs. -31 mmHg for normal BET, p = 0.03) and defecation index (0.29 vs. 0.56, p = 0.03). On logistic regression analysis, RAPD (OR: 0.99, 95% CI: 0.97-0.99, p = 0.03) remained a negative predictor of abnormal BET. On ROC analysis, RAPD had an AUC of 0.65. There was good agreement between dyssynergic patterns on 3D-HDAM and defecographic evidence of dyssynergia (sensitivity 80%, specificity 90%, PLR 9, NLR 0.22, accuracy 85%).
CONCLUSIONS: Manometric parameters, when measured with the 3D-HDAM probe, poorly predict prolonged balloon expulsion time. RAPD remains the best predictor of prolonged balloon expulsion time. The 3D-HDAM probe may not be the ideal tool to diagnose functional defecatory disorders.

Pelvic floor disorders are common and can negatively impact quality of life. Imaging of patients with pelvic floor disorders has been extremely heterogeneous between institutions due in part to variations in clinical expectations, technical considerations, and radiologist experience. In order to assess variations in utilization and technique of pelvic floor imaging across practices, the society of abdominal radiology (SAR) disease-focused panel on pelvic floor dysfunction developed and administered an online survey to radiologists including the SAR membership. Results of the survey were compared with published recommendations for pelvic floor imaging to identify areas in need of further standardization. MRI was the most commonly reported imaging technique for pelvic floor imaging followed by fluoroscopic defecography. Ultrasound was only used by a small minority of responding radiologists. The survey responses demonstrated variability in imaging utilization, patient referral patterns, imaging protocols, patient education, and interpretation and reporting of pelvic floor imaging examinations. This survey highlighted inconsistencies in technique between institutions as well as potential gaps in knowledge that should be addressed to standardize evaluation of patients with pelvic floor dysfunction.

OBJECTIVE: Magnetic resonance defecography (MRD) was used to evaluate anatomic and functional pelvic floor disorders in women with stress urinary incontinence (SUI) before and after midurethral sling (MUS) intervention.
METHODS: We performed MRD in both SUI patients and continent controls. Static MR was used to describe the anatomic abnormalities in levator ani muscle and periurethral ligaments (PUL). Dynamic MR was used to depict the function of the urethra and pelvic floor. We compared the MRD parameters between the SUI patients and continent controls before surgery. For SUI patients, dynamic MR images evaluated the functional changes of the urethra and pelvic floor after surgery.
RESULTS: In SUI group, 75.8 % have PUL defects, 65.7 % discontinuity or complete loss of pubococcygeal muscle, as compared to the continent groups (p < 0.01). There was no significant difference between the perimenopausal volunteers and SUI patients in the puborectalis defection (p > 0.05). The dynamic MR showed the urethral hypermobility, functional urethra shortening, bladder neck funneling, urethra opening and cystocele were significantly associated with SUI patients (p < 0.01). Postoperative MR indicated that SUI patients after MUS had a lower risk of bladder funneling and urethral opening at the defection phase (p < 0.01), but no significant difference in urethral hypermobility or pelvic floor prolapse was seen (p>0.05).
CONCLUSIONS: MRD with high-resolution and defecation phases provides a detailed anatomic and functional evaluation of the pelvic floor in female SUI before and after pelvic reconstruction.

To develop recommendations for magnetic resonance (MR) defecography technique based on consensus of expert radiologists on the disease-focused panel of the Society of Abdominal Radiology (SAR).
An extensive questionnaire was sent to a group of 20 experts from the disease-focused panel of the SAR. The questionnaire encompassed details of technique and MRI protocol used for evaluating pelvic floor disorders. 75% agreement on questionnaire responses was defined as consensus.
The expert panel reached consensus for 70% of the items and provided the basis of these recommendations for MR defecography technique. There was unanimous agreement that patients should receive coaching and explanation of commands used during MR defecography, the rectum should be distended with contrast agent, and that sagittal T2-weighted images should include the entire pelvis within the field of view. The panel also agreed unanimously that IV contrast should not be used for MR defecography. Additional areas of consensus ranged in agreement from 75 to 92%.
We provide a set of consensus recommendations for MR defecography technique based on a survey of expert radiologists in the SAR pelvic floor dysfunction disease-focused panel. These recommendations can be used to develop a standardized imaging protocol.

OBJECTIVE: To compare utility of supine Magnetic Resonance Defecography (MRD) with upright Voiding Cystourethrogram (VCUG) for evaluation of cystocele and urethral hypermobility (UHM).
METHODS: This was an IRB-approved, HIPAA-compliant, retrospective study of 51 consecutive patients with symptomatic pelvic organ prolapse (POP) and lower urinary tract symptoms who underwent both upright VCUG and supine MRD. Cystocele height was defined in centimeters with reference to the inferior edge of the pubic bone on VCUG and the pubococcygeal line on MRD. Urethral angle at rest (UAR) and during straining (UAS) was measured in degrees between the urethral axis and a vertical line at the external meatus. Pairedt-test and simple linear regression were applied to compare VCUG and MRD data sets. p <  0.05 was considered significant.
RESULTS: The mean cystocele extent was 1.58 cm lower (more inferior to the reference point) (95% CI for the mean difference: 1.21, 1.94;p < 0.0001) on MRD (-2.73 ± 1.99 cm) than on VCUG (-1.16 ± 1.75 cm). Mean UAS on MRD (72.29 ± 26.45) was 31.8 degrees higher compared to that on VCUG (40.45 ± 21.41), (95% CI for mean difference in UAS: 37.57, 26.11; p < 0.0001). Mean UAS-UAR on MRD (74.30 ± 28.50) was 58.6 degrees higher compared to that on VCUG (15.70 ± 11.27) (95% CI for mean difference in UAS-UAR 65.94, 51.26; p < 0.0001). Cystocele size was upgraded in 22 (43.3%) patients on MRD compared to VCUG. Five (9.8%) patients demonstrated UHM on VCUG; 48 (94.1%) patients demonstrated UHM on MRD. The differences between VCUG and MRD scores persisted across the range of VCUG measurements. Cystocele size was significantly larger in POP (+) patients than in POP (-) patients on MRD (p =  0.005) but not on VCUG (p =  0.06).
CONCLUSIONS: Supine MRD demonstrates significantly higher prevalence and degree of cystocele and UHM than upright VCUG, and alters the grade of bladder prolapse in a significant portion of the patient population. Cystocele size on MRD correlates with clinical presence of prolapse symptoms.