By: Dr. Francesca Iacobellis, Medical Director of Diagnostic Radiology, UOC General and Emergency Radiology, AORN “A. Cardarelli”, Naples
Dr. Luigia Romano, Director of General and Emergency Radiology UOC, AORN “A. Cardarelli”, Naples
Functional disorders of the pelvic floor include a variety of clinical conditions that mostly affect females and can have a high impact on the quality of life, resulting in symptoms such as urinary or fecal incontinence, obstructed defecation syndrome, difficulty emptying the bladder, prolapse of the pelvic organs (bladder, uterus and rectum), pelvic-perineal pain.
Given the anatomical and functional complexity of the pelvis, and the frequent multiple involvement of the organs it contains, a multidisciplinary approach to this type of pathology is necessary as is the availability of diagnostic methods for panoramic and minimally invasive images; among these, the morphological and functional study of the pelvic floor in magnetic resonance imaging (MRI) is taking on an ever-increasing role.
In fact, this exam allows a complete and detailed evaluation of the anatomical structures of the pelvis, including muscles and ligaments, in the absence of ionizing radiation, and allows the evaluation of the bladder and the supporting ligament structures, without the need for preventive catheterization. The use of this method is important especially in pre-operative planning, allowing a detailed morphological and functional evaluation of the entire pelvis. In the morphological sequences it is possible to identify any anatomical alterations affecting the ligament structures supporting the pelvic organs, the urethral and anal sphincter apparatus as well as the muscular structures of the pelvis.
The dynamic sequences, acquired with a semi-full bladder after distension of the rectal ampulla and, sometimes, of the vaginal lumen with water-based gel, allow the study of pelvic dynamics in the phases of contraction, pumping and evacuation. In these sequences it is possible to evaluate the possible presence of dyskinesias of the evacuation act associated or not with paradoxical contraction of the puborectalis muscle, the presence of perineal fall, bladder prolapse, uterine prolapse, rectal prolapse, rectocele and enterocele with an accurate overview of functional interactions between pelvic organs in real time.
The MRI examination also allows the pudendal nerves to be studied in a dedicated manner, if the symptoms reported by the patient lead to the hypothesis of involvement of these anatomical structures. The pathological conditions affecting the pudendal nerves may be primitive neuropathic, or may depend on the presence of expansive processes or compressive phenomena which can be accurately identified and characterized by MRI.
Bibliography:
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Iacobellis F, Brillantino A, Renzi A, Monaco L, Serra N, Feragalli B, Iacomino A, Brunese L, Cappabianca S. MR Imaging in Diagnosis of Pelvic Floor Descent: Supine versus Sitting Position. Gastroenterol Res Pract. 2016;2016:6594152. doi: 10.1155/2016/6594152. Epub 2016 Jan 12. PMID: 26880893; PMCID: PMC4737448.
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Captions
Figure:
MRI: morphological study
Video:
In the video acquired during the dynamic evacuation phase, a pathological fall of the perineal plane is observed with prolapse of the bladder, uterus and rectum, which engage the perineal hiatus.