0:02

Hello and welcome to Noon Conference hosted by MRI online.

0:03

3 00:00:06,750 --> 00:00:08,700 In response to the changes happening around the

0:08

world right now and the shutting down of in-person

0:10

events, we have decided to provide free daily

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noon conferences to all radiologists worldwide.

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Today we are joined by Dr. Lalwani.

0:21

Dr. Lalwani is an abdominal radiologist

0:24

with a specific interest in hippo-

0:28

hepatopancreatobiliary and pelvic imaging.

0:32

He is an established academian and researcher

0:35

and the recipient of the ARRS Figley

0:39

Fellowship and the RSNA Honored Educator Awards.

0:45

Although this conference is prerecorded,

0:49

there will be a live Q and A session with

0:52

the doctor at the end of the conference.

0:55

So if you could please use the Q and A

0:57

function to ask your questions,

0:59

we will try to get to as many of

1:01

those as we can after the talk.

1:04

That being said, thank you all

1:06

for joining us today. Dr. Lalwani,

1:08

I'll let you take it from here.

1:10

Good afternoon, everyone.

1:12

I am Neeraj Lalwani, an Associate

1:15

Professor of Radiology at VCU Health.

1:18

Today I'm going to deal an important

1:20

topic, MR Defecography, essential for radiologists.

1:23

MR Defecography has gained lots of popularity in the recent

1:28

past, and, um, virtually replaced the

1:32

conventional proctography at majority of institutions.

1:36

It is a very good investigation and has been

1:39

used to assess pelvic floor dysfunction.

1:43

So what is pelvic floor dysfunction?

1:45

Before we proceed further, we should know about that.

1:48

So once we have laxity of the pelvic floor, that

1:52

can lead to descent or various kinds of problems,

1:56

symptomatic problems, which may include, uh, pelvic

1:59

pain, pelvic floor descent, or organ prolapse, um,

2:05

incontinence of stool or urine, or even constipation.

2:11

And that spectrum of entire symptomatology has been

2:16

assigned to pelvic floor dysfunction.

2:18

So it is mainly a problem of the

2:20

multiparous and postmenopausal females.

2:24

And it also affects premenopausal women

2:26

and men in smaller proportion as well.

2:29

But it can lead to one of these symptoms and patients

2:32

present to either GI clinic or colorectal clinic.

2:36

And these clinicians refer

2:39

to the department to assess further

2:42

and see what compartments are affected.

2:45

So, risk factors mostly are age, obesity, and menopause.

2:49

So what happens as the female, uh, ages or

2:53

goes beyond the menopausal age, uh, the

2:57

quantity of estrogen decreases in the body.

3:00

And that leads to multiple issues, which

3:02

includes the pelvic floor dysfunction.

3:04

In addition to that, history of prior vaginal

3:07

deliveries or hysterectomies are also

3:10

responsible for pelvic floor dysfunction.

3:12

So if you're going to alter the anatomy of the

3:14

pelvis either by, uh, any operative procedure

3:18

or with deliveries, that can also

3:20

lead to pelvic floor dysfunction.

3:22

And it has been assessed that about 50%

3:25

of the females, more than 50 years of age, are

3:28

suffering from some kind of pelvic floor dysfunction.

3:32

And out of these, about 20% show up in

3:35

the clinic to get rid of this problem

3:38

because it is affecting their daily life.

3:40

And about 30% of them are actually operated.

3:45

Some of these actually have more than one surgery to

3:48

repair these problems and these compartments, as I

3:52

said, there are three compartments in the pelvis, which

3:55

include anterior compartment, posterior compartment,

4:00

and the middle compartment. These are the compartments

4:04

that belong to different specialties.

4:05

The anterior compartment, which contains the

4:08

bladder, bladder neck, and the urethra; the middle

4:11

compartment, which contains the uterus or vagina,

4:14

actually are the field of urogynecology, while

4:18

the posterior compartment is colorectal surgery.

4:21

So if there is a surgical issue

4:23

which has to be repaired,

4:25

it'll be a multifactorial or multidisciplinary

4:29

team which is going to address it.

4:31

So it'll be a combination of urogynecologist and colorectal

4:33

surgeons who are going to operate on these patients.

4:36

So these are very complicated surgeries,

4:38

and it is not uncommon to have second

4:40

or third surgeries for these problems.

4:43

Our role is very important because on

4:46

clinical examination, which is called

4:48

a POP system. The POP system doesn't

4:51

assess pelvic floor dysfunction

4:55

very clearly, accurately, or precisely.

4:58

So it can either misdiagnose the problem area or

5:02

the compartment, or it'll underestimate things.

5:05

So MRI can significantly affect the

5:07

diagnosis and change the clinical

5:11

outcome or clinical treatment in as

5:15

high as 41% of the patients.

5:18

So MR Defecography, as I said earlier, has virtually replaced

5:22

the conventional proctography, which, um, we are

5:27

going to discuss at the end of the talk as well.

5:31

So before we proceed further, let's quickly go

5:33

through the anatomy of the pelvic floor.

5:36

Here we can see there are three compartments,

5:38

uh, bladder, bladder neck, and the urethra,

5:41

and the uterus, vagina, and the rectum and

5:44

anal canal, and what I'm trying to show here.

5:47

These are the muscles

5:49

that are supporting these three organs or three

5:51

compartments. And the first layer, which I'm showing

5:55

here, is the levator ani muscle, which extends from

5:57

the pubic symphysis and iliac bones to the coccyx.

6:01

So it is a large fan-shaped muscle.

6:04

And then it has a component on another component

6:08

on the inferior aspect, which is called puborectalis muscle,

6:11

which actually joins the external sphincter.

6:14

And this yellow structure, which I'm trying to show,

6:16

supports just the anterior two compartments.

6:18

The anterior compartment is actually

6:21

urogenital diaphragm. And all of these

6:23

muscles are composed of different kinds of

6:26

muscular fibers that can be added separately here.

6:30

So in females we can see two

6:32

pubococcygeus and puborectalis muscles.

6:35

Those actually support the anterior compartment.

6:37

And, um, surgically, actually you cannot separate

6:41

puborectalis from the levator ani muscle.

6:45

But anatomically they're different.

6:47

And the levator ani muscle, as I said earlier,

6:49

comes from the pubic symphysis.

6:52

There are certain fibers from the iliac spine

6:54

here, and they join together to form a

6:57

big muscle, which joins here with the coccyx.

7:00

And these fibers, which we are seeing

7:02

on the posterior aspect, are the iliococcygeus plate.

7:05

Actually, it is a kind of conjoined tendon formed

7:08

by the joining of multiple muscular fibers together.

7:14

And this is the muscle I'm talking about,

7:16

puborectalis muscle, which is very, very important

7:18

for us because once it contracts under voluntary

7:21

contraction, this is the muscle which

7:24

is joined together with the external sphincter.

7:27

And once it contracts, it can be

7:29

contracted with voluntary efforts.

7:31

It leads to acute angulation

7:33

where the anorectal junction is.

7:35

So anorectal junction surgically

7:37

corresponds to puborectalis muscle.

7:39

Uh, and typically the dentate line, which is slightly

7:42

lower, but surgically, anorectal junction corresponds to perineal muscle.

7:47

And then we are showing here different

7:50

components of the external sphincter

7:53

muscles, or external sphincter.

7:56

This is the deep component, and then you have a subcutaneous

7:59

component, and there is a superficial component.

8:01

So all of these three components are joined together

8:04

to form the external sphincter component.

8:08

Though puborectalis muscle is not a part of levator ani,

8:11

functionally it works with the

8:15

external sphincter to cause acute angulation.

8:20

What is functional MR?

8:21

So MR Defecography, also called functional MR, basically

8:26

is not dynamic imaging as we say by giving IV contrast.

8:31

It is dynamic because we are

8:32

assessing the dynamic function.

8:34

That is why it is functional.

8:36

So functional MR, or dynamic MR, what we do is

8:38

basically assessing a live telecast of defecatory

8:43

effort.

8:44

That is why it is called functional.

8:46

What MR system do we use? We use

8:49

MR, either 1.5 Tesla or 3 Tesla.

8:53

It doesn't matter.

8:53

It doesn't affect the final outcome of the study.

8:57

But with 3 Tesla, there is a possibility

8:58

that you get more artifact. Open-configuration

9:01

MR has been a topic of discussion for years

9:05

because people think that once the patient is sitting

9:08

in sitting posture, you can get better physiological results.

9:14

Yes.

9:19

Lower Tesla, lower strength magnets, and they

9:23

are very few nowadays. People are not

9:25

buying those because they have very limited, uh,

9:28

ability to assess certain investigations.

9:31

So open-configuration MR, though it

9:34

sounds more practical for sitting

9:36

position, but in reality, the patient, in the

9:41

supine position on routine MR, open-bore MR,

9:45

gives you almost the same information,

9:49

close to the same as open configuration or fluoroscopic.

9:55

So what happens is that it is possible that you

9:57

slightly less assess a certain pathology.

10:02

For example, there is a cystocele which is

10:04

about three centimeters on conventional MR or

10:08

in sitting position, it'll be assessed 2.5

10:11

centimeters or two centimeters on supine

10:14

position, but it is not going to be missed.

10:16

It has been proven multiple times in different

10:19

papers that MR Defecography in

10:23

supine position gives you the same information

10:26

as the conventional proctography gives.

10:32

So how do we place the patient?

10:35

We place the patient in supine position with feet first.

10:38

This is also important because

10:39

these magnets are very small.

10:41

Bore and patient might have claustrophobia

10:44

issues, or because patients are older and

10:47

they might not feel

10:49

comfortable going inside that small bore.

10:51

If you're putting feet first,

10:53

the patient will be more comfortable.

10:55

There will be less apprehension, less anxiety.

10:58

And that will give you a better examination.

11:01

You can use either pelvic coil or the

11:04

cardiac coil to get better, crisp images.

11:07

I personally prefer the cardiac coil

11:09

because it gives you better images.

11:12

How do you prepare the patient?

11:14

Compared to conventional defecography, you

11:16

don't even prepare the patient here.

11:18

You can just perform the study on

11:20

the same day without any preparation.

11:22

Call the patient from the clinic

11:24

and just start doing the examination.

11:27

You don't have to prepare bowel or rectum.

11:30

You just have to empty the bladder about 30

11:32

minutes before the study and you can give

11:36

just ultrasound gel through the rectum.

11:39

No oral or IV contrast is required.

11:42

So we have to opacify the rectum and vagina with the help

11:46

of ultrasound gel, and we can use a Foley catheter.

11:52

Those can be about 20 French to 30 French,

11:54

depending on the bore or how much

11:58

effort you want to put through the syringes.

12:00

You have to put the syringe inside the

12:03

Foley catheter and just push the gel inside.

12:06

Each of these syringes is about 60

12:08

ccs, so three syringes means about 180 ccs.

12:12

So you can have anything between 120

12:16

to 300 ccs to have a proper distention of the rectum.

12:20

In most patients, three syringes work very well.

12:23

It should not be less than 120 ccs, or it

12:25

can extend up to where the patient feels full

12:28

completely, and then you can start the study because

12:31

if the patient is not feeling it completely, the

12:33

patient may not be able to defecate properly.

12:37

So how the patient is positioned once

12:40

we are putting the Foley catheter inside the rectum.

12:42

The patient is placed in the left decubitus

12:45

position, or right decubitus position depending

12:47

on the patient's preference, and you enter

12:49

from the side and then put the Foley

12:53

catheter inside the rectum or vagina as needed.

12:56

Insertion of the contrast into the vagina is optional.

13:00

Nowadays, some institutions are doing

13:04

it and some institutions are not doing it.

13:07

In addition, the patient is covered really well with

13:10

a good quality diaper to avoid any leak of ultrasound

13:15

gel on the table, which can cause issues with the

13:18

patient's comfort, as well as may lead to some

13:21

electrical catastrophes or accidents on the MR table.

13:27

And before you start the procedure, you have to go and

13:30

talk to the patient and explain the examination,

13:34

because these patients are suffering from these problems

13:36

for years, and they're just frustrated and

13:39

they may not be able to cooperate during the

13:42

study because they're apprehensive, they're

13:44

anxious, and think about a patient coming to

13:47

the hospital, defecating on the table of the MR.

13:51

It is not a good situation because a patient might

13:54

not be feeling happy about this examination.

13:57

So you have to go and talk to them

13:59

and say that this investigation

14:02

is very, very important.

14:04

If you do it correctly, we can get better

14:06

information, and then we can help you better.

14:09

So that motivation, that helping

14:11

them, is very important.

14:14

And then you have to explain

14:16

these terms: relaxing,

14:18

squeezing, bear down, and evacuate.

14:21

So in some of the recent papers, people have suggested

14:24

that we don't have to do a bear down step.

14:27

You just have to explain to the patient

14:29

to squeeze and just evacuate.

14:31

But bear down actually gives you an

14:33

opportunity to train the patient.

14:35

So bear down is basically Valsalva.

14:36

Squeezing is basically doing Kegels.

14:41

And evacuation is basically defecation.

14:43

So you have to explain.

14:44

You have to explain all these terms to the

14:46

patient because once you give the command,

14:48

or the technicians are giving commands on the

14:50

table, and if the patient is not following it

14:52

correctly, you may not get the right information.

14:57

The MR Defecography has been divided into two different studies.

15:05

So static study is basically nothing.

15:07

It is you are getting normal pelvic images on

15:10

high resolution, high‑detailed images here, and

15:13

then getting the information beyond the rectum.

15:16

So you are trying to assess the anatomy, and then you

15:19

are trying to assess the shape of the levator ani muscle.

15:21

You're trying to see the other

15:23

structures of the pathways.

15:24

But on the dynamic study, you

15:26

are trying to get the dynamic

15:28

information of the rectum while the patient is defecating,

15:32

and these images are taken as single‑shot images.

15:37

So the name can vary according to the vendor.

15:40

It can be balanced FFE or TrueFISP,

15:43

or FASE, depending on the vendor.

15:44

But it is the same technique.

15:47

It is single‑shot T2 sequences,

15:49

which can be acquired very quickly.

15:51

One image

15:52

can be acquired in less than one second.

15:55

So you have 30 images in less than one minute actually.

15:59

And so you can acquire about 30 images in

16:02

the midsagittal location as the patient is

16:05

defecating, and it looks like it's a loop

16:07

you are taking through that area.

16:10

And these high‑resolution images are actually

16:14

T2 fast spin echo images, and they

16:18

can be taken on axial, coronal, or sagittal planes.

16:24

This is how the MRI of pelvis or pelvic

16:28

floor looks through the portion, and this is the image.

16:32

So here what I'm trying to show

16:34

you is that there are three layers

16:36

that actually support

16:37

the pelvic floor. The first layer is basically

16:39

the fascia and the peritoneum, which we do

16:41

not see on MR. But we can see some of these

16:44

black structures, black lines on the

16:46

side of the iliac vessels here on the pelvic side wall.

16:49

And these actually suggest the

16:51

neurovascular bundles running along with

16:53

those fascia or peritoneal ligaments.

16:58

So see here, these are the ligaments

17:01

which we cannot otherwise see on MR. The

17:03

second layer is basically levator ani, and the third

17:06

layer is basically urogenital diaphragm.

17:09

You won't be able to differentiate these two

17:11

layers separately. Surgically, they are

17:13

the same, just anatomically they are different.

17:16

They are different.

17:18

On the posterior aspect of the bladder,

17:19

you can see this kind of concavity.

17:22

And then the vagina is usually Honda‑shaped.

17:28

You can assess the

17:30

superior convexity of the levator ani muscle

17:33

and the thickness of the levator ani muscle.

17:35

If these are thin or atrophic muscles, and

17:38

this convexity superiorly is lost, it's like

17:40

flat, or it is concave here, that suggests

17:43

that these muscles are lax or at rest even.

17:47

And here what I'm trying to show you

17:49

is basically the insertion of the puborectalis

17:51

muscle fibers with the external sphincter.

17:54

So this is the junction of anorectum surgically.

17:59

And these are the fibers of superficial and

18:02

subcutaneous portions of the external sphincter.

18:06

And on the posterior aspect, as we go closer

18:09

to the coccyx, we can see these merging

18:11

fibers from the levator ani forming a conjoined

18:15

tendon here, which is called the iliococcygeus plate.

18:18

And this is how the iliococcygeus plate looks on MR images.

18:24

And these are the muscular fibers of the

18:26

external sphincter where we have the

18:28

insertion of the muscle. And these are the

18:31

different landmarks we should know on midsagittal

18:34

plane.

18:35

So pubic symphysis, obviously we should know that.

18:39

Urinary bladder, bladder neck, and the urethra.

18:43

So bladder neck is our

18:44

landmark in the anterior compartment.

18:48

In the middle compartment,

18:49

the important landmark is anterior cervix.

18:52

If the uterus is absent, then it is going

18:54

to be posterior fornix of the vagina,

18:56

which is going to be our landmark.

18:59

And then in the posterior compartment, the puborectalis

19:02

muscle insertion or anal junction is our landmark.

19:06

So what we mean by landmark here, because we are gonna

19:09

observe these points once the patient is trying to evacuate.

19:12

And if we draw a line from the undersurface

19:15

of the pubic symphysis

19:19

to the last visible joint of the coccyx.

19:22

So I said last visible joint, not the

19:24

last joint — the last visible joint.

19:26

And that line is actually called the pubococcygeal line.

19:31

And if these landmarks are going below that line,

19:34

that suggests that there is pelvic floor dysfunction.

19:37

And then here we can see anterior compartment:

19:40

the urethra, the vagina, which is filled with the

19:42

contrast or the ultrasound gel, and the rectum, which

19:45

is again filled with the ultrasound gel here.

19:48

So in this, actually, we have filled.

19:50

Ultrasound gel in vagina and rectum, and urinary bladder

19:54

actually has a natural contrast because of the urine.

19:57

As far as the, the contrast in the vagina is

19:59

concerned, some of the people have stopped doing

20:01

it or made it optional because of certain issues.

20:05

Uh, previous issues, or patient concerns, or infection.

20:09

Uh, it is again, as I said, optional.

20:11

Uh, if you want.

20:14

So about 30 cc of ultrasound gel goes to

20:17

the vagina, and about 180 cc at an average.

20:20

Anything between 120 to 200

20:22

cc, uh, goes to the rectum.

20:27

So what we are looking for here on a myography in the

20:30

anterior compartment, we are looking for cystocele.

20:33

Uh, then we have to classify it how, what, what grade

20:36

it is, and if there is any mass effect on the vagina.

20:39

And if we have cystocele, there is a possibility

20:42

that there will be movement of the

20:44

urethra. That is called urethral hypermobility.

20:47

And if we see a sign of incontinence or leakage of urine

20:50

during this study, in the middle compartment, we are

20:53

looking for, uh, any descent of the cervix or vagina.

20:58

So, as I said earlier, there are landmarks

21:00

we are going to pay attention for. That is,

21:02

uh, anterior cervix or posterior fornix.

21:05

And then we had to talk about the grade.

21:08

If the paravaginal fascia is intact, that's

21:11

the easy question you can answer on axial,

21:14

uh, high resolution T2-weighted images.

21:16

As I said earlier, uh, the vagina

21:18

should look H-shape or Honda shape.

21:21

Um, if it is not H-shape, or it is rectangular,

21:25

square, or oval, or rounded, then this fascia is lost.

21:30

Is rectovaginal fascia intact?

21:32

This can be seen if we see any content like

21:35

peritoneum, small bowel, or sigmoid colon,

21:38

colon going in between the rectum and vagina.

21:41

And this usually happens after the

21:43

hysterectomy has been performed.

21:45

Posterior compartment, this is the most important

21:47

compartment and most commonly involved compartment,

21:50

uh, is basically we are looking for any intussusception.

21:53

If their intussusception is full thickness or

21:55

mucosal, because the treatment is different.

21:57

Uh, for full thickness, they have to do

21:59

resection and repair the rectum with rectopexy.

22:03

For mucosal intussusception, you have to just

22:05

resect the mucosa through the transanal route.

22:09

So it is a small strategy and it is a big strategy.

22:11

So we have to be very careful calling the intussusception.

22:15

And then we have to classify whether the intussusception

22:17

is intrarectal, intra-anal, or extra-anal.

22:21

And then comes the end rectocele or what

22:23

grade it is, and if we see any rectal retention

22:26

after at least three attempts of defecation.

22:30

So you should perform at least three attempts

22:32

of defecation before you call whether it

22:34

is emptied completely, or there is a retention,

22:37

or patient was not able to empty at all.

22:40

And then you have to pick up the other

22:41

incidental findings, um, or associated

22:44

finding, like ovarian cyst or uterine fibroids,

22:47

adenomyosis, or Tarlov cyst.

22:50

So it is a possibility that you actually pick up some

22:52

of the Tarlov cyst with the pelvic floor dysfunction.

22:54

It's a common finding.

22:56

Don't ignore those.

22:57

Tarlov cysts are very important because

23:00

they can also lead to the same kind of

23:02

symptoms as pelvic floor does, like pain.

23:04

Pain in the or other

23:06

issues governed by sacral nerves, and all

23:09

of the major structures in the pelvis

23:11

are supplied through the sacral nerves.

23:13

And if you have fibrosis there, that

23:15

can also lead to the same symptoms.

23:17

And unless you treat that before, uh, you cannot

23:20

repair the pelvic floor, because if you repair

23:23

the pelvic floor before you treat the fibrosis,

23:26

it's a possibility that symptoms do not resolve.

23:28

So always comment on the fibrosis before

23:32

uh, you talk about pelvic floor.

23:34

And then comes the functional constipation,

23:37

uh, that is the important aspect the

23:40

gastroenterologists are looking for, and we'll

23:42

deal with this, uh, topic in next few slides.

23:45

So let's deal quickly with the reference lines.

23:48

Most of the assessment of the pelvic floor

23:51

is done with, um, trained, experienced

23:54

eyes without even drawing the lines.

23:56

It is like visual assessment, but in the beginning,

23:59

if you are starting a new service at your place, or

24:02

you are a new learner, uh, you should draw this line.

24:06

And about 20 cases, I, I recommend

24:09

that you read with the line drawing.

24:12

Uh, so one line which is drawn here in the yellow

24:15

from the last visible joint of the coccyx to the

24:17

undersurface of the pubic symphysis is oxford line.

24:20

And from here, from the under surface of, uh.

24:25

Pubic symphysis to the antrum that is called

24:28

less edge line, uh, that is basically hiatus.

24:32

It is L hiatus we are trying to see here.

24:34

And this green line is basically the M line,

24:36

which is the perpendicular line drawn from

24:39

the pubic symphysis line to the anorectal junction.

24:42

So if we see this.

24:44

Is increased more than two centimeter, or if

24:47

we see this line is increased more than six

24:49

centimeter, then it is abnormal, and anything

24:53

less than that should be taken as normal.

24:56

What is anorectal angle?

24:58

If we draw a line along with the posterior aspect of

25:01

the rectum and then the long of the anal canal, this.

25:07

Angulation here is called as anorectal angle,

25:09

and normal range is about 108 to 127.

25:13

The most important thing to understand

25:16

that to begin with, uh, whenever a patient is

25:18

trying to contract or doing Kegel exercise or

25:21

squeezing, this angulation should become acute.

25:25

And once patient is trying to defecate,

25:27

it should become obtuse, and that should

25:30

be within 20 degrees of the baseline.

25:33

That is the most important thing you should

25:35

know. If it is not becoming acute during the

25:39

Kegel exercise or squeezing.

25:40

That means the puborectalis muscle or levator ani are weak.

25:44

If the patient is not able to defecate, or if the

25:47

patient, uh, if the angulation becomes acute during

25:49

the defecation, that means patient has dyssynergia because

25:53

there is a paradoxical contraction of the

25:56

puborectalis muscle once the patient is trying to defecate.

26:01

Then organ descent can be assessed with the landmark.

26:03

We discuss cervix, anterior cervix, or bladder neck.

26:07

If they go below the level of pubococcygeal

26:10

line, then it is called as descent.

26:12

And all of these organ descent or

26:14

classification follow the rule of three.

26:17

Uh, anything between one to three

26:19

centimeter will be called as mild.

26:20

3.1 to six centimeter will be called as moderate, and

26:24

more than 6.1 centimeter will be called as severe.

26:28

Dysfunction.

26:30

So if we have a cystocele here, which goes about

26:32

two centimeter below the PC line, that will be mild.

26:35

Um, and then if you have a cervix, which is

26:38

going below the line about 3.1 centimeter or

26:41

more, that'll be called as moderate descent.

26:46

So here we can see the bladder neck is going below

26:49

the PC line and that is called cystocele.

26:52

And that is actually causing impression over the.

26:54

The vagina here, if we see the funneling

26:57

of proximal urethra is a sign of incontinence,

27:00

and the pitfall, which I'm talking about

27:02

here, we'll discuss in the end of the topic.

27:05

In the end.

27:08

So what is urethral hypermobility?

27:10

So once we have lost the fascia supporting the

27:13

urethra, with the effort to defecate or urinate,

27:18

there is a possibility that the bladder and

27:20

neck actually goes downwards and that urethral

27:23

axis becomes more horizontal or sometime

27:27

even oblique inferiorly. That is actually severe.

27:30

So if we see the movement of the urethra, which

27:32

becomes, which becomes like horizontal,

27:35

that is kind of mild to moderate, uh, mobility.

27:38

And if it becomes inferiorly slanting, that will

27:40

be as actually severe hypermobility of the urethra.

27:46

Um, here what we are talking here, basically

27:49

we are looking for, uh, any descent of.

27:52

Uh, the cervix or the vagina, and if it

27:57

goes below the AL line, that will be

27:59

called as, uh, descent, not the prolapse.

28:02

Remember, the term prolapse is used once

28:04

you have an organ coming out of the orifice.

28:07

Um, that is the prolapse.

28:10

The descent is the right word.

28:11

So don't use the term prolapse in your, in, in your

28:14

reports because surgeon will take it very seriously.

28:17

They will think that some of the organ is

28:19

coming out of the orifice or natural orifice.

28:21

Uh, here we are seeing the vagina in H-shaped

28:24

appearance here, like this looks like H here.

28:27

So this is the normal appearance which

28:28

suggests the pararectal fascia are intact.

28:32

If you lose this appearance on axial

28:35

images, that suggests this fascia is lost.

28:41

Then comes the rectosigmoid and peritoneocele.

28:44

So if you have any structure of these three

28:47

going in between the vagina and the rectum,

28:50

that will be named according to the content.

28:53

So if you have one of these structures going more

28:56

than two centimeter below the pubococcygeal line,

28:59

that's an indication that's going to be operated

29:01

with colpoplasty, and there's a big operation again.

29:05

So you have to be very cautious

29:06

calling these, uh, three pathologies.

29:09

So if you have a small bowel going inside,

29:13

the content, it'll be called a rectocele.

29:15

If you have sigmoid colon going within,

29:17

the content, it'll be called a sigmoidocele.

29:19

And if you have just peritoneum going inside, as

29:21

in this case, we are just seeing the fat-containing

29:24

peritoneum here, it'll be called as peritoneocele.

29:29

Rectocele is a very common pathology, which

29:32

we observe on all defecography, and sometimes it is not

29:35

the cause of the, uh, pelvic floor dysfunction.

29:38

Rather, it is an effect of the pelvic floor dysfunction.

29:41

So be very cautious calling them.

29:43

And this is the only pathology

29:44

which follows the rule of two.

29:46

So anything, uh, more than two centimeter will be

29:49

called as, uh, moderate; up to two centimeters is mild.

29:55

Then more than four centimeter,

29:56

it'll be called a severe rectocele.

29:59

And how we measure it, we just draw a line along

30:01

with the anterior aspect of the anal canal, and then we

30:05

measure maximum outpouching of the rectum anteriorly.

30:09

So this is the commonest rectocele we see on

30:11

defecography, the anterior one, but you can actually have

30:15

lateral, uh, rectoceles as well, which will be

30:18

better seen on coronal images rather than the side.

30:21

But those are uncommon.

30:22

So if you are doing a routine defecography,

30:24

you can just get the anterior rectocele.

30:26

But if we have suspicion of lateral,

30:29

uh, rectal performance, coronal image.

30:32

So the most important thing here to remember, rectoceles

30:36

are usually reduced by putting finger

30:38

through the vagina and pushing it backwards.

30:41

So if the patient is giving you a history that

30:43

to defecate, they have to put finger inside the

30:46

vagina and push, uh, the wall backwards, that is

30:49

a sign that patient actually has a rectocele,

30:52

which is causing issues with the, uh, diary of it.

30:57

Rectal intussusception, uh, once we have a true wall

31:01

of the rectum going inside the lumen, which could

31:03

be intrarectal, intra-anal, or extra-anal.

31:08

So extra-anal intussusception is basically prolapse.

31:11

Remember I told you if the mucosa of

31:13

an organ goes, or an organ itself,

31:16

through a natural orifice and protrudes outside

31:19

the natural orifice, that is the prolapse.

31:21

You should not confuse the term prolapse

31:23

with the descent or intussusception.

31:26

Uh, this is intussusception because we are

31:28

still having a wall inside the lumen.

31:30

It doesn't come out the orifice.

31:33

And then here we can see this intussusception

31:35

has gone into the anal canal and it is extra,

31:38

uh, intussusception or prolapse here.

31:42

So let me show you quick example of intussusception here.

31:46

Pay attention on the posterior wall.

31:48

This rectal wall, which is projecting inside the rectal

31:51

lumen or anorectal lumen here, and becomes prominent

31:54

as the patient is passing stool, and the terminal

31:58

stage, we are seeing it most apparent, uh, here.

32:02

Let's see the movie here.

32:04

So see, keep paying attention to the posterior wall and.

32:11

See what happens here.

32:12

So this is basically intra-anal intussusception, which is

32:16

best seen on the posterior aspect or posterior wall,

32:20

uh, during the end or terminal phase of the defecatory effort.

32:27

So what is functional constipation?

32:29

Functional constipation is one of the

32:30

most common, uh, causes of constipation,

32:33

where fibers may not actually work at all.

32:36

So the clinicians are looking for the cause

32:38

of constipation, which could be radiation,

32:41

and it may or may not respond to the

32:43

different treatment, including the fibers.

32:45

So if the patient doesn't meet the criteria

32:48

of irritable bowel syndrome, if there are no

32:51

loose stools, uh, without the use of laxative.

32:55

Once these two criteria have been

32:56

fulfilled, look for two out of these.

33:00

Uh, six.

33:01

So there is at least, uh, two of these

33:05

symptoms present in 25% of defecatory efforts.

33:08

So if the patient is straining all the time,

33:10

presenting with lumpy or hard stool, this sensation

33:13

of incomplete evacuation after defecatory efforts, sensation

33:17

of anal obstruction or blockade, there is some

33:20

manual, uh, maneuvers to facilitate defecatory efforts.

33:24

Or if there are less than three defecations

33:26

per week, so at least two are fulfilled in 25%

33:31

of the time, then patient may actually meet the

33:33

diagnostic criteria of functional constipation.

33:36

And this is mostly a clinical diagnosis,

33:39

uh, but once they have suspicion about

33:42

that, they actually perform balloon expulsion tests.

33:45

Or manometry.

33:46

So what they do, basically they put a

33:48

balloon filled with about 20 cc of mild,

33:51

uh, lukewarm water inside the rectum.

33:53

And patient is asked to defecate that balloon

33:56

out of the rectum, and they're given with a

33:59

private area or restroom, and they're given with

34:02

a stopwatch, and they have to record the time.

34:05

If, if the time is less than

34:06

one minute, then it is.

34:09

Uh, normal, within normal limits, but once

34:12

the time is beyond one minute or like five

34:14

minutes or four minutes, that is abnormal.

34:16

And during this effort there are probes over

34:21

the balloon, which actually records

34:22

the muscular contraction as well.

34:24

And that is represented on graphical, uh,

34:28

form to form a manometry test as well.

34:31

So once the patient is trying to expel the balloon,

34:34

they're trying to see how, how much time does it take,

34:37

and secondly, what kind of muscle contraction

34:40

to defecate it so that muscular record is noted.

34:43

And that is.

34:44

Manometry together with the balloon

34:46

expulsion is the most important test

34:48

to diagnose, uh, functional constipation.

34:51

But sometimes these tests are not

34:52

contributory, or they are equivocal, or patient

34:55

cannot perform those. In that situation,

34:58

actually, the MR defecography plays a crucial

35:01

role because we are trying to see if there is

35:04

a retention of the contrast after the defecatory

35:07

effort. If you have more than 50% of retention

35:09

of contrast after defecatory effort, that's abnormal.

35:12

If there is inappropriate contraction of

35:14

the anal sphincter or puborectalis muscle during

35:18

the defecatory effort, that is dyssynergia

35:21

anus or spastic pelvic floor syndrome.

35:23

These are the same things with different words.

35:27

Um, so these can be actually diagnosed really

35:29

well on MR defecography. So we play a crucial

35:33

role once the balloon expulsion test is.

35:41

So this is a 52-year female presenting

35:44

with obstructed defecation.

35:45

This is the only case which I'm

35:46

going to show you, uh, images.

35:49

All of the other cases are actually cine loops.

35:51

So what I'm trying to show you

35:52

here, how to do the lining.

35:54

So we have drawn a line from

35:56

the inferior aspect of the pubic symphysis

35:58

to the last visible joint here.

36:00

And then we have drawn a line

36:02

from there to the anal junction.

36:05

And this is the levator hiatus.

36:06

And we can see even at rest.

36:08

This hiatus is bigger than expected.

36:10

It is more than six centimeter.

36:12

So even at rest, the patient has some kind of, uh,

36:15

pelvic floor dysfunction. And see the M line here,

36:18

it is obviously more than, uh, two centimeter.

36:21

So there is pelvic floor dysfunction,

36:23

even at rest, even not trying to defecate.

36:26

And this is the landmark which we

36:28

have talked about, the bladder neck.

36:30

And this is the landmark, the anterior cervix.

36:32

And then we are seeing the urethra here, which

36:36

is almost kind of vertical, but as soon as patient

36:39

starts defecating, we see there is significant

36:41

descent of the middle compartment here.

36:44

What is happening there?

36:45

This vagina, which was filled with the contrast, we

36:48

can see the cervix has gone beyond that and actually

36:51

is projecting outside the vaginal introitus.

36:55

And here we can see some of the movement

36:57

of the urethra, which has become oblique.

37:00

So this will be called as mild urethral hypermobility.

37:04

But the most important thing here is this uterus,

37:06

which has descended down or is coming outside the

37:09

vagina and is actually compressing over the rectum,

37:12

and this has caused retention of the contrast even

37:14

after the defecatory effort, more than 50% or close

37:17

to 50%, and most of the contrast here is seen in the

37:20

lower rectum and there is a small anterior rectocele.

37:23

So this is not important for us.

37:25

The important finding here is the uterine

37:26

movement and causing impression over the rectum.

37:30

Let's move to the second case.

37:32

So lemme run this loop and let's see what happens.

37:36

So this is the baseline, and

37:38

then patient starts defecating.

37:39

We are seeing that most of the movement

37:41

is confined to the posterior compartment,

37:43

but all three compartments are involved.

37:46

When there is a severe involvement

37:47

of three compartments, it is called

37:49

as descending perineal syndrome.

37:52

So in this particular case, what is going on?

37:54

We see a small, uh, cystocele.

37:56

Here we see the mobility of the middle compartment,

38:00

which goes below the level of pubococcygeal, uh,

38:03

line, and then in the posterior compartment.

38:06

Even after defecatory effort, though patient is able to

38:09

defecate, we can see the contrast is coming out of the rectum.

38:12

Uh, we see like a lot of contrast is retained

38:15

after the defecatory effort, and with the, with the

38:18

effort, actually all of this vector of the force

38:20

is going anteriorly and causing this anterior

38:23

rectocele, which is kind of moderate in size.

38:26

So this is basically a pelvic floor

38:28

dysfunction or descent seen during the defecatory

38:31

effort involving all three compartments.

38:35

But most severe in the posterior compartment, uh,

38:38

with a small cystocele, descent of the posterior

38:41

fornix, anterior rectocele, and descent of

38:44

the entire pelvic floor, or descending perineal

38:48

syndrome, mostly involving the posterior compartment.

38:52

Let's deal with the next case.

38:53

53-year female with a history of

38:56

incomplete evacuation and complaint of

38:58

prolapse, and patient has history of post-

39:01

hysterectomy here.

39:02

So hysterectomy means patient has undergone a

39:05

major surgery, which has completely disrupted the

39:08

rectovaginal fascia, and that space has become weaker.

39:12

So in this particular case, what is going on?

39:14

Patient is already feeling the prolapse,

39:16

and it has been confirmed by the clinician.

39:18

But there are certain additional findings

39:20

which are actually missed or underestimated.

39:28

We are, despite, we are seeing.

39:35

Peritoneocele or enterocele, which is compressing

39:38

or sitting on the top of the bladder and the middle

39:41

compartment and the top of the rectum, which is pushing

39:45

everything outwards. And see the severity of cystocele,

39:48

where the bladder was initially here, and it has gone

39:50

all the way down and completely empty here actually.

39:54

And then we can see the movement of the.

39:56

Peritoneocele or enterocele on the top of

39:58

the middle compartment or the vagina, which is

40:00

completely overridden and pushed downwards, which is

40:03

not even seen in the field of view here, and same

40:06

thing is happening despite the rectum is empty.

40:09

We are seeing this rectocele is formed anteriorly, which

40:13

is missed because it is going beyond the field of view.

40:17

So in this particular case, we

40:19

have to extend the field of view,

40:20

first of all.

40:24

In this particular case, what happens?

40:26

We see a large cystocele coming and

40:28

projecting and protruding outside, and

40:30

then we are seeing the movement of the,

40:34

the uterus here.

40:35

We can see the uterus is moving downwards, and

40:37

same thing is happening here. We are seeing the

40:39

projection of the cervix coming out of the vagina.

40:45

And in the posterior compartment, what we see, there

40:48

is a sigmoid colon loop, which actually protrudes

40:50

below the pubococcygeal line, but not significantly.

40:53

So this will not be called a sigmoidocele.

40:56

And then we see the emptying of the rectum is present.

40:58

So most important thing here is

41:00

basically a severe cystocele.

41:03

Or anterior compartmental

41:04

involvement, which is slightly uncommon.

41:06

Isolated anterior compartment is very uncommon,

41:09

but in this case, there is anterior compartment

41:11

as well as the middle compartment, which

41:12

is involved, but posterior compartment is

41:14

relatively spared compared to the other two.

41:17

Usually all three compartments are involved,

41:19

and most common is basically the posterior one.

41:21

But once you have three compartments involved, it can

41:24

be any of, uh, those that are severely involved.

41:29

Let's move to the next case here.

41:31

So, 45-year female with chronic constipation.

41:36

So what is happening here?

41:37

Patient is trying to defecate,

41:39

but there is no, uh, opening here.

41:45

So see here, the external sphincters are not opening

41:48

here, and this anal canal actually should become.

41:52

Should open and become more than a few

41:54

millimeters to allow this emptying from

41:57

the rectum, which is not happening here.

41:59

And despite patient is trying, there's

42:01

no movement in other compartments.

42:03

There's nothing going below the pubococcygeal line.

42:06

And there is almost complete evacuation of the

42:08

contrast through the rectum. That suggests

42:11

that there is non-relaxation of the external

42:14

sphincter during the defecatory effort,

42:16

which is called as anismus or dyssynergia.

42:20

Uh, that is causing this, this,

42:22

these issues of constipation.

42:24

So chronic constipation caused by dyssynergia, and that falls

42:27

into the functional constipation, and that can be

42:29

easily diagnosed on MR. And in this particular case,

42:32

it is almost similar case, 55-year male with obstructed

42:36

defecation or constipation. And see what happens.

42:40

It's more or less similar.

42:41

In this particular case, we are

42:43

seeing a contrast passing anteriorly.

42:47

Through the anal canal.

42:48

So anal canal is actually opening, but what is

42:51

happening, there is a contraction of the,

42:55

so this angulation, an angulation is becoming

42:59

acute as the patient is trying to defecate.

43:02

So this is called spastic pelvic floor dysfunction,

43:05

or paradoxical contraction of the muscle.

43:09

If you have paradoxical contraction of the puborectalis muscle,

43:12

that is actually suggestive of another

43:15

type of dyssynergia caused by the muscle here.

43:18

And this is again, one of the

43:19

causes of functional constipation.

43:22

So in my personal experience, if you, if you

43:24

have a young patient coming with constipation,

43:26

or a male patient coming with constipation,

43:29

you will most likely find, uh,

43:31

dyssynergia in those patients.

43:35

So important pitfall to understand

43:37

is basically non-emptying of the bladder.

43:40

About 30 minutes before, if you don't do

43:41

that, there will be over-distended bladder, and

43:44

that over-distended bladder might actually go

43:46

downwards and cause impression over the vagina,

43:49

or the middle compartment, and these

43:51

findings will not be seen correctly.

43:53

Or you actually miss the middle compartment descent,

43:56

or posterior compartment descent completely.

43:59

So you have to empty the bladder.

44:00

See, in this case what is happening, the

44:03

bladder neck is just here, uh, despite patient

44:05

trying to evacuate, and there is a small cystocele.

44:08

But as soon as we.

44:09

As soon as we have emptied the bladder,

44:12

we see the cystocele activity has become

44:14

more severe, or at least moderate to severe.

44:17

And the urethra is actually lying here,

44:19

uh, at horizontal, and we see the descent

44:22

of the cervix is more than expected.

44:25

Which we saw earlier obviously did not cause

44:28

any significant changes in the posterior

44:30

compartment, but you can actually mis-

44:33

or misdiagnose, uh, or underestimate the descent

44:37

of various compartments if the bladder is filled.

44:40

The second problem which can happen is basically

44:43

patient is not able to follow your commands,

44:46

or patient is not able to defecate properly.

44:49

So in that scenario, I would look on the abdominal

44:52

wall movements and the size of the femoral veins.

44:56

So once patient is trying to defecate, it’s

44:58

increasing the abdominal pressure, uh,

45:01

and that will also cause decreased return

45:03

of the venous circulation to the IVC, and all

45:07

of the peripheral veins will be engorged.

45:09

So if there is distention of the femoral veins

45:12

on the axial plane taken through the groin

45:15

while the patient is trying to evacuate, that means

45:19

patient is doing significant or appropriate efforts. If

45:22

the size of the femoral veins are not increasing, that

45:26

suggests that patient's efforts are not sufficient.

45:30

So let's talk about this comparison

45:32

of fluoroscopic versus MR.

45:34

Defecography, because if you are going to start a new service

45:38

at your place, you are going to face this, uh,

45:41

this question from the clinician, specifically,

45:44

if you're doing the conventional defecography already.

45:46

So there is always a chance of change, uh, about

45:50

the fluoroscopic defecography, because patients

45:52

think that what they're doing is fine.

45:54

And actually it's not bad.

45:55

I mean, because I have done both.

45:58

I'm doing both.

45:59

Uh, so I know what is the difference

46:02

between the two. Fluoroscopic defecography

46:04

can give you slightly lesser information

46:07

compared to MR. Why that happens?

46:10

Because it completely misses the middle compartment.

46:13

And to pacify enterocele, you

46:15

have to give oral contrast.

46:17

And remember, peritoneocele will

46:18

not be seen on plain fluoroscopy.

46:21

And if you talk about, uh, various pathologies, you

46:25

may actually diagnose more or less similar, but sometimes

46:29

on MR, the grading can be slightly lesser than PACS.

46:33

So that is the only aspect where MR is

46:36

slightly less impactful than

46:40

fluoroscopic defecography, but all other aspects

46:43

are far, far superior.

46:45

And that under-assessment will not

46:47

affect the clinical management because

46:49

you are still seeing the pathology.

46:51

So overall sensitivity and specificity is

46:53

actually higher in MR. Middle compartment

46:56

pathologies are better seen on MR. It

46:59

is not even seen at all on fluoroscopy.

47:02

And then to identify the content of the

47:05

peritoneal cul-de-sac, you have to pacify

47:07

the bowel loop, which is not required.

47:09

In MR defecography, you don't have to, uh, call

47:12

the patient earlier or give oral contrast or wait

47:15

until the contrast reaches the terminal ileum.

47:19

So you actually save patient's time.

47:21

It doesn't require any preparation.

47:23

Patient can come to the investigation

47:26

on the same day when they have seen

47:28

the clinician. You can actually establish

47:31

a clinic where you have

47:34

a colorectal surgeon and a urogynecologist and a

47:38

gastroenterologist sitting together where they see

47:41

the patient, and an investigation is performed on the

47:44

same day, and you can provide the results by evening.

47:46

Patient leaves before, before the patient leaves.

47:50

So this is, this is important aspect that you don't pay.

47:54

Don't spend time on, um, preparing the

47:58

patient at all, and then you can actually.

48:01

Intussusception can be only inferred on the fluoroscopy.

48:04

You don't even see that.

48:06

You can actually see the real intussusception,

48:08

whether it is true wall or the mucosa on

48:10

MR. And you can differentiate those two,

48:12

because the treatment is different.

48:16

And the final surgical plan can be

48:17

significantly altered in 30% of the patients.

48:20

So before coming to the VUI, I have worked at Wake

48:23

Forest, in Wake Forest, and University of

48:25

Washington, Seattle, and there in UW, Seattle.

48:28

I started these services, and once I started,

48:31

I just did one patient in the first week.

48:35

In first month rather.

48:36

And then the number went to almost

48:38

five to seven patients a week.

48:41

So this popularity we gained because of the good

48:43

quality investigation and high-quality reports we

48:47

provided, and we significantly helped the clinical

48:49

decision from the surgeons and the gastroenterologists.

48:53

Uh, so after doing about like a hundred

48:56

patients, I took, uh, some of the

48:58

data from my patients and compared.

49:00

Uh, with the preclinical assessment of the clinician

49:03

and then post-graphy assessment of the clinician,

49:07

and compared how much we impacted patient care.

49:10

Actually, we impacted patient care in a significant number

49:13

of the patients, which was almost more than 30 to 40%.

49:18

Um.

49:19

So MR functional MR actually affects the surgical plan,

49:22

and the majority of the patients can significantly change

49:24

the management, and there is no radiation exposure.

49:28

Regarding the patient compliance, and despite it is MR,

49:30

it is an enclosed room.

49:32

Nobody's seeing the patient. On conventional defecography,

49:35

patient is sitting on a chair in a

49:38

fluoroscopic room and there are technicians

49:40

and people sitting or looking at them, and they

49:43

feel embarrassed. On these investigations,

49:47

patient is on the table.

49:49

Patient is covered with a good drape, uh, and

49:53

patient is trying to defecate on a table,

49:55

and nobody's seeing them, so they feel more

49:57

comfortable compared to fluoroscopic

50:00

defecography.

50:01

As I said earlier, no preparation is required

50:03

for MR defecography, and other pathologies can also be

50:05

diagnosed on MR. Um, so MR is far superior,

50:10

um, compared to the fluoroscopic defecography

50:13

and can provide you better information.

50:17

So in my opinion, functional MR has demonstrated a

50:20

promising role and is emerging as investigation of choice.

50:23

And pelvic floor dysfunction is not a small problem.

50:27

It is a big problem, a frequent problem affecting,

50:30

and an effective preoperative assessment

50:33

on imaging could be highly contributory, making

50:35

precise surgical decisions and anterior management.

50:38

And before we finish this talk, I would give

50:41

another stress to a very high-quality examination.

50:45

Very high-quality report.

50:46

If you have questions, uh, you are free

50:48

to email me and ask after this talk.

50:52

And then what we have discussed in this,

50:55

this talk has been described by me in my

50:58

paper, in Radiologic Clinics,

51:02

in 2013, actually, it was published.

51:05

Re-imaging of pelvic dysfunction.

51:07

You can start with my name.

51:09

Uh, whatever we have discussed is,

51:11

is present in this particular paper.

51:12

If you want to go beyond that and go more

51:15

into details about techniques.

51:19

We have recommendations from, uh, from DFP of SAR, and

51:24

this has been taken after we have consulted all of

51:28

the DFP members and what and how

51:30

they're doing in their institutions.

51:32

All of those recommendations and techniques

51:34

have been described in this paper.

51:36

And then this is one of the recent papers I published

51:38

on functional defecography and how to assess them.

51:41

So everybody talks about surgical issues, but nobody

51:44

talks about the constipation issues, which are,

51:48

which can be easily treated by the gastroenterologist.

51:50

Um, in my practice earlier at University of Washington,

51:53

actually most of the patients, those were coming,

51:56

were referred by the gastroenterologist,

51:59

and most of the patients had the same issues.

52:02

Those were the constipation.

52:03

So if you want to deal with those constipation

52:05

patients, uh, in detail and provide a

52:08

good quality report, read this paper.

52:10

It'll give you lots of insight about these,

52:12

um, these patients and investigation.

52:17

Any questions?

52:17

I'm, I'm more than happy to answer.

52:21

We are now joined by Dr. Lei.

52:24

Um, so I will give all of our attendees a

52:27

couple minutes if you have any questions.

52:29

Would you please be able to direct

52:31

them to the Q and A function?

52:34

And Dr. Lei, I see you did already answer a question.

52:37

Would, would you mind terribly if we read

52:40

that out loud, live, uh, for our other

52:43

attendees so they can hear the answer?

52:46

Sure.

52:46

So somebody asked about, uh, emptying the bladder,

52:50

and if they empty the bladder, how they're

52:52

going to find the pathologies in the bladder.

52:54

That was the question.

52:55

So if we empty the bladder about 30 minutes

52:57

before, it'll allow us to have sufficient

53:00

amount of the urine within the bladder, that

53:02

you're not going to miss any diagnosis.

53:05

So 30 minutes is the key here. You empty the

53:07

bladder, but 30 minutes before, then you have the

53:09

sufficient bladder, uh, or urine inside the bladder.

53:15

Alright, and I'll give our attendees a couple more

53:18

minutes if they would like to ask any questions.

53:24

All right.

53:25

Um, it looks like a new one.

53:27

Just hit the Q and A function.

53:29

Okay.

53:30

So do you evaluate lateral rectoceles in all patients?

53:33

No.

53:34

I mean, if you really have clinical suspicion,

53:37

patient is complaining that they put

53:39

the finger, uh, to evacuate, and you do not see any

53:43

pathology anteriorly, then I would go for coronal.

53:46

Otherwise, it is not a part of the routine protocol.

53:51

I'm not seeing it here.

53:53

Okay.

53:54

I'm seeing it says, how do

53:56

you identify the puborectal junction?

54:00

Okay, so that was actually easy.

54:03

I mean, if you just look on the sagittal and, um, if you

54:07

just try to evaluate the fibers of the levator

54:11

ani and then follow them up to the medial aspect.

54:14

Or if you just look on the anorectal junction, which is

54:16

actually a small angulation where the levator plate inserts,

54:19

that is the anal junction, or anorectal junction. The right

54:22

term is actually anal junction, not the AL junction.

54:27

Okay, and we have another one.

54:28

Um, if a patient failed to defecate after

54:31

three attempts, will you stop then or go on?

54:35

Uh, basically, how many attempts

54:36

would you do for dynamic study?

54:39

Okay, so if the patient is not able to

54:41

defecate after three attempts, there are

54:44

issues, either that is dyssynergia of the anus, or patient

54:47

is not able to defecate because of other

54:49

psychological reasons.

54:50

So what I will do after three

54:52

attempts, I will stop on the table.

54:54

I will ask the patient to go to the restroom and

54:56

defecate there and come back and reevaluate if

54:59

the patient was able to defecate in the restroom.

55:02

That means patient had some psychological issues there.

55:05

Uh, if the patient is not able to evacuate even in the

55:07

restroom, and you have more than 50% of the

55:10

contrast retained after defecating in the restroom,

55:13

that means patient is suffering from dyssynergia.

55:17

Okay.

55:19

It doesn't look like there are any other questions.

55:21

So as we bring this to a close, I want to

55:24

thank Dr. Lei for this lecture and thank you to

55:27

everyone for participating in our noon conference.

55:30

A reminder that this conference is

55:32

available on demand on MRIonline.com in

55:35

addition to all previous noon conferences.

55:38

Be sure to join us again on Monday for a lecture

55:40

from Dr. Ana Rosenstein on lung cancer screening.

55:44

You can register for that at MRIonline.com and follow

55:48

us on social media at the MRI Online for updates

55:52

and reminders on upcoming noon conferences.

55:55

Thanks, and have a great day.

55:57

Thank you everyone.