This method of ours is simultaneous visualization of pelvic organ dissent and the impediment on the reg-i-tory under the effect of a intra-abdominal vector focus. I like, during a physical examination and the three deep perineal ultrasound. The images our required during pre-rectal emptying.
And without the embarrassment due to the facility of the examiner. Demonstrating the procedure will be Giulia Melara, nurse. And Andrea Chiapperin and Mattia Bergamasco, technicians.
Both from my laboratory. Before beginning the examination, place a trolley inside the diagnostic room, equipped with all the necessary instruments and supplies;including gloves, syringes, a catheter, lubricant jelly and acoustic. Help the patient fill in a form that provides information on their history, current symptoms, treatments and prior medical records, if any.
After obtaining written consent, clearly explain the characteristics and purpose of the procedure including the performance of various examination maneuvers, such as squeezing, straining and rectal emptying, to the patient. Informing the patient of the, on average, 25 minute duration of the procedure and the need for the insertion of a small catheter into the anal canal for contrast administration. Ask the patient to empty their bladder.
Then, ask the patient to wear an apron and direct the patient to the diagnostic room. Next, help the patient lay on the diagnostic table of the magnetic resonance scanner, in the left lateral position and gently insert the catheter into the rectum, for administration of the rectal contrast until the patient experiences a characteristic desire to evacuate. After rectal filling, help the patient turn to the supine position and adjust the absorbent pad beneath the buttocks.
Then, wrap a surface phased array around the patient's pelvis for the image acquisition. When the patient is in position, acquire a localizer scout scan in the coronal, axial and sagittal planes in the magnetic resonance imaging or MRI Imager to mark the boundaries of the region of interest. Next, obtain three subsequent, dynamic series scans in the mid-sagittal plane, centered over the anal rectal junction, with the patient at rest and squeezing their anal sphincter for 10 seconds per strain.
After the last anal rectal junction scan has been obtained, instruct the patient to begin the movement of rectal emptying;initiating the simultaneous acquisition of images over an entire 58-second cycle upon acoustic device indication of the evacuation. While the patient is expelling the residual rectal contrast, repeat the imaging sequence in coronal plane, before instructing the patient to perform a steady state Valsalva maneuver, without interruption for nine seconds. Using the sagittal images acquired during the rectal emptying, as a reference, select three horizontal planes in the axial plane to image the levator hiatus;first at the mid symphysis, second, tangent to the inferior border of the symphysis, and third, at the point of the maximal bulging of the anterior rectal wall.
Acquire a horizontal, one-centimeter thick section in the axial plane, from each level, during the Valsalva maneuver. Leaving the patient at 30 to 60 second interval between subsequent maneuvers, to relax. Then acquire static, T2-weighted images with the patient at rest in the axial, sagittal and coronal planes, to provide a complete evaluation of the pelvic anatomy.
To measure the position of the pelvic organs at rest and while straining, from the mid-sagittal dynamic MRI images and the analysis software, open the list of toolbar options, positioned at the top of the screen and hover over annotation tools. Click the arrow and select ruler to obtain a linear measurement in millimeters of the vertical distance of the bladder neck, uterine cervix, prostate base, sentinel vesicles and rectal floor, from two reference lines. To measure the hiatal and interior posterior and transverse diameter in millimeters;from the axial static and dynamic images, repeat the same linear measurements and calculate the distance from the pubic symphysis to the anterior margin of the pubo-rectalis sling.
And the distance between the medial borders of the levator ani muscle. To measure the hiatal area when at rest and during maximum strain in square centimeters, select annotation tools and free region of interest to select a free-hand contour tracing technique. Then draw a border around the internal area of the the levator ani muscle and express the differences between the resting and straining measurements, as absolute values.
And an increase in percentage from the symphysis pubis and the ischial tuberosities. Between 2012 and 2018, this protocol has been successfully adopted in three different diagnostic centers in Italy at an average cumulative rate of about 30 exams per month;using the same MRI scanner model and technical parameters. Although pelvic organ prolapse is more common in females, it also occurs in male patients.
Regardless of sex, levator ani hiatus ballooning during straining has emerged as the most reliable index of the disease. And it's area can easily be quantified with axial dynamic MR pelvic imaging for disease screening, compared to the size of the hiatus when at rest. Interestingly, the actual enlargement of the hiatus when straining, cannot be predicted based on its size when at rest.
As demonstrated in a previous study, in New-la Paris and Paris women, whose at rest values did not correlate with those during the Valsalva maneuver. It is important to tailor the examination for each individual. So as to obtain the maximum information from the vibration.
Particularly in cases of chronic pelvic pain and sexual dysfunction. This protocol paves the way for future investigation and cor-ri-gation;with the pressure status and the rectal neuro-physilogical test. This pelvic organ displacement and there, dramatical deformities by MRI in a quantitative manner, will help investigating the mechanism by which pelvic organ prolapse develops.
