Rania Farouk El-Sayed

The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, radiologists, physiotherapists, and other advanced care practitioners. Specialists from these fields are all dedicated to the diagnosis and management of patients with pelvic floor conditions, but they approach, evaluate, and treat such patients with their own unique perspectives given the differences in their respective training. The PFDC was formed to bridge gaps and enable collaboration between these specialties. The goal of the PFDC is to develop and evaluate educational programs, create clinical guidelines and algorithms, and promote high quality of care in this unique patient population. The recommendations included in this article represent the work of the PFDC Working Group on Magnetic Resonance Imaging of Pelvic Floor Disorders (members listed alphabetically in Table 1). The objective was to generate inclusive, rather than prescriptive, guidance for all practitioners, irrespective of discipline, involved in the evaluation and treatment of patients with pelvic floor disorders.

Functional defecation disorders (FDD) encompass causes of constipation associated with anorectal dysfunction, which include dyssynergia or inadequate defecatory propulsion. FDD are frequently encountered in clinical practice and may affect up to 33-50% of patients with chronic constipation. The etiology of FDD is unclear, however, it has been defined as an acquired, but subliminal behavioral disorder. Pathophysiologic mechanisms may include discoordination of rectoanal muscles, paradoxical contraction or insufficient relaxation of puborectalis and/or anal sphincter during defecation, and sluggish colonic transit. A combination of comprehensive clinical assessment, digital rectal examination and a battery of physiologic tests are needed to make an accurate diagnosis of FDD. Defecography may play a crucial role in the evaluation of FDD, especially when a balloon expulsion test (BET) and/or anorectal manometry (ARM) are equivocal or demonstrate contradictory results. In this review, we provide a thorough overview of the epidemiology, pathophysiology, diagnostic criteria, clinical and imaging evaluation, and treatment options for FDD, with an emphasis on available diagnostic imaging tools such as defecography and conventional fluoroscopic methods.

PURPOSE: 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).

METHODS: 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.

RESULTS: 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%.

CONCLUSION: 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.

The pelvic floor is composed of a network of muscles, ligaments, and fasciae, which provide active and passive support for the pelvic organs. Impairment of these pelvic floor elements can result in a variety of functional abnormalities and single or multicompartment organ prolapse. Knowledge of normal pelvic floor anatomy can aid the radiologist in understanding the complex nature of pelvic floor dysfunction and is important for comprehensive image interpretation. This article provides an overview of normal anatomy of the pelvic floor as seen on magnetic resonance imaging, ultrasound, and fluoroscopic studies performed in the evaluation of pelvic floor function.

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.

scholar.cu.edu.eg/raniafarouk

We are pleased to present Diagnostic
Imaging: Gynecology, second edition, the most
extensive book of imaging in gynecologic
diseases. More than 2,500 carefully annotated
images illustrate pertinent pathologic entities
and demonstrate the correlation between
ultrasound (including 3D), sonohysterography,
hysterosalpingography, MR, PET/CT, and gross
pathology. For ease of reference and learning,
diagnoses are grouped according to the organ
involved—uterus, cervix, vagina and vulva,
ovary, fallopian tubes, multiple organs, and
the pelvic floor—and include all pertinent
pathologic entities, including congenital
anomalies, infectious/inflammatory diseases,
and benign and malignant neoplasms.
This reference builds upon the success of
the first edition with new image galleries,
completely revised text, and updated
references. In addition, we include a dedicated
section on techniques, designed to help
optimize imaging protocols and enhance
diagnostic specificity. Each section now begins
with a review of normal anatomy and variants,
including extensive illustrations. As applicable,
we have added modules on tumor staging that
feature quick-reference tables, illustrations,
and case examples of TNM classification,
FIGO staging, and AJCC prognostic groups.
The book closes with a section devoted to
the pelvic floor, the evaluation of which has
become an integral part of our clinical practice
in the last decade.
Diagnostic Imaging: Gynecology, second edition
maintains the signature Amirsys format of concise
bulleted text, Key Facts boxes, and plentiful, highquality
images. The online version includes another
900 images, plus additional diagnostic tips and
references. In all, the book remains extremely useful
for radiologists and gynecologists alike, both those
practicing and those still in training.
I would like to thank all the editors and contributing
authors from the bottom of my heart for their effort
and dedication. We are extremely proud of the
final product and hope that readers will appreciate
the effort required to produce such an amazing
reference.
I also want to acknowledge the sonographers and
the CT and MR technologists for their fine work,
which is used extensively throughout this text.
Thanks also to the amazing Amirsys staff, especially
Angie, Katherine, Kellie, and Jeff—whose attention
to detail makes everything we do better—and to
the illustrators—Lane, Rich, and Laura—who have
helped make this book truly special.
We think you’ll find this new volume a wonderfully
rich resource that will enhance your practice and find
a welcome place on your bookshelf.

Overview
Overview of the Pelvic Floor
Rania Farouk El Sayed, MD, PhD
8-2
Pelvic Floor Imaging
Rania Farouk El Sayed, MD, PhD
8-30
Pelvic Floor Dysfunction
Anterior Compartment
Overview of the Anterior Compartment
Rania Farouk El Sayed, MD, PhD
8-40
Anterior Compartment Imaging
Rania Farouk El Sayed, MD, PhD
8-60
Middle Compartment
Overview of the Middle Compartment
Rania Farouk El Sayed, MD, PhD
8-68
Middle Compartment Imaging
Rania Farouk El Sayed, MD, PhD
8-80
Posterior Compartment
Overview of the Posterior Compartment
Rania Farouk El Sayed, MD, PhD
8-88
Imaging of Fecal Incontinence
Rania Farouk El Sayed, MD, PhD
8-102
Imaging of Obstructed Defecation
Rania Farouk El Sayed, MD, PhD
8-112
Multicompartmental
Multicompartmental Imaging