Objectives

1. Normal anatomy on MRI Proctogram, including appropriate lines and measurements for accurate assessment.

2. Illustration of varying degrees of pelvic organ prolapse (see media file chart)

3. Discussion of management and treatment of pelvic organ prolapse.

4. The potential benefit of a universal grading system when comparing clinical examination with imaging findings.

Background

Pelvic organ prolapse is very common, affecting approximately one-third of women over their lifetime. The pelvic floor is divided into three compartments:

1. Anterior (urinary bladder and urethra)

2. Middle (uterus, cervix, vagina)

3. Posterior (rectum).

MRI defecating proctography is a dynamic, but invasive way of assessing pelvic organ prolapse in all three compartments. We present an illustrative demonstration of our institutional data over the past 2 years, referring to both clinical and radiological assessment.

Imaging findings OR Procedure findings

We present various cases demonstrating normal anatomy and various grades of pelvic organ prolapse. Imaging will be annotated, demonstrating important lines and measurements for an accurate diagnosis.

We refer to an in-house audit performed comparing clinical examination with MRI findings, and the potential for a comparative grading system.

Please see media file for an example

Conclusion

MRI defecating proctography has an important role in assessing various degrees of pelvic floor prolapse. In addition to clinical examination, it has an important role in assessing symptomatic women prior to complex surgery, adding value to the multi-disciplinary team approach.

Objectives

1. Review of the normal anatomy identified via endoanal ultrasound of the anal sphincteric complex.

2. Pictorial demonstration of the various grades of obstetric anal sphincter injury.

3. Emphasise the importance of ultrasound in evaluating this injury.

4. Management of these injuries by both conservative and surgical approaches.

Background

Obstetric anal injury affects up to 3% of women during their first vaginal delivery. Of these, 20-40% may be symptomatic at 12 months. In our institution, these patients are reviewed in the perineal clinic by a member of team and if symptomatic, referred to Radiology for an endoanal ultrasound.

Imaging findings OR Procedure findings

Endoanal sonographic demonstration of:

Normal anatomy at three levels (upper, mid, lower) of endoanal ultrasound.

First-degree tear: Laceration to the perineal skin/ vaginal epithelium.

Second-degree tear: Involvement of the perineal muscles but not the anal sphincter

Third-degree tear: Disruption of the anal sphincter muscles; this is subdivided into:

3a- Tear <50% thickness of external sphincter

3b- Tear >50% thickness of external sphincter

3c- As above, plus anal sphincter also torn,

Fourth degree: Third degree, with disruption of the anal epithelium.

Conclusion

In the post-partum period, sonographic assessment of the anal sphincter complex is a quick, safe and effective way to assess the injury.

Early diagnosis helps reduce patient anxiety and ensure prompt initiation of appropriate therapy. This can minimise the risk of feacal incontinence.

Discussion of both conservative and surgical options will be addressed in this review.