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ARRS Partners With Pelvic Floor Disorders Consortium on MRI Defecography Guidelines

Fig. 1a

Published on December 21, 2021

The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of radiologists, colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, physiotherapists, and other advanced care practitioners—formed to bridge gaps and enable collaboration between these specialties. Specialists from these fields are all dedicated to the diagnosis and management of patients with pelvic floor conditions, but given the differences in their respective training, they approach, evaluate, and treat such patients with their own unique perspectives.

In a multisociety-endorsed article in the October edition of AJR (published concurrently with Diseases of the Colon & Rectum, International Urogynecological Journal, and Female Pelvic Medicine and Reconstructive Surgery Journal), the 24 members of the PFDC Working Group on MRI reached consensus regarding many clinically relevant considerations for performing, interpreting, and reporting MR defecography (MRD). Based upon the PFDC Working Group’s consensus guidelines, corresponding synoptic interpretation templates were suggested for this unique patient population.

Contrast Medium Considerations

On the basis of the literature and their collective expertise, the PFDC Working Group advised that MRD should be performed with rectal distention, using rectal contrast medium, and with image acquisition during defecation. Rectal distention and defecation are both crucial components of MRD that distinguish the examination from simple dynamic pelvic floor MRI performed with the Valsalva maneuver. Moreover, compared with Valsalva images, prior AJR research has shown larger, more recurrent prolapse on MRD examinations with rectal distention and on defecation images. [4] (Fig. 1).

Fig. 1—59-year-old woman with history of rectal bulge and sensation of incomplete defecation. B = bladder, R = rectum, V = vagina. A–C, Sagittal steady-state images at rest (A), Valsalva (B), and defecation (C) show bladder, vaginal apex (asterisk), and anorectal junction (dashed arrow) at or above pubococcygeal line (PCL) (line) at rest (A). During Valsalva (B), bladder extends below PCL and there is small cystocele (solid arrow), vaginal apex is lower than at rest (asterisk) but remains above PCL, and there is descent of anorectal junction (dashed arrow). During defecation (C), there is significantly larger descent of bladder below PCL and enlargement of cystocele (solid straight arrow), vaginal apex now prolapses below PCL (asterisk), and there is significant descent of anorectal junction below PCL (dashed arrow). There are also anterior (left curved arrow) and posterior (right curved arrow) rectoceles.

Technique and Reporting/Grading of Relevant Pathology

Apropos of so many differing clinical backgrounds, the PFDC Working Group debated which of two grading scales to utilize for internal rectal intussusception: descriptive reporting or the Oxford Grading Scale [5]. After much deliberation, the panel agreed that a uniform description of rectal intussusception as intrarectal, intraanal, or complete external (extraanal) would provide adequate clinical details to be deemed the minimum reporting standard.

Ultimately, these consensus definitions and interpretation templates can be augmented with additional radiologic maneuvers and report elements—specific patient indications, health care provider preferences, local practice patterns, etc.—”but the suggested verbiage and steps should be advocated as the minimum requirements when performing and interpreting MRD in patients with evacuation disorders of the pelvic floor,” the 15 coauthors of this AJR article concluded.

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