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Can We Correlate Pelvic Floor Dysfunction Severity on MR

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Can We Correlate Pelvic Floor Dysfunction Severity on MR Updates in Surgery https://doi.org/10.1007/s13304-017-0506-0 ORIGINAL ARTICLE Can we correlate pelvic foor dysfunction severity on MR defecography with patient‑reported symptom severity? Lisa Ramage1 · Panagiotis Georgiou1 · Shengyang Qiu1 · Paul McLean1 · Nasir Khan3,4 · Christos Kontnvounisios1,2 · Paris Tekkis1,2 · Emile Tan5 Received: 18 July 2017 / Accepted: 2 December 2017 © The Author(s) 2017. This article is an open access publication Abstract MR defecography (MRD) is an alternative to conventional defecography (CD) which allows for dynamic visualisation of the pelvic foor. The aim of this study was to assess whether MRI features indicative of pelvic foor dysfunction correlated with patient-reported symptom severity. MR proctograms were matched to a prospectively-maintained functional database. Univariate and multivariate analyses were performed using pre-treatment questionnaire responses to the Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ), Wexner Incontinence Score (WIS), and modifed Obstructed Def- ecation Symptom (ODS) Score. 302 MRI proctograms were performed between January 2012 and April 2015. 170 patients were included. Patients with a rectocele > 2 cm (p = 0.003; OR 5.756) or MRD features suggestive of puborectalis syndrome (p = 0.025; OR 8.602) were more likely to report a higher ODS score on multivariate analysis. Lack of rectal evacuation was negatively associated with an abnormal WIS (p = 0.007; OR 0.228). Age > 50 (p = 0.027, OR 2.204) and a history of pelvic foor surgery (p = 0.042, OR 0.359) were correlated with an abnormal BBUSQ incontinence score. Lack of rectal evacuation (p = 0.027, OR 3.602) was associated with an abnormal BBUSQ constipation score. Age > 50 (p = 0.07, OR 0.156) and the presence of rectoanal intussusception (p = 0.010, OR 0.138) were associated with an abnormal BBUSQ evacuation score. Whilst MRD is a useful tool in aiding multidisciplinary decision making, overall, it is poorly correlated with patient-reported symptom severity, and treatment decisions should not rest solely on results. Keywords Patient-reported outcome measures · Magnetic-resonance defecography · Functional-bowel disorders Introduction Magnetic-resonance defecography (MRD) was frst intro- duced in 1993 [1] as a means of dynamic multi-compart- mental visualisation of the pelvic foor. Its main advantages over fuoroscopic techniques, such as conventional defecog- * Christos Kontnvounisios raphy (CD), were the depiction of signifcantly higher ana- [email protected] tomical detail of the pelvis achievable through T2-weighted 1 Department of Surgery and Cancer, Chelsea images, and the ability to assess the movements of the ante- and Westminster Hospital, Imperial College London rior, middle, and posterior compartments of pelvis and its NHS Trust, Academic Surgery, 3rd Floor, Fulham Road, surrounding structures dynamically. The absence of ionis- London SW10 9NH, UK ing radiation enabled its use in a younger group of patients 2 Department of Colorectal Surgery, The Royal Marsden NHS [2]. However, the utility of MRD over its X-ray counterpart Foundation Trust, London, UK needs further examination. 3 Department of Radiology, Chelsea Westminster Hospital, MRD has been shown to be useful in the diagnosis of London, UK pelvic foor dysfunction, particularly in the diferential diag- 4 Department of Radiology, The Royal Marsden NHS nosis of pelvic organ prolapse, evacuatory as well as conti- Foundation Trust, London, UK nence disorders. It has utility in assessing the surrounding 5 Department of Colorectal Surgery, Singapore General organs, in particular the uterus and vagina in women, and the Hospital, Singapore, Republic of Singapore Vol.:(0123456789)1 3 Updates in Surgery dynamic interplay of the three pelvic compartments. MRD in females [10], has four domains: constipation, inconti- has also facilitated the development of three-dimensional nence, evacuation, and urinary. Each domain is scored out interactive pelvic foor models [3, 4] which can be utilised to from 0–100%, with the higher the score indicating more better understand the dynamic structural relationships of the severe symptoms. As according to its validation criteria, pelvic foor. Several studies assessing predominantly poste- an abnormal score for each domain was indicated as fol- rior compartment dysfunction have found that added benefts lows: constipation ≥ 64%, faecal incontinence ≥ 17%, of MR defecography over CD include the ability to identify evacuation ≥ 17%, and urinary ≥ 20%. With the exception enteroceles and the presence of levator ani hernias [5, 6]. of one question which refers to the presence of a bulge in Scoring systems for radiological diagnosis of severity the vagina, all questions were applicable to both males and of disease include the HMO classifcation [7] and grading females presenting with pelvic foor dysfunction, therefore, systems based on the number of compartments afected [8]. this questionnaire was used in both males and females, with These have concentrated on the presence/absence of entero- the aforementioned question removed in male patients and cele, measurement of pelvic foor descent (M line), widening the evacuation score adjusted accordingly. This score was of the levator hiatus (H line), and the degree of cystocele and chosen as a self-reported functional comparative tool for this rectocele formation and middle compartment descent, using study as it represented both the anterior and middle compart- the pubococcygeal line (PCL) for Ref. [9]. ments in its symptom assessment. Ultimately, clinicians use the fndings of various imag- The Wexner incontinence score (WIS) was frst published ing modalities in conjunction with patient-reported symptom in 1993 [11] and has gained widespread acceptance. Its scor- severity to guide patient management. This is particularly ing system takes into consideration symptoms of solid or important in functional disease, where an attempt to improve liquid faecal and fatal incontinence, in addition to the need patient functional outcomes and quality of life is the indi- to use pads/medication to aid continence and the need to cation for intervention rather than being in the context of alter lifestyle due to problems with incontinence. A WIS of malignancy or another life-threatening condition. There- ten or more in this study was considered to be indicative of fore, it is important to understand the relationship between signifcant symptoms of faecal incontinence. anatomical severity on MRD and patient symptomology to The obstructive defecation symptom score (ODS score) guide treatment decisions. used for the purposes of this study was adapted from the The aim of this study was to assess the main radiologi- original score developed by Longo et al. [12] and comprised cal features examined in MRD and examine the extent to of fve questions, each scoring a maximum of four points which their severity correlates with symptoms as reported relating to the presence of: (1) constipation; (2) straining; (3) by patients. incomplete evacuation of stool; (4) the need to interdigitate the rectum or vagina or use perineal support to initiate def- ecation; and (5) laxative or enema use. A score of 8 or above Methods out of 20 was considered to be abnormal. For each of the four BBUSQ domains, the Wexner Incon- All patients who had undergone MR defecography within tinence Score and the ODS score, patients were marked as a single tertiary referral centre for pelvic foor dysfunction either having a normal or abnormal score as according to between January 2012 and April 2015 were identifed retro- the above criteria. spectively from a prospectively-maintained database. This research database had full ethical approval. Three validated MRI proctogram protocol functional questionnaires were routinely given out during each outpatient clinic attendance to capture pre- and post- The Siemans Avanto 1.5 Tesla MRI scanner was used for all treatment data. examinations. Patients were not administered bowel prepa- Patients with at least one of: Birmingham Bowel and Uri- ration or enemas. 30–50 ml of ultrasonic gel was inserted nary Symptom Questionnaire (BBUSQ); Wexner (Cleveland into the vagina in females, and 50–100 ml was inserted into Clinic) Incontinence Score; Obstructed Defecation Score the rectum. Patients were also advised to have a full blad- (ODS), completed within 12 months of the MRD taking der prior to the examination. Patients were positioned in the place and prior to any treatment intervention were identifed supine position within the MRI scanner. Initial T2-weighted and included within the study. turbo spin echo (TSE) images were acquired in 3 mm slices through the pelvis in sagittal, coronal, and axial directions. Patient‑reported outcome measures An initial sagittal image centred on the anal sphincter complex was taken. Next, Trufsp (TE: 1.69 s; TR: 4.26 s) The BBUSQ, a validated 22-point self-administered ques- 5 mm thickness images were rapidly acquired in 25-image tionnaire for the assessment of urinary and bowel symptoms sequences. A single dynamic run was acquired, whilst the 1 3 Updates in Surgery patient was instructed to contract their pelvic foor. Follow- ing this, the patient was instructed to empty their rectum whilst on the scanner. 2–3 dynamic sequence runs were taken during this evacuation phase. MRI interpretation All MRIs were interpreted on two separate occasions by two reviewers (NK & LR). They were blinded to clinical fndings. In instances where there was disagreement
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