Bildgebende Abklärung bei Beckenbodendysfunktion und Beckenbodenprolaps

Zusammenfassung

Der Beckenboden ist eine komplexe anatomische Struktur, welche die Beckenorgane stabilisiert. Seine Schwächung kann viele verschiedene Ursachen haben und sich entweder als Beckenbodensenkung oder Beckenbodendysfunktion äußern. Eine Beckenbodensenkung oder ‑prolaps ist bei Frauen viel häufiger als bei Männern. Die Diagnostik und vor allem die Behandlung von Patienten mit Beckenbodendysfunktion sind anspruchsvoll. Dabei sind eine sorgfältige Anamnese und die körperliche Untersuchung immer noch die Grundlage der Therapie, die bildgebende Darstellung von Pathologien des Beckenbodens hat jedoch in den letzten Jahren eine zunehmende Bedeutung erlangt, vor allem, wenn das mittlere oder hintere Beckenbodenkompartiment betroffen ist.

Im Gegensatz zu anderen Körperteilen ist es bei der Bildgebung des Beckenbodens entscheidend, dass der Beckenboden unter maximalem Stress untersucht wird, weil die meisten Pathologien erst dann sichtbar werden. Somit ist die Bildgebung des Beckenbodens eine funktionelle Bildgebung, für die aus radiologischer Sichtweise 2 Methoden im Vordergrund stehen: konventionelle Defäkografie und dynamische MRT des Beckenbodens (MR-Defäkografie).

Abstract

The pelvic floor is a complex anatomical structure which stabilizes the pelvic organs. There are several factors which may contribute to pelvic floor weakness which can in result in either pelvic floor descent or pelvic floor dysfunction. Although pelvic floor dysfunction is more common in females, it may also occur in males. The diagnostic algorithm and treatment in patients with pelvic floor dysfunction is complex. Although clinical history and examination are the mainstays for therapeutic decisions, the importance of pelvic floor imaging is increasing. Imaging is of particular importance for therapeutical decisions regarding the middle and posterior pelvic floor compartments since it has been shown that clinical assessment is inaccurate with regard to the middle and posterior pelvic compartments. In contrast to imaging in other body parts, it is of outmost importance that the pelvic floor is imaged under maximal stress. This is because it has been shown that several pelvic floor pathologies are only visible if maximal stress to the pelvic floor is applied. Hence, pelvic floor imaging is functional imaging. From the radiological point of view two imaging modalities are of interest both enabling functional imaging: the conventional barium defecography and dynamic pelvic floor MR imaging (MR-defecography).

Kernaussagen

• Beckenbodendysfunktion und ‑prolaps sind häufige Erktrankungen, bei denen die Bildgebung heute eine wichtige Rolle vor allem bei der Wahl der Therapie spielt.

• Die Bildgebung des Beckenbodens ist eine funktionelle Bildgebung.

• Die MRT ist heute die bevorzugte bildgebende Modalität am Beckenboden, da sie neben Aufnahmen in Ruhe auch eine Bildgebung der Funktion ermöglicht.

• Bei der Bildgebung des Beckenbodens ist eine strukturierte Analyse mit Quantifizierung der Befunde wichtig.

Keywords

Pelvic floor - defecography - pelvic floor Imaging - pelvic floor dysfunction - pelvic floor prolapsed - individualized treatment - image correlation

• Literatur

• 1 Lermann JH et al. Genitalvorfall: Symptomaik, Diagnostik und Therapie. Frauenheilkunde up2date 2010; 2: 111-131
• 2 Sung VW, Hampton BS. Epidemiology of pelvic floor dysfunction. Obstet Gynecol Clin North Am 2009; 36: 421-443
• 3 DeLancey JO. The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment. Am J Obstet Gynecol 2005; 192: 1488-1495
• 4 Herbst F et al. Gastrointestinal transit and prolonged ambulatory colonic motility in health and faecal incontinence. Gut 1997; 41: 381-389
• 5 Roos JE et al. Experience of 4 years with open MR defecography: pictorial review of anorectal anatomy and disease. Radiographics 2002; 22: 817-832
• 6 Kelvin FM, Maglinte DD, Benson JT. Evacuation proctography (defecography): an aid to the investigation of pelvic floor disorders. Obstet Gynecol 1994; 83: 307-314
• 7 Whitehead WE et al. Functional disorders of the anus and rectum. Gut 1999; 45: 55-59
• 8 Bharucha AE et al. Functional anorectal disorders. Gastroenterology 2006; 130: 1510-1518
• 9 Maglinte DD et al. Functional imaging of the pelvic floor. Radiology 2011; 258: 23-39
• 10 Maglinte DD, Hale DS, Sandrasegaran K. Comparison between dynamic cystocolpoproctography and dynamic pelvic floor MRI: pros and cons: Which is the “functional” examination for anorectal and pelvic floor dysfunction. Abdom Imaging 24.03.2012; [Epub ahead of print]
• 11 Santoro GA et al. Endoluminal ultrasonography. In: Santoro GA, Wieczorek AP, Bartram CI, (eds.) Pelvic floor disorders. Milan: Springer-Verlag Italia; 2010: 389-403
• 12 Dietz HP. Translabial ultrasonography. In: Santoro GA, Wieczorek AP, Bartram CI, (eds.) Pelvic floor disorders. Milan: Springer-Verlag Italia; 2010: 405-428
• 13 Mahieu P, Pringot J, Bodart P. Defecography: II. Contribution to the diagnosis of defecation disorders. Gastrointest Radiol 1984; 9: 253-261
• 14 Mathieu PH, Pringot J, Bodart P. Defecography I: Description of a new procedure and results in normal patients. Gastrointest Radiol 1984; 9: 561-570
• 15 Fielding JR et al. MR imaging of the female pelvic floor in the supine and upright positions. J Magn Reson Imaging 1996; 6: 961-963
• 16 Lienemann A et al. Dynamic MR colpocystorectography assessing pelvic-floor descent. Eur Radiol 1997; 7: 1309-1317
• 17 Schoenenberger AW et al. Dynamic MR defecography with a superconducting, open-configuration MR system. Radiology 1998; 206: 641-646
• 18 Farouk El Sayed R. The urogynecological side of pelvic floor MRI: the clinician's needs and the radiologist's role. Abdom Imaging 01.06.2012; [Epub ahead of print]
• 19 El Sayed RF et al. Pelvic floor dysfunction: assessment with combined analysis of static and dynamic MR imaging findings. Radiology 2008; 248: 518-530
• 20 Shorvon PJ et al. Defecography in normal volunteers: results and implications. Gut 1989; 30: 1737-1749
• 21 Bump RC et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175: 10-17
• 22 Gousse AE et al. Dynamic half Fourier acquisition, single shot turbo spin-echo magnetic resonance imaging for evaluating the female pelvis. J Urol 2000; 164: 1606-1613
• 23 Comiter CV et al. Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging. Urology 1999; 54: 454-457
• 24 Fielding JR. Practical MR imaging of female pelvic floor weakness. Radiographics 2002; 22: 295-304
• 25 Singh K, Reid WM, Berger LA. Assessment and grading of pelvic organ prolapse by use of dynamic magnetic resonance imaging. Am J Obstet Gynecol 2001; 185: 71-77
• 26 Broekhuis SR et al. Dynamic magnetic resonance imaging: reliability of anatomical landmarks and reference lines used to assess pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20: 141-148
• 27 Goei R et al. Anorectal function: defecographic measurement in asymptomatic subjects. Radiology 1989; 173: 137-141
• 28 Goh V et al. Dynamic MR imaging of the pelvic floor in asymptomatic subjects. AJR Am J Roentgenol 2000; 174: 661-666
• 29 Healy JC et al. Dynamic MR imaging compared with evacuation proctography when evaluating anorectal configuration and pelvic floor movement. AJR Am J Roentgenol 1997; 169: 775-779
• 30 Bertschinger KM et al. Dynamic MR imaging of the pelvic floor performed with patient sitting in an open-magnet unit versus with patient supine in a closed-magnet unit. Radiology 2002; 223: 501-508
• 31 Mortele KJ, Fairhurst J. Dynamic MR defecography of the posterior compartment: Indications, techniques and MRI features. Eur J Radiol 2007; 61: 462-472
• 32 Kelvin FM et al. Female pelvic organ prolapse: a comparison of triphasic dynamic MR imaging and triphasic fluoroscopic cystocolpoproctography. AJR Am J Roentgenol 2000; 174: 81-88
• 33 Stoker J, Bartram CI, Halligan S. Imaging of the posterior pelvic floor. Eur Radiol 2002; 12: 779-788
• 34 Pescatori M, Quondamcarlo C. A new grading of rectal internal mucosal prolapse and its correlation with diagnosis and treatment. Int J Colorectal Dis 1999; 14: 245-249
• 35 Dvorkin LS et al. Open-magnet MR defaecography compared with evacuation proctography in the diagnosis and management of patients with rectal intussusception. Colorectal Dis 2004; 6: 45-53
• 36 Fengler SA et al. Management of recurrent rectal prolapse. Dis Colon Rectum 1997; 40: 832-834
• 37 Weber AM, Richter HE. Pelvic organ prolapse. Obstet Gynecol 2005; 106: 615-634
• 38 Kuijpers HC, Bleijenberg G. The spastic pelvic floor syndrome. A cause of constipation. Dis Colon Rectum 1985; 28: 669-672
• 39 Minguez M et al. Predictive value of the balloon expulsion test for excluding the diagnosis of pelvic floor dyssynergia in constipation. Gastroenterology 2004; 126: 57-62
• 40 Halligan S et al. Predictive value of impaired evacuation at proctography in diagnosing anismus. AJR Am J Roentgenol 2001; 177: 633-636