Assessment of women with defecatory dysfunction and manual splinting using dynamic pelvic floor magnetic resonance imaging.

OBJECTIVE: This study aimed to describe magnetic resonance imaging (MRI) findings in women with defecatory dysfunction who perform manual splinting.
METHODS: This is a retrospective study of 29 patients from a single urogynecology center who presented with complaints of defecatory dysfunction and who reported manual splinting to assist with bowel movements. Patients were scheduled for an MRI study with a novel "splinting" protocol to evaluate the effects of their manual splinting on the pelvic floor. The protocol involved asking patients to splint during the MRI, as they normally would when trying to defecate. The goal was to evaluate any change in pelvic anatomy and compensation for an anatomic defect that could potentially lead to their defecatory dysfunction. Magnetic resonance images of the pelvis were obtained at rest, with pelvic floor contraction, with Valsalva, and during manual splinting. These images were then reviewed by radiologists who evaluated various parameters, including anorectal angle, levator ani muscle integrity, and the presence of rectocele, cystocele, apical prolapse, and enterocele. The external and internal anal sphincters were also evaluated for continuity.
RESULTS: From September 2008 to October 2010, 29 women reported defecatory dysfunction and the need for manual splinting. Their mean (SD) age was 55.2 (10.5) years. Magnetic resonance images showed a rectocele in 86.2% of the study group, cystocele in 75.9%, enterocele in 10.3%, and a defect of the levator ani muscles in 17.2%. Twenty-one (72.4%) women had more than 1 of these defects. In addition, 27.6% had an anorectal angle less than 90 degrees or greater than 105 degrees.Patients in the study group splinted in the vagina (58.6%), on the perineum (31.0%), or on the buttock (10.3%). In all but 1 woman (96.6%), splinting improved or completely corrected the identified defect(s) as evidenced with MRI. Among those who used vaginal splinting, 52.9% of defects were corrected and 47.1% were improved. Perineal splinting corrected 55.6% and improved 33.3% of cases and was ineffective in 11.1% of cases, whereas buttock splinting corrected 33.3% and improved 66.7% of cases.
CONCLUSIONS: Most women in our study group who used manual splinting to assist in defecation are compensating for a pelvic floor defect that can be detected on MRI. Magnetic resonance imaging of the pelvis may help elucidate the etiology of the defecatory dysfunction in some women and may assist pelvic reconstructive surgeons in planning surgical correction of pelvic floor defects. Magnetic resonance imaging may also identify defects in the pelvic floor that are, at the present time, not amenable to surgical correction.