Reginelli et al.

BMC Surgery 2013, 13(Suppl 2):S53

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RESEARCH ARTICLE Open Access

Role of conventional radiology and MRi

defecography of pelvic floor hernias
Alfonso Reginelli1*, Graziella Di Grezia1, Gianluca Gatta1, Francesca Iacobellis1, Claudia Rossi1, Melchiore Giganti2,
Francesco Coppolino3, Luca Brunese4
From 26th National Congress of the Italian Society of Geriatric Surgery
Naples, Italy. 19-22 June 2013

Abstract
Background: Purpose of the study is to define the role of conventional radiology and MRI in the evaluation of
pelvic floor hernias in female pelvic floor disorders.
Methods: A MEDLINE and PubMed search was performed for journals before March 2013 with MeSH major terms
MR Defecography and pelvic floor hernias.
Results: The prevalence of pelvic floor hernias at conventional radiology was higher if compared with that at MRI.
Concerning the hernia content, there were significantly more enteroceles and sigmoidoceles on conventional
radiology than on MRI, whereas, in relation to the hernia development modalities, the prevalence of elytroceles,
edroceles, and Douglas hernias at conventional radiology was significantly higher than that at MRI.
Conclusions: MRI shows lower sensitivity than conventional radiology in the detection of pelvic floor hernias
development. The less-invasive MRI may have a role in a better evaluation of the entire pelvic anatomy and pelvic
organ interaction especially in patients with multicompartmental defects, planned for surgery.

Introduction the pelvic examination alone has led to the need to use
Pelvic floor disorders represent a significant cause of more direct and comprehensive diagnostic methods [3-6].
morbidity and reduction in quality of life that appear to Purpose of the study is to define the role of conven-
be increasing in frequency during the last few years [1]. tional radiology and MRI in the evaluation of pelvic floor
Pregnancy, multiparity, advanced age, menopause, obe- hernias.
sity, connective tissue disorders, smoking, chronic
obstructive pulmonary disease, are only some of the risk Materials and methods
factors that can rise intra abdominal pressure and cause Subjects
these disorders [2]. A MEDLINE and PubMed search was performed for
Pelvic floor disorders may be associated, with an inci- journals before March 2013 with MeSH major terms MR
dence ranging from 18% to 45%, to the so-called midline Defecography and pelvic floor hernias. Non-English
pelvic floor sagittal hernias (MPH) that represent the speaking literature was excluded.
herniation of the peritoneum and/or peritoneal viscera
in the Douglas, Retzius, and retrorectal spaces. Methods
Although anamnestic and physical examination repre- Conventional radiology
sents the first approach in the evaluation of the patients Entero-colpo-cysto-defecography (ECCD) is considered
with pelvic floor dysfunction, the diagnostic limitation of the gold standard for the evaluation of the patients with
pelvic floor disorders and diagnosis of MPH [7-9]. For this
* Correspondence: [email protected] exam no bowel preparation [10-13]. To obtain small-
1
Department of Internal and Experimental Medicine, Magrassi-Lanzara, bowel contrast, 1 h before the exam, 200 mL of barium
Institute of Radiology, Second University of Naples, Naples, Italy
Full list of author information is available at the end of the article sulfate 60% p/v is administered to each patient. Through a

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catheter inserted in the bladder, 400 cc of iodine contrast According to Yangs classification [7], the limits of
medium (Ultravist, Bayer Schering Pharma, Berlin, normal descent with maximal strain are 1.0 cm below
Germany) is injected until the patient felt a sensation of the PCL for the bladder base, 1.0 cm above for the vagi-
fullness. The patient is placed in the left lateral decubitus nal cuff or lower end of the cervix, and 2.5 cm below
position, after which 200 cc of barium paste (Prontobario for the rectal area.
Esofago 113%, barium paste, Bracco, Milan, Italy) was Pelvic floor hernia classification
introduced into the rectum. During injector removal, the Rectocele could be defined as an out-pouching of the
anal canal is also contrasted. Vagina is contrasted with 25 anterior rectal wall occurring during evacuation or
ml of barium paste. The fluoroscopic table is then tilted straining [15-17] (Figure 1a-b).
upright 90, and the patient is seated on a radiolucent Pelvic floor hernias could be classified, basing on the
commode. An anteroposterior radiograph is taken with content, into enterocele, omentocele, and sigmoidocele,
the patient at rest; after that, five lateral radiographs are whereas, according to the hernia development they
taken at rest, during squeezing, pushing, evacuation, and could be classified as elytrocele, edrocele, retrorectal,
after evacuation (Table 1). and Douglas and Retzius hernias [6] (Figure 2a-b).
Dynamic MR defecography Enterocele, sigmoidocele, and omentocele represent
MRI Defecography should be performed on 1.5-T closed the herniation below the proximal (apical) one third of
magnet using a body-phased-array receiver coil. To the vagina of the peritoneal sac containing ileal loops,
ensure an adequate bladder filling, all patients are invited part of the sigmoid, or peritoneal fat, respectively
to drink 500-700 ml of water 10-15 min before the exam- [18-21]. If the small bowel, the peritoneal fat, or the sig-
ination. The rectum and vagina should be filled with 200 moid colon entered the Retzius or Douglas space, they
mL and about 25-30 mL [14], respectively, of a mixture are identified as Retzius and Douglas hernias, respec-
of ultrasonographic gel (Ultragel, G.P.S., Bologna, Italy) tively; if they entered the vaginal fornix posteriorly,
and gadolinium-diethylenetriamine pentaacetic acid [3] causing a complete eversion of the vaginal wall, an ely-
(Table 1). The study protocol includes TSE T2-W axial trocele is recognized (posterior vaginal hernia) [21,22]
(matrix, 181x256; slices, 25; thickness, 5 mm; TR/TE, (Figure 3). In the same way, if they enter the rectum
6,430/114; flip angle, 180), TSE T1-W sagittal (matrix, anteriorly, leading to a rectal wall eversion, an edrocele
181x256; slices, 25; thickness, 5 mm; TR/TE, 846/11; is detected [3,23-25] (Table 3)
flip angle, 150) sequences, and functional dynamic Conventional radiology diagnosis
sequences TRUFISP T2-W sagittal, during squeezing, On evaluation of conventional radiology, the diagnosis
pushing, and evacuation (matrix, 181x256; slices, 1; thick- of an enterocele/ sigmoidocele/omentocele is made if
ness, 8 mm; TR/TE, 3.75/ 1.6; flip angle, 80) (Table 2). the picture obtained during evacuation compared with
The MR-D images so obtained then are assembled in that during rest showed an increase in the distance
cineview in postprocessing. Examination time took about between the vagina and rectum (Figure 4).
30 min to complete. This expansion should extend below the PCL reference
Image analysis line and shows a sagittal diameter of more than 2 cm.
The reference line used for conventional radiology and Anyway, the distinction between sigmoidocele, entero-
MRI is the Pubococcygeal line (PCL), extending from cele, and omentocele is made basing on the presence of
the most inferior portion of the symphysis pubis to the contrasted small bowel in the expanded recto-vaginal
tangent of the sacrococcygeal joint. space for the enterocele, on the presence of distinguish-
The diagnosis of descent of the bladder, vagina, and able bowel gas bubbles without contrast for the sigmoi-
rectum is based on measurement of the vertical docele alone, and on the absence of contrasted small
distance between the PCL and the bladder base, the bowel and bowel gas bubbles in the expanded recto-
vaginal vault, and the anorectal junction, respectively. vaginal space, for the omentocele.[26-28]

Table 1 Conventional Radiology and MRI Defecography technique

Conventional Radiology MRI Defecography
Bladder 400 cc of iodine contrast medium 500-700 mL of water per os 10-15 min before
Vagina 25 ml of barium paste 25-30 mL of
gadolinium-diethylenetriamine pentaacetic acid
Rectum 200 cc of barium paste 200 mL of a mixture of ultrasonographic gel
Acquisition AP at rest, during squeezing, pushing, evacuation and after evacuation TSE T2 ax, TSE T1 sag, TRUEFISP T2 sag during squeezing,
pushing, evacuation
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Table 2 MRI defecography protocol of previous pelvic surgery in the genesis of MPH [24]. The
TSE T2 TSE T1 TRUEFISP T2 most frequent hernia is enterocele (70%), followed by sig-
ax sag sag* moidocele (21%), and omentocele (9%). On the other
Matrix 181x256 181x256 181x256 hand, the most frequent hernia development modality is
Slices 25 25 1 in Douglas space (78.9%), whereas the Retzius and retro-
Thickness 5 mm 5 mm 8 mm rectal hernias represent only occasional findings. The
TR/TE 6.430/114 846/11 3.75/1.6 development of the hernias in the posterior vaginal wall or
FA 180 150 80
in the anterior rectal wall is observed in 9% and 12% of
cases, respectively. Despite their low prevalence, their
detection is important in the planning of the correct thera-
Mri defecography diagnosis peutic approach. Conventional radiology is currently
On MRI-defecography, the relationship between the considered as the gold standard [5,7,8], because is a cost-
lowest point of the peritoneal border line and the PCL effective procedure, simple to perform, and widely avail-
should be assessed. A descent of parts of the peritoneal able [19]; however, it is an invasive procedure, especially if
content below this line and the identification of her- it is performed with four contrast that uses ionizing radia-
niated contents allowed the distinction in enterocele, tion and visualizes only the lumen of the opacified organs.
sigmoidocele, and omentocele [8]. The hernias detect- MRI Defecography was first described by Yang et al. in
able only during pushing and evacuation are considered 1991 [7,31], is a less-invasive imaging modality that allows
as functional hernias. a multiplanar and multiparametric evaluation of the three
pelvic compartments, also visualizing soft tissue, in a single
Results and discussion procedure without exposure to ionizing radiation. After
In our experience, the specificity of MRI versus conven- this, several studies were performed to compare the diag-
tional radiology is of a 100%; the sensibility of MR-D in nostic efficacy of dynamic MRI defecography versus that
the detection of an omentocele, sigmoidocele, and entero- of conventional radiology in a patient with pelvic floor dis-
cele is, respectively, 95%, 82%, and 65%, showing an infer- orders, with variable results [ 5, 8, 18, 20, 32-34]. In our
ior diagnostic capacity if compared with conventional experience, conventional radiology has higher sensitivity in
radiology [29,30]. The prevalence of MPH ranged from detecting both the content and the developmnet of pelvic
38% among all the enrolled patients to 51% in the patients floor hernias if compared with dynamic MRI Defecogra-
reporting previous hysterectomy. These data are in agree- phy. However, the prevalence of enterocele, sigmoidocele,
ment with the available literature and emphasize the role edrocele, elytrocele, and Douglas hernias at conventional

Figure 1 (a) Rectocele at ECCD defined as an out-pouching of the anterior rectal wall occurring during evacuation or straining,
correctly identified also at MR-Defecography(b).
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Figure 2 (a) Enterocele at ECCD: correctly identified also at MR-Defecography(b).

Figure 3 Omentocele at MR-Defecography: the MR-Defecography clarifies the hernia content as a omentocele.
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Table 3 Classification of pelvic floor hernias [37-40]. The lower sensitivity of MRI Defecography in the
Content Enterocele detection of pelvic floor hernias may be related to the
Omentocele supine position of the patients [41] and defecation also
Sigmoidocele
plays a role by ensuring that intra-abdominal pressure is
Development Elytrocele (posterior vaginal hernia) adequately elevated. A solution on MRI defecography is to
Edrocele (anterior rectal hernia)
Retrorectal repeatedly encourage patients to strain maximally or to
Douglas hernia monitor intra-abdominal pressure [20].
Retzius hernia

Conclusion
radiology is significantly higher than at MRI Defecography. In conclusion, MRI defecography shows lower sensitivity
These findings, in accordance with other authors [5,20], than coventional radiology in the detection of pelvic
emphasize the role of conventional radiology in the diagno- floor hernias. The diagnostic efficacy of conventional
sis of pelvic floor hernias in female pelvic floor disorders, radiology is significantly higher than that of MRI Defe-
whereas MRI defecography could be more useful to clarify cography in the detection of both hernia content (enter-
the intra-pelvic interaction of multiple organ prolapse [33] oceles and sigmoidoceles) and hernia development
and to better define the pelvic anatomy and functioning in (Douglas hernia, elytroceles, and edroceles).
patients planned for surgery [34,35]. Moreover, MRI defe- However, the less-invasive MRi defecpgraphy may
cography is a safe, noninvasive exam and free from ionizing have a role in a better evaluation of the entire pelvic
radiation[32,36] that is able to correctly define the large anatomy and pelvic organ interaction especially in
bowel loop content of a retrorectal hernia, previously mis- patients with multicompartmental defects, planned for
diagnosed as an enterocele at coventional radiology surgery [42].

Figure 4 Elytroceles and Edrocele at ECCD: the small bowel loops enter the vaginal fornix posteriorly with an eversion of the vaginal
posterior wall. And the rectum with an eversion of the rectal anterior wall.
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doi:10.1186/1471-2482-13-S2-S53
Cite this article as: Reginelli et al.: Role of conventional radiology and
MRi defecography of pelvic floor hernias. BMC Surgery 2013
13(Suppl 2):S53.

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