Dynamic pelvic magnetic resonance imaging and cystocolpoproctography alter surgical management of pelvic floor disorders

PURPOSE: Pelvic organ prolapse results in a spectrum of progressively disabling disorders. Despite attempts to standardize the clinical examination, a variety of imaging techniques are used. The purpose of this study was to evaluate dynamic pelvic magnetic resonance imaging and dynamic cystocolpoproctography in the surgical management of females with complex pelvic floor disorders. METHODS: Twenty-two patients were identified from The Johns Hopkins Pelvic Floor Disorders Center database who had symptoms of complex pelvic organ prolapse and underwent dynamic magnetic resonance, dynamic cystocolpoproctography, and subsequent multidisciplinary review and operative repair. RESULTS: The mean age of the study group was 58 ± 13 years, and all patients were Caucasian. Constipation (95.5 percent), urinary incontinence (77.3 percent), complaints of incomplete fecal evacuation (59.1 percent), and bulging vaginal tissues (54.4 percent) were the most common complaints on presentation. All patients had multiple complaints with a median number of 4 symptoms (range, 2-8). Physical examination, dynamic magnetic resonance imaging, and dynamic cystocolpoproctography were concordant for rectocele, enterocele, cystocele, and perineal descent in only 41 percent of patients. Dynamic imaging lead to changes in the initial operative plan in 41 percent of patients. Dynamic magnetic resonance was the only modality that identified levator ani hernias. Dynamic cystocolpoproctography identified sigmoidoceles and internal rectal prolapse more often than physical examination or dynamic magnetic resonance. CONCLUSIONS: Levator ani hernias are often missed by physical examination and traditional fluoroscopic imaging. Dynamic magnetic resonance and cystocolpoproctography are complementary studies to the physical examination that may alter the surgical management of females with complex pelvic floor disorders.