Presentation
Patient presents with a history of long standing constipation managed with daily polythene glycol (MiraLAX), grade II haemorrhoids, and ongoing haematochezia.
Patient Data
Multiple sequences were obtained including static and dynamic images at rest, during squeeze, strain, and evacuation.
120 mL of ultrasound gel was initially instilled into the rectum. Only part of the gel was evacuated, up to 70%. Evaluation is suboptimal due to motion artifact.
Anatomical assessment at rest:
Anorectal angle: 100 degrees (normal: 90-110 degrees)
H line at rest: 4.2 cm (normal: < 5 cm)
M line at rest (extending between the pubococcygeal line and anorectal junction): 1.4 cm (normal: < 2 cm)
Thinning of the puborectalis sling on the left.
Sagging of the bladder wall posteriorly, left greater than right.
During Valsalva/evacuation:
H line during evacuation: 8.5 cm, indicating moderate enlargement of the pelvic hiatus
M line during evacuation: 6.1 cm, indicating severe descent of the hiatus
Mild cystocele, mild vaginal/lower uterine segment prolapse, and severe rectocele. The rectum descends inferiorly and anteriorly during defaecation but does not prolapse outside of the anus. The rectocele likely results in incomplete evacuation.
Descent of the small bowel into the cul-de-sac/rectovaginal space, consistent with enterocele. Associated mesenteric fat in the rectovaginal space, consistent with peritoneocele.
Case Discussion
MR defaecography provides excellent visualisation of pelvic floor dysfunctions, including measurements of the H line, M line, anorectal angle, etc. Multiple static and dynamic sequences are obtained at rest, during Kegel (squeeze), Valsava manoeuvre (strain), and defaecation 2. Cystocele, enterocele, and rectocele are forms of pelvic organ prolapse; common risk factors include normal ageing, menopause, multiparity, and obesity 3.
Following MR Defaecography, the patient underwent colonoscopy. Non-bleeding medium-sized internal haemorrhoids were found. No intervention was performed. The patient had an anal fissure which was treated with topical cream. Combined surgery is being considered for treatment of prolapse.
Case co-authors:
Sharmain Siddiqui
Sara Siddiqui
Emad Allam
Unable to process the form. Check for errors and try again.