Résumé
Pour répondre à l’approche moderne d’une conception globale du plancher pelvien, deux principes doivent guider l’imagerie dynamique des prolapsus des quatre étages du pelvipérinée. Ce sont d’une part, la prise en compte de la compétition des différents prolapsus et d’autre part, la qualité de la poussée abdominale, ces deux principes étant d’ailleurs liés. Ceux-ci sontmis en œuvre dans les deux examens que nous réalisons en routine depuis neuf ans avec le même protocole : la colpocystodéfécographie radiologique avec clichés mictionnels et défécographiques (CCD) et l’IRM dynamique avec défécographie (IRMd). Le respect d’une technique rigoureuse garantit des résultats presque équivalents des deux examens. Les avantages de la CCD sont l’obtention de clichés mictionnels et une meilleure analyse de la pathologie anorectale (intussusception, anisme) au prix d’une irradiation et d’un examen plus invasif. Elle reste l’examen de référence. Les avantages de l’IRMd sont la visibilité permanente du compartiment péritonéal, des coupes dans les trois plans de l’espace et l’étude associée de la morphologie des organes pelviens et des moyens de soutien avec le défaut d’un examen encore actuellement en décubitus. Les résultats de ces examens paraissent toujours supérieurs à ceux de l’examen clinique souvent aléatoire pour le périnée postérieur, en particulier pour les élytrocèles, grâce à la poussée maximum obtenue lors de la défécation. Un consensus concernant les méthodes de mesure des prolapsus en imagerie est souhaitable. L’apport des données de l’imagerie, à la lumière de la plainte fonctionnelle et de l’examen clinique, peut modifier la chirurgie initialement planifiée.
Abstract
To fit the modern approach of a global concept of the pelvic floor, two principles must guide the dynamic imaging of prolapse in the four compartments of the pelvis and perineum. First, the competition between the different levels of prolapse, then the quality of the abdominal strain must be taken into account. These two principles are linked, and we apply both, using the same protocol, in the two examination protocols we have used over the last nine years: X-ray colpocystodefecography (CCD), with voiding and defecating views, and dynamic MRI defecography (MRId). Strictly adhering to the technical procedures guarantees almost equivalent results for the two types of examinations. The advantages of CCD include the availability of voiding views and better assessment of anorectal abnormalities (intussusception and anismus), at the price of radiation exposure and a more invasive procedure. It remains the gold-standard examination. The advantages of MRId include the continuous view of the peritoneal compartment, a multiplanar representation, and the associated exploration of the pelvic organs, pelvic floor musculature and other supporting structures, compensating for the lack of supine examination in most existing MR units. The scores of these two procedures are superior to physical examination, especially for the posterior compartment and the diagnosis of enteroceles, thanks to the optimal strain during defecation. We must aim for consensus regarding imaging evaluation criteria for prolapse. The benefit of imaging, given the signs and symptoms and physical examination results, can lead to changes to the surgical management of pelvic floor disorders.
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Lapray, J.F. Imagerie des prolapsus pelvipérinéaux. Pelv Perineol 2, 227–243 (2007). https://doi.org/10.1007/s11608-007-0139-8
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DOI: https://doi.org/10.1007/s11608-007-0139-8