Anal sex mri

Added: Lor Teague - Date: 27.01.2022 00:12 - Views: 41385 - Clicks: 8417

The pelvic floor is a complex structure that supports the pelvic organs and provides resting tone and voluntary control of the urethral and anal sphincters. Dysfunction of or injury to the pelvic floor can lead to gastrointestinal, urinary, and sexual dysfunction. The prevalence of pelvic floor disorders is much lower in men than in women, and because of this, the majority of the published literature pertaining to MRI of the pelvic floor is oriented toward evaluation of the female pelvic floor.

The male pelvic floor has sex-specific differences in anatomy and pathophysiologic disorders. Despite these differences, static and dynamic MRI features of these disorders, specifically gastrointestinal disorders, are similar in both sexes.

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MRI and MR defecography can be used to evaluate anorectal disorders related to the pelvic floor. MRI can also be used after prostatectomy to help predict the risk of postsurgical incontinence, to evaluate postsurgical function by using dynamic voiding MR cystourethrography, and subsequently, to assess causes of incontinence treatment failure.

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Increased tone of the pelvic musculature in men secondary to chronic pain can lead to sexual dysfunction. This article reviews normal male pelvic floor anatomy and how it differs from the female pelvis; MRI techniques for imaging the male pelvis; and urinary, gastrointestinal, and sexual conditions related to abnormalities of pelvic floor structures in men. Online supplemental material is available for this article. Dysfunction or injury to the pelvic floor may result in debilitating disorders including pelvic organ prolapse, defecatory dysfunction, urinary incontinence, and sexual dysfunction.

Although the most important risk factor for pelvic floor dysfunction in women is pregnancy, those for men include aging, muscle atrophy, injury, obesity, surgery primarily prostatectomyradiation exposure, smoking, trauma, and conditions resulting in increased intra-abdominal pressure including chronic constipation 1. In our anecdotal experience, male patients with sexually transmitted diseases such as human immunodeficiency virus HIV infection can present with pelvic floor dysfunction, although the degree of the association is not known. The prevalence of pelvic floor dysfunction in men remains small relative to that in women 2and the majority of the literature pertaining to MRI of the pelvic floor is thus oriented toward evaluation of the pelvic floor in women.

However, anecdotal reports have suggested a recent increase in interest for imaging evaluation of pelvic floor dysfunction in men. The patient history, physical examination, and functional studies eg, urodynamics, voiding cystourethrography, and anorectal pressures evaluation are the mainstays of evaluation and are used as initial steps in assessment of most patients with pelvic floor dysfunction.

Transperineal, transrectal, transvaginal, and, on rare occasions, transurethral US is used in evaluation of pelvic floor dysfunction. MRI has been shown to have utility in identifying the causes of pelvic floor dysfunction in female patients. However, no validated guidelines exist for MRI of the pelvic floor in male patients. MRI is important in the evaluation of the male pelvis because it provides both anatomic and functional information. Dedicated high-spatial-resolution images of the pelvis allow Anal sex mri of the pelvic floor anatomy, and time-resolved imaging such as MR defecography sequences, which involve real-time imaging during active Anal sex mri evacuation, provide functional information 3.

This article provides a comprehensive review of MRI of the pelvic floor in men. We discuss normal male pelvic floor anatomy and how it differs from the female pelvis at imaging; techniques and protocols for MRI of the male pelvis; and various conditions including gastrointestinal, urinary, and sexual dysfunction related to anatomic and functional abnormalities of pelvic floor structures in men. We discuss conditions pertinent to the differential diagnosis of pelvic floor dysfunction in men, as well as postsurgical imaging of the male pelvic floor. An understanding of pelvic floor anatomy is essential for interpreting imaging examinations of the pelvic floor, particularly in male patients, given the less common Anal sex mri of these examinations at most centers.

The boundaries of the pelvic floor include the pubic bone anteriorly, the sacrum and coccyx posteriorly, and the ischial tuberosities laterally. Multiple muscles and associated fasciae support the pelvic floor and can be divided into three layers from superficial caudal to deep cranial in men: the superficial perineal pouch, the urogenital diaphragm, and the pelvic diaphragm 45. The pelvic floor anatomic structures are illustrated in Figures 1 — 3 and depicted on MR images in Figure 4.

Figure 1. Illustration shows the inferior view of the male pelvic floor and the muscles and fascia that form the superficial perineal pouch and the urogenital diaphragm. Figure 2. Illustration shows the superior view of the male pelvic floor and the muscles and fascia that form the pelvic diaphragm. Figure 3. Illustration shows a sagittal view of the male pelvis and the relationship of the pelvic organs, musculature, and some of the fasciae that form the male pelvic floor. Figure 4a.

MRI anatomy of the male pelvis and pelvic floor in multiple patients aged 50 years or older. This is enclosed in the fascia of the urogenital diaphragm.

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Note the extension of the proximal external sphincter and the proximal membranous urethra into the prostatic apex. Figure 4b. Figure 4c. Figure 4d. Figure 4e. Figure 4f. Figure 4g. The superficial perineal pouch consists of the bulbospongiosus, ischiocavernosus, and superficial transverse perinei muscles Fig 1. These muscles help to maintain urinary continence and are important for penile rigidity during erection and ejaculation. Superficial transverse perineal muscles provide support to pelvic and perineal structures, because simultaneous contraction of these paired muscles serves to stabilize the Anal sex mri body and fix the central tendinous portion of the perineum.

These muscles are vulnerable to traumatic injury related to pelvic fractures and iatrogenic trauma due to surgery. Figure 5a shows the thickened appearance of the superficial transverse perineal muscle on the right and atrophy on the left. The normal appearance of the superficial transverse perineal muscle is also depicted Fig 5b. Figure 5a. These findings are likely due to surgical and radiation changes after prostatectomy for prostate cancer.

Figure 5b. The urogenital diaphragm, sometimes referred to as the perineal membrane, consists of the deep transverse perinei, the sphincter urethrae, and the compressor urethrae muscles Anal sex mri well as a muscular membrane Figs 24 that separates the superficial perineal pouch from the upper pelvis. It assists with urethral closure when there is increased intra-abdominal pressure and has fascial connections to the deep abdominal musculature, which help to stabilize the pelvis including the external genitalia during movement.

The perineal body is an ill-defined structure of connective tissue located in the midline along the posterior border of the urogenital diaphragm and serves as an anchor point where multiple muscles of the pelvic floor and the perineum attach Fig 1including fibers from the external anal sphincter, the external urethral sphincter, the superficial and deep transverse perineal muscles, the bulbospongiosus, and the anterior fibers of the levator ani.

In men, the membranous urethra and deep dorsal vein of the penis traverse the urogenital diaphragm by means of two separate apertures Figs 26.

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Abnormalities of the deep dorsal vein of the penis are rare; however, superficial dorsal vein thrombosis or thrombophlebitis also known as penile Mondor disease can be seen in patients who also have cancer, trauma, sexually transmitted diseases, iatrogenic injury, or intracavernous injections Fig 6. Figure 6. Thrombus in the dorsal vein of the penis in a year-old man with rectal cancer. Sagittal T2-weighted non—fat-saturated MR image shows an incidental thrombus causing loss of normal flow void in and proximal irregular dilatation of the dorsal vein of the penis arrowhead that subsequently resolved without anticoagulative therapy and was not seen at MRI performed 5 months later not shown.

Also note the urethra on the sagittal image, which is composed of four parts: the preprostatic 1prostatic 2membranous 3and spongy or penile 4 urethra. The length of the membranous urethra has been shown to be correlated with continence after prostatectomy. Patients with a longer membranous urethra have a higher chance of achieving continence in the 1st year after intervention.

The pelvic diaphragm extends from the dorsal aspect of the pubic symphysis to the coccyx and from the interior surface of one ilium to the other and is formed mainly by the pubococcygeus-puborectalis complex and iliococcygeus Anal sex mri Figs 24c. The anorectal hiatus is the only opening in the pelvic diaphragm.

The iliococcygeus muscle arises from the external anal sphincter and fans out laterally to insert onto the pelvic sidewall at the tendinous arch. The pubococcygeus arises from the pubic bone and fans out laterally to insert at the pelvic sidewall on the tendinous arch 6.

The posterior condensation of the iliococcygeus and pubococcygeus muscles forms a firm midline raphe known as the levator plate 7.

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The puborectalis forms a U-shaped sling around the rectum. It inserts anteriorly on the pubic symphysis on either side of midline, passing laterally to the anorectum and urethra. The puborectalis is instrumental in maintaining urinary continence, which is achieved by elevating the bladder neck and compressing it against the pubic symphysis. The puborectalis is also responsible for controlling the anorectal angle, thereby maintaining anal continence when it is contracted and allowing for bowel evacuation when relaxed.

Paradoxical contraction or deficient relaxation of the puborectalis is seen in patients with pelvic floor dyssynergia. The anorectal junction is the point where the distal rectum tapers to meet the anal canal and is demarcated by the Anal sex mri impression of the puborectalis muscle.

Together, the iliococcygeus, pubococcygeus, and puborectalis are known as the levator ani and serve to elevate the anal sphincter during contraction. Normal and abnormal appearances of the iliococcygeus muscles are depicted in Figure 7. The obturator internus, while not officially part of the pelvic floor musculature, contributes to the support of the pelvic organs. Contraction of the obturator internus shortens and elevates the pelvic floor, because it originates from the arcus tendinous levator ani, which is a fascial component of the pelvic floor. Figure 7a.

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Different appearances of the iliococcygeus muscles in two men. Figure 7b. The pelvic floor fascia in men lines the walls and floor of the pelvis 8. It is made of the endopelvic fascia ie, extension of the transversalis fascia that covers the pelvic musculaturevisceral pelvic fascia, and the Denonvillier fasciawhich is otherwise known as the rectovesical septum the layer of fascia between the prostate and the rectum that adheres to the prostate posteriorly.

The primary function of the Anal sex mri fascia is to form an important barrier to the spread of malignant and nonmalignant diseases between the perirectal and periprostatic spaces. Transperineal injection of a spacer between the rectum and the prostate gland is contained by the Denonvillier fascia and can be used to separate the rectal wall from the prostate gland to minimize rectal toxicity during prostate radiation therapy Fig 8a. If the injection needle traverses the Denonvillier fascia, it can lead to inadvertent spacer injection in the rectal wall or into the periprostatic vessels Fig 8b.

In addition to being an anatomic distinction between the prostatic compartment and the perirectal space, the Denonvillier fascia provides some structural support to the male pelvic floor 9.

Anal sex mri

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