RCR

Imaging, 13 (2001), 473–477 E 2001 The British Institute of Radiology accredited

Multiple-choice questionnaire: Functional pelvic floor

imaging

The following multiple-choice questions are based (b) Anal incontinence strictly refers to involun-
entirely on the contents of this issue of Imaging, tary stool loss.
and are accredited by the Royal College of (c) Women are most commonly affected.
Radiologists for continuing medical education. (d) Ultrasound evidence of sphincter laceration is
Photocopy and complete the reader response form strongly associated with anorectal physiologi-
on pages 476–477—answers must be received by cal deterioration.
the BIR no later than 7 June 2002. If you achieve (e) Pudendal neuropathy plays no role.
a score of 75% or above you will be awarded 1
Category One CPD Credit.
Up to 6 Credits per year may be obtained through Question 4
journal CME.
Concerning extended proctography:
Answers will be printed in Imaging 14(2), and will (a) Peritoneography is an essential component of
also be available on the BIR’s website www.bir. the examination.
org.uk following the above submission deadline. (b) The depth of a cystocoele is unaffected by the
volume of bladder contrast medium instilled.
(c) The vagina is best opacified with a tampon.
(d) The pubococcygeal line extends from the
Question 1 superior margin of the pubic symphysis to
Concerning endoanal MRI: the sacrococcygeal junction.
(a) A rectal coil can be used. (e) Cystocoele prolapse is graded as ‘‘small’’ if
(b) The length of the imaging coil should be less 3 cm below the pubococcygeal line.
than 6 cm.
(c) The internal anal sphincter returns high signal
on T2 weighted scans. Question 5
(d) The advantage of endoanal MRI over ultra-
sound is better demonstration of the internal Concerning rectocoele:
anal sphincter. (a) The degree of symptoms correlates well with
(e) External anal sphincter thickness diminishes the size of an anterior rectocoele.
with age in both men and women. (b) Emptying of a rectocoele can be assisted by
digital pressure on the perineum.
(c) Rectocoele is found in 75% of asymptomatic
women.
Question 2 (d) Incontinence is frequently associated.
Concerning obstetric sphincter damage: (e) Dynamic pelvic MRI is the gold standard for
(a) External anal sphincter rupture is usually diagnosis.
accompanied by internal anal sphincter rup-
ture.
(b) Isolated internal anal sphincter damage is Question 6
common.
(c) External anal sphincter damage occurs in 50% Concerning the female pelvic floor:
of forceps deliveries. (a) Vaginal delivery is the most common cause of
(d) Primary repair is usually adequate. anal sphincter damage.
(e) Imaging finds 10% more tears than clinical (b) The perineal body means that the anterior
examination. perineum is bulkier in women than in men.
(c) The levator ani may contract inappropriately
in constipated women.
(d) Endoanal ultrasound can differentiate bet-
Question 3 ween incontinence caused by sphincter damage
Concerning anal incontinence: and neuromuscular degeneration.
(a) 10% of the population over 45 years of age (e) Constipation due to slow colonic transit is
are anally incontinent. best evaluated by proctography.

Imaging, Volume 13 (2001) Number 6 473

 Multiple-choice questionnaire: Functional pelvic floor imaging

Question 7 (d) An endovaginal approach is possible.

(e) Interobserver and intraobserver agreement are
Regarding enterocoele: poor.
(a) Enterocoele is best detected at the end of the
examination.
(b) Incomplete bladder emptying may mask
enterocoele descent. Question 12
(c) Vaginal vault prolapse is often associated with Concerning peritoneocele:
enterocoele. (a) Peritoneography is mandatory to demonstrate
(d) Enterocoele may be treated by hysterectomy. these.
(e) Enterocoeles inhibit rectal evacuation. (b) It is defined by rectouterine excavation below
the upper 50% of the vagina.
(c) Approximately 20% contain no bowel on
Question 8 peritoneography.
(d) If present, the cul-de-sac should be closed
Regarding evacuation protography:
during reconstructive surgery.
(a) The volume of instilled rectal contrast med-
(e) It should be suspected at routine DCP if there
ium must be more than 150 ml.
is unexplained narrowing of the rectovaginal
(b) During evacuation, the puborectalis muscle
space.
contracts to open the anorectal angle.
(c) Rectal intussusception is associated with the
sensation of incomplete evacuation.
(d) Anteroposterior views may help diagnose Question 13
intussusception. Regarding dynamic pelvic MRI:
(e) Measurement of the anorectal angle is central (a) A thin anal tube should be inserted to mark
to interpretation of proctography findings. the anal canal.
(b) Urethral hypermobility tends to cause incon-
tinence.
Question 9 (c) Rectal intussusception is generally well visua-
Concerning anismus: lized.
(a) It can be reliably diagnosed on proctography (d) Anatomical MR measurements correlate well
using the anorectal angle. with those found at proctography.
(b) Impaired proctographic evacuation is strongly (e) The coronal plane is best for posterior
associated. perineal hernias.
(c) Rectocoele is commonly associated.
(d) It may be found in incontinent patients.
(e) If associated with intussusception, surgery is Question 14
indicated.
Concerning pelvic floor descent:
(a) A perineometer is more accurate than evacua-
tion proctography for assessment.
Question 10 (b) It may be diagnosed when excursion is greater
Concerning the internal anal sphincter: than 3 cm.
(a) Surgery for haemorrhoids frequently damages (c) It is most often owing to levator plate
the sphincter. laceration.
(b) It thins with age. (d) Associated rectocoele and intussusception are
(c) It enhances more with iv gadolinium than the common.
external anal sphincter does. (e) Surgery is an effective treatment.
(d) Pathology results in passive anal incontinence.
(e) It is responsible for most of the anal canal
resting pressure. Question 15
Regarding normal anal anatomy on ultrasound:
(a) On ultrasound the canal generally comprises
Question 11
four layers.
Concerning endoanal ultrasound: (b) The internal anal sphincter is a distal
(a) The left lateral position is preferred. condensation of rectal longitudinal smooth
(b) A 5 MHz probe is preferred. muscle.
(c) Examination should start with the puborec- (c) The external anal sphincter is frequently
talis. distinguished from the puborectalis.

474 Imaging, Volume 13 (2001) Number 6

Multiple-choice questionnaire: Functional pelvic floor imaging

(d) The external anal sphincter is generally (b) It is ten times more frequent in women than
hyporeflective in men. men.
(e) The longitudinal muscle is derived from (c) Gastric emptying is impaired in slow transit
puboanalis. constipation.
(d) Subjective criteria for diagnosis are prefer-
able.
Question 16 (e) Rectal configuration is relatively unimportant.
Regarding anal sepsis:
(a) Endoanal ultrasound is as effective for
evaluation as MRI is. Question 19
(b) Transsphincteric extension, if present, is usually
Regarding the choice between endoanal ultrasound
seen on endoanal ultrasound.
or endoanal MRI:
(c) The primary track is hyperreflective on endo-
(a) Endoanal MRI can be used effectively as the
anal ultrasound.
primary imaging modality for anal incon-
(d) Secondary tracks are clearly demonstrated on
tinence.
endoanal ultrasound if within the sphincter
(b) Both are comparable for external anal
complex.
sphincter defects.
(e) Supralevator extension is best demonstrated
(c) Endoanal ultrasound is the best choice when a
by MRI.
combination of atrophy and laceration are
suspected.
(d) Motion artefacts are a problem with both
Question 17
techniques.
Concerning sphincter atrophy: (e) Local expertise will determine choice.
(a) A thin internal anal sphincter at a young age
suggests atrophy.
(b) Sphincter atrophy is defined by loss of muscle
Question 20
bulk for both the external and internal anal
sphincters. Regarding genitourinary prolapse:
(c) Electromyography may be used to diagnose (a) Clinical diagnosis relies upon speculum retrac-
external anal sphincter atrophy. tion of the anterior and posterior vaginal
(d) Atrophy is an indication for external anal walls.
sphincter repair. (b) Grade 1 prolapse is defined as cervical descent
(e) External anal sphincter atrophy may be to the introitus.
diagnosed using endoanal ultrasound. (c) Grade 2 prolapse is defined as cervical descent
outside the intriotus.
(d) Grade 3 prolapse is defined by uterine descent
Question 18 outside the introitus.
(e) Grades 1–3 also include definitions of entero-
Regarding constipation:
coele.
(a) Most definitions refer solely to infrequent
defecation.

Imaging, Volume 13 (2001) Number 6 475