Misdiagnosing prolapse, particularly enteroceles, is possible. The NIH supports the use of radiologic studies to better evaluate prolapse and outcomes of prolapse repair. Dynamic MR and dynamic cystocarpopractogram complement physical exam and may alter surgical management. There is a clear advantage in prolapse evaluation with dynamic studies compared to static images. The objective of this video is to demonstrate our technique of performing a dynamic cystocarpopractogram or DCP. The triphasic technique has evolved over more than 20 years and involves evaluation of prolapse at rest during the defecatory sequence and after sequential bowel and bladder emptying. Competition for limited space in the libator hiatus among the bladder, small bowel and rectum make it important to evaluate prolapse with sequential bowel and bladder emptying. Prior to performing the study, the small bowel is opacified with oral contrast. The bladder is opacified using a 5-fringe feeding tube with 50 cc of 5-pamadol injection. Using a 24-fringe Foley catheter, the vagina is opacified with a mixture of barium sulfate cream and liquid barium sulfate. Using a 24-fringe Foley catheter, the rectum is opacified with 60 cc of liquid barium sulfate. 120 cc of barium sulfate paste is also injected using an enema tip in order to mimic stool consistency in the distal rectum. This image shows all the instruments needed to perform the DCP. The patient is then seated on a commode in the fluoroscopy suite. It is important to identify the anatomic structures before performing the DCP. This is a sagittal view of a patient seated on the DCP commode. The vagina and the bladder are easily identified. The catheter placed in the bladder and the urethrovascular junction are identified. The area with contrast coming out of the vagina corresponds to the vaginal introitus. The bowel structures that are identified include the small bowel, sigmoid colon, and the rectum. The anal canal and the anorectal junction are also identified. During phase 1 of the DCP, the patient is asked to perform rest, squeeze, and strain maneuvers to evaluate prolapse and pelvic floor muscle function. The anorectal angle is demonstrated here in red. Elevation of the anorectum as seen in yellow demonstrates good pelvic floor muscle function. At this point, prolapse is evaluated by asking the patient to bear down. During phase 2, the patient is asked to defecate. This permits maximum levator ani relaxation and demonstrates maximum extent of prolapse. Prolapse into the rectovaginal space is often underdiagnosed during physical exam. This is a patient with a chronic history of pelvic pressure and rectal fullness. A DCP was obtained as the physical exam was not compatible with her complaints. When asked to bear down, no significant prolapse is seen. The rectum filled with contrast gives the rectovaginal space a normal appearance. The defecatory sequence, however, shows a large enterocele filling up the rectovaginal space causing the contrast to be expelled from the vagina. Note the widening of the rectovaginal space caused by the enterocele. This is a comparison of the straining images during phase 1 and the images obtained at the end of phase 2. It demonstrates that the dynamic sequence is superior to static images in evaluating prolapse. This is another patient where the DCP helps in evaluating rectal prolapse that was not seen on physical exam. This straining image shows a rectocele. The rectocele and the rectal contents are blocking the descent of an enterocele that is going to be demonstrated in the defecatory sequence. A frozen image from the defecatory sequence demonstrates the invagination of rectum and development of rectal prolapse represented by the red V. A large rectal prolapse with associated enterocele into the rectovaginal space is demonstrated. A comparison of the phase 1 strain image and image obtained from the end of phase 2 is again shown. The strain image only shows a rectocele and is clearly inferior to the defecatory sequence in evaluating prolapse. Similar to the rectovaginal space, the retrorectal space can also be difficult to evaluate during physical exam. Prolapse into the retrorectal space has not been well described in the urogynecologic or colorectal literature. This is a patient with a chronic history of rectal fullness and difficulty with bowel movements whose physical exam was normal. The straining image on DCP was also normal. The defecatory sequence, however, shows a large sigmoidoscele posterior to the rectum in the retrorectal space. This is another patient where the DCP helps in evaluating rectal prolapse that was not seen on physical exam. A large rectal prolapse with an associated enterocele in the retrorectal space is seen. Another condition that can be difficult to evaluate on physical exam is pelvic floor dyssynergia or an isthmus. Radiologically, this is diagnosed by an inability to evacuate two-thirds of rectal contents in 30 seconds. This criteria has a 90% positive predictive value. This is a patient with a chronic history of constipation. A defecatory sequence is attempted and repetitive contractions of the pelvic floor muscles is seen. After 30 seconds of trying to evacuate, more than two-thirds of contents are retained in the rectum. This is suggestive of an isthmus. The final phase of the triphasic technique involves evaluation of prolapse after bowel and bladder emptying. This is performed in order to unmask prolapse that could be obscured by the bladder or rectum. Although bladder emptying is performed on everybody, additional steps to evacuate the rectum is not necessary in patients who are able to empty the rectum satisfactorily during phase 2 of the DCP. This patient has a large contrast retaining rectocele at the end of the defecatory sequence. Note the relatively normal appearing rectovaginal space represented by the double-headed arrow. The patient was allowed to perform the maneuvers required to evacuate her rectum and prolapse was re-evaluated. A large endurocele is seen in the rectovaginal space. A comparison of images from the end of phase 2 and phase 3 are shown. If a large rectocele requires the patient to digitate in order to empty her rectal contents, she should be allowed to perform this and prolapse should be re-evaluated. This is another patient who had a DCP performed because of a chronic history of pelvic pressure with bowel movements. The defecation and the post-defecation images were normal. Note the full bladder and the normal appearing rectovaginal space represented by the double-headed arrow at the end of the defecatory sequence. After the bladder is emptied, this space is filled by a large endurocele. Also note the widening of the rectovaginal space caused by the endurocele. Comparison of post-defecation images with and without bladder emptying are shown. This demonstrates the importance of sequential organ emptying. Defecations can be under-diagnosed if both bowel and bladder are not emptied sequentially. The DCP takes approximately 45 minutes to perform. It is relatively inexpensive and involves minimum amount of radiation exposure. In summary, a DCP should include evaluation of pelvic floor muscle function and evaluation of prolapse at rest during the defecatory sequence and evaluation after sequential organ emptying. The defecatory sequence permits maximum levator ani relaxation which is beyond the scope of physical exam. This can be particularly useful in evaluating patients with defecatory dysfunction and evaluating patients whose physical exam is not compatible with their complaints. Evaluation after sequential organ emptying compensates for competition for pelvic space among the pelvic organs. Although the DCP does not provide the anatomic detail that an MRI does, it provides excellent clinical information. It is relatively inexpensive and performed in a physiologic position. The limitation of physical exam in evaluating prolapse, especially into the rectovaginal and retrorectal space should be considered and radiologic imaging should be reserved for patients when physical exam is not compatible with their complaints.

dynamic radiologic studies

dynamic cystocarpopractogram

prolapse evaluation

surgical management

sequential organ emptying