pdf

MR Imaging in the pelvic organ prolapse
Poster No.:
C-2043
Congress:
ECR 2013
Type:
Educational Exhibit
Authors:
H. Fujisawa, T. Kushihashi, M. Tonouchi, M. Shimada, K.
Watanabe, M. Tanisaka; Kanagawa/JP
Keywords:
Education, MR, Pelvis, Pelvic floor dysfuntion
DOI:
10.1594/ecr2013/C-2043
Any information contained in this pdf file is automatically generated from digital material
submitted to EPOS by third parties in the form of scientific presentations. References
to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in
any way constitute or imply ECR's endorsement, sponsorship or recommendation of the
third party, information, product or service. ECR is not responsible for the content of
these pages and does not make any representations regarding the content or accuracy
of material in this file.
As per copyright regulations, any unauthorised use of the material or parts thereof as
well as commercial reproduction or multiple distribution by any traditional or electronically
based reproduction/publication method ist strictly prohibited.
You agree to defend, indemnify, and hold ECR harmless from and against any and all
claims, damages, costs, and expenses, including attorneys' fees, arising from or related
to your use of these pages.
Please note: Links to movies, ppt slideshows and any other multimedia files are not
available in the pdf version of presentations.
www.myESR.org
Page 1 of 24
Learning objectives
•
•
•
To review the pathophysiologyof pelvic organ prolapse (POP).
To show the normal MR imaging in female for understand POP.
To explain the utility of MRI; key points and how to read from MR imaging in
the diagnosis of POP.
Background
•
•
•
#POP is a common problem that increases with age and is often associated
with urinary incontinence and often significantly affect on quality of life,
especially in women.
#POP occurs when the ligaments, muscles, and nerves that support the
pelvic organs spoil a support function. Damage to a levator ani muscle in
many cases, deliveries are most causes and aging is also a risk factor.
# Diagnosis of the POP is made primarily on the basis of findings at split
speculum pelvic examination. Recently, MRI has become to be used
increasingly to assess POP. It is important for radiologists to understand
familiarity with normal imaging findings and features of pathologic
conditions.
Images for this section:
Page 2 of 24
Fig. 1: Cystocele
Page 3 of 24
Imaging findings OR Procedure details
1.
Key points in the pelvic floor anatomy on MRI in POP (Fig. 2-6)
•
Identification for the lavator ani (poborectaris, pubococcygeus, and
iliococcygeus) muscles and with/ without looseness
#Identification for the ischial spine and sacrospinous ligament
#Identification for the urethral ligaments with/ without tear
#Identification for the external anal sphincter muscles with/ without tear
#Identification for the obturator foramen and the obturator vessels with/
without abnormal lesions including tumor, obturator hernia, abnormal
vessels and so on.
•
•
•
•
2. TVM (tension-free vaginal mesh) procedure for POP (Fig. 8,9)
•
•
•
•
•
#Minimally invasive surgery using mesh
#Support the entire pelvic floor in the shape of a hammock by mesh
#Puncture to obturator foramen for anterior mesh insertion
#Penetrate to sacrospinous ligamentfor posterior mesh insertion
#For blind punctures, checking the presence of anatomical abnormalities on
MRI prior to TVM procedure is important.
3. Example MR protocol for patients with POP
•
•
•
#FSE (TSE) T2WI Axial: #Slice thickness #6mm
#FSE (TSE) T2WI Coronal
#FSE (TSE) T2WI Sagittal
#cine Dynamic Sagittal
•
HASTE, SSFSE, trueFISP :# Temporal resolution 1-2sec, Slice thickness
6-10mm
4. Diagnostic MR reference lines
•
•
•
•
PCL: between lower symphysis pubis and last mobile coccygeal joint (site of
insertion of levator plate)
H line: between lower symphysis pubis and puborectalis insertion on rectum
M line: perpendicular line between H line and PCL, at insertion of H line to
rectum
MPL# a line extending caudally along the long axis of symphysis pubis
5. Grading of POP (Table 1,2)
Page 4 of 24
6. Case presentation (fig. 10-18 )
Images for this section:
Fig. 2: Atlas of normal female pevic floor MRI anatomy: axial 1
Page 5 of 24
Fig. 3: Atlas of normal female pevic floor MRI anatomy: axial 2
Page 6 of 24
Fig. 4: Atlas of normal female pevic floor MRI anatomy: axial 3
Page 7 of 24
Fig. 5: Atlas of normal female pevic floor MRI anatomy: coronal
Page 8 of 24
Fig. 6: Atlas of normal female pevic floor MRI anatomy: coronal and sagittal
Page 9 of 24
Fig. 7: Atlas of normal female pevic floor MRI anatomy: sagittal 2
Fig. 8: Illust for TVM procedure and important anatomical structures for POP.
Page 10 of 24
Fig. 9: TVM (tension-free vaginal mesh) procedure for POP (A,B):Blind puncture to
obturator foramen for anterior mesh insertion. (C):#Blind puncture and penetrate to
sacrospinous ligamentfor posterior mesh insertion.
Page 11 of 24
Table 1: Grading of Pelvic Floor Relaxation
Page 12 of 24
Table 2: MRI staging for PCL and MPL reference line
Page 13 of 24
Fig. 10: Case 1. CYSTOCELE/ VAGINOCELE/ RECTOCELE: MR reference lines. M
line 2.0cm H line 6.2cm Bladder base-PCL > 6cm Bladder base-MPL: eversion
Page 14 of 24
Fig. 11: Case 2. CYSTOCELE/ VABGINOCELE/ RECTOCELE associated with ovarian
mature cystic teratoma (arrow)
Page 15 of 24
Fig. 12: Case 2. CYSTOCELE/ VABGINOCELE/ RECTOCELE associated with ovarian
mature cystic teratoma: MR reference lines. M line 2.8cm H line 8.0cm Bladder basePCL 9.8cm Bladder base-MPL: eversion
Page 16 of 24
Fig. 13: Case 2. MR axial image at the level of pelvic floor. Axila T2WI shows dissection
in the pubouretheral ligament (green arrow) and periurethral ligament(blue allow). A
puborectal muscle thinning and ballooning are also seen(orange allows).
Page 17 of 24
Fig. 14: Case 2. MR coronal image. Coronal T2WI shows a puborectal muscle descend
(arrows).
Page 18 of 24
Fig. 15: Case 3. RECTOCELE: MR reference lines. M line 2.5cm H line 6.0cm Anterior
inferior anorectal junction-PCL 3.4cm Anterior inferior anorectal junction-MPL 1.0cm
Page 19 of 24
Fig. 16: Case 3. RECTOCELE: coronal image Left levator ani muscle(arrow) is thin.
Page 20 of 24
Fig. 17: Case 4. CYSTOCELE: axial image at the level of pelvic floor. Asymmetric
shape on the puborectal muscles. Ballooning on the right puborectal muscle (large arrow)
Dissection on the periurethral ligament (blue arrow)
Page 21 of 24
Fig. 18: Cine dynamic MRI clearly demonstrate a cystocele at the increasing abdominal
pressure.
Page 22 of 24
Conclusion
1. To understand the normal MRI anatomy in female pelvis is important for aware of the
pathophysiology in POP.
2. To know the surgical procedure in POP is notable for present a suitable MRI diagnosis
in preoperative information
3. Various reference lines in MRI are used in the diagnosis for POP staging
4. MRI is useful for a diagnosis in various associated diseases with POP at preoperative
estimation.
5. Dynamic cine MRI is easily able to recognize in POP.
References
•
•
•
•
•
•
•
•
•
# N.A Yang, J L Mostwin, N B Rosenshein, et al.; Pelvic floor descent in
women: dynamic evaluation with fast MR imaging and cinematic display.
Radiology 1991: 179: 25-33
# G. Bennett, E. Hecht, T. Tanpitukponge, et al.; MRI of the urethra in
women with lower urinary tract symptoms: spectrum of findings at static and
dynamic imaging. AJR 2009: 193:1708-15
# L. Boyadzhyan, S. Raman, S.Raz; Role of static and dynamic MR imaging
in surgical pelvic floor dysfunction. Radiographics 2008: 28: 949-67
# M. Colaiacomo, G. Masselli, E. Polettini, et al.; Dynamic MR imaging of the
pelvic floor: a pictorial review. Radiographics 2009: 29: e35
# R. el-Sayed, M.Morsy, S.el-Mashed, et al.; Anatomy of the urethral
supporting ligaments defined by dissection, histology, and MRI of female
cadavers and MRI of healthy nulliparous women. AJR 2007: 189: 1145-57
# E. Hecht, V. Lee, T. Tanpitukpongse, et al.; MRI of pelvic floor dysfunction:
dynamic true fast imaging with steady-state precession versus HASTE. AJR
2008: 191: 352-8
# L. Hoyte, M. Damaser, Magnetic resonance-based female pelvic anatomy
as relevant for maternal childbirth injury simulations. Annals of the New York
Academy of Sciences 2007: 1101: 361-76
# Y. Law, J. Fielding, MRI of pelvic floor dysfunction: review. AJR 2008: 191:
S45-53
# S. Novellas, M. Chanssang, S. Verger, et al.; MR features of the levator
ani muscle in the immediate postpartum following cesarean delivery. Int
Urogynecol J 2010: 21: 563-8
Page 23 of 24
•
•
•
# H. Pannu, Magnetic resonance imaging of pelvic organ prolapse. Abdom
Imaging 2002: 27: 660-73
# C. Woodfield, B. Hampton, V. Surg, et al.; Magnetic resonance imaging
of pelvic organ prolapse: comparing pubococcygeal and midpubic lines with
clinical staging. 2009: 20: 695-701
# C. Woodfield, S. Krishinamoorthy, B. Hampton, et al.; Imaging pelvic floor
disorders: trend toward comprehensive MRI. AJR 20110: 194: 1640-9
Personal Information
Hidefumi Fujisawa: Department of Radiology, Showa University Northern Yokohama
Hospital.
chigasakichuo35-1, Tsuzuki-ku, Yokohama-shi, Kanagawa, Japan
[email protected]
professor Tamio Kushihasi: chairman of the Department of Radiology, Showa University
Northern Yokohama Hospital.
Madoka Tonouchi, Kota Watanabe, and Megumi Tanisaka: Department of Radiology,
Showa University Northern Yokohama Hospital.
professor Makoto Shimada: chairman of the Department of Urology, Showa University
Northern Yokohama Hospital.
Page 24 of 24