Dynamic 3T pelvic floor magnetic resonance imaging in women progressing from the nulligravid to the primiparous state

Total Pelvic Floor Lifting: A New Approach for the Anatomic Repair of Pelvic Floor Hypermobility and Vaginal Laxity in Parous Women

Recent years have seen a steady increase in the information available regarding pelvic floor changes after childbirth. Obstetric trauma, to which all structures of the urogenital sphere are subjected, can affect different anatomical areas, including the vagina, perineum, deep pelvic floor muscles, and sphincter. Main complaints of parous women with regard to their pelvic floor are vaginal laxity, a wide introitus, and increased mobility of the uterus. Unilateral pectineal suspension is a novel method for surgical correction of the sequelae of vaginal birth-giving such as uterine hypermobility and perception of loose tissue, restoring a natural anatomy when conservative therapy has failed. Since the method is not ablative and does not interfere with anatomical structures, subsequent pregnancies and deliveries remain possible. Furthermore, there is no mesh application, adding to the safety aspects of this unique approach. The surgical technique is straightforward and can be adopted by laparoscopically trained surgeons without problems. The procedure consists of five clearly defined steps, which makes it easily reproducible. Unilateral pectineal suspension restores the pelvic floor and the vagina, with a single suture lifting the sagging structures back to their original position. If needed and according to the patient's choice, a short perineum associated with a wide introitus can be corrected in the same session by perineoplasty, resulting in a total aesthetic reconstruction of the female genital anatomy.

Diagnostic Value of Dynamic Magnetic Resonance Imaging (dMRI) of the Pelvic Floor in Genital Prolapses

Pelvic organ prolapse is a chronic disease resulting from a weakening of the musculoskeletal apparatus of the pelvic organs. For the diagnosis of this pathology, it is insufficient to conduct only a clinical examination. An effective diagnostic tool is the method of dynamic magnetic resonance imaging (MRI) of the pelvic floor, which allows a comprehensive assessment of the anatomical and functional characteristics of the walls of the pelvis and pelvic organs. The aim of the study was to analyze the literature data on the possibilities and limitations of using dynamic MRI in pelvic organ prolapse. The widespread use of the dynamic MRI method is due to the high quality of the resulting image, good reproducibility, and the maximum ability to display the characteristics of the pelvic floor. Dynamic MRI of the small pelvis allows a comprehensive assessment of the anatomical and functional features of the pelvis, excluding the effect of ionizing radiation on the body. The method is characterized by good visualization with high resolution and excellent soft tissue contrast. The method allows for assessing the state of the evacuation function of visualized structures in dynamics. Simultaneous imaging of all three parts of the pelvic floor using dynamic MRI makes it possible to assess multicompartment disorders. The anatomical characteristics of the state of the pelvic organs in the norm and in the event of prolapse are considered. The technique for performing the method and the procedure for analyzing the resulting images are described. The possibilities of diagnosing a multicomponent lesion are considered, while it is noted that dynamic MRI of the pelvic organs provides visualization and functional analysis of all three parts of the pelvis and often allows the choice and correction of tactics for the surgical treatment of pelvic organ prolapse. It is noted that dynamic MRI is characterized by a high resolution of the obtained images, and the advantage of the method is the ability to detect functional changes accompanying the pathology of the pelvic floor.

3T external phased-array magnetic resonance imaging in detection of obstetric anal sphincter lesions: a pilot study

BACKGROUND

Three-dimensional endoanal ultrasound (3D EAUS) has been the gold standard for detecting anal sphincter lesions in patients with a history of obstetric anal sphincter injury (OASI). Advances in imaging technologies have facilitated the detection of these lesions with external phased-array magnetic resonance imaging (MRI), which could offer an alternative imaging modality for the diagnosis of residual OASI (ROASI) in centers where 3D EAUS imaging is not available.

PURPOSE

To compare two diagnostic modalities: the 3D EAUS and 3T external phased-array MRI in the detection of residual anal sphincter lesions.

MATERIAL AND METHODS

A total of 24 women with a history of OASI were imaged with both 3D EAUS and 3T external phased-array MRI after primary repair of the injury. Intraclass correlation (ICC) and interrater reliability (IRR) values were calculated for the grade and circumference of the sphincter lesion. Sphincter lesions were graded according to the Sultan classification.

RESULTS

There was an almost perfect agreement between 3D EAUS and 3T external phased-array MRI in determining the extent of the sphincter lesions according to the Sultan classification (κ = 0.881; P < 0.001) and the circumference of the external anal sphincter defects, measured in degrees (κ = 0.896; P < 0.001).

CONCLUSION

The results of this study indicate that 3T external phased-array MRI and 3D EAUS yield comparable results in the diagnosis of ROASI. These findings suggest that 3T external phased-array MRI could serve as an alternative diagnostic modality to 3D EAUS in the diagnosis of ROASI.

The evolution of pelvic canal shape and rotational birth in humans

BACKGROUND

The human foetus typically needs to rotate when passing through the tight birth canal because of the complex shape of the pelvis. In most women, the upper part, or inlet, of the birth canal has a round or mediolaterally oval shape, which is considered ideal for parturition, but it is unknown why the lower part of the birth canal has a pronounced anteroposteriorly oval shape.

RESULTS

Here, we show that the shape of the lower birth canal affects the ability of the pelvic floor to resist the pressure exerted by the abdominal organs and the foetus. Based on a series of finite element analyses, we found that the highest deformation, stress, and strain occur in pelvic floors with a circular or mediolaterally oval shape, whereas an anteroposterior elongation increases pelvic floor stability.

CONCLUSIONS

This suggests that the anteroposterior oval outlet shape is an evolutionary adaptation for pelvic floor support. For the pelvic inlet, by contrast, it has long been assumed that the mediolateral dimension is constrained by the efficiency of upright locomotion. But we argue that the mediolateral elongation has evolved because of the limits on the anteroposterior diameter imposed by upright posture. We show that an anteroposteriorly deeper inlet would require greater pelvic tilt and lumbar lordosis, which compromises spine health and the stability of upright posture. These different requirements of the pelvic inlet and outlet likely have led to the complex shape of the pelvic canal and to the evolution of rotational birth characteristic of humans.

Female squirrel monkeys as models for research on women's pelvic floor disorders

Animal models enable research on biological phenomena with controlled interventions not possible or ethical in patients. Among species used as experimental models, squirrel monkeys (Saimiri genus) are phylogenetically related to humans and are relatively easily managed in captivity. Quadrupedal locomotion of squirrel monkeys resembles most other quadrupedal primates in that they utilize a diagonal sequence/diagonal couplets gait when walking on small branches. However, to assume a bipedal locomotion, the human pelvis has undergone evolutionary changes. Therefore, the pelvic bone morphology is not that similar between the female squirrel monkey and woman, but pelvic floor support structures and impacts of fetal size and malpresentation are similar. Thus, this review explores the pelvic floor support structural characteristics of female squirrel monkeys, especially in relation to childbirth to demonstrate similarities to humans.

Pelvic floor changes in the first term pregnancy and postpartum period

OBJECTIVE

To follow a prospective cohort of women during their first term pregnancy to elucidate the nature and timing of changes to the pelvic floor during pregnancy and after vaginal delivery.

METHODS

Enrolled subjects were evaluated at four time points with dynamic MRI, POP-Q examinations, and validated symptom questionnaires. The four assessments occurred during the first trimester (ePG), late third trimester (lPG), within a week after vaginal delivery (ePP), and three months postpartum (lPP). Two-dimensional T1-weighted MRI measurements included bladder descent and area of the levator hiatus at rest and during Valsalva maneuvers. Sample size of ten subjects was calculated for a power of 0.8 to detect a 20% change in bladder position with p < 0.05. Comparative statistical tests were used for parametric and non-parametric data, respectively.

RESULTS

Twelve subjects completed the study. At lPP, the bladder descent was increased (p = 0.03) at rest and with Valsalva compared to ePG. Levator hiatus area did not differ (p = 0.63) between time points at rest or with Valsalva. Median POP stage increased (p = 0.001) to 1.5 at lPP. Mean genital hiatus increased (p = 0.0003) at each time point. Higher scores were recorded on the UDI-6 (p < 0.001) and the PFDI-20 (p = 0.003) questionnaires at lPG and ePP, but returned to ePG levels by lPP.

CONCLUSION

Anatomic changes measured by dynamic MRI and POP-Q examinations demonstrate significant descent at 3 months postpartum. However, these anatomic changes did not significantly correlate with changes in symptoms.

Use of Dynamic MRI of the Pelvic Floor in the Assessment of Anterior Compartment Disorders

PURPOSE OF REVIEW

Approximately 25% of women in the USA suffer from pelvic floor disorders. Disorders of the anterior compartment of the pelvic floor, in particular, can cause symptoms such as incomplete urinary voiding, urinary incontinence, pelvic organ prolapse, dyspareunia, and pelvic pain, potentially negatively impacting a woman's quality of life. In some clinical situations, clinical exam alone may be insufficient, especially when patient's symptoms are in excess of their pelvic exam findings. In many of these patients, dynamic magnetic resonance imaging (dMRI) of the pelvic floor can be a valuable imaging tool allowing for comprehensive assessment of the entire pelvic anatomy and its function.

RECENT FINDINGS

Traditionally, evaluation of the anterior compartment has been primarily through clinical examination with occasional use of urodynamic testing and ultrasound. In recent years, dMRI has continued to gain popularity due to its improved imaging quality, reproducibility, and ability to display the entire pelvic floor. Emerging evidence has also shown utility of dMRI in the postoperative setting. In spite of advances, there remains an ongoing discussion in contemporary literature regarding the accuracy of dMRI and its correlation with clinical examination and with patient symptoms. Dynamic pelvic MRI is a helpful adjunct to physical examination and urodynamic testing, particularly when a patient's symptoms are in excess of the physical examination findings. Evaluation with dMRI can guide preoperative and postoperative surgical management in many patients, especially in the setting of multicompartmental disorders. This review will summarize relevant pelvic floor anatomy and discuss the clinical application, imaging technique, imaging interpretation, and limitations of dMRI.

Questionnaires to evaluate pelvic floor dysfunction in the postpartum period: a systematic review

Background

Pelvic floor dysfunctions (PFDs) affect the female population, and the postpartum period can be related to the onset or aggravation of the disease. Early identification of the symptoms and the impact on quality of life can be achieved through assessment instruments.

Objective

The purpose of this systematic review is to evaluate questionnaires used to assess PFD in the postpartum period.

Methods

A systematic review study was conducted, following Preferred Reporting Items for the Systematic Reviews and Meta-Analyses (PRISMA) criteria, using the databases: PubMed, Biblioteca Virtual de Saúde (BVS), Web of Science, and Scopus, and the keywords PFD or pelvic floor disorders, postpartum or puerperium, and questionnaire. Articles published up till May 2018 were included, searching for articles using validated questionnaires for the evaluation of PFDs in postpartum women. The articles included were evaluated according to a checklist, and the validation studies and translated versions of the questionnaires were identified.

Results

The search of the databases resulted in 359 papers, and 33 were selected to compose this systematic review, using nine validated questionnaires to assess PFDs in the postpartum period: International Consultation on Incontinence Questionnaire – Vaginal Symptoms (ICIQ-VS), Pelvic Floor Distress Inventory 20 (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), PFDI-46, Pelvic Floor Impact Questionnaire (PFIQ-31), Pelvic Floor Bother Questionnaire (PFBQ), Female Pelvic Floor Questionnaire, electronic Personal Assessment Questionnaire – Pelvic Floor, and PFD questionnaire specific for pregnancy and postpartum. The most frequently reported questionnaires included PFDI-20, PFIQ-7, and ICIQ-VS and are recommended by ICI. In addition, the review identified a specific questionnaire, recently developed, to access PFD during pregnancy and postpartum.

Conclusion

The questionnaires used to evaluate PFD during postpartum period are developed for general population or urology/gynecology patients with incontinence and reinforce the paucity of highly recommended questionnaires designed for postpartum, in order to improve early and specific approach for this period of life.