Study of dynamic magnetic resonance imaging in diagnosis of pelvic organ prolapse

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.

Role of Preoperative and Postoperative Pelvic Floor Distress Inventory-20 in Evaluation of Posthysterectomy Vault Prolapse

Background:

Posthysterectomy vault prolapse is a common problem after vaginal or abdominal hysterectomy. The objective was to assess the role of Pelvic Floor Distress Inventory 20 (PFDI-20) in evaluation of vault prolapse.

Materials and Methods:

Prospective study in 20 women with posthysterectomy vault prolapse of Stage 2 and above. The outcome measure was to calculate PFDI-20 score in all cases before surgical intervention and to recalculate it again in 6 months after different surgical procedures for vault prolapse and to statistically compare the PFDI-20 score in different types of surgery over 4 years period at a tertiary referral hospital for surgical treatment. Prolapse was classified using Pelvic Organ Prolapse Quantification and intraoperative findings. All women were operated for vault prolapse as per hospital protocol and stage of prolapse by either vaginal sacrospinous fixation or abdominal sacrocolpopexy.

Results:

Mean age, parity, and body mass index were 54.8 years, 3.5, and 22.71 kg/m² respectively. Preceding surgery was vaginal hysterectomy in 75% women and abdominal hysterectomy in 25% women. Complaints were bulge or mass feeling at perineum (100%), pressure in lower abdomen and perineum (55%), and constipation (60%). The type of prolapse was vault prolapse (100%), cystocele (100%), rectocele (100%), and enterocele (45%). The range of PFDI-20 was 88–152 with mean being 123.50 ± 22.71 before surgery while its range decreased significantly to 80–126 with mean being 106.40 ± 16.45 after surgery (P < 0.01). Mean postoperative PFDI-20 score was 107.40 in vaginal sacrospinous fixation group and was 105.30 in abdominal sacrocolpopexy group and was not statistically different (P = 0.18).

Conclusion:

PFDI-20 score can be used to see the adverse impact of vault prolapse on pelvic floor and to assess the beneficial effect of different types of surgeries on the score.

The establishment of a 3D anatomical coordinate system for defining vaginal axis and spatial position

BACKGROUND AND OBJECTIVE

Pelvic organ prolapse (POP), the herniation of the pelvic organs toward the vaginal opening, is a common pelvic floor disorder (PFD) whose etiology is poorly understood. Traditional methods for evaluating POP are often constrained to external vaginal examination, limited to 2D, or have poor reproducibility. We propose a reliable 3D anatomic coordinate system for standardized 3D assessment of pelvic anatomy using magnetic resonance imaging (MRI).

METHODS

The novel 3D anatomic reference system is based on six bony landmarks of the pelvis manually identified in MRI: the ischial spines and the superior and inferior pubic points of the left and right pubic symphysis. The origin of this system is defined as the midpoint of the ischial spines. The reproducibility and applicability of the pelvic coordinate system were evaluated by (1) implementing it in a new method to quantify vaginal position and axis (angulation) in 3D space from MRI segmentations of the vagina and (2) computing the intraclass correlation (ICC) on coordinate system and vaginal measures. The MRI analysis was performed by four non-medically trained observers on five pelvic MRI datasets on approximately five separate occasions.

RESULTS

Overall, all bony landmarks had excellent intra-observer reliability and inter-observer reliability (ICC>0.90); intra-observer reliability was moderate-to-good among the vaginal position parameters (0.5<ICC≤0.90) and moderate for the vaginal axis angles (0.50<ICC≤0.75); inter-observer reliability was moderate in the vaginal position coordinates and vaginal axis measures. On average, within-observer differences in the vaginal position and angle measures relative to the overall mean were <1 mm and <1°, respectively.

CONCLUSIONS

The proposed anatomic coordinate system and vaginal analysis approach allow quantitative assessment of pelvic anatomy that is robust to the experience level of the observer. The application of these methods in radiographic studies will give new insight into the underlying anatomic changes involved in the pathogenesis of POP and other PFDs and help better understand their etiology.

International Urogynecological Consultation: clinical definition of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This segment of Chapter 1 of the International Urogynecology Consultation (IUC) on pelvic organ prolapse (POP) reviews the literature on the clinical definition of POP with the intent of creating standard terminology.

METHODS

An international group containing nine urogynecologists and one university-based medical librarian performed a search of the literature using pre-specified search terms in PubMed, Embase, and Scopus. Publications were eliminated if not relevant to the clinical definition of POP, and those articles remaining were evaluated for quality using the Specialist Unit for Review Evidence (SURE). The resulting list of articles was used to inform a comprehensive review and creation of the clinical definition of POP.

RESULTS

The original search yielded 31,931 references, of which 167 were used by the writing group. Ultimately, 78 are referenced in the manuscript.

CONCLUSIONS

The clinical definition of POP for this review of the literature is: "anatomical prolapse with descent of at least one of the vaginal walls to or beyond the vaginal hymen with maximal Valsalva effort WITH the presence either of bothersome characteristic symptoms, most commonly the sensation of vaginal bulge, or of functional or medical compromise due to prolapse without symptom bother."

Clinical applications of pelvic floor imaging: opinion statement endorsed by the society of abdominal radiology (SAR), American Urological Association (AUA), and American Urogynecologic Society (AUGS)

Pelvic floor dysfunction is prevalent, with multifactorial causes and variable clinical presentations. Accurate diagnosis and assessment of the involved structures commonly requires a multidisciplinary approach. Imaging is often complementary to clinical assessment, and the most commonly used modalities for pelvic floor imaging include fluoroscopic defecography, magnetic resonance defecography, and pelvic floor ultrasound. This collaboration opinion paper was developed by representatives from multiple specialties involved in care of patients with pelvic floor dysfunction (radiologists, urogynecologists, urologists, and colorectal surgeons). Here, we discuss the utility of imaging techniques in various clinical scenarios, highlighting the perspectives of referring physicians. The final draft was endorsed by the Society of Abdominal Radiology (SAR), American Urogynecologic Society (AUGS), and the American Urological Association (AUA).

MR defecography review

Pelvic floor dysfunction is a relatively common but often complex condition, presenting with a variety of clinical symptoms, especially when it involves multiple compartments. Clinical exam alone is often inadequate and requires a complementary imaging study. Magnetic resonance defecography (MRD) is an excellent noninvasive diagnostic study with its multiplanar capability, lack of ionizing radiation and excellent soft tissue resolution. It can identify both anatomic and functional abnormalities in the pelvic floor and specifically excels in its ability to simultaneously detect multicompartmental pathology and help with vital pre-operative assessment. This manuscript reviews the relevant anatomical landmarks, describes the optimal technique, highlights an approach to the interpretation of MRD, and provides an overview of the various pelvic floor disorders in the different anatomical compartments.

MAGNETIC RESONANCE IMAGING OF PELVIC FLOOR DYSFUNCTION, REVIEW

Pelvic floor dysfunction is an important medical and social problem in the female population. The impact of pelvic floor disorders (PFD) is likely to grow as the prevalence of these disorders increases with an aging population. Pregnancy and delivery are considered major risk factors in the development of POP and stress urinary incontinence. Pelvic floor dysfunction may involve pelvic organ prolapse and/or pelvic floor relaxation. Organ prolapse can include any combination of the following: urethra (urethrocele), bladder (cystocele), or both (cystourethrocele), vaginal vault and cervix (vaginal vault prolapse), uterus (uterineprolapse), rectum (rectocele), sigmoid colon (sigmoidocele),and small bowel (enterocele).Given the paucity of understanding of PFD pathophysiology ,multicompartmental pathology, the high rate of recurrence and repeat surgery imaging plays a major role in its clinical management.The magnetic resonance imaging (MRI) allows noninvasive, radiation-free, rapid, high-resolution evaluation the multicompartment defects in one examination.Findings reported at MR imaging of the pelvic floor are valuable for selecting candidates for surgical treatment and for indicating the most appropriate surgical approach.

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.

Dynamic Pelvic Magnetic Resonance Imaging Evaluation of Pelvic Organ Prolapse Compared to Physical Examination Findings

OBJECTIVE

To compare dynamic magnetic resonance imaging (dMRI) defecography phase findings with physical examination (PE) grading in the evaluation of pelvic organ prolapse (POP).

METHODS

We retrospectively reviewed 274 consecutive patients who underwent dMRI with defecography. Baden-Walker grading of POP, absolute dMRI values, and grading by dMRI were collected for anterior, apical, and posterior compartments. Anatomically significant POP on PE was defined as Baden-Walker Grade ≥3 and on dMRI by dMRI Grade ≥2. A Spearman's Rank correlation was performed between absolute dMRI values and respective POP grades.

RESULTS

A total of 178 female patients were included. Anatomically insignificant and significant cystoceles had a 26.4% (19/72) and 84.6% (66/78) agreement respectively. Anatomically insignificant and significant apical prolapse had a 2.0% (2/100) and 62.9% (17/27) agreement respectively. Anatomically insignificant and significant posterior prolapse had a 49.5% (51/103) and 78.7% (59/75) agreement respectively. PE detected only 30% (9/30) of total dMRI detected enteroceles and misdiagnosed 10% (3/30) of these patients with a rectocele.

CONCLUSION

The dMRI defecography phase correlated well for anatomically significant prolapse in anterior and posterior compartments. dMRI was superior to PE for enterocele detection and was better able to distinguish an enterocele from a rectocele. Thus, dMRI may have the greatest diagnostic value in cases where the presence of an enterocele is unclear in apical and/or posterior compartments.

Practical guide to dynamic pelvic floor MRI

Pelvic floor dysfunction encompasses a spectrum of functional disorders that result from impairment of the ligaments, fasciae, and muscles supporting the pelvic organs. It is a prevalent disorder that carries a lifetime risk over 10% for undergoing a surgical repair. Pelvic floor weakness presents as a wide range of symptoms, including pain, pelvic pressure or bulging, urinary and fecal incontinence, constipation, and sexual dysfunction. A correct diagnosis by clinical examination alone can be challenging, particularly in cases involving multiple compartments. Magnetic resonance imaging (MRI) allows noninvasive, radiation-free, high soft-tissue resolution evaluation of all three pelvic compartments, and has proved a reliable technique for accurate diagnosis of pelvic floor dysfunction. MR defecography with steady-state sequences allows detailed anatomic and functional evaluation of the pelvic floor. This article provides an overview of normal anatomy and function of the pelvic floor and discusses a practical approach to the evaluation of imaging findings of pelvic floor relaxation, pelvic organ prolapse, fecal incontinence, and obstructed defecation.

LEVEL OF EVIDENCE

5 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1155-1170.

[Assessment before surgical treatment for pelvic organ prolapse: Clinical practice guidelines]

INTRODUCTION

The issue addressed in this chapter of recommendations is: What is the clinical and para-clinical assessment to achieve in women with genital prolapse and for whom surgical treatment has been decided. What are the clinical elements of the examination that must be taken into account as a risk factor of failure or relapse after surgery, in order to anticipate and evaluate possible surgical difficulties, and to move towards a preferred surgical technique?

MATERIAL AND METHODS

This work is based on a systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane Database of Systemactic Reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement [AP]).

RESULTS

It suits first of all to describe prolapse, by clinical examination, helped, if needed, by a supplement of imagery if clinical examination data are insufficient or in case of discrepancy between the functional signs and clinical anomalies found, or in case of doubt in associated pathology. It suits to look relapse risk factors (high grade prolapse) and postoperative complications risk factors (risk factors for prothetic exposure, surgical approach difficulties, pelvic pain syndrome with hypersensitivity) to inform the patient and guide the therapeutic choice. Urinary functional disorders associated with prolapse (urinary incontinence, overactive bladder, dysuria, urinary tract infection, upper urinary tract impact) will be search and evaluated by interview and clinical examination and by a flowmeter with measurement of the post voiding residue, a urinalysis, and renal-bladder ultrasound. In the presence of voiding disorders, it is appropriate to do their clinical and urodynamic evaluation. In the absence of any spontaneous or hidden urinary sign, there is so far no reason to recommend systematically urodynamic assessment. Anorectal symptoms associated with prolapse (irritable bowel syndrome, obstruction of defecation, fecal incontinence) should be search and evaluated. Before prolapse surgery, it is essential not to ignore gynecologic pathology.

CONCLUSION

Before proposing a surgical cure of genital prolapse of women, it suits to achieve a clinical and paraclinical assessment to describe prolapse (anatomical structures involved, grade), to look for recurrence, difficulties approach and postoperative complications risk factors, and to appreciate the impact or the symptoms associated with prolapse (urinary, anorectal, gynecological, pelvic-perineal pain) to guide their evaluation and their treatment. © 2016 Published by Elsevier Masson SAS.

Prevalence of dynamic magnetic resonance imaging-identified pelvic organ prolapse in pre- and postmenopausal women without clinically evident pelvic organ descent

Background Dynamic magnetic resonance imaging (dMRI) is an imaging tool that can be used to evaluate and stage pelvic organ prolapse (POP). Greater understanding of the incidental detection of POP in asymptomatic patients is needed. Purpose To evaluate the prevalence of dMRI-detected POP in pre-and postmenopausal women who were imaged for reasons unrelated to pelvic floor dysfunction. Material and Methods A total of 227 women who had diagnoses that did not include POP underwent abdominal/pelvic dMRI. Patients with a positive gynecological examination for or a clinical history of POP ( n = 11), hysterectomy ( n = 4), or gynecologic-oncology surgery ( n = 2) were excluded, as well as patients who were unable to strain during MRI ( n = 11). A total of 199 patients without visible prolapse were enrolled in the study. An H-line, M-line, pubococcygeal line (PCL), and mid-pubic line (MPL) were used to detect and grade prolapse. Results The prevalence of dMRI-identified POP was higher in postmenopausal subjects. The PCL led to a greater frequency of prolapse detection than the MPL. The frequency of middle compartment descent was similar regardless of whether the PCL or MPL was used as a reference line. There was a higher incidence of prolapse in the posterior compartment. Using an H-line and PCL as references, the anterior and posterior compartments were found to significantly differ between pre- and postmenopausal subjects. The MRI parameters that were used to define POP were not correlated with parity, vaginal birth, BMI, or fetal birth weight. With respect to the MPL, age was correlated with both the presence of an elongated H-line and with descent. Conclusion Dynamic MRI identified incidental pelvic organ prolapse in asymptomatic patients. The prevalence of dMRI-detected POP was higher in postmenopausal women without visible prolapse. These findings suggest the need for further studies to identify how to modify the currently used dMRI thresholds for postmenopausal women.

Pathophysiological aspects of cystocele with a 3D finite elements model

PURPOSES

The objective of this study is to design a 3D biomechanical model of the female pelvic system to assess pelvic organ suspension theories and understand cystocele mechanisms.

METHODS

A finite elements (FE) model was constructed to calculate the impact of suspension structure geometry on cystocele. The sample was a geometric model of a control patient's pelvic organs. The method used geometric reconstruction, implemented by the biomechanical properties of each anatomic structure. Various geometric configurations were simulated on the FE method to analyse the role of each structure and compare the two main anatomic theories.

RESULTS

The main outcome measure was a 3D biomechanical model of the female pelvic system. The various configurations of bladder displacement simulated mechanisms underlying medial, lateral and apical cystocele. FE simulation revealed that pubocervical fascia is the most influential structure in the onset of median cystocele (essentially after 40 % impairment). Lateral cystocele showed a stronger influence of arcus tendineus fasciae pelvis (ATFP) on vaginal wall displacement under short ATFP lengthening. In apical cystocele, the uterosacral ligament showed greater influence than the cardinal ligament. Suspension system elongation increased displacement by 25 % in each type of cystocele.

CONCLUSIONS

A 3D digital model enabled simulations of anatomic structures underlying cystocele to better understand cystocele pathophysiology. The model could be used to predict cystocele surgery results and personalising technique by preoperative simulation.

ACR Appropriateness Criteria pelvic floor dysfunction

Pelvic floor dysfunction is a common and potentially complex condition. Imaging can complement physical examination by revealing clinically occult abnormalities and clarifying the nature of the pelvic floor defects present. Imaging can add value in preoperative management for patients with a complex clinical presentation, and in postoperative management of patients suspected to have recurrent pelvic floor dysfunction or a surgical complication. Imaging findings are only clinically relevant if the patient is symptomatic. Several imaging modalities have a potential role in evaluating patients; the choice of modality depends on the patient's symptoms, the clinical information desired, and the usefulness of the test. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions; they are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals, and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.