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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
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Learning objectives
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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
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#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:
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Fig. 1: Cystocele
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Imaging findings OR Procedure details
1.
Key points in the pelvic floor anatomy on MRI in POP (Fig. 2-6)
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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.
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2. TVM (tension-free vaginal mesh) procedure for POP (Fig. 8,9)
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#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
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#FSE (TSE) T2WI Axial: #Slice thickness #6mm
#FSE (TSE) T2WI Coronal
#FSE (TSE) T2WI Sagittal
#cine Dynamic Sagittal
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HASTE, SSFSE, trueFISP :# Temporal resolution 1-2sec, Slice thickness
6-10mm
4. Diagnostic MR reference lines
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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)
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6. Case presentation (fig. 10-18 )
Images for this section:
Fig. 2: Atlas of normal female pevic floor MRI anatomy: axial 1
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Fig. 3: Atlas of normal female pevic floor MRI anatomy: axial 2
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Fig. 4: Atlas of normal female pevic floor MRI anatomy: axial 3
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Fig. 5: Atlas of normal female pevic floor MRI anatomy: coronal
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Fig. 6: Atlas of normal female pevic floor MRI anatomy: coronal and sagittal
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Fig. 7: Atlas of normal female pevic floor MRI anatomy: sagittal 2
Fig. 8: Illust for TVM procedure and important anatomical structures for POP.
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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.
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Table 1: Grading of Pelvic Floor Relaxation
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Table 2: MRI staging for PCL and MPL reference line
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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
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Fig. 11: Case 2. CYSTOCELE/ VABGINOCELE/ RECTOCELE associated with ovarian
mature cystic teratoma (arrow)
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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
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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).
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Fig. 14: Case 2. MR coronal image. Coronal T2WI shows a puborectal muscle descend
(arrows).
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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
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Fig. 16: Case 3. RECTOCELE: coronal image Left levator ani muscle(arrow) is thin.
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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)
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Fig. 18: Cine dynamic MRI clearly demonstrate a cystocele at the increasing abdominal
pressure.
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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
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# 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.
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# 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:
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# L. Hoyte, M. Damaser, Magnetic resonance-based female pelvic anatomy
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# S. Novellas, M. Chanssang, S. Verger, et al.; MR features of the levator
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# 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
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# 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
hfuji@med.showa-u.ac.jp
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.
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