Pelvic floor imaging with MR defecography: correlation with gynecologic pelvic organ prolapse quantification

Advancements in Magnetic Resonance Imaging for the Evaluation of Pelvic Organ Prolapse: A Comprehensive Review

Pelvic organ prolapse (POP) is a major health issue for women, making accurate diagnosis and assessment essential for effective clinical management. Among the various imaging techniques used for POP evaluation, translabial ultrasound and fluoroscopy have been widely utilized. Translabial ultrasound is a non-invasive, cost-effective method that provides real-time dynamic imaging of the pelvic floor during activities such as straining. Fluoroscopy, often employed in defecography, offers real-time visualization of pelvic organ movement but is limited by radiation exposure. Magnetic resonance imaging (MRI), with its superior soft tissue contrast and non-invasive nature, has emerged as a valuable tool for providing detailed anatomical and functional insights into POP This review outlines the advancements in using MRI to assess POP. It highlights the technical advantages, clinical applications, comparisons with other imaging methods, and future research directions. By analyzing recent research, we aim to clarify the role of MRI in evaluating POP and encourage its integration into clinical practice.

Assessment of Different Pubococcygeal Lines for the Quantitative Diagnosis of Pelvic Organ Prolapse Using Magnetic Resonance Defecography

INTRODUCTION AND HYPOTHESIS

The objective was to elucidate the clinical utility of two reference lines, the pubosacrococcygeal joint line (PCLjnt) and pubococcygeal joint line (PCLcc), in the quantitative diagnosis of pelvic organ prolapse (POP) and pelvic floor laxity.

METHODS

A retrospective analysis of magnetic resonance defecography (MRD) in patients with stage II or above POP was conducted. POP and pelvic floor relaxation were quantitatively assessed using both PCLjnt and PCLcc as reference lines. Further research, point-to-point correlation analysis was performed between the pelvic organ prolapse quantification (POP-Q) system and MRD to investigate the discrepancies between the two reference lines.

RESULTS

There was no significant statistical difference in the degree of cystocele and H line between the PCLjnt and PCLcc groups (p > 0.05). Nevertheless, significant differences in the degree of uterine prolapse and M-line between the two groups were observed (p = 0.00). Both the PCLjnt and PCLcc reference lines demonstrated better correlation with POP-Q, and the PCLcc exhibited slightly higher correlation coefficients than the PCLjnt.

CONCLUSIONS

The results revealed significant moderate correlations between both reference lines and key POP-Q landmarks. Both PCLjnt and PCLcc can be utilized for interpreting MRD images and diagnosing POP for anterior wall and uterine prolapse.

Pelvic floor dysfunction in patients with gestational diabetes mellitus

In this editorial, we comment on an article by Wang et al. Recent literature shows an increase in research on pelvic organ prolapse (POP). Although the true incidence of POP remains uncertain, its impact on quality of life is substantial. Anatomical studies report high incidence rates, surpassing those observed in symptom-based surveys. Weakness of the endopelvic fascia is a primary anatomical risk factor for POP. Additionally, gestational diabetes mellitus (GDM) has emerged as a growing concern, as poor glycemic control increases complications for both mother and fetus. GDM and POP are interconnected, with factors like maternal obesity, macrosomia, and hormonal changes exacerbating pelvic floor dysfunction. Modifiable risk factors, such as obesity and chronic hyperglycemia, along with multiparity, instrumental deliveries, and obstetric trauma, further increase susceptibility. For patients with GDM, gynecological exams, Pelvic Organ Prolapse Quantification staging, and pelvic floor ultrasonography are valuable diagnostics, with proctological exams and magnetic resonance defecography aiding in multi-compartment prolapse diagnoses. Imaging, though uncomfortable during pregnancy, is safe in the early postpartum period. This editorial emphasizes the need for further research on the pathophysiology of GDM-related POP and offers recommendations for improving diagnosis and clinical management of patients with GDM.

MR defecography: comparison of HMO system measurement between supine and lateral decubitus patient position

BACKGROUND

Pelvic floor dysfunction (PVD), a prevalent clinical issue impacting quality of life, can be effectively assessed using magnetic resonance defecography (MRD) with the patient either supine or in the lateral decubitus position.

PURPOSE

To compare the measurement value and grading in dynamic MRD within the closed-magnet system of PFD patients performed in supine versus lateral decubitus position using the H line, M line, and organ prolapse (HMO) classification system.

MATERIAL AND METHODS

During 2017-2019, 100 patients with PFD underwent MRD during defecation in both supine and lateral decubitus positions. MR images were measured and graded by two blinded radiologists. The mean value of each HMO parameter and grading severity were compared between supine and lateral positions. Image quality (IQ) between two positions was also evaluated. Paired t-test and Wilcoxon ranked test were performed for significant difference. P < 0.05 was considered statistically significant.

RESULTS

For HMO measurement, M-line, levator plate angle (LPA), urethral hypermobility (UH), uterine prolapse, and peritoneocele had significantly higher mean values when measured in the lateral decubitus position than in the supine position. For grading, M-line, uterine prolapse, and peritoneocele also had more grading severity in the lateral decubitus than supine position with statistical significance (P = 0.002, 0.004, and 0.001, respectively). Only anterior rectocele had a mean value and grading severity in the supine more than the lateral position (P = 0.003 and P = 0.005). IQ in the supine was better than in the lateral decubitus position (P < 0.001).

CONCLUSION

MRD in lateral decubitus showed a more severe degree of PFD in most parameters based on the HMO grading system irrespective of inferior imaging quality.

Clinical value of MR defecography: What additional knowledge is provided by the radiologist to the surgeon?

PURPOSE

To evaluate the clinical value of MR defecography in supporting surgical decision-making and management strategies in a consecutive series of patients.

MATERIAL AND METHODS

A consecutive series of patients with clinical suspicion of pelvic disorders who underwent MR defecography at a single university hospital from January 2021 to June 2024 were included. MR defecography was performed at rest (axial/sagittal and coronal T2-weighted sequences), during squeezing, straining, and evacuation (dynamic sagittal T2-weighted sequences). An expert surgeon assessed his satisfaction about the diagnostic information given by the prospective radiological report as: 1: insufficient, 2: sufficient, 3: good, 4: excellent. For patients who underwent surgery, the same surgeon assessed the usefulness of the MR defecography, using a score from 1 to 4 (1: discordant findings, useless exam; 2: concordant findings without new information; 3: concordant findings, useful new information; 4: concordant findings, extremely useful new information).

RESULTS

A total of 218 patients (age 27 - 79, mean 60 ± 11; 193 females and 25 males) entered the analysis. For 211 of them (97 %), the radiologist was able to evaluate the images and determine an MR defecography-based diagnosis; in 7 patients (3 %), a diagnosis was not provided due to exam interruption for low patient's compliance. In 195/211 patients (92 %), the radiological diagnosis matched the clinical suspect that prompted the examination. The satisfaction about the diagnostic information given by the radiological report of the 211 exams was assessed by the surgeon as follows: excellent (n = 99, 47 %), good (n = 48, 23 %), sufficient (n = 35, 16 %), and insufficient (n = 29, 14 %). Out of 211 patients, 73 (34.6 %) underwent surgery. MR defecography provided concordant findings with relevant additional information in 63 (86.3 %), concordant findings with additional information in 3 (4.1 %), concordant findings without additional information in 4 (5.5 %), and discordant findings in 3 (4.1 %).

CONCLUSIONS

The diagnostic information prospectively provided by MR defecography resulted to be good or excellent in 70 % of the patients, adding clinical value in the preoperative surgical setting in 86 % of those patients who underwent surgery.

MR defecography in assessing stress urinary incontinence with or without symptomatic pelvic organ prolapse

PURPOSE

Utilize magnetic resonance defecography (MRD) to analyze the primary pelvic floor dysfunctions in patients with stress urinary incontinence (SUI) associated with pelvic organ prolapse (POP), and in SUI patients with asymptomatic POP.

METHOD

We performed MRD in both SUI and POP subjects. As a primary analysis, the functional MR parameters were compared between the isolated POP and POP combined SUI groups. As a secondary analysis, the functional MR data were compared between the POP combined SUI and the SUI with asymptomatic POP (isolated SUI) groups.

RESULTS

MRD noted the main characteristics of SUI combined moderate or severe POP, including the shorter closed urethra length (1.87 cm vs. 2.50 cm, p < 0.001), more prevalent urethral hypermobility (112.31° vs. 85.67°, p = 0.003), bladder neck funneling (48.28% vs. 20.51%, p = 0.020), lower position of vesicourethral junction (2.11 cm vs. 1.67 cm, p = 0.030), and more severe prolapse of the posterior bladder wall (6.26 cm vs. 4.35 cm, p = 0.008). The isolated SUI patients showed the shortest length of the closed urethra (1.56 cm vs. 1.87 cm, p = 0.029), a larger vesicourethral angle (153.80° vs. 107.58°, p < 0.001), the more positive bladder funneling (84.85% vs. 48.28%, p = 0.002) and a special urethral opening sign (45.45% vs. 3.45%, p < 0.001).

CONCLUSIONS

Patients with SUI accompanying POP primarily exhibit excessive urethral mobility and a shortened urethral closure. SUI patients with asymptomatic POP mainly show dysfunction of the urethra and bladder neck, characterized by the opening of the urethra and bladder neck and a shortened urethral closure.

Comparison of Dynamic Magnetic Resonance Defecography With Clinical Examination in Diagnosing Pelvic Floor Dysfunction: An Observational Study

BACKGROUND

Pelvic floor dysfunction (PFD) is frequently reported in both sexes. Dynamic magnetic resonance defecography (DMRD) is the preferred modality, mainly due to its superiority and complementary role in clinical examination. However, studies from the perspective of Indian patients are scarce and mostly restricted to females. Thus, we assessed the diagnostic performance of DMRD in patients with PFD and correlated the findings with those on clinical examination.

MATERIALS AND METHODS

This prospective, observational study involved 57 adult patients of either sex, presenting with pelvic floor symptoms (PFS) and diagnosed with PFD. Initially, the patients underwent clinical examination, and diagnosis was recorded. Subsequently, the patients were subjected to DMRD. The findings were correlated with the Pearson "r" correlation coefficient.

RESULTS

A significantly greater proportion of patients had involvement of multiple compartments (36 vs. 12, p<0.001), cystocele (23 vs. 8, p=0.002), and rectal prolapse (25 vs. 14, p=0.030) on DMRD than clinical examination, while there was no significant difference regarding uterine prolapse (p=0.789). Grading of cystocele and rectal prolapse as well as diagnosis of enterocele/peritoneocele, rectocele, and intussusception could be done only with DMRD. DMRD had a strong and significant correlation with clinical examination regarding cystocele (r=0.943, p=0.003), uterine prolapse (r=0.972, p=0.001), and rectal prolapse (r=0.951, p=0.001).

CONCLUSIONS

DMRD demonstrated significantly better performance in the diagnosis of multiple compartment involvement, cystocele, and rectal prolapse. DMRD and clinical examination were significantly correlated regarding the diagnosis of cystocele, uterine prolapse, and rectal prolapse. Thus, DMRD provides information, in addition to the clinical examination, and should be used in symptomatic patients.

Static and Dynamic Magnetic Resonance Imaging in Female Pelvic Floor Dysfunction: Correlation With Pelvic Organ Prolapse Quantification

BACKGROUND

Pelvic organ prolapse (POP) is clinically assessed and staged commonly by the pelvic organ prolapse quantification (POP-Q) system. Dynamic magnetic resonance imaging (MRI) of the pelvic floor is an emerging modality for anatomical and functional assessment of the pelvic floor and staging of POP. The purpose of this study was to correlate the dynamic MRI findings with POP-Q examination for the staging of POP in each pelvic compartment by comparing various anatomic points.

METHODS

A prospective observational study of the comparative cross-sectional design was conducted among patients who underwent MRI of the pelvic floor and POP-Q at our institute. A total of 50 patients were included. Anatomical landmarks in the three compartments were analyzed in relation to standard reference lines on dynamic MRI and compared with POP-Q measurements.

RESULTS

Most of our patients had multicompartment disease (70%). When compared to POP-Q, MRI has a strong correlation for quantification of anterior (0.723) and middle (0.525) compartments and a weak correlation (0.232) for posterior compartment prolapse.

CONCLUSION

POP-Q examination is based on the various points within the vaginal canal, and all the points do not represent a true anatomic landmark. MRI, on the other hand, is based on a true anatomical plane and gives detailed information about various structures in all three compartments. Thus, MRI also helps bridge the gap between various referring specialties in treating pelvic floor disorders.

Longitudinal changes in pelvic organ support among primiparas with postpartum pelvic organ prolapse: A follow-up magnetic resonance imaging study

OBJECTIVE

To quantify morphological changes of pelvic floor in primiparas with postpartum pelvic organ prolapse (POP) during the early postpartum period.

METHODS

A total of 309 primiparas underwent pelvic floor magnetic resonance imaging (MRI) at 6 weeks postpartum. Those primiparas diagnosed with postpartum POP by MRI criterion were followed up at 3 and 6 months postpartum. Normal primiparas were enrolled in the control group. The puborectal hiatus line, muscular pelvic floor relaxation line, levator hiatus area, iliococcygeus angle, levator plate angle, uterus-pubococcygeal line, and bladder-pubococcygeal line were assessed on MRI. Longitudinal changes in pelvic floor measurements between the two groups were compared by repeated-measures analysis of variance.

RESULTS

Compared with the control group, enlarged puborectal hiatus line, levator hiatus area, and RICA and decreased uterus-pubococcygeal line were observed at rest in the POP group (all P < 0.05). All of the pelvic floor measurements were significantly different in the POP group compared with the control group at the maximum Valsalva maneuver (all P < 0.05). All of the pelvic floor measurements showed no significant change over time in both the POP and control groups (all P > 0.05).

CONCLUSIONS

Postpartum POP accompanied by poor pelvic floor support will persist in the early postpartum period.

The added value of conventional defecography and MRI defecography in clinical decision making on treatment for posterior compartment prolapse

INTRODUCTION AND HYPOTHESIS

Conventional defecography and MRI defecography can be requested as an additional test for diagnosing and differentiating the type of posterior compartment prolapse and/or obstructive defecation disorders. The objective of this study was to determine the added value of conventional defecography, conventional defecography and MRI defecography for clinical decision-making on treatment for patients with posterior compartment prolapse.

METHODS

Four gynecologists were asked to fill in their treatment plan per patient for 32 cases for three different steps. Step 1 consisted of information on the anamnesis and physical examination (POP-Q). Step 2 consisted of Step 1, including conventional defecography (group A) or MRI defecography (group B). In Step 3, all gynecologists received the information on Step 1 including both conventional defecography and MRI defecography. Data analysis solely focused on the assessment of changes in the gynecological treatment plan of the posterior compartment.

RESULTS

After Step 2 a change in treatment plan occurred in 37% and 48% of the women in groups A and B, respectively. Accordingly, after Step 3 (including all imaging data), a change in treatment plan occurred in 19% and 52% of the women in groups A and B, respectively. A change within the surgery group (when a different type of surgery was selected) was seen for a total of 11 cases in group A and 20 in group B in all steps combined.

CONCLUSIONS

Both conventional defecography and MRI defecography had an large effect on the treatment plan for patients with posterior compartment prolapse. The dedicated added value of the imaging modality individually cannot be concluded yet.

Biomechanical integrity score of the female pelvic floor

INTRODUCTION AND HYPOTHESIS

The aim of this study is to develop and validate a new integral parameter, the Biomechanical Integrity score (BI-score), for the characterization of the female pelvic floor.

METHODS

A total of 253 subjects with normal and pelvic organ prolapse (POP) conditions were included in the multi-site observational, case-control study; 125 subjects had normal pelvic floor conditions, and 128 subjects had POP stage II or higher. A Vaginal Tactile Imager (VTI) was used to acquire and automatically calculate 52 biomechanical parameters for eight VTI test procedures (probe insertion, elevation, rotation, Valsalva maneuver, voluntary muscle contractions in two planes, relaxation, and reflex contraction). Statistical methods were applied (t-test, correlation) to identify the VTI parameters sensitive to the pelvic conditions.

RESULTS

Twenty-six parameters were identified as statistically sensitive to POP development. They were subdivided into five groups to characterize (1) tissue elasticity, (2) pelvic support, (3) pelvic muscle contraction, (4) involuntary muscle relaxation, and (5) pelvic muscle mobility. Every parameter was transformed to its standard deviation units against the patient age similar to T-score for bone density. Linear combinations with specified weights led to the composition of five component parameters for groups (1)-(5) and the BI-score in standard deviation units. The p-value for the BI-score has p = 4.3 × 10-31 for POP versus normal conditions. A reference BI-score curve against age for normal pelvic floor conditions was defined.

CONCLUSIONS

Quantitative transformations of the pelvic tissues, support structures, and functions under diseased conditions may be studied with the BI-score in future research and practical applications.