Magnetic resonance imaging for stress incontinence: evaluation of patients before and after surgical correction

Evaluation of the effect of abdominal sacrocolpopexy (ASC) on urethral anatomy and continence mechanism using dynamic MRI

INTRODUCTION

Treatment of pelvic organ prolapse (POP) associated with stress urinary incontinence (SUI) is a surgical challenge. Surgeons may perform combined prolapse and incontinence surgery or may correct prolapse first and evaluate incontinence afterwards. We present a prospective study to evaluate the effect of abdominal sacrocolpopexy (ASC) on urethral anatomy and continence using dynamic magnetic resonance imaging (MRI).

METHODS

Twenty females with concomitant apical prolapse and SUI due to urethral hypermobility were included. Patients with intrinsic sphincteric deficiency (ISD) were excluded. All patients underwent ASC operation as a sole treatment without anti-incontinence procedure. Patients were informed they may need anti-incontinence procedure afterwards. Symptom-specific questionnaires assessing prolapse, incontinence, sexual function and quality of life (QoL), dynamic MRI and pressure flow urodynamic study were administered before and after surgery.

RESULTS

Mean age was 53 years. All patients had apical prolapse; four with cystocele, and five with rectocele. Urethral hypermobility was positive in all patients. After performing ASC, all patients reported significant improvement of all prolapse and incontinence questionnaires as well as QoL and sexual function. Significant improvement of incontinence parameters on dynamic MRI (bladder neck descent, posterior urethrovesical angle and urethral inclination angle) was observed after ASC. Similarly, significant change in the position of the leading edge of prolapse and anorectal junction was observed.

CONCLUSIONS

In patients with prolapse and urethral hypermobility, ASC may return bladder neck and urethral anatomy towards normal as proved by dynamic MRI. However, further studies on larger number of patients with longer follow-up period are required.

MRI findings before and after prolapse surgery

BACKGROUND

Therapeutical outcome after prolapse surgery is evaluated using a standardized grading system based on maximum prolapse extent, which might not provide the full picture of the patient's subjective outcome. We therefore applied an evaluation method, which is detached from a grading system.

PURPOSE

To evaluate the impact of pelvic organ mobility in dynamic magnetic resonance imaging (MRI) before and after mesh-repair surgery in patients with symptomatic pelvic organ prolapse.

MATERIAL AND METHODS

To obtain measurements, we performed parasagittal T2-weighted turbo spin echo sequence at rest (TR, 3460 ms; TE, 85 ms; matrix, 512; slice thickness [ST], 5 mm), parasagittal T2-weighted true fast imaging with steady-state precession (TrueFISP) single-shot sequence during straining (TR, 397.4 ms; TE, 1.5 ms; matrix, 256; ST, 8 mm), and parasagittal T2-weighted TrueFISP sequence at maximum strain (TR, 4.3 ms; TE, 2.15 ms; matrix, 256; ST, 5 mm) at 1.5 T MRI. Pelvic organ prolapse (anatomical landmarks: bladder, cervix, pouch, rectum) was measured perpendicularly with reference to the pubococcygeal and the midpubic line. Pelvic organ mobility was defined as the difference between the measured distance at rest and at maximum strain for each anatomical landmark. All patients underwent mesh-repair procedure. Eighty patients could be included in this short-term follow-up study. Due to the physical diagnosis of pelvic organ prolapse, 51 underwent anterior mesh repair, 16 underwent posterior mesh repair, and 13 underwent total mesh repair. Surgery was performed by one surgeon, using mesh implants from several manufacturers.

RESULTS

Median values of maximum organ prolapse for bladder, cervix, pouch, and rectum preoperatively were 2.54 cm, 0.33 cm, 2.47 cm, and 0.32 cm, respectively, and 12 weeks postoperatively 0.87 cm, -1.79 cm, 1.49 cm, and 0.49 cm, respectively. Highly significant improvement (P < 0.001) of pelvic organ mobility was observed in the treated compartment at 4- and 12-week follow-up. Physical evaluation 12 weeks after mesh-repair showed an asymptomatic POP-Q stage I, if any.

CONCLUSION

Dynamic MRI is useful in visualizing the maximum extent of pelvic organ prolapse, as the evaluation of pelvic organ mobility documents the intraindividual therapeutic outcome detached from a grading system based on maximal prolapse values.

The role of urodynamics in the treatment of lower urinary tract symptoms in women

PURPOSE OF REVIEW

Urodynamic investigation was developed as an extension of patient history and physical examination in order to reveal the pathology of a patient's complaints. Much progress in standardizing definitions and procedures has been made in recent years. In particular, stress urinary incontinence and overactive bladder can be differentiated with urodynamics. The developed parameters, however, cannot distinguish the various types of stress urinary incontinence. Moreover the definition and diagnosis of voiding dysfunction is not clear. Finally our understanding of bladder sensations and the impact on voiding behaviour has only started to emerge. This review is about last year's publications that focus on urodynamics and lower urinary tract symptoms in women.

RECENT FINDINGS

Defining bladder outlet obstruction is based on voiding pressure, urinary flow speed and residual urine but standardization is lacking. Urodynamics to reveal occult stress urinary incontinence in patients with pelvic organ prolapse needs standardization of the reducing manoeuvres. The quest for urodynamic tools for distinguishing intrinsic sphincter deficiency from urethral hypermobility continues. Urodynamics are still not good enough to discriminate between treatment options for stress urinary incontinence. The use of urodynamics in overactive bladder is developing and has elicited new findings. Voiding habit seems to be independent from bladder sensations. Also bladder sensations appear to be imperfectly correlated with bladder filling. Even bladder volumes do not predict entirely bladder fullness sensations.

SUMMARY

In order to use urodynamics as a proper clinical tool, defining subtypes of stress urinary incontinence and standardization of urodynamics in pelvic organ prolapse and bladder outlet obstruction in women is needed.

Incontinence and voiding difficulties associated with prolapse

PURPOSE

Prolapse is the protrusion of a pelvic organ beyond its normal anatomical confines. It represents the failure of fibromuscular supports.

MATERIALS AND METHODS

A MEDLINE search was done using the keywords cystocele, uterine prolapse, vault prolapse, enterocele or rectocele in combination with urinary incontinence. We reviewed 97 articles. From this material the definition, classification, incidence, symptoms and evaluation are described.

RESULTS

Prolapse and urinary incontinence often occur concomitantly and cystocele, rectocele, enterocele, uterine descent or vaginal vault prolapse may also be present. The pathophysiology of prolapse encompasses direct and indirect injury, metabolic abnormalities and chronic high intra-abdominal pressure. Anterior vaginal wall prolapse may present as stress incontinence. A large cystocele may cause urethral kinking and overflow incontinence. Uterine descent can cause lower back and sacral pain. Enterocele may cause only vague symptoms of vaginal discomfort. A rectocele can lead to incomplete evacuation of stool. A thorough history and physical examination are the most important means of assessment. A voiding diary helps determine functional bladder capacity. Uroflow examination determines the average and maximum flow rates, and the shape of the curve can help identify Valsalva augmented voiding. Multichannel urodynamics or video-urodynamics with prolapse reduced can be important. The advantages of dynamic magnetic resonance imaging include excellent depiction of the soft tissues and pelvic organs, and their fluid content during various degrees of pelvic strain. To our knowledge whether it is cost-effective in this manner has not been determined.

CONCLUSIONS

Correction of prolapse must aim to restore vaginal function and any concomitant urinary incontinence.