Dynamic magnetic resonance imaging: reliability of anatomical landmarks and reference lines used to assess pelvic organ prolapse

The aim of this study was to determine the intra- and interobserver reliability of dynamic magnetic resonance (MR) staging in pelvic organ prolapse patients. In 30 patients with pelvic organ prolapse, dynamic MR images were assessed independently by two observers. Various anatomical landmarks to asses pelvic organ prolapse were used in relation to the pubococcygeal line, H-line, and mid-pubic line. Clinical measurement points were assessed in relation to the mid-pubic line. The intraclass correlation coefficients (ICC) were calculated to describe the intra- and interobserver reliability. Overall, the intra- and interobserver reliability of MR imaging measurements was excellent to good. The pubococcygeal line showed superior reliability (ICC range 0.70–0.99). The reliability of clinical measurement points, however, were only moderate (ICC range 0.20–0.96). The intra- and interobserver reliability of quantitative prolapse staging on dynamic MR imaging were good to excellent. The pubococcygeal line appears the most reliable to use.     

Fast magnetic resonance imaging of pelvic organ prolapse

Pelvic organ prolapse is abnormal displacement of the pelvic organs from their normal anatomical position. Patients may present with a variety of symptoms, including pain, incontinence, constipation, urinary retention, and defecatory dysfunction. Any combination of cystocele, rectocele, enterocele, sigmoidocele, peritoneocele, and prolapse of the vagina and uterus may occur. Therefore, accurate preoperative evaluation of each organ is important for proper surgical planning. Compared with physical examination and other imaging modalities, advantages of magnetic resonance imaging (MRI) include a global multiplanar view of the pelvis, and the lack of ionizing radiation and invasive procedures. Subsecond MRI techniques have not only shortened the imaging time to minimize motion artifacts but provide the capability for dynamic MRI. In this pictorial essay, we describe fast MRI techniques, MRI findings, and the associated clinical findings in patients with pelvic organ prolapse. We also refer to limitations of MRI.     

Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging

Objectives. With significant vaginal prolapse, it is often difficult to differentiate among cystocele, enterocele, and high rectocele by physical examination alone. Our group has previously demonstrated the utility of magnetic resonance imaging (MRI) for evaluating pelvic prolapse. We describe a simple objective grading system for quantifying pelvic floor relaxation and prolapse.Methods. One hundred sixty-four consecutive women presenting with pelvic pain (n = 39) or organ prolapse (n = 125) underwent dynamic MRI. The “H-line” (levator hiatus) measures the distance from the pubis to the posterior anal canal. The “M-line” (muscular pelvic floor relaxation) measures the descent of the levator plate from the pubococcygeal line. The “O” classification (organ prolapse) characterizes the degree of visceral prolapse beyond the H-line.Results. The image acquisition time was 2.5 minutes per study. Each study cost $540. In the pain group, the H-line averaged 5.2 ± 1.1 cm versus 7.5 ± 1.5 cm in the prolapse group (P <0.001). The M-line averaged 1.9 ± 1.2 cm in the pain group versus 4.1 ± 1.5 cm in the prolapse group (P <0.001). Incidental pelvic pathologic features were commonly noted, including uterine fibroids, ovarian cysts, hydroureter, urethral diverticula, and foreign body.Conclusions. The HMO classification provides a straightforward and reproducible method for staging and quantifying pelvic floor relaxation and visceral prolapse. Dynamic MRI requires no patient preparation and is ideal for the objective evaluation and follow-up of patients with pelvic prolapse and pelvic floor relaxation. MRI obviates the need for cystourethrography, pelvic ultrasound, or intravenous urography and has become the study of choice at our institution for evaluating the female pelvis.     

Standing open magnetic resonance imaging improves detection and staging of pelvic organ prolapse

IntroductionThe role of imaging in pelvic organ prolapse (POP) assessment is unclear. Open magnetic resonance imaging (MRI) systems have a configuration that allows for imaging women with POP in different positions. Herein, we use a 0.5 Tesla open MRI to obtain supine, seated, and standing images. We then compare these images to evaluate the impact of posture on detection and staging of POP.MethodsWomen presenting with symptoms of POP at a tertiary care university hospital were asked to participate in this prospective cohort study. Symptom scores, POP-Q staging and three-position MRI imaging of the pelvis data were collected. The pubococcygeal line (PCL) was used to quantify within-patient changes in pelvic organ position as defined by: no displacement, <1 cm inferior to the PCL, mild (1–3 cm), moderate (3.1–6 cm), and severe (>6 cm) in the axial and sagittal T2-weighted images. Statistical analysis was completed (T-test; p<0.05 significant).ResultsA total of 42 women, age range 40–78 years, participated. There was a significant difference in the mean values associated with anterior prolapse in the supine (0.7±1.8), seated (2.4±3.4), and upright (4.2±1.6) positions (p=0.015). There was a significant difference in the mean values associated with apical prolapse in the supine (0.5±1.5), seated (1.5±1.4), and upright (2.1±1.5) positions (p=0.036).ConclusionsOur findings suggest that POP is more readily detected and upstaged with standing MRI images as compared to supine and seated positions. The developed two-minute standing MRI protocol may enable clinicians to better assess the extent of POP.     

Magnetic resonance imaging of pelvic organ prolapse: comparing pubococcygeal and midpubic lines with clinical staging

Introduction and hypothesis  The aim of the study was to determine which magnetic resonance imaging (MRI) reference line for staging pelvic organ prolapse, the pubococcygeal line (PCL) vs. the midpubic line (MPL), has the highest agreement with clinical staging. Methods  A retrospective study of women with pelvic floor complaints who underwent dynamic pelvic MRI from January 2004 to April 2007 was conducted. Two radiologists staged descent on MRI for each pelvic compartment (anterior, apical, posterior) by consensus, using PCL and MPL reference lines. Agreement between MRI and clinical staging was estimated using weighted kappas. Results  Twenty women were included. Agreement between clinical and PCL staging was fair in the anterior (κ = 0.29) and poor in the apical (κ = 0.03) and posterior (κ = 0.08) compartments. Agreement between clinical and MPL staging was fair in the anterior (κ = 0.37), apical (κ = 0.31), and posterior (κ = 0.25) compartments. Conclusions  The MPL has higher agreement with clinical staging than the PCL. However, neither reference line has good agreement with clinical staging.     

Static magnetic resonance imaging of the pelvic floor muscle morphology in women with stress urinary incontinence and pelvic prolapse

In a study, the magnetic resonance imaging (MRI) findings of 69 women were analyzed to define the typical MRI appearance of the pelvic floor musculature in healthy subjects (n = 20) and women with urinary incontinence (UI) and/or genitourinary prolapse (GP) (n = 49). The following parameters were determined: thickness and signal intensity of the levator muscles on each side, distance between the urethra and symphysis, diameter of the proximal urethra, and thickness and configuration of the anterior vaginal wall. These parameters were correlated with the patients' age and parity, urodynamic parameters, and the clinical assessment of the pelvic floor. In contrast to healthy subjects, the frequent findings in women with UI and/or GP are higher signal intensity of the levator muscles (p < 0.05) and loss of the hammock-like configuration of the vagina (p < 0.01). On static MRI, the morphometry of the levator musculature identified no findings typical of either UI or GP. Analysis of MRI combined with patients' parity suggests that the severity of damage to the pelvic floor at delivery is determined by the traumatic event as such and not by the number of deliveries. Urethral diameter, distance of the symphysis to the urethra, and vaginal wall thickness cannot distinguish between controls and women with UI and/or GP. Urodynamic and functional clinical parameters do not correlate with the changes in the pelvic floor musculature demonstrated by static MRI. Although morphological changes in UI and/or GP can be demonstrated by MRI, they can be assigned a pathogenic role only if clinical symptoms are present. Neurourol. Urodynam. 17:579–589, 1998. © 1998 Wiley-Liss, Inc.     

An attempt to quantify magnetic resonance imaging in multiple sclerosis — correlation with clinical parameters

The diagnostic value of magnetic resonance imaging (MRI) in multiple sclerosis (MS) is uncontested. But only little information exists on its usefullness in monitoring disease activity. We describe a method of quantification that can be performed in longitudinal MRI-investigations. We used a standardized method of scanning and determined the area of demyelinating lesions with an interactive planimetric computer system. In order to determine the approximate lesion volumes, the computed area was multiplied by the slice thickness. In 89 patients with clinically definite MS we found an average lesion volume of 11900 mm³. The mean score in Kurtzke's expanded disability scale was 3.0. The correlation between computed lesion volume and neurological deficit was significant, but only weak (rho = 0.3). We conclude, that planimetric evaluation of MRI can be a valuable supplement to clinical rating scales in MS patients. The method described here, used in combination with high spacial resolution and better tissue specificity of latest generation MRI scanners, could be helpful in the evaluation of treatment in many other CNS diseases.     

Correlation between clinical features and magnetic resonance imaging findings in lumbar disc prolapse

Background:

Lumbar disc prolapse is one of the common causes of low back pain seen in the working population. There are contradictorty reports regarding the clinical significance of various magnetic resonance imaging (MRI) findings observed in these patients. The study was conducted to correlate the abnormalities observed on MRI and clinical features of lumbar disc prolapse.

Materials and Methods:

119 clinically diagnosed patients with lumbar disc prolapse were included in the study. Clinical evaluation included pain distribution, neurological symptoms and signs. MR evaluation included grades of disc degeneration, type of herniation, neural foramen compromise, nerve root compression, and miscellaneous findings. These MRI findings were tested for inter- and intraobserver variability. The MRI findings were then correlated with clinical symptoms and the level of disc prolapse as well as neurological signs and symptoms. Statistical analysis included the Kappa coefficient, Odd’s ratio, and logistic regression analysis.

Results:

There were no significant inter- or intraobserver variations for most of MRI findings (Kappa value more than 0.5) except for type of disc herniation which showed a interobserver variation of 0.46 (Kappa value). The clinical level of pain distribution correlated well with the MRI level (Kappa 0.8), but not all disc bulges produced symptoms. Central bulges and disc protrusions with thecal sac compression were mostly asymptomatic, while centrolateral protrusions and extrusions with neural foramen compromise correlated well with the dermatomal distribution of pain. Root compression observed in MRI did not produce neurological symptoms or deficits in all patients but when deficits were present, they correlated well with the presence of root compression in MRI. Multiple level disc herniations with foramen compromise were strongly associated with the presence of neurological signs.

Conclusions:

The presence of centrolateral protrusion or extrusion with gross foramen compromise correlates with clinical signs and symptoms very well, while central bulges and disc protrusions correlate poorly with clinical signs and symptoms. The presence of neural foramen compromise is more important in determining the clinical signs and symptoms while type of disc herniation (bulge, protrusion, or extrusion) correlates poorly with clinical signs and symptoms.     

Severity of pelvic organ prolapse associated with measurements of pelvic floor function

This study tested the hypothesis that clinical measurements of the superficial perineum and of pelvic floor muscle (PFM) function correlate with the severity of pelvic organ prolapse. This retrospective cross-sectional study assessed 1037 women in an academic urogynecologic practice. Greatest descent of prolapse, by the Pelvic Organ Prolapse Quantification system, was correlated with two assessments of levator function—the Oxford grading scale and levator hiatus (LH) size measured by digital examination. Correlations were calculated using Pearsons correlation for continuous variables and Kendalls tau-b. Severity of prolapse correlated moderately with genital hiatus (GH) (r=0.5, p<0.0001) and with LH (transverse r=0.4, p<0.0001; longitudinal r=0.5, p<0.0001), but weakly with the Oxford grading scale (r=–0.16, p<0.0001). LH correlated with GH (r=0.5, p<0.0001) but not with perineal body (r=0.06, p=0.06). Both GH and LH size are associated with the severity of prolapse. LH size correlates more strongly to prolapse severity than assessment of PFM function by the Oxford grading scale.W. Thomas Gregory: financial support from NIH/NICHD (K12HD-0143)     

Dynamic magnetic resonance imaging of the pelvic floor in children and adolescents with vesical and anorectal malformations

Background

Magnetic resonance imaging (MRI) of the pelvic floor allows better assessment of pelvic pathology and has a potential as an adjunct for therapy planning. In complex congenital malformations of the pelvic floor and continence organs, it plays a major role in assessing urinary and fecal incontinence or constipation, especially when performed as a dynamic investigation such as MRI defecography.

Patients and Methods

Twenty-three patients (3-21 years old) with urinary and/or fecal incontinence or constipation attributable to congenital malformations of the pelvic region presented at our institution. The diagnoses were anorectal malformations (18), bladder exstrophy (2), and cloacal exstrophy (3). All patients underwent static and dynamic MRI of the pelvic floor with rest, squeeze, and evacuation in supine position.

Results

Morphology and function of the pelvic floor and pelvic organs could be demonstrated in each case. The reason for urinary incontinence, fecal incontinence, or constipation could be defined, and an individual therapeutic management concept was made based upon the data obtained by the investigation.

Conclusions

The advantages of this method, in comparison to others, are direct visualization of the pelvic floor muscles and continence organs and their anatomical relationship during different functional actions. Pelvic floor dysfunction is often the reason for fecal and urinary incontinence and can be detected by MRI. Especially in children, minimizing radiation exposure is of major concern. Disadvantages are the costs and long investigation time.     

Dynamic magnetic resonance imaging of the pelvic floor in patients with idiopathic combined fecal and urinary incontinence

The etiologies of combined fecal and urinary incontinence may be interrelated but remain poorly understood. A potential variable in this process is global pelvic floor dysfunction. The aim of this study was to prospectively assess the use of phased-array, body coil dynamic MRI in identifying pelvic floor abnormalities in patients with combined incontinence symptoms. Symptomatic patients were compared to asymptomatic control subjects and were selected from those referred to the pelvic physiology laboratory with complaints of combined urinary and fecal incontinence. All patients underwent standard urodynamic studies and anorectal physiologic assessment. Colonoscopy and endoanal ultrasonography were also performed. A standardized protocol was used for dynamic MRI, and the parameters were measured using workstation software (callipers, compass, and densitometer). In the incontinent group there was a significant difference, when compared to control subjects, in the angle of the levator ani muscle arch of the levator plate complex (3.0 ± 5 degrees vs. 14 ± 10 degrees; P = 0.004), the width of the levator hiatus (58.3 ± 8 mm vs. 46.5 ± 8 mm; P = 0.001), the area and tissue density of the levator ani muscle (19.5 ±1 mm² vs. 26.9 ±1 mm²; P = 0.001, and 157.3 ± 47 pixels vs. 126.1 ± 23 pixels; P ± 0.025, respectively), and in the length of the external anal sphincter (20.0 ± 5 mm vs. 26.6 ± 13 mm; P = 0.03). Body coil dynamic MRI is a noninvasive and well-tolerated imaging modality. Our data show that it can identify changes in pelvic muscle morphology in patients with disorders of incontinence, and this may help in planning better management strategies. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 18–21, 2003 (oral presentation), and the Eighteenth Annual SSAT Residents and Fellows Research Conference, Orlando, Florida, May 17, 2003.     

经阴道网片盆底重建术治疗盆底脏器脱垂患者临床疗效

目的探讨经阴道网片盆底重建术治疗盆底脏器脱垂（pelvic organ prolapse,POP）患者的临床效果观察及安全性疗效。 方法选取2016年1月至2017年12月,河北省邯郸市中心医院118例POP患者的临床资料,按照术式不同分为2组,每组患者59例。对照组采用传统的手术方式进行治疗,试验组采用经阴道网片盆底重建术进行治疗。 结果试验组手术时间、术后首次下床活动及住院时间均短于对照组,差异有统计学意义（P<0.05）。试验组术中出血量与对照组比较比较,差异无统计学意义（P>0.05）。试验组术后有效率明显高于对照组,差异有统计学意义（P<0.05）。 结论经阴道网片盆底重建术是治疗POP患者有效、安全的术式,可显著改善患者的临床症状,但需严格按照手术适应症进行。     

Physiologic and radiographic testing in patients with pelvic floor disorders and pelvic organ prolapse

Pelvic floor disorders are common conditions that affects mainly the female population, especially the elderly. Anorectal physiology and imaging tests are important way to assess anal sphincter function and structure of the pelvic floor. Those tests are part of the workup for patients with incontinence, defecatory disorders and pelvic organ prolapse. The most relevant tests will be discussed in this article.     

A systematic review of clinical studies on dynamic magnetic resonance imaging of pelvic organ prolapse: the use of reference lines and anatomical landmarks

Introduction and hypothesis  The aim of our study was to provide a systematic literature review of clinical studies on pelvic organ prolapse staging with use of dynamic magnetic resonance (MR) imaging. Methods  The databases EMBASE and PubMed were searched. Clinical studies were included in case they compared pelvic organ prolapse stages as assessed on dynamic MR imaging (using a reference line) with a standardized method of clinical prolapse staging. Results  Ten studies were included, which made use of seven different reference lines in relation to a wide variety of anatomical landmarks. Conclusion  Only few studies have compared pelvic organ prolapse stages as assessed by dynamic MR imaging and clinical examination in a standardized manner. The available evidence suggests that prolapse assessment on dynamic MR imaging may be useful in the posterior compartment, but clinical assessment and dynamic MR imaging seem interchangeable in the anterior and central compartment.     

超声评估盆腔脏器脱垂患者盆底结构的研究进展

目的盆腔器官脱垂(POP)显著影响女性生活质量。本文对比三维超声新技术与其他成像技术,对经二维、三维超声成像技术获取的信息及超声观察POP患者的盆底结构的研究进展进行综述。     

Epidemiology and outcome assessment of pelvic organ prolapse

Introduction and hypothesis

The aim was to determine the incidence and prevalence of pelvic organ prolapse surgery and describe how outcomes are reported.

Methods

Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews, level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. A grade A recommendation usually depends on consistent level 1 evidence. A grade B recommendation usually depends on consistent level 2 and/or 3 studies, or “majority evidence” from RCTs. A grade C recommendation usually depends on level 4 studies or “majority evidence” from level 2/3 studies or Delphi processed expert opinion. A grade D “no recommendation possible” would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi .

Results

Pelvic organ prolapse (POP) when defined by symptoms has a prevalence of 3–6 % and up to 50 % when based upon vaginal examination. Surgery for prolapse is performed twice as commonly as continence surgery and prevalence varies widely from 6 to 18%. The incidence of POP surgery ranges from 1.5 to 1.8 per 1,000 women years and peaks in women aged 60–69. When reporting outcomes of the surgical management of prolapse, authors should include a variety of standardised anatomical and functional outcomes. Anatomical outcomes reported should include all POP-Q points and staging, utilising a traditional definition of success with the hymen as the threshold for success. Assessment should be prospective and assessors blinded as to the surgical intervention performed if possible and without any conflict of interest related to the assessment undertaken (grade C). Subjective success postoperatively should be defined as the absence of a vaginal bulge (grade C). Functional outcomes are best reported using valid, reliable and responsive symptom questionnaires and condition-specific HRQOL instruments (grade C). Sexual function is best reported utilising validated condition-specific HRQOL that assess sexual function or validated sexual function questionnaires such as the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire (PISQ) or the Female Sexual Function Index (FSFI). The sexual activity status of all study participants should be reported pre- and postoperatively under the following categories: sexually active without pain, sexually active with pain or not sexually active (grade C). Prolapse surgery should be defined as primary surgery, and repeat surgery sub-classified as primary surgery different site, repeat surgery, complications related to surgery and surgery for non-prolapse-related conditions (grade C).

Conclusion

Significant variation exists in the prevalence and incidence of pelvic organ prolapse surgery and how the outcomes are reported. Much of the variation may be improved by standardisation of definitions and outcomes of reporting on pelvic organ prolapse surgery.