女性盆腔器官脱垂病人肛提肌的MRI评价

盆腔器官脱垂是指由于盆底支持结构薄弱而导致盆腔脏器脱离正常的解剖位置。肛提肌是盆底支持结构中的重要组成部分,其结构损伤及功能障碍是盆腔器官脱垂的重要致病原因,因此对肛提肌的解剖结构进行详细描述成为盆腔器官脱垂研究的关键。动态MRI、扩散张量成像和纤维束示踪技术以及三维有限元分析等MRI技术能够提供肛提肌形态、运动、功能、微观结构以及生物力学等方面的信息,对于探索盆腔器官脱垂发病机制、完善其临床诊断和治疗具有重要的价值。     

Dynamic MR imaging of pelvic organ prolapse: spectrum of abnormalities.

Pelvic organ prolapse is a relatively common condition in women that can have a significant impact on quality of life. Pelvic organ prolapse typically demonstrates multiple abnormalities and may involve the urethra, bladder, vaginal vault, rectum, and small bowel. Patients may present with pain, pressure, urinary and fecal incontinence, constipation, urinary retention, and defecatory dysfunction. Diagnosis is made primarily on the basis of findings at physical pelvic examination. Imaging is useful in patients in whom findings at physical examination are equivocal. Fluoroscopy, ultrasonography, and magnetic resonance (MR) imaging can be useful in evaluating pelvic organ prolapse. Advantages of MR imaging include lack of ionizing radiation, depiction of the soft tissues of the pelvic floor, and multiplanar imaging capability. Dynamic imaging is usually necessary to demonstrate pelvic organ prolapse, which may be obvious only when abdominal pressure is increased. Treatment is more likely to be successful if a survey of the entire pelvis is performed prior to therapy. Therapy is usually undertaken only in symptomatic patients. In all patients, imaging findings must be interpreted in conjunction with physical examination findings and the patient's symptoms.     

Computed tomography evaluation of pelvic organ prolapse. Techniques and applications

OBJECTIVES: Pelvic organ prolapse is a common debilitating condition affecting women. Cross-sectional imaging with magnetic resonance imaging (MRI) depicts pelvic floor anatomy as well as organ prolapse and can complement or replace fluoroscopy. Occasionally, patients cannot tolerate MRI, but multiplanar visualization of pelvic floor soft tissue anatomy and organ prolapse is clinically desired. The objective of this study was to determine if computed tomography (CT) is a potential diagnostic technique in these specific situations for demonstrating organ prolapse and the pelvic floor. METHODS: Seven women (mean age: 63.5 years) with clinical pelvic organ prolapse were referred for CT of the pelvis from the gynecologic and surgical clinics from November 1998 to September 2001. The CT technique included the following: insufflation of rectal air, positive oral contrast, supine position with knees flexed, and imaging at rest and straining with a single-detector scan in 5 cases (slice thickness of 3 mm, table speed of 5 mm/s, 2-mm reconstruction interval) and a multidetector scan in 1 case (detector collimation of 1 mm, slice thickness of 1.25 mm, 1-mm reconstruction interval). Axial and 3-dimensional images were interpreted. RESULTS: Computed tomography demonstrated prolapse in 5 of 7 patients. At CT, cystocele was present in 2 of 7 patients, vault or cervical prolapse was present in 4 of 7, enterocele was present in 3 of 7, rectocele was present in 2 of 7, and levator abnormalities were present in 4 of 7. Surgery was performed in 3 of the 5 patients with positive CT findings, and prolapse was confirmed. Surgery was also performed in 1 patient with negative CT findings, and global prolapse was detected. CONCLUSIONS: Demonstration of pelvic organ prolapse and muscular pelvic floor abnormalities is feasible with CT if the patient strains adequately. In patients who cannot tolerate MRI, CT may be useful as an alternative diagnostic tool.     

Functional imaging of the pelvic floor

The clinical treatment of patients with anorectal and pelvic floor dysfunction is often difficult. Dynamic cystocolpoproctography (DCP) has evolved from a method of evaluating the anorectum for functional disorders to its current status as a functional method of evaluating the global pelvic floor for defecatory disorders and pelvic organ prolapse. It has both high observer accuracy and a high yield of positive diagnoses. Clinicians find it a useful diagnostic tool that can alter management decisions from surgical to medical and vice versa in many cases. Functional radiography provides the maximum stress to the pelvic floor, resulting in levator ani relaxation accompanied by rectal emptying-which is needed to diagnose defecatory disorders. It also provides organ-specific quantificative information about female pelvic organ prolapse-information that usually can only be inferred by means of physical examination. The application of functional radiography to the assessment of defecatory disorders and pelvic organ prolapse has highlighted the limitations of physical examination. It has become clear that pelvic floor disorders rarely occur in isolation and that global pelvic floor assessment is necessary. Despite the advances in other imaging methods, DCP has remained a practical, cost-effective procedure for the evaluation of anorectal and pelvic floor dysfunction. In this article, the authors describe the technique they use when performing DCP, define the radiographic criteria used for diagnosis, and discuss the limitations and clinical utility of DCP.     

Dynamic MR imaging of female organ prolapse

MR imaging is a viable technique for evaluating pelvic organ prolapse. Dynamic imaging with adequate increase in abdominal pressure is necessary for a successful study. Rectal contrast for patient defecation is easy to administer and also allows for the diagnosis of rectal abnormalities. Additional work is needed on the soft tissue changes of prolapse and grading criteria for MR.     

Dynamic MR imaging of the pelvic floor in asymptomatic subjects

OBJECTIVE: Dynamic MR imaging may be used as an alternative to dynamic cystoproctography for the evaluation of pelvic floor prolapse and configuration. MR criteria for normality are derived from proctographic studies because no large MR study of asymptomatic individuals has been performed. Our study aimed to define the normal range of dynamic pelvic MR appearances in a large group of asymptomatic individuals. SUBJECTS AND METHODS: Fifty healthy adult volunteers (25 men and 25 women; age range, 20-66 years; mean age, 34 years) were prospectively recruited and examined using dynamic MR imaging. All subjects were interviewed and established as healthy using a validated questionnaire. Axial, coronal, and sagittal MR imaging was performed at rest and during maximum pelvic strain using a static 1.0-T unit and a fast-field-echo sequence, providing 10 slices in 31 sec. Standardized measurements of pelvic configuration were taken, and rest and strain imaging were compared to determine the range of normal appearances. RESULTS: Three women developed a cystocele during maximum pelvic strain, two of whom also showed grade 1 uterocervical prolapse, which was also seen in another woman. Three men showed posterior pelvic floor descent in excess of 3 cm during straining. No rectocele, enterocele, rectal prolapse, or perineal hernia was seen in any subject. CONCLUSION: The normal range of pelvic organ descent in asymptomatic subjects seen on dynamic MR imaging included cystocele, uterocervical prolapse, and excessive anorectal junction descent. Although we encountered pelvic prolapse in seven volunteers, it was infrequent and low grade, suggesting that criteria for abnormality derived from proctography are generally applicable to MR imaging.     

Dynamic magnetic resonance imaging; reliability of assessment and correlation with clinical findings of pelvic organ prolapse

Introduction

Pelvic floor dysfunction and prolapse affect about 50% of women past middle age. Failure to recognize the complex set of pelvic floor defects in individuals leads to most postsurgical failures. Diagnosis and grading of pelvic floor dysfunction is primarily done by physical examination. Imaging does not have yet an established role in the investigation of prolapse, yet it is expected to play a role in preoperative planning identifying soft tissue abnormalities which will help avoiding recurrence.

Aim of the work

This is a prospective study targeted at defining the role of MRI in assessment of pelvic floor prolapse in females.

Methods

Dynamic and static MRI was performed in 40 female patients complaining of pelvic organ prolapse and/or stress urinary incontinence or fecal incontinence. Full history was taken and clinical examination performed and findings compared with MRI results.

Results

Good concordance was found between dynamic MRI and clinical examination in all three compartments, it was 82.5% in the anterior compartment, 80% in the posterior compartment, 85% in enteroceles and 65.0% in the middle compartment.

Conclusion

Dynamic MRI is expected to be a promising imaging tool and to play a larger role in the preoperative planning of pelvic organ prolapse in the near future.     

Imaging of the posterior pelvic floor

Disorders of the posterior pelvic floor are relatively common. The role of imaging in this field is increasing, especially in constipation, prolapse and anal incontinence, and currently imaging is an integral part of the investigation of these pelvic floor disorders. Evacuation proctography provides both structural and functional information for rectal voiding and prolapse. Dynamic MRI may be a valuable alternative as the pelvic floor muscles are visualised, and it is currently under evaluation. Endoluminal imaging is important in the management of anal incontinence. Both endosonography and endoanal MRI can be used for detection of anal sphincter defects. Endoanal MRI has the advantage of simultaneously evaluating external sphincter atrophy, which is an important predictive factor for the outcome of sphincter repair. Many aspects of constipation and prolapse remain incompletely understood and treatment is partly empirical; however, imaging has a central role in management to place patients into treatment-defined groups.     

静、动态MRI用于盆底功能障碍肛提肌评价的研究进展

盆底功能障碍是由于盆底支持结构薄弱所引起的包括盆腔器官脱垂、排尿及排便功能障碍等一系列症状的疾病。肛提肌是支持盆底的主要结构,静态MRI具有较高的软组织分辨力,能客观地评价肛提肌的形态及结构,动态MRI能实时反映肛提肌的运动及功能,为其全面评估提供客观依据。就静、动态MRI在盆底功能障碍中对肛提肌评价的应用及研究进展予以综述。     

盆腔器官脱垂病变的MRI技术应用进展

盆腔器官脱垂（POP）的准确诊断对制定治疗策略及评估疾病预后至关重要。MRI具有无辐射、软组织分辨力高及可无创性反映组织微观结构及功能变化等优点,在POP的评估中具有重要价值。目前,传统的动态MRI（dMRI）及三维MRI、扩散张量成像（DTI）、T₂ mapping等功能成像在POP术前、术后及康复治疗后的应用逐步发展。就各种MRI技术在POP诊疗中的研究进展予以综述。     

Magnetic resonance imaging in evaluating functional disorders of female pelvic floor

PURPOSE: To evaluate the diagnostic capabilities of MRI in the study of functional diseases of the female pelvic floor. MATERIALS AND METHODS: Ten healthy volunteers and 30 patients with clinically suspected pelvic floor deficiency, with or without pelvic organ prolapse, were evaluated by a high field strength magnet operating at 1.5 T. In each case SSFSE sequences (TR/TE:25720/67) in axial, coronal and sagittal planes, both at rest and during Valsalva's manoeuvre, were performed. Based on the MRI findings using fixed and mobile anatomical landmarks, the functional disease of the pelvic floor was diagnosed and quantified based on the identification and grading of visceral prolapse. The MRI findings were compared with the clinical findings in all cases and with the surgical data in the 7 patients who had undergone surgery. RESULTS: The MR image quality was adequate in all cases. In the group of symptomatic women MRI diagnosed: urethral hypermobility syndrome: 22 cases; isolated abnormalities of the anterior compartment: 8 cases of cystocele (low grade: 2, middle grade: 2, severe: 4); isolated abnormalities of the middle compartment: 6 cases of hysterocele (low grade: 2, middle grade: 4); isolated abnormalities of the posterior compartment: 5 cases of low-grade rectocele; 2 cases of enterocele (1 low grade, 1 middle grade); multi-compartment abnormalities: 11 cases; joint prolapse of anterior and middle compartment: 5 cases; joint prolapse of posterior and middle compartment: 3 cases; joint prolapse of anterior, middle and posterior compartment: 3 cases. The values of both fixed and mobile landmarks were significantly higher in the symptomatic group compared with the healthy volunteers. MRI confirmed the pelvic examination findings in all cases; in particular MRI findings were in total agreement with the clinical severity of prolapse, as defined by the Baden-Walker classification. In 7 cases MRI detected additional alterations (4 cases of hysterocele and 3 of enterocele) that had been missed at clinical evaluation. DISCUSSION AND CONCLUSIONS: In our experience MRI made an important contribution to the diagnosis and grading of functional disorders of the female pelvic floor and pelvic organ prolapse. The ability to simultaneously demonstrate both muscular and ligamentous structures and pelvic viscera, without using X-rays or contrast agents, is the main reason for the good results achieved by MRI and for its widespread use in this disorder. Furthermore the use of fast, breath-hold sequences can provide high-quality images both at rest and during Valsalva's manoeuvre. In conclusion MRI proved to be an accurate imaging tool that is more sensitive than clinical pelvic evaluation in diagnosing and grading functional disorders of the female pelvic floor and pelvic visceral prolapse.     

Total pelvic floor ultrasound for pelvic floor defaecatory dysfunction: a pictorial review

Total pelvic floor ultrasound is used for the dynamic assessment of pelvic floor dysfunction and allows multicompartmental anatomical and functional assessment. Pelvic floor dysfunction includes defaecatory, urinary and sexual dysfunction, pelvic organ prolapse and pain. It is common, increasingly recognized and associated with increasing age and multiparity. Other options for assessment include defaecation proctography and defaecation MRI. Total pelvic floor ultrasound is a cheap, safe, imaging tool, which may be performed as a first-line investigation in outpatients. It allows dynamic assessment of the entire pelvic floor, essential for treatment planning for females who often have multiple diagnoses where treatment should address all aspects of dysfunction to yield optimal results. Transvaginal scanning using a rotating single crystal probe provides sagittal views of bladder neck support anteriorly. Posterior transvaginal ultrasound may reveal rectocoele, enterocoele or intussusception whilst bearing down. The vaginal probe is also used to acquire a 360° cross-sectional image to allow anatomical visualization of the pelvic floor and provides information regarding levator plate integrity and pelvic organ alignment. Dynamic transperineal ultrasound using a conventional curved array probe provides a global view of the anterior, middle and posterior compartments and may show cystocoele, enterocoele, sigmoidocoele or rectocoele. This pictorial review provides an atlas of normal and pathological images required for global pelvic floor assessment in females presenting with defaecatory dysfunction. Total pelvic floor ultrasound may be used with complementary endoanal ultrasound to assess the sphincter complex, but this is beyond the scope of this review.     

The role of the MR-fluoroscopy in the diagnosis and staging of the pelvic organ prolapse

INTRODUCTION: The aim of the study is to investigate the efficacy of the magnetic resonance fluoroscopy in the diagnosis and staging of the pelvic prolapse. MATERIALS AND METHODS: The study consisted of 46 patients who were known to have pelvic prolapses from their vaginal examination. Thirty women who underwent vaginal exam and shown not have pelvic prolapse were selected as a control group. Firstly, pelvic sagittal FSE T2 weighted images of all the women were acquired in 0.3 T open MR equipment than sagittal MR-fluoroscopic images using spoiled gradient echo sequences were obtained during pelvic strain. Physical examination and MR-fluoroscopic findings were compared. The relationship between the stages of prolapse established by both of the methods was evaluated statistically with Pearson's correlation analysis. RESULTS: Physical examination and MR findings were very concordant in the diagnosis of pelvic prolapse and statistical correlations in the stages of prolapse were established between both of the methods (P<0.01 for anterior and middle comportment, P<0.05 for posterior comportment). CONCLUSION: We conclude that MR-fluoroscopy is a non-invasive, easily applied, dynamic useful method without contrast agent in the diagnosis and staging of pelvic organ prolapse.     

Pelvic floor descent in women: dynamic evaluation with fast MR imaging and cinematic display

The authors present a new method for assessing pelvic prolapse with dynamic fast magnetic resonance (MR) imaging. Twenty-six women with signs and symptoms suggesting pelvic prolapse and 16 control subjects were studied with a series of fast (6-12-second) MR images. Sagittal and coronal images were obtained with graded increase in voluntary pelvic strain, allowing for dynamic display and quantification of the pelvic prolapse process. The distance from the pubococcygeal line was used as an internal reference for measurement of descent in the maximal strain position. With use of control results for normal limit values, prolapse involving the anterior pelvic compartment (cystocele), the middle compartment (vaginal prolapse, uterine prolapse, and enterocele), and the posterior compartment (rectocele) was easily demonstrated. Significant differences between control subjects and patients with prolapse were seen at maximal strain but not in the relaxed state. Quantification of the pelvic descent process with use of fast MR imaging may be of value in surgical planning and postsurgical follow-up.     

Dynamic evaluation of female pelvic organ prolapse by extended proctography

More accurate preoperative assessment by DCP or MR imaging hopefully should reduce the incidence of operative failure. These techniques help the surgeon to plan the different components of pelvic reconstructive surgery and, importantly, whether a transvaginal or transabdominal approach will be required. The current trend is toward the transabdominal route. Available evidence suggests that the reoperative rate is halved when the abdominal approach is employed. Large enteroceles and marked vaginal vault prolapse, in particular, are much more amenable to correction by transabdominal surgery. It should be recognized that enteroceles and sigmoidoceles often escape preoperative detection unless radiologic evaluation is performed. Global assessment of pelvic organ prolapse is optimized by ensuring that competing organs are effectively emptied by virtue of a triphasic approach. As expressed succinctly by Halligan, "the global pelvic floor specialist has arrived, and his closest ally is the radiologist".     

盆底功能性疾病的动态MRI研究

目的　评价盆底动态MRI形态学表现与盆底功能性疾病的相关性。资料与方法　采用Siemens 1.0T超导磁共振成像仪对 6 0例妇女进行MRI检查 ,将这些受试者分为两组 :30例为无症状健康志愿者和 30例为盆底功能性疾病患者。采用仰卧位使用梯度回波二维FLASHT1WI快速扫描序列获得屏气期间盆底横断面、冠状面和矢状面的静息和最大盆腔用力时MR影像。所有影像用于观测盆腔器官脱垂和盆底形态 ,比较两组间盆腔器官脱垂和盆底形态变化的程度。结果　盆腔器官脱垂常发生于多个部位 ,盆底功能性疾病患者发生频率较高 ,与健康受试者比较相差显著 :膀胱膨出 (P <0 .0 1) ,子宫颈脱垂 (P <0 .0 1) ,盆底疝 (P <0 .0 1) ,直肠连接异常下降 (P <0 .0 1) ,直肠膨出 (P <0 .0 1)和盆隔裂孔膨胀 (P <0 .0 1)。结论　盆底动态MRI可用于准确评价盆腔器官脱垂和盆底形态 ,盆底功能性疾病患者常出现整个盆底软弱 ,盆腔器官脱垂频繁发生于多个部位并伴随盆隔裂孔的显著膨胀     

Practical MR imaging of female pelvic floor weakness.

Pelvic floor weakness is common in middle-aged and elderly parous women and is often associated with stress incontinence, uterine prolapse, constipation, and incomplete defecation. Most patients with incontinence and minimal pelvic floor weakness can be treated based on physical examination and basic urodynamic findings. However, in women with symptoms of multicompartment involvement for whom a complex repair is planned or who have undergone previous repairs, magnetic resonance (MR) imaging can be a useful preoperative planning tool. The MR imaging evaluation is performed with the patient in the supine position, without contrast agents, and within 15 minutes. A multicoil array and a rapid half-Fourier T2-weighted imaging sequence are used to obtain sagittal images while the patient is at rest and during pelvic strain, followed by axial images. On these images, the radiologist identifies the pubococcygeal line (which represents the level of the pelvic floor), the H and M lines (which are helpful for confirming pelvic floor laxity), and the angle of the levator plate with the pubococcygeal line (which is helpful for identifying small bowel prolapse). In the appropriate patient, MR images provide relatively easy three-dimensional conceptualization of the pelvic floor and can significantly influence treatment planning.     

Pelvic floor descent: dynamic MR imaging using a half-Fourier RARE sequence

Dynamic magnetic resonance imaging (MRI) using a single shot fast spin-echo technique was evaluated as a noninvasive alternative to cystourethography or colpocystorectography in patients with pelvic organ prolapse and/or urinary incontinence. Thirty-two patients were included in this prospective study. Colpocystorectography was performed in 10 patients who previously had undergone hysterectomy and in 2 patients without history of hysterectomy with clinical suspicion of rectoceles. Bead-chain cystourethrography was performed in 20 patients without hysterectomy. For dynamic MRI, a single-slice half-Fourier RARE sequence (imaging time 2 seconds) was used to depict the pelvic organs at different levels of pelvic strain. The results obtained with dynamic MRI were correlated with the x-ray findings. All 17 cystoceles, 10 rectoceles, 2 enteroceles, and 7 vaginal prolapses could be demonstrated on MRI. Diagnostic information gained from these images was equivalent to that obtained with colpocystorectography and superior to that obtained with cystourethrography; with the latter, important findings were missed (four rectoceles). We conclude that dynamic MRI of the pelvic floor with a half-Fourier RARE sequence can reliably detect descents of all three pelvic compartments, that it requires no contrast agent, and that no radiation exposure is involved.     

MR排便造影在后盆腔障碍性疾病中的评估价值

后盆腔障碍疾病是以肛直肠解剖和功能异常为主的一类盆底功能障碍性疾病,伴有便秘、便失禁等临床症状。MR排便造影是一种动态MR成像方法,可对后盆腔结构形态和运动功能异常情况直观显示,能够鉴别后盆腔障碍性疾病的类型并认识其发病原因,如直肠膨出、肠疝、盆腔器官脱垂和直肠套叠、脱垂等,同时对便失禁早期的肛直肠形态学和功能学异常改变的诊断有重要提示价值。     

高龄女性盆腔脏器脱垂手术的疗效分析

目的探讨≥70岁老年女性盆腔脏器脱垂手术治疗的可行性及近期疗效。方法回顾性分析2006年4月—2010年12月收治的≥70岁的女性盆腔脏器脱垂Ⅱ~Ⅳ度患者的手术和随访情况。结果 66名患者中,除1例术中发生直肠损伤外,余全部顺利完成;平均手术时间为(109.17±35.04)min,术中估计出血量平均(161.06±144.92)ml,2例因出血>500 ml而输血;术后平均住院时间(6.83±2.36)d;住院期间4例患者出现排尿困难,余62例平均保留尿管3.7 d;2例出现心衰,经对症治疗后好转。平均随访(16.23±12.46)个月,随访率95.5%,盆腔器官脱垂解剖治愈率达95.5%,主观治愈率为98.5%。术前尿频尿急症状除1例患者仍存在外余基本消失,术后3例出现新发压力性尿失禁,1例出现盆腔痛,5(8%)例患者出现网片侵蚀,所有症状经对症处理后均消失。结论高龄盆腔脏器脱垂患者,合适的手术治疗是安全、有效的。