dynamic MRI of pelvic floor

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Severe enterocele with vaginal vault prolapse, urethral hypermobility and urinary obstruction. (a, b) Sagittal midline TrueFISP images at rest (a) and during evacuation (b) of a patient previously submitted to hysterectomy, showing an enterocele. Note the herniation of small bowel loops into the rectovaginal septum. It is difficult to identify correctly the vaginal apex, but it is clear it is located below the PCL (red line), corresponding to a vaginal vault prolapse. The volume of the enterocele is so large that its mass effect over the vagina and urethra pushes them anteriorly, inducing also an horizontalization of their normal vertical axis—urethral hypermobility (white arrow)—and inducing obstruction of the bladder (the urinary volume of the bladder on both phases is similar, always above the PCL). Note also that the bladder is more distended than it should be. Although not relevant for this specific case, the bladder should be half distended, as preconized by the ESUR/ESGAR recommendations. Orange line: extent of the enterocele

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Normal female pelvic anatomy. Sagittal midline T2-TSE image demonstrating the perineal body (*) and the levator plate (white arrow). B, bladder; U, uterus; V, vagina; R, rectum

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Rectal prolapse with a moderate uterine prolapse. (a, b, c) Sagittal midline TrueFISP images at the beginning (a), middle (b), and end (c) of the evacuation phase demonstrating a rectal intussusception extending beyond the anal sphincter (red arrows). Note also that it is accompanied by a moderate uterine prolapse and a peritoneocele, both aggravating along the different times of the evacuation phase. Red line: PCL; purple line: extent of the uterine prolapse

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Spastic pelvic floor syndrome. (a, b, c) Sagittal midline TrueFISP images of a 39-year-old patient at rest (a), during squeezing (b) and during evacuation (c). Note in (a) the ARA is 99° (elevated basal tonus), associated with the reduction of the ARA during defecation (c) with 50°, corresponding to a paradoxical contraction of the puborectalis muscle

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Descending perineal syndrome in a man. (a, b) Sagittal midline TrueFISP images at rest (a) and during evacuation (b) of a man with complaints of constipation and incomplete evacuation showing an increase of the H and M lines during evacuation phase (blue line, 88 mm; green line, 63 mm respectively), compatible with descending perineal syndrome with increased hiatal width and descent

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Descending perineal syndrome with tricompartimental prolapse. (a, b) Sagittal midline TruFISP images at rest (a) and during evacuation (b). H line (blue line) measures 7.7 cm (a) and 9.8 cm (b) and the M line (green line) measures 2.3 cm (a) and 4.5 cm (b), demonstrating widening and descent of the levator hiatus, even at rest but aggravating during defecation. It is also associated with tricompartimental prolapse, with a severe cystocele and a severe uterine everted prolapse. Note the verticalization of the levator plate (white arrow). Another interesting finding is that the rectal contrast is only partially expelled (b), because the mass effect by both the cystocele and uterine prolapse induces mechanical posterior obstruction (dilated rectum filled with ultrasound gel) causing constipation and incomplete evacuation (*). (c) Axial T2-TSE image at the pubic symphysis plane showing bilateral ureterohydronephosis causes by the cystocele (red arrows)

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Descending perineal syndrome with tricompartimental prolapse and anterior rectocele. (a, b) Sagittal midline TrueFISP images at rest (a) and during evacuation (b). H line (blue line) measures 5.6 cm (a) and 9.5 cm (b) and the M line (green line) measures 1.3 cm (a) and 4.7 cm (b), demonstrating widening and descent of the levator hiatus. Note the vertical orientation of the levator plate (white arrow). It is also associated with a tricompartimental prolapse and an anterior rectocele (*)

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Peritoneocele with vaginal vault prolapse and rectal intussusception. (a, b) Sagittal midline TrueFISP images at rest (a) and during defecation (b) of a patient previously submitted to hysterectomy, showing a peritoneocele, where adipose peritoneal folds insinuate to the rectovaginal septum. It is associated with a prolapse of the vaginal vault, with the vaginal apex (white arrows) below the PCL (red line) during the evacuation. An apparent rectal invagination is also present (red arrow). Orange line: extent of the peritoneocele

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Moderate anterior rectocele. (a, b) Sagittal midline TrueFISP images at rest (a) and during evacuation (b) revealing a moderate anterior rectocele (orange line: 37 mm). Note also a cystocele (green line) and a rectal intra-anal intussusception (white arrow). Red line: PCL line; black line: normal expected contour of the anterior anorectal wall

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Pelvic compartments. Sagittal midline T2-TSE image representing the three pelvic compartments in different colors

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Small rectoceles. Sagittal midline TrueFISP image during evacuation, showing both anterior and posterior small rectoceles. Black lines: normal expected contours of the anorectal wall; orange lines: extent of the rectoceles: 13 mm anterior and 9 mm posterior

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Uterine prolapse. Sagittal midline TrueFISP image at rest revealing an everted uterus filling of the vaginal space, which extends below the distal third of the vagina. Red line: PCL; purple line: extent of the uterine prolapse

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Moderate cystocele with urethral hypermobility. (a, b) Sagittal midline TrueFISP images at rest (a) and during evacuation (b), demonstrating descent of the bladder during evacuation (green line—3.8 cm) below the PCL (red line), as well as horizontalization of the urethral axis during defecation (white arrows). Note also an anterior rectocele in (b)

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Importance of the evacuation phase. (a, b, c) Sagittal midline TrueFISP images at rest (a), during straining (b), and evacuation (c) of a patient with descending perineal syndrome with tricompartimental prolapse, anterior rectocele, and rectal mucosa intussusception. Note that, although in the straining phase (b) the H and M lines (blue and right green lines) are already above the normal values, indicating a descending perineal syndrome, and a mild bulge of the anterior rectal wall is seen (white arrow), only in the evacuation phase (c) the true pelvic floor disorder is adequately characterized, with a tricompartimental prolapse (cystocele, uterine prolapse, and rectal prolapse) the true size of the rectocele is documented (orange line: 4.8 cm) and the rectal mucosa intussusception is depicted (red arrow). Left green line: extent of cystocele; purple line: extent of uterine prolapse; black line: normal expected contour of the anterior anorectal wall; red line: PCL line

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Normal anorectal angles. (a, b, c) Sagittal midline TrueFISP images at rest (a), during squeezing (b), and evacuation (c), with normal measurements of the ARA: 122° (a); 109° (b); 137° (c)

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Normal H and M lines. Sagittal midline T2-TSE image demonstrating the normal measurements of the H (4.47 cm) and M (1.16 cm) lines. Red line: PCL; blue line: H line; green line: M line

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Representative image of the pelvic floor ligaments and their relative anatomical positions in a female model

Dynamic

magnetic resonance imaging of the female pelvic floor—a pictorial review. Spastic pelvic floor syndrome. (a, b, c) Sagittal midline TrueFISP images of a man at rest (a), during squeezing (b) and evacuation (c), demonstrating a normal ARA angle at rest in (a) (118°), but revealing an increased reduction during squeezing in (b) (85°) and a lack of normal widening in the evacuation phase (c) (120°). During the dynamic evaluation, spastic contractions of the puborectalis muscle during evacuation were noted as well, and an incomplete evacuation with retention of ultrasound gel was present, all signs compatible with paradoxical contraction of the puborectalis muscle