This presentation is prepared in Microsoft PowerPoint and it contains 58 slides. This is uploaded for only education purpose.

1. IMAGING OF PELVIC FLOOR WEAKNESS
By- Dr. Rabin Mili
Guide: Dr. P. Thapa
(Associate Prof. SMCH)

2.  Pelvic floor weakness - a spectrum of functional
disorders caused by impairment of the ligaments,
fasciae, and muscles that support the pelvic organs
 Such disorders include-
o Urinary and fecal incontinence
o Obstructed defecation, and
o Pelvic organ prolapse

3.  ~ 50% of women older than 50 years are
affected -worldwide
 Prolapse is one of the most common
indications for gynecologic surgery
 In developing countries, the prevalence of
Pelvic organ prolapse - 19.7%, Urinary
incontinence - 28.7%, and Fecal
incontinence- 7%

4.  Multiparity
 Advanced age
 Pregnancy
 Obesity
 Menopause
 Connective tissue disorders
 Smoking
 COPD
 Chronic conditions increasing intra-
abdominal pressure

5.  Pain
 Urinary & fecal incontinense
 Constipation
 Difficulty in voiding
 A sense of pressure
 Sexual dysfunction

6.  Pelvic floor-comprising three compartments:
oAnterior compartment: bladder and urethra
oMiddle compartment: vagina and uterus, and
oPosterior compartment: rectum
 Supporting structures of the female pelvis consist
oThe endopelvic fascia
oThe pelvic diaphragm, and
oThe urogenital diaphragm

7.  Urethral ligaments and perineal body are the only
components of the endopelvic fascia and ligaments
that are directly depicted on MR images obtained
with standard sequences
 It is the most superior layer of the pelvic floor,
covers the levator ani muscles and pelvic organs in a
continuous sheet
 In the anterior compartment, the portion of
endopelvic fascia that extends from the anterior
vaginal wall to the pubis - the pubocervical fascia.

8.  Three groups of ligaments supporting the female
urethra:
o Periurethral ligaments arising from the puborectalis
muscle, ventral to the urethra
o Paraurethral ligaments arising from the lateral wall of
the urethra and extending to the periurethral
ligaments; and
o Pubourethral ligaments, which extend from the pelvic
bone to the ventral wall of the urethra

9.  The ligaments and anterior vaginal wall provide a
hammock-like support and play an important role
in maintaining urinary continence in women
 A tear in the pubocervical fascia or periurethral
ligament can lead to a cystocele, urethral
hypermobility, or urinary incontinence
 In the middle compartment, elastic condensations
of endopelvic fascia known as the paracolpium
and parametrium provide support to the vagina,
cervix, and uterus, preventing genital organ
prolapse

10.  The posterior compartment contains an important
anchoring structure for muscles and ligaments, called
the perineal body or central tendon of the perineum,
which lies within the anovaginal septum and prevents
the expansion of the urogenital hiatus
 The rectovaginal fascia is a portion of the endopelvic
fascia that extends from the posterior wall of the
vagina to the anterior wall of the rectum and attaches
to the perineal body, preventing posterior prolapse.
 A tear in the rectovaginal fascia can be inferred from
the presence of an anterior rectocele or enterocele.

11. Axial T2-weighted MR images –
Normal female pelvic floor anatomy.

12. Sagittal T2-weighted MR-
Normal female pelvic floor anatomy

13.  Lies deep to the endopelvic fascia
 Formed by the ischiococcygeus muscles and the
levator ani, which is composed of the
iliococcygeus, puborectalis, and pubococcygeus
muscles
 In healthy people these muscles continuously
contract, providing tone to the pelvic floor and
maintaining the pelvic organs in the correct
position.
 This muscle plays an important role in elevating
the bladder neck and compressing it against the
pubic symphysis

15.  The location of the urogenital diaphragm is caudal
to the pelvic diaphragm and anterior to the
anorectum
 Composed of connective tissue and the deep
transverse muscle of the perineum, which
originates at the inner surface of the ischial ramus.
 It has multiple attachments to surrounding
structures, including the vagina, perineal body,
external anal sphincter, and bulbocavernosus
muscle

16.  Dynamic Cystoproctography
 MR Defecography, and
 Ultrasonography

17.  Advantage: It can be done in standing or sitting
 Disadvantages:
o Invasive
o simultaneous evaluation of all three pelvic
compartments not possible
o Ionizing radiation
 Including squeezing, straining and evacuation
phases

18.  A dynamic study in which the pelvic organs are evaluated
in real time while the patient is at rest and performing
maneuvers such as defecation after filling of the distal
rectum with a substance such as US gel
 Usually performed to evaluate the posterior pelvic
compartment: rectocele, intussusception, or anismus
 Also detect the detection of prolapse in other
compartments
 Advantages-
o It provides anatomic information about the muscles,
ligaments, and sphincters, as well as functional
information
o Multiplannar, high temporal and spatial resolution of
the soft tissues
o No radiation
o Noninvasive

19.  An alternative method for evaluating the pelvic
floor in patients with symptoms of urinary
incontinence, pelvic organ prolapse, fecal
incontinence, or obstructed defecation
 Translabial (transperineal) technique is commonly
used.
 US is easy to perform, is cost-effective, and does
not expose the patient to ionizing radiation, but
the field of view is confined

20. Pubococcygeal line (PCL):
 A line drawn from the inferior border of the pubic
symphysis to the last coccygeal joint
 Represents the approximate line of attachment of
pelvic floor muscles  the level of the pelvic floor
 Most frequently used for measuring organ prolapse
Midpubic line (MPL):
 The line drawn caudal along the long axis of the
pubic symphysis
 It corresponds to the level of the vaginal hymen
 The perpendicular distance from the reference
points to the PCL or MPL are measured both at rest
and at maximal strain, usually during the defecation
phase

21. Reference point:
 In the anterior compartment: the most posterior
and inferior aspect of the bladder base
 In the middle compartment: the most anterior and
inferior aspect of the cervix and in post-
hysterectomy: posterosuperior vaginal apex
 In the posterior compartment: the anterior aspect
of the anorectal junction
The “rule of three”: grading of severity of prolapse

 Descent of an organ below the PCL by –
o >/= 3 cm  mild
o 3–6 cm  moderate, and
o > 6 cm  severe

22. Mid sagittal T2WI images showing (a) PCL & (b) MPL

23. Grade Distance from the PCL
Mild 1–3 cm below
Moderate 3–6 cm below
Severe >6 cm below

24. Stage Distance from the MPL
0 >3 cm above (TVL* – 2 cm)
1 >1 cm to 3 cm above
2 ≤1 cm above or below
3 >1 cm below
4 Complete organ eversion

25. The H and M lines:
 The H line is drawn on a midsagittal image from the
inferior border of the pubic symphysis to the
posterior wall of the rectum at the level of the
anorectal junction
 The M line is a vertical line drawn perpendicularly
from the PCL to the posterior aspect of the H line
 H line  anteroposterior width of the levator hiatus,
and the M line  the distance of its descent
 Normal value H line= 5cm & M line= 2cm
 It is used to grade the severity of pelvic floor
relaxation on MR images obtained at maximal strain
during defecation

27. Grade H line M line
Normal <6cm <2cm
Mild 6-8 cm 2-4cm
Moderate 8-10cm 4-6cm
Severe >10cm >6cm

28. Anorectal angle:
 The angle between the posterior border of
the distal part of the rectum and the central
axis of the anal canal
 Normally measures 108° to 127° at rest
 This angle decreases by ~ 15° to 20° during
squeezing and increases by about the same
amount during straining and defecation

30.  Pelvic organ prolapse and pelvic floor relaxation are
related and often coexistent components of pelvic
floor weakness but must be differentiated
 Pelvic floor functional disorders include –
Pelvic organ prolapse: Urethra, urinary bladder,
vaginal vault, uterus, and rectum
Pelvic floor relaxation, or descending perineum
syndrome: an excessive caudal movement of the
pelvic floor during evacuation that may result from
obstetric trauma, chronic straining, or pudendal
neuropathy. It has two components: hiatal
enlargement and pelvic floor descent. It can result
in urinary stress incontinence, genital prolapse, and
impaired defecation.

31.  Lower urinary tract symptoms associated with
pelvic floor dysfunction include- stress urinary
incontinence(SUI), overactive bladder, and bladder
outlet obstruction(BOO)
 SUI urethral incompetence  involuntary loss of
urine during physical activity (coughing, sneezing,
laughing, or exercise)
 Overactive bladder (urge incontinence)  sudden
contraction of the detrusor muscle and often is
related to inflammation, infection, and nervous
system diseases
 BOO is frequently reported by patients with pelvic
organ prolapse

32.  SUI is caused by urethral hypermobility (80%–90% of
patients) or intrinsic sphincter dysfunction (10%–20%
of patients) with or without funneling
Urethral hypermobility:
 Laxity of the urethral supporting structures (due to
vaginal delivery, hysterectomy, or menopause) 
rotation of the urethral axis from vertical to
horizontal, to a position more than 30° from its
resting axis, during straining (termed rotational
descent)
 Normally, the urethral axis on sagittal images
remains vertical even at maximal strain during
defecation

34. Axial T2-weighted MR images—
Indirect signs of paravaginal fascial tear

35. Axial T2 WI  Pelvic muscle
defects in a 54-year-old
woman with fecal
incontinence

36.  Cystocele is due to
stretching or tearing of
the endopelvic fascia that
causes herniation of the
bladder on the anterior
vaginal wall
 MR imaging: a descent of
the bladder base below
the PCL
 May be associated with
damage to the urethral
suspension ligaments and
urinary incontinence

37. Typical translabial ultrasound images.

38.  May manifest as voiding hesitancy, required
positional voiding, required manual reduction of a
prolapse for voiding, and frank urinary retention
that occasionally requires catheterization
 Causes-
o Surgical repair for stress urinary incontinence (the
most common cause)
o Urethral hypermobility
o Bladder outlet compression by a prolapsing
uterus or rectocele and
o Kinking of the urethra or bladder outlet in
patients with a cystocele

39. Sagittal SSFSE T2-weighted MR image obtained during
straining in a 46-year-old woman who presented with
difficult voiding and a sensation of incomplete
bladder emptying

40.  Bowel symptoms caused by pelvic organ prolapsed
include- difficult defecation, fecal incontinence,
required digital manipulation to complete
defecation, a feeling of incomplete evacuation
 Rectal disturbances may be due to impairment of
the puborectalis or anal sphincter, because
voluntary defecation requires relaxation of the anal
sphincters and puborectalis muscle, which
straightens the rectoanal angle, and simultaneous
contraction of the rectal smooth muscle.

41.  A sensation of incomplete defecation or anorectal
obstruction for 25% or more of defecations
 Causes include-
oReduced rectal sensation
oA non-relaxing pelvic floor or paradoxical
contraction of the puborectalis muscle
oPelvic floor laxity
oRectal prolapse, and
oRectocele or enterocele formation
 Pelvic floor descent is the most common finding in
patients with obstructed defecation syndrome

42.  Continuous or recurrent passage of fecal material
(>10 mL) for at least 1 month in a person older than
3–4 years
 Most cases of fecal incontinence are acquired
 Pudendal neuropathy (denervation) induced by
chronic straining, advanced age, or heavy smoking
may cause atrophy of the puborectalis muscle and
sphincter
 MR defecography shows a rectal descent of more
than 6 cm

43. Sagittal T2-weighted MR images were obtained at
rest and during straining in a 62-year-old patient
with positional voiding, pelvic organ prolapse, and
occasional fecal incontinence.

44.  An outpouching of the rectal wall that protrudes
onto the posterior aspect of the vagina
 An anterior rectocele is due to a defect in the
rectovaginal fascia, while a less-common
posterior rectocele is due to a defect in the
anococcygeal ligament
 On MR images, a rectocele is measured as the
distance of the anterior or posterior rectal wall
from the anal canal axis.
 A rectal bulge of less than 2 cm is within normal
limits a bulge of more than 3.5 cm is considered
large

45. Sagittal SSFSE T2-weighted MR image obtained
during straining in a 49-year-old woman with urinary
incontinence and descending perineum syndrome
shows an anterior (A) and posterior (P) rectocele

46.  An infolding of the rectal wall that is induced by
chronic straining and fascial disruption
 It can involve only the mucosa or the full wall
thickness (a true intussusception) and may be
internal (intrarectal or intra-anal) or external.
 It is usually circumferential, but mucosal prolapse
limited to the anterior rectal wall may be observed
 Rectal prolapse causes obstructed defecation that
may subsequently progress to pudendal
neuropathy and fecal incontinence.
 External anal sphincter atrophy is an associated
finding.

47. Sagittal SSFSE T2-weighted MR image obtained during straining
in an obese 20-year-old woman with obstructed defecation
syndrome shows a full-thickness rectoanal prolapse
(intussusception).

48. First‐degree rectocele as quantified on translabial
ultrasonography (midsagittal plane), at rest (a) and on
Valsalva maneuver (b). Measurement of rectocele descent

49.  Cul-de-sac hernia- is a herniation of peritoneal
membrane that protrudes between the uterosacral
ligaments at the apex of the vagina and extends distally
into the rectovaginal septum, separating the rectum
from the vagina
 It may contain fat-- a peritoneocele & small bowel, or
sigmoid colon-- a sigmoidocele
 More common in post-hysterectomy- interruption to
the continuity of the pubocervical and rectovaginal
parts of the endopelvic fascia
 An enterocele often manifests only at the end of the
evacuation phase after rectal and bladder emptying
 It may cause symptoms of bowel obstruction, vaginal
pressure, dyspareunia, and low back pain

50. Sagittal SSFSE T2-weighted MR
image obtained during straining in
an obese 58-year-old woman with
urinary incontinence and pelvic
organ prolapse after hysterectomy
shows small bowel loops (E) below
the PCL
78-year-old woman with fecal
incontinence after hysterectomy
shows a large perineal hernia
(arrow) containing fat and sigmoid
colon (S) between the empty
bladder (B) and rectum

51.  Uterine or vaginal vault prolapse is due to muscle
damage and stretching or tearing of the uterosacral
ligaments  descent of the vaginal fornix and
uterus below the PCL
 May manifest as a vaginal mass, dyspareunia,
urinary retention, or back pain.
 Severe genital prolapse may be associated with
ureteral obstruction

52. Genital prolapse in a 62-
year-old woman.

53. Genital prolapse causing hydronephrosis.
Coronal FSE T2-weighted MR image obtained at rest in a
71-year-old woman with urinary tract obstruction
shows uterine prolapse (U) causing ureteral
compression (arrows) and bilateral hydronephrosis

54.  Due to paradoxical contraction of the puborectalis
muscle during straining
 Also known as anismus or solitary rectal ulcer
syndrome
 Prolonged and incomplete evacuation is the main
sign of spastic pelvic floor syndrome

55. Spastic pelvic floor syndrome. (a) Sagittal FSE T2-weighted MR
image obtained at rest in a 61-year-old woman with urinary
incontinence and occasional difficult defecation after
hysterectomy shows the anorectal angle

56.  Multiple anatomic and functional lesions usually
coexist in a patient with pelvic floor failure.
 Even in patients who present with symptoms in a
single compartment, the pelvic floor as a whole is
usually damaged, and relapses may occur if only
the symptomatic compartment is surgically
repaired.
 Radiologists can use MR imaging to evaluate pelvic
floor functional abnormalities (eg, descending
pelvic floor syndrome and pelvic organ prolapse)
and accurately assess associated muscular and
fascial defects, thus providing the surgeon with a
road map for tailored treatment.

57.  Reference-
 1.Grazia T. Bitti, MD Giovanni M. Argiolas, MD Nicola Ballicu, MD Elisabetta Caddeo, MD Martina Cecconi, MD
Giovanna Demurtas, MD Gildo Matta, MD M. Teresa Peltz, MD Simona Secci, MD Paolo Siotto, MD: Pelvic Floor Failure:
MR Imaging Evaluation of Anatomic and Functional Abnormalities.
 2. Laura García del Salto, MD Jaime de Miguel Criado, MD Luis Felipe Aguilera del Hoyo, MD Leticia Gutiérrez Velasco,
MD Patricia Fraga Rivas, MD Marcos Manzano Paradela, MD María Isabel Díez Pérez de las Vacas, MD Ana Gloria Marco
Sanz, MD Eduardo Fraile Moreno, MD, PhD : MR Imaging–based Assessment of the Female Pelvic Floor..

58. THANK YOU