MRIMRI ININ

Pelvic Floor DisordersPelvic Floor DisordersMAHYAR GHAFOORI M.D.MAHYAR GHAFOORI M.D.

Associate Professor of RadiologyAssociate Professor of Radiology

Tehran UniversityTehran UniversityOfOf

Medical SciencesMedical Sciences

Pelvic floor in WomenPelvic floor in Women

• Anterior Compartment: Bladder & UrethraAnterior Compartment: Bladder & Urethra

• Middle Compartment: Uterus & VaginaMiddle Compartment: Uterus & Vagina

• Posterior Compartment: AnorectalPosterior Compartment: Anorectal

Normal AnatomyNormal Anatomy

Reference LinesReference LinesPubococcygeal line (PCL):Pubococcygeal line (PCL):From the inferior border of pubic symphysis to the last coccygeal joint.From the inferior border of pubic symphysis to the last coccygeal joint.

Level of Pelvic FloorLevel of Pelvic Floor

H line: H line: Max. 5 cmMax. 5 cm

From inferior border of pubic symphysis to the posterior wall of the rectum From inferior border of pubic symphysis to the posterior wall of the rectum at the level of anorectal junction.at the level of anorectal junction.

AP Width of Levator HiatusAP Width of Levator Hiatus

M line:M line: Max. 2 cmMax. 2 cm

Perpendicularly from PCL to the most posterior aspect of H Perpendicularly from PCL to the most posterior aspect of H line.

Vertical descent of the levator hiatus

RestRest StrainingStraining

NormalNormal

RestRest StrainingStraining

71 Y/O F: Prolapse & Fecal Incontinence71 Y/O F: Prolapse & Fecal Incontinence

Prolapse Severity Grading

Prolapse of an organ below the PCL:Prolapse of an organ below the PCL:

3 cm or less Mild3 cm or less Mild

Between 3 and 6 cm ModerateBetween 3 and 6 cm Moderate

More than 6 cm SevereMore than 6 cm Severe

Anorectal AngleAnorectal Angle

Rest 108 - 127°Rest 108 - 127°

Squeezing CloseSqueezing Close

Defecation OpenDefecation Open

RestRest SqueezingSqueezing StrainingStraining

Puborectalis MusclePuborectalis Muscle

CystoceleCystocele

Urethral HypermobilityUrethral Hypermobility

Anterior CompartmentAnterior Compartment

RestRest StrainStrain

48 Y/O Stress urinary incontinence & frequency 48 Y/O Stress urinary incontinence & frequency

33mm 0°33mm 0° 18mm 65°18mm 65°

56 Y/O F: Stress urinary incontinence, feeling of incomplete bladder voiding, ODS56 Y/O F: Stress urinary incontinence, feeling of incomplete bladder voiding, ODS

Middle CompartmentMiddle Compartment

Uterine or Vaginal Vault ProlapseUterine or Vaginal Vault Prolapse

RestRest StrainingStraining DefecationDefecation

41 Y/O F: Severe uterine prolapse41 Y/O F: Severe uterine prolapse

72 Y/O F: Prolapse after Hysterectomy 72 Y/O F: Prolapse after Hysterectomy

RestRest DefecationDefecation

Posterior CompartmentPosterior Compartment

45 Y/O F: history of obstructed defecation 45 Y/O F: history of obstructed defecation

Anterior RectoceleAnterior Rectocele

41 Y/O F with ODS41 Y/O F with ODS

Posterior RectocelePosterior Rectocele

During DefecationDuring Defecation

65 Y/O F: History of incomplete evacuation 65 Y/O F: History of incomplete evacuation

During DefecationDuring Defecation Intrarectal ResidueIntrarectal Residue

RectoceleRectocele

57 Y/O F: Feeling of incomplete evacuation 57 Y/O F: Feeling of incomplete evacuation

Intrarectal InvaginationIntrarectal Invagination

Extraanal Invagination (Rectal Prolapse)Extraanal Invagination (Rectal Prolapse)

63 Y/O F: Fecal Incontinence, Hx of Hysterectomy63 Y/O F: Fecal Incontinence, Hx of Hysterectomy

RestRest Progressive StrainingProgressive Straining

64 Y/O F: Prolapse after Hysterectomy64 Y/O F: Prolapse after Hysterectomy

Early DefecationEarly Defecation Late DefecationLate Defecation

EnteroceleEnterocele

68 Y/O F: Perineal descent, ODS68 Y/O F: Perineal descent, ODS

3 Compartment Prolapse3 Compartment Prolapse

During DefecationDuring Defecation Complete DefecationComplete Defecation

3 Compartment Prolapse3 Compartment Prolapse

62 Y/O F: 3 Compartment Descent62 Y/O F: 3 Compartment Descent

RestRest SqueezingSqueezing DefecationDefecation

65 Y/O F: ODS, Hx of Hysterectomy65 Y/O F: ODS, Hx of Hysterectomy

Progressive StrainingProgressive Straining

Spastic Pelvic Floor SyndromeSpastic Pelvic Floor Syndrome(Pelvic Floor Uncoordination, Anismus)(Pelvic Floor Uncoordination, Anismus)

Functional abnormality.Functional abnormality.Involuntary, inappropriate & paradoxical contraction of striated pelvic Involuntary, inappropriate & paradoxical contraction of striated pelvic floor musculature: evacuation failure & Constipation.floor musculature: evacuation failure & Constipation.Paradoxical contraction of puborectalis muscle.Paradoxical contraction of puborectalis muscle.Puborectalis muscle is hypertrophic & makes an impression on Puborectalis muscle is hypertrophic & makes an impression on posterior rectal wall during defecation. posterior rectal wall during defecation. Etiology is unclear (Abnormal muscle activity, psychologic, cognitive) Etiology is unclear (Abnormal muscle activity, psychologic, cognitive) Anorectal Manometry: Increased pressure at rest & during defecation.Anorectal Manometry: Increased pressure at rest & during defecation.Pathologic signals at electromyography. Pathologic signals at electromyography.

51 Y/O M: ODS51 Y/O M: ODS

Spastic Pelvic Floor SyndromeSpastic Pelvic Floor Syndrome

RestRest StrainStrain

68 Y/O F: Excessive straining & incomplete evacuation68 Y/O F: Excessive straining & incomplete evacuation

RestRest Progressive StrainingProgressive Straining

Mahyar Ghafoori M.D.Mahyar Ghafoori M.D.The End The End