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Female Pelvic Organ Prolapse

A Comparison of Triphasic Dynamic MR Imaging and Triphasic Fluoroscopic Cystocolpoproctography

Frederick M. Kelvin1, Dean D. T. Maglinte1, Douglass S. Hale2 and J. Thomas Benson2

1 Department of Radiology, Methodist Hospital of Indiana, 1701 N. Senate Blvd., Indianapolis, IN 46202.
2 Urogynecology Section, Methodist Hospital of Indiana, Indianapolis, IN 46202.



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  		Fig. 1. —65-year-old woman with urinary incontinence, voiding dysfunction, and external vaginal prolapse.

A, Sagittal true fast imaging in a steady-state free precession MR image obtained with patient straining during dynamic MR imaging shows large cystocele (c) with hourglass configuration. Note pubococcygeal line (solid line). Cystocele (dotted line) extends 7 cm below pubococcygeal line.

 


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  		Fig. 1. —65-year-old woman with urinary incontinence, voiding dysfunction, and external vaginal prolapse.

B, Lateral dynamic fluoroscopic image obtained with patient straining during cystographic phase shows similarly shaped large cystocele (c). Note pubococcygeal line (solid line). Cystocele (dotted line) extends 8.5 cm below pubococcygeal line. Also note that fluoroscopic image is considerably more magnified than image in A, and pubococcygeal line in A has greater tilt because of supine position of patient.

 


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  		Fig. 2. —44-year-old woman with symptomatic vaginal prolapse and voiding dysfunction.

A, Sagittal true fast imaging in steady-state free precession image obtained during posttoilet phase of dynamic MR imaging shows vaginal vault prolapse (arrow), enterocele (e), and peritoneocele (arrowhead). Incompletely drained cystocele (c) is also present. Note pubococcygeal line (dotted line).

 


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  		Fig. 2. —44-year-old woman with symptomatic vaginal prolapse and voiding dysfunction.

B, Lateral dynamic fluoroscopic image obtained during posttoilet phase shows vaginal vault prolapse (arrow) and enterocele (e). Barium trapping within rectocele (r) is also present. Note pubococcygeal line (dotted line). Also note that fluoroscopic image is considerably more magnified than image in A.

 


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  		Fig. 3. —74-year-old woman with difficulty emptying rectum and stress urinary incontinence.

A, Sagittal true fast imaging in steady-state free precession image obtained during proctographic phase of dynamic MR imaging. Image shows open anal canal (white arrow) indicating that rectal evacuation is occurring. Rectocele (r) size is measured as maximal anterior extension (arrowed line) perpendicular to line extending upward from anterior margin of anal canal (black line).

 


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  		Fig. 3. —74-year-old woman with difficulty emptying rectum and stress urinary incontinence.

B, Lateral dynamic fluoroscopic image obtained during proctographic phase shows rectocele (r) with extent (arrowed line) measured at right angles to line extended upward from anal canal (black line). Note that fluoroscopic image is considerably more magnified than image in A.

 


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  		Fig. 4. —74-year-old woman with symptomatic vaginal prolapse and stress urinary incontinence.

A, Axial true fast imaging in steady-state free precession image obtained at rest at level of pubic symphysis shows no ballooning of puborectalis muscle (arrowheads).

 


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  		Fig. 4. —74-year-old woman with symptomatic vaginal prolapse and stress urinary incontinence.

B, Axial true fast imaging in steady-state free precession image obtained at same level as A on straining shows marked ballooning of entire puborectalis muscle (arrowheads) within which there are cystocele (c), enterocele (e), and peritoneocele (p).

 


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  		Fig. 5. —79-year-old woman with difficulty emptying rectum and symptomatic vaginal prolapse.

A, Sagittal true fast imaging in steady-state free precession image obtained during proctographic phase of dynamic MR imaging shows rectal evacuation, with contrast material expelled through anal canal (arrow).

 


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  		Fig. 5. —79-year-old woman with difficulty emptying rectum and symptomatic vaginal prolapse.

B, Sagittal true fast imaging in steady-state free precession image obtained at later stage of proctographic phase shows both redundant rectocele (r) and sigmoidocele (arrowheads) extending down from sigmoid colon (s).

 


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  		Fig. 6. —69-year-old woman with marked voiding dysfunction and symptomatic vaginal prolapse.

A, Sagittal true fast imaging in steady-state precession image obtained at rest shows considerable amount of contrast within bladder (b) and vagina (v).

 


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  		Fig. 6. —69-year-old woman with marked voiding dysfunction and symptomatic vaginal prolapse.

B, After catheterization and drainage of approximately 300 ml of liquid from bladder, sagittal true fast imaging in steady-state free precession image obtained with patient straining shows deep peritoneocele (arrowheads) previously obscured by distended bladder. Note pubococcygeal line (white line).

 


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  		Fig. 7. —74-year-old woman with symptomatic vaginal prolapse and stress urinary incontinence.

A, Sagittal true fast imaging in steady-state free precession image obtained during cystographic phase shows no evidence of enterocele or peritoneocele.

 


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  		Fig. 7. —74-year-old woman with symptomatic vaginal prolapse and stress urinary incontinence.

B, Sagittal true fast imaging in steady-state precession image obtained during proctographic phase shows contrast-filled rectum (r), vagina (v), and bladder (b). Note diminished volume of contrast material in bladder caused by catheter drainage and voiding in bathroom. Distended organs occupy entire anteroposterior diameter of pelvis, thereby preventing descent of enterocele. Anal canal is open indicating rectal evacuation.

 


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  		Fig. 7. —74-year-old woman with symptomatic vaginal prolapse and stress urinary incontinence.

C, Sagittal true fast imaging in steady-state free precession image obtained during posttoilet phase shows presence of large enterocele (arrowheads) and associated large peritoneocele (p). Note that rectum has been completely evacuated between proctographic and posttoilet phases. Also note pubococcygeal line (black line).

 

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