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Anatomy of the Urethral Supporting Ligaments Defined by Dissection, Histology, and MRI of Female Cadavers and MRI of Healthy Nulliparous Women

¹ Department of Radiology, Faculty of Medicine, Cairo University, Kaser El Aini St., Cairo 11511, Egypt.
² Department of Anatomy, Faculty of Medicine, Cairo University, Cairo, Egypt.
³ Department of Urology, Faculty of Medicine, Cairo University, Cairo, Egypt.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —Anatomic dissection and MR images of pubourethral ligaments (PULs) in cadaver with corresponding MR appearance of PULs in healthy nulliparous volunteer. Digital image of sagittal section from female cadaver shows three PULs coursing anteroposterior from pubic bone (PB) to urethra: proximal PUL (PPUL, pink arrow), intermediate PUL (IPUL, blue arrow), and distal PUL (DPUL, green arrow). White arrows delineate anterior and posterior urethral wall.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —Anatomic dissection and MR images of pubourethral ligaments (PULs) in cadaver with corresponding MR appearance of PULs in healthy nulliparous volunteer. Consecutive sagittal proton density MR images (TR/TE, 4,000/18) of cadaver shown in A. B reveals marker (white arrow) placed on proximal PUL (pink arrow, C) to be of high signal intensity.C depicts proximal PUL (pink arrow), intermediate PUL (blue arrow), and distal PUL (green arrow); all are of intermediate signal intensity. PB = pubic bone.

View larger version (92K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —Anatomic dissection and MR images of pubourethral ligaments (PULs) in cadaver with corresponding MR appearance of PULs in healthy nulliparous volunteer. Consecutive sagittal proton density MR images (TR/TE, 4,000/18) of cadaver shown in A. B reveals marker (white arrow) placed on proximal PUL (pink arrow, C) to be of high signal intensity.C depicts proximal PUL (pink arrow), intermediate PUL (blue arrow), and distal PUL (green arrow); all are of intermediate signal intensity. PB = pubic bone.

View larger version (102K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D —Anatomic dissection and MR images of pubourethral ligaments (PULs) in cadaver with corresponding MR appearance of PULs in healthy nulliparous volunteer. Sagittal T2-weighted turbo spin-echo MR image (5,000/132) in 28-year-old female volunteer shows proximal PUL (pink arrow) with its bone attachment to back of pubic bone (PB) at junction of its upper two thirds and lower one third. White arrow points to periurethral ligament.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —Anatomic dissection and MR images of ventral and dorsal groups of urethral supporting ligaments and their corresponding MR appearance in healthy nulliparous volunteers. Digital image of top view of female cadaver in which symphysis pubis (SP) was divided in midline shows proximal pubourethral (PUL) (pink arrow), intermediate PUL (blue arrow), and distal PUL (green arrow). Another ligament (white arrow) that is lateral to proximal PUL—referred to as "suburethral ligament"—extends from lateral pelvic wall to dorsolateral aspect of urethra (U). Transverse band (red diamonds) traversing anterior to proximal urethra is periurethral ligament. BN = bladder neck.

View larger version (85K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —Anatomic dissection and MR images of ventral and dorsal groups of urethral supporting ligaments and their corresponding MR appearance in healthy nulliparous volunteers. Consecutive axial proton density MR images (TR/TE, 4,000/18) of cadaver shown in A reveal periurethral ligament (red asterisk). Marker (arrow) is of high signal intensity.

View larger version (89K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —Anatomic dissection and MR images of ventral and dorsal groups of urethral supporting ligaments and their corresponding MR appearance in healthy nulliparous volunteers. Consecutive axial proton density MR images (TR/TE, 4,000/18) of cadaver shown in A reveal periurethral ligament (red asterisk). Marker (arrow) is of high signal intensity.

View larger version (78K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —Anatomic dissection and MR images of ventral and dorsal groups of urethral supporting ligaments and their corresponding MR appearance in healthy nulliparous volunteers. Axial T2-weighted turbo spin-echo MR image (5,000/132) of 30-year-old woman shows proximal PUL (pink arrows), periurethral ligament (red asterisks), and suburethral ligament (white arrows). V = vagina, PB = pubic bone, PR = puborectalis muscle.

View larger version (86K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2E —Anatomic dissection and MR images of ventral and dorsal groups of urethral supporting ligaments and their corresponding MR appearance in healthy nulliparous volunteers. Axial oblique balanced fast-field echo MR image (5.0/1.6) of 28-year-old woman (same volunteer as in Fig. 1D) obtained in plane of proximal PUL, as shown in sagittal image (inset), reveals same structures as those seen in A of dissected cadaver, including right and left proximal PULs (pink arrows) and periurethral ligaments (red arrows). PR = puborectalis muscle. Inset is sagittal MR image; white line shows plane of proximal PUL, arrow points to PUL.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —Paraurethral ligaments in healthy nulliparous volunteer and in female cadaver. On axial T2-weighted turbo spin-echo MR images (TR/TE, 5,000/132) of 30-year-old woman (A and B) and on axial proton density MR image (4,000/18) of cadaver (C) with high-signal marker placed in urethra (white arrow in C), low-signal-intensity paraurethral ligament (black arrow) is better seen on left side. U = urethra.

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —Paraurethral ligaments in healthy nulliparous volunteer and in female cadaver. On axial T2-weighted turbo spin-echo MR images (TR/TE, 5,000/132) of 30-year-old woman (A and B) and on axial proton density MR image (4,000/18) of cadaver (C) with high-signal marker placed in urethra (white arrow in C), low-signal-intensity paraurethral ligament (black arrow) is better seen on left side. U = urethra.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —Paraurethral ligaments in healthy nulliparous volunteer and in female cadaver. On axial T2-weighted turbo spin-echo MR images (TR/TE, 5,000/132) of 30-year-old woman (A and B) and on axial proton density MR image (4,000/18) of cadaver (C) with high-signal marker placed in urethra (white arrow in C), low-signal-intensity paraurethral ligament (black arrow) is better seen on left side. U = urethra.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —Histologic analyses of three pubourethral ligaments (PULs) and periurethral ligaments from dissected cadavers. Photomicrograph of proximal PUL from female cadaver shows smooth muscle (short arrow) within collagen bundles (long arrow). (x100, Masson trichrome stain)

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —Histologic analyses of three pubourethral ligaments (PULs) and periurethral ligaments from dissected cadavers. Photomicrograph of intermediate PUL from female cadaver shows collagen bundles (long white arrow), a few capillaries (black arrow), and a few muscle fibers (short white arrow). (x40, Masson trichrome stain)

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —Histologic analyses of three pubourethral ligaments (PULs) and periurethral ligaments from dissected cadavers. Photomicrograph of distal PUL from female cadaver shows that distal PUL is composed of dense collagen bundles. (x100, Masson trichrome stain)

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4D —Histologic analyses of three pubourethral ligaments (PULs) and periurethral ligaments from dissected cadavers. Photomicrographs of periurethral ligament from female cadaver show periurethral ligament contains mainly collagen bundles (arrow, D) and a few scattered skeletal muscle bundles (arrowhead, E). (D, x40, Masson trichrome stain; E, x100, Masson trichrome stain)

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4E —Histologic analyses of three pubourethral ligaments (PULs) and periurethral ligaments from dissected cadavers. Photomicrographs of periurethral ligament from female cadaver show periurethral ligament contains mainly collagen bundles (arrow, D) and a few scattered skeletal muscle bundles (arrowhead, E). (D, x40, Masson trichrome stain; E, x100, Masson trichrome stain)

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —Anatomic dissection and MR images of suburethral ligament and pubourethral ligaments (PULs) in female cadaver with corresponding MR images of ligaments in healthy nulliparous volunteer. Digital image of top view of Retzius space in female cadaver shows four broad linear structures extending from bladder neck (BN) to back of pubic bone, two on either side of midline. These structures are proximal PUL (pink curves) and suburethral ligament (white curves). UB = urinary bladder, SP = symphysis pubis.

View larger version (88K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —Anatomic dissection and MR images of suburethral ligament and pubourethral ligaments (PULs) in female cadaver with corresponding MR images of ligaments in healthy nulliparous volunteer. Axial proton density MR image (TR/TE, 4,000/18) of same specimen as A with high-signal-intensity marker placed on proximal PUL (pink arrow) and suburethral ligament (white arrow). SP = symphysis pubis, IS = ischial tuberosity.

View larger version (95K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —Anatomic dissection and MR images of suburethral ligament and pubourethral ligaments (PULs) in female cadaver with corresponding MR images of ligaments in healthy nulliparous volunteer. Two consecutive axial STIR images (2,752/15) obtained with fat suppression in 35-year-old woman show that, dorsal to urethra, there is hypointense ligamentous structure (arrows) that runs retrourethral forming suburethral sling. Plane of cleavage between ligament and vagina (V) is better depicted in D. SP = symphysis pubis, IS = ischial tuberosity.

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D —Anatomic dissection and MR images of suburethral ligament and pubourethral ligaments (PULs) in female cadaver with corresponding MR images of ligaments in healthy nulliparous volunteer. Two consecutive axial STIR images (2,752/15) obtained with fat suppression in 35-year-old woman show that, dorsal to urethra, there is hypointense ligamentous structure (arrows) that runs retrourethral forming suburethral sling. Plane of cleavage between ligament and vagina (V) is better depicted in D. SP = symphysis pubis, IS = ischial tuberosity.

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5E —Anatomic dissection and MR images of suburethral ligament and pubourethral ligaments (PULs) in female cadaver with corresponding MR images of ligaments in healthy nulliparous volunteer. Microscopic image of suburethral ligament specimen obtained at its lateral attachment to pelvic sidewalls reveals that this ligament contains skeletal muscle bundles (asterisks) among collagen fibers (arrowheads). (x100, Masson trichrome stain)

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —Variations in number of urethral supporting ligaments. Digital image of midline section from female cadaver reveals two ligaments with oblique course attached to urethra (U). Proximal ligament (P) extends from lower end of posterior aspect of pubic bone to urethral wall at junction of its upper one third and lower two thirds (variants of proximal pubourethral ligament [PUL]), whereas a second distal ligament (D) extends from inferior part of ventral surface of pubic bone to middle of urethra (variant of distal PUL). UT = uterus, UB = urinary bladder, SP = symphysis pubis, V = vagina.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —Variations in number of urethral supporting ligaments. Digital image of midline section from another female cadaver shows only one ligament (arrow) extending from lower part of back of pubic bone to urethra (U) at junction of its upper two thirds with lower one third. SP = symphysis pubis.

View larger version (70K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —Grid system used to collect data about ligaments supporting urethra. Application of grid system for collecting data. First, identify most cranial image on which arcuate pubic ligament (APL) can be visualized and define that image as "image A" (middle image, A). Second, number sequential axial images cephalad to image A with positive numbers and those caudad, with negative numbers. Finally, use grid to record which ligaments are visible on each image. For example, consecutive axial T2-weighted turbo spin-echo MR images (TR/TE 5,000/132) (A–C) of healthy nulliparous 30-year-old woman (same volunteer as in Table 1) are numbered in relation to image A, as shown in bottom right-hand corner of each image. In this patient, periurethral ligament (PerUL) is seen on images 2 through 6 above APL. However, ligament on left is better seen on images 4 through 6 than on other images. Overall, periurethral ligament is easily visible (visibility score = 4) on MRI in this volunteer.SP = symphysis pubis, ParUL = paraurethral ligament, PPUL = proximal pubourethral ligament, U = urethra, SUL = suburethral ligament, UVJ = urethrovesical junction.

View larger version (48K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —Grid system used to collect data about ligaments supporting urethra. Application of grid system for collecting data. First, identify most cranial image on which arcuate pubic ligament (APL) can be visualized and define that image as "image A" (middle image, A). Second, number sequential axial images cephalad to image A with positive numbers and those caudad, with negative numbers. Finally, use grid to record which ligaments are visible on each image. For example, consecutive axial T2-weighted turbo spin-echo MR images (TR/TE 5,000/132) (A–C) of healthy nulliparous 30-year-old woman (same volunteer as in Table 1) are numbered in relation to image A, as shown in bottom right-hand corner of each image. In this patient, periurethral ligament (PerUL) is seen on images 2 through 6 above APL. However, ligament on left is better seen on images 4 through 6 than on other images. Overall, periurethral ligament is easily visible (visibility score = 4) on MRI in this volunteer.SP = symphysis pubis, ParUL = paraurethral ligament, PPUL = proximal pubourethral ligament, U = urethra, SUL = suburethral ligament, UVJ = urethrovesical junction.

View larger version (69K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —Grid system used to collect data about ligaments supporting urethra. Application of grid system for collecting data. First, identify most cranial image on which arcuate pubic ligament (APL) can be visualized and define that image as "image A" (middle image, A). Second, number sequential axial images cephalad to image A with positive numbers and those caudad, with negative numbers. Finally, use grid to record which ligaments are visible on each image. For example, consecutive axial T2-weighted turbo spin-echo MR images (TR/TE 5,000/132) (A–C) of healthy nulliparous 30-year-old woman (same volunteer as in Table 1) are numbered in relation to image A, as shown in bottom right-hand corner of each image. In this patient, periurethral ligament (PerUL) is seen on images 2 through 6 above APL. However, ligament on left is better seen on images 4 through 6 than on other images. Overall, periurethral ligament is easily visible (visibility score = 4) on MRI in this volunteer.SP = symphysis pubis, ParUL = paraurethral ligament, PPUL = proximal pubourethral ligament, U = urethra, SUL = suburethral ligament, UVJ = urethrovesical junction.

View larger version (185K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7D —Grid system used to collect data about ligaments supporting urethra. Sagittal T2-weighted turbo spin-echo MR image (5,000/132) shows that images –1 to + 6 are planned from caudal to cranial direction (arrow).

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