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Dynamic MR Imaging of the Pelvic Floor in Asymptomatic Subjects

¹ Intestinal Imaging Centre, Level 4V, St. Mark's Hospital, Northwick Park, Watford Rd., Harrow, London, HA1 3UJ, United Kingdom.
² Department of Radiology, Chelsea & Westminster Hospital, Fulham Rd., London, SW10 9NH, United Kingdom.

Received May 24, 1999; accepted after revision August 11, 1999.

 
Supported by Lister Bestcare, Selby, United Kingdom.

Address correspondence to S. Halligan.

Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
OBJECTIVE. Dynamic MR imaging may be used as an alternative to dynamic cystoproctography for the evaluation of pelvic floor prolapse and configuration. MR criteria for normality are derived from proctographic studies because no large MR study of asymptomatic individuals has been performed. Our study aimed to define the normal range of dynamic pelvic MR appearances in a large group of asymptomatic individuals.

SUBJECTS AND METHODS. Fifty healthy adult volunteers (25 men and 25 women; age range, 20-66 years; mean age, 34 years) were prospectively recruited and examined using dynamic MR imaging. All subjects were interviewed and established as healthy using a validated questionnaire. Axial, coronal, and sagittal MR imaging was performed at rest and during maximum pelvic strain using a static 1.0-T unit and a fast-field-echo sequence, providing 10 slices in 31 sec. Standardized measurements of pelvic configuration were taken, and rest and strain imaging were compared to determine the range of normal appearances.

RESULTS. Three women developed a cystocele during maximum pelvic strain, two of whom also showed grade 1 uterocervical prolapse, which was also seen in another woman. Three men showed posterior pelvic floor descent in excess of 3 cm during straining. No rectocele, enterocele, rectal prolapse, or perineal hernia was seen in any subject.

CONCLUSION. The normal range of pelvic organ descent in asymptomatic subjects seen on dynamic MR imaging included cystocele, uterocervical prolapse, and excessive anorectal junction descent. Although we encountered pelvic prolapse in seven volunteers, it was infrequent and low grade, suggesting that criteria for abnormality derived from proctography are generally applicable to MR imaging.

Introduction

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Pelvic floor weakness and consequent organ prolapse may result in a variety of symptoms, including pain, urinary or fecal incontinence, and constipation. The pelvic floor has traditionally been divided into three compartments—anterior, middle, and posterior—each attracting its own specialist interest from urologists, gynecologists, and proctologists, respectively [1]. Clinical examination either underestimates or inaccurately diagnoses the site of prolapse in a significant proportion of patients, and preoperative imaging has assumed a prominent role because of this [2]. Furthermore, it is now apparent that pelvic floor weakness is usually generalized, so that the various pelvic floor compartments are best imaged simultaneously [3]. Conventionally, this has been achieved using evacuation proctography modified by additional opacification of the bladder and small bowel, an examination termed dynamic cystoproctography [4,5,6]. However, cystoproctography is a relatively invasive procedure, involves ionizing radiation, and images only the lumen of the organs opacified. In an attempt to overcome these limitations, dynamic pelvic MR imaging has been introduced and is superseding fluoroscopic methods in some centers [7,8,9]. An MR diagnosis of abnormality has been based on concordance with established proctographic findings. However, proctographic studies of healthy subjects have unexpectedly revealed findings often assumed to be abnormal [10, 11]. To our knowledge, no corresponding study has been performed for dynamic pelvic MR imaging. The aim of this prospective study was to define the normal range of dynamic pelvic MR appearances in a large group of healthy volunteers.

Subjects and Methods

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Subjects
Our local ethics committee approved the study. Fifty adult subjects, 25 men and 25 women, who were 20-66 years old (mean, 34 years), were recruited prospectively after giving informed written consent. Seven women were parous (range, one to three; median parity, two). Twenty-six subjects were volunteers recruited from hospital personnel; the remaining 24 were recruited from patients in the MR unit for musculoskeletal examinations. All subjects were interviewed before examination and completed a questionnaire that detailed bowel frequency; the need for laxatives; use of digital maneuvers to assist evacuation; incontinence to urine, gas, or feces; pelvic pain; organ prolapse; and any need to consult a physician regarding these symptoms. Any abnormal response excluded the subject from the study. Any patient with a history of pelvic surgery was also excluded.

MR Imaging
MR imaging was performed with a 1.0-T static unit (Gyroscan NT 1.0; Philips, Hammersmith, United Kingdom). No preparation of the subject was required. The subject lay supine on a waterproof pad placed on the MR table. Maximum pelvic straining was practiced with the patient before examination; patients were encouraged to bear down as if emptying their bowels. Images were obtained in sagittal, axial, and coronal orientations using the body coil, first with the patient at rest and then again during maximum pelvic strain. A T1-weighted fast-field-echo sequence was used with the following parameters: flip angle, 55°; TR/TE, 79/240 msec; field of view, 34 cm; slice thickness, 8 mm; interslice gap, 2 mm; matrix size, 256 x 256; and four excitations. This sequence gave 10 slices in 31 sec. The examinations were downloaded onto a dedicated workstation (Easyvision; Philips) for radiologist review.

Image Analysis
All examinations were analyzed by two radiologists in consensus, who recorded standard measurements of pelvic floor anatomy and also noted the presence or absence of any structural abnormality. The pubococcygeal line, defined as the line that joined the inferior border of the pubic symphysis to the last coccygeal joint [7, 11], was drawn onto the midline sagittal resting image. The position of the bladder base, cervix, and anorectal junction, defined as the junction of the rectal ampulla and anal canal, were measured at 90° to the pubococcygeal line. The anorectal angle, defined as the angle between the longitudinal axis of the anal canal and the posterior rectal wall, and the levator plate angle, defined as the angle between the levator plate and the pubococcygeal line, were measured [7]. These values were then compared with measurements taken from the corresponding sagittal straining image, and the change on straining was calculated. A cystocele was diagnosed if the bladder base descended below the inferior border of the symphysis pubis [1, 5]. Uterocervical prolapse was defined as cervical descent below the pubococcygeal line (grade 1), to the introitus (grade 2), or to the exterior (grade 3). Anorectal junction descent was defined as excessive if more than 2.5 cm below the pubococcygeal line at rest or if more than 3 cm on maximum strain [10,11,12]. The axial images were used to calculate the pelvic floor hiatal area and perimeter at rest and during maximum strain [7, 8], which were measured at the level of the most inferior point of the symphysis pubis. All images at rest and during maximum strain were also evaluated for the presence or absence of any other structural abnormality as follows: enterocele was defined as small bowel within the rectovaginal septum that reached or crossed the junction of the upper one third and distal two thirds of the vagina [13]. Rectocele was defined as an anterior rectal wall bulge exceeding 2 cm [10, 11]. Rectal prolapse and any perineal hernia through the levator plate were also noted if present.

Statistical Analysis
Descriptive statistics were performed on all data at rest and during maximum strain. The Student's t test was used to compare parametrically distributed continuous data, and statistical significance was assigned to a p value of less than 0.05. Calculations were performed using Arcus Quickstat Biomedical 1.0 (Research Solutions, Cambridge, United Kingdom).

Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The examination was well tolerated by all volunteers. All MR images both at rest and during maximum strain were considered technically adequate.

Mean values with standard deviations (SDs) for the bladder base, cervix, and anorectal junction at rest, during maximum strain, and the descent on straining are shown in Table 1. The bladder base lay above the pubococcygeal line in all subjects at rest but descended below this line during maximum strain in three women, two of whom were parous (one with two and one with three vaginal deliveries), resulting in a diagnosis of cystocele (Table 1, Figs. 1A,1B and 2A,2B). Although the mean bladder base was significantly higher in men than in women at rest and during maximum strain, no significant difference was seen between men and women with respect to the distance descended. No statistical difference was noted between any bladder base value when parous and nulliparous women were compared.

View larger version (20K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —Position of bladder base relative to pubococcygeal line. Ladder plots show position of bladder base relative to pubococcygeal line at rest and during maximum strain for 25 asymptomatic men (A) and 25 asymptomatic women (B). Note that bladder base descends below this line in three women, indicating cystocele. = multiparous, • = nulliparous.

View larger version (20K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —Position of bladder base relative to pubococcygeal line. Ladder plots show position of bladder base relative to pubococcygeal line at rest and during maximum strain for 25 asymptomatic men (A) and 25 asymptomatic women (B). Note that bladder base descends below this line in three women, indicating cystocele. = multiparous, • = nulliparous.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —40-year-old asymptomatic multiparous woman. Sagittal T1-weighted fast-field-echo MR image of pelvis at rest shows pubococcygeal line (black line) and no apparent abnormality.

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —40-year-old asymptomatic multiparous woman. Sagittal T1-weighted fast-field-echo MR image of pelvis at strain shows cystocele diagnosed because bladder base descent is below pubococcygeal line (white arrow). Cervix has also descended below pubococcygeal line (black arrow).

The cervix descended below the pubococcygeal line in two (one nulliparous and one with three vaginal deliveries) of the three women with cystocele, and in a third (who did not have a cystocele), resulting in a diagnosis of grade 1 uterocervical prolapse (Figs. 3 and 4A,4B). Grade 2 or 3 uterocervical prolapse was not seen in any woman. No significant difference was seen when nulliparous and parous women were compared for any uterocervical measurement.

View larger version (24K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3. —Ladder plot shows position of uterocervical junction relative to pubococcygeal line at rest and during maximum strain for 25 asymptomatic women. Note that uterocervical junction descends below this line in three women, indicating prolapse. = multiparous, • = nulliparous.

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A. —50-year-old asymptomatic nulliparous woman. Sagittal T1-weighted fast-field-echo MR image of pelvis at rest shows pubococcygeal line (black line) and cervix (arrowhead). No apparent abnormality is seen.

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B. —50-year-old asymptomatic nulliparous woman. Sagittal T1-weighted fast-field-echo MR image of pelvis at strain shows grade 1 uterocervical prolapse (white arrow) indicated by cervical descent below pubococcygeal line (black line). Note also cystocele (black arrow).

The mean anorectal junction position lay on the pubococcygeal line in both men and women (Table 1) and was not more than 2.0 cm below this level in any subject at rest. However, anorectal junction descent was more than 3.0 cm in three men during maximum strain (Fig. 5A,5B). No overall statistical difference was noted between men and women (Table 1) or between parous and nulliparous women.

View larger version (23K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A. —Position of anorectal junction relative to pubococcygeal line. Ladder plots show position of anorectal junction relative to pubococcygeal line at rest and during maximum strain for 25 asymptomatic men (A) and 25 asymptomatic women (B). Note that anorectal junction descent is excessive (3 cm of descent) in three men. = multiparous, • = nulliparous.

View larger version (22K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B. —Position of anorectal junction relative to pubococcygeal line. Ladder plots show position of anorectal junction relative to pubococcygeal line at rest and during maximum strain for 25 asymptomatic men (A) and 25 asymptomatic women (B). Note that anorectal junction descent is excessive (3 cm of descent) in three men. = multiparous, • = nulliparous.

Mean values at rest and during maximum strain for the anorectal angle, the levator plate angle, the pelvic floor hiatal area, and the hiatal perimeter in men and women are shown in Table 2. The anorectal angle during maximum pelvic strain was significantly more acute in men than in women, but no significant difference was seen either between sexes or between women of different parity for any other measurement. No rectocele, enterocele, rectal prolapse, or perineal hernia was seen in any subject when all images were examined for further structural abnormality. An unsuspected ovarian dermoid cyst was seen in one woman, and this diagnosis was subsequently confirmed surgically.

Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The effects of pelvic floor weakness may not be localized to one organ or compartment, and failure to identify all sites of prolapse may lead to incomplete surgical repair and subsequent recurrence [11]. Clinical examination tends to underestimate the degree of prolapse or may miss it altogether; in one study of 300 women, enteroceles were revealed on dynamic cystoproctography in 111, of which 93 (84%) were missed clinically [4]. Because of this, many investigators take the opportunity to modify the standard proctographic examination by either administering an oral barium suspension approximately 1-2 hr before the procedure [2] or, alternatively, using a vaginal marker so that enteroceles can be diagnosed by rectovaginal separation. The best choice is probably a barium paste because a tampon may inhibit prolapse by splinting the vagina [14]. Dynamic cystoproctography is essentially evacuation proctography preceded by a cystogram [5]; it extends the examination into the anterior pelvic floor so that any cystocele can be diagnosed.

Although evacuation proctography is rapid and easy to perform, the modifications necessary to image other organs may be time-consuming, invasive, and complex, and the musculature of the pelvic floor itself is not visualized. Furthermore, examination involves irradiation, and many patients will be women in their childbearing years, especially if the examination is being performed to investigate constipation. In an attempt to overcome these limitations, MR imaging has been applied to pelvic floor dynamics with promising results. Initial reports were necessarily compromised by slow acquisition times [15, 16], but advancing MR technology has enabled multislice imaging during a single straining effort. A study of constipated and anally incontinent women using this technique revealed unsuspected visceral prolapse at multiple sites [7]. However, these studies have recruited limited numbers of control subjects. Previous proctographic studies of asymptomatic control subjects have unexpectedly shown that many of these individuals show findings previously considered abnormal [10, 11]. MR criteria for abnormality have been based on proctographic examinations but it is likely that values will differ between the two techniques, primarily because the seated position achieved during proctography is available only to the few investigators with access to open-architecture magnets [17, 18]. Supporting this, a study of 10 women who underwent both proctography and dynamic MR imaging found good correlation but poor agreement between corresponding measurements [19]. Because of this, the range of normal values for dynamic MR imaging needs to be defined. We have attempted to do this in the largest dynamic MR study to date, to our knowledge.

All subjects examined in this study satisfied vigorous and validated criteria for health. Despite this, we encountered some findings con-sidered abnormal. We showed significant differences between men and women with respect to the position of the bladder base, as would be expected, but a cystocele developed in three women during maximum pelvic strain, two of whom also developed grade 1 uterocervical prolapse; the latter was also seen in one additional woman. However, no large cystocele was seen, nor was any higher grade of uterocervical prolapse. Similarly, three men showed significant pelvic floor descent (3 cm) when judged by proctographic criteria, but this also was low grade. These findings are broadly in agreement with those encountered in proctographic studies of asymptomatic individuals in which most subjects were "normal," but there is some crossover with findings considered abnormal [10, 11]. Supporting this, no rectocele, enterocele, rectal prolapse, or perineal hernia was seen in any subject when all images were reviewed. The range of normal values for the anorectal and levator plate angle has also been defined. Although the anorectal angle during maximum pelvic strain was significantly more acute in men, this result is likely to have occurred because of multiple statistical testing. These measurements were included for completeness but are rarely of major clinical significance and do not influence management, as would diagnosis of a prolapse site. The pelvic floor hiatus is a relatively new measurement that is already clinically relevant and is increased in women with pelvic organ prolapse [20]. We were unable to find any significant difference between the sexes for this measurement, nor were we able to show any significant difference between parous and nulliparous women for any parameter, possibly because of the relatively few parous women recruited. The vigorous questionnaire excluded many older and parous women from the study, predominantly because of minor anal incontinence, a symptom strongly associated with previous vaginal delivery [21].

Dynamic pelvic MR imaging is evolving, and an optimal technique remains to be defined. A major disadvantage of the technique may relate to the inability to ensure an adequate straining effort. In an attempt to minimize this effect, straining was practiced with the subject before the examination, and the volunteer was placed on an absorbent pad to minimize the fear of leakage. Despite this, some subjects raised their pelvic floor during straining, evidenced by ano-rectal junction ascent, which suggests pelvic floor contraction rather than relaxation. To eliminate this effect, some investigators fill the rectum and bladder and encourage evacuation in the magnet despite the supine position [9]. This approach will provide additional information relating to the rate and completeness of rectal evacuation, important parameters when constipation is being investigated [22]. A seated position is optimal but only achievable in an open magnet [17, 18].

If prolapse is shown, it is tempting to attribute symptoms to the prolapse, but the prolapse may merely be secondary to an underlying functional disorder. For example, constipated patients who strain excessively may develop cystocele, enterocele, rectocele, rectal prolapse, and pelvic floor descent [23], but surgery to correct these will not treat the underlying disorder [24]. The results of any dynamic pelvic examination, be it cystoproctography or MR imaging, need to be considered in the light of the patient's history and other tests so that therapy is appropriate.

In summary, we examined 50 healthy volunteers using dynamic pelvic MR imaging to define the range of normal appearances encountered during this relatively new test. Although we encountered some pelvic floor prolapse, it was infrequent and of low grade, suggesting the criteria for abnormality derived from proctographic examinations are generally applicable to MR imaging.

References

Top Abstract Introduction Subjects and Methods Results Discussion References

 

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