Aim: To assess the role of Magnetic resonance imaging (MRI) and pelvic organ prolapse quantification (POPQ) system in the evaluation of female pelvic organ prolapse. Design: Prospective study. Setting: TantaUniversityHospital. Patients: The study was carried out on 60 patients having clinical manifestations suggesting pelvic floor weakness. Intervention: All the patients were subjected to history taking, physical examination including POPQ, and pelvic MRI (static and dynamic) examination. Outcome measures: Quantitative measurements of genital prolapse. Results: All patients showed loss of the normal position of the perineal plate indicating generalized weakness of the whole pelvic floor muscles. Dynamic MRI exhibited pelvic floor abnormalities in 46 patients who did not show any abnormalities on the static images. Conclusion: Dynamic MRI is a helpful tool in defining the nature and quantitative measurements of pelvic organ prolapse. Also, MRI has and advantage over POPQ system in diagnosing lateral prolapse.
MRI is the diagnostic imaging modality of choice for many disorders of the female pelvis. Benign uterine disease is well-demonstrated using rapid sequences and minimal examination time, whereas evaluation of malignancy is best performed with high-resolution techniques. Wide-spread availability of ultrafast sequences has expanded MR imaging applications to include evaluation of pelvic floor relaxation and fetal anomalies [
Disadvantages of MRI are its high cost and long scanning time. Its excellent tissue contrast underscores its importance in the evaluation of adnexal masses, however, because it allows specific diagnoses of fat, blood, and fibrous tissue. Even if normal in size, an ovary may present with tiny foci of endometrial implants or dermoid cysts that are only identifiable on MR imaging; however, MR imaging is generally used as a problem-solving modality. When ultrasound results are inconclusive, the use of MR imaging may alter treatment decisions, eliminate the need for surgery, and result in reduced overall costs [
The use of MRI for pelvic organ prolapse was introduced by Yang et al. in 1991 [
The aim of the work was to assess the role of MRI and POPQ system in the evaluation of female pelvic organ prolapse.
This study included 60 patients having clinical manifestations of pelvic organ prolapse (≥Stage I), otherwise were considered normal.
All the patients were subjected to: history taking, clinical examination including assessment of pelvic organ prolapse according to POPQ system [
The mean age of the patients was 38 ± 4.2 years, mean parity 4.2 ± 1.4, MBI 27.6 ± 3.5, urinary symptoms in 81.67%.
The main complaints were: sensation of heaviness or pulling in the pelvis with something protruding from the vagina in 34/60 cases, low back pain (24/60), sexual dysfunction, including decreased libido (36/60), and difficulty achieving orgasm (24), constipation (12/60), urinary incontinence (18/60).
Stage of prolapse at baseline according to POPQ system, Stage one 13 cases (21.7%), Stage two 18 cases (30.0%), Stage three 29 cases (48.3%).
Clinical examination revealed that 24 women had anterior and posterior prolapse, 30 had anterior prolapse only, and 6 had uterine and apical prolapse. The MRI findings showed that among 30 women diagnosed clinically as anterior prolapse, three women had lateral cystocele. Meanwhile, The POPQ evaluation did not find the lateral cystocele to be related to the prolapse score.
In addition, MRI illustrated that in 26 patients the urinary bladder was just touching the pubococcygeal ligament (PCL) and caudal inclination of the perineal plate at straining sequences, 18 patients showed descent of the urinary bladder and the uterine cervix below the PCL, the last 13 patients showed anterior descent of the urinary bladder and 3 cases exhibited lateral descent of the urinary bladder. The uterine cervix and lower segment of the uterus were below the PCL, associated with enterocele and caudal inclination of the levator plate on straining sequences. All patients showed loss of the normal position of the perineal plate indicating generalized weakness of the whole pelvic floor muscles (Figures 1 and 2).
Only half of the cases exhibited abnormalities on the static MRI images i.e. none of the organs was seen touching or below the PCL. Dynamic MRI revealed
pelvic organ prolapse in double the cases found by static MRI as depicted in Tables 1 and 2.
Pelvic prolapse is a common problem affecting women of all ages. Pelvic prolapse involves the herniation of various portions of the vaginal wall. Symptoms vary according to the area of the vagina affected. Proper evaluation is imperative for providing proper treatment. Various surgical approaches to repair have been developed and techniques continue to evolve [
Pelvic floor dysfunction encompasses a variety of fascial and anatomic defects that can include a combination of cystocele, rectocele, uterine prolapse, enterocele and vault prolapse. Accurate diagnosis of the coexisting abnormalities is essential in planning reconstructive procedures so that the risks of recurrence and reoperation can be minimized. At this time, dynamic magnetic resonance imaging is the study of choice to evaluate
the female pelvis and delineate the possible components of pelvic floor dysfunction [
Fielding [
We based our study by using the PCL as a reference point for measuring pelvic organ descent in relation to it as it is a best reference line in cases of cystocele and uterine prolapse. We measured the distance of the bladder-neck, distal edge of cervix/posterior fornix, and the most ventrocaudal point of the ventral rectal wall, respectively, to the pubococcygeal line (PCL), the horizontal tangent of the inferior rim of the pubic bone, and the line drawn through the long axis of the pubic bone. On functional MRI the best correlation with the clinical results was achieved using the PCL for the anterior compartment. This agree with the findings of Lienemann et al. [
In the current study we found that there was great association between parity status and the high incidence of pelvic floor dysfunction as patients of pelvic floor dysfunction in our study were found in patients with more than two normal vaginal deliveries, however 71.4% of our patients were complaining of symptoms related to pelvic floor dysfunction representing.
Hoyte et al. [
Pannu [
Gufler et al. concluded that dynamic MRI of the pelvic floor with a half-Fourier RARE sequence can reliably detect descents of all three pelvic compartments, that it requires no contrast agent, and that no radiation exposure is involved [
The advantages of dynamic magnetic resonance imaging include excellent depiction of the soft tissues and pelvic organs, and their fluid content during various degrees of pelvic strain. To our knowledge whether it is cost-effective in this manner has not been determined [
Signs of genital prolapse are frequently found in the female general population but are seldom symptomatic. Of factors associated with genital prolapse found in this study, pelvic floor muscle strength appears to be the only one that could be affected [
In the present study we found that 26 patients showed that the urinary bladder just touching the PCL and caudal inclination of the perineal plate at straining sequences, 18 patients showed descent of the urinary bladder and the uterine cervix below the PCL, 16 patients showed also descent of the urinary bladder, uterine cervix and lower segment of the uterus below the PCL, associated with enterocele and caudal inclination of the levator plate on straining sequences, All patients showed loss of the normal position of the perineal plate indicating generalized weakness of the whole pelvic floor muscles.
The results of the current investigation supported the importance of the dynamic pulse sequences in the diagnosis of genital descent. We observed pelvic floor abnormalities in 46 patients which did not show any abnormalities on the static images.
Lastly, we concluded that Dynamic MRI is a helpful tool in defining the nature, degree and quantitative measurements of genital prolapse because physical examination is often insufficient in defining the nature and degree of visceral prolapse. Moreover, quantitative measurements are difficult to obtain by clinical examination only.