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MRI
IN
Pelvic Floor Disorders
MAHYAR GHAFOORI M.D.
Associate Professor of Radiology
Tehran University
Of
Medical Sciences
Pelvic floor in Women
• Anterior Compartment: Bladder & Urethra
• Middle Compartment: Uterus & Vagina
• Posterior Compartment: Anorectal
Normal Anatomy
Reference Lines
Pubococcygeal line (PCL):
From the inferior border of pubic symphysis to the last coccygeal joint.
Level of Pelvic Floor
H line:
Max. 5 cm
From inferior border of pubic symphysis to the posterior wall of the rectum
at the level of anorectal junction.
AP Width of Levator Hiatus
M line:
Max. 2 cm
Perpendicularly from PCL to the most posterior aspect of H line.
Vertical descent of the levator hiatus
Rest
Normal
Straining
Rest
Straining
71 Y/O F: Prolapse & Fecal Incontinence
Prolapse Severity Grading
Prolapse of an organ below the PCL:
3 cm or less
Mild
Between 3 and 6 cm
More than 6 cm
Moderate
Severe
Anorectal Angle
Rest
108 - 127°
Squeezing
Close
Defecation
Open
Puborectalis Muscle
Rest
Squeezing
Straining
Anterior Compartment
Cystocele
Urethral Hypermobility
Rest
33mm 0°
Strain
18mm 65°
48 Y/O Stress urinary incontinence & frequency
56 Y/O F: Stress urinary incontinence, feeling of incomplete bladder voiding, ODS
Middle Compartment
Uterine or Vaginal Vault Prolapse
Rest
Straining
41 Y/O F: Severe uterine prolapse
Defecation
Rest
72 Y/O F: Prolapse after Hysterectomy
Defecation
Posterior Compartment
Anterior Rectocele
45 Y/O F: history of obstructed defecation
Posterior Rectocele
During Defecation
41 Y/O F with ODS
Rectocele
During Defecation
Intrarectal Residue
65 Y/O F: History of incomplete evacuation
Intrarectal Invagination
57 Y/O F: Feeling of incomplete evacuation
Extraanal Invagination (Rectal Prolapse)
Rest
Progressive Straining
63 Y/O F: Fecal Incontinence, Hx of Hysterectomy
Enterocele
Early Defecation
64 Y/O F: Prolapse after Hysterectomy
Late Defecation
3 Compartment Prolapse
During Defecation
68 Y/O F: Perineal descent, ODS
Complete Defecation
3 Compartment Prolapse
Rest
Squeezing
62 Y/O F: 3 Compartment Descent
Defecation
Progressive Straining
65 Y/O F: ODS, Hx of Hysterectomy
Spastic Pelvic Floor Syndrome
(Pelvic Floor Uncoordination, Anismus)
Functional abnormality.
Involuntary, inappropriate & paradoxical contraction of striated pelvic
floor musculature: evacuation failure & Constipation.
Paradoxical contraction of puborectalis muscle.
Puborectalis muscle is hypertrophic & makes an impression on
posterior rectal wall during defecation.
Etiology is unclear (Abnormal muscle activity, psychologic, cognitive)
Anorectal Manometry: Increased pressure at rest & during defecation.
Pathologic signals at electromyography.
Spastic Pelvic Floor Syndrome
Rest
51 Y/O M: ODS
Strain
Rest
Progressive Straining
68 Y/O F: Excessive straining & incomplete evacuation
The End
Mahyar Ghafoori M.D.