Pelvic Floor Magnetic Resonance Imaging Research Articles

Longitudinal changes in pelvic organ support among primiparas with postpartum pelvic organ prolapse: A follow-up magnetic resonance imaging study.

To quantify morphological changes of pelvic floor in primiparas with postpartum pelvic organ prolapse (POP) during the early postpartum period. A total of 309 primiparas underwent pelvic floor magnetic resonance imaging (MRI) at 6 weeks postpartum. Those primiparas diagnosed with postpartum POP by MRI criterion were followed up at 3 and 6months postpartum. Normal primiparas were enrolled in the control group. The puborectal hiatus line, muscular pelvic floor relaxation line, levator hiatus area, iliococcygeus angle, levator plate angle, uterus-pubococcygeal line, and bladder-pubococcygeal line were assessed on MRI. Longitudinal changes in pelvic floor measurements between the two groups were compared by repeated-measures analysis of variance. Compared with the control group, enlarged puborectal hiatus line, levator hiatus area, and RICA and decreased uterus-pubococcygeal line were observed at rest in the POP group (all P< 0.05). All of the pelvic floor measurements were significantly different in the POP group compared with the control group at the maximum Valsalva maneuver (all P< 0.05). All of the pelvic floor measurements showed no significant change over time in both the POP and control groups (all P> 0.05). Postpartum POP accompanied by poor pelvic floor support will persist in the early postpartum period.

Pelvic Floor Anatomical Variations in Children With Exstrophy-Epispadias Complex Using Magnetic Resonance Imaging

ObjectiveTo quantitatively measure the anatomical variations of the pelvic floor in children with exstrophy-epispadias complex using magnetic resonance imaging. Materials and MethodsSix cases of classic bladder exstrophy (CBE), 5 cases of penile epispadias (PE) and 11 cases of penopubic epispadias (PPE) were included. Another 8 cases with the testicular tumor were taken as the controls. A series of measurements obtained from the pelvic floor magnetic resonance imaging were analyzed, and the measurements with significant differences were obtained by ANOVA. ResultsThe pelvic floor of the CBE was significantly different from that of controls in measurements including wider pubic diastasis (P <.001), greater posterior anal distance (P = .019), greater posterior bladder neck distance (P = .004), larger iliac wing angle (P <.001), diminutive ischial angle (P <.001), bigger puborectalis angle (P <.001), larger ileococcygeous angle (P = .002) and shortened anterior corporal length (P <.001). For the PE, the posterior bladder neck distance (P = .038) was greater than that of controls. In the PPE, the posterior bladder neck distance (P = .001) and puborectalis angle (P = .026) was greater than that of controls, respectively. ConclusionCBE shows severe anatomical variations of the pelvic floor. The bladder neck moves more anteriorly both in PE and PPE than the control. The enlarged puborectalis angle resulting from wider pubic diastasis and more anterior position of the anorectal canal is also noticed in PPE.

Pelvic floor assessment using magnetic resonance imaging after vaginal delivery and elective caesarean delivery.

We aimed to compare quantitative static and dynamic magnetic resonance imaging (MRI) measurements of pelvic floor changes during postpartum recovery from 1 week to 6 months after different modes of delivery. In this prospective study, 51 primiparous women (vaginal delivery group: 30 women; elective caesarean delivery group: 21 women) underwent static and dynamic MRI at 1 week, 6 weeks, 3 months, and 6 months postpartum to measure pelvic floor MRI values. Between-group differences in pelvic floor values at these time points were determined; subsequently, within-group comparisons according to time were performed. Analysis included independent samples t-tests and paired t-tests. The puborectal hiatus line (H line), muscular pelvic floor relaxation line (M line), bladder-pubococcygeal line (B-PCL), and uterus-pubococcygeal line (U-PCL) differed significantly between groups during the Valsalva manoeuvre at 1 week postpartum (p < 0.05). The H line, M line, and B-PCL values differed significantly between groups during the Valsalva manoeuvre at 6 weeks postpartum (p < 0.05). There were few significant between-group differences in pelvic floor values at 3 months and 6 months postpartum. In the vaginal delivery group, the differences in the H line and M line at 1 week, 6 weeks, and 3 months postpartum were significant (p < 0.001). In the elective caesarean delivery group, U-PCL differed significantly at 6 weeks compared to 1 week postpartum during the Valsalva manoeuvre (p < 0.05). Pelvic floor recovery primarily occurred during the early phase after delivery in both groups. Elective caesarean delivery had a non-significant protective effect on postpartum pelvic floor structure and function compared to vaginal delivery.

How to develop and sustain a successful pelvic floor MRI practice.

Magnetic resonance imaging (MRI) of the pelvic floor has become a commonly requested diagnostic tool for pelvic floor assessment. We provide a practical guide for developing, growing, and troubleshooting a dedicated pelvic floor imaging service. The authors provide an organized approach to the development of a pelvic floor MRI program based on the experience of the SAR Pelvic Floor Disease Focused Panel in academic and private practice settings. Topics addressed include creating interest, staff education, patient preparation both before and after arrival to the imaging center, image acquisition, reporting, and troubleshooting. Using the organization and approach in this guide, the challenge of growing this relatively complex imaging program can be simplified. Familiarity with best practices and established techniques used by successful programs will allow new sites to avoid early pitfalls and quickly develop a mature and autonomous workflow. The development and growing of a pelvic floor MRI program presents its own set of challenges and unique workflow issues which can create anxiety in both patients and providers. We systematically present an approach to streamline the development of a successful pelvic floor MRI program.

Improved Detection of Pelvic Organ Prolapse: Comparative Utility of Defecography Phase Sequence to Nondefecography Valsalva Maneuvers in Dynamic Pelvic Floor Magnetic Resonance Imaging

To evaluate the utility of a defecography phase (DP) sequence in dynamic pelvic floor MRI (DPMRI), in comparison to DPMRI utilizing only non-defecography Valsalva maneuvers (VM). Inclusion criteria identified 237 female patients with symptoms and/or physical exam findings of pelvic floor prolapse. All DPMRI exams were obtained following insertion of ultrasound gel into the rectum and vagina. Steady-state free-precession sequences in sagittal plane were acquired in the resting state, followed by dynamic cine acquisitions during VM and DP. In all phases, two experienced radiologists performed blinded review using the H-line, M-line, Organ prolapse (HMO) system. The presence of a rectocele, enterocele and inferior descent of the anorectal junction, bladder base, and vaginal vault were recorded in all patients using the pubococcygeal line as a fixed landmark. DPMRI with DP detected significantly more number of patients than VM (p<0.0001) with vaginal prolapse (231/237, 97.5% vs. 177/237, 74.7%), anorectal prolapse (227/237, 95.8% vs. 197/237, 83.1%), cystocele (197/237, 83.1% vs. 108/237, 45.6%), and rectocele (154/237, 65% vs. 93/237, 39.2%). The median cycstocele (3.2cm vs. 1cm), vaginal prolapse (3cm vs. 1.5cm), anorectal prolapse (5.4cm vs. 4.2cm), H-line (8cm vs. 7.2cm) and M-line (5.3cm vs. 3.9cm) were significantly higher with DP than VM (p<0.0001). Addition of DP to DPMRI demonstrates a greater degree of pelvic floor instability as compared to imaging performed during VM alone. Pelvic floor structures may show mild descent or appear normal during VM, with marked prolapse on subsequent DP images.

Dynamic 3T pelvic floor magnetic resonance imaging in women progressing from the nulligravid to the primiparous state.

The objective was to prospectively characterize dynamic pelvic 3-Tesla magnetic resonance imaging (dp3T MRI) findings in nulligravida women and characterize changes 6months after delivery in the same woman. In this prospective study, nulligravida women seeking assisted reproductive technology for pregnancy were recruited. After physical examination by Pelvic Organ Prolapse Quantification (POP-Q), Brink assessment and measures including the Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire-7, pre-pregnancy dp3T MRI at rest, with strain, and evacuation were performed. Assessments were repeated ≥6months postpartum. Analysis included Welch and paired t tests for continuous variables, Fisher's exact test for differences in categorical outcomes, and paired t tests for postpartum symptoms. Nineteen subjects (mean±SD age, 31±5years) completed baseline clinical and dp3T MRI studies, 15 delivered and 10 (30.5±3years) completed pre-pregnancy and post-delivery clinical and dp3T MRI assessments. There were no significant changes in scores of validated questionnaires (all p>0.05) or on POP-Q measures post-delivery. Two (20%) subjects without pre-pregnancy levator tears had tears on MRI post-delivery. MRI measures of pelvic organ descent were increased post-delivery. Seventeen pelvic soft-tissue parameters increased by greater than 10% post-delivery, including 5 out of 70 (7.1%), 17 out of 110 (15.5%), and 50 out of 110 (45.5%) values exceeding thresholds at rest, strain, and evacuation respectively. Dynamic pelvic 3T MRI detected levator tears and increased pelvic organ descent, which can be directly attributed to pregnancy and delivery.

Dynamic Magnetic Resonance Imaging of the Pelvic Floor

Pelvic floor dysfunction is a widespread condition affecting up to 50% of elderly women. It markedly compromises the quality of life owing to various disabling symptoms such as pelvic pain, pelvic organ prolapse, and urinary and fecal incontinence. Although age and female sex are the main risk factors, others include multiparity, obesity, and connective tissue disorders. Pelvic floor dysfunction is frequently multicompartmental, and failure to diagnose it accurately often leads to treatment failure. Dynamic pelvic floor magnetic resonance imaging is a robust tool that enables simultaneous visualization of the 3 pelvic floor compartments and is indispensable for precise preoperative evaluation.

Influence of rectal gel volume on defecation during dynamic pelvic floor magnetic resonance imaging

PurposeTo evaluate effects of altering rectal contrast volume on defecatory effort during magnetic resonance defecography (MRD). MethodsWe assessed defecation qualitatively and quantitatively as a function of rectal distention (group A: 180 cc, n=31; group B: 120 cc, n=31). Quantitative evaluation comprised measuring rectal area on midline sagittal images pre- and post-defecation. ResultsResting rectal area was significantly higher for group A than for group B (35.2 vs. 28.3 cm2, P<.0001). Post-defecation rectal area and change in area (pre- to post-defecation) were not significantly different. Subjective evaluation showed no significant difference. ConclusionDecreasing rectal gel volume from 180 to 120 cc did not compromise defecation performance during MRD.

Magnetic resonance imaging of pelvic floor disorders.

Physical examination alone is often inadequate for evaluation of pelvic floor dysfunction. Magnetic resonance imaging (MRI) is a robust modality that can provide high-quality anatomic and functional evaluation of the pelvic floor. Although lack of standardized technique and radiologist inexperience may be relative deterrents in universal acceptance of pelvic floor MRI, the role of MRI is increasing as it is technically feasible on most magnets and offers some advantages over the traditional fluoroscopic defecography. This review focuses on the technical and interpretational aspects of anatomic and functional pelvic floor MRI.

A pictorial overview of pubovisceral muscle avulsions on pelvic floor magnetic resonance imaging.

ObjectivesDespite extensive research aimed at clarifying (failing) pelvic organ support, the complete aetiology of pelvic organ prolapse (POP) is still not fully understood. During vaginal delivery, the pelvic floor can be irreversibly traumatised, resulting in pubovisceral muscle avulsions. The aetiology of these avulsions is discussed in this pictorial overview. Normal female pelvic floor anatomy is described and variations are exemplified using magnetic resonance (MR) images. The clinical relevance of detecting pubovisceral muscle avulsions is specified.MethodsT2-weighted MR imaging has multiplanar capabilities with high diagnostic accuracy allowing for detailed visualisation of the pelvic floor. Together with the use of a three-dimensional (3D) post-processing program, the presence and severity of pubovisceral muscle avulsions can be quantified.ResultsPelvic floor MR imaging is a non-invasive method that enables adequate identification of pubovisceral muscle avulsions which are known risk factors for the development of POP. They can be scored with good to excellent inter- and intra-observer reliability.ConclusionsRadiologists and urogynaecology subspecialists should be familiar with MR imaging findings of pubovisceral muscle avulsions as this birth-related trauma is observed in over 36 % of vaginally parous women.Teaching Points• Pelvic organ prolapse (POP) is a growing problem for both patients and for our healthcare system• Pubovisceral muscle avulsions are known risk factors for pelvic organ prolapse (POP)• T2-weighted MR imaging visualises pubovisceral muscle avulsions adequately• Pubovisceral muscle avulsions are scored with good to excellent inter- and intra-observer reliability

Correlating signs and symptoms with pubovisceral muscle avulsions on magnetic resonance imaging

We sought to correlate signs and symptoms of pelvic organ prolapse (POP) with pubovisceral muscle avulsions on magnetic resonance imaging (MRI). In this retrospective cohort study of 189 women with recurrent POP or unexplained symptoms of pelvic floor dysfunction, we reviewed T2-weighted pelvic floor MRI and categorized defects as minor or major avulsion, or as no defect present. Outcomes were correlated to quality-of-life questionnaire scores and data on obstetric and surgical history, together with POP-Quantification (POP-Q) measurements. Multivariable ordinal logistic regression analysis with manual backward elimination was applied to calculate odds ratios (ORs). Major pubovisceral avulsions were diagnosed in 83 (44%) women, minor avulsions in 49 (26%) women, while no defects were seen in 57 (30%) women. Women with a history of episiotomy or anterior vaginal wall reconstructive surgery had a higher OR for more severe pubovisceral muscle avulsions (adjusted OR, 3.77 and 3.29, respectively), as did women with symptoms of POP (OR, 1.01, per unit increase) or higher stage POP of the central vaginal compartment based on POP-Q measurement "C" (OR, 1.18). Women with symptoms of obstructive defecation were more likely to have no defect of the pubovisceral muscle on MRI (OR, 0.97, per unit increase). The variables episiotomy, previous anterior vaginal wall reconstructive surgery, POP-Q measurement "C," and symptoms scored with the Urogenital Distress Inventory "genital prolapse" and Defecatory Distress Inventory "obstructive defecation" subscales are correlated with pubovisceral muscle avulsions on pelvic floor MRI.

Comparison between dynamic cystocolpoproctography and dynamic pelvic floor MRI: pros and cons: Which is the “functional” examination for anorectal and pelvic floor dysfunction?

"Functional" imaging of anorectal and pelvic floor dysfunction has assumed an important role in the diagnosis and management of these disorders. Although defecography has been widely practiced for decades to evaluate the dynamics of rectal emptying, debate concerning its clinical relevance, how it should be done and interpreted continues. Due to the recognition of the association of defecatory disorders with pelvic organ prolapse in women, the need to evaluate the pelvic floor as a unit has arisen. To meet this need, defecography has been extended to include not only evaluation of defecation disorders but also the rest of the pelvic floor by opacifying the small bowel, vagina, and the urinary bladder. The term "dynamic cystocolpoproctography" (DCP) has been appropriately applied to this examination. Rectal emptying performed with DCP provides the maximum stress to the pelvic floor resulting in complete levator ani relaxation. In addition to diagnosing defecatory disorders, this method of examination demonstrates maximum pelvic organ descent and provides organ-specific quantification of organ prolapse, information that is only inferred by means of physical examination. It has been found to be of clinical value in patients with defecation disorders and the diagnosis of associated prolapse in other compartments that are frequently unrecognized by history taking and the limitations of physical examination. Pelvic floor anatomy is complex and DCP does not show the anatomical details pelvic magnetic resonance imaging (MRI) provides. Technical advances allowing acquisition of dynamic rapid MRI sequences has been applied to pelvic floor imaging. Early reports have shown that pelvic MRI may be a useful tool in pre-operative planning of these disorders and may lead to a change in surgical therapy. Predictions of hypothetical increase cancer incidence and deaths in patients exposed to radiation, the emergence of pelvic floor MRI in addition to questions relating to the clinical significance of DCP findings have added to these controversies. This review analyses the pros and cons between DCP and dynamic pelvic floor MRI, addresses imaging and interpretive controversies, and their relevance to clinical management.

Dynamic pelvic floor imaging: MRI techniques and imaging parameters

Magnetic resonance imaging (MRI) is an excellent tool to understand the complex anatomy of the pelvic floor and to assess pelvic floor disorders. MRI enables static and dynamic imaging of the pelvic floor. Using static T2-weighted sequences the morphology of the pelvic floor can be visualized in great detail. A rapid half-Fourier T2-weighted, balanced steady state free precession, or gradient-recalled echo sequence are used to obtain sagittal images while the patient is at rest, during pelvic squeeze, during pelvic strain and to document the evacuation process. On these images the radiologist identifies the pubococcygeal line (PCL) (which represents the level of the pelvic floor). In normal findings, the base of the anterior and the middle compartment are above the PCL at rest, and the pelvic floor elevates during contraction. During straining the pelvic floor muscles should relax and the pelvic floor descends normally less than 3 cm below the PCL. Pelvic floor MRI based on the static and dynamic MRI sequences allows for the detection and characterization of a vast array of morphologic and functional pelvic floor disorders. In this review, we focus on technical aspects of static and dynamic pelvic floor MRI.

Assessment of Women With Defecatory Dysfunction and Manual Splinting Using Dynamic Pelvic Floor Magnetic Resonance Imaging

This study aimed to describe magnetic resonance imaging (MRI) findings in women with defecatory dysfunction who perform manual splinting. This is a retrospective study of 29 patients from a single urogynecology center who presented with complaints of defecatory dysfunction and who reported manual splinting to assist with bowel movements. Patients were scheduled for an MRI study with a novel "splinting" protocol to evaluate the effects of their manual splinting on the pelvic floor. The protocol involved asking patients to splint during the MRI, as they normally would when trying to defecate. The goal was to evaluate any change in pelvic anatomy and compensation for an anatomic defect that could potentially lead to their defecatory dysfunction. Magnetic resonance images of the pelvis were obtained at rest, with pelvic floor contraction, with Valsalva, and during manual splinting. These images were then reviewed by radiologists who evaluated various parameters, including anorectal angle, levator ani muscle integrity, and the presence of rectocele, cystocele, apical prolapse, and enterocele. The external and internal anal sphincters were also evaluated for continuity. From September 2008 to October 2010, 29 women reported defecatory dysfunction and the need for manual splinting. Their mean (SD) age was 55.2 (10.5) years. Magnetic resonance images showed a rectocele in 86.2% of the study group, cystocele in 75.9%, enterocele in 10.3%, and a defect of the levator ani muscles in 17.2%. Twenty-one (72.4%) women had more than 1 of these defects. In addition, 27.6% had an anorectal angle less than 90 degrees or greater than 105 degrees.Patients in the study group splinted in the vagina (58.6%), on the perineum (31.0%), or on the buttock (10.3%). In all but 1 woman (96.6%), splinting improved or completely corrected the identified defect(s) as evidenced with MRI. Among those who used vaginal splinting, 52.9% of defects were corrected and 47.1% were improved. Perineal splinting corrected 55.6% and improved 33.3% of cases and was ineffective in 11.1% of cases, whereas buttock splinting corrected 33.3% and improved 66.7% of cases. Most women in our study group who used manual splinting to assist in defecation are compensating for a pelvic floor defect that can be detected on MRI. Magnetic resonance imaging of the pelvis may help elucidate the etiology of the defecatory dysfunction in some women and may assist pelvic reconstructive surgeons in planning surgical correction of pelvic floor defects. Magnetic resonance imaging may also identify defects in the pelvic floor that are, at the present time, not amenable to surgical correction.

EARLY OUTCOME FOLLOWING COMPLETE PRIMARY REPAIR OF BLADDER EXSTROPHY IN THE NEWBORN

Complete primary repair of bladder exstrophy (CPRE) represents a paradigm shift from the staged approach for surgical management. We present early clinical outcomes in our patients following CPRE. From 1996 to 2004 all newborns with bladder exstrophy were treated with CPRE within 48 hours of birth. We reviewed parameters including transfusions (packed red blood cells), urethral meatal position, complications, findings on renal ultrasound and renal scan, and post-CPRE procedures and infections. A total of 16 boys and 7 girls were treated with CPRE. Followup ranged from 8 to 96 months. Twelve boys (75%) and 2 girls (29%) received packed red blood cells at CPRE (p = 0.066). The tubularized urethral plate could not be brought to the penile tip, resulting in hypospadias in 9 of 11 boys (82%) with the running suture technique and only 1 of 5 boys (20%) with the interrupted technique (p = 0.036). Of the 23 patients 6 had a total of 8 complications after CPRE. Vesicoureteral reflux was present in 17 of 23 patients. After CPRE a total of 93 endoscopic/surgical procedures (median 4, range 0 to 16 per patient) were performed. Five patients had 1 to 4 episodes of pyelonephritis, 16 of 23 had 1 or more episodes of asymptomatic bacteriuria and 5 had cortical defects on renal scan. We recommend that urethral closure during CPRE be performed with interrupted suture technique to prevent hypospadias. An aggressive approach should be taken toward reflux in the setting of urinary infection. Consideration should be given for repair of all aspects of the defect during CPRE, including bilateral ureteral reimplantation.

Faecal Incontinence in the Elderly

Faecal incontinence occurs in up to 10% of community dwelling persons > or = 65 years of age and approximately 50% of nursing home residents. It is a vastly under-reported problem that has a devastating effect on those who experience it as well as their spouses and caregivers. There are three broad categories of faecal incontinence among the elderly: (i) overflow incontinence; (ii) reservoir incontinence; and (iii) rectosphincteric incontinence. The first two can be diagnosed based upon the patient's history and physical examination and the response to dietary and pharmacological interventions. The third is assessed by careful physical examination supplemented by diagnostic tests directed towards evaluation of anorectal continence mechanisms. The most important of these is anorectal manometry, which can be supplemented by studies of structure (anal ultrasonography or pelvic floor magnetic resonance imaging) and neuromuscular function (electromyogram). A variety of therapeutic interventions are employed in patients with rectosphincteric incontinence; these include dietary, behavioural, pharmacological and surgical modalities chosen on the basis of the results of diagnostic testing. For isolated internal anal sphincter weakness, a cotton barrier in the anal canal is often effective. Acute sphincter injury is best treated with sphincteroplasty but, otherwise, surgical procedures are of uncertain benefit. Peripheral neurogenic incontinence may be treated with antidiarrhoeal agents, biofeedback techniques and dietary manipulations. Sacral spinal nerve stimulation is a promising new technique for selected patients with neurogenic faecal incontinence and is currently undergoing testing in the US and Europe. Significant improvement in quality of life can be achieved in most elderly persons with faecal incontinence.

Pelvic Floor Magnetic Resonance Imaging after Neonatal Single Stage Reconstruction in Male Patients With Classic Bladder Exstrophy

We evaluate a magnetic resonance imaging (MRI) protocol used to study the pelvic floor anatomy in male patients following neonatal single stage complete bladder exstrophy and epispadias repair with osteotomies. From 1996 to 2002, 9 males underwent surgical correction of bladder exstrophy and epispadias with osteotomies within 1 to 12 days of birth. Pelvic floor MRI was conducted comparing this group to 5 aged matched male patients with no pelvic anatomical abnormality who underwent MRI for other illness. We compared various measurement of pelvic musculature by unpaired Wilcoxon test. Median followup was 3 years (range 0.5 to 5.3). All surgical procedures succeeded in closure of abdominal wall and genitalia defects. MRI data showed that in the exstrophy group symphyseal distance was significantly wider than that in controls (median 3.8 vs 1.1 cm). In addition, the levator ani fibers diverted more laterally (42 vs 22 degrees), the pelvic floor in coronal view was more flat (103 vs 80 degrees) and the anus was more anteriorly displaced (2.8 vs 4.4 cm). We also documented shorter anterior corporeal bodies in the exstrophy group (1 vs 2 cm). No statistical difference between the 2 groups was found in the dimensions of the levator and obturator muscles, sagittal angle of the pelvic floor, and the dimensions and angle of the posterior corporal bodies. Two patients achieved some degree of continence around the age of 4 years. They had the shortest symphyseal distance and sharpest angle of levator ani fiber divergence, and the bladder neck was more deeply located in the pelvic. We applied novel MRI parameters to the pelvic floor anatomy providing a new quantifiable approach. Our protocol is feasible and reproducible, allowing for future comparison of the impact of different surgical modalities, and correlation between anatomical findings and continence.

Role of dynamic pelvic floor magnetic resonance imaging (MRI) in the assessment of patients with idiopathic combined faecal and urinary incontinence

The aetiology of combined urinary and faecal incontinence (UFI) are interrelated and remain poorly understood; affecting appropriate patient selection, thus accountmg for sub-optimal surgical outcome. A potential variable in this process is Global pelvic floor dysfunction (GPFD). The aim of this study was to prospectively assess whether use of phased array body coil MRI could identify global pelvic floor dysfunction in these patients with multisystem dysfunctional symptoms. Symptomatic parncipants were selected from patients presenting with complaints of combined urinary and faecal incontinence either in the colorectal or urology outpatient clinics. Patients who have had previous pelvic floor surgery were excluded from this study. All underwent standard urodynamics and anorectal physiology assessment. Voiding cystometry, coIonoscopy and endoanal ultrasound were also performed. A standardised protocol was used for the MRI imaging. Thirty individual parameters were measured using buih-in-sofiware (callipers, compass and densitometer). Statistical analysis was performed using SPSS software Nineteen consecutive patients were assessed. Patiems were age, sex and parity matched with asymptomatic controls (n= 11). The MRI procedure was tolerated well by all the participants. Results are shown in the table. Body coil MRI is a non-invasive, well-tolerated imaging modafity. The novel use of MR1 in these patients has demonstrated for the first time distinct anatomical features evident in the levator plate, Urethrovesical angle and anal sphincter complex in patients with GFPD. Our data suggests that body coil dynamic MR1 may have a potential role in identifying patients with global perineal muscle dysfunction, thus facilitating definitive surgical management.

Critical Evaluation of the Problem of Chronic Urinary Retention After Orthotopic Bladder Substitution in Women

We studied the possible causes of chronic retention after radical cystectomy and orthotopic bladder substitution in women. Between January 1995 and January 2001, 136 women with a mean age plus or minus standard deviation of 52 +/- 8 years underwent standard radical cystectomy and orthotopic substitution for organ confined bladder cancer. Videourodynamics, pelvic floor electromyography, pelvic floor magnetic resonance imaging and pan-endoscopy were done. In the last 37 cases some technical modifications were adopted to circumvent the development of chronic urinary retention. One woman died postoperatively of massive pulmonary embolism. Of the 100 patients evaluable at a mean followup of 36 months 95 were continent in the daytime, 86 were continent at night, 2 were completely incontinent and 16 were in chronic retention. Videourodynamics showed that retention was mechanical in nature due to the pouch falling back in the wide pelvic cavity, resulting in acute angulation of the posterior pouch-urethral junction. In addition, herniation of the pouch wall through the prolapsed vaginal stump was observed in most cases. Pelvic floor electromyography demonstrated complete pelvic floor silence during voiding. No abnormality of the pelvic floor or rhabdosphincter was noted on magnetic resonance imaging. Pan-endoscopy showed a normal urethra with no urethroileal stricture. A 4 mg. dose of the alpha1-adrenergic blocker doxazosin daily was ineffective, excluding the possibility that sprouting from adjacent adrenergic neurons into the denervated proximal urethral muscles may have been the cause of this problem. After omental packing behind the pouch, suturing of the peritoneum on the rectal wall to the vaginal stump, suspension of the latter by the preserved round ligaments and suspension of the pouch near its dome to the back of the rectus muscle at cystectomy the incidence of chronic retention decreased from 18.7% (14 of 75 cases) before to 8% (2 of 25) after modifications. Furthermore, after vaginal wall descent was mechanically corrected by a pessary there was significant improvement in evacuation. Strong evidence was provided that chronic urinary retention after orthotopic substitution is due to anatomical rather than to functional or neurogenic reasons. Modifications to increase back support of the pouch with ventral suspension near its dome and support the vaginal stump are recommended to avoid this complication.

PELVIC FLOOR ANATOMY IN CLASSIC BLADDER EXSTROPHY USING 3-DIMENSIONAL COMPUTERIZED TOMOGRAPHY: INITIAL INSIGHTS

We present the pelvic floor anatomy of the major pelvic floor musculature in classic bladder exstrophy, including the levator ani, obturator internus and obturator externus. By improving our knowledge of pelvic floor anatomy we hope to understand better the relationship of the pelvic floor to the bony anatomy as well as the role of osteotomy in changing pelvic floor anatomy to enhance urinary control after surgery. 3-Dimensional computerized tomography was done in 6 boys and 1 girl, including 5 patients 2 days to 5 months old (mean age 7 months) undergoing primary closure and 2 who were 4 and 8 years old undergoing repeat closure. The pelvic floor musculature, including the levator ani, obturator internus and obturator externus, in these cases was compared to that in 26 age and sex matched controls. The levator ani musculature encompasses a significantly wider area of 9.5 cm.2 in patients with classic bladder exstrophy than in controls. The anterior segment of the levator ani was shorter (1.2 cm.) and the posterior segment of the levator ani was longer (2.5 cm.) than in controls. The degree of divergence of the levator ani in classic exstrophy was significantly more outwardly rotated (38.8 degrees) than controls. In addition, the transverse diameter of the levator hiatus was 2-fold that in our control group and in that of published controls, while the length of the hiatus was 1.3-fold that in normal controls. There was also significant flattening, involving a 31.7 degree decrease in steepness between the right and left halves of the levator ani, of the puborectal sling in classic bladder exstrophy versus controls. Because of these findings, there is more anterior superior rotation in the pelvic floor in exstrophy cases. The obturator internus was more outwardly rotated (15.1 degrees) in exstrophy and the obturator externus also showed more outward rotation (16.9 degrees) than in controls. This study provides better understanding of the pelvic floor anatomy in classic bladder exstrophy. Significant differences have been documented in the pelvic floor in classic bladder exstrophy cases and controls. Hopefully these differences may have a pivotal role in providing new insight into long-term issues, such as urinary and fecal incontinence, and pelvic organ prolapse, in classic bladder exstrophy.