NEWER TECHNIQUES IN MRI:

PELVIC FLOOR IMAGING IN FEMALE STRESS

INCONTINENCE

M. Devaraj1 Dr. J. Geethanjali2 R. Balu1

Senior MRI Technologist Head Guest Lecture & Ph.D Research Scholar
Sri Ramakrishna Hospital Department of Radiology School of Computer Science and Engg.
Coimbatore Sri Ramakrishna Hospital, Coimbatore Bharathiar University, Coimbatore
bmdevaraj@yahoo.co.in geethanjalij@yahoo.co.in rvkbalu@yahoo.co.in

I would like to present one case of pelvic floor imaging done in our department.

A 59 year old female was referred with stress incontinence for pelvic floor imaging.

Introduction

For patients with severe urinary or fecal incontinence thought to be multi factorial or
multiple compartment involvement or who have failed prior surgery, imaging can be
extremely valuable.

Magnetic Resonance Imaging

During past 10 years, MRI has emerged as a competitor to other imaging modalities
for evaluation of the female pelvic floor.

The main advantages are

1. Ability to evaluate the three compartments of the pelvic floor simultaneously

during rest and strain.
2. Direct visualization of supporting structures.

Disadvantages

To be usually performed in supine or left lateral decubitus position.

The requirement that the exam to be usually performed in supine, or left lateral
decubitus position

MRI techniques

 To obtain high quality useful images requires careful attention to patient

preparation and examination techniques.
Patient preparation:

 Just prior to imaging, the patient is asked to void. This prevents a distended
bladder from distorting adjacent anatomy. If the exam is focused on the
posterior compartment, 60 ml of ultrasound gel is placed in the rectum using a
small catheter.

 The patient is the coached on how to maintain maximum valsalva. Most

women maintain maximum pressure for less than 10 seconds.

 No oral or intravenous contrast used.

 Examination completed in 15 mts.

 A multicoil array either pelvic or torso coil is wrapped around the inferior
portion of the pelvis and the patient placed in the supine or left lateral
decubitus position.

 It is important that the coil be placed low enough so that prolapsing structure
can be seen.

Examination steps

Rapid T1 weighted or gradient echo large field of view (FOV) localizer sequence in
the sagittal plane, the midline is identified.

Using an ultra fast spin echo (SSFSE, GE) or half-acquisition single –shot turbo spin
echo (HASTE) (siemens), sagital midline images 10 mm in thickness are obtained at
rest and at maximal valsalva strain.

Standard fast spin echo [ FSE;GE ] or turbo spin echo [ TSE; SIEMENS ] sequences
are obtained in the axial and coronal planes.
Protocol for MR Imaging Evaluation of Incontinence and Pelvic Floor Weakness

Section Matrix
Pulse Imaging TR/TE FOV Thickness/ Flip Frequency Number of
Sequence Plane (msec) (cm) Gap (mm) Angle x Phase Excitations
Scout Sagittal 15/5 350–400 10/0 1° 160 x 256 ...
HASTE* Sagittal 4.4/90 300 10/0 180° 128 x 256 1, center
low
T2 turbo SE Axial 5,000/132 200–240 5/inter- 180° 270 x 256 2
leaved
T2 turbo SE Coronal 5,000/132 200–240 5/1 180° 270 x 256 2
(optional)

Note.— FOV = field of view, HASTE = half-acquisition single-shot turbo spin echo, SE = spin echo,
TR/TE = repetition time/echo time.

*Repeat this sequence while the patient performs maximal pelvic strain (Valsalva maneuver).
MRI Anatomy

On sagittal images the pubococcygeal line (PCL) should be drawn between the last
horizontal joint of the coccyx and the inferior most aspect of the symphysis. Urologist
and gynecologist use this line as an indicator of the pelvic floor. In early work yang et
al used gradient echo images to define maximal normal descent of the bladder base
(1.0 cm below) vagina ( 1 cm above) and rectum (2.5 cms blow) with respect to the
PCL. In practical terms, descent of the bladder or vagina more than 1 cm below the
PCL indicates some degree of laxity while descent of greater than 2 cms in a
symptomatic patient often required surgical therapy.

Normal images of the pelvic

STUDY PATIENT

Imaging done at rest

 IMAGING DONE WHILE STRAINING

Shows the H line measuring 5.48 cms M line measuring 1.47 cms.
 Right puborectalis muscle is thinned out comparatively

Measurement of the H and M lines are useful ways to evaluate loss of pelvic floor
support. The H line is drawn from the inferior aspect of the symphysis pubic to the
posterior wall of the rectum and measures the anterior posterior dimension of the
pelvis hiatus. The M line is drawn as the perpendicular line from the PCL to the
posterior most aspect of the H line. It measures the height of the hiatus . In the healthy
women the H line should not exceed 5 cms and the M line 2 cms . The values greater
then these indicates loss of pelvic floor support.

CASE I:
In our patient the descent of bladder base below the pubococcygeal line is 4.5 cms. H
line measures 5.48 cms which has exceeded the normal value M line measured 1.47
cms and is within normal limits. This patient also had thinned out puborectalis muscle
on right side. So the patient had anterior compartment pathology and is a good
candidate for surgical therapy.
Reference

1. Julia R. Fielding, MD, Practical MR Imaging of Female Pelvic Floor

Weakness, RadioGraphics 2002; 22:295–304.

2. Yang A, Mostwin JL, Rosenshein NB, Zerhouni EA. Pelvic floor descent in
women: dynamic evaluation with fast MR imaging and cinematic display.
Radiology 1991; 179:25–33.

3. 16. Comiter CV, Vasavada SP, Barbaric ZL, Gousse AE, Raz S. Grading
pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance
imaging. Urology 1999; 3:454–457.

4. Klutke C, Golomb J, Barbaric Z, Raz S. The anatomy of stress incontinence:

magnetic resonance imaging of the female bladder neck and urethra. J Urol
1990; 143:563–566.

5. 20. Tan IL, Stoker J, Zwamborn AW, Entius KAC, Calame JJ, Lame´ris JS.
Female pelvic floor: endovaginal MR imaging of normal anatomy. Radiology
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