Dynamic MR Imaging of Pelvic Organ Prolapse: Spectrum of Abnormalities1
Harpreet K. Pannu, MD,
Howard S. Kaufman, MD,
Geoffrey W. Cundiff, MD,
René Genadry, MD,
David A. Bluemke, MD, PhD and
Elliot K. Fishman, MD
1 From the Departments of Radiology (H.K.P., D.A.B., E.K.F.), Surgery (H.S.K.), and Gynecology and Obstetrics (G.W.C., R.G.), Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287. Recipient of a Cum Laude award for a scientific exhibit at the 1999 RSNA scientific assembly. Received February 28, 2000; revision requested March 31 and received June 9; accepted June 9. Address correspondence to H.K.P. (e-mail: hpannu@jhmi.edu).
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Figure 1. Axial schematic shows the anatomic structures that provide pelvic floor support. A = arcus tendineus fascia pelvis ("white line"), B = pubic bone, P = puborectalis sling, R = rectum, U = urethra, V = vagina.
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Figure 2. Sagittal schematic of the pelvis demonstrates various sites of prolapse, including the bladder neck and urethra (1), bladder base (2), cervix-vaginal vault (3), cul-de-sac (4), and rectum (5). B = bladder, R = rectum, U = uterus.
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Figure 3a. Urethral hypermobility with funneling in a 48-year-old woman with stress urinary incontinence and frequency. (a) Sagittal T2-weighted MR image obtained with the patient at rest shows the urethra in its normal verti-cal orientation (solid arrow). The bladder (open arrow), cervix (*), and rectum are also seen. (b) On a sagittal T2-weighted MR image obtained with the patient straining, the urethra is approximately horizontal in orientation and lies inferior to the pubis. This hypermobility explains the patient's stress urinary incontinence. The proximal portion of the urethra (arrow) is inferior to the distal portion (double arrows). The entire urethra appears shortened due to funneling or dilation of the proximal urethra and the presence of urine in the lumen. * = cervix. (c, d) MR images illustrate measurements of urethral length with the patient at rest (c) and while straining (d). Arrowhead in c and arrow in d indicate the urethra. The urethra measures 33 mm (0° angle from the vertical) in c and 18 mm (65° angle from the vertical) in d. Bladder prolapse is also noted. (e) On a coronal MR image obtained with the patient straining, the urethra (arrow) is seen en face below the pubic symphysis because it is now horizontal in orientation. The striated outer muscle layer in the wall of the urethra is seen as a circular hypointense band.
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Figure 3b. Urethral hypermobility with funneling in a 48-year-old woman with stress urinary incontinence and frequency. (a) Sagittal T2-weighted MR image obtained with the patient at rest shows the urethra in its normal verti-cal orientation (solid arrow). The bladder (open arrow), cervix (*), and rectum are also seen. (b) On a sagittal T2-weighted MR image obtained with the patient straining, the urethra is approximately horizontal in orientation and lies inferior to the pubis. This hypermobility explains the patient's stress urinary incontinence. The proximal portion of the urethra (arrow) is inferior to the distal portion (double arrows). The entire urethra appears shortened due to funneling or dilation of the proximal urethra and the presence of urine in the lumen. * = cervix. (c, d) MR images illustrate measurements of urethral length with the patient at rest (c) and while straining (d). Arrowhead in c and arrow in d indicate the urethra. The urethra measures 33 mm (0° angle from the vertical) in c and 18 mm (65° angle from the vertical) in d. Bladder prolapse is also noted. (e) On a coronal MR image obtained with the patient straining, the urethra (arrow) is seen en face below the pubic symphysis because it is now horizontal in orientation. The striated outer muscle layer in the wall of the urethra is seen as a circular hypointense band.
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Figure 3c. Urethral hypermobility with funneling in a 48-year-old woman with stress urinary incontinence and frequency. (a) Sagittal T2-weighted MR image obtained with the patient at rest shows the urethra in its normal verti-cal orientation (solid arrow). The bladder (open arrow), cervix (*), and rectum are also seen. (b) On a sagittal T2-weighted MR image obtained with the patient straining, the urethra is approximately horizontal in orientation and lies inferior to the pubis. This hypermobility explains the patient's stress urinary incontinence. The proximal portion of the urethra (arrow) is inferior to the distal portion (double arrows). The entire urethra appears shortened due to funneling or dilation of the proximal urethra and the presence of urine in the lumen. * = cervix. (c, d) MR images illustrate measurements of urethral length with the patient at rest (c) and while straining (d). Arrowhead in c and arrow in d indicate the urethra. The urethra measures 33 mm (0° angle from the vertical) in c and 18 mm (65° angle from the vertical) in d. Bladder prolapse is also noted. (e) On a coronal MR image obtained with the patient straining, the urethra (arrow) is seen en face below the pubic symphysis because it is now horizontal in orientation. The striated outer muscle layer in the wall of the urethra is seen as a circular hypointense band.
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Figure 3d. Urethral hypermobility with funneling in a 48-year-old woman with stress urinary incontinence and frequency. (a) Sagittal T2-weighted MR image obtained with the patient at rest shows the urethra in its normal verti-cal orientation (solid arrow). The bladder (open arrow), cervix (*), and rectum are also seen. (b) On a sagittal T2-weighted MR image obtained with the patient straining, the urethra is approximately horizontal in orientation and lies inferior to the pubis. This hypermobility explains the patient's stress urinary incontinence. The proximal portion of the urethra (arrow) is inferior to the distal portion (double arrows). The entire urethra appears shortened due to funneling or dilation of the proximal urethra and the presence of urine in the lumen. * = cervix. (c, d) MR images illustrate measurements of urethral length with the patient at rest (c) and while straining (d). Arrowhead in c and arrow in d indicate the urethra. The urethra measures 33 mm (0° angle from the vertical) in c and 18 mm (65° angle from the vertical) in d. Bladder prolapse is also noted. (e) On a coronal MR image obtained with the patient straining, the urethra (arrow) is seen en face below the pubic symphysis because it is now horizontal in orientation. The striated outer muscle layer in the wall of the urethra is seen as a circular hypointense band.
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Figure 3e. Urethral hypermobility with funneling in a 48-year-old woman with stress urinary incontinence and frequency. (a) Sagittal T2-weighted MR image obtained with the patient at rest shows the urethra in its normal verti-cal orientation (solid arrow). The bladder (open arrow), cervix (*), and rectum are also seen. (b) On a sagittal T2-weighted MR image obtained with the patient straining, the urethra is approximately horizontal in orientation and lies inferior to the pubis. This hypermobility explains the patient's stress urinary incontinence. The proximal portion of the urethra (arrow) is inferior to the distal portion (double arrows). The entire urethra appears shortened due to funneling or dilation of the proximal urethra and the presence of urine in the lumen. * = cervix. (c, d) MR images illustrate measurements of urethral length with the patient at rest (c) and while straining (d). Arrowhead in c and arrow in d indicate the urethra. The urethra measures 33 mm (0° angle from the vertical) in c and 18 mm (65° angle from the vertical) in d. Bladder prolapse is also noted. (e) On a coronal MR image obtained with the patient straining, the urethra (arrow) is seen en face below the pubic symphysis because it is now horizontal in orientation. The striated outer muscle layer in the wall of the urethra is seen as a circular hypointense band.
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Figure 4a. Cystocele and urethral hypermobility in a 68-year-old woman with stress urinary incontinence and incomplete bladder emptying. (a) Sagittal T2-weighted MR image of the pelvis obtained with the patient at rest shows the urethra angled posteriorly (arrow). This finding suggests that the urethra is not well supported, which would be compatible with stress incontinence. Unlike in Figure 3a, the urethra has an abnormal appearance. (b) On a sagittal T2-weighted MR image of the pelvis obtained with the patient straining, the urethra (arrow) is horizontal in orientation. Bladder prolapse is also present (arrowhead), a finding that is compatible with cystocele. As a result, a portion of the bladder lies below the urethrovesical junction, which is kinked. This accounts for the patient's symptom of incomplete evacuation. (c) Coronal T2-weighted MR image shows the prolapsed bladder with an elongated appearance (arrow).
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Figure 4b. Cystocele and urethral hypermobility in a 68-year-old woman with stress urinary incontinence and incomplete bladder emptying. (a) Sagittal T2-weighted MR image of the pelvis obtained with the patient at rest shows the urethra angled posteriorly (arrow). This finding suggests that the urethra is not well supported, which would be compatible with stress incontinence. Unlike in Figure 3a, the urethra has an abnormal appearance. (b) On a sagittal T2-weighted MR image of the pelvis obtained with the patient straining, the urethra (arrow) is horizontal in orientation. Bladder prolapse is also present (arrowhead), a finding that is compatible with cystocele. As a result, a portion of the bladder lies below the urethrovesical junction, which is kinked. This accounts for the patient's symptom of incomplete evacuation. (c) Coronal T2-weighted MR image shows the prolapsed bladder with an elongated appearance (arrow).
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Figure 4c. Cystocele and urethral hypermobility in a 68-year-old woman with stress urinary incontinence and incomplete bladder emptying. (a) Sagittal T2-weighted MR image of the pelvis obtained with the patient at rest shows the urethra angled posteriorly (arrow). This finding suggests that the urethra is not well supported, which would be compatible with stress incontinence. Unlike in Figure 3a, the urethra has an abnormal appearance. (b) On a sagittal T2-weighted MR image of the pelvis obtained with the patient straining, the urethra (arrow) is horizontal in orientation. Bladder prolapse is also present (arrowhead), a finding that is compatible with cystocele. As a result, a portion of the bladder lies below the urethrovesical junction, which is kinked. This accounts for the patient's symptom of incomplete evacuation. (c) Coronal T2-weighted MR image shows the prolapsed bladder with an elongated appearance (arrow).
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Figure 5a. Cystocele from a surgically proved focal defect in the pubocervical fascia in a 54-year-old woman with pelvic floor relaxation. Sagittal (a) and axial (b) T2-weighted MR images of the pelvis show a small protrusion of the bladder (solid arrow) into the space between the vagina (open arrow in a) and the urethrovesical junction (* in a). The axial image shows this protrusion to be midline.
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Figure 5b. Cystocele from a surgically proved focal defect in the pubocervical fascia in a 54-year-old woman with pelvic floor relaxation. Sagittal (a) and axial (b) T2-weighted MR images of the pelvis show a small protrusion of the bladder (solid arrow) into the space between the vagina (open arrow in a) and the urethrovesical junction (* in a). The axial image shows this protrusion to be midline.
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Figure 6a. Vaginal vault prolapse in a 52-year-old woman with pelvic pain and pressure. Sagittal T2-weighted MR images of the pelvis obtained with the patient at rest (a) and straining (b) demonstrate inferior prolapse of the vaginal vault during straining (solid arrow). As a result, the cul-de-sac (open arrow) also descends. There is peritoneal fat in the cul-de-sac, but bowel may be present. Bladder descent also occurs with straining.
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Figure 6b. Vaginal vault prolapse in a 52-year-old woman with pelvic pain and pressure. Sagittal T2-weighted MR images of the pelvis obtained with the patient at rest (a) and straining (b) demonstrate inferior prolapse of the vaginal vault during straining (solid arrow). As a result, the cul-de-sac (open arrow) also descends. There is peritoneal fat in the cul-de-sac, but bowel may be present. Bladder descent also occurs with straining.
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Figure 7a. Attenuation of paravaginal attachments in a 52-year-old woman. (a) Axial T2-weighted MR image of the pelvis obtained with the patient at rest shows the vagina with an H shape (arrowheads) with the lateral portions extending anteriorly. The levator ani muscle (arrow) is closely apposed to the vagina. (b) On an axial T2-weighted MR image of the pelvis obtained with the patient straining, the vagina maintains its shape but is displaced posteriorly. There is stretching of the paravaginal attachments, with those on the patient's left side (arrow) being thinner than those on the right (arrowhead). A left paravaginal fascial defect was diagnosed at surgery.
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Figure 7b. Attenuation of paravaginal attachments in a 52-year-old woman. (a) Axial T2-weighted MR image of the pelvis obtained with the patient at rest shows the vagina with an H shape (arrowheads) with the lateral portions extending anteriorly. The levator ani muscle (arrow) is closely apposed to the vagina. (b) On an axial T2-weighted MR image of the pelvis obtained with the patient straining, the vagina maintains its shape but is displaced posteriorly. There is stretching of the paravaginal attachments, with those on the patient's left side (arrow) being thinner than those on the right (arrowhead). A left paravaginal fascial defect was diagnosed at surgery.
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Figure 8. Deformity of the anterior vaginal wall in a 67-year-old woman with cystocele. The patient had undergone hysterectomy. Sagittal T2-weighted MR image of the pelvis obtained with the patient straining demonstrates bowing of the anterior wall of the vagina (arrowhead) caused by the bladder (arrow). This finding correlates with physical examination findings in patients with cystoceles.
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Figure 9. Deformity of the posterior vaginal wall in a 55-year-old woman with a rectocele. On an axial T2-weighted MR image of the pelvis obtained with the patient straining, the rectum protrudes anteriorly and the vagina is bowed forward in the midline (arrow). This bulging in the posterior wall of the vagina correlates with physical examination findings in patients with rectoceles.
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Figure 10a. Uterine descent and rotation in a 48-year-old woman with a sensation of cervical prolapse through the vagina. (a) Sagittal T2-weighted MR image of the pelvis obtained with the patient at rest depicts the cervix (*) and uterus (straight solid arrow). The uterine body is higher than the superior margin of the pubic bone (open arrow), and a submucosal fibroid (curved arrow) is seen in the uterus. (b) On a sagittal T2-weighted MR image of the pelvis obtained with the patient straining, the uterus has descended so that it lies posterior to the pubis. There is also uterine rotation, which reveals a pedunculated fibroid in the fundus (straight arrows). The submucosal fibroid (curved arrow) is not as well defined as in a, and a greater portion of the endometrial cavity is seen. A cystocele and perineal descent are also noted.
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Figure 10b. Uterine descent and rotation in a 48-year-old woman with a sensation of cervical prolapse through the vagina. (a) Sagittal T2-weighted MR image of the pelvis obtained with the patient at rest depicts the cervix (*) and uterus (straight solid arrow). The uterine body is higher than the superior margin of the pubic bone (open arrow), and a submucosal fibroid (curved arrow) is seen in the uterus. (b) On a sagittal T2-weighted MR image of the pelvis obtained with the patient straining, the uterus has descended so that it lies posterior to the pubis. There is also uterine rotation, which reveals a pedunculated fibroid in the fundus (straight arrows). The submucosal fibroid (curved arrow) is not as well defined as in a, and a greater portion of the endometrial cavity is seen. A cystocele and perineal descent are also noted.
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Figure 11a. Uterine procidentia in a 65-year-old woman with bulging pelvic tissues at physical examination. Sagittal (a), coronal (b), and axial (c) MR images of the pelvis obtained with the patient at rest show complete extrapelvic prolapse of the bladder (straight white arrow in a, solid arrow in c) and uterus (black arrow in a, open arrow in c). Curved arrow in a indicates the pubic bone. The endometrial cavity and fibroids can also be identified. The coronal and axial images show the prolapsed organs between the thighs.
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Figure 11b. Uterine procidentia in a 65-year-old woman with bulging pelvic tissues at physical examination. Sagittal (a), coronal (b), and axial (c) MR images of the pelvis obtained with the patient at rest show complete extrapelvic prolapse of the bladder (straight white arrow in a, solid arrow in c) and uterus (black arrow in a, open arrow in c). Curved arrow in a indicates the pubic bone. The endometrial cavity and fibroids can also be identified. The coronal and axial images show the prolapsed organs between the thighs.
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Figure 11c. Uterine procidentia in a 65-year-old woman with bulging pelvic tissues at physical examination. Sagittal (a), coronal (b), and axial (c) MR images of the pelvis obtained with the patient at rest show complete extrapelvic prolapse of the bladder (straight white arrow in a, solid arrow in c) and uterus (black arrow in a, open arrow in c). Curved arrow in a indicates the pubic bone. The endometrial cavity and fibroids can also be identified. The coronal and axial images show the prolapsed organs between the thighs.
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Figure 12a. Rectocele in a 54-year-old woman with fecal incontinence. (a) On a sagittal T2-weighted MR image of the pelvis obtained with the patient at rest, the rectum appears normal (arrow). (b) Sagittal T2-weighted MR image of the pelvis obtained with the patient straining reveals a large anterior rectocele (black arrow). The rectum is also folded upon itself due to poor posterior fixation (white arrow). (c) Axial MR image obtained with the patient straining shows an anteriorly protruding rectum (arrow).
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Figure 12b. Rectocele in a 54-year-old woman with fecal incontinence. (a) On a sagittal T2-weighted MR image of the pelvis obtained with the patient at rest, the rectum appears normal (arrow). (b) Sagittal T2-weighted MR image of the pelvis obtained with the patient straining reveals a large anterior rectocele (black arrow). The rectum is also folded upon itself due to poor posterior fixation (white arrow). (c) Axial MR image obtained with the patient straining shows an anteriorly protruding rectum (arrow).
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Figure 12c. Rectocele in a 54-year-old woman with fecal incontinence. (a) On a sagittal T2-weighted MR image of the pelvis obtained with the patient at rest, the rectum appears normal (arrow). (b) Sagittal T2-weighted MR image of the pelvis obtained with the patient straining reveals a large anterior rectocele (black arrow). The rectum is also folded upon itself due to poor posterior fixation (white arrow). (c) Axial MR image obtained with the patient straining shows an anteriorly protruding rectum (arrow).
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Figure 13a. (a, b) Enterocele in a 58-year-old woman with tissue bulging through the vagina, a condition that had worsened over the past 10 years. Perineal descent and widening of the perineal body were seen at physical examination. (a) Sagittal T2-weighted MR image obtained with the patient at rest shows the small bowel above the rectovaginal septum (solid arrow). Arrowhead indicates vaginal cuff, open arrow indicates rectum. (b) Sagittal T2-weighted MR image obtained with the patient straining shows the small bowel (arrow) prolapsing between the vagina and rectum. The perineal body is stretched (*). (c) Enterocele in a 48-year-old woman. Coronal MR image obtained with the patient straining demonstrates bulging of the levator ani muscles (solid arrows) and prolapse of the small bowel (open arrow). * = level of the labia.
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Figure 13b. (a, b) Enterocele in a 58-year-old woman with tissue bulging through the vagina, a condition that had worsened over the past 10 years. Perineal descent and widening of the perineal body were seen at physical examination. (a) Sagittal T2-weighted MR image obtained with the patient at rest shows the small bowel above the rectovaginal septum (solid arrow). Arrowhead indicates vaginal cuff, open arrow indicates rectum. (b) Sagittal T2-weighted MR image obtained with the patient straining shows the small bowel (arrow) prolapsing between the vagina and rectum. The perineal body is stretched (*). (c) Enterocele in a 48-year-old woman. Coronal MR image obtained with the patient straining demonstrates bulging of the levator ani muscles (solid arrows) and prolapse of the small bowel (open arrow). * = level of the labia.
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Figure 13c. (a, b) Enterocele in a 58-year-old woman with tissue bulging through the vagina, a condition that had worsened over the past 10 years. Perineal descent and widening of the perineal body were seen at physical examination. (a) Sagittal T2-weighted MR image obtained with the patient at rest shows the small bowel above the rectovaginal septum (solid arrow). Arrowhead indicates vaginal cuff, open arrow indicates rectum. (b) Sagittal T2-weighted MR image obtained with the patient straining shows the small bowel (arrow) prolapsing between the vagina and rectum. The perineal body is stretched (*). (c) Enterocele in a 48-year-old woman. Coronal MR image obtained with the patient straining demonstrates bulging of the levator ani muscles (solid arrows) and prolapse of the small bowel (open arrow). * = level of the labia.
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Figure 14a. Sigmoidocele in an 82-year-old woman with a high rectocele at physical examination. (a) Sagittal T2-weighted MR image obtained with the patient straining shows the sigmoid colon prolapsing inferiorly and anteriorly. The bladder and an incidental ovarian mass (arrow) are also seen. (b) On a coronal T2-weighted MR image obtained with the patient straining, the sigmoid colon is seen at the level of the bladder (open arrow) due to anterior prolapse (white arrow). The incidental ovarian mass is again noted (solid black arrow).
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Figure 14b. Sigmoidocele in an 82-year-old woman with a high rectocele at physical examination. (a) Sagittal T2-weighted MR image obtained with the patient straining shows the sigmoid colon prolapsing inferiorly and anteriorly. The bladder and an incidental ovarian mass (arrow) are also seen. (b) On a coronal T2-weighted MR image obtained with the patient straining, the sigmoid colon is seen at the level of the bladder (open arrow) due to anterior prolapse (white arrow). The incidental ovarian mass is again noted (solid black arrow).
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Figure 15a. Increase in pelvic hiatus area in the same patient as in Figure 13a and 13b. Axial T2-weighted MR images of the pelvis obtained with the patient at rest (a) and straining (b) show how the area enclosed by the levator ani muscles increases as the small bowel prolapses and the pelvic floor descends during straining (arrows).
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Figure 15b. Increase in pelvic hiatus area in the same patient as in Figure 13a and 13b. Axial T2-weighted MR images of the pelvis obtained with the patient at rest (a) and straining (b) show how the area enclosed by the levator ani muscles increases as the small bowel prolapses and the pelvic floor descends during straining (arrows).
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Figure 16a. Perineal hernia containing fluid in a 59-year-old woman with fecal incontinence and minimal levator contraction at physical examination. Axial (a) and coronal (b) T2-weighted MR images of the pelvis reveal discontinuity in the left levator ani muscle (solid arrow). The muscle is focally thin and bulges outward compared with the normal right levator ani muscle (open arrow in a). Fluid in the pelvis is seen protruding out through the defect (* in a).
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Figure 16b. Perineal hernia containing fluid in a 59-year-old woman with fecal incontinence and minimal levator contraction at physical examination. Axial (a) and coronal (b) T2-weighted MR images of the pelvis reveal discontinuity in the left levator ani muscle (solid arrow). The muscle is focally thin and bulges outward compared with the normal right levator ani muscle (open arrow in a). Fluid in the pelvis is seen protruding out through the defect (* in a).
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Figure 17a. Perineal hernia containing small bowel in a 71-year-old woman with constipation. (a) Coronal T2-weighted MR image obtained with the patient at rest demonstrates the normal position of the small bowel (solid arrow), levator ani muscle (open arrow), and rectum (*). (b) On a coronal T2-weighted MR image obtained with the patient straining, a focal defect in the right levator ani muscle becomes apparent, and small bowel is seen protruding into the hernia (arrow).
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Figure 17b. Perineal hernia containing small bowel in a 71-year-old woman with constipation. (a) Coronal T2-weighted MR image obtained with the patient at rest demonstrates the normal position of the small bowel (solid arrow), levator ani muscle (open arrow), and rectum (*). (b) On a coronal T2-weighted MR image obtained with the patient straining, a focal defect in the right levator ani muscle becomes apparent, and small bowel is seen protruding into the hernia (arrow).
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Copyright © 2000 by the Radiological Society of North America.
