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DOI: 10.1148/rg.264055133
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Right arrow Magnetic Resonance Imaging
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MR Imaging of the Female Urethra and Supporting Ligaments in Assessment of Urinary Incontinence: Spectrum of Abnormalities1

Katarzyna J. Macura, MD, PhD, Rene R. Genadry, MD and David A. Bluemke, MD, PhD

1 From the Russell H. Morgan Department of Radiology and Radiological Science (K.J.M., D.A.B.) and Department of Obstetrics and Gynecology (R.R.G.), Johns Hopkins Medical Institutions, 600 N Wolfe St, BLA-B 179 RAD, Baltimore, MD 21287. Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received June 17, 2005; revision requested July 15 and received September 7; accepted September 7. K.J.M. supported by an RSNA Research Seed Grant and the Young Investigator Award from the Society of Computed Body Tomography and Magnetic Resonance. The authors discuss an investigational or unlabeled use of a commercial product, device, or pharmaceutical that has not been approved for such purpose by the FDA. D.A.B. receives research support from Surgi-Vision, Columbia, Md; all other authors have no financial relationships to disclose.

Figure 1
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  		Figure 1a.  Intraurethral MR images of an incontinent 72-year-old woman. The images were obtained with a 14-F endourethral coil (*) and the following parameters: repetition time msec/echo time msec = 3400/68, 2.0-mm section thickness, 2.5-mm section spacing, eight signals acquired, 5 x 5-cm field of view. (a) Axial intensity-corrected T2-weighted fast spin-echo image of the mid-urethra shows a multilayered targetlike appearance: The inner smooth muscle layer (white arrow) has higher signal intensity, whereas the outer layer of low-signal-intensity tissue encircling the smooth muscle represents striated urogenital sphincter muscle (black arrow). The periurethral ligament (black arrowheads) is anterior to the urethra, and the pubourethral ligament (white arrowheads) is posterior to the urethra and anterior to the vagina; these ligaments contribute to the hammocklike support of the urethra. Note the reduction of near-field artifact and the good visualization of the dark mucosa and submucosa around the coil on this intensity-corrected image. (b) Axial intensity-corrected T2-weighted fast spin-echo image of the distal urethra shows the pubourethral ligament (arrowheads) posterior to the urethra and anterior to the vagina. Dark striated muscle encircles the urethra. (c) Axial intensity-corrected T2-weighted fast spin-echo image shows the urethra at the level of the compressor urethrae. Note the fanning of the dark striated muscle (arrows) of the urethral sphincter around the urethra and extending toward the anterior vaginal wall.

 

Figure 1
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  		Figure 1b.  Intraurethral MR images of an incontinent 72-year-old woman. The images were obtained with a 14-F endourethral coil (*) and the following parameters: repetition time msec/echo time msec = 3400/68, 2.0-mm section thickness, 2.5-mm section spacing, eight signals acquired, 5 x 5-cm field of view. (a) Axial intensity-corrected T2-weighted fast spin-echo image of the midurethra shows a multilayered targetlike appearance: The inner smooth muscle layer (white arrow) has higher signal intensity, whereas the outer layer of low-signal-intensity tissue encircling the smooth muscle represents striated urogenital sphincter muscle (black arrow). The periurethral ligament (black arrowheads) is anterior to the urethra, and the pubourethral ligament (white arrowheads) is posterior to the urethra and anterior to the vagina; these ligaments contribute to the hammocklike support of the urethra. Note the reduction of near-field artifact and the good visualization of the dark mucosa and submucosa around the coil on this intensity-corrected image. (b) Axial intensity-corrected T2-weighted fast spin-echo image of the distal urethra shows the pubourethral ligament (arrowheads) posterior to the urethra and anterior to the vagina. Dark striated muscle encircles the urethra. (c) Axial intensity-corrected T2-weighted fast spin-echo image shows the urethra at the level of the compressor urethrae. Note the fanning of the dark striated muscle (arrows) of the urethral sphincter around the urethra and extending toward the anterior vaginal wall.

 

Figure 1
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  		Figure 1c.  Intraurethral MR images of an incontinent 72-year-old woman. The images were obtained with a 14-F endourethral coil (*) and the following parameters: repetition time msec/echo time msec = 3400/68, 2.0-mm section thickness, 2.5-mm section spacing, eight signals acquired, 5 x 5-cm field of view. (a) Axial intensity-corrected T2-weighted fast spin-echo image of the midurethra shows a multilayered targetlike appearance: The inner smooth muscle layer (white arrow) has higher signal intensity, whereas the outer layer of low-signal-intensity tissue encircling the smooth muscle represents striated urogenital sphincter muscle (black arrow). The periurethral ligament (black arrowheads) is anterior to the urethra, and the pubourethral ligament (white arrowheads) is posterior to the urethra and anterior to the vagina; these ligaments contribute to the hammocklike support of the urethra. Note the reduction of near-field artifact and the good visualization of the dark mucosa and submucosa around the coil on this intensity-corrected image. (b) Axial intensity-corrected T2-weighted fast spin-echo image of the distal urethra shows the pubourethral ligament (arrowheads) posterior to the urethra and anterior to the vagina. Dark striated muscle encircles the urethra. (c) Axial intensity-corrected T2-weighted fast spin-echo image shows the urethra at the level of the compressor urethrae. Note the fanning of the dark striated muscle (arrows) of the urethral sphincter around the urethra and extending toward the anterior vaginal wall.

 

Figure 2
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  		Figure 2a.  Pelvic MR images of a continent 16-year-old girl. Imaging parameters were as follows: 4000/90, 6.0-mm section thickness, 2.0-mm section spacing, four signals acquired, 18 x 18-cm field of view. (a) Axial T2-weighted fast spin-echo fat-saturated image obtained at the level of the mid symphysis pubis shows the dark outer striated urethral sphincter muscle encircling the midurethra (arrow). R = rectum. (b) Axial image obtained at the level of the inferior pubis shows the low-signal-intensity urethrovaginal sphincter (arrowheads) with fibers surrounding both the urethra and vagina.

 

Figure 2
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  		Figure 2b.  Pelvic MR images of a continent 16-year-old girl. Imaging parameters were as follows: 4000/90, 6.0-mm section thickness, 2.0-mm section spacing, four signals acquired, 18 x 18-cm field of view. (a) Axial T2-weighted fast spin-echo fat-saturated image obtained at the level of the mid symphysis pubis shows the dark outer striated urethral sphincter muscle encircling the midurethra (arrow). R = rectum. (b) Axial image obtained at the level of the inferior pubis shows the low-signal-intensity urethrovaginal sphincter (arrowheads) with fibers surrounding both the urethra and vagina.

 

Figure 3
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  		Figure 3a.  Pelvic MR images of a continent 32-year-old woman. Imaging parameters were as follows: 3800/99, 6.0-mm section thickness, 2.0-mm section spacing, four signals acquired, 20 x 20-cm field of view. R = rectum. (a) Axial T2-weighted fast spin-echo image obtained at the level of the upper urethra shows the paraurethral ligament (arrows) extending from the lateral wall of the urethra (U). (b) Axial image obtained at the level of the mid-urethra shows the periurethral ligament (arrows) extending between the medial aspects of the pubococcygeus muscle (arrowheads) and coursing ventrally to the urethra (U).

 

Figure 3
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  		Figure 3b.  Pelvic MR images of a continent 32-year-old woman. Imaging parameters were as follows: 3800/99, 6.0-mm section thickness, 2.0-mm section spacing, four signals acquired, 20 x 20-cm field of view. R = rectum. (a) Axial T2-weighted fast spin-echo image obtained at the level of the upper urethra shows the paraurethral ligament (arrows) extending from the lateral wall of the urethra (U). (b) Axial image obtained at the level of the mid-urethra shows the periurethral ligament (arrows) extending between the medial aspects of the pubococcygeus muscle (arrowheads) and coursing ventrally to the urethra (U).

 

Figure 4
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  		Figure 4a.  Drawings show the pressure distribution at rest and during the Valsalva maneuver when the bladder is well supported and when there is pelvic floor laxity. (a) Pabd is the abdominal pressure measured endorectally or endovaginally, Pves is the pressure measured with an intravesical catheter, Pdet (detrusor pressure) is calculated as Pves – Pabd, Pura is the sum of the urethral pressure – Pabd, and Puc (urethral closure pressure) is Pura – Pves. (b) If the bladder is properly suspended, increased intraabdominal pressure (Pabd) is also reflected in the urethra. For the patient to remain dry, the pressure in the urethra (Pura) should be equal to or greater than the vesical pressure during bladder filling. When the bladder and urethra are in their proper anatomic locations, any pressure increases in the abdominal cavity, from straining or any other cause, will also affect the urethra, thus preventing leakage. (c) When there is pelvic floor laxity, the bladder base and bladder neck are displaced below the pelvic floor level. The increase in abdominal pressure during the Valsalva maneuver will lead to higher pressure in the bladder than in the urethra (Pves > Pura), and the urethral closure pressure (Puc) becomes negative, thus resulting in stress incontinence.

 

Figure 4
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  		Figure 4b.  Drawings show the pressure distribution at rest and during the Valsalva maneuver when the bladder is well supported and when there is pelvic floor laxity. (a) Pabd is the abdominal pressure measured endorectally or endovaginally, Pves is the pressure measured with an intravesical catheter, Pdet (detrusor pressure) is calculated as Pves – Pabd, Pura is the sum of the urethral pressure – Pabd, and Puc (urethral closure pressure) is Pura – Pves. (b) If the bladder is properly suspended, increased intraabdominal pressure (Pabd) is also reflected in the urethra. For the patient to remain dry, the pressure in the urethra (Pura) should be equal to or greater than the vesical pressure during bladder filling. When the bladder and urethra are in their proper anatomic locations, any pressure increases in the abdominal cavity, from straining or any other cause, will also affect the urethra, thus preventing leakage. (c) When there is pelvic floor laxity, the bladder base and bladder neck are displaced below the pelvic floor level. The increase in abdominal pressure during the Valsalva maneuver will lead to higher pressure in the bladder than in the urethra (Pves > Pura), and the urethral closure pressure (Puc) becomes negative, thus resulting in stress incontinence.

 

Figure 4
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  		Figure 4c.  Drawings show the pressure distribution at rest and during the Valsalva maneuver when the bladder is well supported and when there is pelvic floor laxity. (a) Pabd is the abdominal pressure measured endorectally or endovaginally, Pves is the pressure measured with an intravesical catheter, Pdet (detrusor pressure) is calculated as Pves – Pabd, Pura is the sum of the urethral pressure – Pabd, and Puc (urethral closure pressure) is Pura – Pves. (b) If the bladder is properly suspended, increased intraabdominal pressure (Pabd) is also reflected in the urethra. For the patient to remain dry, the pressure in the urethra (Pura) should be equal to or greater than the vesical pressure during bladder filling. When the bladder and urethra are in their proper anatomic locations, any pressure increases in the abdominal cavity, from straining or any other cause, will also affect the urethra, thus preventing leakage. (c) When there is pelvic floor laxity, the bladder base and bladder neck are displaced below the pelvic floor level. The increase in abdominal pressure during the Valsalva maneuver will lead to higher pressure in the bladder than in the urethra (Pves > Pura), and the urethral closure pressure (Puc) becomes negative, thus resulting in stress incontinence.

 

Figure 5
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  		Figure 5.  Photograph shows the 14-F endourethral MR coil. The imaging part of the receiver coil (arrows) is inserted under sterile conditions, similarly to placement of a regular urethral catheter.

 

Figure 6
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  		Figure 6a.  Intrinsic sphincter deficiency at urodynamics and a short urethral sphincter at MR imaging in a 55-year-old woman. (a) Coronal T2-weighted fast spin-echo image (4000/90) shows a urethra with a length of 2.5 cm between the internal and external meatus (arrowheads). The average length of the urethra in continent women is 38 mm ± 3. (b) Sagittal single-shot fast spin-echo image ({infty}/70) obtained during straining shows the short urethra (arrowheads). Note the minimal funneling at the urethrovesical junction. (c) Coronal MR image obtained in a continent patient for comparison with a shows a 3.8-cm-long urethra (arrowheads).

 

Figure 6
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  		Figure 6b.  Intrinsic sphincter deficiency at urodynamics and a short urethral sphincter at MR imaging in a 55-year-old woman. (a) Coronal T2-weighted fast spin-echo image (4000/90) shows a urethra with a length of 2.5 cm between the internal and external meatus (arrowheads). The average length of the urethra in continent women is 38 mm ± 3. (b) Sagittal single-shot fast spin-echo image ({infty}/70) obtained during straining shows the short urethra (arrowheads). Note the minimal funneling at the urethrovesical junction. (c) Coronal MR image obtained in a continent patient for comparison with a shows a 3.8-cm-long urethra (arrowheads).

 

Figure 6
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  		Figure 6c.  Intrinsic sphincter deficiency at urodynamics and a short urethral sphincter at MR imaging in a 55-year-old woman. (a) Coronal T2-weighted fast spin-echo image (4000/90) shows a urethra with a length of 2.5 cm between the internal and external meatus (arrowheads). The average length of the urethra in continent women is 38 mm ± 3. (b) Sagittal single-shot fast spin-echo image ({infty}/70) obtained during straining shows the short urethra (arrowheads). Note the minimal funneling at the urethrovesical junction. (c) Coronal MR image obtained in a continent patient for comparison with a shows a 3.8-cm-long urethra (arrowheads).

 

Figure 7
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  		Figure 7.  Circumferential urethral diverticulum in a 41-year-old woman. Axial T2-weighted fast spin-echo image (4000/90) shows an area of fluid signal intensity (arrowheads) around the lateral and posterior urethra.

 

Figure 8
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  		Figure 8.  Funneling in a 36-year-old woman with urinary incontinence. Sagittal single-shot fast spin-echo image ({infty}/70) obtained during straining shows urethral hypermobility and widening of the proximal urethra at the vesical neck. Funneling (arrowheads) is associated with weakness of the proximal sphincter.

 

Figure 9
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  		Figure 9a.  Complete disruption of the periurethral ligament in a 54-year-old woman with urethral hypermobility and incontinence. R coil = endorectal coil. (a) Axial T2-weighted fast spin-echo image (4000/90) shows an irregular and discontinuous left periurethral ligament (arrow). Note the loss of the left vaginolevator attachment (black arrowhead). The right vaginolevator attachment and right periurethral ligament attachment are intact (white arrowhead). (b) Axial MR image obtained at the level of the midurethra shows the discontinuous left periurethral ligament (arrow) and the detached left vaginal wall (black arrowhead). White arrowhead = intact right vaginal attachment.

 

Figure 9
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  		Figure 9b.  Complete disruption of the periurethral ligament in a 54-year-old woman with urethral hypermobility and incontinence. R coil = endorectal coil. (a) Axial T2-weighted fast spin-echo image (4000/90) shows an irregular and discontinuous left periurethral ligament (arrow). Note the loss of the left vaginolevator attachment (black arrowhead). The right vaginolevator attachment and right periurethral ligament attachment are intact (white arrowhead). (b) Axial MR image obtained at the level of the midurethra shows the discontinuous left periurethral ligament (arrow) and the detached left vaginal wall (black arrowhead). White arrowhead = intact right vaginal attachment.

 

Figure 10
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  		Figure 10a.  Partial disruption of the periurethral ligament in a 53-year-old woman with mixed urinary incontinence, intrinsic sphincter deficiency, and urethral hypermobility. (a) Axial T2-weighted fast spin-echo image (4100/95) obtained with an endovaginal coil (EV) shows mild fluttering and laxity of the right periurethral ligament (arrow) but no discontinuity. Note the intact and taut left periurethral ligament. Also, note the medially displaced right anterior vaginal wall (black arrowhead) and the intact left vaginal attachment (white arrowhead). R = rectum. (b) Sagittal single-shot fast spin-echo image ({infty}/70) obtained during straining shows hypermobility of the urethra, which has rotated into the horizontal plane (arrow), and mild funneling at the urethrovesical junction (arrowhead), which is a sign of proximal sphincter weakness.

 

Figure 10
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  		Figure 10b.  Partial disruption of the periurethral ligament in a 53-year-old woman with mixed urinary incontinence, intrinsic sphincter deficiency, and urethral hypermobility. (a) Axial T2-weighted fast spin-echo image (4100/95) obtained with an endovaginal coil (EV) shows mild fluttering and laxity of the right periurethral ligament (arrow) but no discontinuity. Note the intact and taut left periurethral ligament. Also, note the medially displaced right anterior vaginal wall (black arrowhead) and the intact left vaginal attachment (white arrowhead). R = rectum. (b) Sagittal single-shot fast spin-echo image ({infty}/70) obtained during straining shows hypermobility of the urethra, which has rotated into the horizontal plane (arrow), and mild funneling at the urethrovesical junction (arrowhead), which is a sign of proximal sphincter weakness.

 

Figure 11
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  		Figure 11.  Normal resting position of the urethra in a 53-year-old woman with urinary incontinence. Sagittal T2-weighted fast spin-echo image (4100/95) obtained with an endovaginal coil shows the normal resting position of the urethra, with the most inferior portion of the sphincter (arrowhead) at the level of the inferior pubis (P). Note the narrow hyperintense retropubic space, which is the distance between the posterior pubis and the anterior urethral wall. B = bladder.

 

Figure 12
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  		Figure 12.  Inferior displacement of the urethra at rest in a 69-year-old woman with urinary incontinence. Sagittal T2-weighted fast spin-echo image (4100/95) obtained with an endovaginal coil shows inferior displacement of the urethra at rest, with the most inferior portion of the sphincter (arrowheads) below the level of the pubis (P). About one-third of the urethral sphincter is inferior to the pubis. More extensive defects of the urethral support ligaments and paravaginal fascia lead to a larger infrapubic component. Note the widened retropubic space compared with that in Figure 11. B = bladder.

 

Figure 13
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  		Figure 13.  Urethral hypermobility in a 62-year-old woman with pelvic floor laxity. Sagittal single-shot fast spin-echo image ({infty}/70) obtained during straining shows hypermobility of the urethra (arrowheads), which has descended and rotated into the horizontal plane.

 

Figure 14
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  		Figure 14a.  Cystocele in an 87-year-old woman with pelvic floor prolapse. (a) Sagittal single-shot fast spin-echo image ({infty}/70) obtained during straining shows a large cystocele (arrow). Note that the 10-cm-long cystocele fills the prolapsing perineum. (b) Coronal single-shot fast spin-echo image ({infty}/70) obtained during straining shows the broad cystocele (arrow), which resulted from a large central defect in the vesicopelvic fascia. Arrowheads = level of the pelvic floor. (c) Axial single-shot fast spin-echo image ({infty}/70) obtained during straining shows the cystocele (arrow) at the level of the inferior pubis. Note the ballooning of the thinned levator ani muscle (arrowhead).

 

Figure 14
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  		Figure 14b.  Cystocele in an 87-year-old woman with pelvic floor prolapse. (a) Sagittal single-shot fast spin-echo image ({infty}/70) obtained during straining shows a large cystocele (arrow). Note that the 10-cm-long cystocele fills the prolapsing perineum. (b) Coronal single-shot fast spin-echo image ({infty}/70) obtained during straining shows the broad cystocele (arrow), which resulted from a large central defect in the vesicopelvic fascia. Arrowheads = level of the pelvic floor. (c) Axial single-shot fast spin-echo image ({infty}/70) obtained during straining shows the cystocele (arrow) at the level of the inferior pubis. Note the ballooning of the thinned levator ani muscle (arrowhead).

 

Figure 14
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  		Figure 14c.  Cystocele in an 87-year-old woman with pelvic floor prolapse. (a) Sagittal single-shot fast spin-echo image ({infty}/70) obtained during straining shows a large cystocele (arrow). Note that the 10-cm-long cystocele fills the prolapsing perineum. (b) Coronal single-shot fast spin-echo image ({infty}/70) obtained during straining shows the broad cystocele (arrow), which resulted from a large central defect in the vesicopelvic fascia. Arrowheads = level of the pelvic floor. (c) Axial single-shot fast spin-echo image ({infty}/70) obtained during straining shows the cystocele (arrow) at the level of the inferior pubis. Note the ballooning of the thinned levator ani muscle (arrowhead).

 

Figure 15
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  		Figure 15.  Symmetric pubococcygeus muscle in a 38-year-old woman without urinary dysfunction. Axial T2-weighted fast spin-echo image (3800/99) shows a normal symmetric H-shaped vagina (white arrowheads) and an intact symmetric pubococcygeus portion of the levator ani (black arrowheads). R = rectum.

 

Figure 16
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  		Figure 16.  Disrupted pubococcygeus muscle in a 68-year-old woman with urinary incontinence. Axial T2-weighted fast spin-echo image (3200/100) shows the pubococcygeus muscle (black arrowheads), which is completely disrupted on the right with a large gap (arrows). Note the asymmetric configuration of the vagina (white arrowheads), which is "dropping" on the right. R = rectum.

 




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