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esur2018EUROPEAN SOCIETY OF UROGENITAL RADIOLOGY

25TH EUROPEAN SYMPOSIUM ON

UROGENITAL RADIOLOGYBARCELONA, 13 - 16 SEPTEMBER 2018

esur2018EUROPEAN SOCIETY OF UROGENITAL RADIOLOGY

TECHNIQUES FOR SUCCESSFUL PELVIC IMAGING

WITH ANATOMY OVERVIEW

Joana Almeida – Urogenital imaging Unit Hospital da Luz, Lisbon Portugal

25TH EUROPEAN SYMPOSIUM ON UROGENITAL RADIOLOGY

BARCELONA, 13th – 16th SEPTEMBER 2018

INTRODUCTIONincludes all the structures supporting the

abdominal and pelvic cavity

• Pelvic Floor disorder spectrum of functional disorders:

• Urinary incontinence (UI)

• Pelvic organ Prolapse (POP)

• Defectory disfunction

• Sensory and emptying abnormalities of the LUT

• Sexual dysfunction

• Chronic pain syndromes

Most Common



INTRODUCTION

• 50% of women over 50 years are affected by this condition

• One in nine women will undergo an invasive procedure for treatment of UI or POP

30% require additional surgery for symptom recurrence by 80 years of age



PELVIC FLOOR ANATOMY

Traditionally described 3 compartments:• Anterior (urologists)

• Middle (gynecologists)

• Posterior (general surgeons)

The complexity of pelvic floor failure

Ignores

Courtesy – Garcia del Salto in Radiographics 34 -2014 Sagittal T2 WI



PELVIC FLOOR ANATOMY

Courtesy – R. Farouk El Sayed in Abdominal imaging -2012



Form three layers from superior to inferior:1. ENDOPELVIC FASCIA

2. THE PELVIC DIAFRAGHM

3. THE UROGENITAL DIAPHRAGM



1. Endopelvic fascia - Anterior

• 3 groups of ligaments supporting da urethra:

• Peri-urethral

• Para-urethral

• Pubo-urethral

Axial T2 WI



• Level I – suspension- suspend the vaginal apex to uterosacralligaments and ischial spine

• Level II – attachment- attach the vaginal wall to the arcustendineus fascia pelvis (ATFP) at the lateral pelvic wall

• Level III – fusion – vagina is fused to the levator ani and perineal body

Courtesy – Grazia T Bitti in Radiographics 34 -2014

1. Endopelvic fascia - Middle

Axial T2 WI



1. Endopelvic fascia - Posterior

Sagittal T2 WI

• Rectovaginal fascia –extends from posterior wall of the vagina to anterior wall of therectum

• Perineal body (PB) –anovaginal septum



2. Pelvic diaphragm

Ischiococcygeus muscle

Levator ani muscle:• Iliococcygeus

• Puborectalis

• Pubococcygeus

Courtesy – Garcia del Salto in Radiographics 34 -2014



2. Pelvic diaphragm


Coronal T2 WI



2. Pelvic diaphragm


Sagittal T2 WI



2. Pelvic diaphragm

Courtesy – Garcia del Salto in Radiographics 34 -2014 Axial T2 WI




3. Urogenital diaphragm

Axial T2 WI



MR Imaging with dynamic sequences has been proven accurate and reliable for identifying pelvic

floor weakness

Especially when multiple compartments are involved



HOW TO PERFORM PELVIC FLOOR MRI?



HOW TO PERFORM PELVIC FLOOR MRI?

Follow ESUR Guideline MR Imaging protocol



Patient’s preparation

• Equipment : preferable 1.5 T magnet and phased array coil

• Take patients’ history of pelvic floor disorder

• Ask the patient to void 2 h before the examination

• Train the patient on how to perform squeezing, straining and evacuation

• Use diaper for protection

• Do rectal filling with ultrasound gel (120-250cc)

• Examine the patient in supine position with elevated knees on high pillow



MR IMAGING PROTOCOL

Static sequences

T2-weighted TSE; FSE, RARESagittalTransverseCoronal

Dynamic SSFP or BSFP sequences in sagittal planeSqueezing phaseStraining phaseEvacuation phase



MR IMAGING PROTOCOL



MR IMAGING PROTOCOL

Imaging at rest in 3 planes:

Sagittal, Coronal, Transverse

Patient is asked to breath slowly

2-3 min each plane



MR IMAGING PROTOCOL

Axial T2 WI Coronal T2 WI



MR IMAGING PROTOCOL

Sagittal T2 WI

Optional - Axial T1 WI



MR IMAGING PROTOCOL

Imaging during squeezing in sagittal plane

Patient is asked to squeeze as trying to prevent the escape of urine or faeces and hold this position

Less than 20s as the patient needs to hold the breath



MR IMAGING PROTOCOL

Sagittal T2 WI during squeezing



Imaging during maximum straining - sagittal plane

Patient is asked to bear down as much as she could as though she is constipated and tries to defecate and hold this position

Less than 20s as the patient needs to hold the breath

Optional sequences – transverse and coronal planes



MR IMAGING PROTOCOL

Sagittal T2 WI during straining Sagittal T2 WI during straining



MR IMAGING PROTOCOL

Sagittal T2 WI during straining Sagittal T2 WI during strainingAxial T2 WI during straining Coronal T2 WI during straining

USED TO EVALUATE PELVIC FLOOR MUSCLES



MR IMAGING PROTOCOLImaging during evacuation of the rectal gel in sagittal plane

Patient is asked to evacuate the rectum continuously and to relax the pelvic floor before the next evacuation phase

The sequence should be repeated until the rectum is emptied

Optional sequences –coronal plane



MR IMAGING PROTOCOL

Sagittal T2 WI during evacuation



TAKE HOME POINTS


• STUDY BASIC ANATOMY

• FOLLOW ESUR MRI PROTOCOL

• EXPLAIN THE PROCEDURE TO PATIENT – COOPERATION IS CRUCIAL FOR THE SUCCESS OF THE EXAMINATION

• THE EVACUATION SEQUENCE SHOULD BE REPEATED UNTIL THE RECTUM IS EMPTIED




Thank you!

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