Static magnetic resonance imaging of the pelvic floor muscle morphology in women with stress urinary incontinence and pelvic prolapse

In a study, the magnetic resonance imaging (MRI) findings of 69 women were analyzed to define the typical MRI appearance of the pelvic floor musculature in healthy subjects (n = 20) and women with urinary incontinence (UI) and/or genitourinary prolapse (GP) (n = 49). The following parameters were determined: thickness and signal intensity of the levator muscles on each side, distance between the urethra and symphysis, diameter of the proximal urethra, and thickness and configuration of the anterior vaginal wall. These parameters were correlated with the patients' age and parity, urodynamic parameters, and the clinical assessment of the pelvic floor. In contrast to healthy subjects, the frequent findings in women with UI and/or GP are higher signal intensity of the levator muscles (p < 0.05) and loss of the hammock-like configuration of the vagina (p < 0.01). On static MRI, the morphometry of the levator musculature identified no findings typical of either UI or GP. Analysis of MRI combined with patients' parity suggests that the severity of damage to the pelvic floor at delivery is determined by the traumatic event as such and not by the number of deliveries. Urethral diameter, distance of the symphysis to the urethra, and vaginal wall thickness cannot distinguish between controls and women with UI and/or GP. Urodynamic and functional clinical parameters do not correlate with the changes in the pelvic floor musculature demonstrated by static MRI. Although morphological changes in UI and/or GP can be demonstrated by MRI, they can be assigned a pathogenic role only if clinical symptoms are present.     

Cervical assessment by magnetic resonance imaging--its relationship to gestational age and interval to delivery

The aim of this cross-sectional study was to assess the uterine cervix in late pregnancy, using MRI, and to study its relationship to the gestational age and the time interval to delivery. 91 women with a singleton cephalic presenting fetus had MRI of the pelvis between 35 and 41 weeks. All had had one prior lower segment Caesarean section and no history of prior vaginal delivery. The cervical length, internal and external os diameter, cervical signal intensity and the angulation of the cervix with the cephalocaudal axis were measured on sagittal T2 weighted images and correlated with the gestational age and the interval from the MRI examination to delivery. It was found that the signal intensity of the cervical stroma increased with the gestational age. A higher signal intensity in the cervical stroma was associated with a shorter time interval to delivery. Deliveries after 40 weeks tended to occur more commonly in those with lower signal intensity in the cervical stroma and also in those with a smaller external os diameter. It is concluded that cervical softening as assessed on MRI correlated with gestational age and the time interval to delivery.     

Benefit of uncooked cornstarch in the management of children with dumping syndrome fed exclusively by gastrostomy

PURPOSE: Our goal was to evaluate the diagnostic value of MRI in plica syndrome. METHOD: MR images of a patient group (n = 55) with arthroscopically confirmed pathologic mediopatellar plicae were retrospectively analyzed and compared with those of a control group (n = 100). We obtained axial multiplanar gradient-recalled (MPGR), axial T1-weighted, and sagittal T2-weighted MR images. MR images were assessed for the width and length of all medial plicae. RESULTS: In the diagnosis of plica syndrome, sensitivity and specificity were 73 and 78% on axial MPGR images, 71 and 83% on sagittal T2-weighted images, and 95 and 72% on combination of both images, respectively. The incidence of pathologic medial plica increased with a criterion of extension beyond the medial end of the patella on axial MPGR images. CONCLUSION: MRI is a useful screening method in the diagnosis of plica syndrome.     

Imaging studies of the pelvic floor

A variety of imaging modalities complement the history and physical examination in the investigation of pelvic floor dysfunction in women. Current fluoroscopic techniques, including defocography, can reveal underlying pelvic floor defects by reproducing normal daily activities that cause symptoms. Magnetic resonance imaging provides fine musculoskeletal detail of this region in anatomic plane not well seen via computerized tomography. Ultrasound is used primarily in assessment of the anal sphincter muscles. Cystourethroscopy provides direct visualization of the lower urinary tract. This article describes the clinical applications and technique of each modality.     

Clinical and instrumental evaluation after Burch's colposuspension in patients with stress urinary incontinence

The authors performed a retrospective study of 29 patients undergoing Burch's anterior colposuspension to treat stress incontinence. Patients were aged between 32 and 71 years old and before surgery presented a urodynamic picture with low mictional pressure, normal filling and Max P of lower closing at 40 mm. Follow-up monitoring ranged from a minimum of 6 months to a maximum of 5 years (mean length 33 months) and was carried out using a urodynamic examination and transvaginal scan to evaluate the distance of the bladder neck from the posterior face of the pubic symphysis. Seventeen women (65.5%) were fully cured after surgery, whereas 27% improved. In "dry" patients the urodynamic examination showed increased significantly of the functional length of the urethra and the transvaginal scan showed that mean values of the distance between bladder neck and pubic symphysis were lover than those in those patients who still presented symptoms. The authors also used ultrasonography to evaluate the efficacy of the latter in the study of urinary incontinence. As reported in other studies, they affirm that intracavitary ultrasonography using a linea probe is equivalent to radiography using cystography with metallic repere, making the examination less invasive and easily repeatable; in addition, it is also important for studying the dynamics of the pelvic floor to establish effective rehabilitative treatment.     

Hydatid disease of the CNS: imaging features

OBJECTIVE: The objective of this study was to assess the usefulness of dynamic single-shot MR cholangiopancreatography in the evaluation of the morphology and contractility of the normal Vaterian sphincter complex and to assess whether i.v. injection of glucagon can improve visualization. SUBJECTS AND METHODS: Sixty patients without signs of Vaterian sphincter complex dysfunction were studied. A fast single-shot MR imaging sequence was used to obtain 20 consecutive images of the Vaterian sphincter complex during successive episodes of breathholding. In patients of group A (n = 30), 10 images were obtained before and 10 after i.v. administration of a sphincter-relaxing agent (glucagon). In the patients of group B (n = 30), no glucagon was administered. The degree of visualization of the Vaterian sphincter complex was assessed. RESULTS: Overall, the morphology and contractility of the Vaterian sphincter complex was adequately assessed in 57 patients (95%). However, the number of repetitions required to obtain this result varied greatly (mean, seven; range, two to 18). Glucagon had no apparent effect on the visibility of the most distal portion of the common bile duct. CONCLUSION: Nonvisualization of the most distal portion of the common bile duct on MR cholangiopancreatography studies is a normal variant that can simulate disease. Obtaining serial breath-hold images using a single-shot technique is helpful to avoid diagnostic errors.     

Rectovestibular fistula with absent vagina: a unique anorectal malformation

BACKGROUND/PURPOSE: A very unusual anorectal defect consisting of a vestibular fistula and absent vagina is presented. Only two previous isolated reports were found in the literature describing a repair that included both abdominal and perineal approach. The authors present another technical alternative that allows the repair via posterior sagittal. METHODS: Of 1,007 patients with anorectal malformations analyzed, eight female cases shared the common anatomic features of a vestibular fistula and absent vagina. What appeared to be the vagina was actually the rectal orifice ending in the vestibule, and the vagina was absent. With the posterior sagittal approach, the distal rectum was used to create the neovagina. The proximal rectum was mobilized and placed within the limits of the sphincter mechanism. Two of the eight patients were born with a patent upper third remnant of the vagina. In one case, the remnant was anastomosed to the neovagina at the time of colostomy closure; in the second one, the anastomosis was performed during the main repair. RESULTS: Four patients are continent of urine and have voluntary bowel movements. One patient is younger than 3 years and therefore has not been evaluated. One patient has a very poor sacrum and therefore is incontinent. One patient had a primary repair elsewhere and therefore is excluded, and another patient is lost to follow-up. One patient is already sexually active. CONCLUSIONS: It is mandatory to perform a meticulous inspection of the perineum in female patients with anorectal malformations to detect unusual defects. Also, a high index of suspicion is necessary to establish the diagnosis of this defect and avoid an inadequate treatment. The posterior sagittal approach represents another alternative to treat these defects without the need for a laparotomy.     

MR imaging of the anal sphincter in multiparous women using an endoanal coil: correlation with in vitro anatomy and appearances in fecal incontinence

OBJECTIVE: The aim of this study was to correlate the components of the normal female anal sphincter seen on high-resolution MR images with the in vitro anatomy and to describe the change in appearances of these components in multiparous women with fecal incontinence. SUBJECTS AND METHODS: Ten asymptomatic female volunteers (32-72 years old; mean, 54 years old) and 22 women with fecal incontinence were studied. In six patients (26-68 years old; mean, 49 years old) fecal incontinence began immediately after childbirth; in the remaining 16 patients (45-77 years old; mean, 58 years old) fecal incontinence developed 15- 30 years after childbirth. In the latter group of patients, terminal motor latencies of the pudendal nerve were measured. Imaging was done on a 0.5-T Picker Asset unit and on a 1.0-T Picker HPQ unit. A saddle geometry endoanal receiver coil was used for all imaging. T1-weighted spin-echo (720-820/20 [range of TR/TE]), T2-weighted spin-echo (2500/80 [TR/TE]), fast spin-echo (4500/96 [TR/ effective TE]), and short inversion time inversion recovery (2500/80 [TR/TE]; inversion time, 107 msec) MR images were obtained in transverse, coronal oblique, and sagittal planes. Images were assessed for integrity of the sphincter components. A nonpaired separate-variance t test was used to compare thickness of individual muscle components between patients with delayed-onset fecal incontinence and asymptomatic age-matched volunteers. Degree of muscle atrophy was correlated with degree of delay in the terminal motor latency of the pudendal nerve. RESULTS: The high resolution obtained with an endoanal coil allowed differentiation of the various muscle components of the anal sphincter complex. The internal sphincter was seen as a ring of homogeneously high signal intensity with a low-signal-intensity rim that was rich in collagen and contained neurovascular bundles. The external anal sphincter, which had low signal intensity on T1- and T2-weighted images, was shown as three components: subcutaneous, superficial, and deep. In six patients who had fecal incontinence that began immediately after childbirth, endoanal MR imaging revealed the site and extent of a tear. All tears were confirmed at surgery. In the 16 patients who had fecal incontinence that began several years after childbirth, atrophy of the external sphincter was revealed in all cases in the superficial and deep components. The internal sphincter remained normal. However, we found that the degree of atrophy of individual components of the external sphincter did not correlate with the degree of delay in pudendal nerve conduction. CONCLUSION: MR imaging with an endoanal coil reveals the integrity and bulk of individual muscle components of the anal sphincter in multiparous women with fecal incontinence.     

Anal sphincter defects. Correlation between endoanal ultrasound and surgery

OBJECTIVE: This study was performed to (1) correlate and sphincter defects, identified by endoanal ultrasound with operative findings, and (2) define the appearance of such sphincter defects as seen at operation. SUMMARY BACKGROUND DATA: Endoanal ultrasonography is a minimally invasive method of imaging the anal sphincter complex and enables identification of anal sphincter defects. Little is known about the accuracy and limitations of endoanal ultrasound in identifying such defects. Furthermore, there are no data about the appearances of these endosonic sphincter defects as seen at operation. METHODS: Forty-four patients (40 women; age range, 26 to 80 years; mean age, 56 years) with fecal incontinence, undergoing pelvic floor repair, were investigated by endoanal ultrasound before operation. Endosonic findings were correlated with the appearances of external anal sphincter, internal anal sphincter, and intersphincteric space, at operation. Diagnosis of the site and type of defect was made by macroscopic appearances. Uncertainty about the type of sphincter defect was resolved by obtaining muscle biopsies for histology. RESULTS: All external sphincter defects seen by endoanal ultrasound (n = 23) were confirmed at operation. Twenty-one of 22 internal sphincter defects identified by endosonography also were confirmed at operation. In ten patients with a neuropathic anal sphincter complex, the morphology was normal on endosonography, and this was confirmed at operation. (Sensitivity and specificity of 100% for external anal sphincter; 100% and 95.5%, respectively, for internal and sphincter) CONCLUSIONS: These data show that endoanal ultrasound is an accurate method of identifying anal sphincter defects.     

Projections of the ventral tegmental area of the midbrain, the substantia nigra, and the amygdaloid body in different parts of the putamen in the dog

INTRODUCTION: We investigated the accuracy of endorectal coil Magnetic Resonance Imaging (MRI) and Fast Spin Echo (FSE) technique in staging prostate cancer. MATERIAL AND METHODS: MRI was performed in 70 patients with biopsy proved prostatic cancer. A total of 33 patients subsequently underwent radical prostatectomy. T2-weighted FSE sequences (TR 3400-4100, TE 120, Echo train length 13) were acquired in all patients. Axial, sagittal and coronal 4-5 mm images were obtained with 13-14 cm field of view and 256 x 256 matrix. Additional T1-weighted spin echo images were acquired in 9 patients. Lesion staging on MR images was performed according to the American Urological System. MR data were compared with the pathologic findings of whole-mount sections of the surgical specimens. RESULTS: Overall accuracy for endorectal coil MR imaging was 60%; ten cases were underestimated and 3 cases were overestimated. The sensitivity and the specificity of endorectal coil MRI in diagnosing capsular penetration were 77% and 81%, respectively. Seminal vesicle invasion was detected with 87% sensitivity and 96% specificity. CONCLUSIONS: Endorectal coil MRI provides a more accurate preoperative local staging.     

Trace elements in egg contents and egg shells of slider turtles (Trachemys scripta) from the Savannah River Site

OBJECTIVES: Stricture of the vesico-urethral anastomosis is a well-known complication after radical prostatectomy. Dilatation, stricture incision or resection have been proposed for endoscopic treatment. METHODS: In a retrospective study of 340 patients with prostatic cancer who underwent a radical retropubic prostatectomy from 1988 until 1996, we looked at the incidence of anastomotic strictures. RESULTS: An anastomotic stricture was found in 24 cases (7%) requiring endoscopic treatment. Based on prospective X-ray studies, we were able to show that the site of stricture is located below the bladder neck musculature in most cases well above the distal urethral sphincter and pelvic floor. No continence problems were encountered following structure resection in a follow-up of 12-72 months determined by a questionnaire and pad test. CONCLUSION: The transurethral resection of anastomotic stricture allows for a rather generous tissue resection, which is preferable to incision or dilatation in our hands.     

Magnetic resonance imaging anatomy of the female urethra: a direct histologic comparison

OBJECTIVE: To define the urethral structures visible on magnetic resonance imaging (MRI) relevant to stress urinary incontinence. METHODS: The urethra and surrounding tissues were harvested from 13 female cadavers (ages 21-81) and fixed in 10% buffered formalin. High-resolution T1- and T2-weighted images were obtained at 1.5 tesla. Mallory trichrome-stained histologic sections were prepared in corresponding planes from the cadaveric specimens. Immunohistologic stains for smooth muscle (actin) and vascular endothelium (CD-34 and factor VIII) were obtained on two specimens. Histology and MRI were compared using side-by-side correlation of projected images and by superimposing projected images. Comparison was also made to a non-cadaveric urethral MRI of a 29-year-old woman and to the MRI of another specimen imaged pre- and post-fixation. RESULTS: Distinct layers of the cadaveric urethra were seen best on proton density and T2-weighted images. From the center to the periphery, a series of concentric rings were visible: an inner bright ring, the mucosa; a dark ring, the submucosa; an outer bright ring, the smooth muscle of the urethra in a loose connective tissue matrix; and a peripheral dark ring, the striated urogenital sphincter muscle of the urethra in dense connective tissue. No significant alterations were caused by fixation. These cadaveric images matched the non-cadaveric MRI of the 29-year-old woman. CONCLUSION: The internal urethral anatomy visible on high-resolution MRI can be identified and confirmed histologically, and these findings may form the basis for future anatomic investigation of stress urinary incontinence and other urethral abnormalities.     

Randomized trial comparing three forms of pelvic floor repair for neuropathic faecal incontinence

A randomized controlled trial in women with neuropathic faecal incontinence compared total pelvic floor repair (n = 12) with anterior levatorplasty and sphincter plication alone (n = 12) and postanal repair alone (n = 12). Review at 6 and 24 months indicated that results were significantly better for total pelvic floor repair than either of the other procedures. Complete continence was achieved in eight of the 12 patients 2 years after total pelvic floor repair. Only total repair significantly elongated the anal canal. Both total pelvic floor repair and anterior levatorplasty improved sensation in the upper anal canal.     

A transpubic approach for reconstructive surgery of genitourinary injuries and congenital malformations

Four children were operated on by the transpubic approach for injury to the vagina or urethra and to correct malformations within the pelvis minor. One boy had posttraumatic stricture of the urethra, and a girl presented with disruption of the urethra and vagina. One of two boys who had congenital malformations was treated for epispadias and incontinence; the other for a large urethral diverticulum caused by anal atresia. Total reconstruction was achieved, and no complications of symphysis restoration were observed.     

Anatomical anterior exenteration with urethral and vaginal preservation: illustrated surgical method

PURPOSE: We describe in detail a method for urethral and vaginal preservation in women considering orthotopic urinary tract reconstruction after bladder removal. MATERIALS AND METHODS: We retrospectively reviewed the pathological reports of patients treated with anterior exenteration at our hospital between 1984 and 1997 for specific evidence of urethral, vaginal, cervical or uterine involvement by the primary bladder tumor. Based on our findings we describe our approach to anterior exenteration in 6 patients. RESULTS: A total of 46 patients were treated at our center with en bloc anterior exenteration and pelvic lymphadenectomy for primary bladder cancer between 1984 and 1997. In 7 patients (15%) pathological review of the surgical specimen documented urethral involvement by the primary tumor. In 1 patient (2%) microscopic evidence of tumor was identified in the cervix and 1 (2%) had tumor extension to the vagina documented in the final pathology report. CONCLUSIONS: The observed rates of vaginal and urethral involvement agree with those reported by others, and suggest that in the majority of women treated with anterior exenteration sacrifice of the urethra and vagina is usually not necessary from an oncological perspective. This procedure is particularly appropriate in women concerned with postoperative sexual function and those considering orthotopic reconstruction of the lower urinary tract after exenterative bladder cancer surgery.     

Pelvic stress injuries: the relationship between osteitis pubis (symphysis pubis stress injury) and sacroiliac abnormalities in athletes

OBJECTIVE: To demonstrate with radiographic imaging the association between pubic stress injury and sacroiliac abnormalities in athletes. DESIGN AND PATIENTS: Eleven athletes (9 men and 2 women), comprising seven male long-distance runners, one male soccer player, one male and two female basketball players, were imaged with plain films for complaints of pubic symphysis pain, sciatica, groin pain, or a combination of these complaints. In addition to the plain films, four patients were imaged with CT, two patients had MR imaging, and a bone scan was performed in three patients. Anteroposterior plain films of the pelvis of 20 patients without back pain or pubic pain were evaluated for comparison as a control group (ages 18-72 years, average 49 years; 11 women and 9 men). RESULTS: All athletes showed plain film evidence of either sclerosis, erosions or offset at the pubic symphysis. Four had avulsion of cortical bone at the site of insertion of the gracilis tendon. Four patients demonstrated sacroiliac joint abnormalities on plain films consisting of sclerosis, erosions and osteophytes, and in one of these athletes, bilateral sacroiliac changes are present. Two patients with normal sacroiliac joints on plain films had a bone scan showing increased radionuclide uptake bilaterally at the sacroiliac joints. One patient with both plain film and CT evidence of sacroiliac abnormalities had an MR examination showing abnormal signal at both sacroiliac joints and at the pubic symphysis. A sacral stress fracture was found on CT in one patient with complaints of sciatica. In the control group, six patients, all over the age of 55 years, had mild sclerosis of the symphysis, but no plain film evidence of sacroiliac abnormalities. CONCLUSION: We have found a group of athletes in whom stress injuries to the pubic symphysis are associated with changes in the sacroiliac joint as demonstrated by degenerative changes or in the sacrum as manifested as a sacral stress fracture. These findings are probably due to abnormal stresses across the pelvic ring structure that lead to a second abnormality in the pelvic ring. The abnormality in the sacrum is not always well seen with conventional imaging. Recognition of the association of stress injury of the symphysis with back pain is important in that it can help avoid inappropriate studies and diagnostic confusion.     

Magnetic resonance imaging of the pelvic floor in patients with obstructed defaecation

BACKGROUND: Evacuation proctography and measurements of anorectal physiology are frequently used to clarify the pathophysiology of obstructed defaecation. In some patients these tests are normal, despite convincing clinical evidence of defaecatory difficulty. The aim of this study was to determine whether magnetic resonance imaging (MRI) could reveal pelvic floor abnormality in patients with obstructed defaecation. METHODS: Eleven women with obstructed defaecation, in whom evacuation proctography and anorectal physiology were normal, were examined by MRI, using a fast gradient echo sequence. Measurements of pelvic visceral and muscular descent were taken at rest and during straining, and compared with those obtained from 13 asymptomatic volunteers. RESULTS: Patients with obstructed defaecation had significantly greater pelvic visceral descent (P < 0.05), levator muscle descent (P = 0.04), levator plate angle change (P = 0.003) and increase in the area of the pelvic floor hiatus (P = 0.0002) than asymptomatic volunteers. CONCLUSION: MRI demonstrated marked pelvic visceral and levator muscle descent in women with obstructed defaecation, despite normal evacuation proctography and anorectal physiology. MRI should be considered if these examinations have been normal.     

Our experience with pubovaginal slings in patients with stress urinary incontinence

PURPOSE: Pubovaginal slings successfully treat stress urinary incontinence in women with intrinsic sphincter deficiency. Because of its durability, it has been an attractive procedure in select patients with urethral hypermobility. We examine our experience with pubovaginal sling. MATERIALS AND METHODS: A total of 150 patients were evaluated for pelvic prolapse and urinary incontinence. An abdominal leak point pressure was determined in all patients. Of patients with type II stress urinary incontinence, 36 patients (80%) underwent additional gynecological procedures at the time of the pubovaginal sling, compared to 29% with intrinsic sphincter deficiency and 33% with coexisting urethral hypermobility and intrinsic sphincter deficiency. RESULTS: The overall cure rate was 93% with a mean followup of 22 months. At 1 week postoperatively spontaneous voiding was accomplished by 56% of the patients with urethral hypermobility and 57% with intrinsic sphincter deficiency. Only 2.8% of patients required surgical therapy for prolonged urinary retention. De novo urgency/urge incontinence occurred in 19% of women with a 3% incidence of persistent urge incontinence. CONCLUSIONS: Pubovaginal slings are effective and durable. Voiding dysfunction is uncommon and is temporary in most patients.     

Internal and external anal sphincter anatomy as it relates to midline obstetric lacerations

OBJECTIVE: To examine the anatomy of the internal and external anal sphincters in the area of midline obstetric lacerations, to gain insight into sphincter damage and repair. METHODS: The length, craniocaudal extent, and overlap of the internal and external anal sphincters in the perineal body were measured in 17 cadavers. Further anatomic observations were made in four sets of whole pelvis cross-sections taken in the sagittal, coronal, and transverse planes. During the repair of 20 acute fourth-degree lacerations, observations were made to determine the internal sphincter visibility following birth. RESULTS: The external and internal and sphincters overlap by 17.0 mm (standard deviation [SD] 6.9), with the internal sphincter lying between the external sphincter and the anal canal. The internal sphincter extends an additional 12.2 mm (SD 5.9) cranial to the proximal extent of the external sphincter, whereas the caudal margin of the internal sphincter lies 3.7 mm (SD 7.2) cranial to the distal margin of the external sphincter. In pregnant women who sustained a fourth-degree laceration, we found that the internal sphincter can be identified as a rubbery white layer adjacent to the anal submucosa lying between the external sphincter and the anal canal. CONCLUSION: The internal anal sphincter lies between the anal mucosa and the external anal sphincter and extends more than a centimeter above the cranial margin of the external sphincter, a region where it is disrupted when a fourth-degree obstetric laceration has occurred.     

Low-field magnetic resonance imaging (0.2 T) of tendons with sonographic and histologic correlation. Cadaveric study

RATIONALE AND OBJECTIVES: The authors evaluate the role of low-field strength magnetic resonance imaging (MRI) compared with sonography in the evaluation of degenerative changes of tendons, with histologic correlation, based on investigations of horse cadavers. METHODS: Low-field MRI and sonography was performed in 42 hours specimens for the evaluation of tendons and ligaments. Magnetic resonance imaging included sagittal and axial T1-weighted, T2-weighted, and gradient echo images. Sonography and MR images were evaluated for degenerative changes or tears and the findings were correlated with the histologic results. RESULTS: Using histologic findings as a gold standard, the accuracy for the sonographic evaluation was 65.9%, sensitivity was 16.7%, and specificity was 100%. The corresponding data for low-field MR imaging were 70.5% accuracy, 44.4% sensitivity, and 88.5% specificity. CONCLUSIONS: Low-field MRI investigation allows more accurate staging of tendinous changes than sonography. It is more reproducible and potentially includes the advantages of the combined evaluation of bones, ligaments, and soft tissue.