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MRIMRI ININ
Pelvic Floor DisordersPelvic Floor DisordersMAHYAR GHAFOORI M.D.MAHYAR GHAFOORI M.D.
Associate Professor of RadiologyAssociate Professor of Radiology
Tehran UniversityTehran UniversityOfOf
Medical SciencesMedical Sciences
Pelvic floor in WomenPelvic floor in Women
• Anterior Compartment: Bladder & UrethraAnterior Compartment: Bladder & Urethra
• Middle Compartment: Uterus & VaginaMiddle Compartment: Uterus & Vagina
• Posterior Compartment: AnorectalPosterior Compartment: Anorectal
Normal AnatomyNormal Anatomy
Reference LinesReference LinesPubococcygeal line (PCL):Pubococcygeal line (PCL):From the inferior border of pubic symphysis to the last coccygeal joint.From the inferior border of pubic symphysis to the last coccygeal joint.
Level of Pelvic FloorLevel of Pelvic Floor
H line: H line: Max. 5 cmMax. 5 cm
From inferior border of pubic symphysis to the posterior wall of the rectum From inferior border of pubic symphysis to the posterior wall of the rectum at the level of anorectal junction.at the level of anorectal junction.
AP Width of Levator HiatusAP Width of Levator Hiatus
M line:M line: Max. 2 cmMax. 2 cm
Perpendicularly from PCL to the most posterior aspect of H Perpendicularly from PCL to the most posterior aspect of H line.
Vertical descent of the levator hiatus
RestRest StrainingStraining
NormalNormal
RestRest StrainingStraining
71 Y/O F: Prolapse & Fecal Incontinence71 Y/O F: Prolapse & Fecal Incontinence
Prolapse Severity Grading
Prolapse of an organ below the PCL:Prolapse of an organ below the PCL:
3 cm or less Mild3 cm or less Mild
Between 3 and 6 cm ModerateBetween 3 and 6 cm Moderate
More than 6 cm SevereMore than 6 cm Severe
Anorectal AngleAnorectal Angle
Rest 108 - 127°Rest 108 - 127°
Squeezing CloseSqueezing Close
Defecation OpenDefecation Open
RestRest SqueezingSqueezing StrainingStraining
Puborectalis MusclePuborectalis Muscle
CystoceleCystocele
Urethral HypermobilityUrethral Hypermobility
Anterior CompartmentAnterior Compartment
RestRest StrainStrain
48 Y/O Stress urinary incontinence & frequency 48 Y/O Stress urinary incontinence & frequency
33mm 0°33mm 0° 18mm 65°18mm 65°
56 Y/O F: Stress urinary incontinence, feeling of incomplete bladder voiding, ODS56 Y/O F: Stress urinary incontinence, feeling of incomplete bladder voiding, ODS
Middle CompartmentMiddle Compartment
Uterine or Vaginal Vault ProlapseUterine or Vaginal Vault Prolapse
RestRest StrainingStraining DefecationDefecation
41 Y/O F: Severe uterine prolapse41 Y/O F: Severe uterine prolapse
72 Y/O F: Prolapse after Hysterectomy 72 Y/O F: Prolapse after Hysterectomy
RestRest DefecationDefecation
Posterior CompartmentPosterior Compartment
45 Y/O F: history of obstructed defecation 45 Y/O F: history of obstructed defecation
Anterior RectoceleAnterior Rectocele
41 Y/O F with ODS41 Y/O F with ODS
Posterior RectocelePosterior Rectocele
During DefecationDuring Defecation
65 Y/O F: History of incomplete evacuation 65 Y/O F: History of incomplete evacuation
During DefecationDuring Defecation Intrarectal ResidueIntrarectal Residue
RectoceleRectocele
57 Y/O F: Feeling of incomplete evacuation 57 Y/O F: Feeling of incomplete evacuation
Intrarectal InvaginationIntrarectal Invagination
Extraanal Invagination (Rectal Prolapse)Extraanal Invagination (Rectal Prolapse)
63 Y/O F: Fecal Incontinence, Hx of Hysterectomy63 Y/O F: Fecal Incontinence, Hx of Hysterectomy
RestRest Progressive StrainingProgressive Straining
64 Y/O F: Prolapse after Hysterectomy64 Y/O F: Prolapse after Hysterectomy
Early DefecationEarly Defecation Late DefecationLate Defecation
EnteroceleEnterocele
68 Y/O F: Perineal descent, ODS68 Y/O F: Perineal descent, ODS
3 Compartment Prolapse3 Compartment Prolapse
During DefecationDuring Defecation Complete DefecationComplete Defecation
3 Compartment Prolapse3 Compartment Prolapse
62 Y/O F: 3 Compartment Descent62 Y/O F: 3 Compartment Descent
RestRest SqueezingSqueezing DefecationDefecation
65 Y/O F: ODS, Hx of Hysterectomy65 Y/O F: ODS, Hx of Hysterectomy
Progressive StrainingProgressive Straining
Spastic Pelvic Floor SyndromeSpastic Pelvic Floor Syndrome(Pelvic Floor Uncoordination, Anismus)(Pelvic Floor Uncoordination, Anismus)
Functional abnormality.Functional abnormality.Involuntary, inappropriate & paradoxical contraction of striated pelvic Involuntary, inappropriate & paradoxical contraction of striated pelvic floor musculature: evacuation failure & Constipation.floor musculature: evacuation failure & Constipation.Paradoxical contraction of puborectalis muscle.Paradoxical contraction of puborectalis muscle.Puborectalis muscle is hypertrophic & makes an impression on Puborectalis muscle is hypertrophic & makes an impression on posterior rectal wall during defecation. posterior rectal wall during defecation. Etiology is unclear (Abnormal muscle activity, psychologic, cognitive) Etiology is unclear (Abnormal muscle activity, psychologic, cognitive) Anorectal Manometry: Increased pressure at rest & during defecation.Anorectal Manometry: Increased pressure at rest & during defecation.Pathologic signals at electromyography. Pathologic signals at electromyography.
51 Y/O M: ODS51 Y/O M: ODS
Spastic Pelvic Floor SyndromeSpastic Pelvic Floor Syndrome
RestRest StrainStrain
68 Y/O F: Excessive straining & incomplete evacuation68 Y/O F: Excessive straining & incomplete evacuation
RestRest Progressive StrainingProgressive Straining
Mahyar Ghafoori M.D.Mahyar Ghafoori M.D.The End The End