Levels of Pelvic Floor Support What do they look like on Magnetic Resonance Imaging?
IUGA Academy. Huebner M. Jun 30, 2018; 212982; 321
Markus Huebner
Markus Huebner

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Levels of pelvic floor support; What do they look like on magnetic resonance imaging?

Huebner, M1; DeLancey, J2

1: Women's Center Bern, Lindenhofgruppe, Bern, Switzerland; 2: Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA

Introduction: Magnetic Resonance Imaging (MRI) has become a valuable scientific tool for understanding pelvic floor mechanics. To date, however, the appearance of the three levels used to understand prolapse have not been defined in MR imaging.

Objective: The purpose of this pilot study is to describe the MRI appearance and optimal imaging planes for studying the three levels of support.

Methods: This is an IRB-approved secondary analysis of an ongoing MRI study. N=10 healthy women who volunteered to serve as normal controls on studies of pelvic organ prolapse and who were asymptomatic on standard prolapse questionnaires and had normal support on POP-Q examination were selected from our research MRI-database. Women with prolapse and or defects of the levator ani muscle were excluded. Resting T2 weighted proton density images were made in standard orthogonal planes. This study has been funded by NIH R01 HD 38665 and P50 HD 44406.

Results: Mean age of the subjects was 57.5 ± 6.2 years (mean ± standard deviation, SD), mean body mass index was 28.0 ± 6.4 (mean ± SD), median parity was 2 (min 1, max 4). In all 10 women, all three levels of support and their characteristic appearances could be identified as follows: In Level I the cardinal ligaments are seen coronally (Figure 1c), both cardinal and uterosacral ligaments could be seen in the axial scan plane (Figure 1d). The analysis of Level II showed the lateral vagina adjacent to the levator ani muscle but with clear distinction between then (Figure 1b, c, e). Loss of separation between the vagina and the levator ani muscle could be seen best in Level III (Figure 1b&f). The transition from Level I to Level II is seen in the mid-urethral axial and coronal scan (Figure 1b) where the separation between the vagina and pelvic wall disappears, whereas the transition from Level II to III can be identified in the mid vaginal plane in the coronal scan (Figure 1c). The sagittal scan plan is best for identifying the Level III perineal body in the midline, see Figure 1a for sagittal orientation.

Conclusions: MRI can be used to visualize the characteristic appearance of the specific anatomical structures previously described as Levels of support.

Figure 1: MRI characteristics of Levels of support. (Ut, uterus; B, bladder; Ur, urethra; V, vagina; CL, cardinal ligament; USL, uterosacral ligament; Cx, cervix; R, rectum; b. white arrowheads show the transition zone between Level II and III, arrow show loss of separation; c. arrowheads show transition zone from Level I to Level II as well as the clear separation between vagina an pelvic sidewall, arrow show loss of separation; e. arrow show clear separation between vagina and pelvic sidewall; f. arrowheads show loss of separation between vagina and levator)


Work supported by industry: no. A consultant, employee (part time or full time) or shareholder is among the authors (Dr. DeLancey's disclosures: Hologic and Proctor and Gamble).

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