Top

Insights into Imaging

Published in:

Open Access 01-08-2013 | Pictorial Review

A pictorial overview of pubovisceral muscle avulsions on pelvic floor magnetic resonance imaging

Authors: Karin Lammers, Mathias Prokop, Mark E. Vierhout, Kirsten B. Kluivers, Jurgen J. Fütterer

Published in: Insights into Imaging | Issue 4/2013

Abstract

Objectives

Despite extensive research aimed at clarifying (failing) pelvic organ support, the complete aetiology of pelvic organ prolapse (POP) is still not fully understood. During vaginal delivery, the pelvic floor can be irreversibly traumatised, resulting in pubovisceral muscle avulsions. The aetiology of these avulsions is discussed in this pictorial overview. Normal female pelvic floor anatomy is described and variations are exemplified using magnetic resonance (MR) images. The clinical relevance of detecting pubovisceral muscle avulsions is specified.

Methods

T2-weighted MR imaging has multiplanar capabilities with high diagnostic accuracy allowing for detailed visualisation of the pelvic floor. Together with the use of a three-dimensional (3D) post-processing program, the presence and severity of pubovisceral muscle avulsions can be quantified.

Results

Pelvic floor MR imaging is a non-invasive method that enables adequate identification of pubovisceral muscle avulsions which are known risk factors for the development of POP. They can be scored with good to excellent inter- and intra-observer reliability.

Conclusions

Radiologists and urogynaecology subspecialists should be familiar with MR imaging findings of pubovisceral muscle avulsions as this birth-related trauma is observed in over 36 % of vaginally parous women.

Teaching Points

• Pelvic organ prolapse (POP) is a growing problem for both patients and for our healthcare system

• Pubovisceral muscle avulsions are known risk factors for pelvic organ prolapse (POP)

• T2-weighted MR imaging visualises pubovisceral muscle avulsions adequately

• Pubovisceral muscle avulsions are scored with good to excellent inter- and intra-observer reliability

Patel DA, Xu X, Thomason AD, Ransom SB, Ivy JS, DeLancey JO (2006) Childbirth and pelvic floor dysfunction: an epidemiologic approach to the assessment of prevention opportunities at delivery. Am J Obstet Gynecol 195(1):23–28PubMedPubMedCentralCrossRef

de Boer TA, Slieker-Ten Hove MC, Burger CW, Kluivers KB, Vierhout ME (2011) The prevalence and factors associated with previous surgery for pelvic organ prolapse and/or urinary incontinence in a cross-sectional study in The Netherlands. Eur J Obstet Gynecol Reprod Biol 158(2):343–349PubMedCrossRef

Clark AL, Gregory T, Smith VJ, Edwards R (2003) Epidemiologic evaluation of reoperation for surgically treated pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 189(5):1261–1267PubMedCrossRef

Denman MA, Gregory WT, Boyles SH, Smith V, Edwards SR, Clark AL (2008) Reoperation 10 years after surgically managed pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 198(5):555 e551–e555CrossRef

Miedel A, Tegerstedt G, Maehle-Schmidt M, Nyren O, Hammarstrom M (2009) Nonobstetric risk factors for symptomatic pelvic organ prolapse. Obstet Gynecol 113(5):1089–1097PubMedCrossRef

Lince SL, van Kempen LC, Vierhout ME, Kluivers KB (2012) A systematic review of clinical studies on hereditary factors in pelvic organ prolapse. Int Urogynecol J 23(10):1327–1336PubMedPubMedCentralCrossRef

Bump RC (1993) Racial comparisons and contrasts in urinary incontinence and pelvic organ prolapse. Obstet Gynecol 81(3):421–425PubMed

Jelovsek JE, Maher C, Barber MD (2007) Pelvic organ prolapse. Lancet 369(9566):1027–1038PubMedCrossRef

Mant J, Painter R, Vessey M (1997) Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol 104(5):579–585PubMedCrossRef

10.

DeLancey JO, Morgan DM, Fenner DE, Kearney R, Guire K, Miller JM et al (2007) Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol 109(2 Pt 1):295–302PubMedCrossRef

11.

Dietz HP, Shek C, Clarke B (2005) Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound. Ultrasound Obstet Gynecol 25(6):580–585PubMedCrossRef

12.

Delancey JO, Hurd WW (1998) Size of the urogenital hiatus in the levator ani muscles in normal women and women with pelvic organ prolapse. Obstet Gynecol 91(3):364–368PubMedCrossRef

13.

Maglinte DD, Kelvin FM, Fitzgerald K, Hale DS, Benson JT (1999) Association of compartment defects in pelvic floor dysfunction. AJR Am J Roentgenol 172(2):439–444PubMedCrossRef

14.

Fielding JR (2002) Practical MR imaging of female pelvic floor weakness. Radiographics 22(2):295–304PubMedCrossRef

15.

Zijta FM, Lakeman MM, Froeling M, van der Paardt MP, Borstlap CS, Bipat S et al (2012) Evaluation of the female pelvic floor in pelvic organ prolapse using 3.0-Tesla diffusion tensor imaging and fibre tractography. Eur Radiol 22(12):2806-2813PubMedPubMedCentralCrossRef

16.

Chitty LS, Altman DG, Henderson A, Campbell S (1994) Charts of fetal size: 2. Head measurements. Br J Obstet Gynaecol 101(1):35–43PubMedCrossRef

17.

Lien KC, Mooney B, DeLancey JO, Ashton-Miller JA (2004) Levator ani muscle stretch induced by simulated vaginal birth. Obstet Gynecol 103(1):31–40PubMedPubMedCentralCrossRef

18.

DeLancey JO, Kearney R, Chou Q, Speights S, Binno S (2003) The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol 101(1):46–53PubMedPubMedCentralCrossRef

19.

Dietz HP, Lanzarone V (2005) Levator trauma after vaginal delivery. Obstet Gynecol 106(4):707–712PubMedCrossRef

20.

Lammers K, Futterer JJ, Inthout J, Prokop M, Vierhout ME, Kluivers KB (2013) Correlating signs and symptoms with pubovisceral muscle avulsions on magnetic resonance imaging. Am J Obstet Gynecol 208(2):148.e1-e7CrossRef

21.

Weemhoff M, Vergeldt TF, Notten K, Serroyen J, Kampschoer PH, Roumen FJ (2012) Avulsion of puborectalis muscle and other risk factors for cystocele recurrence: a 2-year follow-up study. Int Urogynecol J 23(1):65–71PubMedPubMedCentralCrossRef

22.

Dietz HP, Chantarasorn V, Shek KL (2010) Levator avulsion is a risk factor for cystocele recurrence. Ultrasound Obstet Gynecol 36(1):76–80PubMedCrossRef

23.

Gainey HL (1943) Post-partum observation of pelvic tissue damage. Am J Obstet Gynecol 46:457–466

24.

Dietz HP, Hoyte LPJ, Steensma AB (2008) Atlas of pelvic floor ultrasound. Springer, LondonCrossRef

25.

Kearney R, Miller JM, DeLancey JO (2006) Interrater reliability and physical examination of the pubovisceral portion of the levator ani muscle, validity comparisons using MR imaging. Neurourol Urodyn 25(1):50–54PubMedPubMedCentralCrossRef

26.

Dietz HP, Shek C (2008) Validity and reproducibility of the digital detection of levator trauma. Int Urogynecol J Pelvic Floor Dysfunct 19(8):1097–1101PubMedCrossRef

27.

Dietz HP, Moegni F, Shek KL (2012) Diagnosis of levator avulsion injury: a comparison of three methods. Ultrasound Obstet Gynecol 40(6):693–698PubMedCrossRef

28.

van Delft K, Schwertner-Tiepelmann N, Thakar R, Sultan AH (2013) Inter-rater reliability of assessment of levator ani muscle strength and attachement to the pubic bone in nulliparous women. Ultrasound Obstet Gynecol. doi: 10.1002/uog.12426PubMed

29.

Dietz HP (2004) Ultrasound imaging of the pelvic floor. Part II: three-dimensional or volume imaging. Ultrasound Obstet Gynecol 23(6):615–625PubMedCrossRef

30.

Notten KJ, Weemhoff M, Kluivers KB, Schweitzer KJ, Mulder F, Stoker J et al (2011) Protocol for Translabial 3D-Ultrasonography for diagnosing levator defects (TRUDIL): a multicentre cohort study for estimating the diagnostic accuracy of translabial 3D-ultrasonography of the pelvic floor as compared to MR imaging. BMC Womens Health 11:23PubMedPubMedCentralCrossRef

31.

Terra MP, Beets-Tan RG, Vervoorn I, Deutekom M, Wasser MN, Witkamp TD et al (2008) Pelvic floor muscle lesions at endoanal MR imaging in female patients with faecal incontinence. Eur Radiol 18(9):1892–1901PubMedCrossRef

32.

Kruger JA, Heap SW, Murphy BA, Dietz HP (2008) Pelvic floor function in nulliparous women using three-dimensional ultrasound and magnetic resonance imaging. Obstet Gynecol 111(3):631–638PubMedCrossRef

33.

Morgan DM, Umek W, Stein T, Hsu Y, Guire K, DeLancey JO (2007) Interrater reliability of assessing levator ani muscle defects with magnetic resonance images. Int Urogynecol J Pelvic Floor Dysfunct 18(7):773–778PubMedPubMedCentralCrossRef

34.

Lammers K, Kluivers KB, Vierhout ME, Prokop M, Futterer JJ (2013) Inter- and intraobserver reliability for diagnosing levator ani changes on magnetic resonance imaging. Ultrasound Obstet Gynecol. doi: 10.1002/uog.12462PubMed

35.

Tunn R, DeLancey JO, Howard D, Shton-Miller JA, Quint LE (2003) Anatomic variations in the levator ani muscle, endopelvic fascia, and urethra in nulliparas evaluated by magnetic resonance imaging. Am J Obstet Gynecol 188(1):116–121PubMedCrossRef

36.

Chou Q, DeLancey JO (2001) A structured system to evaluate urethral support anatomy in magnetic resonance images. Am J Obstet Gynecol 185(1):44–50PubMedCrossRef

37.

Kearney R, Miller JM, Ashton-Miller JA, DeLancey JO (2006) Obstetric factors associated with levator ani muscle injury after vaginal birth. Obstet Gynecol 107(1):144–149PubMedPubMedCentralCrossRef

38.

Dietz HP, Franco AV, Shek KL, Kirby A (2012) Avulsion injury and levator hiatal ballooning: two independent risk factors for prolapse? An observational study. Acta Obstet Gynecol Scand 91(2):211–214PubMedCrossRef

Title: A pictorial overview of pubovisceral muscle avulsions on pelvic floor magnetic resonance imaging
Authors: Karin Lammers
Mathias Prokop
Mark E. Vierhout
Kirsten B. Kluivers
Jurgen J. Fütterer
Publication date: 01-08-2013
Publisher: Springer Berlin Heidelberg
Published in: Insights into Imaging / Issue 4/2013
Electronic ISSN: 1869-4101
DOI: https://doi.org/10.1007/s13244-013-0261-9

At a glance: The STEP trials

Springer Medicine

A pictorial overview of pubovisceral muscle avulsions on pelvic floor magnetic resonance imaging

Abstract

Objectives

Methods

Results

Conclusions

Teaching Points

At a glance: The STEP trials

Springer Medicine

Abstract

Objectives

Methods

Results

Conclusions

Teaching Points

Please log in to get access to this content

Other articles of this Issue 4/2013

Radiographic features of osteogenesis imperfecta

Parenteral ferumoxytol interaction with magnetic resonance imaging: a case report, review of the literature and advisory warning

Magnetic resonance imaging of solid urethral and peri-urethral lesions

Cost-effectiveness of CTA, MRA and DSA in patients with non-traumatic subarachnoid haemorrhage

Evaluation of Bosniak category IIF complex renal cysts

PET/CT versus body coil PET/MRI: how low can you go?