Top

Published in:

01-01-2016 | Original Article

MRI suggests increased tonicity of the levator ani in women with interstitial cystitis/bladder pain syndrome

Authors: A. Lenore Ackerman, Una J. Lee, Forrest C. Jellison, Nelly Tan, Maitraya Patel, Steven S. Raman, Larissa V. Rodriguez

Published in: International Urogynecology Journal | Issue 1/2016

Abstract

Introduction and hypothesis

In interstitial cystitis/bladder pain syndrome (IC/BPS), pelvic floor dysfunction may contribute significantly to pelvic pain. To determine if pelvic floor hypertonicity manifests alterations on magnetic resonance imaging (MRI) in patients with IC/BPS, we retrospectively compared pelvic measurements between patients and controls.

Methods

Fifteen women with IC/BPS and 15 age-matched controls underwent pelvic MRI. Two blinded radiologists measured the pelvic musculature, including the H- and M lines, vaginal length, urethral length and cross-sectional area, levator width and length, and posterior puborectalis angle. MRI measures and clinical factors, such as age, parity, and duration of symptoms, were compared using a paired, two-tailed t test.

Results

There were no significant differences in age, parity, or symptom duration between groups. Patients with IC/BPS exhibited shorter levator muscles (right: 5.0 ± 0.7 vs. 5.6 ± 0.8, left: 5.0 ± 0.8 vs. 5.7 ± 0.8 cm, P < 0.002) and a wider posterior puborectalis angle (35.0 ± 8.6 vs. 26.7 ± 7.9°, P < 0.01) compared with controls. The H line was shorter in patients with IC/BPS (7.8 ± 0.8 vs. 8.6 ± 0.9 cm, P < 0.02), while M line did not differ. Total urethral length was similar, but vaginal cuff and bladder neck distances to the H line were longer in patients with IC/BPS (5.7 ± 0.6 vs. 5.1 ± 0.9 cm, P < 0.02; 1.9 ± 0.4 vs. 1.4 ± 0.2 cm, P < 0.001, respectively).

Conclusions

Patients with IC/BPS have pelvic floor hypertonicity on MRI, which manifests as shortened levator, increased posterior puborectalis angles, and decreased puborectal distances. We identified evidence of pelvic floor hypertonicity in patients with IC/BPS, which may contribute to or amplify pelvic pain. Future studies are necessary to determine the MRI utility in understanding pelvic floor hypertonicity in patients with IC/BPS.

Clemens JQ (2010) Afferent neurourology: a novel paradigm. Neurourol Urodyn 29(Suppl 1):S29–S31. doi:10.1002/nau.20792 PubMedCrossRef

Barsky AJ, Borus JF (1999) Functional somatic syndromes. Ann Intern Med 130(11):910–921PubMedCrossRef

Butrick CW (2003) Interstitial cystitis and chronic pelvic pain: new insights in neuropathology, diagnosis, and treatment. Clin Obstet Gynecol 46(4):811–823PubMedCrossRef

Peters KM, Carrico DJ, Diokno AC (2008) Characterization of a clinical cohort of 87 women with interstitial cystitis/painful bladder syndrome. Urology 71(4):634–640. doi:10.1016/j.urology.2007.11.013 PubMedCrossRef

Peters K, Girdler B, Carrico D, Ibrahim I, Diokno A (2008) Painful bladder syndrome/interstitial cystitis and vulvodynia: a clinical correlation. Int Urogynecol J Pelvic Floor Dysfunct 19(5):665–669. doi:10.1007/s00192-007-0501-y PubMedCrossRef

Schmidt RA, Vapnek JM (1991) Pelvic floor behavior and interstitial cystitis. Semin Urol 9(2):154–159PubMed

Simons DG, Travell JG, Simons LS (1999) Travell & Simons’ myofascial pain and dysfunction: the trigger point manual, 2nd edn. Williams & Wilkins, Baltimore

Bassaly R, Tidwell N, Bertolino S, Hoyte L, Downes K, Hart S (2011) Myofascial pain and pelvic floor dysfunction in patients with interstitial cystitis. Int Urogynecol J 22(4):413–418. doi:10.1007/s00192-010-1301-3 PubMedCrossRef

Doggweiler-Wiygul R, Wiygul JP (2002) Interstitial cystitis, pelvic pain, and the relationship to myofascial pain and dysfunction: a report on four patients. World J Urol 20(5):310–314. doi:10.1007/s00345-002-0298-8 PubMed

10.

FitzGerald MP, Payne CK, Lukacz ES, Yang CC, Peters KM, Chai TC, Nickel JC, Hanno PM, Kreder KJ, Burks DA, Mayer R, Kotarinos R, Fortman C, Allen TM, Fraser L, Mason-Cover M, Furey C, Odabachian L, Sanfield A, Chu J, Huestis K, Tata GE, Dugan N, Sheth H, Bewyer K, Anaeme A, Newton K, Featherstone W, Halle-Podell R, Cen L, Landis JR, Propert KJ, Foster HE Jr, Kusek JW, Nyberg LM (2012) Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. J Urol 187(6):2113–2118. doi:10.1016/j.juro.2012.01.123 PubMedPubMedCentralCrossRef

11.

Weiss JM (2001) Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol 166(6):2226–2231PubMedCrossRef

12.

Gousse AE, Barbaric ZL, Safir MH, Madjar S, Marumoto AK, Raz S (2000) Dynamic half Fourier acquisition, single shot turbo spin-echo magnetic resonance imaging for evaluating the female pelvis. J Urol 164(5):1606–1613PubMedCrossRef

13.

Comiter CV, Vasavada SP, Barbaric ZL, Gousse AE, Raz S (1999) Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging. Urology 54(3):454–457PubMedCrossRef

14.

Pannu HK (2003) Dynamic MR imaging of female organ prolapse. Radiol Clin N Am 41(2):409–423PubMedCrossRef

15.

Singh K, Reid WM, Berger LA (2002) Magnetic resonance imaging of normal levator ani anatomy and function. Obstet Gynecol 99(3):433–438PubMedCrossRef

16.

Hsu Y, Summers A, Hussain HK, Guire KE, Delancey JO (2006) Levator plate angle in women with pelvic organ prolapse compared to women with normal support using dynamic MR imaging. Am J Obstet Gynecol 194(5):1427–1433. doi:10.1016/j.ajog.2006.01.055 PubMedPubMedCentralCrossRef

17.

Ansquer Y, Fernandez P, Chapron C, Frey C, Bennis M, Roy C, Salomon L, Mandelbrot L, Carbonne B (2006) Static and dynamic MRI features of the levator ani and correlation with severity of genital prolapse. Acta Obstet Gynecol Scand 85(12):1468–1475. doi:10.1080/00016340600984837 PubMedCrossRef

18.

Ludescher B, Rommel M, Willmer T, Fritsche A, Schick F, Machann J (2011) Subcutaneous adipose tissue thickness in adults - correlation with BMI and recommendations for pen needle lengths for subcutaneous self-injection. Clin Endocrinol (Oxf) 75(6):786–790. doi:10.1111/j.1365-2265.2011.04132.x CrossRef

19.

Metz CE (1978) Basic principles of ROC analysis. Semin Nucl Med 8(4):283–298PubMedCrossRef

20.

Zweig MH, Campbell G (1993) Receiver-operating characteristic (ROC) plots: a fundamental evaluation tool in clinical medicine. Clin Chem 39(4):561–577PubMed

21.

Wessely S, Nimnuan C, Sharpe M (1999) Functional somatic syndromes: one or many? Lancet 354(9182):936–939. doi:10.1016/S0140-6736(98)08320-2 PubMedCrossRef

22.

Tunn R, Delancey JO, Howard D, Ashton-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

23.

Hsu Y, Chen L, Huebner M, Ashton-Miller JA, DeLancey JO (2006) Quantification of levator ani cross-sectional area differences between women with and those without prolapse. Obstet Gynecol 108(4):879–883. doi:10.1097/01.AOG.0000233153.75175.34 PubMedCrossRef

24.

Nickel JC, Shoskes D, Irvine-Bird K (2009) Clinical phenotyping of women with interstitial cystitis/painful bladder syndrome: a key to classification and potentially improved management. J Urol 182(1):155–160. doi:10.1016/j.juro.2009.02.122 PubMedCrossRef

25.

Fenton BW (2007) Limbic associated pelvic pain: a hypothesis to explain the diagnostic relationships and features of patients with chronic pelvic pain. Med Hypotheses 69(2):282–286. doi:10.1016/j.mehy.2006.12.025 PubMedCrossRef

26.

Malykhina AP, Qin C, Greenwood-van Meerveld B, Foreman RD, Lupu F, Akbarali HI (2006) Hyperexcitability of convergent colon and bladder dorsal root ganglion neurons after colonic inflammation: mechanism for pelvic organ cross-talk. Neurogastroenterol Motil 18(10):936–948. doi:10.1111/j.1365-2982.2006.00807.x PubMedCrossRef

27.

Kaddumi EG, Hubscher CH (2007) Changes in rat brainstem responsiveness to somatovisceral inputs following acute bladder irritation. Exp Neurol 203(2):349–357. doi:10.1016/j.expneurol.2006.08.011 PubMedCrossRef

28.

Rudick CN, Chen MC, Mongiu AK, Klumpp DJ (2007) Organ cross talk modulates pelvic pain. Am J Physiol Regul Integr Comp Physiol 293(3):R1191–R1198. doi:10.1152/ajpregu.00411.2007 PubMedCrossRef

29.

Pezzone MA, Liang R, Fraser MO (2005) A model of neural cross-talk and irritation in the pelvis: implications for the overlap of chronic pelvic pain disorders. Gastroenterology 128(7):1953–1964PubMedCrossRef

30.

Kilpatrick LA, Kutch JJ, Tillisch K, Naliboff BD, Labus JS, Jiang Z, Farmer MA, Apkarian AV, Mackey S, Martucci KT, Clauw DJ, Harris RE, Deutsch G, Ness TJ, Yang CC, Maravilla K, Mullins C, Mayer EA (2014) Alterations in resting state oscillations and connectivity in sensory and motor networks in women with interstitial cystitis/painful bladder syndrome. J Urol 192(3):947–955. doi:10.1016/j.juro.2014.03.093 PubMedPubMedCentralCrossRef

Title: MRI suggests increased tonicity of the levator ani in women with interstitial cystitis/bladder pain syndrome
Authors: A. Lenore Ackerman
Una J. Lee
Forrest C. Jellison
Nelly Tan
Maitraya Patel
Steven S. Raman
Larissa V. Rodriguez
Publication date: 01-01-2016
Publisher: Springer London
Published in: International Urogynecology Journal / Issue 1/2016
Print ISSN: 0937-3462
Electronic ISSN: 1433-3023
DOI: https://doi.org/10.1007/s00192-015-2794-6

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

MRI suggests increased tonicity of the levator ani in women with interstitial cystitis/bladder pain syndrome

Abstract

Introduction and hypothesis

Methods

Results

Conclusions

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Introduction and hypothesis

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2016

Comparison of graft-reinforced repairs and suture repair using a novel biomechanical test

Association between pelvic floor muscle trauma and pelvic organ prolapse 20 years after delivery

Laparoscopic sacral hysteropexy versus laparoscopic sacrocolpopexy with hysterectomy for pelvic organ prolapse

Vaginal adhesions after transvaginal pelvic reconstructive surgeries: prevalence and clinical implications

Vaginal birth and pelvic floor dysfunction revisited: Can cesarean delivery be protective?

Delivery-related risk factors for covert postpartum urinary retention after vaginal delivery