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Pelvic Floor Imaging¹

¹ From the Department of Radiology, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 Amsterdam, the Netherlands (J.S.), and the Intestinal Imaging Centre, St Mark’s Hospital, London, England (S.H., C.I.B.). Received June 18, 1999; revision requested August 9; revision received November 9; accepted November 16; updated September 28, 2000. Address correspondence to J.S. (e-mail: j.stoker@amc.uva.nl).

View larger version (0K): [in a new window]   Figure 1. Permission to reprint this figure electronically was denied by the publisher. Please see print version.

View larger version (94K): [in a new window]   Figure 2. Drawing shows the retropubic space (space of Retzius) viewed from above, with the bladder and vagina transected at a level just below the bladder, revealing the attachment of the vagina to the levator ani muscles. ATFP = arcus tendineus fascia pelvis, ATLA = arcus tendineus levator ani, LA = levator ani muscles, OIF = obturatorius internus fascia, PS = pubic symphysis, PVM = pubovesical muscle, PVP = periurethral vascular plexus, R = rectum, U = urethra, VLA = vaginolevator attachment, VW = vaginal wall. (Reprinted, with permission, from reference 6.)

View larger version (143K): [in a new window]   Figure 3a. (a) Midvaginal coronal T2-weighted fast spin-echo (repetition time msec/echo time msec, 2,826/120) MR image obtained with an endovaginal coil and (b) corresponding drawing in a 23-year-old asymptomatic female volunteer demonstrate the vaginal wall (VW), urogenital diaphragm (UG), puborectal muscle (PR), bulbocavernous muscle (BC), levator ani muscle (LA), internal obturator muscle (IOM), arcus tendineus levator ani (ATLA), bladder (B), and uterus (UT).

View larger version (46K): [in a new window]   Figure 3b. (a) Midvaginal coronal T2-weighted fast spin-echo (repetition time msec/echo time msec, 2,826/120) MR image obtained with an endovaginal coil and (b) corresponding drawing in a 23-year-old asymptomatic female volunteer demonstrate the vaginal wall (VW), urogenital diaphragm (UG), puborectal muscle (PR), bulbocavernous muscle (BC), levator ani muscle (LA), internal obturator muscle (IOM), arcus tendineus levator ani (ATLA), bladder (B), and uterus (UT).

View larger version (196K): [in a new window]   Figure 4a. (a) Coronal T2-weighted fast spin-echo (2,500/100) MR image obtained through the anterior anal sphincter complex with an endoanal coil and (b) corresponding drawing in a 30-year-old asymptomatic female volunteer demonstrate the internal sphincter (IS), external sphincter (ES), puborectal muscle (PR), levator ani muscle (LA), arcus tendineus levator ani (ATLA), internal obturator muscle (IOM), and urogenital diaphragm (UG).

View larger version (39K): [in a new window]   Figure 4b. (a) Coronal T2-weighted fast spin-echo (2,500/100) MR image obtained through the anterior anal sphincter complex with an endoanal coil and (b) corresponding drawing in a 30-year-old asymptomatic female volunteer demonstrate the internal sphincter (IS), external sphincter (ES), puborectal muscle (PR), levator ani muscle (LA), arcus tendineus levator ani (ATLA), internal obturator muscle (IOM), and urogenital diaphragm (UG).

View larger version (150K): [in a new window]   Figure 5a. (a) Coronal midanal T2-weighted fast spin-echo (2,500/100) MR image obtained with an endoanal coil and (b) corresponding drawing in a 21-year-old asymptomatic male volunteer demonstrate the internal sphincter (IS), intersphincteric space (ISS), longitudinal muscle (LM), external sphincter (ES), puborectal muscle (PR), and levator ani muscle (LA).

View larger version (38K): [in a new window]   Figure 5b. (a) Coronal midanal T2-weighted fast spin-echo (2,500/100) MR image obtained with an endoanal coil and (b) corresponding drawing in a 21-year-old asymptomatic male volunteer demonstrate the internal sphincter (IS), intersphincteric space (ISS), longitudinal muscle (LM), external sphincter (ES), puborectal muscle (PR), and levator ani muscle (LA).

View larger version (120K): [in a new window]   Figure 6a. (a) Transverse T2-weighted fast spin-echo (2,826/120) MR image obtained with an endovaginal coil and (b) corresponding drawing in an asymptomatic 31-year-old female volunteer show the vaginal wall (VW), puborectal muscle (PR), urethral smooth muscle (SM) and striated muscle (ST), urethral mucosa and submucosa (MS), urethropelvic (or parapelvic) ligament (UP) and parapelvic ligament (PU), anorectum (A), and internal anal sphincter (IS).

View larger version (37K): [in a new window]   Figure 6b. (a) Transverse T2-weighted fast spin-echo (2,826/120) MR image obtained with an endovaginal coil and (b) corresponding drawing in an asymptomatic 31-year-old female volunteer show the vaginal wall (VW), puborectal muscle (PR), urethral smooth muscle (SM) and striated muscle (ST), urethral mucosa and submucosa (MS), urethropelvic (or parapelvic) ligament (UP) and parapelvic ligament (PU), anorectum (A), and internal anal sphincter (IS).

View larger version (124K): [in a new window]   Figure 7a. (a) Transverse T2-weighted fast spin-echo (2,500/100) MR image obtained through the upper part of the anal sphincter with an endoanal coil and (b) corresponding drawing in an asymptomatic 30-year-old female volunteer show the internal sphincter (IS), longitudinal muscle (LM), puborectal muscle (PR), vagina (V), urethral mucosa and submucosa (MS), urethral smooth muscle (SM) and striated muscle (ST), urethropelvic (or parapelvic) ligament (UP), and parapelvic ligament (PU).

View larger version (35K): [in a new window]   Figure 7b. (a) Transverse T2-weighted fast spin-echo (2,500/100) MR image obtained through the upper part of the anal sphincter with an endoanal coil and (b) corresponding drawing in an asymptomatic 30-year-old female volunteer show the internal sphincter (IS), longitudinal muscle (LM), puborectal muscle (PR), vagina (V), urethral mucosa and submucosa (MS), urethral smooth muscle (SM) and striated muscle (ST), urethropelvic (or parapelvic) ligament (UP), and parapelvic ligament (PU).

View larger version (145K): [in a new window]   Figure 8a. (a) Transverse T2-weighted fast spin-echo (2,500/100) MR image obtained through the lower edge of the anal sphincter with an endoanal coil and (b) corresponding drawing in a 25-year-old asymptomatic female volunteer show the external sphincter (ES), anococcygeal ligament (AC), bulbocavernous muscle (BC), ischiocavernous muscle (IC), superficial transverse perineal muscle (STP), and vaginal introitus (VI).

View larger version (28K): [in a new window]   Figure 8b. (a) Transverse T2-weighted fast spin-echo (2,500/100) MR image obtained through the lower edge of the anal sphincter with an endoanal coil and (b) corresponding drawing in a 25-year-old asymptomatic female volunteer show the external sphincter (ES), anococcygeal ligament (AC), bulbocavernous muscle (BC), ischiocavernous muscle (IC), superficial transverse perineal muscle (STP), and vaginal introitus (VI).

View larger version (179K): [in a new window]   Figure 9a. (a) Midanal sagittal T2-weighted fast spin-echo (2,826/120) MR image obtained with endoanal coil and (b) corresponding drawing in a 30-year-old asymptomatic female volunteer demonstrates the internal sphincter (IS), longitudinal muscle (LM), external sphincter (ES), puborectal muscle (PR), levator ani muscle (LA), perineal body (P), vagina (V), urethra (U), bladder (B), and rectum (R) (window settings optimized for demonstration of the external sphincter).

View larger version (48K): [in a new window]   Figure 9b. (a) Midanal sagittal T2-weighted fast spin-echo (2,826/120) MR image obtained with endoanal coil and (b) corresponding drawing in a 30-year-old asymptomatic female volunteer demonstrates the internal sphincter (IS), longitudinal muscle (LM), external sphincter (ES), puborectal muscle (PR), levator ani muscle (LA), perineal body (P), vagina (V), urethra (U), bladder (B), and rectum (R) (window settings optimized for demonstration of the external sphincter).

View larger version (167K): [in a new window]   Figure 10a. (a) Transverse T2-weighted fast spin-echo (2,500/100) MR image obtained through the lower part of the anal sphincter with an endoanal coil and (b) corresponding drawing in a 40-year-old asymptomatic male volunteer show the internal sphincter (IS), longitudinal muscle (LM), intersphincteric space (ISS), external sphincter (ES), anococcygeal ligament (AC), and bulbocavernous muscle (BC).

View larger version (35K): [in a new window]   Figure 10b. (a) Transverse T2-weighted fast spin-echo (2,500/100) MR image obtained through the lower part of the anal sphincter with an endoanal coil and (b) corresponding drawing in a 40-year-old asymptomatic male volunteer show the internal sphincter (IS), longitudinal muscle (LM), intersphincteric space (ISS), external sphincter (ES), anococcygeal ligament (AC), and bulbocavernous muscle (BC).

View larger version (144K): [in a new window]   Figure 11. Lateral dynamic cystoproctogram in a 62-year-old woman with urinary and fecal incontinence and feelings of incomplete evacuation reveals a cystocele (C) and enterocele (E). Part of the perspex seat is visible as a horizontal bar. A = anterior.

View larger version (216K): [in a new window]   Figure 12. Transverse endoanal US image obtained with a 10-MHz transducer shows normal sphincter anatomy in a 37-year-old asymptomatic male volunteer. Subepithelial tissues (SE), the internal sphincter (IS), the intersphincteric space and longitudinal muscle (IL), and the external sphincter (ES) are visible.

View larger version (157K): [in a new window]   Figure 13a. Dynamic sagittal T1-weighted gradient-echo (79/240; flip angle, 55°) MR images obtained in a 45-year-old woman with pelvic pain. B = bladder, line = pubococcygeal line. (a) Image obtained at rest. (b) Image obtained during maximal straining shows a large cystocele (c).

View larger version (158K): [in a new window]   Figure 13b. Dynamic sagittal T1-weighted gradient-echo (79/240; flip angle, 55°) MR images obtained in a 45-year-old woman with pelvic pain. B = bladder, line = pubococcygeal line. (a) Image obtained at rest. (b) Image obtained during maximal straining shows a large cystocele (c).

View larger version (92K): [in a new window]   Figure 14. Lateral evacuation proctogram in a 52-year-old woman who complained of incomplete evacuation shows a large anterior rectocele (R). Part of the acrylic plastic seat is visible as a horizontal bar.

View larger version (138K): [in a new window]   Figure 15. Lateral evacuation proctogram in a 48-year-old woman who complained of difficult rectal evacuation reveals a high-grade intrarectal intussusception (curved arrows). Part of the acrylic plastic seat is visible as a horizontal bar.

View larger version (218K): [in a new window]   Figure 16. Transverse endoanal US image obtained with a 10-MHz transducer in a 30-year-old woman who complained of urge incontinence after vaginal delivery 1 year previously shows an anterior (A) internal sphincter (IS) defect (solid arrows) and an external sphincter defect (open arrows).

View larger version (155K): [in a new window]   Figure 17. Transverse T2-weighted gradient-echo (24/14; flip angle, 60°) MR image obtained with an endoanal coil in a 63-year-old woman with fecal incontinence demonstrates right anterior defect of the external anal sphincter (ES, arrows) and scar tissue (S) anteriorly on the left side. Thinning of the internal sphincter (IS) anteriorly (arrowheads) can also be seen.

View larger version (139K): [in a new window]   Figure 18. Coronal T2-weighted fast spin-echo (2,500/100) MR image obtained with an endoanal coil in 45-year-old woman with fecal incontinence shows atrophy of the external sphincter (ES). Compare the thickness and signal intensity of the external sphincter with those of the nonatrophied puborectal muscle (PR) and levator ani muscle (LA) and to a normal external sphincter (see Fig 5). The external sphincter muscle is partly replaced by fat.