NO DISCLOSURES Pelvic Organ Prolapse Which Imaging Modalities Help in Investigation & Management of POP Phyllis Glanc Sunnybrook Health Sciences Center Department Medical Imaging, Obstetrics & Gynecology Associate Professor, University of Toronto Associate Scientist, Sunnybrook Research Institute phyllis.glanc@sunnybrook.ca Hello, incontinence helpline - can you hold? Special Thank You Professors Hans Peter Dietz Objectives Background Permission use educational materials Imaging Options US, MRI, Fluoroscopic DCP/CCP Conclusion Pelvic Floor Dysfunction Common umbrella term for below Urinary (UI) & Fecal Incontinence (FI) Pelvic Organ Prolapse (POP) Levator ani trauma Post operative (Mesh, complications) Pelvic Floor Dysfunction Affect 50% women by age 50 1/10 have surgery by age 70 1/3 repeat surgeries Pelvic organ prolapse affect 1/3 PMW Societal costs Billions for UI Millions for POP and AI Wu JM et al. Predicting the number of women who will undergo incontinence and prolapse surgery, 2010 to 2050. Am J Obstet Gynecol. 2011;205(3):230 e1 5. 1
Risk Factors Pelvic Floor Dysfunction Pelvic Floor Imaging Big 3 Female gender and age > risk factors Prolonged 2nd stage labor Pelvic surgery - especially hysterectomy Chronic increased abdominal pressure eg obesity, weight lifting Poor pelvic support due connective tissue disorders, post radiation Chronic straining lead to pudendal neuropathy 1. Fluoroscopic, defecation sitting 2. MRI = Static +/or Dynamic 3. Ultrasound = TPUS or endoanal (AS) Fleuroscopic Cystocolpoproctography (CCP) Defecation proctography(dcp) sitting on a commode Gold standard obstructed defecation disorders Rectal contrast Cystocolpoproctography extension DCP Requires opacification bladder, SI, vagina, rectum Start drinking prior pm, invasive, radiation Still not see muscles/soft tissues Fleuroscopic Cystocolpoproctography (CCP) Evacuation/defecation is considered optimum Time of maximum stress on pelvic floor with complete relaxation levator ani thus ID most pathology Thus actual defecation/evacuation is considered optimal MR defecography in sitting position commode not widely available Role MRI Static, Dynamic modes Global view organs & muscles & ligaments High resolution Better for AS atrophy or muscle replaced with fat Equivalent to endoanal US for AS Performed supine nonetheless may ID up to 70% diagnosis associated with obstructed defecation on DCP Most abnormalities occur at end evacuation Rectocele, enterocele, pelvic floor descent, intussception Role MRI Static, Dynamic modes Open magnet permit closer functional positioning but lower resolution thus MR defecography generally in closed magnet in supine position Literature inconsistent on supine vs upright however overall CCP / evacuation proctography gold standard Literature demonstrate high variability in pelvic MR floor reporting 2
Typical protocol pelvic floor dysfunction Ultrasound - TPUS - Bladder emptied, 100cc warm US gel (+/- mashed potatoes), wrap patient in incontinence pad, knees bent - Strain/squeeze 18 sec acquisition vs evacuation 40-60sec - Kegel want elevation 1-2 cm AR junction - If suspect lateral rectocele/prolapse then need dynamic coronal and axial ( not routine) US inexpensive, well tolerated c/w DCP/CCP Multicompartment view * suburethral slings Detailed info on urethral/bladder neck/perineum Stored volume / cine sets, tomographic slices and multiplanar images, 3D for UG hiatus & LA Real-time ability gauge stress maneuver, can sit partially upright, immediate feedback Relatively limited FOV, may compress by transducer Ultrasound - TPUS Few studies compare US to MR defocgraphy Challenge: Diagnosis, Management Anatomy is complex & require multidisciplinary team Urologists, gynecologists, proctologists, physical therapists, radiologists Different imaging subspecialists for 3 main choices Rush et al 1995; *Halligan et al, 1996 Clin Radiol;51, 785-790** Challenge: Diagnosis, Management Suspect POP Adaption ACR AC 2015 Suspect Urinary Dysfunction Suspect Defecatory Dysfunction Recurrent symptoms 10-30% after surgery may indicative of underestimation involved compartments Different surgeries for different issues 50% SUI and 80% uterovaginal prolapse also symptoms obstructed defecation* CCP study demonstrated 71% cystocele, 65% urethral hypermobility, vault prolapse 50%** Beer- Gabel et al ( 2008) compared TPUS to defecation procotography: TPUS 100% cystoceles, 92% rectoceles, 71% perineal descent, 75% rectal prolapse Rush et al 1995; *Halligan et al, 1996 Clin Radiol;51, 785-790** Pannu HK, Javit M, Glanc P et al. J of American College of Radiology 12.2 (2015): 134-142. Post op POP or pelvic floor dysfunction 3
Compartments Pelvic Floor Level Reference Slide Anterior compartment Posterior Compartment 1 Highest Bladder base Inferior 1/3 rectum 2 Mid Bladder neck Anorectal junction Pubic symphysis Puborectalis muscle Anterior: Bladder, urethra Middle: Uterus, cervix, vagina Posterior: Anal spincter, rectum Puborectalis sling surrounds bladder neck, vagina and rectum Virtual space (rectouterine, cul-de-sac) develop enterocele, peritonocele, sigmoidocele 3 Low Midurethra Upper 1/3 anal canal Levator Ani Sling -Lateral vagina -Posterior Anal canal -Attach PR anterior 4* Lowest Distal urethra Mid/lower 1/3 anal canal Perineal body & superficial perineal muscles (perineal muscles, bulbospongiosus, ischiocavernosus,superficial transverse * Level measure AP diameter UG hiatus ( pubosymphysis-perineal 20 body distance) Real-time dynamic study with stored cine-loops Assess all 3 compartments simultaneously Pelvic Organ Prolapse (POP) Perineum Urethra Vagina PS AS Anterior Anterior Posterior R CASE Normal Anatomy Review Posterior 9% women clinical symptoms 30% undergo repeat operation Negative impact on quality of life including sexual function LA avulsion from pubic bone or pelvic sidewall is associated with POP LA avulsion is associated with vaginal delivery Pelvic Organ Prolapse Pelvic Organ Prolapse (POP) Abnormal descent vagina involving anterior wall, posterior wall and/or apex Due to protrusion of adjacent pelvic organs such as cystocele, uterine, entero/recoceles Imaging complementary to clinical evaluation Descent of the pelvic organs beneath a theoretical line between PS and ARA Cystocele bladder Rectocele anterior wall rectum Into widened rectovaginal space is enterocele or sigmoidocele Vaginal prolapse or procidentia (uterus) Evaluate all compartments pre-op Important if clinically symptomatic 4
Prolapse Assessment US EVALUATION Line between pubic symphysis - anorectal angle Plane minimum dimension No anchor point but reproducible Key Proper push/valsalva which is time dependant May take 4-5 seconds to reach final organ descent Rehearse in real-time with patient watch screen Pelvic Organ Prolapse ( Posterior) Line from PS to ARA at rest.. MR - Pubococcygeal line Rest Strain Rest Strain Pelvic Organ Prolapse (posterior) Grade prolapse rule of three : descent of an organ below the PCL by 3 cm mild, 3 6 cm moderate, > 6 cm severe Urinary Incontinece Urinary Incontinence Women more susceptible Anatomy : Urethra shorter thus less resistance to outflow when bladder contracts Life style Risks: Vaginal Delivery/2 nd stage labor prolonged Stress : (SUI) -increase abdominal pressure (cough, laugh, sneeze) results involuntary loss urine Sphincteric defect / hypermobility urethra Urge urinary incontinence (UUI) - detrusor overactivity (destrusor thickness > 5mm) or damage innervation bladder Overflow: Leakage 5
Anterior Compartment: UI & Prolapse Anterior Compartment: UI & Prolapse Post void residual, bladder wall thickness Does urethra rotate or descend? In presence cystocele Hypermobile? (SUI) Kinked ( bladder dysfunction, urine retention) Does bladder neck descend or open Does cystocele develop Abnormal retrovesical angle > 120 degrees Significant POP can hinder urethral hypermobility and mask SUI Key role of Ultrasound ID position bladder neck / urethra, assess PVR Assess UVJ for rotation and descent -maintain RVA (retrovesical angle > 120 degrees) Assess develop cystocele ( if UVJ stable may kinked urethra and bladder dysfuntion/retention Distinguish between cystocele with urethral hypermobility versus a cystocele without urethral rotation Findings: Bladder neck remains closed but descends Urethra rotates horizontal Small cystocele develops Bladder Rest Strain Bladder - Less common - Bladder neck remains in place - Voiding dysfunction rather than SUI - Association with levator ani trauma Case 1 Classic Stress Urinary Incontinence Case 2 Isolated Cystocele Posterior Compartment Anal continence normal @ rest Anorectal angle 90-130 0 rest Anorectal junction above or at level PS POP descent rectal ampulla Perineal hypermobility Rectovaginal defect Rectocele (> 2 cm AP diam), sigmoidocele, enterocele Rectal intussception Anal sphincter defects Bladder neck open with strain but no descent Rectocele Rectocele ( pivot ant/post) MOVE PROBE POSTERIOR ON PERINEUM RECTOCELE & OBTUSE ARA 6
Posterior Compartment Anal Sphincter ENTEROCOLE SIGMOIDOCELE EAUS gold standard assess anal sphincter but MRI nearly as good Distinguish Incontinent patients with intact anal sphincter 90% sensitivity/specificity scar, defect Case Posterior Compartment MRI good big picture/muscles FECAL INCONTINENCE TPUS ANAL SPHINCTER Results less validated c/w endoanal US Rapid assessment AS Not gold standard Courtesy Dr. Dietz Case Normal anal sphincter TPUS Case Multiplanar Reformats, Tomographic Slices TPUS - ANAL SPHINCTER 3D & Volume Rendered Critical Dimensions urogenital hiatus POP IAS =2-3mm, EAS variable thickness US sensitivity/specificity muscular defect ~ 90% Case Pannu et al Radiographics 2010 Yagel et al., Valsky et al., UOG 2006, 2007 Levator Ani Trauma (Slings and Things) 7
Display Modes : MPR/Rendered Urogenital Diaphragm MPR/orthogonal display mode shows cross-sectional planes through the volume in question (a,b,c) d = standard rendered image of the levator hiatus, with the rendering direction set from caudally to cranially Largest natural hiatus in body Mean 16 cm young nullip Mean 25 cm overall Most caudal layer pelvic floor Composed of CT and peroneus muscle run from ischial rami to perineal body and EAS Perineal body is site attachment for endopelvic fascia, UG diaphragm, bulbocavernosus muscle and puborectalis muscle Courtesy Dr. Dietz UG Hiatus Plane minimum dimension Narrowest diameter from PS to ARA Urogenital Hiatus REST Valsalva Biometric Indices: AP diameter 4.5-4.8 cm Laterolateral diameter 3.3-4.7cm Hiatal area 11.3-12 cm Circumference Courtesy Dr. Dietz Functional Assessment Valsalva and PFMC allow its functional assessment. Ballooning of the hiatus(excessive distensibility of LA) increase in hiatal area to > 25 cm 2 on Valsalva maneuver Generally associated with full pelvic organ prolapse (POP) Dietz et al and Santoro et al. Levator Avulsion Normal Levator Ani Avulsion Defect Occur in 10-35% post vaginal delivery Forceps 3x risk Result in: Reduction contraction strength Increased risk prolapse (ant/central) 2-3x Increased risk prolapse recurrence post surgery May not affect SUI or FI Direct sign: avulsion of LA Indirect sign: disruption of H configuration vagina posterior displacement vaginal fornix Case Levator ani avulsion defect 8
Levator ani (puborectalis) avulsion: TUI Display LAM Trauma Images courtesy Dr. Dietz Case RHS LA defect with muscle retraction * Definitions of complete and partial trauma of the LAM on TUI using 2.5mm slice intervals: Complete Avulsion When all three central slices, namely, the slice at the plane of the minimal hiatal dimensions plus the two above Partial avulsion When any of the 3-8 slices were abnormal. May not be a clinically important diagnosis. Dietz HP, Bernardo MJ, Kirby A, Shek KL. Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound. Int Urogynecol J 2011; 22: 699 704. Normal Pelvic Floor Anatomy (T2W) MRI EVALUATION RadioGraphics, http://pubs.rsna.org/doi/abs/10.1148/rg.345140137 Normal Pelvic Floor Anatomy (T2W) MIDLINE PELVIC FLOOR EVALUATION PCL or pubococcygeal line posterior inferior pubic symphysis (PI-PS) to 1 st coccygeal joint -levator plate is parallel to this line H-line PI-PS to posterior rectal wall at the anorectal junction ( similar TPUS) M-line is a line from where the H-line intersects the posterior rectum drawn perpendicular to the puborectal muscle. ~vertical extent of levator musculature. - PR muscle posterior to ARjunction RadioGraphics, http://pubs.rsna.org/doi/abs/10.1148/rg.345140137 9
MR - Pubococcygeal line Case : 75yo female with rest midline and dynamic lateral pelvic floor laxity and cystocele Rest Valsalva Kegel Rest Strain Grade prolapse rule of three : descent of an organ below the PCL by 3 cm mild, 3 6 cm moderate, > 6 cm severe A B C Dynamic MRI - Sagittal FIESTA images: H-Line < 5cm, M-Line < 2cm Rest : Baseline elongation H-line & M-line = midline pelvic floor laxity Valsalva : Dynamic midline laxity as evidenced by elongated H-line and M- line, dynamic cystocele. Kegel : Reversal of the dynamic pelvic floor laxity with the H-line (red) M-line now within normal limits Coronal: Lateral Pelvic Floor Evaluation Case : 75yo female with rest midline and dynamic lateral pelvic floor laxity and cystocele The lateral pelvic floor assess shape iliococcygeus muscle Normal is convex upwardarise from EAS and fan out laterally to arcus tendinous Posterior condensation is the firm midline raphe called the levator plate External sphincter Iliococcygeus muscles AS Rest Valsalva Kegel Normal Invert Ileococcygeus Fig. 2 ENTEROCELE Posterior perineal hernia 10
FLEUROSCOPIC EVALUATION Sagging lateral aspect bladder which may be related to defects in endopelvic fascia/muscles Video defecography - Rectocele Contrast in vagina Dynamic cystocolpoproctography (CCP) Defecography MRI Rectocele - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/260128420_fig1_figure-3- Dynamic-cystocolpoproctography-DCP-showing-an-internal-rectal-prolapse [accessed 24 May, 2016] Technique TPUS MRI DCP, CCP 3 compartments Yes Non-invasive Yes Non-invasive Availability Variable - Cheap Expensive Limited Effectiveness Valsalva Ease learning Anterior -immediate feedback on effort - Can mimic sitting upright with patient 60 degrees Basic easy 3D skills Urethral hypermobility, funneling better - No feedback - Supine only - Dynamic cine Basic easy Advanced Anatomy No anatomy Invasive, radiation Go to end evacuation sitting position Easy but undesirable SLINGS & THINGS Middle +/-shadowed by ant/post POP Easier global view Posterior Yes AS atrophy, Easier ID enterocele vs sigmoidocele, rectocele Mesh Yes No No Levator Ani Yes Yes No +/- (barium vagina) +/- 11
Slings Mesh Concept: Continence maintained at midurethra instead of the bladder neck Failure of the pubourethral ligaments Propylene mesh pore size minimum 75 microns Permit entry macrophages, fibroblasts, collagen fibres Mesh erosion rate ~ 9% Bleeding pv 31% Pain 13% Voiding dysfunction 21% Complications PS - Mesh gap in Valsalva < 1cm < 7mm increase probability functional obstruction thus may consider tape division 20% mesh arm dislodge - mesh mobile TVT Mesh Line straight or obtuse, wide gap? not anchored Mesh can fold up into itself, migrate, perforate FDA & MESH WARNINGS 2008: First warning complications TV mesh implants 2011:Update complications not rare, with comment mesh erosion most common, new complication mesh contraction result in vaginal shortening/pain, more complications than transabd approach Mesh removal only through revision surgery painful, difficult to impossible as fuses with patient s tissues and may require multiple surgeries to remove it all pieces Repair via obturator foramen for anchoring may be useful for women with levator avulsion injuries to decrease risk recurrence Recommend specialized training for placement with careful watch for erosion and infection, warn patients permanent and may not be able to remove & risk of adverse effects on quality life TVT (tensionless vaginal tape TOT (Transobturator tape April 29 2014 FDA issues 2 proposals: Classify surgical mesh from moderate risk(classs II) to high risk device ( class III) Pre-market approval will be required if reclassify from II to III Risks: perioperative of organ perforation, injury, bleeding; vaginal mesh exposure via vagina or extrusion into adjacent organs including bladder, rectum with possible fistulas and requirement corrective surgery including suprapubic catheter, diverting colostomy. Other risks like vaginal scarring, shrinkage, tightening, pain, voiding dysfunction, recurrent prolapse, neuromuscular problems including groin and leg pain Benefits correction cystocele, rectocele, uterine prolapse, vaginal apical prolapse TOT Sagittal Mesh midurethral level Harder to obtain information but doable Axial view Relatively straight extending laterally to insert on puborectalis/levator ani and out thru obturator foramen Narrow gap < 7mm PS- Mesh Gap Too Narrow Problem: Voiding Dysfunction Typically > 1cm Typically cut mesh to cure this PS Mesh Gap Too wide/high PROBLEM: Recurrent UI Mesh high in location Bladder neck opens wide with stress although remains fixed high in position 12
Mesh for Prolapse & SUI Mesh for Prolapse & SUI Synthetic nonabsorbable polypropylene mesh (mesh) has become the dominant reconstructive material Macroporous < complications than microporous Absorbable or non-absorbable More available than biological grafts thus cost-effective and lack risk donor-host infections Transvaginal mesh kits associated high rates complications & re-operations 18% mesh exposure, 9% surgery to correct exposure Re-operation rate 3x >than with native tissue repair Thus higher complication rate with similar outcomes Surgical management of pelvic organ prolapse in women. AU Maher C, Feiner B, Baessler K, Schmid C SO Cochrane Database Syst Rev. 2013; SUI synthetic mesh slings recommended due high efficacy, low morbidity POP initial repair recommend native tissue reconstruction Higher failure rate but < complications POP recurrence or high risk recurrence a prior recommend synthetic mesh via abdominal route Synthetic mesh requires detailed consent process to include complications and alternatives Serious mesh complications are not rare : extrusion, erosion, pain, contraction, infection Surgical removal mesh is potentially morbid requiring multiple procedures and incomplete symptom resolution Surgical management of pelvic organ prolapse in women. AU Maher C, Feiner B, Baessler K, Schmid C SO Cochrane Database Syst Rev. 2013; Problem Post-Operative Urinary Dysfunction Cut Sling Mesh for Prolapse & SUI Recommendations include: Specialized training Transabdominal placement results < risk than transvaginal route Common complications are mesh exposure, mesh contraction (shrinkage of the mesh), pain (including dyspareunia and associated with contracture), infection, urinary problems, bleeding, and organ perforation [44]. Deaths have been reported in association with bowel perforation and hemorrhage Midurethral slings are associated with the lowest risk of exposure; transvaginal mesh kits are associated with the highest risk. Courtesy Dr. Dietz Surgical management of pelvic organ prolapse in women. AU Maher C, Feiner B, Baessler K, Schmid C SO Cochrane Database Syst Rev. 2013; Problem Post-Operative - Pain Tomographic Slice Rendered Image TVT curve anchoring anterior, deshiscient Mesh frayed & migrated into vagina. TVT curve anchoring anterior, the left side is split in two and not obviously anchored, concern Edges migrated into vagina. 13
Problem Post Operative Why do we need imaging TVT perforation / migration into urethra Improves our clinical skills - feedback Find unsuspected pathology Select patients for appropriate surgery Complex Research into etiology/pathophysiology Understanding what we do helpful. Teaching and training is issue Courtesy Dr. Dietz Conclusion Pelvic floor disorders common Complex area Best for POP, LA avulsion defects, hiatal ballooning, SUI Biofeedback pelvic floor contraction Does not always correlate well with clinical symptoms More research needed THANK YOU VERY MUCH 14