Pelvic Organ Prolapse

Abdominal Pain and Acute Renal Failure • Xray of the Week

This 88 yo female presented with abdominal pain and acute renal failure. Multiple co-morbidities (cardiac disease, old MI, cirrhosis, portal hypertension, asthma, hypertension, pancytopenia, diabetes) precluded surgery for the patient's condition. What is the diagnosis?

Figure 1. CT scan of the abdomen and pelvis. Axial images (A and B) demonstrate bilateral hydronephrosis. Sagittal image (C) demonstrates global pelvic floor “failure” with prolapse of the vagina, uterus, bladder, and rectum.

In this case, the hydronephrosis [Fig. 1 A,B] is caused by compression of the vesicoureteric junctions as the bladder has prolapsed below the pelvic floor. In the above sagittal image [Fig. 1C], it is apparent that the vagina, uterus and bladder have prolapsed, indicating that there is likely global pelvic floor “failure”.

The incidence of pelvic organ prolapse (POP) has been difficult to estimate accurately, partially due to a relative lack of knowledge about the symptoms, diagnostic tools and therapeutic options amongst both the general population and the medical community.

Options for imaging of POP include defecating x-ray/fluoroscopic proctography (aka defecography), or MRI. The major benefits of MRI are the ability to image the bladder, vagina, uterus and small bowel without additional contrast administration, due to the inherent soft tissue imaging capability of MRI. These structures can be imaged using x-ray defecography, but at the expense of a much more invasive test as it necessitates bladder catheterization and insertion of a vaginal swab, and also involves exposure to ionizing radiation. Both methods do require insertion of rectal contrast material to enable more accurate assessment of rectoanal mucosal prolapses and rectocele size.

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Dynamic pelvic floor MRI utilizes rapid sequences such as Siemens’ TRUE FISP (Fast Imaging with Steady-state free Precession), GE’s FIESTA (Fast Imaging Employing Steady-state Acquisition) or Philips’s Balanced-FFE (Fast Field Echo). The trade off for the rapidity of the exam acquisition is in image quality, but for the purposes of the study, this compromise is acceptable. The technique uses 100 ml of ultrasound gel inserted through the anal canal using bladder (catheter tip) syringes. Ultrasound gel is readily available and easy to place into the syringes; and the syringes have a nozzle shape and size ideal for anal insertion. After gel injection, the patient is asked to “push” the gel out and images are acquired at a frame rate of approximately 1 image per second. The images are viewed as a cine clip, and alongside a qualitative assessment, are analyzed using the pubococcygeal line (PCL) scoring system. By measuring the relative distances of the anterior, middle and posterior compartmental organs from the PCL, prolapses can be graded as mild, moderate or severe [Fig. 2].

The above video in a different patient is an example of a severe bladder prolapse (cystocele), severe anorectal junction descent and a moderate sized anterior rectocele.

Figure 2. The PCL line on a still image from the above video, with the red arrow indicating the cystocele, and the green arrow indicating the anorectal descent and anterior rectocele. The pubococcygeal line (PCL) is the yellow line.

References:

1. García del Salto L, de Miguel Criado J, et al. MR Imaging–based Assessment of the Female Pelvic Floor. RadioGraphics 2014; 34:1417–1439. http://pubs.rsna.org/doi/full/10.1148/rg.345140137

2. Chiara Colaiacomo M, Masselli G, et al. Dynamic MR Imaging of the Pelvic Floor: a Pictorial Review. RadioGraphics 2009, 10.1148/rg.e35. http://pubs.rsna.org/doi/abs/10.1148/rg.e35

3. Boyadzhyan L, Raman S, et al. Role of Static and Dynamic MR Imaging in Surgical Pelvic Floor Dysfunction. RadioGraphics 2008; 28:949–967. http://pubs.rsna.org/doi/pdf/10.1148/rg.284075139

4. Bitti G, Argiolas G, et al. Pelvic Floor Failure: MR Imaging Evaluation of Anatomic and Functional Abnormalities. RadioGraphics 2014; 34:429–448. http://pubs.rsna.org/doi/abs/10.1148/rg.342125050

Vikas Shah, MBBS FRCR is a Consultant Radiologist specializing in gastrointestinal and colorectal imaging at University Hospitals of Leicester NHS Trust. Dr. Shah did his Radiology training in London, England at Imperial College Hospitals NHS Trust, and subsequently did subspecialty training in oncologic imaging at Mount Vernon Hospital and in pelvic floor and colonic imaging at St. Mark's Hospital. Dr. Shah is passionate about teaching, and in particular the use of social media and mobile technology to enhance teaching and education. His expertise in pelvic floor imaging is underlined by his appointment to the Medical Advisory Committee of the Association of Pelvic Organ Prolapse Support (APOPS). The originator of #xrayofthewek, Dr. Shah blogs at www.thexraydoctor.co.uk

Follow Dr. Shah on Twitter @DrVikasShah

Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator.

Follow Dr. Rice on Twitter @KevinRiceMD

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