Dynamic Study of the Pelvic Floor. Hospital De Clínicas Experience

Dynamic stuDy of the pelvic floor. hospital De clínicas experience.

Dr. Pablo Pedetti*, Dr. Federico Cabo**, Dr. Federico Avondet**, Dr. Edgardo Castillo***

Award Best Original Work XII Congreso de Imagenología RESUMEN ABSTRACT

Objetivos: Mostrar la experiencia en el estudio dinámico Objectives: To analyze the experience in the dynamic del piso pélvico por resonancia magnética (RM) en el ser- study of the pelvic floor by magnetic resonance ima- vicio de imagenología del Hospital de Clínicas (HC), en el ging (MRI) in the imaging service of Hospital de Clíni- período comprendido entre julio de 2015 a julio de 2017. cas (HC), in the period from July 2015 to July 2017. Interesa evaluar el protocolo de adquisición utilizado, los It is interesting to evaluate the acquisition protocol hallazgos fundamentales y la implementación de un infor- fundamental findings and implementation of a struc- me radiológico estructurado basado en el sistema HMO. tured radiological report based on the HMO system.

Materiales y métodos: Se revisaron en forma retrospectiva Materials and methods: We retrospectively reviewed 16 estudios imagenológicos por RM de pacientes de sexo 16 MRI scans of female patients, performed at the HC femenino, realizados en el servicio de imagenología del Imaging service. The protocol used consisted of mor- HC. El protocolo utilizado constó de secuencias morfoló- phological sequences FSE T1 axial, T2 high resolution gicas FSE T1 axial, T2 de alta resolución en los tres planos in the three planes and dynamic sequences TRUE y secuencias dinámicas TRUE FISP en el plano sagital FISP in the sagittal plane in the midline, during rest, en la línea media, durante el reposo, contracción de la contraction of the pelvic muscles, Valsalva maneuvers musculatura pélvica, maniobras de Valsalva y defecación. and defecation.

Resultados: Todos los estudios de RM mostraron patología. Results: All MR studies showed pathology. In cases En los casos en los que se aportó un dato clínico, el estudio in which a clinical data was provided, the MRI study de RM la confirmó, y en algunos casos añadió un diagnós- confirmed it, and in some cases added an alternative tico alternativo (cistocele, prolapso uterino, enterocele). diagnosis (cystocele, uterine prolapse, enterocele). The Los diagnósticos realizados fueron los de cistocele e diagnoses were those of cystocele and hypermotility of hipermotilidad de uretra en el compartimento anterior, the urethra in the anterior compartment, hysterocele histerocele y prolapso vaginal en el compartimento me- and vaginal prolapse in the middle compartment and dio y sigmoidocele, Douglascele, rectocele y anitis, en el sigmoid, Douglascele, rectocele and anitis, in the compartimento posterior. posterior compartment.

Discusión: La afectación del piso pélvico representa una Discussion: The involvement of the pelvic floor patología de alta frecuencia, aumentando su prevalencia represents a high frequency pathology, increasing its con la edad. Su alto porcentaje de recidivas y de afectación prevalence with age. Its high percentage of relapses multicompartimental, dificultan la valoración clínica y la and of multicompartimental affectation makes clinical resolución quirúrgica. La RM ofrece un método diagnóstico assessment and surgical resolution difficult. MRI offers de fácil realización, con capacidad de valorar en forma a diagnostic method that is easy to perform, capable simultánea los tres compartimentos de la pelvis, especial- of simultaneously evaluating the three compartments mente importante cuando existe afectación multicompar- of the pelvis, especially important when there is mul- timental. El sistema HMO constituye una herramienta que ticompartimental involvement. The HMO system is permite interpretar, comunicar y categorizar los hallazgos a tool that allows interpreting, communicating and patológicos para la realización de un informe radiológico categorizing the pathological findings for a standardi- * Former assistant estandarizado. zed radiological report. of the Imaging Department, Palabras claves: Piso pélvico, línea pubococcígea, línea H, Key Words: Pelvic floor, pubococcygeal line, H line, M Hospital de Clínicas, ** Resident of the línea M, cistocele, histerocele, sigmoidocele, Douglascele, line, cystocele, hysterocele, sigmoidocele, Douglascele, Imaging Department, rectocele y anitis. rectocele and anitis. Hospital de Clínicas, *** Prof. Agdo. Clinical Department of Gynecology, Hospital de Clínicas.

ORIGINAL WORK / Dr. P. Pedetti, Dr. F. Cabo, Dr. F. Avondet, Dr. E. Castillo 67 INTRODUCTION studies. It presents high resolution of tissue contrast, which allows a better characterization of complex pelvic Functional disorders of the pelvic floor, such as prolapse anatomy, in addition to the possibility of performing static of pelvic organs and defecatory dysfunction, represent a and dynamic studies, without the need for intravenous common health problem, especially in female patients. It is contrast. (3) estimated that more than 15% of multiparous women are The supporting structures of female pelvic floor consist affected by some type of pelvic disorder and that between of a complex network of fascias, ligaments and muscles, 10% and 20% of patients consult for pelvic dysfunction. inserted into pelvic bones. These structures form three These conditions significantly affect quality of patient’s life continuous layers, which are located from cranial to caudal and give rise to a variety of symptom. Pelvic floor is divided and are composed of the endo-pelvic fascia, the pelvic into three compartments: anterior compartment (bladder diaphragm and the urogenital diaphragm (1). and urethra), middle compartment (vagina and uterus) Prolapse of pelvic organs and relaxation of pelvic floor are and posterior compartment (anus-rectal). The spectrum closely related, being necessary the exhaustive evaluation of pelvic floor dysfunction depends on the compartment of both components individually to fully assess weakness of involved and includes incontinence, constipation and the floor pelvic. Prolapse is defined as the abnormal des- prolapse, which occur in variable combinations. (1-2) cent of pelvic structures through the urogenital hiatus (1).

Clinical examination underestimates or results in a mispla- Pelvic floor relaxation dysfunctions, is defined as the ced diagnosis of prolapse site in 45-90% of the patients, weakness and inefficiency of pelvic floor support struc- and it is not reliable to evaluate anomalies of evacuation. tures, generating a descent and widening excessive of it, In addition, weakness of pelvic floor is usually complete, in the rest and / or maneuvers dynamic, regardless of the so different compartments should be evaluated simulta- presence of prolapse (1). neously. Magnetic Resonance (MR) is presented as a new Pelvic floor evaluation is done through the morphological diagnostic technique, complementary to conventional assessment, the HMO system and the anus rectal angle

Figure 1 Anatomical evaluation. Reference lines used for evaluation of pelvic floor weakness. High resolution T2-weighted images in the sagittal plane at the midline of a woman during rest. Rectum distended with warm ultrasound gel. The uterus is not well visualized given its situation for median. A) PCL: Pubococcygeal line (continuous line). B) MLP: Average pubic line (solid line). To evaluate the prolapse of the pelvic organs, perpendicular lines are drawn from the anatomical reference points in the anterior, middle and posterior compartments to the PCL and / or MLP line.

Figure 2 Figure 3 Reference lines. Middle line images in T2 sequences in the sagittal Reference angles. plane, during rest. Measurement of the anus-rectal angle in a patient without pelvic floor The PCL line (blue solid line), line H (orange dotted line) and line M (light pathology. Image of the midline enhanced in T2 in the sagittal plane. blue dotted line) were drawn. The puborectal muscle is immediately During rest, the anorectal angle should be between 108 and 127 °. topographed behind the anus-rectal junction and the elevator plane is During defecation the angle becomes more obtuse with a variation of up parallel to the PCL line. to plus 20 ° with respect to rest.

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(See figures 1, 2 and 3) (1) partment at the level of the Douglas pouch, place where Morphological assessment is performed with in T2 high mesenteric fat herniation may occur (peritoneocele), small resolution sequences, which allows a detailed anatomical bowel or sigmoid colon (sigmoidocele) (5-6). study. The anomalies found in each compartment should be ca- The HMO system is a standardized method created to tegorized according to their severity, which is determined characterize and document prolapse and relaxation of by the distance acquired by the evaluated organ until the pelvic floor, which is based on the layout of three fun- PCL and MPL during the dynamic maneuvers (See table damental lines. 1, 2 and 3). Although both methods can be used, the use The pubococcygeal line (PCL) extends from the inferior of the PCL line is more accepted. edge of the pubis to the last coccygeal joint and represents the level of the pelvic floor, forming the line of reference In addition, relaxation of the pelvic floor should be asses- from which the prolapses are measured, both at rest and sed, through the value acquired by both the H line (ope- in Valsalva.

The H line is drawn from the lower edge of the pubis to the posterior wall of the rectum at the level of the rectal anus, representing the anteroposterior diameter of the urogenital TABLE 1: Cysostele severity and uterine prolapse based on pLC (cm) hiatus, with a normal value less than 6 cm (See figures 4). The M line is perpendicular to the PCL at the posterior Severity Distance from pLC (cm) sector of H line and represents the decrease of elevator hiatus, with a normal value of less than 2 cm. Mild 1-3 cm below The anus rectal angle is the angle between the central axis Moderate 3-6 cm below of the anal canal and the posterior wall of the rectum, with a value normal between 108º and 127º and a variation Severe >6 cm below of up to 15º in Valsalva. Adapted from Garcıa del Salto L, de Miguel Criado J, Aguilera del Hoyo LF, et al. MR An additional line called the pubic media line is described imaging based assessment of the female pelvic floor. Radiographics 2014;34:1417–39 (MPL) that is traced caudally following the major axis of the pubis symphysis. This line corresponds to the level of vaginal hymen, which is used historically as benchmark for clinical assessment. (12-13) TABLE 2: Cysostele severity, uterine prolapse and anus rectal The classification of pelvic floor anomalies in compart- descent based on pCL line ments is artificial (3), since the dysfunction of the floor Stage Distance from pLC (cm) pelvic, as we have indicated, is usually generalized. In the anterior compartment highlights the cystocele, which it is 0 >6 cm above diagnosed when the bladder descends more than 1 cm 1 >1 cm a 3 cm above below the pubococcygeal line and line H and M are greater than 5 and 2 cm respectively. The back wall of the bladder 2 <1_ cm above or below descends posteriorly and inferiorly deforming the anterior 3 >1 cm below wall of the vagina and can bulge in the vaginal introitus. In situations of hypermotility of the bladder neck and the 4 Comlplete eversion proximal urethra, bladder prolapse can cause a “kinking” Adapted from Garcıa del Salto L, de Miguel Criado J, Aguilera del Hoyo LF, et al. MR at the level of the urethro-vesical union with rectification imaging based assessment of the female pelvic floor. Radiographics 2014;34:1417–39 of the urethra. Secondarily it produces urinary retention that sometimes masks an incontinence of effort (4). At the level of the middle compartment, it highlights the TABLE 3: presence of prolapse vaginal and / or cervical, descent of Anterior rectocele severity the vaginal vault (hysterectomized patients) or cervix below of the pubococcygeal line. The sensitivity in the defecatory Severity parietal depth protrusion (cm) phase increases in its assessment since a rectum full of stool can limit the descent. Small <2 cm Medium 2-4 cm At the level of the posterior compartment, rectocele is defined as the abnormal protrusion of the anterior rectal Large >4 cm wall on the posterior wall of the vagina that is associated Adapted from Garcıa del Salto L, de Miguel Criado J, Aguilera del Hoyo LF, et al. MR hypermobility of the endo-pelvic fascia. They can also be imaging based assessment of the female pelvic floor. Radiographics 2014;34:1417–39 lateral or posterior due to weakness of the pubo-rectal muscle. Weakness of the pelvic floor can create a fourth com-

ORIGINAL WORK / Dr. P. Pedetti, Dr. F. Cabo, Dr. F. Avondet, Dr. E. Castillo 69 ning of the urogenital hiatus) and the M line (pelvic floor descent) during dynamic maneuvers (see Table 4) (7). All TABLE 4: this information must be detailed in the radiological report, Graduation of the relaxation of the pelvic floor through lines h & M to provide the treating surgeon with all the necessary tools Urogenital hiatus pelvic floor descent for the correct repair of the pelvic floor. The absence of Graduation (h line) (M line) multidisciplinary teams, as well as the heterogeneity in the way of studying and addressing these patients, generates 0 <6 cm <2 cm substantial differences in their diagnostic and therapeutic 1 6-8 cm 2-4 cm approach. MRI emerges as a new modality, which must be integrated among the different specialties that parti- 2 8-10 cm 4-6 cm cipate in this process. The absence of a structured report results in disparate radiological reports, with information 3 >10 cm >6 cm not always complete, which generate a negative impact Adapted from Boyadzhyan L, Raman SS, Raz S. Role of static and dynamic MR on the surgical resolution of pelvic floor dysfunctions (8). imaging in surgical pelvic floor dysfunction. RadioGraphics 2008; 28:949–967

rectum and bones. The morphological assessment of the OBjECTIvE pelvic floor is achieved in great detail through high resolution T2 sequences, acquired in the three planes. To describe the experience of the dynamic study of the pelvic floor in the imaging service of the Hospital de Dynamic study includes the acquisition of images at rest Clínicas (HC), in the period from July 2015 to July 2017, (9), during the contraction of the musculature pelvic, Val- with special attention to the acquisition protocols and salva maneuvers and defecation. Steady-state sequences the fundamental findings. Emphasis will be placed on of free precession in the mid-sagittal plane (TRUE FISP for the implementation of a radiological report based on the SIMENS, PARTY for GE). This sequence, provides high-re- HMO system. solution anatomical images, with very high -to-noise ratio. They are not sensitive to movements since they are ultra fast acquisition, although their signal MATERIALS AND METhODS arises from a T1 / T2 ratio, T2 contrast predominates and can be used in movie mode. Information about internal MRI studies of 16 patients were retrospectively reviewed 3a and external anal sphincter competition, of the strength with symptoms and / or findings physical symptoms sug- of the pelvic muscles and the function of the pubo-rectal gestive of urinary incontinence or prolapse of the pelvic muscle, in addition to being the sequence that applies organs, in the imaging service of the HC in the period July the HMO system. 2015 to July 2017. Findings interpretation begins by plotting Pubococcygeal The ages were between 36 and 81 years, with an average line (LPC) (1-2) from the lower edge of the pubis symphysis of 61 years. Of the total, 6 patients were in pre-menopau- until the last coccygeal joint. sal stage, 3 menopause and 7 in post-menopausal stage. This line represents the floor level of the pelvis and is the A3c radiologist with three years of experience analyzed the reference point for measuring the prolapse organs. The imaging studies performed in the imaging service of the distance from the LPC to the neck of the bladder, cervix, HC. The images were correlated with the clinical data and the ano-rectal junction, respectively, it must be mea- provided. Symptoms that motivated the dynamic pelvic sured in images obtained when the patient is at rest and MRI included heaviness or pelvic pain, urinary inconti- during maximum Valsalva. nence, incontinence for gases, difficulty in the initiation of urination and / or pain with sexual relationships. It is also important to assess the anus-rectal angle (angle A Siemens Avanto 1.5 Teslas was used. between the posterior border of the distal part of the rectum, and the central axis of the anal canal. After signing the informed consent patient were instructed During exertion and defecation, the anus-rectal angle be- in carrying out static and dynamic maneuver after in- comes more obtuse, the anal canal opens and the straight tra-rectal administration of 200 cc of warm ultrasound gel. is shortened for evacuation. Finally, the anal channel is The protocol used (Table 5) consists of morphological closed and the anus-rectal angle return to their positions sequences FSE T1 axial, T2 high resolution in the three before the evacuation (2). planes, and TRUE FISP dynamic sequences in the midline sagittal plane, during rest, contraction of the Pelvic mus- Centers specializing in pelvic floor study these patients with culature, Valsalva maneuvers and defecation. a multidisciplinary approach, with active participation of urologists, gynecologists, general surgeons and imaging. The T1 panoramic sequence in in the axial plane, allows These centers use structured radiological reports, which an overall anatomical assessment of the pelvic organs, facilitate the interpretation of the findings, reducing the including the entire bladder, both ureters, uterus, vagina, possibility of omitting important information (10-11).

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In conjunction with the chair of gynecology of the HC, of the pelvic organs in relation to the PCL line, both at a structured report was adapted, easy to perform, with rest and during defecation; the value of the H and M line essential information that must be included in a dynamic during rest and defecation; the presence and severity study by pelvic floor MRI (See structured report). of the prolapse, as well as functional abnormalities and All reports should include measurements of the position morphological defects.

STRUCTURED REp ORT

A) Measure Rest Defecation

h line (cm)

M line (cm)

Elevator plane angulation

B) prolapsed organ Severity Content

Anterior compartment

Cystocele Mild / moderate / severe ......

Medium compartment

Uterine prolapse Mild / moderate / severe ......

prolapse of the vaginal apex Mild / moderate / severe ......

Cul-de-sac

Enterocele Mild / moderate / severe Low Intestine

peritoneocele Mild / moderate / severe Mesenteric fat

Sigmoidocele Mild / moderate / severe Colon sigmoidocele

posterior compartment

Rectocele Mild / moderate / severe ......

C) Other functional anomalies

paradoxical contraction of the puborectal yes / no

Anismus yes / no

D) pelvic floor relaxation Mild / moderate / severe

E) Defect Side

Adapted from Garcıa del Salto L, de Miguel Criado J, Aguilera del Hoyo LF, et al. MR imaging based assessment of the female pelvic floor. Radiographics 2014;34:1417–39

TABLE 5: protocol used in hC for the evaluation of the pelvic floor dysfunction

Sequence plane fOv phase of the study

fSE T1 Axial panoramic Rest

fSE T2 Axial, coronal, sagittal 25 x 25 Rest

TRUE fISp Sagittal (middle line) 40 x 40 Rest

TRUE fISp Sagittal (middle line) 40 x 40 valsalva

TRUE fISp Sagittal (middle line) 40 x 40 Defecation

Adapted from Garcıa del Salto L, de Miguel Criado J, Aguilera del Hoyo LF, et al. MR imaging based assessment of the female pelvic floor. Radiographics 2014;34:1417–39

ORIGINAL WORK / Dr. P. Pedetti, Dr. F. Cabo, Dr. F. Avondet, Dr. E. Castillo 71 RESULTS All the MRI studies showed pathology. In the cases in which A total of 16 requests were received in our department to a clinical data was provided, the MRI study confirmed it, perform MRI in women with clinical suspicion of pelvic and in some cases the MRI added an alternative diagnosis floor dysfunction. The 16 patients were diagnosed with (cystocele, uterine prolapse, enterocele). prolapse of at least one compartment. The diagnoses made were those of cystocele and hyper- Dynamic MR images of quality were obtained in all motility of the urethra in the anterior compartment (see patients. Figures 6 and 7), hysterocele and vaginal prolapse in the The first set of images were sagittal slices volumetric from medium compartment (See figures 5, 6, 11 and 13) and left to right, used to locate the mid-sagittal plane at the sigmoidocele, Douglascele, rectocele and anism, in the symphysis pubis and to examine the pelvic anatomy. The posterior compartment.(See figures 7, 8, 9, 10 and 14). second set of images was obtained as four cycles of rela- Although all women were instructed to perform muscle xation and effort. The total acquisition time of the image contractions of the pelvic floor, one woman who used was 2.5 minutes, and the time of the room was mainly abdominal and gluteal muscles during the voluntary 10 minutes per study. contraction unable to complete the study. In the sagittal images the iliococcygeus muscle is obser- The degree of prolapse in most cases was mild, but proved in the form of a dome at rest. During the voluntary lapse was detected in all three compartments (see Figures contractions of the pelvic floor, the muscle becomes more 11, 12 and 13). convex in an upward direction. During contraction, the Although the number of patients studied is low, this study pelvic floor moved ventrally and cranially simultaneously proved that the diagnoses found were according to those with the base of the bladder. mentioned in the literature.

Figure 4 Line H and line M. High resolution T2-weighted images in the sagittal plane. Change in the value adopted by line M and line H is observed when comparing rest versus defecation. According to its measurements in centimeters, it can be graduated in four different stages.

Figure 5 Uterocele. High resolution T2-weighted images in the A) sagittal and B) coronal plane at the midline of a woman during rest. Rectum distended with warm ultrasound gel (star in A). Prolapse of the vaginal vault (triangle in A) and severe uterocele is observed. See mesenteric fat herniation (blue arrow in A) and weak supporting structures (orange arrows in B). Uterine myoma (green arrow in B).

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Figure 6 Cystocele. Small anterior rectocele and prolapse of the vaginal vault. TRUE FISP images of high resolution in the sagittal plane at the level of the midline of a woman during A) rest and during B) defecation. Prolapse of the vaginal vault (triangle in b) and anterior rectocele (star in B). The dotted lines in green measure the severity of prolapses.

Figure 7 Anterior rectocele and cystocele. TRUE FISP images of high resolution in the sagittal plane at the level of the midline of a woman during A) rest and during B) defecation. B shows caudal angulation of the elevator plane (orange arrow), anterior rectocele (Triangle) and cystocele with urethral hypermotility (dotted blue in B).

Figure 8 Anterior rectocele. TRUE FISP images of high resolution in the sagittal plane at the level of the midline of a woman during A) rest and during B) defecation. In B) anterior rectocele (triangle) and descent of the anorectal angle (orange arrow) are observed.

ORIGINAL WORK / Dr. P. Pedetti, Dr. F. Cabo, Dr. F. Avondet, Dr. E. Castillo 73 Figure 9 Rectocele eversion. A) High resolution T2-weighted images in the sagittal plane at the midline of a woman during rest. B) TRUE FISP sagittal during Valsalva maneuver. C, D) TRUE FISP sagittal during defecation. The effort during defecation decreases the anus rectal angle and therefore elongates the M line and increases the H line, which represents the opening of the urogenital hiatus (B). Evidence cystocele (green stippling in C), vaginal prolapse (star) and eversion of the rectum (orange arrow).

Figure 10 Rectocele eversion. A) High resolution T2-weighted images in the sagittal plane at the midline of a woman during rest. B) TRUE FISP sagittal during Valsalva maneuver. C-D) TRUE FISP sagittal during defecation. Evidence cystocele, vaginal prolapse and eversion of the rectum. Blue dotted lines quantify the severity of prolapse.

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Figure 11 Multicompartmental prolapse. A) High resolution T2-weighted images in the sagittal plane. In blue the axis of the urethra is shown, which is rotated in the horizontal plane, generating urethral hypermotility. B) TRUE FISP sagittal during Valsalva maneuver. Cystocele is identified, prolapse of the vaginal vault and anterior rectocele.

Figure 12 Multicompartmental prolapse. TRUE FISP high resolution in the sagittal plane during Valsalva. There is prolapse of the three compartments. The axis of the urethra is shown in blue, which is rotated in the horizontal plane, generating ureteral hypermotility.

Figure 13 Multicompartmental prolapse. A) High resolution T2- weighted images in the sagittal plane. B) TRUE FISP sagittal during defecation. Cystocele, prolapse of the vaginal vault, uterine prolapse and anterior rectocele are identified both at rest and during dynamic maneuvers. See mesenteric fat herniation (blue in B).

ORIGINAL WORK / Dr. P. Pedetti, Dr. F. Cabo, Dr. F. Avondet, Dr. E. Castillo 75 Figure 14 Anterior cystocele and rectocele. A) High resolution T2-weighted images in the sagittal plane. B) TRUE FISP sagittal during defecation. Anterior cystocele and rectocele are identified both at rest and during dynamic maneuvers. Cistocele (dotted) and anterior rectocele (arrow).

DISCUSSION affected, since it allows simultaneous visualization of the Pelvic floor dysfunction is one of the main causes of mor- anterior compartment (bladder and urethra), of the middle bidity in women over 50 years of age (2). compartment (uterus and vagina) and the compartment Although clinical picture and physical examination in posterior (rectum and anus). general are sufficient for a correct assessment of many of Within sequences used all have great importance since these pathologies, there are some limitations that prevent they provide functional and structural data, the dynamics a correct diagnosis and require imaging methods. sequences in TRUFISP allow the analysis of pelvic floor Some of these limitations may be the differences in acces- and thus allow visualize the existence or not of prolapse. sibility of the compartments during physical examination. As for the static sequences like high resolution T2 image, it provides morphological information to diagnose pathology Difficulty in diagnosis increases when there are multiple related to the pelvic floor (1). prolapses. In these situations is when imaging methods are useful to confirm the clinical suspicion, specify which However, MRI presents limitations such as its realization organ is prolapsed and detect unsuspected anomalies. in dorsal decubitus, different from the habitual position One of the most widespread methods is videodefeco- in which the prolapses are manifested, although there graphy, although it has been used successfully in many are some publications that demonstrate that there are no prolapses, it has certain limitations such as difficulty in vi- clinically relevant differences in the information provided sualizing bone landmarks, it is only possible to visualize the in both studies. opacified sectors of the organs and not the walls thereof. Another limitation is to obtain the dynamics sequences It also does not provide information on the anatomical only in the mid-sagittal plane, justified by the fact that structures of the pelvic floor support system. alterations that can be underdiagnosed as the lateral rectocele are relativity uncommon. The absence of ionizing radiation, its multiplanar capa- Regarding the use of a structure report in comparison with city, its high contrast resolution and capacity to perform a free copy of the report, has as an advantage to optimize dynamic studies, position MRI as a complementary study the knowledge and capacity of identify pathologies, also of high diagnostic value (3). allows clarity and assertiveness, but above all it reduces MRI allows a correct assessment of pelvic floor dysfunction, the omission of information relevant for clinical decision especially when there is more than one compartment making.

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CONCLUSION

Pelvic floor involvement represents a pathology of high frequency, increasing its prevalence with age. Its high percentage of recurrences and the multicompartmental affectation, make difficult clinical evaluation and surgical resolution. MRI offers a reliable, easily reproducible, high repro- ducibility diagnostic method that provides objective information to clinicians in a single study. Simultaneous visualization of the three compartments of the pelvis, especially important when there is multicompartmental involvement. It allows the precise morphological study of fascias, ligaments and muscles, providing dynamic sequences for the functional assessment of these disorders. The HMO system is a tool that allows interpreting, communicating and categorizing pathological findings for the performance of a standardized radiological report. The realization of these studies allowed us to obtain experience in the pathology of the female pelvic floor, contributing to a better understanding of the pathology. At the same time the protocols to be used in the pelvis were standardized, implementing the standardized radiological report based on the HMO system.

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ORIGINAL WORK / Dr. P. Pedetti, Dr. F. Cabo, Dr. F. Avondet, Dr. E. Castillo 77