Midpubic Line to Stage Pelvic Organ Prolapse by MRI Defecography As Compared to POP-Q

Abstract

described as a landmark for MRI staging of pelvic organ prolapse. Fresh cadaver data has established the midpubic line as a reliable indicator of the clinical hymen, which is the landmark used for clinical scoring [4].Previous studies have shown MRI to demonstrate a more advanced degree of prolapse; however, none have attempted to establish POP-Q equivalent MRI scoring. The merging of clinical and radiological reference points would allow detailed compartmental comparison between clinical and MRI evaluation. AbstractObjective: To compare the degree of pelvic organ prolapse (POP) as measured by the pelvic organ prolapse quantification (POP-Q) system to the degree of prolapse as measured by magnetic resonance imaging (MRI) defecography and to merge clinical and radiologic terminology in reference to POP.Methods: A retrospective analysis of 29 patients who presented with POP and defecatory complaints and underwent MRI defecography (2008)(2009)(2010)(2011). POP-Q scores were recorded by two attending urogynecologists. A radiologist, blinded to the clinical POP-Q scores, measured the maximum prolapse of the anterior vagina, posterior vagina, and vaginal apex/cervix on each subject's MRI.Results: Prolapse as measured by MRI defecography was significantly more advanced as compared to the clinical POP-Q measurements in all three compartments studied. The differences were both statistically significant and potentially, clinically relevant. A mean difference of 2.0 centimeters ± 1.5 SD, 2.3 centimeters ± 2.7 SD, and 5.0 centimeters ± 2.0 SD was observed in the anterior, apical, and posterior vaginal compartments, respectively. Conclusion:The increased degree of prolapse as demonstrated by MRI defecography may change clinical decision making and surgical planning. Therefore, MRI defecography may be a valuable adjunct in the clinical assessment of POP. 2/5 Materials and MethodsThis retrospective study was conducted at North Shore University Hospital. Institutional review board approval was obtained. Thirty-six women presenting for assessment of POP, who required MRI defecography as part of their clinical assessment, constituted the study population. The senior authors examined all patients in the study using the standard guidelines for the POP-Q examination. The clinical exams and MRIs were performed prior to any intent of studying the relationship between MRI and the POP-Q examination. MRI TechniquePatients underwent MRI with a 1.5-T scanner (Signa Excite HDx; GE Healthcare, Milwaukee, WI) with an 8-channel phased array coil in the supine position. Patients administered a fleet enema in the morning and emptied their bladders prior to imaging. 60ml of sterile lubricating jelly (Triad Disposables, Inc, Mukwonago, WI) was instilled into the vagina. 200ml of lubricating ultrasound transmission gel (Aquasonic, Parker Laboratories, Inc, Fairfield, NJ) was instilled into the rectum.Following an initial three plane localizer sequence, sagittal images were obtained employing a steady-state acquisition (FIESTA=fast imaging employin...

Magnetic resonance imaging to evaluate anterior pelvic prolapse: H line is the key

“…In the study by Woodfield et al, 6 they obtained a weak agreement using the MPL and the PCL compared to the POP‐Q classification for the anterior compartment, concluding that none of them could be considered a direct correlation with clinical staging. Nossier's study compared MRI using the MPL with clinical staging, obtaining a difference of 2 ± 1.5 cm SD in the anterior compartment, with a statistically significant difference 7 . Fauconnier's study questioned whether MPL represents the hymen line in humans (as opposed to cadaveric studies).…”

“…It is a line that passes through two points: the lower border of the pubic symphysis and the last intercoccygeal joint (Figure 2). 6,7,11 This line corresponds to the pelvic floor as it passes through the pubococcygeus and puborectalis muscles 6 . We use the classification in Table 2 to divide the prolapses into stages 12 .…”

“…Nossier's study compared MRI using the MPL with clinical staging, obtaining a difference of 2 ± 1.5 cm SD in the anterior compartment, with a statistically significant difference. 7 Fauconnier's study questioned whether MPL represents the hymen line in humans (as opposed to cadaveric studies). Their study showed that the MPL is actually above the hymen and there is a line that gets closer (perineal line, drawn as a tangent from the inner surface of the pubic symphysis to the external anal sphincter).…”

“…Several studies have compared clinical POP-Q findings with MRI findings using these two reference lines. [6][7][8][9][10][11] Most of them agree that there is a low correlation. Therefore, there is no standardized and accepted method of objectification of POP in MRI that accurately correlates with the results of the physical examination.…”

“…Several studies have compared clinical POP‐Q findings with MRI findings using these two reference lines 6‐11 . Most of them agree that there is a low correlation.…”