| Pelvic organ prolapse(POP)is a common pelvic floor dysfunction.The theory of three compartment divides the pelvic floor into three compartments:anterior,middle and posterior.The defect of the anterior compartment mainly refers to the prolapse of the anterior vaginal wall,the defect of the middle compartment mainly refers to the prolapse of the uterus or the vaginal vault,the defect of the posterior compartment mainly refers to the prolapse of the posterior vaginal wall.Pelvic organ prolapse quantitation(POP-Q)is the international general evaluation system and application of the pelvic organ prolapse most widely.Compared with other staging systems,POP-Q is objective,detailed,reliable and repeatable,but there are also some deficiencies in the assessment of anterior,middle and posterior compartment.For example,it is difficult to evaluate whether there is intestinal hernia or peritoneal hernia,to evaluate the defects of levator ANI,paravaginal and central defects,to reflect the hypermobility of the urethra.Unable to accurately measure the length of the cervix and the vaginal axis,unable to accurately assess the vaginal apical descent,unable to distinguish the specific organs of posterior vaginal wall prolapse and the degree of perineal decline.In addition to POP-Q staging,the function of female pelvic floor muscles in POP can be judged clinically by vaginal palpation,but it is too subjective.The method of sponge forceps was used to judge paravaginal defects by combining with the disappearance of vaginal mucosal plica,while too rough.The swab test was used to measure urethral activity,but it was invasive and was not accurate due to the depth of swab insertion.B-ultrasound and MRI are the most widely used methods to evaluate pelvic organ prolapse.Transperineal three-dimensional/four-dimensional ultrasound is relatively inexpensive and readily available,can be evaluated at rest and Valsalva,and is widely used in bladder prolapse and stress urinary incontinence.However,pelvic floor ultrasound requires high operator experience,limited window,and limited resolution of soft tissue.MRI has excellent soft tissue resolution,no ionizing radiation,no invasive,and shows the entire pelvic at the same time.Static MRI can evaluate anatomical structures in detail,dynamic MRI can assess the movement of pelvic organs and show the pelvic floor in the state of maximum prolapse.The effectiveness and feasibility of the application of dynamic and static MRI in POP has been proved,but there is seldom systematic study on the three compartments of POP.Digital 3d reconstruction technology can realize the conversion from MRI 2d image to 3d image,and at the same time,the pelvis can be individually corrected for tilting and movement,so as to accurately evaluate the movements of urethra,vaginal apex and anal rectum.The 2d and 3d MRI study of POP women can make up for the shortage of clinical evaluation and b-ultrasound,visually observe the specific prolapse organ behind the vaginal wall,observe the defect of levator ANI and the paravaginal and central defects,measure the length of the anterior and posterior vaginal wall and genital hiatus under the action of Valsalva,and accurately measure the segmental mobility of the urethra.Through the apical(cervix and posterior fornix)mobility accurately reflects the decline of apical support force,accurately measures the cervical length and the vaginal axis.lt can be distinguished from genuine posterior vaginal wall prolapse,true rectocele and intestinal hernia.The size of rectocele and perineal mobility were also measuredTherefore,this study intends to use dynamic and static MRI 2d images combined with 3d reconstruction technology to evaluate the three compartments of POP women.There are three parts:the first part is the application of dynamic and static MRI and 3d reconstruction in the evaluation of the anterior compartment of POP women;The second part is the application of dynamic and static MRI and 3d reconstruction in the evaluation of the middle compartment of POP women.The third part is the application of dynamic and static MRI and 3d reconstruction in the evaluation of the posterior compartment of POP women.Part 1The application of dynamic and static MRI and 3d reconstruction in the evaluation of the anterior compartment of POP womenChapter 1:Characteristics of anterior compartment in women with anterior vaginal wall prolapse[Purpose]Dynamic and static MRI was used to analyze the anatomic parameters of the anterior compartment in women with mainly anterior vaginal wall prolapse and the difference between them and non-pop.[Methods]Retrospective analysis was performed on anterior vaginal wall prolapse patients who underwent dynamic and static MRI in the outpatient department of nanfang hospital of southern medical university from October 2014 to December 2019,and whose anterior vaginal wall bulking reached or exceeded the hymen(the main manifestation)and no hysterectomy were included(42 cases).Non-pop patients with matched general data were included in the same period(42 cases).During the static scan,the viscera are put back in their original position,and the maximum downward force was required by the dynamic scan(Valsalva).The contents of anterior vaginal wall prolapse were analyzed,to observe the defects of the levator ANI,type and size of bladder swelling,the length of the anterior vaginal wall,and the length of the genital hiatus in the two groups.Then Mimics 21.0 software was used to conduct 3d reconstruction and align,and 3d individualized correction of pelvic tilt and movement caused by Valsalva movement was performed to measure the mobility of the vaginal apex(cervix and posterior fornix)of the two groups.The different indexes between the two groups were included in the multi-factor analysis to search for the independent factors affecting the size of the anterior vaginal wall prolapse[Results]1.There were no statistical differences in age,BMI,parity,delivery mode,menopausal status and uterine position between the anterior vaginal wall prolapse group and the non-pop group(P>0.05).2.Static:Anterior vaginal wall prolapse group than the non-pop group had more bilateral levator defect(85.7%vs.64.3%,P<0.05),and longer genital hiatus(24.46±6.18mm vs.15.51±3.65mm,P<0.05),but the two groups of type and size of bladder swelling,anterior vaginal wall length had no statistic difference(P>0.05).3.Dynamic:Anterior vaginal wall prolapse group had more spherical sign of bladder(35.7%vs.0%,P<0.05)than the non-pop group,and the anterior vaginal wall was longer(78.30±22.82mm vs.49.34±8.16mm,P<0.05),and the genital hiatus was longer(57.29±15.01mm vs.19.54±6.30mm,P<0.05).In the anterior vaginal wall prolapse group,3 patients(7.1%)urethra only moved backwards and downwards,while 39 patients(92.9%)had bladder prolapse combined with urethra moved backwards and downwards.Dynamic,some patients with anterior vaginal wall prolapse showed spherical sign of bladder,failed to establish a reference line at the base of the bladder,and thus did not measure the size of bladder swelling.5.Dynamic and static align:The mobility of the vaginal apex in the anterior vaginal wall prolapse group was significantly greater than that in the non-pop group(cervix:42.11±20.91mm vs.12.17±8.17mm,P<0.05,posterior vaginal vault:34.16±20.07mm vs.12.00±7.90mm;P<0.05).6.Multi-factor analysis showed that Ba had independent linear correlation with the defect of the levator ANI,the length of the dynamic anterior vaginal wall and the cervical mobility(P<0.05),Cervical mobility had the greatest effect,followed by dynamic anterior vaginal wall length,and levator ANI muscle defect was the least.[Conclusion]1.It may be of little help to observe the morphology and size of bladder swelling by static MRI to determine whether there are paravaginal and central defects.The dynamic bladder spherical sign may be a sign of severe damage to the fascia around the vagina.2.In patients with anterior vaginal wall prolapse,the vaginal compliance is great,the contractile function of the pubic visceral muscle is weakened,and the support of the vaginal apex is weakened.3.The restoration of the vaginal apex and the shortening of the anterior vaginal wall are very important for patients with the anterior vaginal wall prolapse.Chapter 2:Comparison and analysis of influencing factors of the anterior vaginal wall prolapse with or without stress urinary incontinence[Purpose]Based on dynamic and static MRI,the characteristics of urethra of anterior vaginal wall prolapse with or without stress urinary incontinence were compared to explore the non-invasive MRI evaluation index.[Methods]Retrospective analysis was performed on anterior vaginal wall prolapse patients who underwent dynamic and static MRI in the outpatient department of nanfang hospital of southern medical university from October 2014 to December 2019,as long as the anterior vaginal wall bulged or exceed the hymen and without hysterectomy were included(80 cases),namely 36 cases of anterior vaginal wall prolapse with stress urinary incontinence,44 cases of anterior vaginal wall prolapse without stress urinary incontinence.During the static scan,the viscera are put back in their original position,and the maximum downward force was required by the dynamic scan(Valsalva).The two groups were compared for POP-Q scores,urethra length,urethral funnel,funnel size,urethra folding angle,posterior vesicourethral angle and anterior bladder prolapse.Then,Mimics 21.0 3d reconstruction and align were used to individually correct the pelvic tilt and movement caused by the Valsalva movement.The rotation angle of the proximal urethra and distal urethra,and the movement of the urethra(bladder neck,urethra midpoint,urethra outer orifice)were measured and compared between the two groups.Logistic regression was used to analyze the independent influencing factors of anterior vaginal wall prolapse with or without stress urinary incontinence.[Results]1.There was no significant difference between the two groups in age,BMI,parity,delivery mode and menopausal status(P>0.05).2.The Aa point of anterior vaginal wall prolapse with SUI was slightly larger than that of women without SUI(1.63±1.06 cm vs.0.81 ± 1.51 cm,P<0.05),the incidence of anterior bladder prolapse was more(33.3%vs.11.4%,P<0.05),and the mobility of bladder neck,urethra midpoint,and urethra external orifice were all larger(36.38±11.46 mm vs.28.81±11.72 mm,P<0.05;22.94±6.50mm vs.19.23±6.65mm,P<0.05;22.42±8.16mm vs.18.03±8.51mm,P<0.05).3.There was no significant difference between the two groups in urethra length,urethral funnel,funnel size,urethra folding Angle,posterior vesicourethral angle,proximal and distal urethra rotation Angle(P>0.05).4.Binary logistic regression showed that bladder neck mobility was an independent influencing factor of anterior vaginal wall prolapse with or without stress urinary incontinence(OR:1.060,95CI:1.015-1.107,P<0.05).[Conclusion]The urethral length,bladder neck funnel,funnel size,urethral folding angle,posterior vesicourethral angle,and urethral rotation angle are not helpful to distinguish the stress urinary incontinence from the anterior vaginal wall prolapse.But the Aa point,anterior bladder prolapse and urethral mobility are helpful and bladder neck mobility was the best indicator.Bladder neck mobility increased by 1mm,and the risk of SUI of anterior vaginal wall prolapse increased by 1.060 times.Part 2The application of dynamic and static MRI and 3d reconstruction in the evaluation of the middle compartment of POP women.Chapter 1:Characteristics of middle compartment in women with uterine prolapse[Purpose]Dynamic and static MRI was used to analyze the anatomical characteristics of middle compartment in women with mainly uterine prolapse and the difference between them and non-POP.[Methods]Retrospective analysis was performed on uterine prolapse patients who visited the outpatient department of nanfang hospital of southern medical university from October 2014 to December 2019 and underwent dynamic and static MRI examination.Only 34 patients(mainly uterine prolapse)whose cervix reached or exceeded the hymen were included,and non-pop patients(34 cases)with matching general data were included during the same period.Static scanning was performed to put back the viscera,and dynamic scanning was performed to order the patient to exert maximum downward pressure(Valsalva).Levator ANI muscle defects,cervical position,vaginal axis and vaginal horizontal angle,cervical length,genital hiatus length.Then through Mimics 21.0 software individualized correction pelvic tilt caused by Valsalva action to measure the mobility of the vaginal apex(cervical and vaginal fornix).[Results]1.There were no statistical differences in age,BMI,parity,delivery mode and menopausal status between the main uterine prolapse group and the non-pop group(P>0.05).2.Static:Bilateral defects of levator ANI were more in the uterine prolapse group than in the non-pop group(82.4%vs.58.8%,P<0.05),external cervical orifice was less at the level of the ischial spine(2.9%vs.82.4%,P<0.05),cervix was longer(39.71±10.70mm vs.25.97±5.19mm,P<0.05),and genital hiatus was longer(23.87±6.69mm vs.14.60±2.98mm,P<0.05).There was no significant difference between the two groups in the vaginal axis and vaginal horizontal angle(P>0.05).3.Dynamics:Compared with the non-pop group,the uterine prolapse group had fewer external cervical orifice at the level of the ischial spine(0%vs.61.8%,P<0.05),longer cervix(47.27±10.70mm vs.25.77±5.04mm,P<0.05),and longer genital hiatus(57.40±14.14mm vs.17.88±4.92mm,P<0.05).In addition,due to uterine prolapse sometimes combined with vaginal vault out of hymen,failed to measure the vaginal axis and vaginal horizontal angle.4.Dynamic and static align:The mobility of the vaginal apex of the uterine prolapse group was significantly greater than that of the non-pop group(cervix:70.72±32.16mm vs.9.39±6.55mm,P<0.05;Posterior fornix mobility:65.74±38.13mm vs.9.04±6.10mm,P<0.05).[Conclusion]1.In women with uterine prolapse,the cervix is prolonged,the contractile function of the pubovesical muscle is weakened,and the apical support of the vagina is weakened.2.In addition to regaining apical support,patients with uterine prolapse also need to pay attention to the problem of excessive cervical length.Chapter 2:Comparison of POP-Q C-D and MRI measurements of cervical length in patients with uterine prolapse and analysis of influencing factors[Purpose]The cervical length estimated by clinical POP-Q C-D was compared with that measured by dynamic MRI,and the factors influencing the differences between the two assessment methods were analyzed.[Methods]Retrospective analysis was performed on uterine prolapse patients who underwent dynamic and static MRI examination in nanfang hospital of southern medical university from October 2014 to December 2019.Uterine prolapse patients whose cervix reached or exceeded the hymen were included in the analysis(67 cases).Clinical estimate of the cervical length was POP-Q point C minus point D.The cervical length measured by dynamic MRI was two-dimensional sagittal plane to measure the curve length from the internal cervix to the external cervix.The cervical length measured by the two methods was compared and the factors influencing the difference in cervical length were evaluated by multiple linear regression analysis.[Results]1.The cervical length assessed by clinical POP-Q C-D was significantly greater than that measured by dynamic MRI(48.36±28.05mm vs.40.39±12.18mm,P<0.05).2.Multivariate analysis showed that the difference between the two assessment methods was independently correlated with Ba and Bp(P<0.05),in which the Ba point was positively correlated with the difference between the two assessment methods(r=7.15),and the Bp point was negatively correlated with the difference between the two assessment methods(r=-11.99).Parity,menopause and BMI were not associated with the difference between the two assessment methods.[Conclusion]The more obvious the prolapse of the anterior vaginal wall,the greater the difference between the cervical length measured by POP-Q C-D and dynamic MRI.The greater the prolapse of the posterior vaginal wall,the smaller the difference in cervical length measured by POP-Q C-D and dynamic MRI.Part 3Application of dynamic and static MRI and 3d reconstruction in the evaluation of the posterior compartment of POP womenChapter 1:Characteristics of posterior compartment in women with posterior vaginal wall prolapse[Purpose]Based on dynamic and static MRI,the anatomical characteristics related to posterior compartment in women with posterior vaginal wall prolapse and their differences with non-pop were analyzed.[Methods]Retrospective analysis was performed on patients with posterior vaginal wall prolapse who underwent dynamic and static MRI in nanfang hospital of southern medical university from October 2014 to December 2019.Only 27 patients with posterior vaginal wall reached or exceeded the hymen margin(Bp≥0)and had no history of hysterectomy were included.Non-pop patients with matched general data were included in the same period(22 cases).The contents of posterior vaginal wall prolapse,and the H-shape of the vagina,the length of the perineal body,the length of the genital hiatus,the length of the posterior vaginal wall and the size of the rectocele in the two groups were observed.Mimics 21.0 was used to individuately correct the pelvic tilt caused by Valsalva,and the mobility of perineal body in the two groups was measured.[Results]1.All the 27 patients clinically diagnosed with posterior vaginal wall prolapse had no prolapse at rest,and at dynamic 59.3%(16 cases)were genuine posterior vaginal wall prolapse,33.3%(9 cases)were rectocele,and 3.7%(1 case)were rectocele with peritoneal hernia,and 3.7%(1 case)were intestinal hernia.2.There were no statistical differences in age,BMI,parity,delivery mode and menopausal status between the posterior vaginal wall prolapse group and the non-pop group(P>0.05).3.Static:The posterior vaginal wall prolapse group had less vaginal H-shaped(18.5%vs.45.5%,P<0.05),and longer genital hiatus(24.20±6.25 vs.14.35±3.36mm,P<0.05),and there was no significant difference in the length of perineal body and posterior vaginal wall length(P>0.05),and all no rectocele.4.Dynamics:The posterior vaginal wall prolapse group had longer genital hiatus(62.19±11.42mm vs.17.10±4.65mm,P<0.05),and there was no significant difference in the posterior vaginal wall length between the two groups(P>0.05).6.Dynamic and static align:The mobility of perineal body(20.12±10.80mm vs.7.03±4.30mm,P<0.05)in the posterior vaginal wall prolapse group were significantly greater than those in the non-pop group.[Conclusion]1.The clinical diagnosis of posterior vaginal prolapse is about 60%genuine posterior vaginal prolapse,about 30%with rectocele,7.4%with intestinal hernia or peritoneal hernia,which can not be observed by static MRI,so dynamic MRI should be performed.2.The perineal body of patients with posterior vaginal wall prolapse is not too short,but hypermobility,which may be caused by the loose or broken connection between the perineal body and the surrounding connective tissue.3.Patients with posterior vaginal wall prolapse should pay attention to the reinforcement of the perineal body surrounding fascia.The length of the posterior vaginal wall may not need to be significantly shortened.Chapter 2:Comparison of anatomical characteristics associated with posterior compartment in women with rectocele and with genuine posterior vaginal wall prolapse[Purpose]To compare the anatomical differences between rectocele and genuine posterior vaginal wall prolapse in patients with Bp≥0,and to provide a preliminary reference for clinicians.[Methods]Retrospective analysis was performed on patients with posterior vaginal wall prolapse who underwent dynamic and static MRI in nanfang hospital of southern medical university from October 2014 to December 2019.All patients with Bp≥0 and no hysterectomy were included.10 cases of rectocele and 16 cases of genuine posterior vaginal wall prolapse were observed by dynamic MRI.In addition to the first chapter in part 3,the observed indicators also increased the mobility of the vaginal vault.[Results]1.There were no statistical differences in age,BMI,parity,delivery mode and menopausal status between the rectocele group and the genuine posterior vaginal wall prolapse group(P>0.05).2.Static:There was no significant difference in the rectocele size and vaginal H-shape,the length of the perineal body and genital hiatus,the length of the posterior vaginal wall between 2 groups(P>0.05).3.Dynamic:The average size of rectocele in the rectocele group was 9.48mm±4.58mm.There was no significant difference in genital hiatus length and posterior vaginal wall length between the two groups(P>0.05).5.Dynamic and static align:The mobility of the perineal body was greater in the rectocele group(27.33mm±9.80mm vs.15.71 ±9.43mm,P<0.05)than in the genuine posterior vaginal wall prolapse group.However,the mobility of the vaginal vault was less in the rectocele group than in the genuine posterior vaginal wall prolapse group(52.71 ±28.89 mm vs.88.24±38.36 mm,P<0.05).[Conclusion]1.It is difficult to observe the rectocele statically,but the size of rectocele can be well reflected dynamically.2.Rectocele may be mainly due to the surrounding fascia connection relaxation or rupture with the perineal body,thus showing excessive perineal body movement,attention should be paid to the reinforcement of the fascia around the perineal body.The genuine posterior vaginal wall prolapse may be mainly caused by apical prolapse pulling the posterior vaginal wall down,thus showing excessive vaginal apex movement,attention should be paid to level I suspension. |
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