Imaging Pelvic Floor Disorders, 2nd Revised Edition (Medical Radiology Diagnostic Imaging)

282 Pages·2008·33.66 MB·English

by  Jaap Stoker

I
Contents
MEDICAL RADIOLOGY
Diagnostic Imaging
Editors:
A. L. Baert, Leuven
M. Knauth, Göttingen
III
Contents
J. Stoker · S. A. Taylor · J. O. L. DeLancey (Eds.)
Imaging
Pelvic Floor
Disorders
2nd Revised Edition
With Contributions by
P. Abrams · C. I. Bartram · A. E. Bharucha · A. C. de Bruijne-Dobben · J. O. L. DeLancey
H. P. Dietz · A. V. Emmanuel · J. G. Fletcher · D. S. Hale · S. Halligan · F. Housami
M. Oelke · J.– P. Roovers · S. Shawki · H. Siddiki · J. Stoker · S. A. Taylor · W. H. Umek
D. B. Vodušek · C. Wallner · S. D. Wexner
Foreword by
A. L. Baert
With 212 Figures in 276 Separate Illustrations, 68 in Color and 23 Tables
123
IV
Contents
Jaap Stoker, MD, PhD John O. L. DeLancey, MD
Professor of Radiology Norman F. Miller Professor of Gynecology
Department of Radiology Director, Pelvic Floor Research Group
Academic Medical Center Director, Fellowship in Female Pelvic Medicine and
University of Amsterdam Reconstructive Surgery
Meibergdreef 9 L4000 Women’s Hospital
1105 AZ Amsterdam University of Michigan
The Netherlands 1500 E. Medical Center Drive
Ann Arbor, Mi 48109-0276
Stuart A. Taylor, MD, MRCP, FRCR USA
Senior Lecturer in Radiology
Department of Specialist X-Ray
University College Hospital
2F Podium, 235 Euston Road
London NW1 2BU
UK
Medical Radiology · Diagnostic Imaging and Radiation Oncology
Series Editors:
A. L. Baert · L. W. Brady · H.-P. Heilmann · M. Knauth · M. Molls · C. Nieder
Continuation of Handbuch der medizinischen Radiologie
Encyclopedia of Medical Radiology
ISBN 978-3-540-71966-3 e-ISBN 978-3-540-71968-7
DOI 10.1007 / 978-3-540-71968-7
Medical Radiology · Diagnostic Imaging and Radiation Oncology ISSN 0942-5373
Library of Congress Control Number: 2007942181
(cid:2) 2008, Springer-Verlag Berlin Heidelberg
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V
Contents
Foreword
Pelvic fl oor disorders represent an increasingly important clinical problem due to the
aging of the population.
Recent technical progress in cross-sectional imaging with ultrasound as well as with
MRI now enables us to obtain totally new insights into the anatomy and pathophysiol-
ogy of the complex pelvic fl oor structures.
This second edition has been fully updated to represent the current state of the art
and provide an excellent and comprehensive overview of the techniques to be applied
in a focused study of the pelvic fl oor. It also offers expert guidance in modern manage-
ment of the various clinical conditions related to the dysfunction of specifi c compo-
nents of the pelvic fl oor.
J. Stoker and S. A. Taylor have joined J. O. L. DeLancey as editors for this second
edition. They are internationally recognized leaders in the fi eld and I am very much
indebted to them for their judicious choice of topics and collaborating authors, as well
as for the expedient and rapid preparation of this superb volume.
I am convinced that this second edition will again be met with great interest by radi-
ologists and all other clinicians involved in the care of patients with pelvic disorders.
Leuven Albert L. Baert
VII
Contents
Preface
Disorders of the pelvic fl oor are very common, particularly affecting the female popu-
lation. Although not life-threatening, the impact of these disorders on the quality of life
of those affected cannot be understated, and indeed may be devastating. Imaging plays
an important role in the management of these disorders, its utility further increased
with the new and valuable insights provided by current techniques.
The aim of this book is to provide those practitioners with an interest in the imag-
ing, diagnosis and treatment of pelvic fl oor dysfunction with a thorough update of this
rapidly evolving fi eld. As in the fi rst edition, this volume is written by a combination
of radiologists and clinicians (urogynaecologists, surgeons, urologists), refl ecting the
importance of a multidisciplinary approach when considering pelvic fl oor disorders in
both clinical practice and research.
Based on the success of the fi rst edition, edited by our friend and colleague Clive
Bartram, the overall structure of this new edition remained largely unchanged. Intro-
ductory chapters on anatomy and (patho)physiology are followed by chapters on state-
of-the-art imaging techniques and their application in pelvic fl oor dysfunction. The
closing chapters describe modern clinical management of pelvic fl oor disorders with
specifi c emphasis on the integration of diagnostic and treatment algorithms. All exist-
ing chapters have been rewritten or updated to refl ect the rapid developments in this
fi eld, and chapters on several new topics have been added, including perineal ultra-
sound and MRI of the levator muscles.
We thank the contributing authors for their valuable contribution to this book. We
are very fortunate to have so many distinguished experts in the fi eld contributing to
this volume. Professor Baert has our thanks for his invitation to contribute a second
edition of Imaging Pelvic Floor Disorders to the renowned Medical Radiology series.
We also thank Ursula Davis and her colleagues at Springer for the very effective pro-
duction process and polite, timely communication.
Amsterdam Jaap Stoker
London Stuart A. Taylor
Ann Arbor John O. L. DeLancey
IX
Contents
Contents
1 The Anatomy of the Pelvic Floor and Sphincters
Jaap Stoker and Christian Wallner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Functional Anatomy of the Pelvic Floor
John O. L. DeLancey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3 Pelvic Floor Muscles-Innervation, Denervation and Ageing
David B. Vodušek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4 Imaging Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
4.1 Evacuation Proctography and Dynamic Cystoproctography
Stuart A. Taylor and Steve Halligan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
4.2 Dynamic MR Imaging of the Pelvic Floor
Joel G. Fletcher, Adil E. Bharucha, and Hassan Siddiki . . . . . . . . . . . . . 75
4.3 MRI of the Levator Ani Muscle
Wolfgang H. Umek and John O. L. DeLancey . . . . . . . . . . . . . . . . . . . . . . . . 89
4.4 Endoanal Ultrasound
Clive I. Bartram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
4.5 Pelvic Floor Ultrasound
Hans Peter Dietz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
4.6 Endoanal Magnetic Resonance Imaging
Annette C. de Bruijne-Dobben and Jaap Stoker . . . . . . . . . . . . . . . . . . . . 131
4.7 Urodynamics
Fadi Housami and Paul Abrams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
4.8 Anorectal Physiology
Anton V. Emmanuel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
5 Urogenetical Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
5.1 Surgery and Clinical Imaging for Pelvic Organ Prolapse
Douglass S. Hale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
5.2 Urinary Incontinence: Clinical and Surgical Considerations
Jan-Paul Roovers and Matthias Oelke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
X
Contents
6 Coloproctological Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
6.1 Constipation and Prolapse
Steve Halligan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
6.2 Investigation of Fecal Incontinence
Adil E. Bharucha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
6.3 Surgical Management of Fecal Incontinence
Steven D. Wexner and Sherief Shawki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
1
The Anatomy of the Pelvic Floor and Sphincters
1
The Anatomy of the Pelvic Floor and Sphincters
Jaap Stoker and Christian Wallner
CONTENTS 1.3.6 Perineum and Ischioanal Fossa 19
1.3.6.1 Perineal Body 19
1.3.6.2 Ischioanal Fossae 19
1.1 Introduction 1
1.3.6.3 Perianal Connective Tissue 20
1.2 Embryology 2 1.3.7 Rectum 20
1.2.1 Cloaca and Partition of the Cloaca 2 1.3.7.1 Rectal Wall 21
1.2.2 Bladder 3 1.3.7.2 Rectal Support 21
1.2.3 Urethra 3 1.3.7.3 Neurovascular Supply of the Rectum 21
1.2.4 Vagina 3 1.3.8 Anal Sphincter 21
1.2.5 Anorectum 4 1.3.8.1 Lining of the Anal Canal 22
1.2.6 Pelvic Floor Muscles 4 1.3.8.2 Internal Anal Sphincter 23
1.2.7 Fascia and Ligaments 4 1.3.8.3 Intersphincteric Space 23
1.2.8 Perineum 4 1.3.8.4 Longitudinal Layer 23
1.2.9 Newborn 4 1.3.8.5 External Anal Sphincter 23
1.3.8.6 Pubovisceral (Puborectal) Muscle 25
1.3 Anatomy 5
1.3.8.7 Anal Sphincter Support 25
1.3.1 Pelvic Wall 5
1.3.8.8 Anal Sphincter Anatomy Variance and
1.3.1.1 Tendineus Arcs 7
Ageing 25
1.3.2 Pelvic Floor 8
1.3.8.9 Neurovascular Supply of the
1.3.2.1 Supportive Connective Tissue
Anal Sphincter 26
(Endopelvic Fascia) 8
1.3.9 Nerve Supply of the Pelvic Floor 27
1.3.2.2 Pelvic Diaphragm 8
1.3.9.1 Somatic Nerve Supply 27
1.3.2.3 Perineal Membrane
1.3.9.2 Autonomic Nerve Supply 27
(Urogenital Diaphragm) 9
1.3.2.4 Superfi cial Layer References 27
(External Genital Muscles) 10
1.3.3 Bladder 12
1.3.3.1 Detrusor 13
1.3.3.2 Adventitia 13
1.3.3.3 Bladder Support 13
1.3.3.4 Neurovascular Supply 13
1.1
1.3.4 Urethra and Urethral Support 14
1.3.4.1 Female Urethra 14 Introduction
1.3.4.2 Male Urethra 15
1.3.4.3 Urethral Support 16
The pelvic fl oor supports the visceral organs, is
1.3.5 Uterus and Vagina 18
crucial in maintaining continence, facilitates mic-
1.3.5.1 Uterus and Vaginal Support 18
turition and evacuation and in women forms part
of the birth canal. This multifunctional unit is a
complex of muscles, fasciae and ligaments that
J. Stoker, MD, PhD have numerous interconnections and connections
Professor of Radiology, Department of Radiology, Academic to bony structures, organs and the fi broelastic net-
Medical Center, University of Amsterdam, Meibergdreef 9, work within fat-containing spaces. A detailed appre-
1105 AZ Amsterdam, The Netherlands ciation of the pelvic fl oor is essential to understand
C. Wallner, MSc
normal and abnormal function. The embryology of
Department of Anatomy and Embryology, Academic Medical
the pelvic fl oor is included to help explain certain
Center, University of Amsterdam, Meibergdreef 69–71, 1105
BK Amsterdam, The Netherlands anatomical features.
2
J. Stoker and C. Wallner
The anatomy of the pelvic fl oor is described in sac 4 weeks after fertilization to form the foregut,
an integrated manner, with special attention to the midgut and hindgut. A diverticulum, the allantois,
connections between structures that are crucial for develops from the hindgut. The part of the hind-
a proper function of the pelvic fl oor. Apart from line gut connected to the allantois is called the cloaca
drawings, T2-weighted magnetic resonance imag- (Figs. 1.1, 1.2). The cloaca is joined laterally by the
ing (MRI) is used to illustrate normal anatomical nephric (later mesonephric) ducts. At the angle of
structures. the allantois and hindgut there is a coronal rim of
The structure of the pelvic fl oor and its attach- endoderm and mesenchyme proliferation – the uro-
ments to pelvic bones are an evolutionary adapta- genital septum (or cloacal septum), which develops
tion to our upright position, which requires greater from the sixth week (Fig. 1.1). The septum grows in
support for the abdominal and pelvic organs overly- the direction of the cloacal membrane while fork-
ing the large pelvic canal opening. The initial evolu- like extensions produce lateral cloacal infolding. At
tionary step was the development of a pelvic girdle, the margins of the cloacal membrane, mesenchyme
as found in amphibians, which were the fi rst ver- migrates from the primitive streak to form lateral
tebrates adapted to living on land. The second was (genito- or labioscrotal) folds and a midline genital
adaptation of the pelvic fl oor muscles. Pelvic organ tubercle (precursor of the phallus) (Hamilton and
support in early primates was controlled by contrac- Mossman 1972). By the seventh week, the urogenital
tion of the caudal muscles pulling the root of the tail septum divides the endodermal lined cloaca in a
forward against the perineum. With the gradual larger anterior urogenital sinus (including the vesi-
introduction of upright posture and loss of the tail, courethral canal) continuous with the allantois, and
this mechanism became inadequate, and further a smaller posterior anorectal canal (Bannister et
adaptive changes occurred with the caudal muscles al. 1995). The nodal centre of division of the cloacal
becoming more anterior, extra ligamentous support plate is the future perineal body. A recent experi-
(coccygeus and sacrospinous ligament), and the ori- mental study demonstrated that the cloacal sphinc-
gin of the iliococcygeus muscle moving inferiorly to ter muscles develop from migrating cells from the
arise from the arcus tendineus levator ani with some embryonic hind limb muscle mass (Valasek et al.
associated changes in the bony pelvis (Lansman 2005).
and Robertson 1992). Partial loss of contact of the
pubococcygeus with the coccyx led to the develop-
ment of the pubovisceralis (puborectalis).
Umbilical artery Urorectal septum Notochord
Hindgut Spinal chord
1.2
Embryology
The embryology of the pelvic fl oor and related struc-
tures remains unclear, and new concepts are contin-
Allantoic duct
ually being introduced, e.g. the fusion of the urogen-
Umbilical vein
ital septum and cloacal membrane (N ievelstein et
Ectodermal cloaca
al. 1998). This brief overview may be supplemented
by more detailed texts (Arey 1966; Hamilton and Cloacal
membrane
Mossman 1972; Moore and Persaud 1998).
Endodermal
cloaca
Postanal
1.2.1 gut
Cloaca and Partition of the Cloaca
The earliest stage in the development of the pelvic
Fig. 1.1. The tail end of a human embryo, about 4 weeks old.
fl oor, comprising the urogenital, anorectum and Reprinted from Bannister et al. (1995, p. 206), by permis-
perineal regions, is the invagination of the yolk sion of Churchill Livingstone