The authors are especially indebted to nurses Paola Garavello and Giulia Melara, for their valuable assistance during the examinations.

Procedures involving human subjects have been performed according to the National Guidelines of the Italian Radiological Society
1. Patient preparation
<ol>
	<li>Help patients to fill in a form which provides information on their history, current symptoms, treatments (either medical or surgical), and prior medical records, if any.</li>
	<li>Obtain each patient&#39;s written consent before beginning the examination.</li>
	<li>Clearly explain in advance the characteristics and purpose of the procedure, including the performance of various maneuvers such as squeezing, straining, and rectal emptying.</li>
	<li>Give information on the duration (average time: 25 min) of the procedure and the need for the insertion of a small catheter into the anal canal for contrast administration (acoustic gel).</li>
	<li>Ask the patients to empty their bladder in the toilet just before starting the examination. 
	NOTE: On the basis of the patients&#39; histories and presenting symptoms, tailor the procedure to each single case with regard to the amount of contrast administered and the number of scan planes and pulse sequences used.</li>
</ol>
2. Diagnostic room and facilities
<ol>
	<li>Keep a trolley inside the area of the diagnostic room, equipped with all necessary instruments and supplies, including gloves, syringes, a catheter, lubricant jelly, acoustic gel, etc. (see Table of Materials).</li>
</ol>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/58534/58534fig1.jpg" /> 
Figure 1: Supplies. This picture shows (A) a trolley with supplies for the MR examination and (B) the dilution of acoustic gel with water (50/30 mL per syringe) in the area adjacent to the diagnostic room before the administration. <a href="https://jove.unicartagenaproxy.elogim.com/files/ftp_upload/58534/58534fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol start="2">
	<li>Ask the patient to lay on the diagnostic table of the MR scanner in the left lateral position (Sims&#39; position). Gently insert the catheter into the rectum and administer the contrast administration (acoustic coupling gel) until the patient experiences a characteristic desire to evacuate (the average amount is 250 mL). Turn the patient in the supine position afterward.</li>
	<li>Adjust the absorbent pad beneath the buttocks, and wrap around the patient&#39;s pelvis a surface phased-array coil for the image acquisition. 
	NOTE: In case of anticipated sensation, urgency, discomfort, or involuntary leakage, interrupt the injection and register the total volume injected before the leakage, as well as the volume leaked.</li>
</ol>
3. Technique and image acquisition
<ol>
	<li>Acquire a localizer scout scan in the coronal, axial, and sagittal planes (TFE T1 pulse sequence, TR of 8 ms, TE of 5 ms, flip angle (FA) of 25&#176;, thickness of 15 mm, and the number of images: 5-11) to mark the boundaries of the region of interest (ROI).</li>
	<li>Then, obtain three subsequent dynamic series in the midsagittal plane (see Table 1, series 1: TR/TE of 2.7/1.3 ms; FA of 45&#176;) centered over the anorectal junction, with the patient at rest, squeezing his/her anal sphincter, and straining (10 s each).</li>
	<li>Thereafter, instruct the patient to start - at will - the movement of rectal emptying, and notice when it starts (by acoustic device) to allow the simulatenous acquisition of images over an entire time cycle of 58 s (see Table 1, series 1: TR/TE of 2.7/1.3 ms; FA of 45&#176;; thickness of 35 mm; acquisition time of 58 s). 
	NOTE: If necessary, repeat the series until obtaining an adequate stream of contrast.</li>
	<li>Repeat the latter sequence in the coronal plane (see Table 1, series 2: TR/TE of 2.8/1.3 ms; FA of 45&#176;; thickness of 35 mm; acquisition time of 58 s) while the patient is expelling the residual rectal contrast.</li>
	<li>Then, instruct the patient to perform a steady-state Valsalva maneuver without interruption for 9 s.</li>
	<li>Taking the sagittal images acquired during the rectal emptying as a reference, select three horizontal planes in the axial plane (see Figure 3) to image the levator hiatus as follows: the first at the midsymphysis (level I), the second tangent to the inferior border of the symphysis (level II), and the third at the point of the maximal bulging of the anterior rectal wall (level III). 
	NOTE: The reason for the above is to include most relevant anatomical areas inside and outside the hiatus boundaries of both sexes in the ROI: bladder base, urethra, vagina, cervix, perineal body, anorectal junction, endopelvic fascia, and fat recesses (female), or bladder base, retropubic space, prostate, seminal vesicles, Denonvilliers&#39; fascia, anorectal junction, mesorectal fascia, and presacral space (male).</li>
	<li>Acquire a horizontal 1 cm-thick section in the axial plane (see Table 1, series 3: TR/TE of 3/1.5 ms; FA of 45&#176;; thickness of 10 mm; acquisition time of 9 s) from each level during the Valsalva maneuver, leaving the patient a 60 s interval between two subsequent maneuvers to relax.</li>
	<li>Finally, acquire static T2-weighted images when at rest in the axial, sagittal, and coronal planes (see Table 1, series 4, 5, and 6: TR/TE of 3649-4656/100; FA of 90&#176;; thickness/gap of 4/0.4 mm; acquisition time of 3:00-3:44 min) to provide a complete evaluation of the pelvic anatomy. 
	NOTE: Refer to Table 1 for the technical settings.</li>
</ol>
<img alt="Table 1" src="/files/ftp_upload/58534/58534table1v2.jpg" /> 
Table 1: Technical settings for MR defecography, using a 1.5 T scanner and an external coil.
4. Image analysis and measurements
<ol>
	<li>To measure the position of the pelvic organs when at rest and while straining, from midsagittal dynamic MR images in the analysis software, go to the list of toolbar options positioned at the top of the screen and hover over Annotation Tools.</li>
	<li>Then, click on the arrow and select Ruler to obtain a linear measurement in millimeters of the vertical distance of the bladder neck, uterine cervix, prostate base, seminal vesicles, and rectal floor from two reference lines, as follows: express the distances by negative (proximal) or positive (distal) numbers relative to the hymen plane (female) or to a horizontal line drawn tangent to the inferior border of the symphysis pubis (male).</li>
</ol>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/58534/58534fig2.jpg" /> 
Figure 2: Reference lines for pelvic organ descent on midsagittal MR images. (A) A 61-year-old woman with a rectal descent of &#62;10 cm below the hymen plane (yellow line) and sigmoidocele. (B) A 42-year-old man with rectal intussusception and a descent of &#62;3 cm below the lower border of the symphysis pubis (yellow line). bl = bladder; sp = symphysis pubis; ut = uterus; r = rectum; p = prostate. <a href="https://jove.unicartagenaproxy.elogim.com/files/ftp_upload/58534/58534fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol start="3">
	<li>To measure the hiatal anterior/posterior and transverse diameter (in millimeters) from the axial static and dynamic images, repeat the same selection of linear measurements described in steps 4.1-4.2 and calculate the distance from the pubic symphysis to the anterior margin of the puborectalis sling and the distance between the medial borders of the levator ani muscle.</li>
	<li>To measure the hiatal area (in square centimeters) when at rest and during maximum strain, click again on Annotation Tools and choose Free-ROI to select a free-hand contour-tracing technique (see Figure 3).</li>
	<li>Depict the internal area of the levator ani muscle and express the differences between resting and straining measurements as absolute values and an increase in percentage from sections of the same level identified by the recognition of bony landmarks, namely the symphysis pubis and the ischial tuberosities (level 2). 
	NOTE: Register any impingement of the organs within the levator ani hiatus and refer, for organ prolapse definition and grading, to the standards recommended by the international committee on pelvic organ prolapse14,15 and to the traditional &#34;HMO&#34; MRI classification system of pelvic organ prolapse described by Comiter&#160;et al.9.</li>
</ol>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/58534/58534fig3.jpg" /> 
Figure 3: Method for levator ani hiatus imaging and area measurement. (A) A selection of three axial scan sections from a midsagittal image taken relative to the midsymphysis pubis (level 1), tangent to its lower border (level 2), and at the maximal bulging of the anterior rectal wall (level 3) during rectal emptying. (B) An example of an asymmetric area measured when at rest from level 2 with the free-hand contour-tracing method in a 52-year-old woman with a focal defect of the right pubococcygeus muscle (arrow). s = symphysis pubis; bl = bladder; r = rectum.The left panel = a sagittal view;the right panel = a coronal view.The area values are expressed in square centimeters.1 = first level; 2 = second level; 3 = third level. <a href="https://jove.unicartagenaproxy.elogim.com/files/ftp_upload/58534/58534fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

<ol>
	<li>DeLancey, J. O. L., Hurd, W. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Size+of+the+urogenital+hiatus+in+the+levator+ani+muscles+in+normal+women+and+women+with+pelvic+organ+prolapse.">Size of the urogenital hiatus in the levator ani muscles in normal women and women with pelvic organ prolapse.</a> Obstetrics &amp; Gynecology. 91 (3), 364-368 (1998).</li><li>Siproudhis, L., Ropert, A., Vilotte, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=How+accurate+is+clinical+examination+in+diagnosing+and+quantifying+pelvirectal+disorders?+A+prospective+study+in+a+group+of+50+patients+complaining+of+defecatory+difficulties.">How accurate is clinical examination in diagnosing and quantifying pelvirectal disorders? A prospective study in a group of 50 patients complaining of defecatory difficulties.</a> Diseases of the Colon &amp; Rectum. 36 (5), 430-438 (1993).</li><li>Maglinte, D. D. T., Kelvin, F. M., Fitzgerald, K., Hale, D. S., Benson, J. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Association+of+compartment+defects+in+pelvic+floor+dysfunction.">Association of compartment defects in pelvic floor dysfunction.</a> American Journal of Roentgenology. 172 (2), 439-444 (1999).</li><li>Dietz, H. P., Jarvis, S. K., Vancaillie, T. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+assessment+of+Levator+muscle+strength:+a+validation+of+three+ultrasound+techniques.">The assessment of Levator muscle strength: a validation of three ultrasound techniques.</a> International Urogynecology Journal and Pelvic Floor Dysfunction. 13 (3), 156-159 (2002).</li><li>Dietz, H. P., Shek, C., Clarcke, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Biometry+of+the+pubovisceral+muscle+and+levator+hiatus+by+three-dimensional+pelvic+floor+ultrasound.">Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound.</a> Obstetrics &amp; Gynecology. 25 (6), 580-585 (2005).</li><li>Yang, A., Mostwin, J. L., Rosenhein, N. B., Zerhouni, E. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pelvic+floor+descent+in+women:+dynamic+evaluation+with+fast+MR+imaging+and+cinematic+display.">Pelvic floor descent in women: dynamic evaluation with fast MR imaging and cinematic display.</a> Radiology. 179 (1), 25-33 (1991).</li><li>Lienemann, A., Anthuber, C., Baron, A., Kohz, P., Reiser, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dynamic+MR+colpocystorectography+assessing+pelvic+floor+descent.">Dynamic MR colpocystorectography assessing pelvic floor descent.</a> European Radiology. 7 (8), 1309-1317 (1997).</li><li>Healy, J. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Patterns+of+prolapse+in+women+with+symptoms+of+pelvic+floor+weakness:+assessment+with+MR+imaging.">Patterns of prolapse in women with symptoms of pelvic floor weakness: assessment with MR imaging.</a> Radiology. 203 (1), 77-81 (1997).</li><li>Comiter, C. V., Vasavada, S. P., Barbaric, Z. L., Gousse, A. E., Raz, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Grading+pelvic+prolapse+and+pelvic+floor+relaxation+using+dynamic+magnetic+resonance+imaging.">Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging.</a> Urology. 54 (3), 454-457 (1999).</li><li>Kelvin, F. M., Maglinte, D. D. T., Hale, D. S., Benson, J. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Female+pelvic+organ+prolapse:+a+comparison+of+triphasic+dynamic+MR+imaging+and+triphasic+fluoroscopic+cystocolpoproctography.">Female pelvic organ prolapse: a comparison of triphasic dynamic MR imaging and triphasic fluoroscopic cystocolpoproctography.</a> American Journal of Roentgenology. 174 (1), 81-88 (2000).</li><li>Pannu, H. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dynamic+MR+imaging+of+pelvis+organ+prolapse:+spectrum+of+abnormalities.">Dynamic MR imaging of pelvis organ prolapse: spectrum of abnormalities.</a> RadioGraphics. 20 (6), 1567-1582 (2000).</li><li>Hoyte, L., Ratiu, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Linear+measurements+in+2-dimen&#172;sional+pelvic+floor+imaging:+the+impact+of+slice+tilt+angles+on+measurement+reproducibility.">Linear measurements in 2-dimen&#172;sional pelvic floor imaging: the impact of slice tilt angles on measurement reproducibility.</a> American Journal of Obstetrics and Gynecology. 185 (3), 537-544 (2001).</li><li>Tunn, R., DeLancey, J. O. L., Quint, E. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Visibility+of+pelvic+organ+support+system+structures+in+magnetic+resonance+images+without+an+endovaginal+coil.">Visibility of pelvic organ support system structures in magnetic resonance images without an endovaginal coil.</a> American Journal of Obstetrics and Gynecology. 184 (6), 1156-1163 (2001).</li><li>Bump, R. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+standardization+of+terminology+of+female+pelvic+organ+prolapse+and+pelvic+floor+dysfunction.">The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction.</a> American Journal of Obstetrics and Gynecology. 175 (1), 10-17 (1996).</li><li>Haylen, B. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+inter-national+Urogynecological+Association+(IUGA)+/+International+Continence+Society+(ICS)+Joint+Report+on+the+Terminology+for+Female+Pelvic+Floor+Dysfunction.">An inter-national Urogynecological Association (IUGA) / International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Floor Dysfunction.</a> Neurology and Urodynamics. 29 (1), 4-20 (2009).</li><li>Fielding, J. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=MR+imaging+of+pelvic+floor+continence+mechanisms+in+the+supine+and+sitting+positions.">MR imaging of pelvic floor continence mechanisms in the supine and sitting positions.</a> American Journal of Roentgenology. 171 (6), 1607-1610 (1998).</li><li>Bertschinger, K. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dynamic+MR+imaging+of+the+pelvic+floor+performed+with+patient+sitting+in+an+open-magnet+unit+versus+with+patient+supine+in+a+closed-magnet+unit.">Dynamic MR imaging of the pelvic floor performed with patient sitting in an open-magnet unit versus with patient supine in a closed-magnet unit.</a> Radiology. 223 (2), 501-508 (2002).</li><li>Piloni, V., Ambroselli, V., Nestola, M., Piloni, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Quantification+of+levator+ani+(LA)+hiatus+enlargement+and+pelvic+organs+impingement+on+Valsalva+maneuver+in+parous+and+nulliparous+women+with+obstructed+defecation+syndrome+(ODS):+a+biomechanical+perspective.">Quantification of levator ani (LA) hiatus enlargement and pelvic organs impingement on Valsalva maneuver in parous and nulliparous women with obstructed defecation syndrome (ODS): a biomechanical perspective.</a> Pelviperineology. 35 (1), 25-31 (2016).</li><li>Piloni, V., Pierandrei, G., Pignalosa, F., Galli, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fusion+imaging+by+transperineal+sonography/magnetic+resonance+in+patients+with+fecal+blockade+syndrome.">Fusion imaging by transperineal sonography/magnetic resonance in patients with fecal blockade syndrome.</a> EC Gastroenterology and Digestive System. 5 (1), 11-16 (2018).</li><li>Piloni, V., Bergamasco, M., Melara, G., Garavello, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+clinical+value+of+magnetic+resonance+defecography+in+males+with+obstructed+defecation+syndrome.">The clinical value of magnetic resonance defecography in males with obstructed defecation syndrome.</a> Techniques in Coloproctology. 22 (3), 179-190 (2018).</li><li>Chanda, A., Unnikrishnan, V. U., Roy, S., Ricther, H. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Computational+modeling+of+the+female+pelvic+support+structures+and+organs+to+understand+the+mechanisms+of+pelvic+organ+prolapse:+a+review.">Computational modeling of the female pelvic support structures and organs to understand the mechanisms of pelvic organ prolapse: a review.</a> Applied Mechanics Reviews. 67 (4), 040801-040814 (2015).</li><li>Rostaminia, G., Abramowitch, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Finite+element+modeling+in+female+pelvic+floor+medicine:+a+literature+review.">Finite element modeling in female pelvic floor medicine: a literature review.</a> Current Obstetrics and Gynecology Reports. 4 (2), 125-131 (2015).</li></ol>

The authors have nothing to disclose.

This method has an overt advantage over pelvic examinations that are limited to the assessment of the urogenital hiatus in only females. In contrast, the method presented here examines the entire levator ani hiatus in both sexes. Moreover, although easily examined by palpation by the gynecologist, the female hiatus can be calculated only approximately with a ruler, to produce the area of an oval1. Similarly, an advantage does exist over 2- and 3-D TPUS4,<sup clas...

Pelvic organ prolapse (POP) develops when the forces acting inside the boundaries of levator ani hiatus are no longer counteracted by those outside, leading to abnormal enlargement and organ impingement. Several factors are responsible for the disease, including ligaments, fascia, or muscular tonic activity. Whatever the mechanism involved, the increased hiatus size has been credited with a reliable index to assess the inability to keep it closed. Usually, the status of pelvic support is determined in women during a pelvic examination1 by observing the location of the cervix, vaginal apex, and vaginal walls during the Valsalva maneuver. However, the inaccuracy of the method, combined with a failure to identify all involved sites2,3 and sex-related constrictions (female only), has led clinicians and researchers to seek alternative methods, namely diagnostic imaging.
Current methods for determining hiatus size include transperineal ultrasonography (TPUS)4,5 and, more recently, magnetic resonance imaging (MRI). Unfortunately, existing methods of performing the examination and measurement of individual parameters vary greatly among researchers6,7,8,9,10,11,12,13, making a comparison of study results difficult. Moreover, significant differences still exist in the definition and terminology of the most common pelvic descent processes, as well as in the classification and quantification of the adopted systems14,15.
This study highlights the advantages of MRI over other methods and describes the technical details and diagnostic criteria for the quantification of POP in patients of both sexes. In particular, the description focuses on the quantification of pelvic organs descent and levator ani hiatus enlargement when straining, with the patient supine, to demonstrate that the lack of a vertically oriented MR system16,17 (i.e., gravity will not adversely affect the detection of various changes associated with POP).

<table><tbody><tr><td>MR scanner</td><td>Philips Medical Systems, High Tech Campus&amp;nbsp; 37, 5656 AE, Eindhoven,&lt;br/&gt; The Netherlands</td><td></td><td>Description: 1.5 T horizontally oriented, Multiva model, SENSE XL Torso coil&lt;br/&gt; Procedure: Position the patient in the left lateral decubitus on the diagnostic table with the coil warpped around the pelvis</td></tr><tr><td>Catheter</td><td>Convatek ltd, First avenue Deeside, Flintshire CH5 2NU&lt;br/&gt; UK</td><td></td><td>Description: Sterile vaginal catheter, 16 ch,180 mm long, 3 mm wide&lt;br/&gt; Procedure: Gently insert the lubricated tip inside the anal canal for contrast administration with patients in the left side position</td></tr><tr><td>Holder</td><td>Kartell Plastilab, Artiglas Srl, Via Carrara Padua, Italy</td><td></td><td>Description: Universal test-tube holder with multiple 13-mm holes&lt;br/&gt; Procedure: Put 3 empty syringes vertically inside the holes with the outlet cone down</td></tr><tr><td>Syringe</td><td>Pikdare Srl, Via Saldarini Catelli 10 , 22070 Casnate con Bernate (Como) Italy</td><td></td><td>Description: Sterile, latex free,60 mL graduated transparent cylinder, catheter cone&lt;br/&gt; Procedure: Fill with contrast, adjust the plunger and connect to the catheter</td></tr><tr><td>Contrast</td><td>Ceracarta SpA, Via Secondo Casadei 14 47122 Forl&amp;igrave;&lt;br/&gt; Italy</td><td></td><td>Description: Eco supergel not irritant, water soluble, salt free&lt;br/&gt; Procedure: Dilute the content of each syringe adding 30 mL of tap water to 50 mL of acustic gel</td></tr><tr><td>Mixer device</td><td>Kaltek Srl, Via del Progresso 2 Padua&lt;br/&gt; Italy</td><td></td><td>Description: Kito-Brush for endovaginal sampling&lt;br/&gt; Procedure: Rotate one full turn 10-20 times until obtaining an homogeneous gel</td></tr><tr><td>Pad</td><td>Fater SpA, Via A. Volta 10, 65129 Pescara&lt;br/&gt; Italy</td><td></td><td>Description: Pad for incontinent subjects&lt;br/&gt; Procedure: Wrap around patient&#039;s pelvis to collect any material and prevent diagnostic table contamination</td></tr><tr><td>Lubricant</td><td>Molteni farmaceutici, Localit&amp;agrave; Granatieri Scandicci (Florence)&lt;br/&gt; Italy</td><td></td><td>Description: Luan gel 1%&lt;br/&gt; Procedure: Apply on the tip of catheter before insertion</td></tr><tr><td>Apron</td><td>Mediberg Srl, via Vezze 16/18 Calcinate 24050 (Bergamo)&lt;br/&gt; Italy</td><td></td><td>Description: Kimono&lt;br/&gt; Procedure: Put on counteriwise (opening back) to maintain patient&#039;s dignity</td></tr><tr><td>Gloves</td><td>Gardening Srl, Via B. Bosco 15/10 16121 Genova&lt;br/&gt; Italy</td><td></td><td>Description: Nitrile, latex free, no talcum powdered&lt;br/&gt; Procedure: Wear during contrast preparation and catheter insertion; change regularly to prevent cross contamination</td></tr></tbody></table>

quantification of levator ani hiatus enlargement by magnetic resonance imaging in males and females with pelvic organ prolapse

Here we present a protocol to examine the levator ani hiatus in males and females with pelvic organ prolapse, during the Valsalva maneuver and while evacuating acoustic gel, using a horizontally oriented 1.5 T magnetic resonance (MR) scanner. On midsagittal images, the vertical distance of pelvic organs is measured in millimeters relative to the hymen plane (female) and to the lower border of the symphysis pubis (male), preceded by - (above) or + ( below) signs. On axial images, the levator ani area is calculated in square centimeters with a free-hand tracing method from three key images, passing through the midsymphysis (level I), tangential to the lower border of the symphysis (level II), and at the maximal anterior rectal wall bulging (level III). Areas at rest and strained are compared to find evidence of a percentage of increase. The purpose is to provide objective evidence of the maximal extent of pelvic organs descent and hiatus enlargement without the interference of foreign objects or the examiner&#39;s proximity, so as to overcome the limitations of pelvic examination and transperineal sonography (i.e., subjectivity and sex-related limitations [female only]).

Between 2012 and 2018, this protocol has been successfully adopted in three different diagnostic centers in Italy at an average cumulative rate of 30 &#177; 4 exams per month, using the same 1.5 T MR scanner model and technical settings (see Table 1 and Table of Materials). During this period, over 2,000 examinations have been performed in patients of both sexes for the following three main disease categories: pelvic organ prolapse and evacuation disturba...

Watch this Scientific Journal Video about Quantification of Levator Ani Hiatus Enlargement by Magnetic Resonance Imaging in Males and Females with Pelvic Organ Prolapse at JoVE.com

Quantification of Levator Ani Hiatus Enlargement by Magnetic Resonance Imaging in Males and Females with Pelvic Organ Prolapse

Here we present a protocol to standardize the measurement of the levator ani hiatus size&#160;by magnetic resonance imaging. The purpose is to extract biomechanical inferences from image analysis by comparing resting and straining values in patients of both sexes with pelvic prolapse, using consistent anatomical bony landmarks.

Here we present a protocol to examine the levator ani hiatus in males and females with pelvic organ prolapse, during the Valsalva maneuver and while ...

quantification-levator-ani-hiatus-enlargement-magnetic-resonance

Universidad de Cartagena UDEC

Research

JoVE Journal

Medicine

9.8K Views.  Iniziativa Medica. Here we present a protocol to standardize the measurement of the levator ani hiatus size by magnetic resonance imaging. The purpose is to extract biomechanical inferences from image analysis by comparing resting and straining values in patients of both sexes with pelvic prolapse, using consistent anatomical bony landmarks.

Video: Quantification of Levator Ani Hiatus Enlargement by Magnetic Resonance Imaging in Males and Females with Pelvic Organ Prolapse

Magnetic Resonance Imaging Assessment of Carcinogen-induced Murine Bladder Tumors

Murine bladder tumor models are critical for the evaluation of new therapeutic options. Bladder tumors induced with the N-butyl-N-(4-hydroxybutyl) nitrosamine (BBN) carcinogen are advantageous over cell line-based models because they closely replicate the genomic profiles of human tumors, and, unlike cell models and xenografts, they provide a good opportunity for the study of immunotherapies. However, bladder tumor generation is heterogeneous; therefore, an accurate assessment of tumor burden is needed before randomization to experimental treatment. Described here is a BBN mouse model and protocol to evaluate bladder cancer tumor burden in vivo using a fast and reliable magnetic resonance (MR) sequence (true FISP). This method is simple and reliable because, unlike ultrasound, MR is operator-independent and allows for the straightforward post-acquisition image processing and review. Using axial images of the bladder, analysis of regions of interest along the bladder wall and tumor allow for the calculation of bladder wall and tumor area. This measurement correlates with ex vivo bladder weight (rs= 0.37, p = 0.009) and tumor stage (p = 0.0003). In conclusion, BBN generates heterogeneous tumors that are ideal for evaluation of immunotherapies, and MRI can quickly and reliably assess tumor burden prior to randomization to experimental treatment arms.

Murine bladder tumors are induced with the N-butyl-N-(4-hydroxybutyl) nitrosamine carcinogen (BBN). Bladder tumor generation is heterogeneous; therefore, an accurate assessment of tumor burden is needed before randomization to experimental treatment. Here we present a fast, reliable MRI protocol to assess tumor size and stage.

Murine bladder tumor models are critical for the evaluation of new therapeutic options. Bladder tumors induced with the N-butyl-N-(4-hydroxybutyl) ...

Cancer Research

Intraoperative Detection of Subtle Endometriosis: A Novel Paradigm for Detection and Treatment of Pelvic Pain Associated with the Loss of Peritoneal Integrity

Endometriosis is a common disease affecting 40 to 70% of reproductive-aged women with chronic pelvic pain (CPP) and/or infertility. The purpose of this study was to demonstrate the use of a blue dye (methylene blue) to stain peritoneal surfaces during laparoscopy (L/S) to detect the loss of peritoneal integrity in patients with pelvic pain and suspected endometriosis. Forty women with CPP and 5 women without pain were evaluated in this pilot study. During L/S, concentrated dye was sprayed onto peritoneal surfaces, then aspirated and rinsed with Lactated Ringers solution. Areas of localized dye uptake were evaluated for the presence of visible endometriotic lesions. Areas of intense peritoneal staining were resected and some fixed in 2.5% buffered gluteraldehyde and examined by scanning (SEM) electron microscopy. Blue dye uptake was more common in women with endometriosis and chronic pelvic pain than controls (85% vs. 40%). Resection of the blue stained areas revealed endometriosis by SEM and loss of peritoneal cell-cell contact compared to normal, non-staining peritoneum. Affected peritoneum was associated with visible endometriotic implants in most but not all patients. Subjective pain relief was reported in 80% of subjects. Based on scanning electron microscopy, we conclude that endometrial cells extend well beyond visible implants of endometriosis and appear to disrupt the underlying mesothelium. Subtle lesions of endometriosis could therefore cause pelvic pain by disruption of peritoneal integrity, allowing menstrual or ovulatory blood and associated pain factors access to underlying sensory nerves. Complete resection of affected peritoneum may provide a better long-term treatment for endometriosis and CPP. This simple technique appears to improve detection of subtle or near invisible endometriosis in women with CPP and minimal visual findings at L/S and may serve to elevate diagnostic accuracy for endometriosis at laparoscopy.

Loss of peritoneal integrity provides a new paradigm to understand and treat chronic pelvic pain in women with mild forms of endometriosis and can be easily detected using intraoperative instillation of dye at the time of laparoscopy.

Endometriosis is a  common disease affecting 40 to 70% of reproductive-aged women with chronic  pelvic pain (CPP) and/or infertility. The purpose of this ...

In Vivo Morphometric Analysis of Human Cranial Nerves Using Magnetic Resonance Imaging in Meni&#232;re's Disease Ears and Normal Hearing Ears

Analysis of neural structures in Meni&#232;re's Disease (MD) is of importance, since a loss of such structures has previously been proposed for this patient group but has yet to be confirmed. This protocol describes a method of in vivo evaluation of neural changes especially well suitable for cranial nerve analysis using magnetic resonance imaging (MRI). MD-patients and normal hearing persons were examined in a 3-T MR-scanner using a scan protocol including strongly T2-weighted 3D gradient-echo-sequence (3D-CISS). In the patient group, MD was additionally confirmed using MRI-based assessment of endolymphatic hydrops. Morphometric analysis was performed using a freeware DICOM viewer. Evaluation of cranial nerves included measurements of cross-sectional areas (CSAs) of the nerves at different levels as well as orthogonal diametric measurements.

To evaluate morphological changes of cranial nerves such as loss of neural structures or swelling of cranial nerves in Meni&#232;re&#39;s Disease (MD) or in healthy persons in vivo, a protocol of evaluation has been developed using magnetic resonance imaging (MRI). Additional MRI-based confirmation of MD was performed.

Analysis of neural structures in Meni&#232;re's Disease (MD) is of importance, since a loss of such structures has previously been proposed for this ...

Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse (POP) Quantification System

Anogenital distance (AGD) is a sexually dimorphic attribute, twice longer in males than in females, and a marker of intrauterine hormonal environment. Interest in AGD measurements is increasing due to mounting evidence on their potential clinical implications. A parallel set of perineal measurements, the Pelvic Organ Prolapse Quantification System (POP-Q), include similar, but not exactly the same, landmarks: the perineal body (PB) and the genital hiatus (GH) lengths. However, clinical reproducibility of both perineal measurements and their usefulness to describe perineal anthropometry needs to be elucidated. To our knowledge, there is no publication in video format showing the methodology of these measurements. The main objective of this work is to show how to properly perform perineal anthropometry, including measurements of the AGD in its two variants [anoclitoral (AGDAC) and anofourchette (AGDAF)], genital hiatus (GH) and perineal body (PB). Moreover, we explored if there were differences in these measurements in women with and without Pelvic Organ Prolapse (POP). We research whether the anthropometric characteristics of the perineum, such as AGD (which is determined prenatally), may be altered in these women and be an independent etiological factor for pelvic floor dysfunction. We show two different ways of measuring perineal lengths, as they might be quite comparable. Our suggestion is that unifying perineal measurements could be useful for clinical and biomedical investigation. More studies are needed in order to compare GH and PB measurements and its AGD counterparts to analyze which procedures are more reproducible with less intra and interobserver variability.

Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse POP Quantification System

This manuscript describes the procedures to perform anogenital distance (AGD) and perineal measurements standardized by the Pelvic Organ Prolapse Quantification System (POP-Q): perineal body (PB) and genital hiatus (GH). These measurements are compared in women with and without pelvic organ prolapse.

Anogenital distance (AGD) is a sexually dimorphic attribute, twice longer in males than in females, and a marker of intrauterine hormonal environment. ...

Ultrasonography of the Adult Male Urinary Tract for Urinary Functional Testing

The incidence of clinical benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) is increasing due to the aging population, resulting in a significant economic and quality of life burden. Transgenic and other mouse models have been developed to recreate various aspects of this multifactorial disease; however, methods to accurately quantitate urinary dysfunction and the effectiveness of new therapeutic options are lacking. Here, we describe a method that can be used to measure bladder volume and detrusor wall thickness, urinary velocity, void volume and void duration, and urethral diameter. This would allow for the evaluation of disease progression and treatment efficacy over time. Mice were anesthetized with isoflurane, and the bladder was visualized by ultrasound. For non-contrast imaging, a 3D image was taken of the bladder to calculate volume and evaluate shape; the bladder wall thickness was measured from this image. For contrast-enhanced imaging, a catheter was placed through the dome of the bladder using a 27-gauge needle connected to a syringe by PE50 tubing. A bolus of 0.5 mL of contrast was infused into the bladder until a urination event occurred. Urethral diameter was determined at the point of the Doppler velocity sample window during the first voiding event. Velocity was measured for each subsequent event yielding a flow rate. In conclusion, high frequency ultrasound proved to be an effective method for assessing bladder and urethral measurements during urinary function in mice. This technique may be useful in the assessment of novel therapies for BPH/LUTS in an experimental setting.

We describe the use of high frequency ultrasound with contrast imaging as a method to measure bladder volume, bladder wall thickness, urine velocity, void volume, void duration, and urethral diameter. This strategy can be used to assess voiding dysfunction and treatment efficacy in various mouse models of lower urinary tract dysfunction (LUTD).

The incidence of clinical benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) is increasing due to the aging population, resulting ...

Development of a Uterosacral Ligament Suspension Rat Model

Pelvic organ prolapse (POP) is a common pelvic floor disorder (PFD) with the potential to significantly impact a woman's quality of life. Approximately 10%-20% of women undergo pelvic floor repair surgery to treat prolapse in the United States. PFD cases result in an overall $26.3 billion annual cost in the United States alone. This multifactorial condition has a negative impact on the quality of life and yet the treatment options have only dwindled in the recent past. One common surgical option is uterosacral ligament suspension (USLS), which is typically performed by affixing the vaginal vault to the uterosacral ligament in the pelvis. This repair has a lower incidence of complications compared to those with mesh augmentation, but is notable for a relatively high failure rate of up to 40%. Considering the lack of standard animal models to study pelvic floor dysfunction, there is an urgent clinical need for innovation in this field with a focus on developing cost-effective and accessible animal models. In this manuscript, we describe a rat model of USLS involving a complete hysterectomy followed by fixation of the remaining vaginal vault to the uterosacral ligament. The goal of this model is to mimic the procedure performed on women to be able to use the model to then investigate reparative strategies that improve the mechanical integrity of the ligament attachment. Importantly, we also describe the development of an in situ tensile testing procedure to characterize interface integrity at chosen time points following surgical intervention. Overall, this model will be a useful tool for future studies that investigate treatment options for POP repair via USLS.

Pelvic organ prolapse affects millions of women worldwide and yet some common surgical interventions have failure rates as high as 40%. The lack of standard animal models to investigate this condition impedes progress. We propose the following protocol as a model for uterosacral ligament suspension and in vivo tensile testing.

Pelvic organ prolapse (POP) is a common pelvic floor disorder (PFD) with the potential to significantly impact a woman's quality of life. Approximately ...

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore apical support for treating POP. Sacrocolpopexy and pectopexy are indicated for apical prolapse. Using a synthetic mesh in these techniques increases success by enhancing apical support. However, the implantation of synthetic mesh is associated with mesh-related complications. In addition, the exorbitant cost of synthetic mesh and lack of universal access limit the popularity of these procedures. The current study develops a unique technique known as laparoscopic non-mesh cerclage pectopexy (LNMCP), in which permanent cervical cerclage sutures are embedded in the round ligament until the iliopectineal ligament. The iliopectineal ligament was sutured, resulting in a firm cervical suspension. The procedure was successfully performed in 16 cases in the hospital. The surgical duration was 67.8 min &plusmn; 15.5 min, and the blood loss was 73.1 mL &plusmn; 51.1 mL. No procedural complications were seen. LNMCP is associated with an objective success rate of 100% and a subjective success rate of 93.8%. LNMCP for patients with apical prolapse obviates the need for a mesh, thereby avoiding complications associated with mesh erosion and reducing medical costs. In addition, it is easy to perform even in resource-poor areas without access to synthetic mesh.

The present pilot study describes the development of laparoscopic non-mesh cerclage pectopexy to treat pelvic organ prolapse. The procedure can be used to prevent any complications associated with the use of mesh.

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore ...

Uterine-Preserving Laparoscopic Cerclage Pectopexy 

Laparoscopic Non-Mesh Cerclage Pectopexy with Uterine Preservation for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) affects millions of women globally and carries a significant socioeconomic burden. Adequate apical support is essential for treating POP. Recent research has increasingly validated the efficacy and safety of laparoscopic pectopexy (LP) for addressing apical POP. However, the cost of synthetic mesh and associated complications restrict the widespread use of this technique. Our team previously published a study describing a novel, non-mesh procedure called laparoscopic non-mesh cerclage pectopexy (LNMCP), demonstrating successful outcomes with satisfactory objective and subjective success rates. Many patients express a preference for retaining their uterus during prolapse surgery due to considerations related to sexuality, partnership, and body image. 
The present research introduces a novel approach known as laparoscopic non-mesh cerclage pectopexy with uterine preservation (LNMCPUP) for POP, wherein the uterus is suspended to the iliopectineal ligament through the round ligament using permanent cerclage sutures. We successfully performed this procedure in 14 cases at our hospital, six of whom still had menstruation, and the remaining eight were postmenopausal, with a mean operation time of 54.43 min (&plusmn; 10.18 min) and an average bleeding volume of 53.57 mL (&plusmn; 48.77 mL). The mean follow-up duration was 19.71 &plusmn; 15.87 months. The objective success rate of LNMCPUP was 100%, with a subjective success rate of 92.86%. No significant complications were observed during or after surgery. LNMCPUP integrates cervical cerclage and shortening of the round ligament, as well as LP without using mesh, thereby eliminating the risk of mesh erosion and lowering healthcare costs. Moreover, this novel technique is relatively easy to master, making it accessible even in rural and underdeveloped areas where synthetic mesh is unavailable. Therefore, it is worthwhile to adopt LNMCPUP in POP patients who desire the preservation of their uterus.

Author Spotlight: Advancing Pelvic Prolapse Treatment with a Non-Mesh Approach using Laparoscopic Pectopexy

Here we introduce a novel approach known as laparoscopic non-mesh cerclage pectopexy with uterine preservation for pelvic organ prolapse (LNMCPUP) for patients who wish to preserve their uterus. Permanent cerclage sutures are used to suspend the uterus to the iliopectineal ligament through the round ligament.

Pelvic organ prolapse (POP) affects millions of women globally and carries a significant socioeconomic burden. Adequate apical support is essential for ...

Isolation and Characterization of the Murine Uterosacral Ligaments and Pelvic Floor Organs

Pelvic organ prolapse (POP) is a condition that affects the integrity, structure, and mechanical support of the pelvic floor. The organs in the pelvic floor are supported by different anatomical structures, including muscles, ligaments, and pelvic fascia. The uterosacral ligament (USL) is a critical load-bearing structure, and injury to the USL results in a higher risk of developing POP. The present protocol describes the dissection of murine USLs and the pelvic floor organs alongside the acquisition of unique data on the USL biochemical composition and function using Raman spectroscopy and the evaluation of mechanical behavior. Mice are an invaluable model for preclinical research, but dissecting the murine USL is a difficult and intricate process. This procedure presents an approach to guide the dissection of murine pelvic floor tissues, including the USL, to enable multiple assessments and characterization. This work aims to aid the dissection of pelvic floor tissues by basic scientists and engineers, thus expanding the accessibility of research on the USL and pelvic floor conditions and the preclinical study of women's health using mouse models.

This article presents a detailed protocol for dissecting uterosacral ligaments and other pelvic floor tissues, including the cervix, rectum, and bladder in mice, to expand the study of female reproductive tissues.

Pelvic organ prolapse (POP) is a condition that affects the integrity, structure, and mechanical support of the pelvic floor. The organs in the pelvic ...

Biology

A Cognitive Fusion-guided Prostate Biopsy Using Multiparametric Magnetic Resonance Imaging and Transrectal Ultrasound

Traditional transrectal ultrasound (TRUS)-guided prostate biopsy has limited sensitivity and specificity, particularly for detecting early-stage prostate cancer, due to a lack of precise lesion targeting. An improved cognitive fusion-guided prostate biopsy method has been developed to enhance lesion targeting by integrating three parameters of prostate multiparametric MR (mpMRI) images into TRUS images. Prostate mpMRI measurement is initially performed to obtain three key parameters: the rotation angle (&#945;), the distance from the rectal wall (X), and the distance from the prostate apex (Y). These parameters are then cognitively applied in real-time, TRUS-guided prostate needle biopsy to detect target lesions. This improved transperineal cognitive fusion biopsy method enhances diagnostic accuracy, improves reproducibility, and reduces reliance on operator experience. Clinical application in 423 patients demonstrated a prostate cancer detection rate of 73.5%, with 62.9% classified as clinically significant cancers. Compared with equipment-intensive methods such as MRI-ultrasound fusion biopsy, this approach is cost-effective, practical, and well-suited for broader clinical adoption. Additionally, the method&#39;s flexibility supports integration with other imaging techniques, such as 68Ga-PSMA PET/CT, further improving detection rates for patients with high-risk prostate cancer.

Prostate biopsy is the gold standard diagnostic method for prostate cancer. Cognitive fusion-guided prostate biopsy, which combines transrectal ultrasound with pre-measured MRI parameters, improves biopsy accuracy and enhances the detection rate of clinically significant prostate cancer.

Traditional transrectal ultrasound (TRUS)-guided prostate biopsy has limited sensitivity and specificity, particularly for detecting early-stage prostate ...