Global pelvic floor descent during evacuation

Case contributed by Dr Vikas Shah

Presentation

Mixed stress and urge urinary incontinence. Vaginal discomfort. Difficult defecation.

Patient Data

Age: 35 years
Gender: Female

Structural findings:
Unremarkable appearances of the urinary bladder, vagina, uterus, ovaries, anal canal and rectum. No evidence of endopelvic fascial defect. TVT (tension free transvaginal) tape is identified on the axial and coronal images as linear low signal structures extending from the lower anterior abdominal wall, passing posterior to the bladder neck. Symmetric appearances of the levator musculature. No lymphadenopathy and no bony abnormality.

Dynamic findings:
Measurements obtained using the PCL system at maximal straining are as follows:
Bladder neck: 37 mm below line (mild cystocele)
Uterine cervix: 12 mm below line (mild uterine descent)
Anorectal junction: 63 mm below line (moderate anorectal junction descent)
Anterior rectocele: 36 mm in depth (moderate sized anterior rectocele)

At the onset of evacuation, there is marked global pelvic floor descent. As the rectal gel is evacuated from the lumen, the posterior portion of the cystocele is allowed to enlarge and forms a relatively broad base compressing the anterior wall of the vagina. The gel within the rectocele is not expelled, but there is no significant rectal mucosal thickening and no intussusception or external prolapse. The angle between the bladder neck and urethra changes markedly during evacuation, in keeping with the clinical finding of urethral hypermobility. No definite loss of urine was observed during the study. There is no enterocele.

In summary:
No structural abnormality.
Moderate global pelvic floor descent, with the anterior and posterior compartments being the worst affected, with moderate sized anterior rectocele.
No rectoanal mucosal intussusception or external prolapse.
Reduction of vesico-urethral angle during evacuation in keeping with urethral hypermobility.

Case Discussion

The presence of the TVT reflects a previous attempt at treating the stress urinary incontinence. However there is marked descent of the urinary bladder on evacuation, and this with the change in urethral angle are anatomical changes that contribute to stress incontinence. There is also rectal descent along with a rectocele. The imaging findings can explain all of the symptoms.

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