Variations in structural support site failure patterns by prolapse size on stress 3D MRI.

INTRODUCTION AND HYPOTHESIS: Our objective was to develop a standardized measurement system to evaluate structural support site failures among women with anterior vaginal wall-predominant prolapse according to increasing prolapse size using stress three-dimensional (3D) magnetic resonance imaging (MRI). METHODS: Ninety-one women with anterior vaginal wall-predominant prolapse and uterus in situ who had undergone research stress 3D MRI were included for analysis. The vaginal wall length and width, apex and paravaginal locations, urogenital hiatus diameter, and prolapse size were measured at maximal Valsalva on MRI. Subject measurements were compared to established measurements in 30 normal controls without prolapse using a standardized z-score measurement system. A z-score greater than 1.28, or the 90th percentile in controls, was considered abnormal. The frequency and severity of structural support site failure was analyzed based on tertiles of prolapse size. RESULTS: Substantial variability in support site failure pattern and severity was identified, even between women with the same stage and similar size prolapse. Overall, the most common failed support sites were straining hiatal diameter (91%) and paravaginal location (92%), followed by apical location (82%). Impairment severity z-score was highest for hiatal diameter (3.56) and lowest for vaginal width (1.40). An increase in impairment severity z-score was observed with increasing prolapse size among all support sites across all three prolapse size tertiles (p < 0.01 for all). CONCLUSIONS: We identified substantial variation in support site failure patterns among women with different degrees of anterior vaginal wall prolapse using a novel standardized framework that quantifies the number, severity, and location of structural support site failures.

Comparison of the anterior pelvis and levator ani muscle on MRI in women with and without anterior pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The objective was to compare the differences in pelvic and levator ani muscle diameters in women with and without anterior pelvic organ prolapse. METHODS: Three groups were included, including 50 nulliparous women (nulliparous group), 50 women with stage III-IV anterior vaginal prolapse (prolapse group), and 50 women of the same age as the prolapse group but without prolapse (nonprolapse control group). The ischial interspinous diameter (ISD), anterior pelvic area (APA), levator defect score (LDS), levator ani hiatus width (LH-W), H-line, M-line, levator ani plate length, levator ani plate angle, and cervix length (CL) were measured. RESULTS: There were no significant differences in ISD (10.6±0.8 vs 10.6±0.9 cm), LH-W (3.0±0.4 vs 3.3±0.4 cm), or CL (2.9±0.6 vs 3.0±0.5 cm) between the nulliparous group and the nonprolapse control group (p>0.05). However, there were significant differences between them and the prolapsed group (11.2±0.6 cm, 3.6±0.4 cm, 4.2±1.5 cm; p<0.05). There were no significant differences in LDS (0.70±0.61 vs 0.70±0.65) or APA (58.4±8.4 vs 60.1±7.4 cm2) between the nonprolapse control group and the prolapse group (p>0.05), but they were significantly different from those of the nulliparous group (0.08±0.34, 55.1±6.0 cm2) (p<0.05). The area under the receiver-operating characteristic curve for the ISD of nonprolapse control and prolapse groups was 0.713, and the cutoff value was 10.95 cm. CONCLUSIONS: The levator ani hiatus width and cervix length were larger in patients with anterior vaginal prolapse than in those without prolapse. An ischial ISD greater than 10.95 cm was associated with prolapse.

Predictive Model for the Diagnosis of Uterine Prolapse Based on Transperineal Ultrasound.

We want to describe a model that allows the use of transperineal ultrasound to define the probability of experiencing uterine prolapse (UP). This was a prospective observational study involving 107 patients with UP or cervical elongation (CE) without UP. The ultrasound study was performed using transperineal ultrasound and evaluated the differences in the pubis−uterine fundus distance at rest and with the Valsalva maneuver. We generated different multivariate binary logistic regression models using nonautomated methods to predict UP, including the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver. The parameters were added progressively according to their simplicity of use and their predictive capacity for identifying UP. We used two binary logistic regression models to predict UP. Model 1 was based on the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver and the age of the patient [AUC: 0.967 (95% CI, 0.939−0.995; p < 0.0005)]. Model 2 used the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver, age, avulsion and ballooning (AUC: 0.971 (95% CI, 0.945−0.997; p < 0.0005)). In conclusion, the model based on the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver and the age of the patient could predict 96.7% of patients with UP.

Natural Orifice Endosonographic Colposuspension With Rectopexy for Combined Pelvic Organ Prolapse: A Feasibility Study.

BACKGROUND: We describe a natural orifice technique for simultaneous endoluminal lateral suspension of apical vaginal wall and rectal prolapse fixation with ultrasound and fluoroscopic assistance. IMPACT OF INNOVATION: The technique is minimally invasive, can be performed under regional anaesthesia, and avoids laparotomy or use of a mesh in addition to preserving the uterus. TECHNOLOGY MATERIALS AND METHODS: This technique involves suprapubic transvaginal ventral suture colposuspension, fixation of the anterior rectal wall to the undersurface of the anterior abdominal wall and tack fixation of the posterior rectal wall to the underlying sacral promontory through a submucosal tunnel performed endoscopically with fluoroscopic and ultrasound assistance. PRELIMINARY RESULTS: Seven patients with a mean age of 63 years were followed between 3 to 11 months. CONCLUSIONS: This is a novel minimally invasive transluminal procedure that repairs concomitant rectal and vaginal prolapse in the same sitting. FUTURE DIRECTIONS: Improvement in the instrument design and incorporation of endoluminal robotic systems will enhance the technical ease. The study needs validation in larger series of patients with longer follow-up.

Interobserver variability of ultrasound measurements for the differential diagnosis of uterine prolapse and cervical elongation without uterine prolapse.

OBJECTIVES: Our study aims to determine the interobserver variability of different ultrasound measurements (pubis-cervix distance, pubis-uterine fundus distance, and pubis-Douglascul-de-sac distance) previously analyzed for the ultrasound differential diagnosis of uterine prolapse (UP) and cervical elongation CE without UP. MATERIALS AND METHODS: We conducted a prospective observational study with 40 patients scheduled to undergo surgical correction of UP and CE without UP. All patients underwent pelvic floor ultrasound examination by an examiner (E1) who acquired ultrasound images. Using these images, E1 measured the distances for the ultrasound differential diagnosis of UP and CE without UP, and these distances were compared with those measured by the other examiner (E2). Values were analyzed by calculating ICCs with 95% CIs. RESULTS: For UP, excellent reliability was obtained for all measurements except the pubis-Douglascul-de-sac measurement at rest, which was moderate (ICC 0.596; p = 0.028) and for the difference between the pubis-Douglascul-de-sac measurement at rest and during the Valsalva maneuver, which was good (ICC 0.691; p < 0.0005). For CE without UP, interobserver reliability was excellent for all measurements analyzed except the pubis-cervix measurement during the Valsalva maneuver, which was moderate (ICC 0.535; p = 0.052) and for the pubis-Douglascul-de-sac measurement at rest, which was good (ICC 0.768; p < 0.0005). CONCLUSIONS: There is excellent interobserver reliability in measurements of the difference in the distance from the pubic symphysis to the uterine fundus at rest and during the Valsalva maneuver for both UP and CE without UP, which are used for the ultrasound differential diagnosis of UP and CE without UP.

Managing Reproduction Emergencies in the Field: Part 2: Parturient and Periparturient Conditions.

Selected conditions affecting broodmares are discussed, including arterial rupture, dystocia, foal support with ex utero intrapartum treatment, uterine prolapse, postpartum colic, the metritis/sepsis/systemic inflammatory response syndrome complex, and retained fetal membranes. Postpartum colic beyond third-stage labor contractions should prompt comprehensive evaluation for direct injuries to the reproductive tract or indirect injury of the intestinal tract. Mares with perforation or rupture of the uterus are typically recognized 1 to 3 days after foaling, with depression, fever, and leukopenia; laminitis and progression to founder can be fulminant. The same concerns are relevant in mares with retention of fetal membranes.

Defining mechanisms of recurrence following apical prolapse repair based on imaging criteria.

BACKGROUND: Prolapse recurrence after transvaginal surgical repair is common; however, its mechanisms are ill-defined. A thorough understanding of how and why prolapse repairs fail is needed to address their high rate of anatomic recurrence and to develop novel therapies to overcome defined deficiencies. OBJECTIVE: This study aimed to identify mechanisms and contributors of anatomic recurrence after vaginal hysterectomy with uterosacral ligament suspension (native tissue repair) vs transvaginal mesh (VM) hysteropexy surgery for uterovaginal prolapse. STUDY DESIGN: This multicenter study was conducted in a subset of participants in a randomized clinical trial by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Overall, 94 women with uterovaginal prolapse treated via native tissue repair (n=48) or VM hysteropexy (n=46) underwent pelvic magnetic resonance imaging at rest, maximal strain, and poststrain rest (recovery) 30 to 42 months after surgery. Participants who desired reoperation before 30 to 42 months were imaged earlier to assess the impact of the index surgery. Using a novel 3-dimensional pelvic coordinate system, coregistered midsagittal images were obtained to assess study outcomes. Magnetic resonance imaging-based anatomic recurrence (failure) was defined as prolapse beyond the hymen. The primary outcome was the mechanism of failure (apical descent vs anterior vaginal wall elongation), including the frequency and site of failure. Secondary outcomes included displacement of the vaginal apex and perineal body and change in the length of the anterior wall, posterior wall, vaginal perimeter, and introitus of the vagina from rest to strain and rest to recovery. Group differences in the mechanism, frequency, and site of failure were assessed using the Fisher exact tests, and secondary outcomes were compared using Wilcoxon rank-sum tests. RESULTS: Of the 88 participants analyzed, 37 (42%) had recurrent prolapse (VM hysteropexy, 13 of 45 [29%]; native tissue repair, 24 of 43 [56%]). The most common site of failure was the anterior compartment (VM hysteropexy, 38%; native tissue repair, 92%). The primary mechanism of recurrence was apical descent (VM hysteropexy, 85%; native tissue repair, 67%). From rest to strain, failures (vs successes) had greater inferior displacement of the vaginal apex (difference, -12 mm; 95% confidence interval, -19 to -6) and perineal body (difference, -7 mm; 95% confidence interval, -11 to -4) and elongation of the anterior vaginal wall (difference, 12 mm; 95% confidence interval, 8-16) and vaginal introitus (difference, 11 mm; 95% confidence interval, 7-15). CONCLUSION: The primary mechanism of prolapse recurrence following vaginal hysterectomy with uterosacral ligament suspension or VM hysteropexy was apical descent. In addition, greater inferior descent of the vaginal apex and perineal body, lengthening of the anterior vaginal wall, and increased size of the vaginal introitus with strain were associated with anatomic failure. Further studies are needed to provide additional insight into the mechanism by which these factors contribute to anatomic failure.

Methods for the defining mechanisms of anterior vaginal wall descent (DEMAND) study.

INTRODUCTION AND HYPOTHESIS: The protocol and analysis methods for the Defining Mechanisms of Anterior Vaginal Wall Descent (DEMAND) study are presented. DEMAND was designed to identify mechanisms and contributors of prolapse recurrence after two transvaginal apical suspension procedures for uterovaginal prolapse. METHODS: DEMAND is a supplementary cohort study of a clinical trial in which women with uterovaginal prolapse randomized to (1) vaginal hysterectomy with uterosacral ligament suspension or (2) vaginal mesh hysteropexy underwent pelvic magnetic resonance imaging (MRI) at 30-42 months post-surgery. Standardized protocols have been developed to systematize MRI examinations across multiple sites and to improve reliability of MRI measurements. Anatomical failure, based on MRI, is defined as prolapse beyond the hymen. Anatomic measures from co-registered rest, maximal strain, and post-strain rest (recovery) sequences are obtained from the "true mid-sagittal" plane defined by a 3D pelvic coordinate system. The primary outcome is the mechanism of failure (apical descent versus anterior vaginal wall elongation). Secondary outcomes include displacement of the vaginal apex and perineal body and elongation of the anterior wall, posterior wall, perimeter, and introitus of the vagina between (1) rest and strain and (2) rest and recovery. RESULTS: Recruitment and MRI trials of 94 participants were completed by May 2018. CONCLUSIONS: Methods papers which detail studies designed to evaluate anatomic outcomes of prolapse surgeries are few. We describe a systematic, standardized approach to define and quantitatively assess mechanisms of anatomic failure following prolapse repair. This study will provide a better understanding of how apical prolapse repairs fail anatomically.

The use of 3D ultrasound in comparing surgical techniques for posterior wall prolapse repair: a pilot randomised controlled trial.

The most appropriate method for repairing posterior vaginal wall prolapse is still debatable. Women with symptomatic prolapse scheduled to undergo surgical repair in the posterior compartment were randomised to standard posterior colporrhaphy (SPC) or fascial and vaginal epithelial plication (FEP). Participants were assessed with the Prolapse Quality of Life (P-QOL) questionnaire, pelvic organ prolapse quantification (POP-Q) examination and three-dimensional ultrasound (3D US) prior to surgery and 6 months postoperatively. The research hypothesis is that 3D US of the pelvic floor is a reliable tool in comparing the anatomical outcomes of the two different surgical techniques. Differences in anatomical outcomes, assessed clinically and by ultrasonographic evaluation, were compared between the two groups using the Independent Mann-Whitney U-test and the Wilcoxon signed-rank sum test. Twenty-two women were included in the analysis. Six months postoperatively, women in the FEP arm had better anatomical outcomes compared to those who had undergone SPC (p = .02). Repeatability of the ultrasound technique was confirmed, showing moderate to very good agreement in all parameters and the 3D US evaluation was corroborated with the clinical examination, showing a greater reduction in the urogenital size in the FEP group.Impact statementWhat is already known on this subject? The low cost and universal availability of the ultrasound (US) makes it the most commonly used diagnostic modality. The ability to see beyond surface anatomy is important and useful in the assessment of the posterior vaginal wall prolapse and the obstructed defaecation, where this method may replace the defaecation proctography (Dietz 2019). Recent advances in pelvic floor ultrasonography (3D US) have achieved repeatability in the measurement of the levator hiatal (LH) dimensions, introducing a valid and readily available tool for researchers and clinicians (Dietz et al. 2005). Ultrasound may distinguish a true rectocele due to the weakening of the rectovaginal fascia from an enterocele, a rectal intussusception, or just a deficient perineum (Guzman Rojas et al. 2016).What do the results of this study add? Our study demonstrates that 3D translabial pelvic floor ultrasound is a useful and reliable tool in assessing the anatomical outcome of prolapse surgery.What are the implications of these findings for clinical practice and/or further research? Our study demonstrates that 3D translabial ultrasound of the pelvic floor is a useful and reproducible method in evaluating the anatomical outcomes of surgical repair for posterior wall prolapse. Genital hiatus (GH) and levator hiatus (LH) dimensions measured by ultrasound can be used as surrogate anatomical markers in comparing the efficacy of different surgical techniques.

Cut-offs for defining uterine prolapse using transperineal ultrasound in Chinese women: prospective multicenter study.

OBJECTIVE: Transperineal ultrasound is a simple and highly repeatable method that has been used increasingly in the quantification of pelvic organ prolapse, but abnormal uterine descent on ultrasound in Chinese women is still poorly defined. We aimed to determine the optimal cut-off to define abnormal uterine descent on transperineal ultrasound in Chinese women. METHODS: This prospective multicenter study recruited women who were examined in tertiary-level gynecological centers, due to symptoms of lower urinary tract and/or pelvic floor dysfunction, between February 2017 and September 2018. All recruited women underwent a standardized interview, pelvic organ prolapse quantification (POP-Q) examination, and four-dimensional transperineal ultrasound examination. On ultrasound, uterine descent was measured relative to the posteroinferior margin of the symphysis pubis during maximum Valsalva maneuver. The optimal cut-off value for definition of abnormal uterine descent was selected as the value with the highest Youden index and the diagnostic performance of this cut-off for the prediction of prolapse symptoms and POP-Q stage was assessed and compared by means of the area under the receiver-operating-characteristics curve (AUC). RESULTS: In total, 538 Chinese women, with a mean age of 39.4 (range, 18-81) years, were enrolled into the study. Both uterine descent on transperineal ultrasound (P < 0.001) and POP-Q stage (P < 0.001) were associated strongly with presence of prolapse symptoms. Uterine descent on ultrasound was associated significantly with POP-Q stage for apical compartment prolapse (P < 0.001). The optimal cut-off value for the definition of abnormal uterine descent on transperineal ultrasound during maximum Valsalva maneuver in the prediction of prolapse symptoms was 4.79 mm above the symphysis pubis (AUC, 0.75 (95% CI, 0.71-0.78)), while the optimal cut-off values in the prediction of prolapse of POP-Q Stage ≥ 1 and POP-Q Stage ≥ 2 were 6.63 mm above the symphysis pubis (AUC, 0.83 (95% CI, 0.80-0.86)) and 8.42 mm below the symphysis pubis (AUC, 0.85 (95% CI, 0.82-0.88)), respectively. CONCLUSIONS: The optimal cut-off value to define abnormal uterine descent on transperineal ultrasound during maximum Valsalva maneuver for the prediction of prolapse symptoms in this population of Chinese women was 4.79 mm above the symphysis pubis, close to that for predicting apical compartment prolapse of POP-Q Stage ≥ 1 (6.63 mm above the symphysis pubis). These are somewhat different from values described previously in mainly Caucasian populations. Ethnic differences should be taken into account in the evaluation of pelvic organ prolapse using transperineal ultrasound. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound assessment of pelvic floor muscle contraction: reliability and development of an ultrasound-based contraction scale.

OBJECTIVES: To determine intra- and interrater reliability and agreement for ultrasound measurements of pelvic floor muscle contraction and to assess the correlation between ultrasound and vaginal palpation. We also aimed to develop an ultrasound scale for assessment of pelvic floor muscle contraction. METHODS: This was a cross-sectional study of 195 women scheduled for stress urinary incontinence (n = 65) or prolapse (n = 65) surgery or who were primigravid (n = 65). Pelvic floor muscle contraction was assessed by vaginal palpation using the Modified Oxford Scale (MOS) and by two- and three-dimensional (2D/3D) transperineal ultrasound. Proportional change in 2D and 3D levator hiatal anteroposterior (AP) diameter and 3D levator hiatal area between rest and contraction were used as measures of pelvic floor muscle contraction. One rater repeated all ultrasound measurements on stored volumes, which were used for intrarater reliability and agreement analysis, and three independent raters analyzed 60 ultrasound volumes for interrater reliability and agreement analysis. Reliability was assessed using the intraclass correlation coefficient (ICC) and agreement using Bland-Altman analysis. Tomographic ultrasound was used to identify women with major levator injury. Spearman's rank correlation coefficient (rS ) was used to assess the correlation between ultrasound measurements of pelvic floor muscle contraction and MOS score. The proportion of women allocated to each category of muscle contraction (absent, weak, moderate or strong) by palpation was used to determine the cut-offs for the ultrasound scale. RESULTS: Intrarater ICC was 0.81 (95% CI, 0.74-0.85) for proportional change in 2D levator hiatal AP diameter. Interrater ICC was 0.82 (95% CI, 0.72-0.89) for proportional change in 2D AP diameter, 0.80 (95% CI, 0.69-0.88) for proportional change in 3D AP diameter and 0.72 (95% CI, 0.56-0.83) for proportional change in hiatal area. The prevalence of major levator injury was 22.6%. The strength of correlation (rS ) between ultrasound measurements and MOS score was 0.52 for 2D AP diameter, 0.62 for 3D AP diameter and 0.47 for hiatal area (P < 0.001 for all). On the ultrasound contraction scale, proportional change in 2D levator hiatal AP diameter of < 1% corresponds to absent, 2-14% to weak, 15-29% to normal and > 30% to strong contraction. CONCLUSIONS: Ultrasound seems to be an objective and reliable method for evaluation of pelvic floor muscle contraction. Proportional change in 2D levator hiatal AP diameter had the highest ICC and moderate correlation with MOS score assessed by vaginal palpation, and we constructed an ultrasound scale for assessment of pelvic floor muscle contraction based on this measure. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

A Hypothesis Generating the Mechanical Systems Underlying Posterior Vaginal Prolapse Based on Observed Displacements by Dynamic Magnetic Resonance Imaging.

OBJECTIVE: The aim of this study was to analyze quantified displacements of the posterior vaginal wall (PVW) on dynamic magnetic resonance imaging (MRI), which may generate hypotheses for the detailed mechanisms that underlie the development of posterior vaginal prolapse. METHODS: Pelvic dynamic MRI scans were obtained for 12 women with normal vaginal structure (stage 0) and 62 women with 4 consecutive stages (1-4) of posterior vaginal prolapse. Structural locations (apex vagina, distal vagina, and mid-perineal body [PB]) and equidistant points along the PVW (points 4-6 were considered as midvagina) were identified, and PVW length, straight distance of PVW, levator ani parameters (levator hiatus length [LHL], levator hiatus width [LHW], levator plate angle, anorectal angle, and M line [ML]), urogenital hiatus, and prolapse diameter were measured at rest and maximal Valsalva, respectively. The displacement of these measurements was obtained. RESULTS: From stage 0 to 2, the variables LHL, LHW, levator plate angle, anorectal angle, and ML increased gradually, but midvagina, distal vagina, and mid-PB were the opposite. From stage 2 to 3, apex vagina, midvagina, distal vaginal, mid-PB, LHL, LHW, and ML raised rapidly and peaked at stage 3, then declined at stage 4. In addition, the correlation coefficients between each measurement from stage 2 to 3 were statistically higher than those from stage 0 to 2. CONCLUSIONS: Quantified displacements of the PVW and its supporting structure were shown on dynamic MRI, and the mechanical mechanisms were hypothesized regarding the interaction between pressure and the support force contributing to the deformation of the PVW and the supporting structures.

U-turn of uterine arteries: a novel sign pathognomonic of uterine inversion.

A uterine inversion occurs when the uterine fundus collapses into the endometrial cavity. It is a rare complication in obstetrics following delivery, and it is even more infrequently encountered in gynecology with the non-puerperal uterus. A submucous fibroid is the most common reported cause of the non-puerperal uterine inversion. If not promptly recognized and treated, uterine inversion may lead to a severe hemorrhagic shock and death. We describe a novel three-dimensional power Doppler feature for the diagnosis of uterine inversion.

Comparison of measurement systems for posterior vaginal wall prolapse on magnetic resonance imaging.

INTRODUCTION AND HYPOTHESIS: A wide variety of reference lines and landmarks have been used in imaging studies to diagnose and quantify posterior vaginal wall prolapse without consensus. We sought to determine which is the best system to (1) identify posterior vaginal wall prolapse and its appropriate cutoff values and (2) assess the prolapse size. METHODS: This was a secondary analysis of sagittal maximal Valsalva dynamic MRI scans from 52 posterior-predominant prolapse cases and 60 comparable controls from ongoing research. All eight existing measurement lines and a new parameter, the exposed vaginal length, were measured. Expert opinions were used to score the prolapse sizes. Simple linear regressions, effect sizes, area under the curve, and classification and regression tree analyses were used to compare these reference systems and determine cutoff values. Linear and ordinal logistic regressions were used to assess the effectiveness of the prolapse size. RESULTS: Among existing parameters, "the perineal line-internal pubis," a reference line from the inside of the pubic symphysis to the front tip of the perineal body (cutoff value 0.9 cm), had the largest effect size (1.61), showed the highest sensitivity and specificity to discriminate prolapse with area under the curve (0.91), and explained the most variation (68%) in prolapse size scores. The exposed vaginal length (cutoff value 2.9) outperformed all the existing lines, with the largest effect size (2.09), area under the curve (0.95), and R-squared value (0.77). CONCLUSIONS: The exposed vaginal length performs slightly better than the best of the existing systems, for both diagnosing and quantifying posterior prolapse size. Performance characteristics and evidence-based cutoffs might be useful in clinical practice.

Metastatic Acinic Cell Carcinoma to the Vagina: A First Reported Case.

This is a case of a 62-year-old woman with a remote history of acinic cell carcinoma of the parotid gland, who presented with a palpable vaginal mass, anterior vaginal wall prolapse, and stress urinary incontinence. A 2 cm firm mobile mass on the anterior vaginal wall was found on clinical examination. A computed tomographic scan revealed a mass between the vaginal vault and bladder that was eventually surgically excised. The histology, supported by the immunohistochemistry, revealed metastatic acinic cell carcinoma to the vagina after 37 years of her initial diagnosis. This is the first reported case in the literature to occur in the vagina.

Improved Detection of Pelvic Organ Prolapse: Comparative Utility of Defecography Phase Sequence to Nondefecography Valsalva Maneuvers in Dynamic Pelvic Floor Magnetic Resonance Imaging.

PURPOSE: To evaluate the utility of a defecography phase (DP) sequence in dynamic pelvic floor MRI (DPMRI), in comparison to DPMRI utilizing only non-defecography Valsalva maneuvers (VM). MATERIALS AND METHODS: Inclusion criteria identified 237 female patients with symptoms and/or physical exam findings of pelvic floor prolapse. All DPMRI exams were obtained following insertion of ultrasound gel into the rectum and vagina. Steady-state free-precession sequences in sagittal plane were acquired in the resting state, followed by dynamic cine acquisitions during VM and DP. In all phases, two experienced radiologists performed blinded review using the H-line, M-line, Organ prolapse (HMO) system. The presence of a rectocele, enterocele and inferior descent of the anorectal junction, bladder base, and vaginal vault were recorded in all patients using the pubococcygeal line as a fixed landmark. RESULTS: DPMRI with DP detected significantly more number of patients than VM (p<0.0001) with vaginal prolapse (231/237, 97.5% vs. 177/237, 74.7%), anorectal prolapse (227/237, 95.8% vs. 197/237, 83.1%), cystocele (197/237, 83.1% vs. 108/237, 45.6%), and rectocele (154/237, 65% vs. 93/237, 39.2%). The median cycstocele (3.2cm vs. 1cm), vaginal prolapse (3cm vs. 1.5cm), anorectal prolapse (5.4cm vs. 4.2cm), H-line (8cm vs. 7.2cm) and M-line (5.3cm vs. 3.9cm) were significantly higher with DP than VM (p<0.0001). CONCLUSIONS: Addition of DP to DPMRI demonstrates a greater degree of pelvic floor instability as compared to imaging performed during VM alone. Pelvic floor structures may show mild descent or appear normal during VM, with marked prolapse on subsequent DP images.

Detection of Concealed Uterine Prolapse in the Volume-Rendering Mode of 4-Dimensional Translabial Ultrasound: A Retrospective Observational Study.

OBJECTIVES: To assess the association between a widened vaginal canal on volume-rendered ultrasound (US) imaging with concealed uterine prolapse. METHODS: This work was a retrospective study of 253 women who had an International Continence Society Pelvic Organ Prolapse Quantification System examination and translabial US examination. The anteroposterior diameter of the vaginal canal was measured in the rendered axial plane for all women. The widened vaginal canal was defined as an anteroposterior diameter above the 95th centile in women with normal uterine descent. The performance of the widened vaginal canal for prediction of clinical uterine prolapse was tested. RESULTS: Valid data from 233 women were analyzed. A mean anteroposterior diameter of 5.6 mm (range, 2.3-10.5 mm; 95th percentile, 10 mm) was seen in 119 women with normal uterine descent. An eye-shaped vaginal canal with a mean anteroposterior diameter of 17.8 mm (range, 10.7-26.8 mm) was seen in 69 women with uterine prolapse. A widened vaginal canal was defined as an anteroposterior diameter of greater than 10 mm. Of 45 concealed uterine descents, 32 had a widened vaginal canal (ie, anteroposterior diameter > 10 mm), and 27 had clinical uterine prolapse. The κ test showed good agreement between physical and US findings (κ = 0.76; P < .001). Ultrasound findings had excellent predictive value (odds ratio, 82.3) for the diagnosis of clinical uterine prolapse. CONCLUSIONS: An eye-shaped vaginal canal with an anteroposterior diameter of greater than 10 mm in the rendered axial plane was a sign of uterine prolapse. This sign may be helpful for detecting concealed uterine prolapse in complex pelvic organ prolapse.