Reproductive: Acquired

Question 1

Answer 1

Salpingitis isthmica nodes (nodular scarring of the Fallopian tubes)

Note: Usually involving the proximal 2/3 of the uterine tubes.

Question 2

Salpingitis isthmica nodosa is strongly associated with…

Answer 2

Infertility and ectopic pregnancy

Question 3

Persistant vaginal bleeding s/p dilation and curettage

Answer 3

Think uterine AVM

Note: Tubular/serpiginous anechoic structure in uterine myometrium with high velocity color Doppler.

Question 4

Infertility

Answer 4

Think Asherman’s syndrome

Note: Multiple intrauterine filling defects.

Question 5

Fever

Answer 5

Think endomteritis

Note: Irregular thickening of the endometrium (yellow arrow) and fluid-filled endometrial cavity containing gas (blue arrow).

Question 6

Endopelvic facia

Answer 6

Ligaments and fascia that provide the main support for the anterior and middle pelvic compartments (bladder/urethra and vagina/cervix/uterus)

Question 7

Levator ani

Answer 7

The main muscular component of the pelvic floor composed of the puborectalis, pubococcygeus, and iliococcygeus

Question 8

Urogenital diaphragm

Answer 8

An anatomic landmark (the most caudal/superficial musculofascial structure of the pelvic floor) used to classify urethral injury

Question 9

What are the two components of pelvic floor relaxation?

Answer 9

• Pelvic floor descent
• Pelvic floor widening

Note: These can be graded on sagittal MRI during maximum strain.

Question 10

Pubococcygeal line

Answer 10

A line drawn from the inferior margin of the symphysis pubis to the junction between the first and second coccygeal elements

Note: This is helpful when evaluating the pelvic floor on MRI.

Question 11

H line (pelvic floor MRI)

Answer 11

A line drawn from the inferior margin of the pubic symphysis to the posterior aspect of the puborectalis muscle sling

Note: This is helpful when evaluating hiatal enlargement of the pelvic floor on MRI.

Question 12

M line (pelvic floor MRI)

Answer 12

The shortest distance between the posterior aspect of the puborectalis muscle sling and the pubocyccygeal line

Note: This is helpful when evaluating pelvic floor descent on MRI.

Question 13

What is considered hiatal enlargement when evaluating the pelvic floor on MRI?

Answer 13

H line >6 cm (pubic symphysis to puborectalis muscle sling)

Question 14

What is considered abnormal hiatal descent when evaluating the pelvic floor on MRI?

Answer 14

M line >2 cm (puborectalis muscle sling to pubococcygeal line)

Question 15

Imaging features of pelvic floor dysfunction

Answer 15

• Hiatal enlargement (H line >6 cm)
• Longer pelvic floor descent (M line >2 cm)

Question 16

Pelvic floor MRI protocol

Answer 16

• Steady state (T2 imaging in 3 planes)
• Dynamic state (Sagittal T2 fat sat during Valsavla, Kegel, and/or defecation)

Question 17

Cystocele

Answer 17

Bladder descent >1 cm below the pubococcygeal line

Question 18

Treatment for cystocele

Answer 18

• Retropubic urethropexy (if normal stress incontinence)
• Pubovaginal sling (if there is also urethral hypermobility)

Question 19

Imaging definition of uterine prolapse

Answer 19

Descent of the cervix (or posterior vaginal fornix) >1 cm below the pubococcygeal line

Note: Should be measured when there is no stool in the rectum as this can “prop up” the uterus.

Question 20

What are the major categories of pelvic organ prolapse?

Answer 20

• Cystocele (anterior compartment)
• Uterine prolapse (middle compartment)
• Rectocele (posterior compartment)

Question 21

Rectocele

Answer 21

Abnormal rectal bulging due to weakening of the rectovaginal fascia (described by how far they bulge relative to the anal canal)

Question 22

Major risk factor for uterine prolapse

Answer 22

Hysterectomy

Question 23

Risk factors for cystocele

Answer 23

Multiple prior vaginal births

Question 24

Risk factors for rectocele

Answer 24

• Vaginal surgery
• Hysterectomy
• Chronic constipation
• Old age