Pelvic Floor Imaging

Evaluation of pessary placement on the anatomy of the pelvic organs in patients with pelvic organ prolapse using imaging techniques 



Lisan Morsinkhof

Promotor: Bennie ten Haken
Co-promotor: Frank Simonis and Anique Bellos-Grob

Ziekenhuisgroep Twente  (ZGT)
Medisch Spectrum Twente (MST)

Pelvic organ prolapse (POP) is a common problem in middle aged women. In the Netherlands, the prevalence of symptomatic POP in women between 45-85 years is 11.4%. A pessary is a relatively inexpensive treatment option that reduces POP symptoms. However, in 56% of the cases complications occur and the success rates after 1 year are only between 50 and 73%. Furthermore, researchers and clinicians have different thoughts about the position of a pessary inside the body and research into risk factors associated with unsuccessful pessary fitting shows conflicting result. Therefore, it is needed to investigate the position of a pessary and the influence of a pessary on the pelvic organs to gain more insight in factors associated with successful pessary fitting.  Imaging techniques can be used to evaluate the position of a pessary. Magnetic resonance imaging (MRI) is an imaging technique in which three dimensional imaging of multiple compartments is possible. The additional value of the use of upright MRI is that pessary fitting can be evaluated in the position in which the extent of prolapse is significantly larger than in supine position. There is a large amount of unknowns considering the effect of a pessary on the pelvic organs. Insight in these unknowns may be useful to optimize the pessary treatment and reduce the complication rate and the amount of unsuccessful fittings. 

Investigate the effect of a pessary on the position and shape of the pelvic organs in patients with POP, when pessary fitting is successful (i.e. the patient continues the use of a pessary for ≥ 3 months). 

Figure: Sagitaal Upright MRI image of female pelvis. Illustrating the descent of the bladder (green line/orange arrow) anterior to the inserted pessary (orange circles).

EPPA is executed in a multi-phase set-up.

Phase 1: A total of 15 pessary wearing POP-patients are included and scanned with and without pessary during the day. MRI scans are made in the morning, during lunch break and at the end of the working day to study changes in pelvic anatomy with and without pessary. Inclusion ended Jan 2022.

Phase 1B: To study the “normal” variation in non-symptomatic woman, we studied 3 cohorts on pelvic organ descent during the day. A total of 15 nullipara (never been pregnant); 15 para-pre-menopausal and 15 para post-menopausal women were scanned. Inclusion ended Nov 2021.

Phase 1C: A total of 15 patients with POP were scanned to estimate the true amount of POP during the day in patients without previous POP treatment. Inclusion ended Jan 2022.

Phase 2: One POP patient was scanned without and with pessary ring in different MRI angulation (0;20;40;60;80), to enable set by step analysis of the re-orientation of the pessary from supine to upright position.