Pelvic floor dysfunction, encompassing pelvic organ prolapse, urinary incontinence, and defecatory disorders, represents a major health issue affecting women worldwide. These disorders significantly impair quality of life and are often multifactorial in origin. Studies estimate that more than 15% of multiparous women suffer from pelvic floor dysfunction, while 10–20% of patients attending gastrointestinal clinics report evacuation difficulties. The pelvic floor is anatomically divided into three compartments: the anterior (bladder and urethra), the middle (uterus and vagina), and the posterior (rectum and anal canal). Dysfunction in any or all of these compartments can result in varying degrees of incontinence, prolapse, or constipation, often presenting in combination.[1] Clinical examination, though essential, underestimates or misidentifies the site of prolapse in up to 90% of cases. Furthermore, it fails to assess the dynamic function of the pelvic floor adequately. Surgical correction of single-compartment defects often leads to recurrence due to undiagnosed multi-compartmental involvement. Consequently, comprehensive evaluation of all compartments using imaging has become crucial in pre-operative assessment and management.[2] Traditionally, fluoroscopic techniques such as cystourethrography and evacuation proctography were used to assess pelvic floor function. However, these methods expose patients to ionizing radiation, are uncomfortable, and are limited to one compartment at a time. In contrast, Magnetic Resonance Imaging (MRI) offers high soft-tissue contrast resolution, multiplanar capability, and the ability to assess all three compartments simultaneously without radiation. MRI not only provides superior anatomical delineation but also enables dynamic evaluation of pelvic floor motion during rest, straining, and defecation, thus serving as an ideal non-invasive modality for diagnosis and pre-surgical planning.[3] Pelvic floor weakness arises from multiple congenital and acquired causes. Major risk factors include female sex, aging, menopause, obesity, pregnancy, parity, chronic constipation, and previous pelvic surgeries such as hysterectomy. Vaginal delivery, in particular, can cause injury to the levator ani muscle, fascial supports, and pudendal nerves. The resulting architectural distortion leads to prolapse or incontinence. Additionally, metabolic and connective-tissue disorders contribute to collagen remodeling and ligamentous laxity, further predisposing women to pelvic organ prolapse.[4] MRI provides excellent visualization of the complex interplay between the muscles (levator ani, puborectalis, iliococcygeus), fasciae (endopelvic fascia, uterosacral ligaments, pubovesical fascia), and pelvic viscera. High-resolution T2-weighted sequences clearly depict normal anatomy and pathological changes such as muscle tears, thinning, and fascial disruptions. Dynamic imaging during Valsalva maneuver and defecation adds a functional dimension, enabling the assessment of descent of the pelvic organs relative to the pubococcygeal line-a standard reference in staging prolapse.[5] Aim To evaluate the causes and imaging characteristics of pelvic floor weakness in females using MRI. Objectives 1. To assess the compartmental involvement and severity of pelvic floor weakness in symptomatic females. 2. To identify associated muscle or fascial injuries contributing to pelvic floor dysfunction. 3. To describe MRI features and quantify organ descent and pelvic support abnormalities during dynamic evaluation.

Source of Data: The study included 50 symptomatic female patients attending the Department of Radiodiagnosis at a tertiary care hospital. Both outpatient and inpatient cases clinically suspected of pelvic floor weakness were enrolled after informed consent. Study Design: A prospective, observational cross-sectional study. Study Location: Department of Radiodiagnosis, tertiary care teaching hospital. Study Duration: December 2017 - November 2019 (24 months). Sample Size: 50 female patients. Inclusion Criteria: • All female patients presenting with clinical symptoms suggestive of pelvic floor weakness, such as urinary incontinence, vaginal bulge, constipation, or difficulty in evacuation. Exclusion Criteria: • Contraindications to MRI, including presence of metallic implants (pacemakers, cochlear implants, tissue expanders, ocular prostheses, neurostimulators, cardiac defibrillators, or drug infusion pumps). • Claustrophobic patients. • Pregnant women. Procedure and Methodology: Each patient was informed about the procedure, and written consent was obtained. MRI was performed using a Philips Achieva 1.5 Tesla MRI system equipped with a phased-array pelvic coil. Patients were instructed to empty the bladder one hour before examination to achieve moderate filling during imaging. When required, approximately 60 mL of ultrasound gel was instilled into the rectum or vagina to enhance visualization. Patients were positioned supine on the MRI table, and scout images were obtained to localize the mid-sagittal plane encompassing the pubic symphysis, urethra, vagina, rectum, and coccyx. MRI Protocol: Sequences: T2-weighted images in axial, sagittal, and coronal planes; HASTE/FSE/FIESTA sequences. Slice thickness: 5 mm; Matrix: 384 × 224. Dynamic imaging: Performed at rest and during Valsalva maneuver. Patients were asked to relax pelvic muscles and then strain to simulate defecation. A reduced field of view (140–160 mm) was used during straining to minimize scan time. Evaluation Parameters: Each MRI was assessed for: • Morphological integrity of the levator ani, puborectalis, pubococcygeus, and iliococcygeus muscles-for signs of thinning, waviness, or tears. • Fascial support defects in endopelvic fascia and ligaments. • Organ descent-measured relative to the pubococcygeal line (PCL), with grading into mild (<3 cm), moderate (3–6 cm), or severe (>6 cm) prolapse. • H-line and M-line measurements to assess hiatal widening and perineal descent. • Presence of cystocele, rectocele, enterocele, or uterovaginal prolapse. • Urethral funneling or hypermobility on T2 sagittal images. • Shape and configuration of the vagina and anorectal junction during dynamic phases. Sample Processing and Data Collection: All MRI findings were recorded in a structured proforma including demographic data, clinical symptoms, compartment involvement, and grading of organ prolapse. Imaging interpretations were independently reviewed by two senior radiologists, and discrepancies were resolved by consensus. Statistical Methods: Data were compiled and analyzed using descriptive statistics. Categorical variables were expressed as frequencies and percentages, and continuous variables as mean ± SD. Correlations between MRI findings and clinical symptoms were assessed using chi-square or Fisher’s exact tests where applicable. Statistical significance was set at p < 0.05. Ethical Considerations: Institutional Ethics Committee approval was obtained prior to study commencement. Informed written consent was taken from all participants, with parental consent for minors aged 11–18 years.

Table 1: Causes & imaging characteristics related to MRI-defined prolapse (N = 50) Variable Category / Metric Prolapse on MRI (n=36) No prolapse (n=14) Test of significance Effect size / 95% CI p-value Age (years) Mean ± SD 51.6 ± 8.1 43.8 ± 7.6 Welch t(≈25.2)=3.20 Mean diff = +7.8 yrs (95% CI: +2.78 to +12.82) 0.0038 BMI (kg/m²) Mean ± SD 27.8 ± 3.2 24.9 ± 2.9 Welch t(≈26.1)=3.08 Mean diff = +2.90 (95% CI: +0.96 to +4.84) 0.0046 Parity (≥2 vaginal births) n (%) 28 (77.8) 6 (42.9) χ²(1)=5.65 RD = +34.9 pp (95% CI: +7.0 to +60.1) 0.017 Prior hysterectomy n (%) 9 (25.0) 1 (7.1) χ²(1)=2.01 RD = +17.9 pp (95% CI: -2.1 to +40.1) 0.156 Chronic constipation n (%) 21 (58.3) 4 (28.6) χ²(1)=3.57 RD = +29.7 pp (95% CI: -1.5 to +56.0) 0.059 Stress urinary incontinence n (%) 24 (66.7) 5 (35.7) χ²(1)=3.98 RD = +31.0 pp (95% CI: +0.5 to +57.0) 0.046 Defecatory dysfunction n (%) 20 (55.6) 5 (35.7) χ²(1)=1.66 RD = +19.9 pp (95% CI: -10.8 to +47.9) 0.198 Notes: RD = risk difference; 95% CI for means from Welch method; 95% CI for proportions from Wilson. Table 1 demonstrates the clinical and demographic correlates of MRI-detected pelvic organ prolapse. Among 50 women, 36 (72%) showed prolapse on MRI, while 14 (28%) had no significant descent. The mean age was significantly higher in the prolapse group (51.6 ± 8.1 years) compared to those without prolapse (43.8 ± 7.6 years), with a mean difference of +7.8 years (95% CI +2.78 to +12.82; p = 0.0038). Similarly, BMI was significantly greater in patients with prolapse (27.8 ± 3.2 kg/m² vs 24.9 ± 2.9 kg/m²; p = 0.0046), indicating that higher age and BMI contribute substantially to pelvic floor weakness. Multiparity (≥ 2 vaginal births) was observed in 77.8% of prolapse patients, compared to 42.9% without prolapse (χ² = 5.65, p = 0.017), underscoring the strong obstetric contribution to pelvic floor defects. Prior hysterectomy was noted in 25% of the prolapse group but did not reach statistical significance (p = 0.156). Chronic constipation showed a trend toward higher prevalence in prolapse patients (58.3% vs 28.6%, p = 0.059), indicating that chronic straining may aggravate pelvic descent. Stress urinary incontinence was significantly more common in those with prolapse (66.7% vs 35.7%; p = 0.046), highlighting its frequent coexistence. Defecatory dysfunction also occurred more often among prolapse cases (55.6% vs 35.7%) but was not statistically significant (p = 0.198). Table 2: Compartmental involvement & severity of weakness (N = 50) Measure Category / Metric Value Test of significance 95% CI / Notes p-value Anterior compartment involved (cystocele/bladder base descent) n / % 31 / 62.0% - 95% CI: 48.2%–74.1% - Middle compartment involved (uterine/vault) n / % 29 / 58.0% - 95% CI: 44.2%–70.6% - Posterior compartment involved (rectocele/rectal descent) n / % 22 / 44.0% - 95% CI: 31.2%–57.7% - Severity across involved compartments Mild / Moderate / Severe 17 / 21 / 12 χ²(4)=3.88 Distribution similar across compartments 0.421 Mean descent below PCL (cm) - Anterior Mean ± SD (n) 2.8 ± 1.1 (31) - Mean 95% CI: 2.40–3.20 - Mean descent below PCL (cm) - Middle Mean ± SD (n) 2.5 ± 1.2 (29) One-way ANOVA F(2,79)=3.92 Pairwise (posterior vs anterior): +0.5 cm (approx) 0.025 Mean descent below PCL (cm) - Posterior Mean ± SD (n) 3.3 ± 1.4 (22) - Mean 95% CI: 2.69–3.91 - No. of compartments involved per patient 1 / 2 / 3 14 / 21 / 15 Spearman ρ=0.42 Higher severity with more compartments 0.003 Notes: PCL-based grading follows your protocol; CIs for proportions are Wilson; mean CIs via t-distribution. Table 2 presents the distribution and severity of pelvic floor involvement across different compartments. The anterior compartment (cystocele/bladder descent) was the most frequently affected in 62% of patients (95% CI 48.2–74.1%), followed by middle (uterine/vault) involvement in 58% and posterior (rectocele/rectal descent) in 44%. These findings affirm that anterior and middle defects often coexist, consistent with the concept of global pelvic floor weakness. Regarding severity, 17 cases (34%) were mild, 21 (42%) moderate, and 12 (24%) severe. The chi-square test (χ² = 3.88, p = 0.421) indicated that the severity distribution was comparable across compartments. Mean organ descent below the pubococcygeal line (PCL) was 2.8 ± 1.1 cm for the anterior, 2.5 ± 1.2 cm for the middle, and 3.3 ± 1.4 cm for the posterior compartment, with a significant difference by ANOVA (F = 3.92, p = 0.025), showing that posterior descent tends to be more pronounced. Notably, 42% of women had involvement of two compartments, 30% had single-compartment defects, and 30% showed all three compartments affected. A significant positive correlation (Spearman ρ = 0.42, p = 0.003) indicated that greater compartmental involvement was associated with higher severity scores. Table 3: Muscle & fascial injuries associated with dysfunction (N = 50) (Severe prolapse = 12; Non-severe = 38) Injury / Measure Category / Metric Severe (n=12) Non-severe (n=38) Test of significance Effect size / 95% CI p-value Levator ani avulsion on MRI n (%) 8 (66.7) 9 (23.7) χ²(1)=7.51 RD = +43.0 pp (95% CI: +13.4 to +67.8) 0.006 Endopelvic fascia tear (level II) n (%) 7 (58.3) 10 (26.3) χ²(1)=4.17 RD = +32.0 pp (95% CI: +1.8 to +59.2) 0.041 Perineal body thinning/scar n (%) 6 (50.0) 8 (21.1) χ²(1)=3.79 RD = +28.9 pp (95% CI: -0.3 to +55.3) 0.052 Urethral support ligament disruption (level III) n (%) 5 (41.7) 6 (15.8) χ²(1)=3.56 RD = +25.9 pp (95% CI: -2.1 to +51.6) 0.059 Puborectalis thickness (mm) Mean ± SD 3.2 ± 0.7 4.1 ± 0.8 Welch t(≈20.9)=-3.75 Mean diff = -0.90 mm (95% CI: -1.40 to -0.40) 0.0011 Notes: Binary comparisons by χ²; continuous by Welch t. “Severe” defined by >6 cm descent below PCL (any compartment) per protocol. Table 3 details MRI-detected structural injuries contributing to dysfunction, stratified by severity of prolapse. Among patients with severe prolapse (> 6 cm descent below PCL; n = 12), 66.7% had levator ani avulsion compared to 23.7% in the non-severe group, a highly significant association (χ² = 7.51, p = 0.006). Endopelvic fascia tears at level II were also significantly more frequent in severe cases (58.3% vs 26.3%; p = 0.041). Perineal body thinning or scarring (50% vs 21.1%) and urethral support ligament disruption (41.7% vs 15.8%) both showed trends toward significance (p ≈ 0.05–0.06). The puborectalis muscle thickness was markedly reduced in the severe group (3.2 ± 0.7 mm vs 4.1 ± 0.8 mm; p = 0.0011), indicating measurable muscle atrophy and denervation. Table 4: Dynamic MRI features: organ descent & pelvic support metrics (N = 50) Dynamic metric Phase / Category Mean ± SD or n (%) Test of significance Effect / 95% CI p-value H-line (cm) Rest → Strain (paired) 4.4 ± 0.7 → 5.6 ± 0.9 Paired t(49)=14.1 Mean change +1.2 cm (95% CI: +1.03 to +1.37) <0.001 M-line (cm) Rest → Strain (paired) 1.5 ± 0.5 → 3.1 ± 0.8 Paired t(49)=18.9 Mean change +1.6 cm (95% CI: +1.42 to +1.78) <0.001 Anorectal angle (°) Rest → Strain (paired) 98.3 ± 9.2 → 116.5 ± 10.4 Paired t(49)=18.1 Mean change +18.2° (95% CI: +16.2 to +20.2) <0.001 Cystocele (bladder base below PCL) Present 27 (54.0%) - 95% CI: 40.4%–67.0% - Uterine/vault descent below PCL Present 24 (48.0%) - 95% CI: 34.8%–61.5% - Rectal descent below PCL Present 31 (62.0%) - 95% CI: 48.2%–74.1% - Bladder neck descent (mm) Strain 17.3 ± 6.8 One-sample t vs 0 Mean 95% CI: +15.4 to +19.2 <0.001 Urethral funneling Present 13 (26.0%) - 95% CI: 15.9%–39.6% - Pelvic floor descent >3 cm (any compartment) Present 19 (38.0%) - 95% CI: 25.9%–51.8% - Table 4 summarizes dynamic MRI measurements of pelvic floor motion and organ descent. During straining, the mean H-line increased from 4.4 ± 0.7 cm at rest to 5.6 ± 0.9 cm (p < 0.001), while the M-line increased from 1.5 ± 0.5 cm to 3.1 ± 0.8 cm (p < 0.001). Both parameters reflect significant widening and caudal displacement of the levator hiatus during strain. The anorectal angle also widened substantially-from 98.3° ± 9.2° at rest to 116.5° ± 10.4° on strain (p < 0.001)-confirming the dynamic loss of pelvic support. Anatomic descent below the PCL was most frequent in the rectal compartment (62%), followed by cystocele (54%) and uterine/vault prolapse (48%). The mean bladder neck descent during strain was 17.3 ± 6.8 mm (p < 0.001), demonstrating significant urethral hypermobility. Urethral funneling was seen in 26% of cases, and overall pelvic floor descent exceeding 3 cm was present in 38% of subjects (95% CI 25.9–51.8%).

The present MRI-based analysis of 50 symptomatic females with pelvic floor weakness reveals findings consistent with, yet distinct from, multiple prior imaging studies examining the etiology, anatomic compartments, and muscular or fascial correlates of prolapse. 1. Correlation of Demographic and Clinical Risk Factors (Table 1) The present study showed significantly higher mean age and BMI in women with MRI-detected prolapse (51.6 ± 8.1 years and 27.8 ± 3.2 kg/m², respectively) compared with controls. This aligns with Van Gruting IM et al. (2022)[6], who found age > 45 years and BMI > 26 kg/m² as independent predictors of pelvic floor dysfunction on MRI. Similarly, Wang Y et al. (2022)[7] confirmed that parity and higher body weight correlated with greater organ descent and levator hiatus widening. Multiparity (≥ 2 vaginal births) was a significant contributor in the present data (77.8%, p = 0.017), comparable to findings by van Gruting IM et al. (2021)[8], who demonstrated a 2.8-fold higher risk of levator avulsion in multiparous women. Chronic constipation and stress urinary incontinence also trended higher in prolapse cases, paralleling Santoro GA et al. (2022)[9], who emphasized repetitive straining and increased intra-abdominal pressure as major contributors to pelvic floor muscle fatigue. 2. Compartmental Involvement and Severity (Table 2) MRI revealed anterior compartment descent in 62%, middle in 58%, and posterior in 44% of cases-similar to Duarte Thibault M et al. (2023)[10], who found 60–70% anterior and 50–55% middle compartment involvement. The current mean descent below the pubococcygeal line (PCL) was greatest in the posterior compartment (3.3 ± 1.4 cm), supporting Iacobellis F et al. (2020)[11], who described posterior prolapse as frequently underestimated clinically but clearly demonstrable on MRI. The positive correlation between multi-compartmental involvement and higher severity (ρ = 0.42, p = 0.003) matches Jha P et al. (2023)[12], who found that combined defects in the anterior and posterior compartments reflected generalized pelvic connective-tissue weakness. 3. Muscle and Fascial Injury Patterns (Table 3) Severe prolapse cases exhibited significantly higher rates of levator ani avulsion (66.7%) and endopelvic fascial tears (58.3%), consistent with Refaat MM et al. (2021)[13], who demonstrated levator avulsion as a critical MRI marker strongly associated with advanced prolapse and recurrent descent after surgery. The reduced puborectalis thickness (3.2 ± 0.7 mm vs 4.1 ± 0.8 mm, p = 0.0011) aligns with Gautam D et al. (2024)[14], who noted measurable thinning and asymmetry of the puborectalis in women with chronic pelvic floor dysfunction. These structural disruptions reflect the cumulative impact of childbirth trauma and sustained mechanical loading, validating the role of MRI as a sensitive modality for visualizing both direct muscular injury and fascial detachment. 4. Dynamic MRI Parameters (Table 4) Dynamic imaging showed significant increases in H-line (from 4.4 cm to 5.6 cm) and M-line (from 1.5 cm to 3.1 cm) during straining, indicating marked levator hiatus widening. This is comparable to Langenbach MC et al. (2021)[15], who observed average H-line elongation of 1.1–1.4 cm during Valsalva in women with pelvic floor laxity. The anorectal angle also increased by ≈ 18°, similar to results by Zulfiqar M et al. (2021)[16], confirming dynamic alteration of anorectal junction and functional descent of pelvic structures. Rectocele (62%), cystocele (54%), and uterine descent (48%) prevalence rates match Yaşar AB et al. (2024)[17], underscoring MRI’s accuracy in delineating multi-compartmental defects. The observed bladder neck descent (17.3 ± 6.8 mm, p < 0.001) further supports previous reports that urethral hypermobility accompanies anterior compartment prolapse.

The present study demonstrates that MRI provides a comprehensive, non-invasive, and highly reproducible assessment of both anatomical and functional abnormalities in females with symptomatic pelvic floor weakness. Increasing age, higher BMI, and multiparity were identified as significant clinical risk factors, with anterior and middle compartment involvement being most prevalent. MRI effectively delineated levator ani avulsion, fascial tears, and puborectalis thinning, which were strongly associated with the severity of organ descent. Dynamic sequences clearly quantified H-line and M-line elongation, anorectal angle widening, and bladder neck descent, providing objective parameters for grading prolapse. Overall, MRI emerges as a superior diagnostic modality that enables accurate compartmental mapping, aids surgical planning, and enhances understanding of the pathophysiological mechanisms underlying pelvic floor dysfunction in women.

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