**7. Proposed clinical scenario for imaging**

As an example of the benefits of this protocol, a 60-year-old multiparous woman presented with increasing urinary incontinence, constipation, a sensation of incomplete emptying, pelvic pressure, and pain. On pelvic examination (supine and inclined, at rest, and with Valsalva), no organ descent was detected. Conventional supine magnetic resonance imaging (MRI) did not identify pelvic organ prolapse (POP), but evaluation using upright open MRI diagnosed that organ prolapse involving the bladder occurred when standing. In **Figure 1** an example of anterior views of sagittal images showing gravity-induced quantification prolapse can be

**Figure 1.** Anterior views of sagittal images show gravity-induced quantification prolapse. When a supine midsagittal single-shot fast SE image obtained at 0.5 T (panel A) and the corresponding image in standing (panel B) T2-weighted sagittal images of the female midline pelvic floor structures are compared, elongation of the bladder below the pubococcygeal reference line identifies significant prolapse when this patient is standing. A) Sagittal MRI image of female pelvis in the supine position, B) Sagittal MRI image of female pelvis in the standing position, C) Sagittal MRI image of female pelvis in the sitting position.

seen. When a supine midsagittal single-shot fast SE image obtained at 0.5 T (Panel A) and the corresponding image in standing (Panel B) also the corresponding image in sitting position (Panel C) T2-weighted sagittal images of the female midline pelvic floor structures are compared, elongation of the bladder below the pubococcygeal reference line identifies significant prolapse when this patient is standing.

## **8. 3D computer-generated images**

An additional component for more comprehensive evaluation of POP is to generate 3D images. After mid-sagittal pelvic MRI scans are complete, the images are transmitted to a workstation for processing to generate 3D models. On average, 40 axial images were combined to generate each 3D model. The data were first segmented to anatomically major components, including bladder, urethra, vagina, uterus, rectum, obturator internus, and all three components of the levator ani (puborectalis, iliococcygeus, and coccygeus) using manual editing. Old reference 3D reconstruction is labor intensive and hence costly. However, the resulting images yield a huge amount of detailed information that simply cannot be obtained from 2D images. Moreover, use of mathematical modeling will be helpful in the future to assist in defining the relationships of organs and quantifying mobility and pressure gradients to resolve questions of continence and pelvic floor prolapse [47]. Further, advantages of 3D reconstruction include the additional data provided for patient–clinician interaction to enhance understanding, more comprehensive surgical planning, and to advance medical research, and education [46]. A three-dimensional model of the levator can be produced for living individuals and muscle volume calculated old reference.

The limitations include high cost and relative complexity of acquiring the initial images and the requirement for computer hardware and dedicated software [46]. Examples of the 3D imaging of the female pelvic floor can be seen in **Figure 2**.

**9. Conclusions**

Physicians should be aware that as upright open MRI becomes available this form of imaging will offer new levels of anatomic details relevant to a more accurate staging of POP and improved allocation to medical or surgical treatment. In POP, posture and gravity impact

**Figure 2.** Three-dimensional imaging of the female pelvic floor: (A) anterior view of 3D pelvic floor model: (gray, pelvic bones), (pink, obturator internus m, piriformis m), (red, levator ani m). (B) Anterior view of 3D reconstruction of the whole female pelvis: (yellow, bladder, urethra), (red, uterus), (pink, vagina), (blue, rectum) as segmented from MRI images. A) Anterior view of 3D pelvic floor model as segmented from MRI images. B) Anterior view of 3D computer

Effects of Posture and Gravity on Pelvic Organ Prolapse http://dx.doi.org/10.5772/intechopen.77040 29

model of the whole female pelvis including supporting structures and organs.

**Figure 2.** Three-dimensional imaging of the female pelvic floor: (A) anterior view of 3D pelvic floor model: (gray, pelvic bones), (pink, obturator internus m, piriformis m), (red, levator ani m). (B) Anterior view of 3D reconstruction of the whole female pelvis: (yellow, bladder, urethra), (red, uterus), (pink, vagina), (blue, rectum) as segmented from MRI images. A) Anterior view of 3D pelvic floor model as segmented from MRI images. B) Anterior view of 3D computer model of the whole female pelvis including supporting structures and organs.
