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Urinary Imaging

E3333. Pelvic Floor Intrinsic Dyssynergy in Pudendal Neuralgia Patients With Hypertonicity on Dynamic MRI

Flicek K,  HU C,  Holemon S,  Matthees M,  Kalinkin O. St. Joseph’s Hospital Medical Center, Phoenix, AZ

Address correspondence to O. Kalinkin (

Objective: Pelvic floor is a complex 3D muscular structure functioning in synergy in women and girls to support pelvic organs and provide continence for urethral, vaginal, and anal openings. The pudendal nerve is involved in complex innervations of pelvic floor musculature. Is coordinated motion of pelvic floor musculature affected in patients suffering from pudendal neuralgia and pelvic floor hypertonicity? The aim of this exhibit is to establish intrinsic correlates of complex 3D pelvic floor movement by use of dynamic multiplanar pelvic MRI protocol and provocative maneuvers evaluating the midline and lateral pelvic floor parameters in pudendal neuralgia female patients suffering from physical and clinical signs of hypertonicity as compared to the patients without.

Materials and Methods: Of 101 women (median age,51 years; range, 22–83 years) with pudendal neuralgia, 28 had signs of pelvic floor hypertonicity. All 101 women underwent multiplanar pelvic MRI (sagittal and coronal balanced steady-state free precession pulse sequences at rest) with provocative Valsalva and Kegel maneuvers to evaluate midline and lateral movement of the pelvic floor musculature. Midline pelvic floor was assessed by measuring the length of the H-line (urogenital hiatus length) and M-line (pelvic floor depth from pubococcygeal line to anorectal junction) at rest and with Valsalva and Kegel maneuvers. Lateral depth of convexity or concavity of the right and left iliococcygeus muscles in the coronal plane was assessed during rest and provocative maneuvers. Multivariable statistical data analysis of all measured parameters at rest and during provocative maneuvers in these two groups of patients was performed using Kruskal-Wallis test and Spearman rho correlation.


Median values of measured midline and lateral parameters characterized the shape of pelvic floor at rest and during motion were not statistically different according to Kruskal-Wallis test (p > 0.05). Pairwise correlation analysis between the medial and lateral parameters at rest revealed negative correlation only for the patient’s group without physical signs of hypertonicity (M-line of pelvic floor depth and lateral depth of pelvic floor, Spearman rho p < 0.05). This correlation is responsible for preservation of normal or basin 3D shape of the pelvic floor at rest. All patients with and without clinical signs of hypertonicity demonstrated negative correlations between the M-line of midline and lateral pelvic floor depth explaining the expected conversion of basin to dome shape of pelvic floor (Spearman rho, p < 0.05 and p < 0.0001, respectively) induced during Valsalva maneuver. During Kegel exercises the unique positive correlation was only in patients with signs of hypertonicity (Spearman rho, p < 0.05).

Conclusion: Only pudendal neuralgia female patients with signs of hypertonicity revealed unique intrinsic dyssynergy between parameters characterized 3D shape of pelvic floor at rest during MRI study. Application of Kegel maneuver restored intrinsic synergy of pelvic floor musculature in pudendal neuralgia patients with hypertonicity.