Dynamic Pelvic Floor MRI · Pelvic Organ Prolapse (HMO)

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Dynamic pelvic floor MRI (HMO, strain/defecation phase)
   Dynamic pelvic floor MRI (HMO system, maximal strain/defecation phase) findings? (Dynamic pelvic floor MRI (MR defecography) assesses all three compartments (anterior = bladder-urethra, middle = uterus-vagina, posterior = rectum-anal canal). Gel in the rectum (± vagina), sagittal SSFP at rest/squeeze/strain/defecation phases (the defecation phase detects prolapse better than Valsalva alone). Reference lines: PCL (pubococcygeal line: inferior pubic symphysis to last coccygeal segment), H line (inferior pubic symphysis to anorectal junction, normal ~5 cm), M line (perpendicular from PCL to the posterior end of the H line, normal ~2 cm). Prolapse = an organ descending below the PCL on strain.)
   • Organs do not descend below the PCL, H/M lines normal → Normal support
   • Mild-moderate prolapse/pelvic floor laxity (H 6–10 cm, M 2–6 cm, organ descends 1–6 cm below the PCL) → Mild-moderate laxity/prolapse
   • Severe prolapse (H >10 cm, M >6 cm, organ descends >6 cm below the PCL) → Severe prolapse · surgical planning
2. [End] Normal support
   No prolapse, normal H/M lines (H <6 cm, M <2 cm), levator plate parallel to the PCL (angle <10 degrees): normal pelvic floor support; correlate clinically for other causes.
3. [End] Mild-moderate laxity/prolapse
   Mild-moderate pelvic floor laxity/prolapse (H 6–10 cm, M 2–6 cm; bladder/uterus/rectum descending 1–6 cm below the PCL): grade each compartment by HMO — anterior = cystocele, middle = uterine/vaginal vault prolapse, posterior = rectocele/enterocele; conservative (pelvic floor muscle training/pessary) or surgical planning by symptoms.
4. [End] Severe prolapse · surgical planning
   Severe prolapse (H >10 cm, M >6 cm, organ descends >6 cm below the PCL, or multi-compartment prolapse, large enterocele): surgical planning (distinguish cystocele/enterocele/rectocele — an enterocele/vault prolapse affects the procedure; a history of hysterectomy predisposes to vault prolapse); MRI is better than physical exam for detecting an enterocele.

Source guidelines & references

• Dynamic pelvic floor MRI and HMO grading (H line/M line/organ prolapse)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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