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Best Practice & Research Clinical Obstetrics and Gynaecology

Vol. 20, No. 1, pp. 322, 2006


doi:10.1016/j.bpobgyn.2005.09.001
available online at http://www.sciencedirect.com

Pelvic anatomy and MRI

S. Paramasivam* MBBS, MRCOG, FRANZCOG


Staff Specialist

A. Proietto BSc(Med), MBBS, MRCOG, FRANZCOG, CGO


Conjoint Associate Professor/Director
Hunter Centre for Gynaecological Cancer, John Hunter Hospital, 2310 New Lambton, NSW, Australia

M. Puvaneswary MBBS, FRCR


Senior Staff Specialist/Senior Lecturer
Division of Medical Imaging, John Hunter Hospital/University of Newcastle, New Lambton, NSW, Australia

An in-depth knowledge of the anatomy of the pelvis and pelvic sidewall is necessary before a
gynaecologist can even contemplate making an initial examination and start management in cases
of pelvic pathology or malignancy. This chapter provides basic information on gross pelvic
anatomy structures that are of clinical relevance and discusses their correlation with medical
imaging, especially magnetic resonance imaging (MRI).
MRI is an ideal non-invasive technique in the assessment of normal anatomy and tissue
characterization of pelvic pathology. The excellent soft-tissue contrast and the ability to direct
multiplanar imaging and to demonstrate blood vessels without the use of intravenous contrast
make MRI superior to other imaging modalities in the evaluation of pelvic abnormalities. The
anatomical relation of the visceral organs, the differential zonal anatomy of the corpus uteri and
the cyclical endometrial changes during the menstrual cycle are well depicted with MRI.

Key words: MRI; pelvic anatomy; pelvic sidewall; pelvis.

BASIC ANATOMY OF THE PELVIS AND PELVIC SIDEWALL

The pelvis consists of an osseous ring formed by the innominate bones and sacrum,
with numerous muscles for support. Anatomically, the pelvis can be divided into true

* Corresponding author. Tel.: C61 2 4985 5480; Fax: C61 2 4921 3906.
E-mail address: sellvakumaran.paramasivam@hnehealth.nsw.gov.au (S. Paramasivam).

1521-6934/$ - see front matter Q 2005 Elsevier Ltd. All rights reserved.
4 S. Paramasivam et al

Median umbilical
plica & urachus
Inferior epigastric vessels
Medial umbilical plica & lig
Round lig Bladder

Paravesical fossa
External iliac vessels Uterus Ovarian lig
Uterosacral lig
Ovary
Ureteric fold
Fallopian tube Paragenital fossa
Infundibulopelvic
Cut edge of peritoneum
(suspensory) lig
Rectum
Sigmoid colon Cecum
Sacral promontory

Ureter
Aorta

Inferior vena cava Ureter


Ovarian vessels

Figure 1. Gross pelvic anatomy in the adult woman as seen through the peritoneum.

and false pelvis by an oblique line that extends from the sacral promontory along the
anterior aspect of S1 to the symphysis pubis.1 The greater, or false, pelvis is situated
above this plane. The ascending, descending and sigmoid colon; the small bowel and
bifurcations of the great vessels traverse the greater pelvis (Figure 1). The lesser, or
true, pelvis is situated below the pelvic brim and contains the reproductive organs,
bladder, pelvic ureters, small bowel loops and rectum.
The magnetic resonance image (MRI) appearance of the reproductive organs
(uterus, cervix and vagina) is markedly influenced by hormonal status of the patient.
The pelvic cavity is separated into an anterior and posterior component by the
transversely orientated broad ligament, in the centre of which is the uterus. Attached
to the uterus are the round ligaments, which run anterolaterally in the broad ligament
to the pelvic wall, where they turn medially around the inferior epigastric vessels to exit
the pelvis via the internal inguinal ring and inguinal canal.
A useful anatomic landmark is the adnexal triangle, bounded anteriorly by the
round ligament, posteriorly by the infundibulopelvic ligament and laterally by the
peritoneal reflection on the psoas muscle. This area provides easy surgical access
to the retroperitoneum. Between the uterus and the bladder is the vesicouterine
pouch, which has small lateral recesses, the paravesical fossae. Similarly, between
the uterus and the rectum is the pouch of Douglas, which is continuous with the
pararectal fossae.
The surgical anatomy of the pelvis is based on three pairs of fibrovascular ligaments
that attach to the cervix/vagina and eight avascular tissue planes (Figure 2). The three
pairs of ligaments are: the cardinal ligaments, the uterosacral ligaments with rectal
pillars and the bladder pillars. The eight tissue planes are: the paired lateral paravesical/
paravaginal spaces, the paired lateral pararectal spaces, the midline retropubic
(prevesical) space of Retzius, the vesicocervico/vaginal space, the rectovaginal space
and the retrorectal space (Table 1).
Pelvic anatomy and MRI 5

Symphysis

Space of Retzius
Femoral a & v
Inguinal lig
Umbilical a
Vesicovaginal space
Vesicouterine lig Paravesical space
External iliac a & v
Cervix
Uterine a
Cardinal lig
Internal iliac a
Uterosacral lig/Rectal pillar
Rectovaginal space Pararectal space
Rectum

Retrorectal space with


Ureter
Waldeyer's fascia
Common iliac a & v
Sacrum

Figure 2. Transverse view of the pelvic anatomy showing the three pairs of ligaments attaching to the cervix
and the eight avascular planes of the female pelvis.

AVASCULAR PLANES (TABLE 1)

Pelvic ligaments

The broad ligament is formed by two layers of peritoneum, which surround the uterus
and extend laterally to the pelvic sidewall. The fallopian tube, round ligament, ovarian
ligament, uterine and ovarian vessels, nerves, lymphatics, mesonephric remnants, a
portion of the ureter and loose connective tissue and fat known as the parametrium are
found between the two leaves of the broad ligament. At the superior free edge, the
broad ligament encircles the fallopian tube. At the inferior aspect of the broad ligament
is the ureter. The cardinal (transverse cervical) ligament extends from the cervix and
upper vagina to merge with the fascia of the obturator internus muscle. It forms the
base of the broad ligament and is the primary ligamentous support of the uterus and
upper vagina. The uterine artery traverses the superior aspect of the cardinal ligament.
The normal cardinal ligament has a wide variation in shape, contour and thickness; it is
usually seen on axial imaging as a triangular structure with the apex tapering towards
the pelvic sidewall.2 The uterosacral ligament extends posteriorly from the lateral
aspect of the cervix and vagina to the anterior body of the sacrum at the second or
third sacral vertebra, and fuses medially with the cardinal ligaments.
The round ligament is a fibromuscular band extending from the anterolateral
aspect of the uterine fundus to the internal inguinal ring, terminating in the labia
majora. Axial images show the round ligament to be a thin band that has a broad
base at the uterine attachment but that gradually tapers as it extends laterally.2
6 S. Paramasivam et al

Table 1. Avascular planes.

Boundaries Surgical significance


Paravesical Medial Bladder and vagina The space provides access for
Lateral External iliac vessels and parametrial and cardinal
obturator fossa ligament resection at radical
Posterior wall Cardinal ligaments hysterectomy. It is developed
Anterior wall Superior pubic ramus and prior to pelvic lymph node
obturator internus fascia dissection
Floor Endopelvic fascia
Pararectal Medial Rectum Developed prior to internal
Lateral wall Posterior division of the iliac ligation
hypogastric artery
Posteror Lateral surfaces of the
sacrum
Anterior Cardinal ligament and
uterine artery
Vesicovaginal Two compartments Dissection into this space
space Vesico-cervical space Between bladder and frees the bladder
cervix attachment
Vesico-vaginal-space Between bladder and
vagina
Rectovaginal Space between the vagina Developed prior to resection
space anteriorly and rectum of the uterosacral at radical
posteriorly hysterectomy

The ovary has two supporting ligamentsthe ovarian ligament and the suspensory
ligament of the ovary.
The suspensory ligament of the ovary is a peritoneal fold containing the ovarian
artery and vein. It extends anterolaterally from the ovary, over the external iliac vessels
to the pelvic sidewall, where it fuses with the connective tissue overlying the psoas
muscle.2
On MRI, the cardinal and sacrouterine ligaments are hypointense on T1-weighted
images; they are hyperintense on T2-weighted images.3 The high signal intensity on
T2-weighted images is attributed to stagnant blood flow and varicosities within the
ligament; the rich fibrous connective tissue and vascular structure have no significant
signal intensity on T1-weighted images. On T2-weighted images, the prominent high
signal intensity from stagnant blood flow hides the low signal intensity of the fibrous
connective tissue (Figure 3).

MUSCULOSKELETAL STRUCTURES

Pelvic skeleton

The pelvis is a bony ring of four bones. The paired innominate bones form the major
boundary anteriorly and laterally, with the sacrum and coccyx located between them.
The innominate bones consist of the iliac bone superiorly, the ischium poster-
oinferiorly, and the pubis anteroinferiorly.1
Pelvic anatomy and MRI 7

Figure 3. MRI of the normal cervix. The cardinal ligament and uterosacral ligaments are demonstrated
(arrows).

Pelvic musculature

The major skeletal muscles of the lesser pelvis are the psoas and iliacus. The psoas
majora long, thick, fusiform-shaped muscleoriginates from the lumbar vertebrae
and extends caudally. The iliacus arises from the anterior and superior aspect of the iliac
bone and sacrum. These two muscles join to form the iliopsoas, which continues
caudally, anteriorly and laterally and exits the pelvis to insert on the lesser trochanter of
the femur.
The muscles of the true pelvis consist of four major groups (Figure 4): the levator ani
and coccygeus (pelvic diaphragm), the obturator internus and the piriformis. The
obturator internus and piriformis muscles originate within the pelvis and, with their
fascia, form the pelvic sidewall. The obturator internus originates from the margins of
the obturator foramen and extends from the anterolateral walls of the true pelvis
along the inner aspect of the acetabulum and inserts on the greater trochanter of the
femur. The piriformis originates from the sacrum and the margin of the greater sciatic
foramen and inserts on the greater trochanter.4 The levator ani and coccygeus muscles
form the main support of the pelvic floor (pelvic diaphragm) separating the pelvis from
the perineum. The levator ani is V-shaped muscle that surrounds the rectum. It extends
anteriorly from the superior surface of the pubic rami and medially from the inner
aspect of the ischium to insert posteriorly on the lower coccyx and the anococcygeal
8 S. Paramasivam et al

Pubic Symphysis
Transverse perineal lig
Superior fascia of
urogenital diaphragm
Urethra
Levator ani
Vagina
(puborectalis) m
Arcus tendineus
Levator ani Obturator canal
(pubococcygeus) m
Rectum
Levator ani Obturator internus m
(iliococcygeus) m Levator plate
lschial spine (median raphe)
Coccygeus
(ischiococcygeus) m Sacrococcygeus lig
Piriformis m Coccyx

Sacrum

Figure 4. Muscles of the pelvic wall and pelvic floor. Note the anterior hiatus between the levatores ani,
through which the urethra, vagina and the rectum exit.

raphe.5 The coccygeus is a triangular muscle that extends from the ischial spine to the
coccyx. The urethra, vagina and rectum pass through the pelvic diaphragm from the
lesser pelvis to the perineum.
The perineum lies below the pelvic floor and appears as a diamond-shaped
space. It is divided into an anterior or urogenital triangle and a posterior or anal
compartment by a line extending between the ischial tuberosities. The anterior or
urogenital compartment contains the external urinary and genital organs. The
ischiorectal fossa is a wedge-shaped, fat-containing space located on either side of
the midline and bounded medially by the external anal sphincter muscles, laterally
by the ischial tuberosity and the obturator fascia, and posteriorly by the gluteus
maximus muscles.
The parietal layer of the endopelvic fascia covers the levator ani, coccygeus and
pelvic portions of the obturator internus and the piriformis muscles, and continues
directly with the transversalis fascia lining the abdominal cavity. The visceral layer covers
the bladder, the lower third of the ureters, the uterus, the vagina and the rectum. The
fascial investments of the pelvic musculature and the fascial sheaths of the pelvic blood
vessels (superior gluteal arteries) provide anatomical pathways to the buttocks, hips
and thighs; above the pelvic diaphragm there is continuity with the extraperitoneal
portion of the abdomen. Thus, infection, haemorrhage and malignancy can spread from
the retroperitoneum and pelvis to the ischiorectal fossa, buttocks, hips and lower
extremities and vice versa.4
The skeletal muscles in the pelvis are depicted as low-to-intermediate signal
intensity on T1-weighted MR images.6 Striated muscle displays low signal intensity on
T1-weighted images and decreases in signal intensity on T2-weighted MR images
(Figure 5).7
Pelvic anatomy and MRI 9

Figure 5. Normal sciatic nerve. Axial T2-weighted images depict the sciatic nerve as an intermediate tubular
(coronal image) or circular structure (axial) (arrow).

GENITOURINARY SYSTEM

Ureter

The ureters originate from the kidneys and insert into the trigone of the bladder, on
both sides of the cervix at the level of the superior portion of the vaginal canal. Initially,
the ureters lie anterior to the psoas muscle and medial to the tips of the transverse
processes of the lumbar vertebra, crossing the pelvic brim at the sacroiliac joint. As
they enter the greater pelvis, they run anterior to the common iliac artery and vein
(Figure 6). They then descend into the lesser pelvis, passing over the pelvic brim and
continuing posterior to the ovary and anteromedial to the internal iliac vessels. In the
pelvis, the ureters pass close to the ovary and to the cervix, and any abnormality of
these structures can cause obstruction of the ureter, with resultant hydronephrosis and
hydroureter on that side (Figure 7). Similarly, as the ureters pass over the pelvic brim,
uterine enlargement of any cause can obstruct them, causing bilateral hydronephrosis
and proximal hydroureters.

Urinary bladder

The normal bladder wall is thin and smooth and, when moderately distended, measures
approximately 2 mm in thickness. The smooth muscle of the bladder has intermediate
signal intensity on T1-weighted images and low signal intensity on T2-weighted images.
The muscle is slightly higher in signal intensity than urine and slightly lower in signal
intensity than the surrounding perivesical fat on T1-weighted images. On T2-weighted
10 S. Paramasivam et al

Bladder

Uterine a

Superior vesical a
Umbilical a

Round lig (cut)


Edge of opened peritoneum

External iliac vessels


Uterus
Ureter

Ovary
Fallopian tube
Top View
Ovarian vessels

Common iliac a

Figure 6. Lateral pelvic anatomy. Entry to the paravesical and paravaginal spaces is made by dissecting
between umbilical artery and the external iliac vein. The posterior pararectal space is entered by dissecting
between the hypogastric artery laterally and ureter medially.

images, three muscle layers have been reported.8 The superficial muscle layer has
intermediate signal intensity and the deep muscle layer has lower signal intensity. The
bladder is generally well imaged in the axial, sagittal and coronal planes. The bladder
mucosa/submucosa demonstrates enhancement with gadolinium and is depicted as a
thin, high signal intensity lining of the inner bladder wall (Figure 8).9

Urethra

The female urethra is approximately 4 cm long. It extends from the internal urethral
meatus, at the bladder neck, to the external urethral meatus, which is anterior to the
opening of the vagina. It runs downwards and forwards obliquely, traversing the
urogenital diaphragm. The urethra is a round structure on axial images. On axial T2-
weighted images or gadolinium-enhanced T1-weighted images, the normal urethra
demonstrates a characteristic target-like appearance (Figure 9).10 Four concentric rings
of different signal intensity can be seen on axial T2-weighted images. There is an outer
ring of low signal intensity, a middle layer of higher signal intensity, an inner ring of low
signal intensity and a central zone of high signal intensity.11 The outer layer of low signal
intensity corresponds to outer striated muscle, the middle layer of high signal intensity
to the smooth muscle and submucosa, and the central zone of low signal intensity
Pelvic anatomy and MRI 11

Figure 7. Coronal STIR image in 56-year-old female with stage 3b carcinoma of the cervix demonstrating
right hydronephrosis (arrow).

correspond to the mucosa.10,11 The zonal anatomy of the urethra can be depicted on
sagittal images as well.

THE REPRODUCTIVE ORGANS

Uterus and cervix

The normal uterus is a smooth, hollow, pear-shaped organ located behind the bladder
and anterior to the rectum. The peritoneal lining of the uterus is reflected anteriorly to
cover the posterior wall of the bladder at the level of the cervix.
The peritoneal recess (vesicouterine pouch) between the bladder and uterus is
usually empty but can occasionally contain loops of small bowel The rectouterine pouch
(posterior cul-de-sac) is the most dependent and caudal portion of the peritoneal
cavity, and a trace of the fluid that frequently occurs during ovulation and bowel loops is
often present.5 In the reproductive years, the uterine body is twice the length of the
cervix. In the premenarcheal and postmenopausal years, the uterine body-to-cervix
ratio approaches 1:1. The uterus atrophies in postmenopausal women, decreasing in
size to 46 cm in length.
12 S. Paramasivam et al

Figure 8. Normal bladder. Sagittal gadolinium-enhanced image. The bladder mucosa/submucosa is depicted
as a thin, high signal intensity lining of the inner bladder wall due to contrast enhancement (arrow).

The degree of bladder distension greatly influences the position and shape of the
uterus. When the bladder is empty, the uterus is most commonly anteflexed. With a
distended bladder, the uterus is displaced from an anteverted towards a horizontal
position. Occasionally, uterine compression and elongation can occur with a distended
bladder.
On axial imaging, an anteverted uterus is depicted on the superior and posterior
aspect of the bladder, and a retroverted or retroflexed uterus is seen projecting into
the cul-de sac. A markedly anteverted or retroverted uterus can appear enlarged on
axial image because the entire uterine length might be imaged on a single axial slice.
The optimal demonstration of the uterine anatomic details and pathology on MRI is
dependent on the pulse sequences, the magnetic field strength and the imaging
plane.7,12,13 The uterus is best depicted in the sagittal plane with T2-weighted
sequences12 and is anatomically divided into corpus, isthmus and cervix. On T1-
weighted spin-echo (SE) sequences, the myometrium has a homogeneous intermediate
signal intensity, slightly higher than the striated muscles of the pelvic wall.5
The endometrium undergoes distinct changes during the course of a womans life.
The endometrium is thin in the premenarcheal uterus; a thicker, high signal intensity
endometrium on T2-weighted images is seen during the reproductive age. The
thickness of the endometrium changes during the menstrual cycle. The endometrium
measures 13 mm during the proliferative phase and 35 mm during the secretary
Pelvic anatomy and MRI 13

Figure 9. MRI of a normal female urethra. This axial T2-weighted image demonstrates the characteristic
target-like appearance with four concentric rings: an outer ring of low signal intensity (short arrow), a middle
layer of higher signal intensity (short black arrow), an inner ring of low signal intensity (long thin arrow) and a
high signal intensity zone in the centre (long black arrow).

phase of the menstrual cycle. This variation in thickness of the cyclic endometrium can
be detected on MRI.7
The signal intensity of the myometrium is similarly affected by hormonal changes. On
T2-weighted sequences, the signal intensity of the myometrium is highest during the
secretory phase. The signal intensity of myometrium in women who take oral
contraceptives is slightly higher than in those who do not, probably due to higher water
content from myometrial odema.14 The endometrial width is significantly larger, and the
total uterine volume is greatest, during the secretory phase (Figure 10).14
Females of reproductive age who take oral contraceptives display poor demarcation
between the myometrium and endometrium. There is endometrial atrophythe
junctional zone is not consistently visualized and no significant change in the
endometrial thickness occurs during the menstrual cycle.
The endometrium is the high signal intensity central zone seen on T2-weighted images.
The mean width during the follicular phase is 6 mm; during the secretory phase the mean
width is 10 mm. The endometrium is thin in postmenopausal females, and does not exceed
25 mm in width; females taking exogenous estrogen have a thicker endometrium.
The junctional zone is a relatively thin band of low signal intensity on T2-weighted
images, separating an outer intermediate signal intensity myometrium from the inner
14 S. Paramasivam et al

Figure 10. Sagittal MR images of the normal uterus. This T2-weighted spin-echo image demonstrates the
three zones of the uterus: a high signal intensity endometrium(e), a low signal intensity junctional zone of the
myometrium(j) and an intermediate signal intensity of the outer myometrium(m).

high signal intensity endometrium. The average width of the junctional zone is 5 mm,
and varies little during the menstrual cycle or in women on gonadotrophin-releasing
hormone (GnRH) analogues.14,15
MR imaging with high-resolution multisection dynamic imaging with surface coil
during a single breath-hold demonstrates early enhancement of the inner layer of the
uterine body during the arterial phase.16 This allows visualization of myometrial
invasion by endometrial carcinoma, as most endometrial carcinoma are hypointense
relative to the well-enhanced myometrium.17 In addition, dynamic MR imaging can assist
in the evaluation of the extension of cervical carcinoma into the parametrium.
In contrast to endometrial carcinoma, most cervical carcinoma are seen as areas of
increased signal intensity, compared to the surrounding cervical stroma, during the
arterial phase. Parametrial invasion is depicted as infiltrating tumour of high signal
intensity, whereas the normal parametrium is not enhanced during the arterial phase.
Dynamic MR imaging is essential as both cervical tumour and the parametrium often
display similar high signal intensity on T2-weighted images.16
The normal cervix varies in length and orientation. The anatomical relationship to
the urinary bladder and rectum, and the depiction of the anterior and posterior cervical
lips, are best displayed on T2-weighted sagittal images (Figure 11). As is the case with
the uterus, the MR appearance of the cervix varies with the menstrual cycle.6 Dynamic
Pelvic anatomy and MRI 15

Figure 11. Normal vagina. This sagittal T2-weighted image demonstrates the vaginal canal (long arrow) and
the vaginal wall (short arrow).

imaging with contrast reveals rapid enhancement of the endocervical mucosa, with a
more gradual enhancement of the outer fibromuscular cervical stroma.18

Vagina

The vagina extends inferiorly from the cervix to the vestibule. It measure 67 cm in
length (the ventral wall) and 9 cm along its dorsal wall; it forms an axis with the uterus
of more than 908. Anteriorly, the vagina is closely related to the bladder above and the
urethra inferiorly. Posteriorly, the superior third of the vagina is related to
the rectovaginal pouch (pouch of Douglas), the middle third is related to the ampulla
of the rectum and inferiorly it is related to the perineal body, which separates it from
the anal canal. Superiorly there are the anterior, lateral and posterior fornices.1
On sagittal MRI, the vagina is seen as a narrow band between the bladder and
rectum.6 The anatomic demarcation of the vagina is best appreciated on axial images.
The superior third is visualized at the level of the fornices, the middle third is located at
the level of the bladder base and the inferior third is at the level of the urethra.
However, the coronal and sagittal planes best display the relation of the vagina with the
cervix, bladder and rectum. On T1-weighted MR images, the signal intensity of the
vaginal wall is similar to that of the uterus and cervix.7 On T2-weighted images,
16 S. Paramasivam et al

the vaginal wall has a homogeneous but lower signal intensity than uterus.6 The central
vaginal canal, consisting of vaginal epithelium and mucus is of high signal intensity
(Figure 11).

Ovaries/fallopian tube

The adult ovaries are ellipsoid in shaped and measure 2.55 cm in length, 1.53 cm in
width, and 0.61.5 cm in thickness. The neonatal ovary measures 1.5 mm in length, is
2.5 mm thick and is 3 mm wide. The maximal volume of the ovary during reproductive
age is 6 ml; in the postmenopausal female this is 2.5 ml. The ovary is attached to the
posterosuperior aspect of the broad ligament and, posteroinferiorly, to the fallopian
tube. Where it extends between the attachment of the mesovarium and the lateral wall
of the pelvis, the broad ligament is sometimes called the suspensory ligament of the
ovary.
Ovaries may be found in the cul-de-sac, pelvic inlet, iliac fossa or lower abdomen.19
In a nulliparous female, the ovaries are located in the ovarian fossa (fossa of Waldeyer)
on the lateral wall of the pelvis bound by the obliterated umbilical artery anteriorly, the
external iliac vein superiorly, and the ureter and internal iliac artery posteriorly.
The ovarian fimbria of the fallopian tube and the suspensory ligament of the ovary
are attached on the superior surface of the ovary.
The fallopian tubes arise posteriorly from the uterus, at the junction of the fundus
and the uterine body. They are approximately 10 cm long and lie in the superior aspect
of the broad ligament. The fimbriated end opens into the peritoneal cavity. The isthmus
is the medial third of the fallopian tube. Normal fallopian tubes are usually not visualized
at any age on MRI.20
The MRI appearance of the ovary is variable, depending on the pulse sequences
utilized, as well as the menstrual status of the women. Normal ovaries in females of
reproductive age can usually be visualized. On T1-weighted images, in premenopausal
females, the ovaries appear as a homogeneously low to intermediate signal intensity
similar to that of muscle. Signal intensity increases on T2-weighted images, with the
ovarian stroma being isointense with that of fat; follicles that are present are of high
signal intensity.15,20 The presence of follicles is helpful in the differentiation from fluid-
filled bowel and blood vessels. Ovarian cysts appear as well-circumscribed, smooth
hypointense lesions on T1-weighted images, and as hyperintense on T2-weighted
images, similar to simple fluid.
After ovulation, the follicle becomes irregular in outline and its contents have a
heterogeneous decrease in signal intensity. Post-contrast images demonstrate intense
enhancement of the wall due to prominent vascularity.18

GASTROINTENSTINAL TRACT

The caecum generally lies in the right iliac fossa, although it might occasionally descend
into the pelvis. The descending colon lies in the left iliac fossa and continues, as the
sigmoid colon, in the midpelvis. The sigmoid colon might ascend into the abdominal
cavity before descending to become the rectum at the level of S2/S3 segment. The
rectum is approximately 12 cm long and extends through the anal hiatus at the level of
the pelvic diaphragm. On MRI, an air-filled bowel loop appears as a signal void, tubular
Pelvic anatomy and MRI 17

Figure 12. Normal fluid-filled bowel loops. This axial T2-weighted image shows high signal intensity fluid-
filled small bowel loops (arrow).

or round/ovoid structure on all sequences. Fluid-filled bowel loops appear as high signal
intensity on T2-weighted images (Figure 12).

VASCULAR SUPPLY

The common iliac arteries bifurcate into the internal and external iliac arteries at
about the level of the lower sacroiliac joint (Figure 13). The paired uterine arteries
are branches from the anterior trunk of the internal iliac artery. The uterine artery
runs medially above the cardinal ligament within the base of the broad ligament to
provide the primary blood supply to the uterus. The artery crosses anterior to the
pelvic ureter to reach the cervix and divides into a large uterine branch and a
smaller cervicovaginal branch. Both of these branches are tortuous and form
extensive vascular networks lateral to the uterus and vagina. At the superior level
of the uterus, the uterine artery trifurcates, giving branches to the fallopian tube,
the uterine fundus and the ovary. In addition, the ovaries receive a direct blood
supply from the ovarian arteries, which arise from the aorta just below the origin
of the renal arteries. In the pelvis, the ovarian artery enters the broad ligament via
the suspensory ligament of the ovary, and provides branches to the ovary through
the mesovarium.2
Venous drainage of the uterus, cervix, upper vagina and ovaries is via an extensive
venous plexus within the parametrium. This plexus finally forms veins that parallel the
arterial blood supply. The left ovarian is the only exception, draining into the left renal
vein instead of the inferior vena cava.
18 S. Paramasivam et al

External iliac a
Deep circumflex iliac a
Twig to round lig
Common iliac a Inferior epigastric a
External iliac v
Internal iliac a Umbilical a
(medial umbilical lig)
Posterior Division Twig to obturator fossa
iliolumbar a Obturator a
superior lateral sacral a
superior gluteal a Superior vesical a
inferior lateral sacral a Vaginal a
S1
Lumbosacral plexus Uterine a
Inferior vesical (vaginal) a
Inferior gluteal a
Levator ani (cut)
Internal pudendal a
Internal pudendal a
Middle rectal a
Inferior rectal a

Sacrotuberous lig

Figure 13. This internal iliac arterial system, showing its relationship to the pelvic muscles and the sciatic nerve.

The MRI signal intensity of flowing blood depends on several factors, including the
velocity and direction of flow, the pulse sequence, the slice position and the imaging
plane used. Rapidly flowing blood has no signal and appears as signal void. These signal-
void blood vessels can be differentiated from adjacent soft-tissue structures without
the need for intravenous contrast.
Stagnant blood flow results in the venous plexus appearing as network of small
vessels of high signal intensity extending along the lateral aspect of the cervix and vagina.
The larger draining veins are prominent vessels that parallel the arteries.

LYMPH NODES

The pelvic lymph nodes are identified by their relationship to normal vessels (Figure 14).
The common iliac nodes are dorsal and lateral to the common iliac arteries; the internal
iliac nodes or hypogastric nodes parallel the branches of the internal iliac artery; and the
external iliac nodes are lateral, anterior and medial to the external iliac vessels. The
obturator nodes are found along the lateral pelvic sidewalls, adjacent to the obturator
internus muscles. The inguinal nodes consist of superficial and deep chains. The superficial
inguinal nodes are anterior to the inguinal ligament, within the subcutaneous tissue that
accompanies the superficial femoral and saphenous veins. The lymphatic drainage of the
perineum is into the superficial inguinal lymph nodes. The deep inguinal lymph nodes are
located medial to the femoral artery and vein within the femoral sheath.
On MRI, lymph nodes appear as intermediate signal intensity, rounded or oval soft-
tissue structures varying in size with location. Normal pelvic lymph nodes are less than
1.5 cm in diameter.1 It is possible to distinguish between lymph nodes and blood vessels
because normally flowing blood emits no signal and the blood vessels appear signal
void.4,5 Thus, differentiation between the two is possible without the use of intravenous
contrast.
Pelvic anatomy and MRI 19

Aortic nodes

Subaortic (presacral)
nodes
Ureter
Common iliac lateral
& medial nodes
Superior gluteal
(hypogastric) nodes

External iliac node

Obturator nodes
Obturator n
Hypogastric nodes
Deep circumflex
iliac a Ureteral node

External iliac node Cardinal lig

Inferior epigastric a

Figure 14. Parametrial iliac lymphatics. The constant large distal external iliac node is seldom involved by
pelvic cancer. The obturator nodes often connect directly to the femoral canal lymphatics rather than the
obturator canal lymphatics.

NERVES

The femoral nerve is the largest branch of the lumbar plexus and enters the pelvis along
the lateral border of the psoas muscle. It extends between the psoas and iliacus muscle
and exits the pelvis inferior the inguinal ligament and lateral to the femoral artery. The
obturator nerve emerges from the inferomedial border of the psoas muscle and runs
through the obturator fossa to the obturator canal in the obturator internus muscle. It
is joined by the obturator artery and vein within the obturator fossa and leaves the
pelvis via the obturator foramen. The sacral nerve is a continuation of the sacral plexus
and leaves the pelvis through the sciatic foramen along the inferior border of the
piriformis muscle (Figure 6). It then crosses the distal portion of the obturator internus
muscle and lies anterior to the gluteus maximus.
On MRI, the sciatic nerve is visualized as a circular or linear structure, of
intermediate signal intensity, just lateral and posterior to the ischial spine and dorsal to
the obturator internus muscle and anterior to the gluteus maximus.

Pelvic autonomous nervous system

Two hypogastric nerves originate from the superior hypogastric plexus located over the
surface of the sacral promontory (Figure 15). They run in parallel to and approximately
2 cm mediodorsally of the ureters into the small pelvis. The hypogastric nerves contain
predominately sympathetic fibres, which are responsible for a variety of functions, such
as bladder compliance, urinary continence and small muscle contractions at orgasm.
20 S. Paramasivam et al

Superior hypogastric
plexus (presacral n)

Inferior hypogastric
Right hypogastric n (pelvic) plexus

Parasympathetic nn
Vesical plexus
or nervi erigentes
Utero-vaginal plexus

Rectal plexus

Figure 15. Left pelvic autonomous nerves and plexuses. Nerves of the inferior hypogastric plexus traverse
the cardinal ligament on their way to the bladder and rectum. For this reason, complete division of both
cardinal ligaments can result in significant urinary bladder dysfunction.

The fibres of the pelvic splanchnic nerves are mainly parasympathetic and are
responsible for vaginal lubrication and genital swelling during sexual arousal, detrusor
contractility and various rectal functions.
The hypogastric nerves fuse with the pelvic splanchnic nerves that come from
the sacral roots S2 to S4. They form the inferior hypogastric plexus, a triangular-
shaped plexus placed in a sagittal plane. The inferior hypogastric plexus stretches
from an area anterolateral to the rectum and passes the cervix and the vaginal wall
and base of the bladder. The distal part of the inferior hypogastric plexus is located
in the dorsal part of the vesicouterine ligament parallel to and laterodorsally of the
crossing of the ureter and uterine artery in the ureteric tunnel. This part of the
plexus is closely related to the inferior vesical artery and the venous plexus of the
bladder and the vagina.

SUMMARY

Imaging has become an important adjunct to the clinical assessment of gynaecological


pathology. Imaging, integrated with clinical findings, can optimise care and assist in the
development of a treatment plan specific for the individual and extent of the disease.
The pretreatment evaluation of uterine and ovarian pathology has traditionally
consisted of clinical evaluation, laboratory tests and conventional radiological studies.
Cross-sectional imaging, together with an in-depth knowledge of pelvic anatomy, is
Pelvic anatomy and MRI 21

increasingly considered a necessary complement in the evaluation and subsequent


surgical management of pathologies in the pelvis.
This chapter outlines the role of MRI in the preoperative assessment and
management of female genital tract pathologies that has evolved during the last two
decades. The figures illustrate the normal anatomical relationships in the pelvis and
pelvic sidewall.
The advantages of MRI include superb spatial and tissue resolution, no use of ionising
radiation, it multiplanar capability and its speed. Current indications for MRI in the
evaluation of women with gynaecological malignancy include: (1) the staging of invasive
cervical cancer as an adjunct to clinical examination; (2) assessment of myometrial
invasion in endometrial cancer in young patients contemplating fertility-sparing
conservative measures; and (3) characterization of adnexal lesions when ultrasono-
graphy and clinical examination are indeterminate. Although MRI is still relatively
expensive, it has been shown to be cost minimizing in some clinical settings by
eliminating or limiting the need for more expensive and/or more invasive diagnostic or
surgical procedures.
Future innovations in gynaecology and gynaecological oncology imaging will go
beyond anatomy to focus on function. Nevertheless, an in-depth knowledge of pelvic
anatomy and cross-sectional imaging techniques cannot be overemphasized for all
surgeons undertaking pelvic surgery.

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