Prostate cancer remains one of the most commonly diagnosed cancers among men, yet the pathway to effective screening can be fraught with confusion and uncertainty. With varying recommendations from different health organizations and a multitude of testing options available, patients often find themselves unsure about when and how to pursue screening. Two of the screening methods often recommended are the Prostate-Specific Antigen (PSA) test and MRI.

Prostate-Specific Antigen (PSA) Testing
Screening for prostate cancer has been confusing for some patients in terms of what is recommended. Prostate-Specific Antigen (PSA) is used by some providers, but some patients are unsure when to proceed with testing. The US Preventative Services Task CDC recommends that the use of PSA screening between in men aged 55 to 69 should be an individual choice, however, it should not be performed in men over the age of 70. Other websites recommend having a discussion for screening between individuals and their medical provider, which may include PSA testing, starting at 50, earlier if there is a risk present.

Some of the issues for screening for prostate cancer with PSA include false positives that require additional testing and biopsy, overdiagnosis, and overtreatment. The treatment for prostate cancer has a lot of side effects including urinary incontinence, erectile dysfunction, and bowel issues. This is concerning when quality of life can be greatly influenced by these side effects.

MRI
With improved technology, MRI is emerging as a nice screening tool for prostate cancer. MRI has shown promising results. MRI does identify cancer before it is too advanced. It also is decreasing the number of patients that are diagnosed with clinically insignificant cancer, which means fewer patients are being overtreated. According to Hugosoon et al in 2024, using MRI to decide if a biopsy should be performed “eliminated more than half of diagnoses of clinically insignificant prostate cancer,” while the risk of being diagnosed at an incurable stage was “very low.”¹ The use of MRI is more than for diagnosis at the pre-biopsy stage but is progressing to screening, active surveillance, clinical staging, and detection of recurrent disease. ² Artificial intelligence (AI) based algorithms are being explored for the use of detecting and characterizing prostate cancer on an MRI. These are showing promising results as well, particularly with decreasing false positives.³

As the landscape of prostate cancer screening evolves, it is crucial for patients and healthcare providers alike to remain informed and engaged in discussions about the best approaches to diagnosis and treatment. The decision to undergo screening should not be taken lightly; it requires a thorough understanding of the benefits and risks associated with various testing methods, including PSA testing and the promising role of MRI.

In an era where technology, including artificial intelligence, is reshaping how we approach cancer detection, it’s imperative to remain proactive and adaptable. By prioritizing education and open communication, we can ensure that the journey through prostate cancer screening and treatment is navigated with confidence and clarity.

Join us in Oncology of the Pelvic Floor Level 1 (OPF1) to receive an introduction to oncology of the pelvic floor, or Oncology of the Pelvic Floor Level 2A (OPF2A) for a deeper understanding of prostate cancer and empower yourself or your patients with the knowledge needed for informed health choices. In OPF1, we address issues that are commonly seen in a patient who has been diagnosed with cancer such as cardiotoxicity, peripheral neuropathy, and radiation fibrosis while in OPF2A, we cover topics of prostate cancer, testicular and penile cancers, as well as colorectal and anal cancers. You will learn the latest diagnostic testing for each type of cancer as well as medical treatment and how that treatment can influence our patients’ bodies. Hands-on treatment techniques that can be used in the rehabilitation process are learned. Join us to learn more about prostate cancer and more!

Oncology of the Pelvic Floor Level 1 is next offered January 11-12, 2025.
Oncology of the Pelvic Floor Level 2A is next offered March 8-9, 2025.

Resources

1. Hugosson J, Godtman RA, Wallstrom J, et al. (2024). Results after four years of screening for prostate cancer with PSA and MRI. New England Journal of Medicine. 391; 1083-1095.
2. Trecarten S, Sunnapwar AG, Clarke GD, Liss MA. (2024). Chapter Three- Prostate MRI for the detection of clinically significant prostate cancer: update and future directions. Advances in Cancer Research. Vol 161. 71-118.
3. Roubiere O, Jaouen T, Baseilhac P, et al. (2023). Artificial intelligence algorithms aimed at characterizing or detecting prostate cancer on MRI: How accurate are they when tested on independent cohorts?- A systematic review. Diagnostic and Interventional Imaging. Vol 104 (5): 221-234.

AUTHOR BIO:
Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC

Allison Ariail has been a physical therapist since 1999. She graduated with a BS in physical therapy from the University of Florida and earned a Doctor of Physical Therapy from Boston University in 2007. Also in 2007, Dr. Ariail qualified as a Certified Lymphatic Therapist. She became board-certified by the Lymphology Association of North America in 2011 and board-certified in Biofeedback Pelvic Muscle Dysfunction by the Biofeedback Certification International Alliance in 2012. In 2014, Allison earned her board certification as a Pelvic Rehabilitation Practitioner. Allison specializes in the treatment of the pelvic ring and back using manual therapy and ultrasound imaging for instruction in a stabilization program. She also specializes in women’s and men’s health including conditions of chronic pelvic pain, bowel and bladder disorders, and coccyx pain. Lastly, Allison has a passion for helping oncology patients, particularly gynecological, urological, and head and neck cancer patients.

In 2009, Allison collaborated with the Primal Pictures team for the release of the Pelvic Floor Disorders program. Allison's publications include: “The Use of Transabdominal Ultrasound Imaging in Retraining the Pelvic-Floor Muscles of a Woman Postpartum.” Physical Therapy. Vol. 88, No. 10, October 2008, pp 1208-1217. (PMID: 18772276), “Beyond the Abstract” for Urotoday.com in October 2008, “Posters to Go” from APTA combined section meeting poster presentation in February 2009 and 2013. In 2016, Allison co-authored a chapter in “Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies.”

Allison works in the Denver metro area in her practice, Inspire Physical Therapy and Wellness, where she works in a more holistic setting than traditional therapy clinics. In addition to instructing Herman & Wallace on pelvic floor-related topics, Allison lectures nationally on lymphedema, cancer-related changes to the pelvic floor, and the sacroiliac joint. Allison serves as a consultant to medical companies, and physicians.

Faiq Shaikh, M.D. is a dual fellowship-trained nuclear medicine physician & Informaticist, with a focus on translational research in the domains of Cancer imaging, Radiomics, Genomics, Informatics and Machine learning applications in Medicine. He has written more than 35 scientific articles and abstracts and 3 book chapters on related topics.

Introduction

Pelvic floor weakening is a common (occuring in half of women 50+) condition that leads to descent of the urinary bladder, uterovaginal vault, and rectum in the females, leading to urinary and fecal incontinence, and in extreme cases, pelvic organ prolapse.

Causes

Pelvic floor weakness is caused by a variety of factors, most of which increase the intra-abdominal pressure, such as pregnancy, multiparity, advanced age, menopause, obesity, connective tissue disorders, smoking, chronic obstructive pulmonary disease, etc. All these conditions lead to weakness of the pelvic musculature, ligaments, and fascia support result in descent of the pelvic floor organs.

Anatomy

The pelvic floor is divided into three compartments:

• Anterior compartment: contains the urinary bladder and urethra
• Middle compartment: contains the uterus, cervix, and vagina
• Posterior compartment: contains the rectum.

The structures in these compartments are supported by muscles, fascia, and ligaments anchoring them to the bony pelvis.

The endopelvic fascia is the most superior layer and covers the levator ani muscles and the pelvic viscera. Laterally, it forms the arcus tendineus. It attaches the cervix and vagina to the pelvic side wall as the parametrium and paracolpium. Posteriorly, the endopelvic fascia forms the rectovaginal fascia between the posterior vaginal wall and the rectum.

These fascial condensations are not well visualized on conventional MRI but their defects may be seen indirectly through secondary findings. These ligaments are not visualized on conventional MRI but may be visualized with an endovaginal coil which allows higher resolution and signal-to-noise ratio.

The levator ani muscles lie deep in relation to the endopelvic fascia and comprise of the puborectalis and the iliococcygeus muscles. Posteriorly and in the midline, the iliococcygeus condenses to form the levator plate. These are all well visualized on MRI. The perineal membrane lies inferior to the levator ani muscles and separates the vagina and rectum, which may be damaged during vaginal delivery when episiotomy is performed.

Pathophysiology

Pelvic floor relaxation is the weakness of the supporting muscles, fascia, and ligaments. This weakness progresses with age and may be related to hypoestrogenic states, such as menopause.

• occurs when the urinary bladder prolapses into the anterior vaginal wall, which may cause urinary incontinence.
• occurs due to weakness of the rectovaginal fascia, prolapsing rectum into the posterior vaginal wall, which may cause fecal incontinence.
• The parametrium and paracolpium weakness causes prolapse of the cervix and uterus.
• occurs when the small bowel prolapses through the rectovaginal fascia.

Accurate assessment of all compartments of the pelvic floor is necessary for surgical planning in order to minimize the risk of recurrence.

Diagnostics

Methods for the assessment of pelvic floor weakness include urodynamics, voiding cystourethrography, ultrasonography of the bladder neck and anal sphincter, fluoroscopic cystocolpodefecography, and MRI - which m is now the standard-of-care for preoperative planning for pelvic floor dysfunction, although it’s still not used for routine assessment.

Magnetic resonance imaging

MRI visualizes all three compartments of the pelvic floor and the pelvic support muscles and organs. We perform dynamic MRI of the pelvic floor with the patient in the supine or lateral decubitus positions. Conversely, MRI defecography or fluoroscopic cystocolpodefecography are performed in the sitting position, which is closer to the physiologic state. MR defecography is not superior to dynamic supine MRI for depiction of clinically relevant bladder descent and rectoceles. Overall, MRI accurately detects enteroceles and its contents when compared with fluoroscopic cystodefecography.

The preferred MRI pelvis protocols include: Ultrafast, large-field-of-view, T2-weighted sequences such as single-shot fast spin-echo (SSFSE), and half-Fourier acquisition turbo spin-echo (HASTE). After the dynamic examination is completed, small-field-of-view (20–24 cm) T2-weighted axial fast spin-echo (FSE) or axial turbo spin-echo (TSE) sequences are acquired to obtain high-resolution images of the muscles and fascia of the pelvic floor. The entire examination is typically completed in 20 minutes. This exam is performed with a torso phased-array coil wrapped around the pelvis. Endovaginal coil may be used to improve the spatial resolution of the pelvic ligaments, but it is invasive and can be uncomfortable.

MRI visualizes the uterus, cervix, and rectovaginal space. Ultrasonic gel may be administered into the vagina and rectum for better visualization. Also, incompletely voiding the urinary bladder improves visualization of the bladder and anterior vaginal wall prolapse.

For patients with a rectocele, patient is imaged after having evacuated the rectal contents. Chronic constipation and perineal hernias show as ballooning of the iliococcygeus muscle. The level of the pelvic floor is demarcated radiologically on the midsagittal image using the pubococcygeal line (from the most inferior portion of the pubic symphysis to the last horizontal sacrococcygeal joint). The levator plate should be parallel to the pubococcygeal line in normal cases.
The H line (5 cm) extends from the inferior symphysis pubis to the posterior anorectal junction on the midsagittal image and depicts the levator hiatus. The M line (2 cm) goes perpendicular from the pubococcygeal line to the most distal aspect of the H line and depicts the descent of the levator hiatus from the pubococcygeal line. Pelvic floor prolapse causes sloping of the levator plate and increasing length of the H and M lines, indicating widening and descent of the levator hiatus.

The T2-weighted axial images of the pelvic floor should be analyzed for signal intensity, symmetry, thickness, and fraying of the pelvic floor muscles. Bladder neck at strain should be less than 1 cm away from the pubococcygeal line. Descent of the bladder neck below the pubococcygeal line depicts the prolapse of the urinary bladder through the anterior vaginal wall resulting in a cystocele. Descent of the bladder neck during strain results in clockwise rotational descent of the bladder neck and proximal urethra. Distortion of the periurethral and paraurethral ligaments is seen in stress urinary incontinence. The normal butterfly shape of the vagina may also be altered by weakening of the paravaginal ligaments as it is displaced posteriorly. Prolapse of the middle compartment is associated with the vaginal apical prolapse and damage to the paracolpium seen in post-hysterectomy patients.  On midsagittal MR images, descent of the uterus, cervix and vagina usually suggests disruption of the uterosacral or cardinal ligaments and elongated H and M lines. Pelvic organ prolapse increases the urogenital hiatus in the levator muscles. Caudal angle of more than 10° between the levator plate and the pubococcygeal line on midsagittal image is a sign of pelvic floor weakness.

On the midsagittal image, rectocele is identified by a rectal bulge of more than 3 cm (from anal canal and the tip of the rectocele). Contrast-enhanced MR shows hyperintense T2 signal in peritoneal fat contents in peritoneoceles, the hyperintense fluid-filled small-bowel loops in enteroceles, and the hyperintense gel-filled rectum/sigmoid colon in rectoceles/sigmoidoceles. Intussusception of the rectum on MR is seen as rectum invaginating distally toward the anal canal (MR defecography is superior to dynamic supine MR for this indication).

Performing MRI for pelvic floor dysfunction when indicated for surgical planning and the assessment if the extent of disease may reduce the risk of surgical failure.
This information is extremely useful to urogynecologists and surgeons.

MRI of pelvic floor dysfunction: review. Law YM, Fielding JR. AJR Am J Roentgenol. 2008.