Diffusion tensor imaging of the pelvic floor muscles and pelvic organs: a systematic review

PURPOSE: This paper provides a systematic review of the current applications of diffusion tensor imaging (DTI) in the imaging of pelvic floor-related anatomical structures and the assessment of microscopic pathological changes. METHODS: A systematic search of the PubMed, EMBASE, and Cochrane Library databases was conducted, with a focus on studies involving the application of diffusion tensor imaging to pelvic organs and muscles. The search was conducted from the inception of each database through to 11 December 2025. The present study incorporated a range of research methodologies, including randomized controlled trials (RCTs) and observational studies. The screening and reporting phases of the study adhered to the PRISMA guidelines, while the quality assessment was conducted using the Oxford Centre for Evidence-Based Medicine (OEBM) evidence grading tool. RESULTS: The final sample comprised a total of 30 studies. Of these, two studies reported the application of DTI on the anal canal and its diagnostic value for anal fistula. Five studies demonstrated the ability of DTI to visualize microstructural alterations in endometriosis and uterine fibroids by measuring uterine anisotropy fraction and fibre tracking. A total of 19 studies reported the utilization of DTI applications in the context of prostate and prostate tumor analysis. Four studies have documented its use in healthy pelvic muscles and pelvic floor dysfunction. CONCLUSION: The findings suggest that the application of diffusion tensor imaging metrics in the pelvic region may aid in the assessment of tissue microstructural disruption and the distinction between benign and malignant or inflammatory lesions through relevant parameters, thereby enhancing diagnostic specificity. As diffusion tensor imaging becomes increasingly utilized in imaging for treatment guidance, it is imperative to develop a comprehensive understanding of its application in the pelvic region.