Ageing effects of the female pelvis and organ endo-pelvic fascia space as shown by novel MRI measurements

Ageing effects of the female pelvis and organ endo-pelvic fascia space as shown by novel MRI measurements | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Ageing effects of the female pelvis and organ endo-pelvic fascia space as shown by novel MRI measurements Yun Chen, Cheng Qian, Yan Yin, Yinjian Zhou, Zhuangzhuang Xu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6182348/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract OBJECTIVE : In this study, several groups of data were measured by MRI to reflect the effect of age on the pelvis and organ-endopelvic fascia space, and to investigate the anatomical causes of pelvic floor dysfunction. METHODS : A total of 120 women aged 15-74 with no definite pelvic floor functional disorders were divided into six groups with a span of 10 years for each age group. A review of MRI data from all female pelvis was conducted to measure the pubic symphysis inclination angle, the anterior bladder space area, the puborectal muscle pinch angle, and the rectovaginal anal levator gap area. RESULTS : All cases were evaluated quantitatively for the pubic symphysis inclination angle, the anterior bladder space area, the puborectal muscle pinch angle, and the rectovaginal anal levator gap area. The results showed that with increasing age, the pubic symphysis inclination angle was enlarged in women (the group aged 65-74 years vs. the other five groups; P<0.05), the anterior bladder space area increased (the three groups aged <45 years vs. the three groups aged≥45 years; P<0.05), the puborectal muscle pinch angle was enlarged (the group aged 15-24 years vs. the other five groups; P<0.05), and the rectovaginal anal levator gap area increased (the group aged 65-74 years vs. the other five groups; P<0.05). All measures were positively correlated with age. CONCLUSION : It is known from imaging that linear degeneration of the pelvis and pelvic floor muscles with increasing age may be an anatomical factor in the occurrence of pelvic floor dysfunction diseases such as pelvic organ prolapse.Refining the quantitative evaluation method of female pelvic floor MRI to alert the occurrence of pelvic organ prolapse in middle-aged and elderly women who have given birth. age magnetic resonance imaging pelvis pelvic floor muscle Figures Figure 1 Figure 2 Synopsis It is known from imaging that increasing age may be an anatomical factor in the occurrence of pelvic floor dysfunction diseases. Introduction The occurrence of female pelvic floor disorders is a complex problem that can be recognized anatomically by some classical theories. Since 1908, Fothergill, Petros and DeLancey 1 – 3 have proposed the holistic theory of the pelvic floor, the three-level theory and the hammock hypothesis, suggesting that the structure and function of the female pelvic floor is an interconnected and dynamic anatomical whole. While women go through pregnancy phase, during which there are significant changes in pelvic floor morphology, some of which occur after delivery 4 . Remodeling during pregnancy and/or injury during vaginal delivery can have lasting effects on the pelvic floor muscles, fascia, ligaments and other tissues 5 .In addition, several studies have shown that age-related changes are an independent risk factor for the decline of pelvic floor support 6 . Therefore, further study of the female pelvic floor anatomy is an essential pathway to explore the pathogenesis of female pelvic floor dysfunctional diseases(PFD). Pelvic floor MRI is recognized as the most preferred method for comprehensive assessment of pelvic floor anatomy and defects because of its high soft tissue resolution 7 .On pelvic floor MRI images, the pelvic floor is divided into three main layers from the outside to the inside, with the outer layer referring to the superficial fascia and superficial muscles, the middle layer referring to the perineal diaphragm (also known as the genitourinary diaphragm), and the inner layer being the pelvic diaphragm.The connective tissues of the pelvis, perineal diaphragm and intrapelvic fascia provide passive support to the pelvic floor, while the pelvic diaphragm layer provides active support to the pelvic floor through timely contraction and relaxation 8 .Cheng W et al 9 studies showed that MRI images suggest some changes in the pelvis and muscles of women with increasing age, and can be used as a diagnostic basis for women with and without prolapse 10 . However, there is a lack of research on the changes of pelvis and pelvic floor muscles in women of different ages. We hope that by performing MRI scans of the pelvis in women of different ages and measuring several indicators to reflect the continuous changes in the pelvis and pelvic floor muscles and fascia.We can analyze the trends of these parameter values with age and clarify the effects of age on the pelvis and pelvic floor muscles and fascia, thus laying the foundation for further studies of pelvic floor dysfunction. Materials and Methods Clinical data: This was a retrospective study using survey data at Huzhou Maternal and Child Health Hospital, and 120 female patients who met the following criteria and received medical care and examinations at the hospital between 2020 and 2023 were included in the study. According to the declaration of Helsinki, ethical approval for this study was obtained from the Ethics Committee of Huzhou Maternal and Child Health Hospital (Ethical approval No. 2023-J-059). Every patient was approached and only participants who provided informed consent were enrolled for the study. Women who declined to provide informed consent were excluded from the study. The inclusion criteria were: age between 15 and 74 years; no pelvic surgery other than cesarean delivery; no definite pelvic floor dysfunctional diseases; no pelvic floor tumors or malformations causing axial changes in the pelvic floor; and no contraindications to other MRI examinations such as claustrophobia and pelvic metal implants. The patients were divided into 6 age groups of 10 years: 15 to 24 years, 25 to 34 years, 35 to 44 years, 45 to 54 years, 55 to 64 years, and 65 to 74 years, and all patients underwent static pelvic floor MRI scans. Prior to the scans, they were informed that their examination data might be used for medical research analysis in the future and signed informed consent forms. Patients meeting the aforementioned criteria, grouped by age, were then included in this retrospective study. Methods: 2.1 MRI scan:The scan was performed using a Siemens 1.5T MRI machine (Siemens, Avanto) with a body coil on the surface. The patient was instructed to fill the bladder appropriately before the examination. During the examination, the subject was placed in the supine position in head advanced mode with the legs straight and relaxed flat The patient is placed on the MR examination bed and told that he is not allowed to move his body during the MRI examination.Scan parameters:sagittal T2WI_SSTSE sequence (TR/TE = 4000/79ms,FOV = 250×250,Nex = 1,matrix = 320×320,layer thickness:5mm); sagittal T1WI_SSTSE sequence (TR/TE = 520/11ms,FOV = 250×250, Nex = 2,matrix = 320×320, layer thickness:3mm); transverse T2WI_SSTSE sequence (TR/TE = 4000/79ms, FOV = 350×350,Nex = 2,matrix = 512×512,layer thickness:3mm, echo chain length = 256,flip angle = 180°);transverse T1WI_SSTSE sequence(TR/TE = 570/12ms,FOV = 350×350,matrix = 512×512,layer thickness:3mm,echo chain length = 256,flip angle = 180°);coronal T2WI_SSTSE sequence(TR/TE = 4170/101ms,FOV = 320×320,Nex = 2,matrix = 320×320,layer thickness = 5mm).All sequences were scanned in 10 layers, and measurements were performed by physicians with associate or higher titles in imaging: the layers that meet the diagnostic requirements were selected as required, and the areas of interest were manually outlined through the PACS workstation to automatically derive the data to be measured. 2.2 Image processing and analysis: The following parameters were measured on the PACS workstation by two radiologists (with 10 years' experience in reading pelvic MR films). The measured values were taken as the mean values measured by the two patients. MRI parameters: (1)the pubic symphysis inclination angle: the angle between the pubic symphysis and the horizontal line was measured in the median sagittal plane (Fig. 1 , a); (2) the anterior bladder space area: the area of the posterior bladder space was calculated by taking the midpoint of the pubic symphysis in the transverse position (Fig. 1 , b); (3)the puborectal muscle pinch angle: take the angle of the puborectal muscle bilaterally in the transection position (Fig. 1 , c); (4)the rectovaginal anal levator gap area: In a transverse position, the area enclosed by the anterolateral rectal wall, the posterior vaginal wall and the bilateral anal levator muscle. (Fig. 1 , d). 3. Statistical analysis: Using SPSS 23 statistical analysis software, all measurements were expressed in square centimeters (cm 2 ) for area and in degrees (°) for angle, to two decimal places. The measures were statistically described as mean ± standard deviation (x ± s).One-way ANOVA was used to compare the parameters among the six groups ,and independent sample t-test was used to compare the parameters of each age group separately. All statistical analyses were performed at P < 0.05 as statistically significant differences. Spearman correlation analysis was used to assess whether the pelvic floor MRI parameters were correlated with age in each group. Results 1. Comparison of pelvic floor MRI parameters between the six groups The statistical data of pelvic floor MRI parameters among the six groups are shown in Table 1 . The differences in symphysis pubis inclination angle, anterior bladder space area, puborectal muscle angle, and rectovaginal anal levator gap area among the six groups were statistically significant (P < 0.05). Pairwise comparison within groups showed that: pubic symphysis inclination angle: The difference between the 65–74 years and the other five groups was statistically significant (P 0.05). Similarly, the differences among the age groups of 45–54 years, 55–64 years, and 65–74 years were not statistically significant (P > 0.05). However, the differences between these two major groups were statistically significant (P < 0.05), indicating a significant change in this area among women around the age of 45; puborectal muscle pinch angle: The difference between the 15–24 years and the other five groups was statistically significant (P < 0.05); rectovaginal anal levator gap area: The difference between the 65–74 years and the other five groups was statistically significant (P < 0.05). Table 1 Comparison of measurements between age groups x̄ ± s Group Age Group pubic symphysis inclination angle(°) Anterior bladder space area(cm2) puborectal muscle pinch angle(°) Rectovaginal Anal levator gap area(cm2) Group1 15–24 years old 34.84 ± 1.57 3.09 ± 0.17 46.29 ± 1.62a 0 Group2 25–34 years old 35.12 ± 1.53 3.49 ± 0.24 59.46 ± 3.03 0 Group3 35–44 years old 35.98 ± 1.17 3.53 ± 0.21 55.22 ± 2.40 0 Group4 45–54 years old 37.74 ± 1.51 4.48 ± 0.37 57.93 ± 3.09 0 Group4 55–64 years old 38.37 ± 1.41 5.01 ± 0.37 56.55 ± 3.92 0.28 ± 0.24 Group6 65–74 years old 42.96 ± 1.87a 5.29 ± 0.41 59.46 ± 3.70 0.47 ± 0.17a P 0.002 0.000 0.0281 0.022 Note: a P<0.05 2. Correlation analysis of pelvic floor MRI parameters with age Pubic symphysis inclination angle (Fig. 2 a, r = 0.320, P < 0.0001), anterior bladder space area (Fig. 2 b, r = 0.503, P < 0.0001), puborectal muscle pinch angle (Fig. 2 c, r = 0.220, P = 0.016), and rectovaginal anal levator gap area (Fig. 2 d, r = 0.378, P < 0.0001) were all positively correlated with age, see Fig. 2 . Discussion 1. pubic symphysis inclination angle: the pelvis is the most gender-specific part of the human skeleton, which unites the iliac and pubic bones on both sides through the pubic symphysis. For women, both morphologically and functionally, the pelvis is adapted to the obstetric requirements of bipedal walking and safe delivery 11 . The angle of the pubic symphysis indirectly reflects the tilt angle of the pelvis, and changes in the tilt angle of the pelvis also have an effect on the pelvic floor load bearing. Cinzia Fornai et al. 12 have shown that in adolescence, the superior margin of the pubic symphysis is skewed forward, and with age, the pelvis is rearranged, with the ilium more vertical and the superior pubic branch more backward near the symphysis. During the perinatal period to facilitate the infant's head into the pelvis, access to the birth canal, and rotation, the ligaments connecting the pubic bones must stretch and the pubic symphysis separate, so the inclination of the pubic symphysis changes at the same time 13 . It can be concluded from our data that this angle of inclination increases linearly with age, with an average difference in angle of nearly 10° between the 15-24 and 65-74 age groups. In younger women the bladder and other organs are equivalent to lying on the pubic symphysis, while in older women the bladder is equivalent to half hanging on the pubic symphysis. In women, the angle of inclination of the pubic symphysis gradually increases from young to old, and the fattening of the triangular ligament and the pubourethral and pubocervical ligaments causes a decrease in adhesion, similar to a "slippery slope".Therefore, an increase in the tilt of the pubic symphysis also means an overall posterior tilt of the pelvis, with the resulting horizontal pelvic floor plane and increased vertical pressure. 2. anterior bladder space area：the anterior bladder space behind the pubic bone is formed by thickening of the pelvic wall fascia below the midpoint of the pubic symphysis, named the triangular ligament of the bladder and the pubourethral ligament, which serves to suspend the urethra and the bladder neck; in addition, the anterior space contains fat, loose fibrous tissue and venous plexus 13,14 (Figure S1). The data in the this paper indicate that differences in the area of the anterior bladder space occur with increasing age. Taking 45 years old as the boundary, the age group younger than 45 years is obviously smaller than the age group older than 45 years. This may be related to the beginning of perimenopause in women around the age of 45 years, when estrogen levels decline, leading to muscle and ligament laxity and steatosis in the pelvis 15 (Figure S2).It can be concluded from our data that the area gradually increases with age, which also suggests the area of the anterior bladder space as a possible participating factor in the occurrence of pelvic organ prolapse. 3. puborectal muscle pinch angle: In ultrasonography, the area of the anal raphe fissure is measured as a basis for determining the degree of prolapse 16,17 . In this study, we used instead a simple method of MRI measurement of the puborectalis muscle pinch angle for assessment. The data in the paper showed that the puborectalis angle widened in the age group after 25 years and did not continue to widen with increasing age thereafter. It is suggested that the angle of the puborectalis muscle increased significantly in women after pregnancy compared to women without pregnancy, that women who experienced pregnancy and childbirth did not return to their pre-pregnancy state after delivery, and that the angle did not continue to expand thereafter. Therefore, the effect of pregnancy and childbirth on the female pelvic floor muscles is lifelong 18 , the perinatal period makes the female pelvic floor muscle extension can be said to be to the peak, and thereafter there is no chance to fully return to pre-pregnancy on its own, which may also be related to the expansion of the pelvis, which provides a channel for pelvic organ prolapse and becomes the basis for the pathogenesis of pelvic floor dysfunctional diseases 19 . 4. rectovaginal anal levator gap area:we know that in men the intrinsic rectal fascia fuses with the surface fascia of the anal raphe and the Denonvilliers fascia anteriorly to form a slightly thickened white fascial structure 20 and thickens directly posteriorly to form the Hiatal ligament to fix end of the rectum 21 . Tsukada Y et al. 22 found that the fibers of the anal raphe inserted longitudinally into the rectal wall play an important role in the fixation of the rectum The anorectalis muscle does not have muscle fibers inserted into the vagina, only tightly bonded by fascia. Meanwhile, Zhang et al. 23 found that the female rectovaginal septum is not a fascial structure, but is filled with adipose tissue, loose reticular fibrous tissue and some muscle fibers. These septa pull on each other and play an important role in maintaining the pelvic organs, increasing adhesion, and limiting the spread of inflammatory or malignant tumors 24 .Therefore, in anatomical studies of pelvic floor structures, it is considered that the rectovaginal septum and the lateral rectal fascial mesh pocket-like support are significant for the stability of the posterior pelvis. Weakness in this area is the main cause of posterior pelvic organ prolapse and rectal prolapse. María Alejandra et al. 25 found that the rectovaginal septum is significantly longer in premenopausal women and decreases in thickness after menopause. Our data suggest that with increasing age, degeneration of the fascias between the rectovaginal-anal septum is seen and eventually the attachment weakens, and in a few patients, a significant gap even begins to appear, with the consequent weakening of the support of the pelvic floor muscles to the posterior vaginal wall, causing prolapse. Conclusions 1. Further refine and establish quantitative evaluation methods for female pelvic floor MRI, particularly focusing on timely monitoring and early warning of pelvic floor structure in middle-aged and elderly women who have given birth, to prevent pelvic organ prolapse. 2. When assessing pelvic floor function, attention should be paid to changes in pelvic bone structure, adhesions between pelvic organs, and the comprehensive consideration of these factors. Note that pelvic floor structure and morphology may change with increasing age, which can lead to greater stability. 3. This study did not differentiate between groups with multiple pregnancies or multiple deliveries, nor did it distinguish between different delivery methods such as vaginal delivery, difficult vaginal delivery, and cesarean section, or measure differences in various indicators among each age group. Future research could refine this aspect of the work. Declarations FUNDING STATEMENT Current Funding Source: Scientific Research Project of Huzhou Municipal Science and Technology Department; Award Number: Project No. 2021GY39. CONFLICT OF INTEREST STATEMENT The authors have no conflicts of interest. DATA AVAILABILITY STATEMENT Research data are not shared. Author Contribution Y.C did the data analysis, and performed the research.C.Q. conceptualized the research study. Y.Y. and Z.X. analyzed the data. Y.Z. investigated and resolved the integrity of all the parts of the work. X.F. did the data acquisition, analysis, and measurement, conducted the work. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be ccountable for all aspects of the work. References Fothergill WE. On the Operative Treatment of Displacements of the Pelvic Viscera. Trans Edinb Obstet Soc. 1908;33:129–45. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992;166(6 Pt 1):1717–24. discussion 1724-8. DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol. 1994;170(6):1713–20. discussion 1720-3. Schulten SFM, Claas-Quax MJ, Weemhoff M, van Eijndhoven HW, van Leijsen SA, Vergeldt TF, IntHout J, Kluivers KB. 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Gynecological influencing factors on the rectovaginal septum's morphology. Int Urogynecol J. 2021;32(6):1427–32. Additional Declarations No competing interests reported. Supplementary Files SuppFigures.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6182348","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":427202264,"identity":"0c5e8aa8-5205-4dd1-be24-5ca638d47fe9","order_by":0,"name":"Yun Chen","email":"","orcid":"","institution":"Huzhou Maternity \u0026 Child Health Care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yun","middleName":"","lastName":"Chen","suffix":""},{"id":427202265,"identity":"81e96ecc-196b-4680-a769-39a368fde42f","order_by":1,"name":"Cheng Qian","email":"","orcid":"","institution":"Huzhou Maternity \u0026 Child Health Care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Cheng","middleName":"","lastName":"Qian","suffix":""},{"id":427202266,"identity":"79cd0782-63d7-49c8-9a08-e3668d994bd3","order_by":2,"name":"Yan Yin","email":"","orcid":"","institution":"Huzhou Maternity \u0026 Child Health Care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Yin","suffix":""},{"id":427202267,"identity":"78587219-3072-441e-94e3-aa157884616b","order_by":3,"name":"Yinjian Zhou","email":"","orcid":"","institution":"Huzhou Maternity \u0026 Child Health Care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yinjian","middleName":"","lastName":"Zhou","suffix":""},{"id":427202268,"identity":"2d6b0d47-b793-4f14-834c-39c525fc6476","order_by":4,"name":"Zhuangzhuang Xu","email":"","orcid":"","institution":"Huzhou Maternity \u0026 Child Health Care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhuangzhuang","middleName":"","lastName":"Xu","suffix":""},{"id":427202269,"identity":"aa232393-0c8d-42f9-aaa8-eb4369b825b1","order_by":5,"name":"Xiangming Fang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYBACNv7m45//VPyX42dmbHyQUFFDWAufxLE0Bp4zzMaS7c2HDR6cOUZYixxDjhkDbxtzokHPsTTJhy3MRDiM4VjaAwk2tgQDiRyzisQGNgb+9u4E/FqYm48bGPDw5JkDtdxI3CHDIHHm7AZCtiRIJEhIFFvOAGk5w8ZgIJFLSEuOgcQBA4PEDTdyzAoS25iJ0mIm2ZCQkLjhDDDoiNMicSzZmOHAAXAgSyScOcZD0C/y/c0HHzP+OwCOyo8/Kmrk+Nt78WvBADykKR8Fo2AUjIJRgBUAAI8lSv2ep1Z8AAAAAElFTkSuQmCC","orcid":"","institution":"Huzhou Maternity \u0026 Child Health Care Hospital","correspondingAuthor":true,"prefix":"","firstName":"Xiangming","middleName":"","lastName":"Fang","suffix":""}],"badges":[],"createdAt":"2025-03-08 06:38:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6182348/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6182348/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78642703,"identity":"79c7756f-db31-44b7-9636-0697f25e1dfe","added_by":"auto","created_at":"2025-03-17 06:59:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":581052,"visible":true,"origin":"","legend":"\u003cp\u003ea: pelvic floor MRI, sagittal T1WI sequence image of a 68-year-old woman with a pubic symphysis inclination angle of 51.8°; b: pelvic floor MRI with transverse T1WI sequence images of a 66-year-old female with an anterior bladder space area of 8.24 cm\u003csup\u003e2\u003c/sup\u003e ; c: pelvic floor MRI with a transverse T1WI sequence image of a 67-year-old female with a puborectal muscle pinch angle of 88.5°; d: pelvic floor MRI with a transverse compression lipid T2WI sequence image of a 67-year-old female with a rectovaginal anal levator gap area of 2.32 cm\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6182348/v1/fe6ab12c66602afab156c9e8.png"},{"id":78642708,"identity":"90f72ac6-f7b4-41b4-9fca-83106cadc981","added_by":"auto","created_at":"2025-03-17 06:59:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":286252,"visible":true,"origin":"","legend":"\u003cp\u003ea: Pubic symphysis inclination angle was positively correlated with age(r=0.320, P＜0.0001).\u003c/p\u003e\n\u003cp\u003eb: Anterior bladder space area was positively correlated with age(r=0.503, P＜0.0001).\u003c/p\u003e\n\u003cp\u003ec: Puborectal muscle pinch angle was positively correlated with age(r=0.220, P=0.016＜0.05).\u003c/p\u003e\n\u003cp\u003ed: Rectovaginal anal levator gap area was positively correlated with age(r=0.378, P＜0.0001).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6182348/v1/3f5d1ffe271798340b3eace6.png"},{"id":97960771,"identity":"a41de112-d2cf-4be1-b817-64ccfcf2d55c","added_by":"auto","created_at":"2025-12-11 08:41:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1609347,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6182348/v1/6144ed3c-61e9-4c32-8a93-48d76d661fff.pdf"},{"id":78642700,"identity":"bd9dcb38-e9f7-4f08-9f35-dd606f2da211","added_by":"auto","created_at":"2025-03-17 06:59:47","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":149947,"visible":true,"origin":"","legend":"","description":"","filename":"SuppFigures.docx","url":"https://assets-eu.researchsquare.com/files/rs-6182348/v1/6ae1e3da492ed0f8580cae8a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ageing effects of the female pelvis and organ endo-pelvic fascia space as shown by novel MRI measurements","fulltext":[{"header":"Synopsis","content":"\u003cp\u003eIt is known from imaging that increasing age may be an anatomical factor in the occurrence of pelvic floor dysfunction diseases.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eThe occurrence of female pelvic floor disorders is a complex problem that can be recognized anatomically by some classical theories. Since 1908, Fothergill, Petros and DeLancey\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e have proposed the holistic theory of the pelvic floor, the three-level theory and the hammock hypothesis, suggesting that the structure and function of the female pelvic floor is an interconnected and dynamic anatomical whole. While women go through pregnancy phase, during which there are significant changes in pelvic floor morphology, some of which occur after delivery\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Remodeling during pregnancy and/or injury during vaginal delivery can have lasting effects on the pelvic floor muscles, fascia, ligaments and other tissues\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.In addition, several studies have shown that age-related changes are an independent risk factor for the decline of pelvic floor support\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Therefore, further study of the female pelvic floor anatomy is an essential pathway to explore the pathogenesis of female pelvic floor dysfunctional diseases(PFD).\u003c/p\u003e \u003cp\u003ePelvic floor MRI is recognized as the most preferred method for comprehensive assessment of pelvic floor anatomy and defects because of its high soft tissue resolution\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.On pelvic floor MRI images, the pelvic floor is divided into three main layers from the outside to the inside, with the outer layer referring to the superficial fascia and superficial muscles, the middle layer referring to the perineal diaphragm (also known as the genitourinary diaphragm), and the inner layer being the pelvic diaphragm.The connective tissues of the pelvis, perineal diaphragm and intrapelvic fascia provide passive support to the pelvic floor, while the pelvic diaphragm layer provides active support to the pelvic floor through timely contraction and relaxation\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.Cheng W et al\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e studies showed that MRI images suggest some changes in the pelvis and muscles of women with increasing age, and can be used as a diagnostic basis for women with and without prolapse\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. However, there is a lack of research on the changes of pelvis and pelvic floor muscles in women of different ages. We hope that by performing MRI scans of the pelvis in women of different ages and measuring several indicators to reflect the continuous changes in the pelvis and pelvic floor muscles and fascia.We can analyze the trends of these parameter values with age and clarify the effects of age on the pelvis and pelvic floor muscles and fascia, thus laying the foundation for further studies of pelvic floor dysfunction.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e Clinical data: This was a retrospective study using survey data at Huzhou Maternal and Child Health Hospital, and 120 female patients who met the following criteria and received medical care and examinations at the hospital between 2020 and 2023 were included in the study. According to the declaration of Helsinki, ethical approval for this study was obtained from the Ethics Committee of Huzhou Maternal and Child Health Hospital (Ethical approval No. 2023-J-059). Every patient was approached and only participants who provided informed consent were enrolled for the study. Women who declined to provide informed consent were excluded from the study. The inclusion criteria were: age between 15 and 74 years; no pelvic surgery other than cesarean delivery; no definite pelvic floor dysfunctional diseases; no pelvic floor tumors or malformations causing axial changes in the pelvic floor; and no contraindications to other MRI examinations such as claustrophobia and pelvic metal implants. The patients were divided into 6 age groups of 10 years: 15 to 24 years, 25 to 34 years, 35 to 44 years, 45 to 54 years, 55 to 64 years, and 65 to 74 years, and all patients underwent static pelvic floor MRI scans. Prior to the scans, they were informed that their examination data might be used for medical research analysis in the future and signed informed consent forms. Patients meeting the aforementioned criteria, grouped by age, were then included in this retrospective study.\u003c/p\u003e \u003cp\u003eMethods:\u003c/p\u003e \u003cp\u003e2.1 MRI scan:The scan was performed using a Siemens 1.5T MRI machine (Siemens, Avanto) with a body coil on the surface. The patient was instructed to fill the bladder appropriately before the examination. During the examination, the subject was placed in the supine position in head advanced mode with the legs straight and relaxed flat The patient is placed on the MR examination bed and told that he is not allowed to move his body during the MRI examination.Scan parameters:sagittal T2WI_SSTSE sequence (TR/TE\u0026thinsp;=\u0026thinsp;4000/79ms,FOV\u0026thinsp;=\u0026thinsp;250\u0026times;250,Nex\u0026thinsp;=\u0026thinsp;1,matrix\u0026thinsp;=\u0026thinsp;320\u0026times;320,layer thickness:5mm); sagittal T1WI_SSTSE sequence (TR/TE\u0026thinsp;=\u0026thinsp;520/11ms,FOV\u0026thinsp;=\u0026thinsp;250\u0026times;250, Nex\u0026thinsp;=\u0026thinsp;2,matrix\u0026thinsp;=\u0026thinsp;320\u0026times;320, layer thickness:3mm); transverse T2WI_SSTSE sequence (TR/TE\u0026thinsp;=\u0026thinsp;4000/79ms, FOV\u0026thinsp;=\u0026thinsp;350\u0026times;350,Nex\u0026thinsp;=\u0026thinsp;2,matrix\u0026thinsp;=\u0026thinsp;512\u0026times;512,layer thickness:3mm, echo chain length\u0026thinsp;=\u0026thinsp;256,flip angle\u0026thinsp;=\u0026thinsp;180\u0026deg;);transverse T1WI_SSTSE sequence(TR/TE\u0026thinsp;=\u0026thinsp;570/12ms,FOV\u0026thinsp;=\u0026thinsp;350\u0026times;350,matrix\u0026thinsp;=\u0026thinsp;512\u0026times;512,layer thickness:3mm,echo chain length\u0026thinsp;=\u0026thinsp;256,flip angle\u0026thinsp;=\u0026thinsp;180\u0026deg;);coronal T2WI_SSTSE sequence(TR/TE\u0026thinsp;=\u0026thinsp;4170/101ms,FOV\u0026thinsp;=\u0026thinsp;320\u0026times;320,Nex\u0026thinsp;=\u0026thinsp;2,matrix\u0026thinsp;=\u0026thinsp;320\u0026times;320,layer thickness\u0026thinsp;=\u0026thinsp;5mm).All sequences were scanned in 10 layers, and measurements were performed by physicians with associate or higher titles in imaging: the layers that meet the diagnostic requirements were selected as required, and the areas of interest were manually outlined through the PACS workstation to automatically derive the data to be measured.\u003c/p\u003e\u003cp\u003e2.2 Image processing and analysis: The following parameters were measured on the PACS workstation by two radiologists (with 10 years' experience in reading pelvic MR films). The measured values were taken as the mean values measured by the two patients. MRI parameters: (1)the pubic symphysis inclination angle: the angle between the pubic symphysis and the horizontal line was measured in the median sagittal plane (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e1\u003c/span\u003e, a); (2) the anterior bladder space area: the area of the posterior bladder space was calculated by taking the midpoint of the pubic symphysis in the transverse position (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e1\u003c/span\u003e, b); (3)the puborectal muscle pinch angle: take the angle of the puborectal muscle bilaterally in the transection position (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e1\u003c/span\u003e, c); (4)the rectovaginal anal levator gap area: In a transverse position, the area enclosed by the anterolateral rectal wall, the posterior vaginal wall and the bilateral anal levator muscle. (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e1\u003c/span\u003e, d).\u003c/p\u003e \u003cp\u003e3. Statistical analysis:\u003c/p\u003e \u003cp\u003eUsing SPSS 23 statistical analysis software, all measurements were expressed in square centimeters (cm\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e) for area and in degrees (\u0026deg;) for angle, to two decimal places. The measures were statistically described as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s).One-way ANOVA was used to compare the parameters among the six groups ,and independent sample t-test was used to compare the parameters of each age group separately. All statistical analyses were performed at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 as statistically significant differences. Spearman correlation analysis was used to assess whether the pelvic floor MRI parameters were correlated with age in each group.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e1. Comparison of pelvic floor MRI parameters between the six groups\u003c/p\u003e\n\u003cp\u003eThe statistical data of pelvic floor MRI parameters among the six groups are shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The differences in symphysis pubis inclination angle, anterior bladder space area, puborectal muscle angle, and rectovaginal anal levator gap area among the six groups were statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Pairwise comparison within groups showed that: pubic symphysis inclination angle: The difference between the 65\u0026ndash;74 years and the other five groups was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); anterior bladder space area: The differences among the age groups of 15\u0026ndash;24 years, 25\u0026ndash;34 years, and 35\u0026ndash;44 years were not statistically significant (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Similarly, the differences among the age groups of 45\u0026ndash;54 years, 55\u0026ndash;64 years, and 65\u0026ndash;74 years were not statistically significant (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, the differences between these two major groups were statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), indicating a significant change in this area among women around the age of 45; puborectal muscle pinch angle: The difference between the 15\u0026ndash;24 years and the other five groups was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); rectovaginal anal levator gap area: The difference between the 65\u0026ndash;74 years and the other five groups was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of measurements between age groups x̄ ± s\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge Group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003epubic symphysis inclination angle(\u0026deg;)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAnterior\u003c/p\u003e\n \u003cp\u003ebladder\u003c/p\u003e\n \u003cp\u003espace\u003c/p\u003e\n \u003cp\u003earea(cm2)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003epuborectal muscle pinch\u003c/p\u003e\n \u003cp\u003eangle(\u0026deg;)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRectovaginal\u003c/p\u003e\n \u003cp\u003eAnal levator gap area(cm2)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGroup1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u0026ndash;24 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.84\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.29\u0026thinsp;\u0026plusmn;\u0026thinsp;1.62a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGroup2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u0026ndash;34 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59.46\u0026thinsp;\u0026plusmn;\u0026thinsp;3.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGroup3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u0026ndash;44 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.98\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55.22\u0026thinsp;\u0026plusmn;\u0026thinsp;2.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGroup4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45\u0026ndash;54 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.74\u0026thinsp;\u0026plusmn;\u0026thinsp;1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.93\u0026thinsp;\u0026plusmn;\u0026thinsp;3.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGroup4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55\u0026ndash;64 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.37\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.55\u0026thinsp;\u0026plusmn;\u0026thinsp;3.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.28\u0026thinsp;\u0026plusmn;\u0026thinsp;0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGroup6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65\u0026ndash;74 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.87a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59.46\u0026thinsp;\u0026plusmn;\u0026thinsp;3.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.17a\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0281\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: a P\u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e2. Correlation analysis of pelvic floor MRI parameters with age\u003c/p\u003e\n\u003cp\u003ePubic symphysis inclination angle (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003ea, r\u0026thinsp;=\u0026thinsp;0.320, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), anterior bladder space area (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eb, r\u0026thinsp;=\u0026thinsp;0.503, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), puborectal muscle pinch angle (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003ec, r\u0026thinsp;=\u0026thinsp;0.220, P\u0026thinsp;=\u0026thinsp;0.016), and rectovaginal anal levator gap area (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003ed, r\u0026thinsp;=\u0026thinsp;0.378, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) were all positively correlated with age, see Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e1. pubic symphysis inclination angle: the pelvis is the most gender-specific part of the human skeleton, which unites the iliac and pubic bones on both sides through the pubic symphysis. For women, both morphologically and functionally, the pelvis is adapted to the obstetric requirements of bipedal walking and safe delivery\u003csup\u003e11\u003c/sup\u003e. The angle of the pubic symphysis indirectly reflects the tilt angle of the pelvis, and changes in the tilt angle of the pelvis also have an effect on the pelvic floor load bearing. Cinzia Fornai et al.\u003csup\u003e12\u003c/sup\u003e have shown that in adolescence, the superior margin of the pubic symphysis is skewed forward, and with age, the pelvis is rearranged, with the ilium more vertical and the superior pubic branch more backward near the symphysis. During the perinatal period to facilitate the infant\u0026apos;s head into the pelvis, access to the birth canal, and rotation, the ligaments connecting the pubic bones must stretch and the pubic symphysis separate, so the inclination of the pubic symphysis changes at the same time\u003csup\u003e13\u003c/sup\u003e. It can be concluded from our data that this angle of inclination increases linearly with age, with an average difference in angle of nearly 10\u0026deg; between the 15-24 and 65-74 age groups. In younger women the bladder and other organs are equivalent to lying on the pubic symphysis, while in older women the bladder is equivalent to half hanging on the pubic symphysis. In women, the angle of inclination of the pubic symphysis gradually increases from young to old, and the fattening of the triangular ligament and the pubourethral and pubocervical ligaments causes a decrease in adhesion, similar to a \u0026quot;slippery slope\u0026quot;.Therefore, an increase in the tilt of the pubic symphysis also means an overall posterior tilt of the pelvis, with the resulting horizontal pelvic floor plane and increased vertical pressure.\u003c/p\u003e\n\u003cp\u003e2. anterior bladder space area：the anterior bladder space behind the pubic bone is formed by thickening of the pelvic wall fascia below the midpoint of the pubic symphysis, named the triangular ligament of the bladder and the pubourethral ligament, which serves to suspend the urethra and the bladder neck; in addition, the anterior space contains fat, loose fibrous tissue and venous plexus\u003csup\u003e13,14\u003c/sup\u003e (Figure S1). The data in the this paper indicate that differences in the area of the anterior bladder space occur with increasing age. Taking 45 years old as the boundary, the age group younger than 45 years is obviously smaller than the age group older than 45 years. This may be related to the beginning of perimenopause in women around the age of 45 years, when estrogen levels decline, leading to muscle and ligament laxity and steatosis in the pelvis\u003csup\u003e15\u003c/sup\u003e (Figure S2).It can be concluded from our data that the area gradually increases with age, which also suggests the area of the anterior bladder space as a possible participating factor in the occurrence of pelvic organ prolapse.\u003c/p\u003e\n\u003cp\u003e3. puborectal muscle pinch angle: In ultrasonography, the area of the anal raphe fissure is measured as a basis for determining the degree of prolapse\u003csup\u003e16,17\u003c/sup\u003e. In this study, we used instead a simple method of MRI measurement of the puborectalis muscle pinch angle for assessment. The data in the paper showed that the puborectalis angle widened in the age group after 25 years and did not continue to widen with increasing age thereafter. It is suggested that the angle of the puborectalis muscle increased significantly in women after pregnancy compared to women without pregnancy, that women who experienced pregnancy and childbirth did not return to their pre-pregnancy state after delivery, and that the angle did not continue to expand thereafter. Therefore, the effect of pregnancy and childbirth on the female pelvic floor muscles is lifelong\u003csup\u003e18\u003c/sup\u003e, the perinatal period makes the female pelvic floor muscle extension can be said to be to the peak, and thereafter there is no chance to fully return to pre-pregnancy on its own, which may also be related to the expansion of the pelvis, which provides a channel for pelvic organ prolapse and becomes the basis for the pathogenesis of pelvic floor dysfunctional diseases\u003csup\u003e19\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e4. rectovaginal anal levator gap area:we know that in men the intrinsic rectal fascia fuses with the surface fascia of the anal raphe and the Denonvilliers fascia anteriorly to form a slightly thickened white fascial structure\u003csup\u003e20\u003c/sup\u003e and thickens directly posteriorly to form the Hiatal ligament to fix end of the rectum\u003csup\u003e21\u003c/sup\u003e. Tsukada Y et al.\u003csup\u003e22\u003c/sup\u003e found that the fibers of the anal raphe inserted longitudinally into the rectal wall play an important role in the fixation of the rectum The anorectalis muscle does not have muscle fibers inserted into the vagina, only tightly bonded by fascia. Meanwhile, Zhang et al.\u003csup\u003e23\u003c/sup\u003e found that the female rectovaginal septum is not a fascial structure, but is filled with adipose tissue, loose reticular fibrous tissue and some muscle fibers. These septa pull on each other and play an important role in maintaining the pelvic organs, increasing adhesion, and limiting the spread of inflammatory or malignant tumors\u003csup\u003e24\u003c/sup\u003e.Therefore, in anatomical studies of pelvic floor structures, it is considered that the rectovaginal septum and the lateral rectal fascial mesh pocket-like support are significant for the stability of the posterior pelvis. Weakness in this area is the main cause of posterior pelvic organ prolapse and rectal prolapse. Mar\u0026iacute;a Alejandra et al.\u003csup\u003e25\u003c/sup\u003e found that the rectovaginal septum is significantly longer in premenopausal women and decreases in thickness after menopause. Our data suggest that with increasing age, degeneration of the fascias between the rectovaginal-anal septum is seen and eventually the attachment weakens, and in a few patients, a significant gap even begins to appear, with the consequent weakening of the support of the pelvic floor muscles to the posterior vaginal wall, causing prolapse.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003e1. Further refine and establish quantitative evaluation methods for female pelvic floor MRI, particularly focusing on timely monitoring and early warning of pelvic floor structure in middle-aged and elderly women who have given birth, to prevent pelvic organ prolapse.\u003c/p\u003e\u003cp\u003e2. When assessing pelvic floor function, attention should be paid to changes in pelvic bone structure, adhesions between pelvic organs, and the comprehensive consideration of these factors. Note that pelvic floor structure and morphology may change with increasing age, which can lead to greater stability.\u003c/p\u003e \u003cp\u003e3. This study did not differentiate between groups with multiple pregnancies or multiple deliveries, nor did it distinguish between different delivery methods such as vaginal delivery, difficult vaginal delivery, and cesarean section, or measure differences in various indicators among each age group. Future research could refine this aspect of the work.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFUNDING STATEMENT\u003c/h2\u003e\n\u003cp\u003eCurrent Funding Source: Scientific Research Project of Huzhou Municipal Science and Technology Department;\u0026nbsp;Award Number: Project No. 2021GY39.\u003c/p\u003e\n\u003ch2\u003eCONFLICT OF INTEREST STATEMENT\u003c/h2\u003e\n\u003cp\u003eThe authors have no conflicts of interest.\u003c/p\u003e\n\u003ch2\u003eDATA AVAILABILITY STATEMENT\u003c/h2\u003e\n\u003cp\u003eResearch data are not shared.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eY.C did the data analysis, and performed the research.C.Q. conceptualized the research study. Y.Y. and Z.X. analyzed the data. Y.Z. investigated and resolved the integrity of all the parts of the work. X.F. did the data acquisition, analysis, and measurement, conducted the work. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be ccountable for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFothergill WE. On the Operative Treatment of Displacements of the Pelvic Viscera. Trans Edinb Obstet Soc. 1908;33:129\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992;166(6 Pt 1):1717\u0026ndash;24. discussion 1724-8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol. 1994;170(6):1713\u0026ndash;20. discussion 1720-3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchulten SFM, Claas-Quax MJ, Weemhoff M, van Eijndhoven HW, van Leijsen SA, Vergeldt TF, IntHout J, Kluivers KB. Risk factors for primary pelvic organ prolapse and prolapse recurrence: an updated systematic review and meta-analysis. Am J Obstet Gynecol. 2022;227(2):192\u0026ndash;208.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoutzong MR, Rostaminia G, Moalli PA, Abramowitch SD. Pelvic floor shape variations during pregnancy and after vaginal delivery. Comput Methods Programs Biomed. 2020;194:105516.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFang J, Ye J, Huang Q, Lin Y, Weng Y, Wang M, Chen Y, Lu Y, Zhang R. Risk factors of pelvic floor muscle strength in south Chinese women: a retrospective study. BMC Pregnancy Childbirth. 2022;22(1):624.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoyte L, Damaser MS. Magnetic resonance-based female pelvic anatomy as relevant for maternal childbirth injury simulations. Ann N Y Acad Sci. 2007;1101:361\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlusberg M, Kobi M, Bahrami S, Glanc P, Palmer S, Chernyak V, Kanmaniraja D, El Sayed RF. Multimodality imaging of pelvic floor anatomy. Abdom Radiol (NY). 2021;46(4):1302\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng W, Chen L, Thibault MD, DeLancey JO, Swenson CW. Age, parity, and prolapse: interaction and influence on levator bowl volume. Int Urogynecol J. 2022;33(12):3415\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl Sayed RF. Magnetic Resonance Imaging of the Female Pelvic Floor: Anatomy Overview, Indications, and Imaging Protocols. Radiol Clin North Am. 2020;58(2):291\u0026ndash;303.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlake KAS, Hartnett-McCann K. Metric Assessment of the Pubic Bone Using Known and Novel Data Points for Sex Estimation. J Forensic Sci. 2018;63(5):1472\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFornai C, Webb NM, Urciuoli A, Krenn VA, Corron LK, Haeusler M. New insights on hip bone sexual dimorphism in adolescents and adults using deformation-based geometric morphometrics. J Anthropol Sci. 2021;99:117\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMirilas P, Skandalakis JE. Surgical anatomy of the retroperitoneal spaces part II: the architecture of the retroperitoneal space. Am Surg. 2010;76(1):33\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim SW, Kim HC, Yang DM, Min GE. The prevesical space: anatomical review and pathological conditions. Clin Radiol. 2013;68(7):733\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReddy RA, Cortessis V, Dancz C, Klutke J, Stanczyk FZ. Role of sex steroid hormones in pelvic organ prolapse. Menopause. 2020;27(8):941\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXuan Y, Friedman T, Dietz HP. Does levator ani hiatal area configuration affect pelvic organ prolapse? Ultrasound Obstet Gynecol. 2019;54(1):124\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHanda VL, Roem J, Blomquist JL, Dietz HP, Mu\u0026ntilde;oz A. Pelvic organ prolapse as a function of levator ani avulsion, hiatus size, and strength. Am J Obstet Gynecol. 2019;221(1):41.e1-41.e7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDasikan Z, Ozturk R, Ozturk A. Pelvic floor dysfunction symptoms and risk factors at the first year of postpartum women: a cross-sectional study. Contemp Nurse. 2020;56(2):132\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCharri\u0026eacute; M, Billecocq S. Troubles pelvip\u0026eacute;rin\u0026eacute;aux de la p\u0026eacute;riode p\u0026eacute;rinatale: \u0026eacute;tat des connaissances des femmes, une revue syst\u0026eacute;matique [Knowledge of pelvic floor disorders in peripartum women: A systematic review]. Prog Urol. 2021;31(4):204\u0026ndash;14. French.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang W, Zhu X. Laparoscopic surgery of total mesorectal excision based on pelvic membrane anatomy[J]. Chin J Gastrointest Surg 2019,22(5):427\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhareeb WM, Wang X, Chi P, Wang W. The 'multilayer' theory of Denonvilliers' fascia: anatomical dissection of cadavers with the aim to improve neurovascular bundle preservation during rectal mobilization. Colorectal Dis. 2020;22(2):195\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsukada Y, Ito M, Watanabe K, Yamaguchi K, Kojima M, Hayashi R, Akita K, Saito N. Topographic Anatomy of the Anal Sphincter Complex and Levator Ani Muscle as It Relates to Intersphincteric Resection for Very Low Rectal Disease. Dis Colon Rectum. 2016;59(5):426\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang M, Kaw A, Chapuis PH, Bokey L. Does Denonvilliers' fascia exist in women? Am J Obstet Gynecol. 2016;214(5):663\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDariane C, Moszkowicz D, Peschaud F. Concepts of the rectovaginal septum: implications for function and surgery. Int Urogynecol J. 2016;27(6):839\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodr\u0026iacute;guez-Abarca MA, Hern\u0026aacute;ndez-Grimaldo EG, De la Fuente-Villarreal D, Jacobo-Baca G, Quiroga-Garza A, Pinales-Razo R, Elizondo-Oma\u0026ntilde;a RE, Guzman-Lopez S. Gynecological influencing factors on the rectovaginal septum's morphology. Int Urogynecol J. 2021;32(6):1427\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"age, magnetic resonance imaging, pelvis, pelvic floor muscle","lastPublishedDoi":"10.21203/rs.3.rs-6182348/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6182348/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eOBJECTIVE\u003c/strong\u003e: In this study, several groups of data were measured by MRI to reflect the effect of age on the pelvis and organ-endopelvic fascia space, and to investigate the anatomical causes of pelvic floor dysfunction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMETHODS\u003c/strong\u003e: A total of 120 women aged 15-74 with no definite pelvic floor functional disorders were divided into six groups with a span of 10 years for each age group. A review of MRI data from all female pelvis was conducted to measure the pubic symphysis inclination angle, the anterior bladder space area, the puborectal muscle pinch angle, and the rectovaginal anal levator gap area.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRESULTS\u003c/strong\u003e: All cases were evaluated quantitatively for the pubic symphysis inclination angle, the anterior bladder space area, the puborectal muscle pinch angle, and the rectovaginal anal levator gap area. The results showed that with increasing age, the pubic symphysis inclination angle was enlarged in women (the group aged 65-74 years vs. the other five groups; P\u0026lt;0.05), the anterior bladder space area increased (the three groups aged \u0026lt;45 years vs. the three groups aged≥45 years; P\u0026lt;0.05), the puborectal muscle pinch angle was enlarged (the group aged 15-24 years vs. the other five groups; P\u0026lt;0.05), and the rectovaginal anal levator gap area increased (the group aged 65-74 years vs. the other five groups; P\u0026lt;0.05). All measures were positively correlated with age.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSION\u003c/strong\u003e: It is known from imaging that linear degeneration of the pelvis and pelvic floor muscles with increasing age may be an anatomical factor in the occurrence of pelvic floor dysfunction diseases such as pelvic organ prolapse.Refining the quantitative evaluation method of female pelvic floor MRI to alert the occurrence of pelvic organ prolapse in middle-aged and elderly women who have given birth.\u003c/p\u003e","manuscriptTitle":"Ageing effects of the female pelvis and organ endo-pelvic fascia space as shown by novel MRI measurements","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-17 06:59:42","doi":"10.21203/rs.3.rs-6182348/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"80e86e9d-6186-4662-8eb8-f43544417e7c","owner":[],"postedDate":"March 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-11T08:40:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-17 06:59:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6182348","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6182348","identity":"rs-6182348","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}