Atlas of

T2 MRI Prostate Anatomy

with CT Correlation
Patrick McLaughlin, MD, Sara Troyer, BS, Sally Berri, MS, George Hixson,
Amichay Meirovitz, MD, Peter Roberson, PhD, Vrinda Narayana, PhD
 Table of Contents:
Introduction 3
Zonal Anatomy5
Part 1: Overview of T2 MRI scans... 9
patient 110
patient 227
patient 342
patient 462

Part 2: Variations in Prostate Anatomy78

Section 1: Variations in TZ size79
Section 2: Base/Bladder Interface Variations83
Section 3: Prostate Apex/GUD variations106

Part 3: Post-prostate implant distortion of anatomy 141

Mild Distortion 142
Moderate Distortion151
Severe Distortion 160

Part 4: Contouring the prostate on MRI and CT 172

Pre implant Scans 173
Post implant Scans 212
 Introduction
The following prostate atlas will serve several purposes. First, it is a review of
pelvic MRI anatomy. T2 pelvic scans disclose details of prostate anatomy as well
as anatomy of adjacent critical structures with much greater detail than CT
scans. It is likely that MRI-based planning will ultimately replace CT scanning
due to this clarity and a review of the details of prostate associated anatomy will
be useful.
A second goal is to improve CT contouring of the prostate. We have noted that
with increased experience with MRI scans CT defined prostate volumes begin to
approach MRI defined volumes. There are also a number of clues on registered
images that allow improved interpretation when CT alone is available. The CT
scans in the atlas were obtained on a CT simulator without contrast. They would
not be considered diagnostic level CT scans in the current era. In some respects,
the lack of clarity serves the atlas well. In spite of the limited detail, it is possible
to contour the prostate on the basis of adjacent anatomy defined on CT.
The atlas was created from multiple patients registered with MRI and CT data
sets. The atlas includes both post implant scans and non-implant scans.
For the registration portion, CT scans were obtained on a helical scanner in 2 or 3
mm intervals. MRIs were obtained in axial, sagittal, and coronal planes. These
three MRI data sets were then fused by mutual information. A composite prostate
was generated. The composite is not a sum total of areas of agreement of coronal,
sagittal, and axial. Instead, the scan that clarified an individual region was
weighed more heavily than the scans in which a region was not well defined. For
example, at the apex, the coronal scan unambiguously defines the apex due to the
clear interface of the GUD and prostate apex. Therefore, disagreements at the
apex were settled in favor of the coronal defined apex. At the base, the sagittal
view can be extremely useful in distinguishing the prostate from bladder and
seminal vesicle. At mid-gland, there was excellent agreement between the three
MRI data sets. When the MRI is projected on the CT scan to instruct in
contouring of the CT images, the projected contour is from the composite prostate
rather than the axial. It has been projected, in many cases, on the axial MRI for
reference.
The second half of the teaching module following MRI anatomy, MRI-CT
correlation, is an interactive test module. In this Prost-A-Doodle module a CT
image is presented, a contour can be entered, followed by review of the registered
MRI image. The MRI contour can then be projected on the CT to allow a back
and forth interactive experience. This module includes both non-implant and
implant patients as well.
 Zonal Anatomy
Zonal anatomy refers to radiographically or histologically distinct
regions within the prostate. The initial description and definition
was by McLean and based on ultrasound defined regions.

4 major zones are visible in young men

- Peripheral zone (PZ)
- Central zone - peri-ejaculatory duct zone(CZ)
- Transition zone (TZ)
- Anterior fibromuscular stroma (AFS)

In the following figure the left image depicts the zonal anatomy
of a younger male. With age hypertrophy of the TZ may occur ,
compressing the CZ. This change is depicted in the right figure.
Zonal Anatomy of the Prostate
 Zonal Anatomy
Zonal Anatomy of the prostate can be confusing due to different uses of
the word central zone. One use of central zone is in reference to the
region immediately around the ejaculatory ducts posterior to the urethra
(McLean). This is visible on ultrasound in young men, but TZ
hypertrophy (BPH) compresses the central zone and it is not visible as a
distinct zone in older men. Ironically the central, peri-ejaculatory duct
zone merges with the peripheral zone (PZ) after TZ hypertrophy.
A second use of the term central is in reference to TZ hypertrophy. This
informal use may appear in ultrasound or radiology reports but creates
confusion. Two solutions to the ambiguous nomenclature are available.
One solution is to abandon the term central completely, because the
central zone is not visible in most prostate cancer patients. TZ is used to
refer to the zone of hypertrophy. A second solution divides the prostate
into inner, outer, and anterior fibromuscular zones, the schema outlined by
Matthew Rifkin in Ultrasound of the Prostate (Lippincott-Raven) . The
inner zone includes the TZ and periurethral stroma. The outer zone
includes the PZ and the central or peri-ejaculatory duct zone.
 Zonal Anatomy
In this atlas the term central will be avoided, and TZ, PZ, and AFS will be
used to define the prostate zones.
Zonal anatomy has replaced lobar anatomy with one exception. The term
median lobe hypertrophy refers to a distinct form of hypertrophy noted on
digital exam as a third lobe palpable between the two lateral lobes . On
cystoscopy and radiographically median lobe hypertrophy extends into the
bladder lumen . In some the median lobe hypertrophy is comparable in
size to the entire remaining prostate. It may cause obstruction by a ball
valve mechanism in which the hypertrophied tissue folds over the urethral
opening.
Unlike TZ hypertrophy and BPH, there is no zonal anatomy correlate for
the median lobe. The actual origin of the median lobe may be posterior
TZ or peri-urethral stroma. Histologically it is not distinct from TZ. In
the prior schematic it is presented as originating from the peri-urethral
stroma (right figure), but its actual origin is uncertain.
Part 1: Overview of T2 MRI
scans on pre-prostate implant
patients
 Patient 1:

Axial T2 MRI Images

 Patient 1, Axial T2 MRI
Level: Penile Bulb

Crura of Corpus Cavernosa

Urethra

Penile Bulb

Rectum

Image 1 Image 2
 Patient 1, Axial T2 MRI
Level: Penile Bulb/ GUD transition

Urethra

Rectum

Image 3 Image 4

Note the penile bulb ends and the GU Diaphragm (GUD) begins.
 Patient 1, Axial T2 MRI
Level: GUD

External External
Sphincter Sphincter

Urethra Urethra
GUD

Pudendal
Canal

Rectum

Image 5 Image 6
Note the thickness of the External Sphincter muscle. The circular shape of the
GUD suggests prostate but this is still 1 cm below the prostate. Also note
the Pudendal Canal is clear near the GUD level.
 Patient 1, Axial T2 MRI
Level : GUD

External External
Sphincter GUD
Sphincter

Levator Ani
muscle

Rectum

Image 7 Image 8

Note the convex shape of the Levator Ani at the upper GUD (Image 7).
On image 8 the concave shape of the Levator Ani marks the transition
to the prostate apex.
 Patient 1, Axial T2 MRI
Level: Prostate Apex

External
Sphincter Prostate apex
Levator Ani
muscle

prostate

Rectum

Image 9 Image 10

Note the external sphincter commonly extends into the prostate apex.
 Patient 1, Axial T2 MRI
Level: Mid-Prostate

Obturator Internus Levator Ani AFS

muscle Obturator Internus

prostate

Rectum

Image 11 Image 12
 Patient 1, Axial T2 MRI
Level: Prostate Base

Bladder muscle /
Bladder neck
TZ

PZ

Rectum

Image 13 Image 14

Note the TZ is visible in images 13 and 14 (also on image 12).

 Patient 1, Axial T2 MRI
Level: Prostate Base
Bladder Bladder
Muscle Muscle

prostate

Seminal
vesicles

Rectum

Image 15 Image 16

Note in image 16 the prostate base merges with the root

of the seminal vesicles.
 Patient 1, Axial T2 MRI
Level: Prostate Base / Seminal Vesicle transition

Bladder
Muscle

Seminal
vesicles

Rectum

Image 17 Image 18
 Patient 1:

Coronal T2 MRI Images

 Patient 1, Coronal T2 MRI
Level: Mid-Prostate

Seminal
vesicles

Prostate
apex prostate
External
Sphincter

GUD

Levator Ani
muscle

Pudendal Image 1 Penile Bulb Image 2

Canal Crura of Corpus
Cavernosa

The distance between the prostate apex and the penile bulb is visible on the
coronal images. Also note, the external sphincter extends through the GUD
and into the prostate.
 Patient 1, Coronal T2 MRI
Level: Mid / Anterior Prostate

prostate

Lower
Sphincter

Urethra

Image 3 Levator Ani Image 4 Crura of Corpus

Penile Bulb muscle Cavernosa
 Patient 1, Coronal T2 MRI
Level: Anterior Prostate

prostate

Penile Bulb/
Corpus Spongiosum

Crura of Corpus
Image 5
Cavernosa
 Patient 1:

Sagittal T2 MRI Images

 Patient 1, Sagittal T2 MRI
Level: Lateral Prostate

Seminal Seminal
vesicles vesicles

prostate

Pubic
Symphysis

Image 1 Image 2
Levator
Ani Muscle
 Patient 1, Sagittal T2 MRI
Level: Mid-Prostate

Seminal AFS Seminal

vesicles vesicles

prostate

Urethra Rectum

Penile Bulb Image 3 Image 4

Rectum Penile Bulb

Note the urethra is visible through the center of the prostate in image 4. Also, the
definition of the apex is less distinct on sagittal than on coronal. Sagittal views
often clarify the prostate base/ seminal vesicle region.
 Patient 2:

Axial T2 MRI Images

 Patient 2, Axial T2 MRI
Level: Penile Bulb

Crura of Corpus Urethra

Cavernosa

Penile Bulb

Rectum

Image 1 Image 2
 Patient 2, Axial T2 MRI
Level: Inferior GUD
External
Sphincter

Urethra

GUD

Pudendal
Canal

Rectum

Image 3 Image 4

In image 3, the penile bulb ends and the GUD begins .

In image 4, the pudendal canals become clear.
 Patient 2, Axial T2 MRI
Level: GUD

GUD

External
Sphincter

Pudendal
Canal
Rectum
Rectum

Image 5 Image 6
 Patient 2, Axial T2 MRI
Level: Apex to Mid-Prostate

Obturator internus AFS TZ

Prostate

Rectum

Image 7 Image 8

Note the TZ becomes clear near the center of the prostate- image 8
 Patient 2, Axial T2 MRI
Level: Mid-Prostate
AFS Bladder
Obturator internus Muscle

Prostate

Rectum

Image 9 Image 10

Note the clarity of the rectal muscle/ rectal wall.

 Patient 2, Axial T2 MRI
Level: Prostate Base

Bladder
Muscle

Prostate

Rectum

Image 11 Image 12
 Patient 2, Axial T2 MRI
Level: Prostate Base

Bladder
Muscle

Prostate

Rectum

Image 13 Image 14

Notice the prostate base in images 12-14.

 Patient 2, Axial T2 MRI
Level: Prostate Base / Seminal Vesicle Transition

Seminal
vesicles transition

Seminal
vesicles

Rectum
Image 15 Image 16
 Patient 2:

Coronal T2 MRI Images

 Patient 2, Coronal T2 MRI
Level: Mid-Prostate
Seminal
vesicles

Prostate

Levator Prostate
Ani muscle apex

External GUD
Sphincter
Urethra
Pudendal Pubis
Canal Image 1 Image 2
Crura of Corpus Penile Bulb
Cavernosa

Note the distance between the prostate apex and the penile bulb
on coronal MRI.
 Patient 2, Coronal T2 MRI
Level: Anterior Prostate

Prostate

GUD
Penile
Bulb

External
Sphincter

Image 3 Image 4
Crura of Corpus Crura of Corpus
Cavernosa Cavernosa
 Patient 2:

Sagittal T2 MRI Images

 Patient 2, Sagittal T2 MRI
Level: Mid-Prostate
Pubic Seminal Seminal
symphysis vesicles vesicles

AFS

Rectum

External
Urethra Sphincter

Rectum

Image 1 Image 2
Penile Bulb
Sagittal image 2 cuts though the center of the prostate showing the urethra. Note
the significant base extension posterior to the bladder. Also note that the anterior
fibromuscular stroma is contiguous with the bladder muscle and external sphincter.
 Patient 2, Sagittal T2 MRI
Level: Lateral Prostate
Seminal Seminal
vesicles vesicles

Prostate Rectum

Rectum

Image 3 Image 4
 Patient 3:

Axial T2 MRI Images

 Patient 3, Axial T2 MRI
Level: Penile Bulb

Urethra

Penile Bulb

Rectum

Image 1 Image 2
 Patient 3, Axial T2 MRI
Level: Inferior GUD

External
Urethra Sphincter

GUD

Pudendal
Canal

Rectum

Image 3 Image 4

Note the pudendal canals in image 4.

 Patient 3, Axial T2 MRI
Level: GUD

GUD

External
Sphincter

Rectum Pudendal
Canal

Image 5 Image 6 Rectum

 Patient 3, Axial T2 MRI
Level: Prostate Apex

Prostate

Rectum

Pudendal
Canal

Image 7 Image 8
 Patient 3, Axial T2 MRI
Level: Mid-Prostate

TZ TZ

Prostate

Rectum

Image 9 Image 10
Obturator internus

The TZ is visible in image 9.

 Patient 3, Axial T2 MRI
Level: Mid-Prostate

TZ

Prostate

Rectum

Image 11 Image 12
 Patient 3, Axial T2 MRI
Level: Prostate Base

Median Lobe Median Lobe

Prostate

Rectum

Image 13 Image 14

Note the hypertrophy extends into the bladder lumen. Such hypertrophy has a
distinct shape referred to as a median lobe.
 Patient 3, Axial T2 MRI
Level: Prostate Base

Median Lobe Median Lobe

Prostate

Seminal
vesicles
Seminal
vesicles
Rectum

Image 15 Image 16

The defining feature of a median lobe is a dolphin nose projection into the
bladder, see coronal view image 6 and sagittal view image 4.
 Patient 3, Axial T2 MRI
Level: Prostate Base

Median Lobe Median Lobe

Prostate

Seminal
vesicles

Rectum

Image 17 Image 18
 Patient 3, Axial T2 MRI
Level: Prostate Base/ Seminal Vesicles

Median Lobe Median Lobe

Prostate

Seminal
vesicles

Rectum

Image 19 Image 20
 Patient 3:

Coronal T2 MRI Images

 Patient 3, Coronal T2 MRI
Level: Mid-Prostate

Prostate

GUD
External
Sphincter
Penile Bulb

Image 1 Levator Ani Image 2

Crura of Corpus
muscle Cavernosa
 Patient 3, Coronal T2 MRI
Level: Mid-Prostate

Prostate Obturator
internus

Prostate External
apex Sphincter

GUD
Urethra

Image 3 Image 4 Levator Ani

Crura of Corpus muscle
Cavernosa Penile Bulb

Notice the median lobe as it pushes into the bladder in coronal

images 4-7.
 Patient 3, Coronal T2 MRI
Level: Anterior Prostate

Median Lobe

Prostate

Urethra
Penile Bulb

Image 5 Image 6 Crura of Corpus

Cavernosa
 Patient 3, Coronal T2 MRI
Level: Anterior Prostate

Median Lobe

Prostate

Crura of Corpus
Cavernosa

Image 7
Penile Bulb
 Patient 3:

Sagittal T2 MRI Images

 Patient 3, Sagittal T2 MRI
Level: Lateral Prostate

Seminal Seminal
vesicles Median Lobe vesicles

Rectum Rectum

Prostate

Image 1 Image 2 Penile Bulb

Notice the median lobe in Sagittal images 2-5.

 Patient 3, Sagittal T2 MRI
Level: Mid-Prostate

Median Lobe Seminal Seminal

vesicles Median Lobe vesicles

Rectum
Rectum
Prostate

External
Sphincter
Urethra

Image 3 Penile Bulb Image 4 Penile Bulb

Notice the urethra in image 4 is not visible through the center of the prostate,
however, it is visible below the prostate.
 Patient 3, Sagittal T2 MRI
Level: Lateral Prostate

Seminal
Median Lobe vesicles

Rectum

Prostate

Image 5
 Patient 4:

Axial T2 MRI Images

 Patient 4, Axial T2 MRI
Level: Penile Bulb

Urethra

Penile Bulb

Rectum

Image 1 Image 2
 Patient 4, Axial T2 MRI
Level: GUD

External
Sphincter

Urethra

GUD

Rectum

Image 3 Image 4
 Patient 4, Axial T2 MRI
Level: Prostate Apex

Prostate apex Prostate

Pudendal
Canal
External
Sphincter

Rectum

Image 5 Image 6

The prostate apex begins in image 5.

 Patient 4, Axial T2 MRI
Level: Mid-Prostate

TZ PZ

Prostate

Rectum

Pudendal
Canal

Image 7 Image 8 Obturator internus

Note the TZ and PZ are visible in image 8.

 Patient 4, Axial T2 MRI
Level: Mid-Prostate

Bladder Bladder
Muscle TZ
Muscle

Prostate

Rectum

Image 9 Image 10
 Patient 4, Axial T2 MRI
Level: Prostate Base

Bladder
Median Lobe Muscle Median Lobe

Prostate
Seminal
vesicles

Rectum

Image 11 Image 12

Note the hypertrophy causes the prostate to protrude into the bladder creating a
median lobe. This is seen in images 11-14.
 Patient 4, Axial T2 MRI
Level: Prostate Base / Seminal Vesicle Interface

Bladder
Muscle

Median Lobe

Prostate Bladder
Muscle

Seminal
vesicles

Rectum
Seminal Image 13 Image 14
vesicles
 Patient 4:

Coronal T2 MRI Images

 Patient 4, Coronal T2 MRI
Level: Mid-Prostate

Obturator internus

Prostate
GUD

External
Sphincter

Image 1 Image 2
Pudendal Penile Bulb
Canal

Note the pudendal canals on Coronal MRI image 2.

 Patient 4, Coronal T2 MRI
Level: Mid-Prostate

TZ

Prostate

GUD
Prostate
apex

Levator Ani
muscle External
Sphincter

Image 3 Image 4
Penile Bulb Crura of Corpus
Cavernosa

Note the TZ is clearly visible in Coronal MRI image 3. Also notice the
short distance between the prostate apex and penile bulb.
 Patient 4, Coronal T2 MRI
Level: Anterior Prostate

Median Lobe Median Lobe

Prostate

GUD

Urethra

Image 5 Image 6
Penile Bulb Crura of Corpus
Cavernosa

Images 5-7 show the median lobe pushing into the bladder.
 Patient 4, Coronal T2 MRI
Level: Anterior Prostate

Median Lobe

Prostate

Urethra Penile Bulb

Image 7
Crura of Corpus
Cavernosa
 Patient 4:

Sagittal T2 MRI Images

 Patient 4, sagittal T2 MRI
Level: Mid-Prostate

Median Lobe Seminal Seminal

Median Lobe vesicles
vesicles

Prostate

Urethra

Rectum

Rectum

Image 1 Image 2 Penile Bulb

Penile Bulb

In Image 1 the urethra is visible through the center of the prostate.

The median lobe can also be seen in sagittal images 1-2.
 Patient 4, sagittal T2 MRI
Level: Lateral Prostate

Seminal Seminal
vesicles TZ vesicles

Prostate

Rectum

Image 3 Image 4 Rectum

Penile Bulb

Note the visible TZ on sagittal MRI in images 3-4.

 Part 2: Variations in
Prostate Anatomy

T2 MRI Axial, Coronal, and Sagittal Pre-Implant scans

Variations in TZ Size
Part 2, Section 1

Pre-prostate implant T2 MRI scans

 Patient 5-medium sized TZ

rectum

prostate

TZ

Axial Prone Image Axial Prone Image

 Patient 6-large TZ

TZ

prostate

rectum

Axial Supine Image Coronal Image

 Patient 7

TZ

prostate

rectum

Axial Supine Image Axial Supine Image

Notice the large TZ accounts for most of the prostate volume.

Base/ Bladder Interface
Variations
Part 2, Section 2
 Distinct Bladder neck

Mid-Sagittal MRI

Prior to prostate hypertrophy the bladder neck muscle is visibly distinct. Often in
patients with small glands, little BPH, a distinct bladder neck muscle can be seen
connecting the bladder and the prostate. This muscle often extending into the
prostate as seen above. The internal sphincter is a direct extension of bladder neck
muscle into the prostate.
 Partially obliterated bladder neck

Mid-Sagittal MRI

As the prostate begins to hypertrophy the bladder neck muscle becomes less
distinct. Often, in this stage, muscle can be seen between the prostate and
bladder but it does not extend into the prostate.
 Obliterated bladder neck

Mid-Sagittal MRI

As hypertrophy continues the bladder neck muscle becomes obliterated by the

expanding prostate. Muscle can no longer be clearly seen between the prostate
and bladder.
 Median Lobe Hypertrophy

Mid-Sagittal MRI

A distinct form of hypertrophy, median lobe hypertrophy, results in a dolphin-

nose projection, originating from the posterior, projecting into the bladder lumen.
It should be noted that there is no direct progression from BPH to median lobe
hypertrophy.
 Visible Bladder Neck 1

Bladder Neck

AFS

Mid-Sagittal

This prostate has minimal hypertrophy and a visible bladder neck. The AFS can
be seen merging with the bladder muscle. Axial MRIs through the base are
shown in the following slides.
 Visible Bladder Neck 1
Bladder Neck

Image 1 Image 2
Bladder Neck

Image 3

Note the bladder neck takes on a circular shape as it attaches to the prostate.
 Visible Bladder Neck 1

Bladder Neck
merging with AFS

Image 4 Image 5

The bladder neck merges with the AFS in images 4 and 5.

 Visible Bladder Neck 2

Bladder Neck

Mid-Sagittal

This prostate also has a distinct bladder neck visible on sagittal MRI. Notice
the appearance of this in the following axial scans.
 Visible Bladder Neck 2
Bladder Muscle

Bladder Neck

Image 1 Image 2
Bladder Muscle

Bladder Neck

Image 3

Note the circular shape of the bladder neck as it attaches to the prostate.
Also note the large amount of bladder muscle visible on the scans.
 Visible Bladder Neck 2

Bladder Neck

Image 4 Image 5
 Visible Bladder Neck 3
Bladder Neck

AFS

Mid-Sagittal

This prostate also has a distinct bladder neck muscle.

 Visible Bladder Neck 3

Bladder Neck

Image 1 Image 2

Note the circular shape of attachment of muscle and prostate.

 Visible Bladder Neck 3
Bladder Neck
merging with AFS
AFS

Image 3 Image 4

Note the bladder neck muscle merges with the AFS.

 Obliterated bladder neck 1

Mid-Sagittal

Notice the displacement of the bladder neck muscle after prostate hypertrophy.
 Obliterated bladder neck 1

Image 1 Image 2

Image 3
 Obliterated bladder neck 1

Image 4 Image 5
 Obliterated bladder neck 2

Mid-Sagittal

Notice the prostate protruding into the bladder obliterating and displacing the
bladder neck.
 Obliterated bladder neck 2

Image 1 Image 2

Image 3
 Obliterated bladder neck 2

Image 4 Image 5

Image 6
 Median lobe 1

The median lobe

enters the bladder
from the posterior

Mid-Sagittal

The presence of a median lobe, while a distinct form of hypertrophy, also

obliterates and displaces the bladder neck muscle.
 Median lobe 1

Image 1 Image 2

Image 3
 Median lobe 1

Image 4 Image 5
Prostate Apex / GUD
Variations
Part 2, Section 3

Pre-prostate implant T2 MRI scans

 Apex Definition
Axial MRI
apex /GUD transition

Ultrasound
apex/GUD transition

Penile Bulb (1.5 cm above penile bulb)

rule condemned

Coronal MRI
apex/GUD transition
 MRI Apex to GUD Transition

Concave
levator ani

Convex
levator ani

Note the transition from concave levator ani

at the apex versus convex just below the apex.
 Ultrasound Apex / GUD Transition

Prostate Apex GUD

external sphincter

The apex / GUD transition

on ultrasound is clearly
Bulbourethral Gland defined in this example.
However in less clear
examples the external
sphincter may be contoured
as prostate. Recognition of
the light H-shaped GUD or
Bulbourethral gland
indicates GUD.
GUD on Ultrasound and MRI

MRI GUD Ultrasound GUD

Note the similar shape of the GUD on MRI and ultrasound.

 Penile Bulb Rule Condemned

Coronal: Posterior Prostate Coronal: Mid-Prostate Coronal: Mid-Prostate

The distance between the prostate apex and penile bulb is highly
variable. When measured on MRI with a sample size of 25 the
distance is 1.33 (.32) cm with a range of 0.6 cm to 1.97 cm. Using
the penile bulb rule ( the prostate apex is 1.5 cm above the penile
bulb ) often results in underestimation of the prostate. Also the
penile bulb / GUD interface may be obliterated post implant. (see
part 3 of atlas)
 Summary of GUD Shape

Image 1.
just above Image 2
penile bulb

Image 3 Image 4. apex

Note the change in shape of the GUD: just above the penile bulb it is triangular
in shape, near the mid-diaphragm it is circular, then hourglass shaped. These
shapes are often visible in subtle form on CT.
 Patient 8

rectum prostate

External
sphincter

GUD

Pudendal Penile
Coronal cross canal bulb
section

Axial Prone Image Coronal Image

Crura of corpus
cavernosa

Notice the circular shape of the GUD in the Axial image. The green line
( ) depicts the plane of the coronal image.
 Patient 9

rectum prostate

External
sphincter

GUD Penile
Coronal cross bulb
section

Axial Prone Image Coronal Image

Crura of corpus
cavernosa

Notice the separation between the prostate and penile bulb

on the Coronal MRI.
 Patient 10

rectum prostate

External
sphincter

GUD
Penile
Coronal cross bulb
section
Pudendal
canal

Coronal Image
Axial Prone Image
 Patient 11

prostate

Coronal cross
section

External
sphincter

GUD Penile
bulb
Pudendal
canal

Axial Supine Image Coronal Image

Note the thickness of the external sphincter on coronal.

 Patient 12

prostate

Coronal cross
section

GUD

Penile
bulb
rectum Pudendal
canal

Axial Supine Image Coronal Image Crura of corpus

cavernosa

Note the thin GUD and the minimal separation between the
prostate and penile bulb.
 Overview of CT and US
contouring errors at the apex
 Clarity, Obscuration, Clarity
GUD

CT Mid-Prostate CT Prostate Apex Level CT GUD Level

Problem: On CT as contouring proceeds inferior, the prostate is clear

above the apex, unclear at the apex, and mistaken for elliptical or circular
GUD elements below the apex
 3 D View- contouring GUD as prostate -
pros-teat

rectum
rectum

GUD contoured as
prostate

3D view of Prostate contoured on The same figure with the

CT to include round GUD and MRI prostate shown in light
external sphincter often mistaken for blue.
prostate.

A 3-dimensional view shows when prostate contours have

included too much GUD. A lateral BEV can also be used
to visualized this projection.
3 D View- contouring prostate with rectum as
reference - love handle

rectum
rectum

Prostate contoured to
the edge of rectum

3D view of Prostate contoured to the The same figure with the

edge of the rectum on CT MRI prostate shown in light
blue

A 3-dimensional view shows the prostate has been contoured in

reference to the clearly visualized rectum, on the assumption the
prostate is adjacent to the rectum . A lateral BEV can be used to
visualize this overestimation. The posterior edge of the prostate is
convex. When aligned to the rectum it appears concave .
 Patient 13: Visible GUD on CT-pre implant

Penile Bulb

Axial CT 1 AxialT2 MRI 1

AxialT2 MRI 2
Axial CT 2

Note directly superior to the penile bulb the CT is unclear.

 Patient 13-pre implant:

Axial CT 3 AxialT2 MRI 3

Axial CT 4 AxialT2 MRI 4

Note the GUD hourglass shape is visible on CT image 4.

 Patient 13-pre implant:

Axial CT 5 AxialT2 MRI 5

AxialT2 MRI 6
Axial CT 6
 Patient 13-pre implant:

Prostate Apex

Axial CT 7 AxialT2 MRI 7

Axial CT 8 AxialT2 MRI 8

 Patient 14: Example of round GUD on CT-pre implant
Penile Bulb

AxialT2 MRI 1
Axial CT 1

AxialT2 MRI 2
Axial CT 2
 Patient 14-pre implant:

Axial CT 3 AxialT2 MRI 3

Axial CT 4 AxialT2 MRI 4

Note the GUD appears round on the CT and can be

mistaken for prostate.
 Patient 14-pre implant:

Axial CT 5 AxialT2 MRI 5

Axial CT 6 AxialT2 MRI 6

The round diaphragm shape continues into the prostate

apex making the GUD/ apex distinction difficult on CT.
 Patient 14-pre implant:

Axial CT 7 AxialT2 MRI 7

Axial CT 8 AxialT2 MRI 8

 Patient 15: Unclear GUD- pre implant

AxialT2 MRI 1
Axial CT 1

AxialT2 MRI 2
Axial CT 2
 Patient 15-pre implant:

Axial CT 3 AxialT2 MRI 3

Axial CT 4 AxialT2 MRI 4

Note that the GUD is not clear on the CT scan making it difficult to determine
prostate apex location. On axial CT 4 the elements are barely visible (external
sphincter and posterior extension of GUD [white on MRI] ).
 Patient 15-pre implant:

AxialT2 MRI 5
Axial CT 5

AxialT2 MRI 6
Axial CT 6

At the apex, the CT image is still not clear.

 Patient 15-pre implant:

AxialT2 MRI 7
Axial CT 7

AxialT2 MRI 8
Axial CT 8
 Patient 16: Example of clear GUD on CT-post implant

AxialT2 MRI 1
Axial CT 1

AxialT2 MRI 2
Axial CT 2
 Patient 16-post implant:

Axial CT 3 AxialT2 MRI 3

Axial CT 4 AxialT2 MRI 4

Notice the shape of the GUD and external sphincter is

visible on the post implant CT scan as a bulls eye target
(Axial CT3)
 Patient 16-post implant:

Axial CT 5 AxialT2 MRI 5

Axial CT 6 AxialT2 MRI 6

 Patient 17: Unclear GUD- post implant

AxialT2 MRI 1
Axial CT 1

AxialT2 MRI 2
Axial CT 2
 Patient 17-post implant:

AxialT2 MRI 3
Axial CT 3

AxialT2 MRI 4
Axial CT 4

Note that the GUD is not clear on the CT scan.

 Patient 17-post implant:

AxialT2 MRI 5
Axial CT 5

AxialT2 MRI 6
Axial CT 6

The lack of GUD/ prostate apex clarity on CT often results

in overestimation of the prostate at the apex.
 Patient 17-post implant:

AxialT2 MRI 7
Axial CT 7

AxialT2 MRI 8
Axial CT 8
Part 3: Post Prostate Implant
Distortion of Anatomy

Post-prostate implant T2 MRI scans

 Patient 18:
mild post-implant distortion
 Patient 18- mild distortion

PRE POST

Pre-implant Coronal T2 MRI Scan Post-implant Coronal T2 MRI Scan

This patient exhibits only mild-post implant distortion of surrounding anatomy.

Note the reduced clarity of the prostate border between pre and post scans.
However, the GUD and external sphincter remain fairly clear.
 Patient 18- mild distortion

PRE POST

Pre-implant sagittal T2 MRI Scan Pre-implant sagittal T2 MRI Scan

Note there is little visible distortion between pre

and post sagittal scans of the same patient.
Patient 18: Post-Implant, mild distortion

Axial image 1 Axial image 2

Patient 18: Post-Implant, mild distortion

Axial image 3 Axial image 4

Patient 18: Post-Implant, mild distortion

Axial image 5 Axial image 6

Patient 18: Post-Implant, mild distortion

Axial image 7 Axial image 8

Note the inner (TZ) and outer (PZ) prostate zones are distinct.
Patient 18: Post-Implant, mild distortion

Axial image 9 Axial image 10

Patient 18: Post-Implant, mild distortion

Axial image 11
 Patient 19:

moderate post-implant distortion

 Patient 19- moderate distortion

PRE POST

Pre-implant Coronal T2 MRI Scan Post-implant Coronal T2 MRI Scan

This patient exhibits moderate post-implant distortion. Note visible distortion

of GUD and external sphincter. Also note the reduced clarity of the
prostate border between pre and post scans.
Patient 19: Post-Implant, moderate distortion

Axial image 1 Axial image 2

Patient 19: Post-Implant, moderate distortion

Axial image 3 Axial image 4

 Patient 19: Post-Implant, moderate distortion

Axial image 5 Axial image 6

Note that the mid-prostate margin remains distinct, however, the inner (TZ) and
outer (PZ) zones are not distinct.
Patient 19: Post-Implant, moderate distortion

Axial image 7 Axial image 8

Patient 19: Post-Implant, moderate distortion

Axial image 9 Axial image 10

Patient 19: Post-Implant, moderate distortion

Axial image 11 Axial image 12

Patient 19: Post-Implant, moderate distortion

Axial image 13
 Patient 20:
severe post-implant distortion
 Patient 20-severe distortion

PRE POST

Possible hemorrhage
with superior
displacement of
prostate

Pre-implant Coronal T2 MRI Scan Post-implant Coronal T2 MRI Scan

This patient exhibits severe post-implant distortion. Note the distortion

of both the obturator internus and levator ani muscles post-implant.
 Patient 20-severe distortion

PRE POST

Pre-implant Coronal T2 MRI Scan Post-implant Coronal T2 MRI Scan

Note the reduced clarity of the prostate border, as well as the

obturator internus and levator ani muscles. Also note the TZ
is difficult to define post-implant.
 Patient 20-severe distortion

PRE POST

Pre-implant Coronal T2 MRI Scan Post-implant Coronal T2 MRI Scan

Note the disappearance of the prostate apex and the GUD post-implant. Also
note the difference in levator ani and obturator internus muscles pre vs post.
 Patient 20-severe distortion

PRE POST

Pre-implant Coronal T2 MRI Scan Post-implant Coronal T2 MRI Scan

Note the swelling and distortion below the prostate.

 Patient 20- Day of MRI

Pre Implant Day of Implant 2 Week Post

Implant

Pre-implant Coronal Day of implant Coronal Post-implant Coronal

T2 MRI Scan T2 MRI Scan T2 MRI Scan

Note the penile bulb in the Day of Implant MRI compared to the pre
and 2 week post MRIs.
Patient 20: Post-Implant, severe distortion

Axial image 1 Axial image 2

Patient 20: Post-Implant, severe distortion

Axial image 1 Axial image 2

Patient 20: Post-Implant, severe distortion

Axial image 3 Axial image 4

Patient 20: Post-Implant, severe distortion

Axial image 5 Axial image 6

Patient 20: Post-Implant, severe distortion

Axial image 7 Axial image 8

Patient 20: Post-Implant, severe distortion

Axial image 9
Part 4: Contouring the Prostate
on MRI and CT
Pre-Implant
Scans
Patient 21
 Patient 21

Axial CT Axial MRI

without Contour without Contour

Penile Bulb Level: inferior to the prostate

 Patient 21

Axial CT Axial MRI

without Contour without Contour

Penile Bulb Level: inferior to the prostate

 Patient 21

Axial CT Axial MRI

without Contour without Contour

Penile Bulb Level: inferior to the prostate

 Patient 21

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate - note outline of the GU

diaphragm is often visible on CT.
 Patient 21

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate - again note the outline of the rectangular
GUD is often visible on CT. In this patient the target of the external sphincter
and urethra is visible as well. At the apex level these distinctions are no longer
visible (see following images)
Note lack of boundaries
Patient 21
at apex vs. GUD

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 21

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 21

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 21

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 21

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 21

Axial CT Axial MRI

without Contour without Contour

Seminal Vesicle Level: superior to the prostate

 Patient 21

Axial CT Axial MRI

without Contour without Contour

Seminal Vesicle Level: superior to the prostate

Patient 22
 Patient 22

Axial CT Axial MRI

without Contour without Contour

Penile Bulb Level: inferior to the prostate

 Patient 22

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate

 Patient 22

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate- in this patient the GUD and external sphincter
are not defined on CT.
 Patient 22

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 22

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 22

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 22

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 22

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 22

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 22
Note the anterior extent of the prostate

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 22

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 22

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 22

Axial CT Axial MRI

without Contour without Contour
Patient 23
 Patient 23

Axial CT Axial MRI

without Contour without Contour

Penile Bulb Level: inferior to the prostate

 Patient 23

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate

 Patient 23

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate

 Patient 23

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate

 Patient 23

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 23

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 23

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 23

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 23

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 23

Axial CT
without Contour Axial MRI
without Contour

Prostate Base/
Seminal Vesicle
Interface

Axial CT Axial MRI

with Contour with Contour
Post Implant Scans
Patient 24
 Patient 24

Axial CT Axial MRI

without Contour without Contour

Penile Bulb Level: inferior to the prostate

 Patient 24

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate

 Patient 24

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate

 Patient 24

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate

 Patient 24

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate

 Patient 24

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 24

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 24

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 24

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 24

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 24

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 24

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 24

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 24

Axial CT
without Contour Axial MRI
without Contour

Prostate Base/
Seminal Vesicle
Interface

Axial CT Axial MRI

with Contour with Contour
 Patient 24

Axial CT Axial MRI

without Contour without Contour
Patient 25
 Patient 25

Axial CT Axial MRI

without Contour without Contour

Penile Bulb Level: inferior to the prostate

 Patient 25

Axial CT Axial MRI

without Contour without Contour

Penile Bulb Level: inferior to the prostate- less distinct post implant on CT
 Patient 25

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate

 Patient 25

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate

 Patient 25 The levator ani is often contoured as
prostate due to circling the seeds

Axial CT
without Contour Axial MRI
without Contour

Prostate Apex/ GUD

Interface

Axial CT Axial MRI

with Contour with Contour
 Patient 25

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 25

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 25

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 25

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 25

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 25

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 25

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 25

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 25

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 25

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
Patient 26
 Patient 26

Axial CT Axial MRI

without Contour without Contour

Penile Bulb Level: inferior to the prostate

 Patient 26

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate

 Patient 26

Axial CT Axial MRI

without Contour without Contour

GUD Level: inferior to the prostate

 Patient 26

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 26

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 26

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 26

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 26

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 26

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 26

Axial CT
without Contour Axial MRI
without Contour

Axial CT Axial MRI

with Contour with Contour
 Patient 26

Axial CT Axial MRI

without Contour without Contour
NEUROVASCULAR BUNDLE
and CAVERNOSAL NERVES
 Neurovascular Bundle

The neurovascular bundle was so named by Dr. Walsh

because the nerves are not grossly visible, but track with
the prostatic capsular arteries and veins. These vessels
serve as a surgical landmark for the nerves in nerve sparing
prostatectomy. The vessels are not visible on time-of-flight
angio (see internal pudendal artery section). They are
visible on Color Doppler ultrasound but are not visible on
CT or MRI. The NVB location can be approximated by a
number of methods (1,2). In the superior prostate/ seminal
vesicle region they pass from the lateral seminal vesicle to
the junction of the prostate and rectum. In the inferior
prostate they course within the triangle formed by the
rectum, prostate and levator ani.
 Neurovascular Bundle (NVB)
Prostate Capsule
Lateral Pelvic Fascia

Prostate Fascia

Levator Fascia
Prostate
NVB

Denonvillieres Fascia Rectum

Neurovascular Bundle (Schematic) : The neurovascular bundle is

located between the two layers of the lateral pelvic fascia (levator
fascia and prostate fascia) near the junction with Denonvillieres fascia.
 Cavernosal Nerves
The terminal branches of the NVB are the cavernosal
nerves. The greater cavernosal nerve was defined in Grays
anatomy as a terminal branch of the NVB which coursed
anterior along the GU diaphragm and through the fault in
the anterior GUD through which the dorsal venous
complex passes. Though described as greater due to its
clarity relative to the lesser cavernosal nerve, there are no
references to the greater cavernosal nerve in the modern
surgical / anatomic literature.
The lesser cavernosal nerve passes through the GUD in a
fixed relationship to the external sphincter. In the supine
position: At the apex the nerves are located in the 7 and 5
oclock position. In mid GUD they are located at 9 and 3
oclock. In the inferior GUD, just above the Corpus
Cavernosa, they are positioned at 11 and 1 oclock.
Patient 1: Axial T2 MRI
 Patient 1, Axial T2 MRI
Bladder

Prostate

NVB

NVB
 Patient 1, Axial T2 MRI
Bladder

Prostate

NVB

NVB
 Patient 1, Axial T2 MRI
Bladder

Prostate

NVB

NVB
 Patient 1, Axial T2 MRI

Prostate

NVB

Rectum
NVB
 Patient 1, Axial T2 MRI

Prostate

NVB

Rectum
NVB
 Patient 1, Axial T2 MRI

Prostate

NVB

Rectum NVB
 Patient 1, Axial T2 MRI

Prostate

NVB

Rectum
NVB
 Patient 1, Axial T2 MRI

Prostate

NVB

NVB
 area alongside Patient 1, Axial T2 MRI
Prostate that area alongside
would contain Prostate that
the Greater would contain
Cavernosal the Greater
Nerves Cavernosal
Nerves

Neurovascular
bundle (NVB)

Neurovascular
bundle (NVB)
 Patient 1, Axial T2 MRI
Level : Prostate Apex

Prostate
Apex

External Lesser
Sphincter Cavernosal
Nerve
Lesser
Cavernosal
Nerve

The lesser cavernosal nerves are not visible radiographically.

At the prostate apex they are located nerves at the 7 and 5oclock position.
 Patient 1, Axial T2 MRI
Level : GUD

GUD

External Lesser
Sphincter Cavernosal
Nerve
Lesser
Cavernosal
Nerve
 Patient 1, Axial T2 MRI
Level : mid-GUD

External GUD
Sphincter

Lesser
Cavernosal
Nerve
Lesser
Cavernosal
Nerve

At the mid GUD they are located at the 9 and 3 oclock position
 Patient 1, Axial T2 MRI

External
Sphincter

Lesser
Lesser Cavernosal
Cavernosal Nerve
Nerve
 Patient 1, Axial T2 MRI

Lesser
Cavernosal
Nerve

Lesser
Cavernosal
Nerve

Rectum

At the mid-to-inferior GUD they transition towards

the 11 and 1oclock positions.
 Patient 1, Axial T2 MRI
Level : 1 cut above penile bulb

Lesser
Lesser Cavernosal
Cavernosal Nerve
Nerve

At the inferior GUD they appear at the 11 and 1oclock position.

Patient 2, Axial T2 MRI
Patient Prone
 Patient 2, Axial T2 MRI
Neurovascular Rectum
bundle (NVB)
Neurovascular
bundle (NVB)

beg. of
Bladder
Prostate

Image 7 Image 8
 Patient 2, Axial T2 MRI
Rectum

NVB

NVB

Prostate
 Patient 2, Axial T2 MRI
Rectum

NVB

NVB

Prostate
 Patient 2, Axial T2 MRI
Rectum

NVB

NVB

Prostate
 Patient 2, Axial T2 MRI
Neurovascular
bundle (NVB)
Neurovascular
bundle (NVB)

Prostate
 Patient 2, Axial T2 MRI
Neurovascular
bundle (NVB)
Neurovascular
bundle (NVB)

area alongside area alongside

Prostate that Prostate that
would contain would contain
the Greater the Greater
Cavernosal Cavernosal
Nerves Nerves
 Patient 2, Axial T2 MRI
Level: Apex

Lesser
Cavernosal
Nerve

Prostate
Lesser Apex
Cavernosal
Nerve

External
Sphincter

The lesser cavernosal nerves appear at the apex. Note that they seem localized at the
11 and 1oclock relative to the prostate because the patient is prone. If supine, it
would be noted at the 5 and 7 oclock position.
 Patient 2, Axial T2 MRI
Rectum

Lesser
Cavernosal
Nerve

Lesser
Cavernosal
Nerve

External
Sphincter

Level: mid-GUD
Here they appear at the 9 and 3oclock positions.
 Patient 2, Axial T2 MRI
Rectum

External
Sphincter Lesser
cavernosal
nerve

Image 7 Image 8
 Patient 2, Axial T2 MRI

GUD

External Rectum
Sphincter

Lesser
Cavernosal
Nerve
Lesser
Cavernosal
Nerve

Image 7 Image 8
 Patient 2, Axial T2 MRI

Lesser
Cavernosal
Nerves

At the inferior GUD the nerves are at 5 and 7 oclok in the prone patient
Patient 3, Axial T2 MRI
Patient Supine
 Patient 3, Axial T2 MRI

Prostate

NVB

Rectum
NVB
 Patient 3, Axial T2 MRI

Prostate

NVB

NVB

Rectum
 Patient 3, Axial T2 MRI

Prostate

NVB

NVB

Rectum
 Patient 3, Axial T2 MRI

Prostate

NVB

NVB

Rectum
 Patient 3, Axial T2 MRI

Prostate

NVB

NVB

Rectum
 Patient 3, Axial T2 MRI

Prostate

NVB

NVB

Rectum
 area alongside
Prostate that
Patient 3, Axial T2 MRI area alongside
would contain Prostate that
the Greater would contain
Cavernosal the Greater
Nerves Cavernosal
Nerves

Neurovascular
bundle (NVB)

Neurovascular
bundle (NVB)
 Patient 3, Axial T2 MRI

NVB/Lesser NVB/Lesser
Cavernosal Cavernosal
Nerve Nerve

Transition from NVB to cavernosal nerves just above the prostate apex
 Patient 3, Axial T2 MRI
Level : mid-GUD

External
Sphincter

Lesser
Cavernosal
Nerve

Lesser
Cavernosal
Nerve

GUD

At mid GUD they appear at the 9 and 3oclock positions.

 Patient 3, Axial T2 MRI
Level : GUD

Lesser
Cavernosal
Lesser Nerve
Cavernosal
Nerve

GUD

External
Sphincter

At the inferior GUD they appear at the 11 and 1oclock position.

 References

G.S. Merrick, W.M. Butler et al., A comparison of

radiation dose to the neurovascular bundles in men with
and without prostate brachytherapy-induced erectile
dysfunction. Int J Radiat Oncol Biol Phys 48 (2000),
pp.1069-1074.

2. S.J. DiBiase, K. Wallner et al., Brachytherapy radiation

doses to the neurovascular bundles. Int J Radiat Oncol
Biol Phys 46 (2000), pp. 1301-1307.
PUDENDAL CANAL and
INTERNAL PUDENDAL
ARTERY
 Internal Pudendal Artery

The internal pudendal artery is a branch of the

internal iliac artery. It passes along the lateral
pelvic wall and through the pudendal canal. The
pudendal canal is a connective tissue sheath on the
medial surface of the Obturator internus. It then
passes through the inferior fascia of the
genitourinary diaphragm (GUD). Its terminal
branches are within the GUD and supply penile
bulb and corpus cavernosa.
Patient 1: Axial T2 MRI
 Bladder
Patient 1, Axial MRI

Prostate
Obturator
internus
Obturator
internus

Ischium
Bone Ischium
Bone

IPA

IPA

Note the two circled structures as they make their way around the
ischium and up towards the crura in the following images.
 Patient 1, Axial MRI
Bladder

IPA
IPA
 Patient 1, Axial MRI

Obturator
internus
Rectum

IPA
IPA
 Patient 1, Axial MRI

IPA
Ischioanal/
Ischiorectal
Fossa (IF)

IPA
 Patient 1, Axial MRI

Obturator
internus

IPA

IPA
 Patient 1, Axial MRI

IPA

IPA
 Patient 1, Axial MRI

IPA
IPA
 Patient 1, Axial MRI

IPA IPA
 Patient 1, Axial MRI

IPA IPA
 Patient 1, Axial MRI

IPA

IPA
 Patient 1, Axial MRI
Prostate
Apex

External
Sphincter
IPA

IPA
 Patient 1, Axial MRI

Prostate
Apex

External
Sphincter IPA

IPA

Rectum
 Patient 1, Axial MRI

External
Sphincter
GUD

IPA

IPA

Rectum
 Patient 1, Axial MRI

External
Sphincter
GUD

IPA Levator
ani

IPA
IF
 Patient 1, Axial MRI

IPA

IPA
 Patient 1, Axial MRI

Penile
Bulb

IPA

IPA

After entering the GUD the IPA into branches to supply the penile
bulb and corpus cavernosum
Patient 2: Axial T2 MRI
 Patient 2, Axial MRI

Bladder

Prostate

Rectum
Ischium

IPA
 Patient 2, Axial MRI

Prostate Obturator
internus

IPA
 Patient 2, Axial MRI

IPA

IPA
 Patient 2, Axial MRI

IPA

IPA
 Patient 2, Axial MRI

IPA

IPA
 Patient 2, Axial MRI

IPA

IPA
 Patient 2, Axial MRI

IPA

IPA
 Patient 2, Axial MRI
External
Sphincter

Prostate
Apex
IPA

IPA
 Patient 2, Axial MRI

Prostate
Apex

IPA

IPA
 Patient 2, Axial MRI

External IPA
Sphincter

IPA

Rectum
 Patient 2, Axial MRI

IPA

IPA
 Patient 2, Axial MRI
Crura of Corpus
Cavernosa

IPA

IPA

Rectum
Patient 3: Axial T2 MRI
 Patient 3, Axial T2 MRI

Rectum IPA

IPA

Prostate

Obturator
internus
 Patient 3, Axial T2 MRI

IPA

IPA
 Patient 3, Axial T2 MRI

IPA

IPA

Prostate
Apex
 Patient 3, Axial T2 MRI

IF

IPA

IPA

External
Sphincter

GUD
 Patient 3, Axial T2 MRI

IPA

IPA
 Patient 3, Axial T2 MRI

IPA

Ischioanal Fossa
(IAF)

IPA

Rectum

The Ischioanal/Ischiorectal Fossa (IF) are the wedge-shaped areas

lateral to the anal canal. The pudendal canal is found on the lateral
wall of the IF.
 Patient 3, Axial T2 MRI

IPA
IPA
 Patient 3, Axial T2 MRI

IPA

IPA

Corpus
Cavernosa
 Patient 3, Axial T2 MRI

IPA

IPA

Penile
Bulb

Corpus Corpus
Cavernosum Cavernosum
Patient 4: Axial CT and T2 MRI

The following images are a side by side comparison of a

patient CT and correlating Axial T2 MRI. In a subset of
patients it is possible to localize the IPA on CT but it is
more obvious on MRI.
 Patient 4, CT vs. Axial T2 MRI
IPA
Post Implant

IPA

IPA

IPA
 Patient 4, CT vs Axial T2 MRI
IPA Patient 4, CT vs. Axial T2 MRI

IPA

IPA

IPA
 Patient 4, CT vs. Axial T2 MRI
IPA

IPA IPA

IPA
 Locating Pudendal Arteries on
Coronal MRI

The terminal branches of the IPA within the GUD are

poorly visualized on Axial MRI. They can be identified on
Coronal MRI as a cluster of vessels above the corpus
cavernosa. These vessels can be traced posterior to the
pudendal canal which is well visualized on coronal view.
Patient 5: Coronal T2 MRI
 Patient 5, Coronal T2 MRI

IPA in the
pudendal canal
IPA

IF
 Patient 5, Coronal T2 MRI

IPA
IPA
 Patient 5, Coronal T2 MRI

IPA

IPA
 Patient 5, Coronal T2 MRI

IPA

IPA

Levator Levator
ani ani
 Patient 5, Coronal T2 MRI

Obturator
internus

IPA IPA
 Patient 5, Coronal T2 MRI

Obturator
internus

IPA IPA
 Patient 5, Coronal T2 MRI

Terminal branches Terminal branches of

of IPA = IPA
Terminal IPA

Crura of Corpus
Cavernosum
 Patient 5, Coronal T2 MRI

Prostate

Terminal IPA
Terminal IPA

Crura of Corpus
Penile Cavernosum
Bulb
Patient 6: Coronal T2 MRI
 Patient 6, Coronal T2 MRI

Rectum

IPA

IPA
 Patient 6, Coronal T2 MRI

IPA

IPA
 Patient 6, Coronal T2 MRI

IPA

IPA
 Patient 6, Coronal T2 MRI

IPA

IPA
 Patient 6, Coronal T2 MRI

IPA

IPA
 Patient 6, Coronal T2 MRI

IPA

IPA
 Patient 6, Coronal T2 MRI

IPA

IPA
 Patient 6, Coronal T2 MRI

Bladder

IPA

IPA
 Patient 6, Coronal T2 MRI

IPA

IPA
 Patient 6, Coronal T2 MRI

IPA

IPA
 Patient 6, Coronal T2 MRI

Levator
Ani

Obturator
IPA internus

IPA in pudendal canal

 Patient 6, Coronal T2 MRI

Prostate

IPA

IPA

beginning
of crura
Patient 7, Coronal T2 MRI
 Patient 7, Coronal T2 MRI

IPA IPA
 Patient 7, Coronal T2 MRI

IPA

IPA
 Patient 7, Coronal T2 MRI
Bladder

IPA
IPA
 Patient 7, Coronal T2 MRI

Bladder

Terminal IPA

Terminal IPA
 Patient 7, Coronal T2 MRI

Bladder

Terminal IPA
Terminal IPA
 Patient 7, Coronal T2 MRI

Bladder

Prostate

Terminal IPA

Terminal IPA

Penile
Bulb
 Patient 7, Coronal T2 MRI

Bladder

Terminal IPA

Terminal IPA

Penile
Bulb
 Patient 7, Coronal T2 MRI

Bladder

Terminal IPA

Terminal IPA

Corpus
cavernosum
 Patient 7, Coronal T2 MRI

Bladder

External
Sphincter

Terminal branches
Terminal branches of IPA
of IPA

Corpus
Cavernosum

Penile
Bulb
 Angio vs. Axial MRI

Prostate

IPA
IPA

This image shows the fusion of the Angio MRI to its correlating
Axial T2 MRI. Note the IPA is visible on both scans.
Pudendal Arteries on Angiogram
The following angiograms were obtained by a time
of flight MRI sequence, a non contrast study
completed in less than 10 minutes. There is great
variation in the quality of an IPA time of flight
angiogram. The range from poor to excellent
visualization may be due to differences in body
habitus, technical factors and vessel patency. The
following images clearly display the course of the
IPA.
Patient 8: IPA Angiogram
 Patient 8, Angio MRI

IPA
IPA
 Patient 8, Angio MRI

Obturator
internus
Prostate

IPA IPA
 Patient 8, Angio MRI

IPA

IPA
 Patient 8, Angio MRI

Prostate

IPA

IPA
 Patient 8, Angio MRI

IPA

IPA
 Patient 8, Angio MRI

IPA

IPA
 Patient 8, Angio MRI

IPA IPA

IF
 Patient 8, Angio MRI

IPA

IPA
 Patient 8, Angio MRI

IPA

IPA
 Patient 8, Angio MRI

IPA

IPA
 Patient 8, Angio MRI

IPA

IPA
 Patient 8, Angio MRI

IPA

IPA
 Patient 8, Angio MRI

IPA
IPA
 Patient 8, Angio MRI

IPA

IPA

Rectum
Patient 9: IPA Angiogram
(Patient Prone)
 Patient 9, Angio MRI
Rectum

IPA IPA

Prostate
Femoral Head

Pubic Symphysis
 Patient 9, Angio MRI

IPA
IPA

Prostate
 Patient 9, Angio MRI

Rectum

IPA
IPA

Prostate
 Patient 9, Angio MRI

IPA IPA
 Patient 9, Angio MRI

IF

IPA
IPA

IF

Rectum
Prostate
 Patient 9, Angio MRI

IPA

IPA
 Patient 9, Angio MRI

IPA IPA
 Patient 9, Angio MRI

IPA

IPA
 Patient 9, Angio MRI

IPA

IPA
 Patient 9, Angio MRI

IPA

IPA
 Patient 9, Angio MRI

IPA
IPA
 Patient 9, Angio MRI

IPA

IPA
 Patient 9, Angio MRI

IPA

IPA
 Patient 9, Angio MRI

IPA

IPA
 Patient 9, Angio MRI

IPA

IPA
 Patient 9, Angio MRI

IPA
IPA
 Patient 9, Angio MRI

IPA

IPA
 Patient 9, Angio MRI

IPA

IPA
 Patient 9, Angio MRI

IPA

IPA
 Patient 9, Angio MRI

IPA

IPA
 Patient 9, Angio MRI

IPA

IPA
 Patient 9, Angio MRI

Penile
Bulb
IPA

IPA
 Angio MRI vs. CT

The following images are side by side comparisons

of IPA visible on Angio MRI and the equivalent CT.
Since it is difficult to locate the IPA on CT, the
contours shown on CT are cut from the correlated
Angio MRI images.
 Patient 10, Angio MRI

Prostate IPA

IPA

Rectum
Rectum
 Patient 10, Angio MRI

IPA

IPA
 Patient 10, Angio MRI

IPA

IPA
 Patient 10, Angio MRI

IPA
IPA
 Patient 10, Angio MRI

IPA

IPA

Note that the IPA is slightly visible on CT.

Its location is relative to the IPA identified in
the Angio.
 Angio MRI vs. CT

The following images on CT show the

visible and estimated position of the the
IPA based on its relationship to adjacent
structures. They have not been contoured
but rather encircled broadly to allow review
of the vessel appearance and location on
CT. Calcification of the vessels may
improve visualization on CT.
 Patient 10, Angio MRI

IPA IPA
 Patient 10, Angio MRI

IPA IPA
 Patient 10, Angio MRI

IPA IPA
 Patient 10, Angio MRI

IPA IPA
 Patient 10, Angio MRI

IPA IPA
A 3D Image of Prostate and critical
adjacent structures