Accuracy of assessing Pelvic Organ Prolapse Quantification points using dynamic 2D transperineal ultrasound in women with pelvic organ prolapse

International Urogynecological Consultation Chapter 2.2: Imaging in the Diagnosis of Pelvic Organ Prolapse

INTRODUCTION AND HYPOTHESIS

This section of Chapter 2.2 of the International Urogynecology Consultation on Pelvic Organ Prolapse (POP), reviews the literature on the role of imaging in the diagnosis of POP.

METHODS

An international group of nine urogynecologists and one university-based medical librarian adhered to the framework of the scoping review. The group performed a search of the literature using pre-specified search terms in Scopus, OVID Medline, and PubMed. Publications were eliminated if not relevant to the diagnostic value of POP imaging. The remaining articles were evaluated for quality using the Joanna Briggs Institute Checklist for Diagnostic Test Accuracy Studies. The resulting list of articles was used to perform a comprehensive narrative review of the diagnostic value of imaging modalities for the diagnosis of POP.

RESULTS

The original search yielded 3,289 references, 135 of which were used by the writing group.

CONCLUSIONS

Most imaging studies utilized in the diagnoses of POP lacked standardization in the definition of POP. Most imaging studies lack standardization in the protocols used to diagnose POP within each imaging technique. Ultrasound- and MRI-related studies are most represented in the literature, compared with fewer CT- and X-ray-/fluoroscopy-related studies. Therefore, radiographic imaging is of limited value in the diagnosis of POP.

Diagnostic utility of translabial ultrasound in pelvic organ prolapse: a prospective observational study

BACKGROUND

The increasing awareness of women's health issues, specifically pelvic organ prolapse (POP) and urinary incontinence (UI), has spurred a surge in patients seeking specialised advice for these conditions, necessitating modern diagnostic approaches for such issues. This study explored the diagnostic utility of translabial ultrasound for POP, emphasising its correlation with clinical assessments based on International Continence Society (ICS) criteria.

METHODS

Seventy-one patients with POP Quantification System (POP-Q) stage 0-IV with or without UI were prospectively enrolled at Jagiellonian University Medical College between 2014 and 2016. The study objectives included evaluating diagnostic accuracy and concordance across pelvic compartments, correlating the diagnoses with patient-reported symptoms, and identifying variables contributing to diagnostic discrepancies.

RESULTS

Translabial ultrasound identified POP in 74.5% of the patients, aligning closely with clinical evaluations. Concordance was the highest in assessments performed in the medial compartment (85.8%), while assessments performed in the anterior (29.6%) and posterior (29.6%) compartments showed higher rates of discrepancies. Correlation analyses showed varying associations, with the posterior compartment exhibiting the least pronounced correlation (R = 0.72, p < 0.0001). Self-perceive POP showed no discernible differences in relation to ultrasonographic and clinical assessments. Among the respondents, 55.9% reported experiencing the sensation of POP. Mean POP levels determined using the two approaches precisely matched in 46.5% of these cases. Discrepancies involved variables such as self-perceived POP, number of deliveries, child weight at birth, UI, and sexual activity.

CONCLUSIONS

Translabial ultrasound showed robust correlation with clinical assessments for evaluating POP, especially for defining defects and facilitating treatment-related decision-making. Our findings highlight the reliability of this method, particularly for assessments in the medial compartment. The evidence did not indicate the superiority of either method in detecting POP disorders for symptomatic versus asymptomatic patients. Significantly, a higher POP-Q measurement in clinical examination was correlated with greater sexual activity.

Is It Possible to Diagnose Surgical Uterine Prolapse With Transperineal Ultrasound? Multicenter Validation of Diagnostic Software

OBJECTIVES

To validate an ultrasound software that uses transperineal ultrasound to diagnose uterine prolapse (UP).

METHODS

Multicenter, observational and prospective study with 155 patients that had indications for surgical intervention for dysfunctional pelvic floor pathology. Each patient underwent an examination with Pozzi tenaculum forceps was performed in the operating room with the patient anesthetized, followed by surgical correction of stages II-IV UP. Transperineal ultrasound was used to assess the difference in the pubis-uterine fundus measurement. With a multivariate logistic regression binary model (with the measurement ultrasound at rest, the Valsalva maneuver and age) using nonautomated methods to predict UP. With the purpose of evaluating the model, a table with coordinates of the receiver operating characteristic (ROC) curve, after which sensitivity and specificity were assessed.

RESULTS

A total of 153 patients were included (73 with a diagnosis of surgical UP). It was obtained from the AUC (0.89) of the probabilities predicted by the model (95% confidence interval, 0.84-0.95; P < .0005). Based on the ROC curve for the model, obtaining a sensitivity of 91.8% and a specificity of 72.7%, values that were superior to those for the clinical exam for surgical UP (sensitivity: 80.8%; specificity: 71.3%).

CONCLUSIONS

We validated software that uses transperineal ultrasound of the pelvic floor and patient age to generate a more reliable diagnosis of surgical UP than that obtained from clinical examinations.

Clinical application of a fixed reference line in the ultrasound quantitative diagnosis of female pelvic organ prolapse

OBJECTIVE

This study explored using an improved ultrasound (US) for quantitative evaluation of the degree of pelvic organ prolapse(POP).

DESIGN

A transluminal probe was used to standardize ultrasound imaging of pelvic floor organ displacements. A US reference line was fixed between the lower edge of the pubic symphysis and the central axis of the pubic symphysis at a 30°counterclockwise angle.

METHOD

Points Aa, Ba, C and Bp on pelvic organ prolapse quantification (POP-Q) were then compared with the points on pelvic floor ultrasound (PFUS).

RESULTS

One hundred thirteen patients were included in the analysis of the standard US plane. Correlations were good in the anterior and middle compartments (PBN:Aa, ICC = 0.922; PBB:Ba, ICC = 0.923; and PC:C, ICC = 0.925), and Bland-Altman statistical maps corresponding to the average difference around the 30°horizontal line were close to 0. Correlations were poor in the posterior compartment (PRA:Bp, ICC = 0.444). However, eight (7.1%) cases of intestinal hernia and 21 (18.6%) cases of rectocele were diagnosed.

CONCLUSIONS

Introital PFUS using an intracavitary probe, which is gently placed at the introitus of the urethra and the vagina, may be accurately used to evaluate organ displacement. The application of a 30°horizontal line may improve the repeatability of the US diagnosis of POP.

Identification of Surgical Uterine Prolapse in Premenopausal Patients With Clinical or Ultrasound Criteria? A Multicenter Comparative Study

OBJECTIVES

It is unknown whether diagnosing uterine prolapse (UP) via ultrasound or surgical criteria is superior. Our objective is to determine whether the diagnostic capacity of ultrasound with surgical criteria differs from that of surgical criteria only.

METHODS

This was a multicenter prospective observational study with 54 premenopausal patients with surgical criteria for a dysfunctional pelvic floor pathology who were consecutively recruited for 1 year. Clinical UP with surgical criteria was defined when UP stage II-IV was identified (during pelvic floor consultation), and UP diagnosed by ultrasound with surgical criteria was established when a difference ≥15 mm was found between rest and Valsalva applied to the pubis-uterine fundus. The sensitivity, specificity and positive and negative predictive values were determined to evaluate clinical and ultrasound methodologies as diagnostic tests.

RESULTS

UP diagnosed by ultrasound with surgical criteria presented better sensitivity (78.57 vs 35.71%), specificity (92.11 vs 81.58%), positive predictive value (61.83 vs 23.99%), and negative predictive value (96.35 vs 11.37%) than UP diagnosed by surgical criteria only.

CONCLUSION

Ultrasound with surgical criteria is superior to surgical criteria alone when diagnosing UP.

Association between 2D trans-perineal ultrasound and physical examination in evaluation of ani function

PURPOSE

To compare the correlation between 2D transperineal ultrasonography and physical examination (intravaginal palpation) for assessing pelvic floor and levator ani function.

METHODS

Due to symptoms of pelvic floor disorder, 40 women between the ages of 29 and 75 were enrolled in this study as candidates for urodynamic and structural evaluation of the pelvic floor. A pelvic floor gynaecologist and radiologist assessed the levator ani function via physical examination (graded based on the Oxford Grading System) and transperineal 2D ultrasound, respectively.

RESULTS

The ultrasound parameters for calculating the Levator Ani Index (LAI) demonstrate a difference between the anteroposterior dimension of the levator hiatus (r = 0.691, p < 0.001) and the cranial shift of muscle (r = 0.499, p < 0.001) at rest and during a squeezing manoeuvre in the mid-sagittal plane. Reduced anteroposterior diameter of the hiatus and increased cranial shift were associated with a higher Oxford Physical Examination Score (OPES). The association between LAI and OPES was independent of baseline variables such as age, BMI, number of births, and the presence of incontinence symptoms.

CONCLUSION

Measures such as the LAI can be used to quantify the function of the levator ani muscle, which may be useful for evaluating the efficacy of pelvic floor physiotherapy and exercise.

Predictive Model for the Diagnosis of Uterine Prolapse Based on Transperineal Ultrasound

We want to describe a model that allows the use of transperineal ultrasound to define the probability of experiencing uterine prolapse (UP). This was a prospective observational study involving 107 patients with UP or cervical elongation (CE) without UP. The ultrasound study was performed using transperineal ultrasound and evaluated the differences in the pubis−uterine fundus distance at rest and with the Valsalva maneuver. We generated different multivariate binary logistic regression models using nonautomated methods to predict UP, including the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver. The parameters were added progressively according to their simplicity of use and their predictive capacity for identifying UP. We used two binary logistic regression models to predict UP. Model 1 was based on the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver and the age of the patient [AUC: 0.967 (95% CI, 0.939−0.995; p < 0.0005)]. Model 2 used the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver, age, avulsion and ballooning (AUC: 0.971 (95% CI, 0.945−0.997; p < 0.0005)). In conclusion, the model based on the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver and the age of the patient could predict 96.7% of patients with UP.

ACR Appropriateness Criteria® Pelvic Floor Dysfunction in Females

Pelvic floor disorders including pelvic organ prolapse (POP), urinary dysfunction, defecatory dysfunction, and complications after pelvic floor surgery are relatively common in the female population. Imaging tests are obtained when the initial clinical evaluation is thought to be incomplete or inconclusive or demonstrates findings that are discordant with patients' symptoms. An integrated imaging approach is optimal to evaluate the complex anatomy and dynamic functionality of the pelvic floor. Fluoroscopic cystocolpoproctography (CCP) and MR defecography are considered the initial imaging tests of choice for evaluation of POP. Fluoroscopic voiding cystourethrography is considered the initial imaging test for patients with urinary dysfunction. Fluoroscopic CCP and MR defecography are considered the initial imaging test for patients with defecatory dysfunction, whereas ultrasound pelvis transrectal is a complementary test in patients requiring evaluation for anal sphincter defects. MRI pelvis without and with intravenous contrast, MRI pelvis with dynamic maneuvers, and MR defecography are considered the initial imaging tests in patients with suspected complications of prior pelvic floor surgical repair. Transperineal ultrasound is emerging as an important imaging tool, in particular for screening of pelvic floor dysfunction and for evaluation of midurethral slings, vaginal mesh, and complications related to prior pelvic floor surgical repair. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

2D ultrasound diagnosis of middle compartment prolapse: a multicenter study

BACKGROUND

Recently, a specific methodology has been defined, using transperineal ultrasound, for the differential diagnosis of middle compartment prolapse [uterine prolapse (UP) or cervical elongation (CE) without UP] based on the difference in the pubis-uterine fundus distance at rest and with the Valsalva maneuver, with a cutoff point of 15 mm. The objective of this study was to validate the diagnostic utility of a ≥15 mm difference between the pubis-uterine fundus distance at rest and during the Valsalva maneuver to define UP in a multicenter study.

METHODS

This prospective multicenter observational study included 94 patients (UP =51; CE without UP =43). The clinical examination was based on the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) system for assessing pelvic organ prolapse (POP) and patients were candidates for corrective surgery of the middle compartment of the pelvic floor (correction of UP or CE without UP). The ultrasound study was performed by transperineal ultrasound (B-mode) with the patient undergoing dorsal lithotomy. The distance evaluation was performed in relation to the posteroinferior pubic margin in the midsagittal plane, with reference to the uterine fundus (established as the most distal hyperechogenic) line from the pubis to the uterine fundus at rest and with the Valsalva maneuver. We defined UP detected using UP as a difference of ≥15 mm between the pubis-uterine fundus distance at rest and with the Valsalva maneuver. Agreement between the clinical and ultrasound diagnosis of UP was assessed using the Cohen kappa coefficient of agreement and its 95% CIs.

RESULTS

The ultrasound diagnosis of global UP at the three centers showed very good agreement, with a kappa index of 0.826 (0.71, 0.94). The agreement of ultrasound with the clinical diagnosis of UP using the ICS POP-Q system was very good for each of the hospitals [Hospital 1: 0.814 (0.64, 0.98), Hospital 2: 0.847 (0.64, 1) and Hospital 3: 0.824 (0.59, 1)].

CONCLUSIONS

A difference of ≥15 mm between the pubis-uterine fundus distance at rest and during the Valsalva maneuver for the diagnosis of UP presents very good agreement with the results of clinical evaluation with the ICS POP-Q system.

Cut-offs for defining uterine prolapse using transperineal ultrasound in Chinese women: prospective multicenter study

OBJECTIVE

Transperineal ultrasound is a simple and highly repeatable method that has been used increasingly in the quantification of pelvic organ prolapse, but abnormal uterine descent on ultrasound in Chinese women is still poorly defined. We aimed to determine the optimal cut-off to define abnormal uterine descent on transperineal ultrasound in Chinese women.

METHODS

This prospective multicenter study recruited women who were examined in tertiary-level gynecological centers, due to symptoms of lower urinary tract and/or pelvic floor dysfunction, between February 2017 and September 2018. All recruited women underwent a standardized interview, pelvic organ prolapse quantification (POP-Q) examination, and four-dimensional transperineal ultrasound examination. On ultrasound, uterine descent was measured relative to the posteroinferior margin of the symphysis pubis during maximum Valsalva maneuver. The optimal cut-off value for definition of abnormal uterine descent was selected as the value with the highest Youden index and the diagnostic performance of this cut-off for the prediction of prolapse symptoms and POP-Q stage was assessed and compared by means of the area under the receiver-operating-characteristics curve (AUC).

RESULTS

In total, 538 Chinese women, with a mean age of 39.4 (range, 18-81) years, were enrolled into the study. Both uterine descent on transperineal ultrasound (P < 0.001) and POP-Q stage (P < 0.001) were associated strongly with presence of prolapse symptoms. Uterine descent on ultrasound was associated significantly with POP-Q stage for apical compartment prolapse (P < 0.001). The optimal cut-off value for the definition of abnormal uterine descent on transperineal ultrasound during maximum Valsalva maneuver in the prediction of prolapse symptoms was 4.79 mm above the symphysis pubis (AUC, 0.75 (95% CI, 0.71-0.78)), while the optimal cut-off values in the prediction of prolapse of POP-Q Stage ≥ 1 and POP-Q Stage ≥ 2 were 6.63 mm above the symphysis pubis (AUC, 0.83 (95% CI, 0.80-0.86)) and 8.42 mm below the symphysis pubis (AUC, 0.85 (95% CI, 0.82-0.88)), respectively.

CONCLUSIONS

The optimal cut-off value to define abnormal uterine descent on transperineal ultrasound during maximum Valsalva maneuver for the prediction of prolapse symptoms in this population of Chinese women was 4.79 mm above the symphysis pubis, close to that for predicting apical compartment prolapse of POP-Q Stage ≥ 1 (6.63 mm above the symphysis pubis). These are somewhat different from values described previously in mainly Caucasian populations. Ethnic differences should be taken into account in the evaluation of pelvic organ prolapse using transperineal ultrasound. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Differential diagnosis of middle compartment pelvic organ prolapse with transperineal ultrasound

INTRODUCTION AND HYPOTHESIS

The objective was to identify the best parameter (pubis-cervix measurement, pubis-uterine fundus measurement or pubis-pouch of Douglas measurement) on transperineal ultrasound, based on the difference between measurements taken at rest and with the Valsalva maneuver, for presurgical differential diagnosis between uterine prolapse (UP) and cervical elongation (CE) without UP.

METHODS

A prospective observational study of 60 consecutively recruited patients who underwent corrective surgery of the middle compartment (UP or CE without UP). A transperineal ultrasound was performed, and the descent of the pelvic organ was measured in relation to the posteroinferior margin of the pubis in the midsagittal plane, referencing the uterine fundus, pouch of Douglas and the cervix at rest and with the Valsalva test.

RESULTS

Receiver operating characteristic (ROC) curves were constructed for the three evaluated measures, based on the difference between rest and Valsalva, for the diagnosis of UP. For the pubis-cervix distance, an area under the curve (AUC) of 0.59 was obtained; for the pubis-uterine fundus distance, the AUC was 0.81; and for the pubis-pouch of Douglas distance, the AUC was 0.69. Based on the best AUC (the difference in the pubis-uterine fundus distance at rest and with the Valsalva maneuver), a cut-off point of 15 mm was established for the diagnosis of UP (sensitivity: 75%; specificity: 95%; positive predictive value: 86%; and negative predictive value: 89%).

CONCLUSION

A difference of ≥15 mm in the pubis-uterine fundus distance at rest and with the Valsalva maneuver is useful for differentiating UP from CE without UP by ultrasound.

Does 4D transperineal ultrasound have additional value over 2D transperineal ultrasound for diagnosing posterior pelvic floor disorders in women with obstructed defecation syndrome?

OBJECTIVE

To establish the diagnostic test accuracy of two-dimensional (2D) and four-dimensional (4D) transperineal ultrasound (TPUS) for diagnosis of posterior pelvic floor disorders in women with obstructed defecation syndrome (ODS), in order to assess if 4D ultrasound imaging provides additional value.

METHODS

This was a prospective cohort study of 121 consecutive women with ODS. Symptoms of ODS and pelvic organ prolapse on clinical examination were assessed using validated methods. All women underwent both 2D- and 4D-TPUS. Imaging analysis was performed by two blinded observers. Posterior pelvic floor disorders were dichotomized into presence or absence, according to predefined cut-off values. In the absence of a reference standard, a composite reference standard was created from a combination of results of evacuation proctography, magnetic resonance imaging and endovaginal ultrasound. Primary outcome measures were diagnostic test characteristics of 2D- and 4D-TPUS for rectocele, enterocele, intussusception and anismus. Secondary outcome measures were interobserver agreement, agreement between the two imaging techniques, and association of severity of ODS symptoms and degree of posterior vaginal wall prolapse with conditions observed on imaging.

RESULTS

For diagnosis of all four posterior pelvic floor disorders, there was no difference in sensitivity or specificity between 2D- and 4D-TPUS (P = 0.131-1.000). Good agreement between 2D- and 4D-TPUS was found for diagnosis of rectocele (κ = 0.675) and moderate agreement for diagnoses of enterocele, intussusception and anismus (κ = 0.465-0.545). There was no difference in rectocele depth measurements between the techniques (19.9 mm for 2D vs 19.0 mm for 4D, P = 0.802). Interobserver agreement was comparable for both techniques, although 2D-TPUS had excellent interobserver agreement for diagnosis of enterocele and rectocele depth measurements, while this was only moderate and good, respectively, for 4D-TPUS. Diagnoses of rectocele and enterocele on both 2D- and 4D-TPUS were significantly associated with degree of posterior vaginal wall prolapse on clinical examination (odds ratio (OR) = 1.89-2.72). The conditions observed using either imaging technique were not associated with severity of ODS symptoms (OR = 0.82-1.13).

CONCLUSIONS

There is no evidence of superiority of 4D ultrasound acquisition to dynamic 2D ultrasound acquisition for the diagnosis of posterior pelvic floor disorders. 2D- and 4D-TPUS could be used interchangeably to screen women with symptoms of ODS. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Comparison of transperineal ultrasound with POP-Q for assessing symptoms of prolapse

INTRODUCTION

Our aim was to study any correlation between pelvic organ prolapse quantification (POP-Q) and ultrasound measurement of prolapse in women from a normal population and to identify the method with a stronger association with prolapse symptoms.

METHODS

A cross-sectional study of 590 parous women responding to the Pelvic Floor Distress Inventory was carried out. They were examined using POP-Q and transperineal ultrasound, and correlation was tested using Spearman's rank test. Numerical measurements and significant prolapse (POP-Q ≥ 2 in any compartment or bladder ≥10 mm, cervix ≥0 mm or rectal ampulla ≥15 mm below the symphysis on ultrasound) were compared in symptomatic and asymptomatic women (Mann-Whitney U and Chi-squared tests).

RESULTS

A total of 256 women had POP-Q ≥ 2 and 209 had significant prolapse on ultrasound. The correlation (r_s) between POP-Q and ultrasound was 0.69 (anterior compartment), 0.53 (middle), and 0.39 (posterior), p < 0.01. Women with a "vaginal bulge" (n = 68) had greater descent on POP-Q and ultrasound in the anterior and middle compartments than asymptomatic women, p < 0.01. For women with a symptomatic bulge, the odds ratio was 3.8 (95% CI 2.2-6.7) for POP-Q ≥ grade 2 and 2.4 (95% CI 1.4-3.9) for prolapse on ultrasound. A sensation of heaviness (n = 90) and incomplete bladder emptying (n = 4) were more weakly associated with ultrasound (p = 0.03 and 0.04), and splinting (n = 137) was associated with POP-Q Bp, p = 0.02.

CONCLUSION

POP-Q and ultrasound measurement of prolapse had moderate to strong correlation in the anterior and middle compartments and weak correlation in the posterior compartment. Both methods were strongly associated with the symptom "vaginal bulge," but POP-Q had a stronger association than ultrasound.

Quality of reporting of diagnostic accuracy studies on pelvic floor three-dimensional transperineal ultrasound: a systematic review

OBJECTIVE

In recent years, a large number of studies have been published on the clinical relevance of pelvic floor three-dimensional (3D) transperineal ultrasound. Several studies compare sonography with other imaging modalities or clinical examination. The quality of reporting in these studies is not known. The objective of this systematic review was to determine the compliance of diagnostic accuracy studies investigating pelvic floor 3D ultrasound with the Standards for Reporting of Diagnostic Accuracy (STARD) guidelines.

METHODS

Published articles on pelvic floor 3D ultrasound were identified by a systematic literature search of MEDLINE, Web of Science and Scopus databases. Prospective and retrospective studies that compared pelvic floor 3D ultrasound with other clinical and imaging diagnostics were included in the analysis. STARD compliance was assessed and quantified by two independent investigators, using 22 of the original 25 STARD checklist items. Items with the qualifier 'if done' (Items 13, 23 and 24) were excluded because they were not applicable to all papers. Each item was scored as reported (score = 1) or not reported (score = 0). Observer variability, the total number of reported STARD items per article and summary scores for each item were calculated. The difference in total score between STARD-adopting and non-adopting journals was tested statistically, as was the effect of year of publication.

RESULTS

Forty studies published in 13 scientific journals were included in the analysis. Mean ± SD STARD checklist score of the included articles was 16.0 ± 2.5 out of a maximum of 22 points. The lowest scores (< 50%) were found for reporting of handling of indeterminate results or missing responses, adverse events and the time interval between tests. Interobserver agreement for rating the STARD items was excellent (intraclass correlation coefficient, 0.77). An independent t-test showed no significant mean difference ± SD in total STARD checklist score between STARD-adopting and non-adopting journals (16.4 ± 2.2 vs 15.9 ± 2.6, respectively). Mean ± SD STARD checklist score for articles published in 2003-2009 was lower, but not statistically different, compared with those published in 2010-2015 (15.2 ± 2.5 vs 16.6 ± 2.4, respectively).

CONCLUSION

The overall compliance with reporting guidelines of diagnostic accuracy studies on pelvic floor 3D transperineal ultrasound is relatively good compared with other fields of medicine. However, specific checklist items require more attention when reported. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Dynamic translabial ultrasound versus echodefecography combined with the endovaginal approach to assess pelvic floor dysfunctions: How effective are these techniques?

BACKGROUND

The aim of this study was to evaluate the role of dynamic translabial ultrasound (TLUS) in the assessment of pelvic floor dysfunction and compare the results with echodefecography (EDF) combined with the endovaginal approach.

METHODS

Consecutive female patients with pelvic floor dysfunction were eligible. Each patient was assessed with EDF combined with the endovaginal approach and TLUS. The diagnostic accuracy of the TLUS was evaluated using the results of EDF as the standard for comparison.

RESULTS

A total of 42 women were included. Four sphincter defects were identified with both techniques, and EDF clearly showed if the defect was partial or total and additionally identified the pubovisceral muscle defect. There was substantial concordance regarding normal relaxation and anismus. Perfect concordance was found with rectocele and cystocele. The rectocele depth was measured with TLUS and quantified according to the EDF classification. Fair concordance was found for intussusception. There was no correlation between the displacement of the puborectal muscle at maximum straining on EDF with the displacement of the anorectal junction (ARJ), compared at rest with maximal straining on TLUS to determine perineal descent (PD). The mean ARJ displacement was similar in patients with normal and those with excessive PD on TLUS.

CONCLUSIONS

Both modalities can be used as a method to assess pelvic floor dysfunction. The EDF using 3D anorectal and endovaginal approaches showed advantages in identification of the anal sphincters and pubodefects (partial or total). There was good correlation between the two techniques, and a TLUS rectocele classification based on size that corresponds to the established classification using EDF was established.

Association between ICS POP-Q coordinates and translabial ultrasound findings: implications for definition of 'normal pelvic organ support'

OBJECTIVES

Female pelvic organ prolapse is quantified on clinical examination using the pelvic organ prolapse quantification system of the International Continence Society (ICS POP-Q). Pelvic organ descent on ultrasound is strongly associated with symptoms of prolapse, but associations between clinical and ultrasound findings remain unclear. This study was designed to compare clinical examination and imaging findings, especially regarding cut-offs for the distinction between normal pelvic organ support and prolapse.

METHODS

This was a retrospective study using 839 archived datasets of women referred to a tertiary urogynecological center for symptoms of lower urinary tract and pelvic floor dysfunction between June 2011 and May 2013. The main outcome measures were the maximum downward displacement of the anterior vaginal wall (point Ba), the cervix (point C) and the posterior vaginal wall (point Bp), the length of the genital hiatus (Gh) and the length of the perineal body (Pb), as defined by the ICS POP-Q; explanatory parameters were measures of pelvic organ descent on translabial ultrasound, ascertained by offline volume data analysis at a later date, by an operator blinded to all other data.

RESULTS

Full datasets were available for 825 women. On clinical examination, 646 (78.3%) were found to have prolapse of at least POP-Q Stage 2. All coordinates on clinical examination were strongly associated with the ultrasound measurements of pelvic organ descent (P < 0.001). These relationships were almost linear, especially for the anterior compartment.

CONCLUSIONS

There is a near linear relationship between sonographic and clinical measures of prolapse. Previously proposed cut-offs to define 'significant prolapse' on ultrasound and POP-Q (Ba ≥ -0.5 and cystocele ≥ 10 mm below the symphysis pubis, C ≥ -5 and uterine position of 15 mm above the symphysis pubis, Bp ≥ -0.5 and rectocele ≥ 15 mm below the symphysis pubis) are plausible and mutually consistent. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Interobserver agreement of multicompartment ultrasound in the assessment of pelvic floor anatomy

OBJECTIVE

To assess the interobserver agreement of pelvic floor anatomical measurements using multicompartment pelvic floor ultrasound.

METHODS

Females were recruited from the urogynaecology/gynaecology clinics between July and October 2009 and underwent multicompartment pelvic floor ultrasonography (PFUS) using two-dimensional (2D) transperineal ultrasound (TPUS), high-frequency 2D/three-dimensional (3D) endovaginal ultrasound (EVUS) using a biplane probe with linear and transverse arrays and a 360° rotational 3D-EVUS. PFUS measurements were independently analysed by two clinicians.

RESULTS

158 females had PFUS assessment. Good-to-excellent interobserver agreement was observed for bladder-symphysis distance at rest and valsalva, urethral thickness, urethral length, urethral volume, levator hiatus area and width, anteroposterior diameter and anorectal angle. Lins Correlation was used to calculate the interobserver agreement and Bland-Altman plots were created to demonstrate the agreement between the researchers. There was also a good-to-excellent agreement between the two clinicians for the assessment of pelvic organ prolapse (POP) in the anterior, middle and posterior compartment.

CONCLUSION

Multicompartment PFUS is a reliable tool in the anatomical assessment of pelvic floor measurements and POP.

ADVANCES IN KNOWLEDGE

We found a good-to-excellent agreement between the two assessors in the assessment of pelvic floor measurements for all three pelvic floor compartments and suggest that multicompartment PFUS could be considered as a systematic integrated approach to assess the pelvic floor.

The value of pre-operative multicompartment pelvic floor ultrasonography: a 1-year prospective study

OBJECTIVE

Comprehensive assessment of the pelvic floor (PF) provides information and diagnoses of coexisting abnormalities that may affect operative decisions. Our aim was to establish if pre-operative PF ultrasonography (PFUS) in patients complaining of PF dysfunction can complement clinical findings and contribute to additional management strategies.

METHODS

Females were recruited from the urogynaecology/gynaecology clinics between July and October 2009 and underwent pelvic organ prolapse quantification (POPQ) by an independent examiner. PFUS was performed using two-dimensional (2D) transperineal ultrasound (TPUS), high-frequency 2D/three-dimensional (3D) endovaginal ultrasound (EVUS) using a biplane probe with linear and transverse arrays and a 360° rotational 3D-EVUS. The clinician performing PFUS was blinded to POPQ results. POPQ and PFUS were repeated at 1 year. Two clinicians analysed the scans independently.

RESULTS

158 of 160 females had a POPQ and PFUS. 105 females had pelvic organ prolapse and/or incontinence and 53 asymptomatic females were controls. 26 additional ultrasound diagnoses were noted at baseline and 46 at 1 year using 2D-TPUS and EVUS. Only one female with additional diagnoses on PFUS needed surgical intervention for this condition.

CONCLUSION

Multicompartment PFUS identifies additional conditions to that diagnosed on clinical assessment. However, it neither changes the initial surgical management nor the management at 1-year follow-up and therefore clinical assessment should not be substituted by PFUS.

ADVANCES IN KNOWLEDGE

PFUS can be helpful in providing additional information; however, it does not change the initial management of the patient and therefore should not replace clinical assessment.