Pelvic floor ultrasound: when, why, and how?

Ultrasound in Female Urinary Incontinence

Urinary incontinence (UI) is a common health condition that may interfere with the quality of life. A comprehensive evaluation of female UI helps with effective and safe treatments. Ultrasound has gained popularity to explore UI recently because it can collect crucial information for treatment planning and counseling. Translabial and introital approaches are commonly and reliably applied to ultrasound. The images can be obtained using two-dimensional and three-dimensional ultrasounds. Ultrasound is the only modality capable of confirming the presence or absence of a mid-urethral sling (MUS) and is able to demonstrate bulking agents as well. Although some of the ultrasound findings may only be incidental or supplementary to the patient's symptoms, ultrasound benefits for investigating the pathophysiology of UI and surgical outcomes of MUS procedures. It is anticipated that standardization in terminology, measurement techniques, and reporting can be established in the near future.

Efficacy of Pelvic Floor Ultrasound for Assessing Transobturator Tape Sling Procedure

IMPORTANCE

Complications after midurethral sling, which require a high degree of clinical suspicion for timely diagnosis, accurate evaluation, and proper intervention, are closely associated with surgical success or failure.

OBJECTIVES

This study aimed to evaluate the efficacy and complications of tension-free midurethral sling for stress urinary incontinence (SUI) using pelvic floor ultrasound.

STUDY DESIGN

This retrospective study included 152 female patients with SUI admitted to the Jinhua Central Hospital between January 2020 and December 2021 who were selected. All patients underwent midurethral transobturator tape sling procedures and were divided into success, voiding dysfunction, overactive bladder, and failure groups according to postoperative efficacy and complications. The pelvic floor ultrasound examination was performed before and after the surgery.

RESULTS

The posterior vesicourethral angle difference ( P < 0.01) was significantly lower after the surgery than before the surgery. The rate of bladder neck funneling ( P < 0.01) and the area of bladder neck funneling ( P < 0.01) were smaller after the surgery than before the surgery. The tape-longitudinal smooth muscle distance, the tape-symphysis pubis distance, the sling angle, and the tape-bladder neck/urethra increased successively in the voiding dysfunction, overactive bladder, success, and failure groups.

CONCLUSIONS

Pelvic floor ultrasound can accurately evaluate the postoperative efficacy and complications of transobturator tape sling procedures for SUI and can reasonably guide the management of complications. Therefore, it is an effective imaging method for postoperative follow-up after tension-free midurethral tape suspension.

Multimodality Imaging of Anterior Compartment Pelvic Floor Repair

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are two common disorders that affect the anterior compartment of the pelvic floor in women. These can be treated conservatively or surgically. Among patients treated surgically, a substantial number present with pain, recurrent POP or SUI, or other conditions that warrant additional interventions. In many of these cases, imaging is key to identifying and characterizing the type of procedure performed, locating synthetic materials that may have been placed, and characterizing complications. Imaging may be particularly helpful when prior surgical records are not available or a comprehensive physical examination is not possible. US and MRI are the most commonly used modalities for such patients, although radiopaque surgical materials may be visible at voiding cystourethrography and CT. The authors summarize commonly used surgical treatment options for patients with SUI and POP, review imaging techniques for evaluation of such patients, and describe the normal imaging appearance and complications of pelvic floor surgical repair procedures in the anterior compartment of the pelvis. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Knowledge, attitudes, and practice of pelvic floor dysfunction and pelvic floor ultrasound among women of childbearing age in Sichuan, China

Objective

Pelvic floor dysfunction (PFD) is highly prevalent among women. Pelvic floor ultrasound (PFU) is a critical method for assessing PFD. This study examined the knowledge, attitudes, and practice (KAP) of women of childbearing age regarding PFD and PFU.

Methods

This cross-sectional study was conducted between August 18, 2022, and September 20, 2022, in Sichuan, China. A total of 504 women of childbearing age participated in this study. A self-administered questionnaire was developed to assess KAP regarding PFD and PFU. Univariable and multivariable logistic regression analyses were conducted to assess the association between demographic characteristics and KAP.

Results

The average scores for knowledge, attitudes, and practice were 12.53, 39.98, and 16.51 out of 17, 45, and 20, respectively. Despite adequate knowledge of PFD symptoms, aging-related risks, and PFD harms (correct rates > 80%), participants showed poor knowledge about the benefits of PFU, PFU types, and Kegel exercise (correct rates < 70%). High scores in knowledge and attitude (odds ratio = 1.23 and 1.11, P < 0.001 and P = 0.005, respectively) were independent predictors of good practice, while never having been pregnant (odds ratio = 0.10, P < 0.001), alcohol consumption (odds ratio = 0.09, P = 0.027), and not being diagnosed with PFD or an unclear diagnosis independently predicted poor practice (both odds ratio = 0.03, both P < 0.001).

Conclusion

Women of childbearing age in Sichuan, China, showed moderate knowledge, positive attitude, and good practice regarding PFD and PFU. Knowledge, attitude, pregnancy history, alcohol consumption, and PFD diagnosis are associated with practice.

Evaluation of the Pelvic Floor of Women with Breast Cancer Using Tamoxifen by Transperineal 3D Ultrasonography

Objective

This study aimed to investigate the anatomical changes in the pelvic floor of women with breast cancer using tamoxifen by transperineal 3D ultrasonography and their effect on the urinary incontinence and sexual dysfunction.

Methods

Ninety-four patients with breast cancer using TAM in the study group and ninety-five healthy women of the same age in the control group were included in this prospective cohort study. Female Sexual Function Index and Incontinence Questionnaire-Short Form scales were applied to both groups. Ultrasonographic evaluation was performed at resting and Valsalva Maneuver with a convex (3-8 MHz) probe transperineally and the levator urethra gap and levator hiatus diameter were measured after 3-dimensional imaging. Independent t-tests were performed for statistical analysis.

Results

The mean age and body mass index of the experimental group versus control groups were 46.3 ± 6.12 years versus 46.4 ± 5.23 years and 27.6 ± 4.34 kg/m2 versus 29.2 ± 6.45 kg/m2, respectively. LUG and LH values were found significantly higher for the experimental groups compared to control groups at 17.23 ± 2.53 mm versus 14.1 ± 2.23 mm and 21 ± 2.45 cm2 versus 18 ± 4.56 cm2, respectively. (p < 0.05). The FSFI score significantly decreased (12.49 ± 3.58 versus 20.89 ± 3.69) and the ICIQ-SF score increased (4.02 ± 0.34 versus 2.34 ± 0.45) in the experimental group in comparison to control group (p < 0.05).

Conclusion

This study demonstrated that the effects of TAM usage on pelvic floor can be detected by measuring the changes in the levator ani muscle using the transperineal 3D USG. With transperineal USG screening, pelvic floor changes can be early diagnosed and clinical measures can be taken before they become symptomatic.

Tactile and Ultrasound Image Fusion for Functional Assessment of the Female Pelvic Floor

INTRODUCTION

The true etiology of pelvic organ prolapse and urinary incontinence and variations observed among individuals are not entirely understood. Tactile (stress) and ultrasound (anatomy, strain) image fusion may furnish new insights into the female pelvic floor conditions. This study aimed to explore imaging performance and clinical value of vaginal tactile and ultrasound image fusion for characterization of the female pelvic floor.

METHODS

A novel probe with 96 tactile and 192 ultrasound transducers was designed. Women scheduled for a urogynecological visit were considered eligible for enrollment to observational study. Intravaginal tactile and ultrasound images were acquired for vaginal wall deformations at probe insertion, elevation, rotation, Valsalva maneuver, voluntary contractions, involuntary relaxation, and reflex pelvic muscle contractions. Biomechanical mapping has included tactile/ultrasound imaging and functional imaging.

RESULTS

Twenty women were successfully studied with the probe. Tactile and ultrasound images for tissues deformation as well as functional images were recorded. Tactile (stress) and ultrasound (strain) images allowed creation of stress-strain maps for the tissues of interest in absolute scale. Functional images allowed identification of active pelvic structures and their biomechanical characterization (anatomical measurements, contractive mobility and strength). Fusion of the modalities has allowed recognition and characterization of levator ani muscles (pubococcygeal, puborectal, iliococcygeal), perineum, urethral and anorectal complexes critical in prolapse and/or incontinence development.

CONCLUSIONS

Vaginal tactile and ultrasound image fusion provides unique data for biomechanical characterization of the female pelvic floor. Bringing novel biomechanical characterization for critical soft tissues/structures may provide extended scientific knowledge and improve clinical practice.

Clinical applications of pelvic floor imaging: opinion statement endorsed by the society of abdominal radiology (SAR), American Urological Association (AUA), and American Urogynecologic Society (AUGS)

Pelvic floor dysfunction is prevalent, with multifactorial causes and variable clinical presentations. Accurate diagnosis and assessment of the involved structures commonly requires a multidisciplinary approach. Imaging is often complementary to clinical assessment, and the most commonly used modalities for pelvic floor imaging include fluoroscopic defecography, magnetic resonance defecography, and pelvic floor ultrasound. This collaboration opinion paper was developed by representatives from multiple specialties involved in care of patients with pelvic floor dysfunction (radiologists, urogynecologists, urologists, and colorectal surgeons). Here, we discuss the utility of imaging techniques in various clinical scenarios, highlighting the perspectives of referring physicians. The final draft was endorsed by the Society of Abdominal Radiology (SAR), American Urogynecologic Society (AUGS), and the American Urological Association (AUA).

Meshy business: MRI and ultrasound evaluation of pelvic floor mesh and slings

Pelvic floor disorders are a complex set of conditions including but not limited to stress urinary incontinence and pelvic organ prolapse that generally affect older and multiparous women. Of the several surgical options available for treatment of these conditions, synthetic mid-urethral slings for stress urinary incontinence and vaginal mesh for pelvic organ prolapse are amenable to imaging evaluation by ultrasound and magnetic resonance imaging techniques. Ultrasound can evaluate the sub- and immediate peri-urethral portions of sling due to its ability to differentiate synthetic material from native tissues with real-time imaging, while MRI is able to better depict the global pelvic floor anatomy and assess the more distant components of mesh and slings material. Given the high prevalence of pelvic floor disorders and complications after surgical repair, it is important that radiologists familiarize themselves with normal and abnormal imaging findings after these procedures. This article provides a review of the spectrum of imaging findings in patients after pelvic floor repair with synthetic mid-urethral slings and vaginal mesh.