Three-dimensional endovaginal sonography of synthetic implanted materials in the female pelvic floor

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.

Pelvic floor ultrasound evaluation in the diagnosis of exposure of synthetic implanted materials in the lower urinary tract

OBJECTIVE

To evaluate the diagnostic performance of pelvic floor ultrasound (PFUS) to recognize prosthetics exposure in the bladder and/or urethra in women with lower urinary tract symptoms (LUTS).

METHODS

A cross-sectional study evaluating patients with LUTS after mesh/sling surgery. PFUS was performed with both transvaginal (TVUS) and translabial (TLUS) approaches. A distance of 1 mm or less from the bladder and/or urethra was considered highly suspect for mesh exposure. After PFUS, patients underwent diagnostic urethrocystoscopy.

RESULTS

A total of 100 consecutive women were analyzed. According to urethrocystoscopy, the rate of tape exposure in the lower urinary tract was 3%. PFUS showed 100% sensitivity and 98%-100% specificity in detecting lower urinary tract mesh exposure. The negative predictive value was 100% and the positive predictive value ranged from 33% to 50% for urethral and 100% for bladder exposure.

CONCLUSIONS

PFUS represents an effective and reliable non-invasive screening test to exclude prosthetics exposure in the bladder and/or urethra in women with LUTS.

The Correlation Between the Sonographic Course of Transobturator Slings and Sling-Related Pain

OBJECTIVES

To determine whether transobturator slings follow a consistent path and whether there is an association between ultrasonographically visualized sling pattern or position with sling-related pain.

METHODS

This was a cross-sectional retrospective pilot study. We evaluated women who were presented to our clinic for pain or other urogynecologic symptoms following transobturator sling placement between 2009 and 2014. Patients had undergone a 3-dimensional endovaginal pelvic floor ultrasound, assessing minimal levator hiatus, antero-posterior diameter, left-right diameter, and the hiatal shape. The mesh patterns were categorized as seagull patterns (normal), lopsided, flat, and convoluted.

RESULTS

A total of 68 cases were reviewed. Fifty patients reported pain, and 18 did not. There were wide variations in the course of the slings. The sling center- minimal levator hiatus position ranged 14.8 mm below and 17.9 mm above the minimal levator hiatus. The lateral arm insertion points ranged between 17.1 mm below and 16.6 mm above the minimal levator hiatus. The right arm insertion points ranged between 9.6 mm below and 18.8 mm above the minimal levator hiatus. Thirty-five of 68 (70%) patients with pain and 13 of 18 (72.2%) without had abnormal sling patterns. The abnormal sling shape was not correlated with pain (P = 1). The levator shape trended toward a statistical significant correlation with sling shape abnormality (P = .084).

CONCLUSIONS

This population of women with transobturator sling complications demonstrated wide variations in anatomic paths. Neither the abnormal sling shape nor the distance of the center of the tape from the minimal levator hiatus level were correlated with pain.

Correlation between pelvic floor ultrasound parameters and vaginal pressures in nulliparous women: a subanalysis of the SUM-AN study

INTRODUCTION AND HYPOTHESIS

Pelvic floor ultrasound is used as a validated technique for measuring levator ani dimensions. Vaginal manometry has been used in the past as a method to assess levator ani muscle (LAM) strength. Whether the combination of both methods can contribute to our understanding of pelvic floor pathophysiology has not yet been described. We hypothesized that as female pelvic floor muscular hiatus increases, the vaginal pressure and strength decrease.

METHODS

We recruited 20 asymptomatic nulliparous women ages 18-85 years. Minimal levator hiatus (MLH) area, anteroposterior/left-right (AP/LR) diameter ratio, the distance between levator plate and the pubic symphysis (LP-PS) while at rest and squeeze were measured using endovaginal ultrasound (US). Vaginal pressure at rest, squeeze (Kegel) and Valsalva were measured using 3D manometry. Logistic and linear regression analysis was performed to assess correlations.

RESULTS

MLH area was negatively correlated with the sum of all the squeeze pressures produced on the four walls of the vagina (p = 0.049, R² = 0.197). There was also a borderline negative correlation between MLH and the sum of rest pressures (p = 0.09, R² = 0.15). AP/LR ratio was negatively correlated with the sum of squeeze pressures (p = 0.056, R² = 0.197). LP-PS distances, both while at rest and during squeeze, were negatively correlated with the vaginal squeeze pressure (p = 0.046, R² = 0.21; p = 0.011, R² = 0.31, respectively). LP-V distance, both at rest and during squeeze, was negatively correlated with the sum of squeeze pressures on four vaginal walls (p = 0.02, R² = 0.25; p = 0.005, R² = 0.36, respectively).

CONCLUSIONS

Stronger levator ani muscles, smaller MLH area and a more oval shape of pelvic floor hiatus as assessed by pelvic floor ultrasound are associated with higher squeeze vaginal pressures as assessed by 3D manometry.

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.

Association between 3D endovaginal and 2D perineal pelvic floor ultrasound findings and symptoms in women presenting with mid-urethral sling complications

OBJECTIVES

To present the characteristics of women attending a tertiary urogynecology pelvic floor scan clinic with mid-urethral sling (MUS) complications and examine the association between patient symptoms and findings on two-dimensional (2D) perineal and three-dimensional (3D) endovaginal ultrasound.

METHODS

This was a cross-sectional study of all women with MUS complications referred to a specialist pelvic floor ultrasound clinic between October 2016 and October 2018. Detailed history was obtained regarding their symptoms and time of onset. All patients underwent 2D perineal and 3D endovaginal ultrasound assessment. The association between patient symptoms and ultrasound findings was evaluated using logistic regression analysis. Only symptomatic women with a single MUS, without other pelvic floor mesh, prior mesh excision or bulking agents, were included in the regression analysis.

RESULTS

A total of 311 women with a history of MUS surgery were seen during the study period. Vaginal and/or non-vaginal pain was reported by 80% of patients and this was the primary presenting complaint in 59% of the patients. One-third of the patients reported symptoms starting within 4 weeks after surgery. The data of 172 patients were included in the regression analysis. MUS position within the rhabdosphincter was significantly associated with voiding dysfunction (odds ratio (OR), 10.6 (95% CI, 2.2-50.9); P = 0.003). Voiding dysfunction was highest in those with C-shaped MUS both at rest and on Valsalva maneuver (OR, 3.2 (95% CI, 1.3-7.6); P < 0.001). MUS position in the distal third of the urethra was significantly associated with a higher rate of recurrent urinary tract infection (OR, 2.9 (95% CI, 1.3-6.3); P = 0.01).

CONCLUSIONS

Pelvic floor ultrasound can provide insight into the position and shape of the MUS, which could explain some patient symptoms and guide management or surgical planning. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The Use of Imaging for Synthetic Midurethral Slings

Ultrasound and magnetic resonance imaging can be used to image midurethral slings, which have may have complications such as pain. There is considerable misunderstanding regarding the utility of the different modalities. This article aims to review the current literature to identify the benefits and limitations of each imaging modality and identify the place that each should have for patients with midurethral sling complications. A literature search was performed, and all relevant articles were identified and reviewed. Different imaging modalities are complementary, but more research is required in this area.

Imaging of Pelvic Floor Reconstruction

Stress urinary incontinence and pelvic organ prolapse are 2 common pelvic floor disorders that are important causes of pelvic pain and disability. Mesh and sling placement are some of the surgical treatment options available for treatment of these conditions. In addition to clinical assessment, imaging plays an important role in managing postoperative patients with complications such as recurrent organ prolapse and chronic pain. Role of high-resolution pelvic magnetic resonance imaging with additional advanced imaging techniques, such as magnetic resonance neurography that are invaluable in managing such patients, are discussed in this article.

In Vivo Ultrasound Characteristics of Vaginal Mesh Kit Complications

OBJECTIVE

The objective of this study was to investigate the ultrasound characteristics of vaginal mesh in women with vaginal mesh complications.

METHODS

This was a cross-sectional study of women presenting with extrusion complications from vaginal mesh kit for prolapse at our tertiary care center between years 2009 and 2014. We included women who concurrently underwent a 3-dimensional endovaginal ultrasound (EVUS) as part of the clinical evaluation. We excluded women with incomplete charts and poor imaging quality. Subjects were categorized by the presence or absence of associated pelvic pain. Based on ultrasound findings, we compared the location of mesh, the appearance of mesh pattern (flat, folding, prominence, convoluted), and other EVUS characteristics of mesh.

RESULTS

Forty-six women with vaginal mesh complications and good image quality were included. When comparing mesh length between posterior and anterior compartments, the posterior meshes were significantly longer than the anterior meshes (42.1 [SD, 11.9] mm vs 25.8 [SD, 9] mm; P < 0.0001) and more often associated with pain. In the posterior compartment, the mean mesh length seen on EVUS was significantly longer in women with pain than in women without pain (46.5 [SD, 9] mm vs 31.8 [SD, 12.1] mm; P = 0.0001). There was also a higher proportion of a "flat" mesh pattern, 14 (58.3%) of 25, in the posterior compartment associated with the presence of pain (P = 0.013). In the posterior compartment, a smaller distance between the distal edge of the mesh and the anal sphincter was significantly associated with the presence of pain (8 mm [0-37] vs 21 mm [8-35], P = 0.024). In both compartments, the EVUS had 100% sensitivity for detection of mesh extrusions.

CONCLUSIONS

In this population of patients presenting with mesh complications, the posterior meshes were more often visualized as a "flat" pattern with a higher frequency of pain. Mesh complications of the anterior compartment had a higher frequency of folding and shrinkage.

Ultrasound Imaging of the Pelvic Floor

This article discusses the background and appraisal of endoluminal ultrasound of the pelvic floor. It provides a detailed anatomic assessment of the muscles and surrounding organs of the pelvic floor. Different anatomic variability and pathology, such as prolapse, fecal incontinence, urinary incontinence, vaginal wall cysts, synthetic implanted material, and pelvic pain, are easily assessed with endoluminal vaginal ultrasound. With pelvic organ prolapse in particular, not only is the prolapse itself seen but the underlying cause related to the anatomic and functional abnormalities of the pelvic floor muscle structures are also visualized.

Female Bladder Outlet Obstruction

The non-specific symptoms the patients express upon the presentation of female bladder outlet obstruction make it a challenge to diagnose. There are subtle differences between the obstructed patient and those whose bladders are underactive and/or fail to mount a detrusor contraction. These disparities can be extracted through a thorough history and examination. At times, the clinician may utilize nomograms, non-invasive uroflow, and urodynamics with the addition of fluoroscopy to establish the diagnosis of obstruction. Management of the obstruction depends on the nature of the condition, whether functional or anatomical. The increase in the number of sling procedures performed to treat stress urinary incontinence has resulted in a rise in the number of iatrogenic obstructions. The temporal relationship between surgery and obstruction is the key to identifying the problem.

Vaginal Mesh in Pelvic Reconstructive Surgery: Controversies, Current Use, and Complications

In 2001, the Food and Drug Administration approved the first surgical mesh product specifically designed for the surgical repair of pelvic organ prolapse and between 2004 and 2008, the use of vaginal mesh in gynecologic surgery was at its peak. Unfortunately, the rise in transvaginal mesh use was accompanied by a surge of adverse events and mesh-related complications. As a result, the Food and Drug Administration put forth several efforts to regulate the manufacturing of vaginal mesh products. These notifications have been supported by several gynecologic societies, and recommendations now exist not only on the placement of mesh and patient selection, but also on the evaluation and management of mesh-related complications. In addition, data on outcomes following management of these complications are now emerging.

Role of ultrasound imaging in advancing treatment of female patients with pelvic floor mesh complications

Application of vaginal mesh for stress urinary incontinence has seen widespread use due to its relatively short operative time in combination with its efficacy in treatment. However, vaginal mesh is not without its drawbacks and can lead to mesh erosion or extrusion, infection, dyspareunia, and recurrence of incontinence. Vaginal mesh complications can lead to feelings of hopelessness, isolation, shame, and emotional distress. Furthermore, failure to identify and address these complications in a timely manner can be permanently damaging to patient health. It is vital to be able to identify mesh complications early. Various imaging methodologies exist to visualize vaginal mesh placement and complications, including ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT). This invited review paper focuses on the role of ultrasound in mesh visualization, mesh complication identification, and operative planning in the event of subsequent surgical mesh revision. Polypropylene mesh is echogenic on ultrasound, making it a useful tool for visualizing post-operative mesh placement. Transperineal, translabial and endovaginal ultrasound technique use has been described in the pre- and peri-operative setting to identify mesh in complex cases. Efficacy and practicality of CT and MRI use in identifying mesh in these cases is limited.

How does 3D endovaginal ultrasound compare to magnetic resonance imaging in the evaluation of levator ani anatomy?

INTRODUCTION AND HYPOTHESIS

To compare magnetic resonance imaging (MRI) to 3D endovaginal ultrasound (EVUS) in the evaluation of major levator ani defects in women with pelvic floor disorders.

METHODS

A total of 21 subjects with pelvic floor with complaints of pelvic floor disorders were included in this study. EVUS imaging of the levator ani muscle (LAM) was performed in all subjects, and the LA muscle groups of interest evaluated were the puboanalis (PA), puborectalis (PR), and pubovisceralis (PV) muscles. The right and left subdivisions were evaluated separately, and classified as (i) normal, normal with only minor irregularities, grossly abnormal, or absent, or (ii) by the levator ani deficiency (LAD) score and classified by no defect (complete attachment of muscle to the pubic bone), <50% detachment or loss, >50% detachment or loss, and completely detached or complete muscle loss. Paired data were analyzed with McNemar's test or Bowker's test of symmetry.

RESULTS

When unilateral LAM subdivisions were classified as "normal," "normal with minor irregularity," "grossly abnormal," and "absent," there were no significant differences between MRI and EVUS by categorization of LAM defects. Comparing "normal" versus "abnormal," there was no difference between imaging modalities. When compared by LAD score evaluation, there were no differences in the categorization of unilateral defects between MRI and EVUS.

CONCLUSIONS

Endovaginal 3D US is comparable to MRI in its ability to identify both normal and abnormal LAM anatomy. Neurourol. Urodynam. 36:409-413, 2017. © 2015 Wiley Periodicals, Inc.

Clinical and ultrasonographic study of patients presenting with transvaginal mesh complications

AIM

The objective of this study was to investigate the clinical and ultrasonographic findings of women who had three-dimensional endovaginal ultrasound (EVUS) for the management of vaginal mesh complications.

METHODS

This was a retrospective study of patients that had EVUS due to mesh complications at a tertiary care center. The clinical charts were reviewed. The stored 3D volumes were reviewed regarding mesh information by two examiners independently. The predictive value of physical examination for detection of vaginal mesh was calculated. Patient outcomes were reviewed.

RESULTS

Seventy-nine patients presented to our center because of their, or their physicians' concern regarding mesh complications. Forty-one (51.9%) had vaginal/pelvic pain, and 51/62 (82.2%) of sexually active women experienced dyspareunia. According to ultrasonographic findings, mesh or sling was not demonstrated in six patients who believed they have had mesh/sling implantation. The positive predictive value for vaginal examination was 94.5% (95% CI: 84.9%-98.8%), negative predictive value was 12.5% (95% CI: 2.8%-32.4%), sensitivity was 72.2% (95% CI: 59.4%-81.2%), and specificity was 50.0% (95% CI: 12.4%-87.6%). Fifty-four patients were indicated for surgical treatment. Median postoperative review was 12 (range, 3-18) months and 38/53 (71.7%) patients were satisfied.

CONCLUSIONS

The most common complaints of vaginal mesh complications were pain and dyspareunia. EVUS appeared to be helpful for assessing mesh presence, location, and extent including planning for surgical intervention.