Visualization of periurethral structures by 3D endovaginal ultrasonography in midsagittal plane is not associated with stress urinary incontinence status

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.

Does aging affect the elastic properties of the bladder and the urethra in nulliparous women: An ultrasound shear-wave elastography study

OBJECTIVE

To investigate how aging and menopausal status in absence of pregnancy and childbirth affect the elasticity of the bladder and urethra.

STUDY DESIGN

A single-center prospective observational study including nulliparous 10 pre- and 12 postmenopausal women. Data collection included baseline characteristics, physical examination data, questionnaire scores, PDFI and the Pelvic Floor Impact Questionnaire, and pelvic floor sonographic measurements as well as elastography measurements. The shear wave elastography (SWE) of tissue was measured using Kilopascal (kPa). The elastography measurements were taken over the rhabdosphincter, the suburethra smooth muscle, and the trigonal areas.

RESULTS

A total of 22 nulliparous subjects were enrolled in the study. The cohort's mean age was 43.5 years, the mean body mass index (BMI) was 26.8, and 86% were of Caucasian ethnicity. The postmenopausal group was older and with higher BMI (p < 0.001 and p = 0.05). They also had higher scores in all the questionnaires (p < 0.05 for all) and did not demonstrate prolapse in any compartments. The SWE results for the whole group were 35.2 kPa in the rhabdosphincter measuring point, 40.2 kPa in the sub-urethra point, and 20.6 kPa in the trigone point. Comparing the premenopause and postmenopause groups, we found lower measurements in the rhabdosphincter area and equivocal measurements for the suburethral zone. No statistically significant differences were found between the groups CONCLUSIONS: The elastic properties of the different bladder components and the urethra change with age and menopause. Using elastic properties of the tissues, we can further explore both stress urinary incontinence and overactive bladder.

Impact of Hysterectomy on Quality of Life, Urinary Incontinence, Sexual Functions and Urethral Length

The aim of the study was to evaluate the influence of different types of hysterectomy on UI symptoms, quality of life and sexual functions using dedicated questionnaires. We investigated a correlation between the urethral length (UL), UI symptoms and the length of the cervix (left after LSH and SH) with sexual functions. The study enrolled 500 consecutive women referred for hysterectomy: 121 underwent VH, 171 underwent LSH, 96 underwent SH, 68 underwent TAH, and 44 underwent TLH. The patients filled in the UI-specific questionnaires and FSFI before and 12 months after hysterectomy. The UL was measured by introital ultrasound before and 12 months after hysterectomy. Before surgery, 137 out of 399 (34.3%) patients had UI symptoms; afterwards, 139 (34.8%) indicated the same (p > 0.05). There was no statistically significant difference in the UL in the patients before and after the procedure, and the cervix length did not differ between patients after LSH and SH. When the entire investigated population was analyzed, a significant improvement of the QoL was found on the IIQ-7. Hysterectomy performed due to benign diseases has effects on UI regardless of the surgical technique used. The UI symptoms improved only in the patients after LSH. The UL measured 12 months after hysterectomy did not change.

3D high frequency endovaginal ultrasound evaluation of urethral and pelvic morphology in stress urinary incontinence in first pregnancy

OBJECTIVE

We aimed to compare the morphological characteristics of pelvis and urethra in nulliparous pregnant women with and without stress urinary incontinence (SUI) by 3D high-frequency endovaginal ultrasound (3D-EVUS).

STUDY DESIGN

At 36-38 weeks of gestation, 40 nulliparous pregnant women with and without SUI underwent 3D-EVUS assessment. The anteroposterior and transverse diameters of levator hiatus (LH), pubovisceral muscle thicknesses at 3,9 and 12 o'clock, right and left paravaginal areas, symphysis angle, bladder-symphysis distance (BSD), uretral complex thickness (Ut), urethral complex width (Uw), urethral complex volume (UV), urethral length (UL), intramural urethra, rhabdosphincter thickness (Rt), rhabdosphincter width (Rw), rhabdosphincter length (RL), and rhabdosphincter volume (RV) were measured by 3D-EVUS.

RESULTS

Longer LH transverse diameter (34.8 ± 3.8 mm vs 31.1 ± 2.1 mm), shorter LH anteroposterior diameter (47.8 ± 6.2 mm vs 52.4 ± 2.6 mm), and wider symphysis angle (116.3 ± 5.6 vs 111.5 ± 5.3 degrees) were detected in nulliparous pregnant women with SUI compared those without SUI (p = 0.001, p = 0.001 and p = 0.013; respectively). RV of less than 1.26 cm³ was found to have a sensitivity of 100 % and a specificity of 100 % for the presence of SUI in nulliparous pregnant women.

CONCLUSIONS

Constitutionally different pelvic shape and decreased urethral rhabdosphincter measurements can be used to predict SUI in nulliparous pregnant women.

Strain Elastography as a New Method for Assessing Pelvic Floor Biomechanics

Strain elastography (SE) is a new technique of parametric imaging that allows quantification of the elasticity of tissue. The aim of our study was to determine if the elasticity of para-urethral tissue correlates with urethral mobility and urinary incontinence (UI). Ninety-nine unselected women were investigated with SE. They were given a standardized interview about UI, and SE raw data for the para-urethral tissue were acquired in a sagittal standard urethra-symphysis view while being stimulated by a coughing fit. We placed one region of interest (ROI A) in the tissue between the urethra and vagina at midlevel of the urethra bordering the urethral wall. The second ROI (ROI B) was set at the level of the os urethra internum in the tissue of the bladder neck in one line to ROI A. We measured elasticity in both ROIs with TDI-Q (Tissue Doppler Imaging-Quantification Software) and calculated the ratio between ROI A and ROI B (A/B). Mobility of the urethra was quantified by measuring the angle between a line parallel to the urethra and a line parallel to the bladder neck during stress and rest. SE analysis was feasible in all cases. A/B was found to be correlated with the incidence of urethral mobility (p < 0.001). The incidence of UI was associated with an increase in urethral mobility (p = 0.04). No correlation between UI and A/B could be shown (p = 0.24). We observed a correlation between urethral mobility and elasticity of the para-urethral tissue. In case of increasing urethral mobility, the para-urethral tissue close to the bladder neck seems to be more elastic, and the patients reported about more symptoms of UI. No noticeable correlation between UI and urethral elasticity was shown. SE may be a useful technique for direct quantification of tissue elasticity and assessment of pelvic floor biomechanics.

Three-dimensional translabial ultrasound assessment of urethral supports and the urethral sphincter complex in stress urinary incontinence

AIMS

The pathophysiological mechanism of incontinence is multifactorial. We evaluated the role of 3D-4D ultrasound in the assessment of the fascial supports of the urethra and the urethral sphincter complex (USC) for diagnosing stress urinary incontinence.

METHODS

Observational case-control study in women with and without stress urinary incontinence attending a urogynecology service and a general gynecology service. All women were interviewed, examined, and classified according to the Pelvic Organ Prolapse Quantification (POP-Q) and underwent a 3D-4D translabial ultrasound. Fascial supports of the urethra were assessed by tomographic ultrasound and were considered to be intact or absent if it was possible to identify them at eight levels on each side, urethral mobility was assessed on maximal Valsalva in sagittal section and the length and volume of the USC at rest and on maximal Valsalva were determined using the Virtual Organ Computer-aided Analysis (VOCAL) program. Variables were compared between continent and incontinent women.

RESULTS

A total of 173 women were examined, 78 continent and 95 incontinent. There was a significant difference in urethral mobility between continent and incontinent women (12.82 mm vs. 21.85 mm, P < 0.001), but there was no significant difference in the percentage of supports affected (43.27% vs. 35.94%, P < 0.070). The length of the USC at rest was significantly shorter (P < 0.001) ​​in incontinent patients.

CONCLUSIONS

Ultrasound evaluation of urethral supports does not discriminate between continent and incontinent women. However, the length of the USC at rest was shorter and urethral mobility was higher in incontinent women. Neurourol. Urodynam. 9999:XX-XX, 2016. © 2016 Wiley Periodicals, Inc.

Is a new high-resolution probe better than the standard probe for 3D anal sphincter and levator ani imaging?

The aim of our study was to determine the accuracy of a new three-dimensional (3D) endoluminal ultrasound probe in assessing the levator ani muscle and anal sphincter complex. A total of 85 patients who had undergone concurrent 3D endovaginal (EVUS) and 3D endoanal (EAUS) ultrasound with both the standard BK 2052 probe and the new high-definition BK 8838 probes were included. For EVUS volumes, the levator ani deficiency (LAD) scores were calculated for each probe. For the EAUS volumes, any defects in the external anal sphincter (EAS) and the internal anal sphincter (IAS) visualized with each probe were recorded. The 3D volumes were evaluated in a blinded fashion. Appropriate statistics were utilized to assess absolute agreements between each pair of imaging modalities. The mean age of the patient population was 59 years (SD ± 10.76), the mean body mass index (BMI) was 28.36 (SD ± 5.99), and the median parity was 2 (range 1, 7). In all, 93% of the patients were Caucasian, 31% had stage 0 or 1 prolapse, while 59% had stage 2 prolapse. The mean total LAD score obtained on EVUS with the standard and the new probes were 11.49 (SD ± 4.94) and 11.53 (SD ± 5.01), respectively, p = 0.3778. Among the 53 patients who had EAUS with both probes, exact agreement for visualization of EAS and IAS for the standard and the new probes was 83% and 98%, respectively. Both transducers can be used for endovaginal imaging of the levator ani muscles interchangeably. Both transducers can be used for endoanal imaging of anal sphincter complex interchangeably.

Is there a correlation between levator ani and urethral sphincter complex status on 3D ultrasonography?

INTRODUCTION AND HYPOTHESIS

To determine the correlation between levator ani deficiency (LAD) and urethral sphincter complex measurements as visualized on 3D endovaginal ultrasonography, and to compare the LAD score with continence status.

METHODS

This was a retrospective analysis of patients seen at our institution between January 2011 and August 2013. Patients were dichotomized into those with urodynamic stress urinary incontinence (SUI) and those with no SUI. Levator ani status was evaluated using a validated scoring system yielding scores of 0 - 6 (normal levator ani/mild LAD), 7 - 12 (moderate LAD), and 13 - 18 (severe LAD). The length, horizontal diameter, and cross-sectional area of the urethra, and the length, width, and the area of the rhabdomyosphincter and smooth muscle sphincter were likewise measured using 3D ultrasound volumes.

RESULTS

Of the 80 patients included, 54 (67.5%) had SUI and 26 (32.5%) were continent. 18 (22.5%) had evidence of mild LAD, 54 (67.5%) had moderate LAD, and 8 (10.0%) had severe LAD. Among patients with SUI, those with normal levator ani muscles or mild LAD had greater urethral smooth muscle width than those with moderate and severe LAD (p = 0.0238). A greater proportion of patients with SUI also had moderate to severe LAD than continent patients (p = 0.0177, OR 3.59, 95% CI 1.21 - 10.65). There was no difference in LAD distribution by type of stress incontinence (presence or absence of intrinsic sphincter deficiency; p =  .2377).

CONCLUSIONS

LAD and urethral sphincter complex status, as visualized on 3D ultrasonography, are independent factors. Moderate to severe LAD is more prevalent in patients with SUI.

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

The objective of this pictorial essay is to emphasize the ability of 3-dimensional endovaginal sonography to image synthetic implanted materials in the female pelvic floor. Implanted materials discussed in this pictorial essay include polypropylene vaginal mesh, polypropylene suburethral slings, and urethral bulking agents. Three-dimensional endovaginal sonography allows for more detailed imaging compared to computed tomography and magnetic resonance imaging of the female pelvic floor, in that each plane can be manipulated to show unique images of synthetic implanted materials.

Both the middle and distal sections of the urethra may be regarded as optimal targets for 'outside-in' transobturator tape placement

Purpose

To investigate whether the position of the tape under the urethra may influence ‘outside-in’ transobturator sling (TOT) outcome.

Methods

The study comprised 141 women who underwent TOT for clinically and urodynamically proved stress urinary incontinence. The postoperative ultrasound examination with an endovaginal biplane probe was performed before discharging the patients from hospital. The measurements obtained described the position of the tape relative to the urethra and pubic symphysis, as well as anatomical relationships in the anterior compartment.

Results

Ninety-six (68.1 %) patients were cured, 27 (19.1 %) significantly improved, and in 18 cases (12.7 %), the surgery failed. The tape position under the midurethra (40–70th percentile of the urethral length) or distal urethra (>70th percentile) coincided with better results (cure rate 67.1 and 82.4 %, respectively) than the location in the proximity of the bladder neck (<40th percentile) (21.4 % cured, p = 0.0015 and p < 0.001, respectively). However, the risk of failure was the lowest when the tape was located under the distal urethra. Other ultrasonographic findings were not related to treatment results.

Conclusions

The highest failure rate for ‘outside-in’ TOT is associated with the location of the tape under the proximal third of the urethra. Both the middle and distal sections of the urethra may be regarded as targets for transobturator tape placement.