Pelvic Floor Ultrasound: A Review

Exploring transvaginal sonographic characteristics of the levator ani muscle in women with postpartum pelvic floor myofascial pain

BACKGROUND

Pelvic floor myofascial pain is one of the pelvic floor dysfunction diseases disturbing women after delivery. There is a lack of objective standardization for the diagnosis of pelvic floor myofascial pain due to the various symptoms and the dependence on the palpating evaluation. Ultrasound imaging has the advantages of safety, simplicity, economy and high resolution, which makes it an ideal tool for the assistant diagnosis of pelvic floor myofascial pain and evaluation after treatment.

METHODS

This is a retrospective case-control study including women accepting evaluation of pelvic floor function at 6 weeks to 1 year postpartum. They were divided into pelvic floor myofascial pain group and normal control group. A BCL 10-5 biplane transducer was applied to observed their puborectalis. The length, minimum width, area, deficiency, deficiency length, deficiency width, deficiency area, rate of deficiency area, local thickening,angle between the tendinous arch of levator ani muscle and puborectalis of corresponding puborectalis in different groups were observed and measured.

RESULTS

A total of 220 postpartum women participated in the study, with 77 in the pelvic floor myofascial pain group and 143 in the normal control group. The Intraclass correlation coefficient value was over 0.750, and Kappa ranged from 0.600 to 0.800. puborectalis deficiency (adjusted odds ratio = 11.625, 95% confidence interval = 4.557-29.658) and focal thickening (adjusted odds ratio = 16.891, 95% confidence interval = 1.819-156.805) were significantly associated with higher odds of having postpartum pelvic floor myofascial pain. Grayscale or the angle between the arch tendineus levator ani and puborectalis measurements on the pain side tended to be smaller than on the non-pain side in patients with unilateral puborectalis or iliococcygeus pain (P < 0.05).

CONCLUSIONS

This study demonstrated that transvaginal ultrasound was a potentially efficient technique for evaluating postpartum pelvic floor myofascial pain due to its ability to assess various sonographic characteristics of the levator ani muscles.

Effects of Pelvic Floor Muscle Physiotherapy on Urinary, Bowel, and Sexual Functions in Women with Deep Infiltrating Endometriosis: A Randomized Controlled Trial

Background and Objectives: Endometriosis is a chronic and recurrent disease defined as the presence and proliferation of endometrial glands and stroma outside the uterine cavity. It affects up to 6-10% of women of reproductive age and can be classified into superficial, ovarian, and deep infiltrating endometriosis (DIE). Deep infiltrating endometriosis can be associated with pain symptoms and pelvic floor muscle hypertone. Moreover, it may be responsible of bowel, urinary, and sexual dysfunctions with impairment of women's quality of life. Few studies have investigated the role of physiotherapy in women with DIE. Here, we aimed first to evaluate the effects of pelvic floor physiotherapy (PFP) on urinary, bowel, and sexual functions. Secondly, we aimed to evaluate the effects of ultrasound visual feedback during PFP on pelvic floor and subjective modifications in the frequency of sexual intercourse. Materials and Methods: This randomized controlled trial was conducted between June 2018 and December 2019 at our tertiary center. Nulliparous women with DIE and superficial dyspareunia were enrolled. At first examination, levator hiatal area (LHA) assessed with 3D/4D transperineal ultrasound, pain symptoms, urinary, bowel, and sexual functions were evaluated. Then, women were randomly assigned to no intervention (control group) or treatment with five individual sessions of PFP (experimental group), and after four months women underwent a second examination. Urinary, bowel, and sexual functions were assessed with validated questionnaires at first and second examinations. In particular, the Bristol Female Lower Urinary Tract Symptoms questionnaire was used to evaluate urinary symptoms, the Knowles-Eccersley-Scott-Symptom questionnaire to assess the presence of constipation, and the Female Sexual Function Index to investigate sexual function. Study outcomes were the comparisons among groups in terms of differences in actual changes in median of questionnaire scores between first and second examinations. Results: Thirty women (17 in the experimental group and 13 in the control group) completed the study. No significant differences were found between the two groups regarding urinary, bowel, and sexual functions, although women in the experimental group showed a tendency towards an improvement in constipation symptoms. Conclusion: In women with DIE, PFP does not appear to affect urinary, bowel, and sexual functions. Therefore, despite the improvement in superficial dyspareunia, chronic pelvic pain, and PFM relaxation with high treatment satisfaction, women should be informed about the unclear impact of PFP on urinary, bowel, and sexual functions. Larger studies are necessary to further investigate the impact of PFP on these functions.

Correlation between clinical examination and perineal ultrasound in women treated for pelvic organ prolapse

INTRODUCTION

Lifetime risk of surgery for female pelvic organ prolapse (FPOP) is estimated at 10 to 20%. Prolapse assessment is mostly done by clinical examination. Perineal ultrasound is easily available and performed to evaluate and stage FPOP. This study's aim is to evaluate the agreement between clinical examination by POP-Q and perineal sonography in women presenting pelvic organ prolapse.

MATERIALS AND METHODS

We carried out a prospective study from December 2015 to March 2018 in the gynecologic department of a teaching hospital. Consecutive woman requiring a surgery for pelvic organ prolapse were included. All women underwent clinical examination by POP-Q, perineal ultrasound with measurements of each compartment descent, levator hiatus area and posterior perineal angle. They also answered several functional questionnaires (PFDI 20, PFIQ7, EQ-5D and PISQ12) before and after surgery. Data for clinical and sonographic assessments were compared with Spearman's test and correlation with functional questionnaires was tested.

RESULTS

82 women were included. We found no significant agreement between POP-Q and sonographic measures of bladder prolapse, surface of the perineal hiatus or perineal posterior angle. There was a significant improvement of most of the functional scores after surgery.

DISCUSSION

Our study does not suggest correlation between clinical POP-Q and sonographic assessment of bladder prolapse, hiatus surface or perineal posterior angle. Ultrasound datasets were limited by an important number of missing data resulting in a lack of power.

[Imaging of the pelvic floor : The gynaecological perspective]

BACKGROUND

Pelvic floor dysfunction is common in women.

OBJECTIVES

To describe the role of ultrasound in the urogynecological examination and imaging of the pelvic floor.

MATERIALS AND METHODS

Analysis and summary of current recommendations and literature on the role of pelvic floor ultrasound.

RESULTS

Pelvic floor ultrasound is a dynamic and real-time imaging modality. It is readily available, allows for a realistic assessment of anatomy and morphology, and poses minimal patient burden.

CONCLUSIONS

Pelvic floor ultrasound is of great value in preoperative diagnostics as well as in the postoperative management of complications.

An evaluation of cervical maturity for Chinese women with labor induction by machine learning and ultrasound images

BACKGROUND

To evaluate the improvement of evaluation accuracy of cervical maturity for Chinese women with labor induction by adding objective ultrasound data and machine learning models to the existing traditional Bishop method.

METHODS

The machine learning model was trained and tested using 101 sets of data from pregnant women who were examined and had their delivery in Peking University Third Hospital in between December 2019 and January 2021. The inputs of the model included cervical length, Bishop score, angle, age, induced labor time, measurement time (MT), measurement time to induced labor time (MTILT), method of induced labor, and primiparity/multiparity. The output of the model is the predicted time from induced labor to labor. Our experiments analyzed the effectiveness of three machine learning models: XGBoost, CatBoost and RF(Random forest). we consider the root-mean-squared error (RMSE) and the mean absolute error (MAE) as the criterion to evaluate the accuracy of the model. Difference was compared using t-test on RMSE between the machine learning model and the traditional Bishop score.

RESULTS

The mean absolute error of the prediction result of Bishop scoring method was 19.45 h, and the RMSE was 24.56 h. The prediction error of machine learning model was lower than the Bishop score method. Among the three machine learning models, the MAE of the model with the best prediction effect was 13.49 h and the RMSE was 16.98 h. After selection of feature the prediction accuracy of the XGBoost and RF was slightly improved. After feature selection and artificially removing the Bishop score, the prediction accuracy of the three models decreased slightly. The best model was XGBoost (p = 0.0017). The p-value of the other two models was < 0.01.

CONCLUSION

In the evaluation of cervical maturity, the results of machine learning method are more objective and significantly accurate compared with the traditional Bishop scoring method. The machine learning method is a better predictor of cervical maturity than the traditional Bishop method.

An Evaluation of the Effects of Gestational Weight Gain on the Early Postpartum Pelvic Floor Using Transperineal Ultrasound

OBJECTIVES

We herein evaluated the effects of gestational weight gain (GWG) on postpartum pelvic floor function using transperineal ultrasound (TPUS).

METHODS

We analyzed retrospectively the data from 228 primiparous women with singleton pregnancies who were evaluated for postpartum pelvic floor function between February 2022 and October 2022. According to the 2009 Institute of Medicine guidelines regarding GWG, subjects were separated into three groups: inadequate GWG, recommended GWG, and excessive GWG. All underwent TPUS 6-10 weeks postpartum to assess bladder neck descent between rest and Valsalva (BND), retrovesical angle at Valsalva (RVA), urethral rotation angle between rest and Valsalva (URA), the area of levator hiatus at Valsalva (LHA), and abnormal pelvic floor function. Univariate and multivariate regression analyses were applied to explore the association measures between GWG and the pelvic floor. A P-value <.05 was considered statistically significant.

RESULTS

Of the 228 primiparous women, 113 (49.6%) showed excessive GWG. Univariate analysis revealed that there were no statistical differences in ultrasonic parameters of the pelvic floor among the three groups (P > .05). After adjusting for potential confounders and using the recommended GWG group as a reference group, inadequate GWG was significantly associated with BND ≥25 mm (OR = 0.36, 95% CI = 0.14-0.93), and excessive GWG was significantly associated with uterine prolapse (OR = 2.79, 95% CI = 1.13-6.92).

CONCLUSIONS

GWG was associated with the ultrasonic parameters of the female pelvic floor in the early postpartum period.

The role of Gestational Diabetes Mellitus and pelvic floor 3D-ultrasound assessment during pregnancy predicting urinary incontinence: a prospective cohort study

Postpartum urinary incontinence may have a severe impact on women's health. Despite pregnancy and parturition being the most recognized risk factors, methods to identify new pregnant predictor risk factors are needed. Our study investigated the Gestational Diabetes Mellitus, clinical and pelvic floor 3D-ultrasound markers in pregnant women as predictors for 6-18 months of urinary incontinence. This prospective cohort study included nulliparous pregnant women submitted to Gestational Diabetes Mellitus screening in the second trimester. Pelvic floor 3D Ultrasound was performed at the second and third trimesters of gestation to evaluate the pelvic floor muscles and functions. Clinical data, the ICIQ-SF, and ISI questionnaires for urinary incontinence were applied in the third trimester and 6-18 months postpartum. Univariate analysis (P < .20) to extract risk factors variables and multivariate logistic regression analysis (P < .05) to obtain the adjusted relative ratio for urinary incontinence were performed. A total of 93 participants concluded the follow-up. Using the variables obtained by univariate analysis and after adjustments for potential confounders, multivariate analysis revealed that Gestational Diabetes Mellitus exposure was a solid and independent risk factor for 6-18 months of urinary incontinence (Adjusted RR 8.08; 95%CI 1.17-55.87; P:0.034). In addition, a higher Hiatal area observed in distension maneuver from the second to third trimester was negatively associated (Adjusted RR 0.96; 95%CI 0.93-0.99; P:0.023). In conclusion, Gestational Diabetes Mellitus was positively associated with 6-18 months of urinary incontinence, and higher Hiatal area distension was negatively associated.

The effect of prolapse surgery on voiding function

INTRODUCTION AND HYPOTHESIS

Of women with symptomatic prolapse, 13-39% experience voiding dysfunction (VD). The aim of our observational cohort study was to determine the effect of prolapse surgery on voiding function.

METHODS

Retrospective analysis of 392 women who underwent surgery between May 2005 and August 2020. All had a standardized interview, POP-Q, uroflowmetry and 3D/4D transperineal ultrasound (TPUS) pre-and postoperatively. Primary outcome was change in VD symptoms. Secondary outcomes were changes in maximum urinary flow rate (MFR) centile and post-void residual urine (PVR). Explanatory measures were change in pelvic organ descent as seen on POP-Q and TPUS.

RESULTS

Of 392 women, 81 were excluded due to missing data, leaving 311. Mean age and BMI were 58 years and 30 kg/m2, respectively. Procedures performed included anterior repair (n = 187, 60.1%), posterior repair (n = 245, 78.8%), vaginal hysterectomy (n = 85, 27.3%), sacrospinous colpopexy (n = 170, 54.7%) and mid-urethral sling (MUS) (n = 192, 61.7%). Mean follow-up was 7 (1-61) months. Pre-operatively, 135 (43.3%) women reported symptoms of VD. Postoperatively, this decreased to 69 (22.2%) (p < 0.001), and of those, 32 (10.3%) reported de novo VD. The difference remained significant after excluding concomitant MUS surgery (n = 119, p < 0.001). Postoperatively, there was a significant decrease in mean PVR (n = 311, p < 0.001). After excluding concomitant MUS surgery, there was a significant increase in mean MFR centile (p = 0.046).

CONCLUSIONS

Prolapse repair significantly reduces symptoms of VD and improves PVR and flowmetry.

Validation of an automatic method for reconstruction, delineation, and measurement of levator hiatus in clinical practice

OBJECTIVES

To evaluate the concordance between an automatic software program and manual evaluation in reconstructing, delineating, and measuring the levator hiatus (LH) on maximal Valsalva maneuver.

METHODS

This was a retrospective study analyzing archived raw ultrasound imaging data of 100 patients underwent transperineal ultrasound (TPUS) examination. Each data were assessed by the automatic Smart Pelvic System software program and manual evaluation. The Dice similarity index (DSI), mean absolute distance (MAD), and Hausdorff distance (HDD) were calculated to quantify delineation accuracy of LH. Agreement between automatic and manual measurement of levator hiatus area was assessed by intraclass correlation coefficient (ICC) and Bland-Altman method.

RESULTS

The satisfaction rate of automatic reconstruction was 94%. Six images were recognized as unsatisfactory reconstructed images for some gas in the rectum and anal canal. Compared with satisfactory reconstructed images, DSI of unsatisfactory reconstructed images was lower, MAD and HDD were larger (p = 0.001, p = 0.001, p = 0.006, respectively). The ICC was up to 0.987 in 94 satisfactory reconstructed images.

CONCLUSIONS

The Smart Pelvic System software program had good performance in reconstruction, delineation, and measurement of LH on maximal Valsalva maneuver in clinical practice, despite misidentification of the border of posterior aspect of LH due to the influence of gas in the rectum.

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.

Is posterior compartment prolapse associated with anal incontinence?

OBJECTIVE

It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI), but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate this association in women with intact anal sphincter presenting with pelvic floor dysfunction.

METHODS

This retrospective study analyzed 1133 women with intact anal sphincter presenting to a tertiary urogynecological center for pelvic floor dysfunction between 2014 and 2016. All women underwent a standardized interview, including assessment of symptoms of AI, clinical examination and three-/four-dimensional transperineal ultrasound. Descent of the rectal ampulla, true rectocele, enterocele, intussusception and anal sphincter trauma were diagnosed offline.

RESULTS

Mean age was 54.1 (range, 17.6-89.7) years and mean body mass index was 29.4 (range, 14.7-67.8) kg/m2 . AI was reported by 149 (13%) patients, with a median St Mark's anal incontinence score of 12 (interquartile range, 1-23). Significant posterior compartment prolapse was seen in 693 (61%) women on clinical examination. Overall, 638 (56%) women had posterior compartment prolapse on imaging: 527 (47%) had a true rectocele, 89 (7.9%) had an enterocele and 26 (2.3%) had an intussusception. Women with ultrasound-diagnosed enterocele had a significantly higher rate of AI (23.6% vs 12.3%; odds ratio (OR), 2.21 (95% CI, 1.31-3.72); P = 0.002), but when adjusted for potential confounders, this association was no longer significant (OR, 1.56 (95% CI, 0.82-2.77); P = 0.134).

CONCLUSION

In women without anal sphincter trauma, posterior compartment prolapse, whether diagnosed clinically or by imaging, was not shown to be associated with AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Is there a difference in pelvic floor muscle tone between women with and without pelvic pain? A systematic review and meta-analysis

BACKGROUND

Alterations in pelvic floor muscle (PFM) function have been observed in women with persistent noncancer pelvic pain (PNCPP) as compared with women without PNCPP; however, the literature presents conflicting findings regarding differences in PFM tone between women with and without PNCPP.

AIM

To systematically review the literature comparing PFM tone in women with and without PNCPP.

METHODS

MEDLINE, Embase, Emcare, CINAHL, PsycINFO, and Scopus were searched from inception to June 2021 for relevant studies. Studies were included that reported PFM tone data in women aged ≥18 years with and without PNCPP. The risk of bias was assessed with the National Heart, Lung, and Blood Institute Quality Assessment Tool. Standardized mean differences (SMDs) for PFM tone measures were calculated via random effects models.

OUTCOMES

Resting PFM tone parameters, including myoelectrical activity, resistance, morphometry, stiffness, flexibility, relaxation, and intravaginal pressure, measured by any clinical examination method or tool.

RESULTS

Twenty-one studies met the inclusion criteria. Seven PFM tone parameters were measured. Meta-analyses were conducted for myoelectrical activity, resistance, and anterior-posterior diameter of the levator hiatus. Myoelectrical activity and resistance were higher in women with PNCPP than in women without (SMD = 1.32 [95% CI, 0.36-2.29] and SMD = 2.05 [95% CI, 1.03-3.06], respectively). Women with PNCPP also had a smaller anterior-posterior diameter of the levator hiatus as compared with women without (SMD = -0.34 [95% CI, -0.51 to -0.16]). Meta-analyses were not performed for the remaining PFM tone parameters due to an insufficient number of studies; however, results of these studies suggested greater PFM stiffness and reduced PFM flexibility in women with PNCPP than in women without.

CLINICAL IMPLICATIONS

Available evidence suggests that women with PNCPP have increased PFM tone, which could be targeted by treatments.

STRENGTHS AND LIMITATIONS

A comprehensive search strategy was used with no restriction on language or date to review studies evaluating PFM tone parameters between women with and without PNCPP. However, meta-analyses were not undertaken for all parameters because few included studies measured the same PFM tone properties. There was variability in the methods used to assess PFM tone, all of which have some limitations.

CONCLUSION

Women with PNCPP have higher PFM tone than women without PNCPP; therefore, future research is required to understand the strength of the relationship between pelvic pain and PFM tone and to investigate the effect of treatment modalities to reduce PFM tone on pelvic pain in this population.

Application of transperineal ultrasound combined with shear wave elastography in pelvic floor function assessment after hysterectomy

This study explored the application of transperineal ultrasound (TPUS) combined with shear wave elastography (SWE) in evaluating the pelvic structure function of women after total hysterectomy. Seventy healthy women and 76 women who underwent total hysterectomy were selected for ultrasound examination. They were divided into normal (nulliparous) group, (parous) group without hysterectomy, and (parous) group with hysterectomy. TPUS combined with SWE was used to evaluate the pelvic floor structure and function in the 3 groups of women. Posterior urethrovesical angle in resting and maximal Valsalva state, anteroposterior diameter of hiatus in the 3 states, the bladder neck descent, the urethral rotation angle, the Young modulus of left and right puborectalisis muscle in resting state, and the incidence of pelvic floor dysfunction diseases were all higher in the group with hysterectomy than in the group without hysterectomy (P < .05). Bladder neck-symphyseal distance and anorectal junction-symphyseal distance in the maximum Valsalva state, and the difference in Young modulus between the left and right PR before and after anus contraction were all lower in the group with hysterectomy than the group without hysterectomy (P < .05). The incidence of pelvic floor dysfunction in postmenopausal patients in the group with hysterectomy was higher than that in premenopausal patients (P < .05). Total hysterectomy had negative effects on female pelvic floor structure and function. TPUS combined with SWE can be used to evaluate pelvic floor function in multiple dimensions.

Assessment of Pelvic Floor Disorders due to the Gestational Diabetes Mellitus Using Three-Dimensional Ultrasonography: A Narrative Review

Gestational diabetes mellitus (GDM)is an entity with evolving conceptual nuances that deserve full consideration. Gestational diabetes leads to complications and adverse effects on the mother's and infants' health during and after pregnancy. Women also have a higher prevalence of urinary incontinence (UI) related to the hyperglycemic status during pregnancy. However, the exact pathophysiological mechanism is still uncertain. We conducted a narrative review discussing the impact of GDM on the women's pelvic floor and performed image assessment using three-dimensional ultrasonography to evaluate and predict future UI.

Automatic Plane of Minimal Hiatal Dimensions Extraction From 3D Female Pelvic Floor Ultrasound

There is an increasing interest in the applications of 3D ultrasound imaging of the pelvic floor to improve the diagnosis, treatment, and surgical planning of female pelvic floor dysfunction (PFD). Pelvic floor biometrics are obtained on an oblique image plane known as the plane of minimal hiatal dimensions (PMHD). Identifying this plane requires the detection of two anatomical landmarks, the pubic symphysis and anorectal angle. The manual detection of the anatomical landmarks and the PMHD in 3D pelvic ultrasound requires expert knowledge of the pelvic floor anatomy, and is challenging, time-consuming, and subject to human error. These challenges have hindered the adoption of such quantitative analysis in the clinic. This work presents an automatic approach to identify the anatomical landmarks and extract the PMHD from 3D pelvic ultrasound volumes. To demonstrate clinical utility and a complete automated clinical task, an automatic segmentation of the levator-ani muscle on the extracted PMHD images was also performed. Experiments using 73 test images of patients during a pelvic muscle resting state showed that this algorithm has the capability to accurately identify the PMHD with an average Dice of 0.89 and an average mean boundary distance of 2.25mm. Further evaluation of the PMHD detection algorithm using 35 images of patients performing pelvic muscle contraction resulted in an average Dice of 0.88 and an average mean boundary distance of 2.75mm. This work had the potential to pave the way towards the adoption of ultrasound in the clinic and development of personalized treatment for PFD.

Three-Dimensional Ultrasound Evaluation of Pelvic Floor Muscle Contraction in Women Affected by Deep Infiltrating Endometriosis: Application of a Quick Contraction Scale

OBJECTIVES

Using transperineal 3D/4D ultrasound, we evaluated the prevalence of the various categories of a 4-point pelvic contraction scale among women affected by ovarian endometriosis (OE), deep infiltrating endometriosis (DIE), and healthy controls.

METHODS

This prospective study was conducted on nulliparous women scheduled for surgery to remove endometriosis, and nulliparous healthy volunteers who did not show any clinical or sonographic signs of endometriosis, who served as controls. Patients were subjected to 3D/4D transperineal ultrasound obtaining measurements of the antero-posterior diameter (APD), both at rest and during maximal pelvic floor muscle (PFM) contraction (PFMC). The difference of APD from rest to maximal PFMC was then calculated as percent change from baseline (ΔAPD) and patients were thus categorized using the 4-point pelvic contraction scale.

RESULTS

One hundred sixty-four patients were considered for the study. Mean difference in APD between relaxed state and maximal PFMC was 23.3 ± 7.9% (range 2.4-40.0) in controls, 20.5 ± 9.0% (range 0.0-37.3) in patients with OE, and 14.6 ± 10.4% (range 0.0-37.1) in patients with DIE (F-test = 19.5, P-value < .001). A significant negative correlation was found between the contraction scale and dyspareunia (rs = -0.17, P = .032), and it appeared to be stronger among patients with DIE (rs = -0.20, P = .076).

CONCLUSIONS

PFM function in endometriotic patients could be assessed reliably through this 4-point scale. The rapid identification of women suffering from PFM dysfunction, along with deep dyspareunia, could enable gynecologists to offer them additional therapies, such as PFM rehabilitation.

Translabial Ultrasound: An Effective Modality for Evaluation of Midurethral Sling Revision

ABSTRACT

Midurethral sling (MUS) surgical procedures, in which a polypropylene synthetic mesh graft is transvaginally placed to support the urethra and manage stress urinary incontinence (SUI), is commonly performed ( Urology. 2013;82(1):38-41; Radiology. 2018;289(3):728-729). Within 10 years of sling placement, about 1 in 20 women undergo subsequent surgery to revise their mesh, in which the mesh is cut or partially excised ( Obstet Gynecol . 2019;133:1099-1108). Translabial ultrasound (TLUS) has been described as a sensitive technique for viewing MUS, although few studies have evaluated its ability to view surgically revised MUS ( Radiology . 2018;289(3):721-727). Understanding the anatomy of the MUS is critical to urologists and urogynecologists striving to optimize management of patients presenting with lower urinary tract symptoms and history of MUS. To assess the clinical utility and reliability of TLUS as a diagnostic tool in its detection of MUS discontinuity, we conducted a retrospective analysis on patients who underwent TLUS at a tertiary care center between September 2017 and May 2020 for indication of lower urinary tract symptoms and history of MUS placement. Performance of TLUS was evaluated by comparing findings with operative or clinical records. Among the 81 women included, detection of MUS revision, which was defined as a discontinuity in sling material, had a sensitivity of 84.6% and specificity of 97.1%. Translabial ultrasound is an inexpensive, nonirradiating, and noninvasive modality that is effective at visualizing MUSs. It is a reliable identifier of previous MUS revision, in which it detects a midline discontinuity of the hyperechoic mesh with an average 10 mm gap.

Automatic identification and segmentation of slice of minimal hiatal dimensions in transperineal ultrasound volumes

OBJECTIVE

To develop and validate a tool for automatic selection of the slice of minimal hiatal dimensions (SMHD) and segmentation of the urogenital hiatus (UH) in transperineal ultrasound (TPUS) volumes.

METHODS

Manual selection of the SMHD and segmentation of the UH was performed in TPUS volumes of 116 women with symptomatic pelvic organ prolapse (POP). These data were used to train two deep-learning algorithms. The first algorithm was trained to provide an estimation of the position of the SMHD. Based on this estimation, a slice was selected and fed into the second algorithm, which performed automatic segmentation of the UH. From this segmentation, measurements of the UH area (UHA), anteroposterior diameter (APD) and coronal diameter (CD) were computed automatically. The mean absolute distance between manually and automatically selected SMHD, the overlap (dice similarity index (DSI)) between manual and automatic UH segmentation and the intraclass correlation coefficient (ICC) between manual and automatic UH measurements were assessed on a test set of 30 TPUS volumes.

RESULTS

The mean absolute distance between manually and automatically selected SMHD was 0.20 cm. All DSI values between manual and automatic UH segmentations were above 0.85. The ICC values between manual and automatic UH measurements were 0.94 (95% CI, 0.87-0.97) for UHA, 0.92 (95% CI, 0.78-0.97) for APD and 0.82 (95% CI, 0.66-0.91) for CD, demonstrating excellent agreement.

CONCLUSIONS

Our deep-learning algorithms allowed reliable automatic selection of the SMHD and UH segmentation in TPUS volumes of women with symptomatic POP. These algorithms can be implemented in the software of TPUS machines, thus reducing clinical analysis time and simplifying the examination of TPUS data for research and clinical purposes. © 2021 The Authors. Ultrasound in Obstetrics &amp; Gynecology published by John Wiley &amp; Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

3D Ultrasound in Pelvic Floor: Is It Useful as a Prognostic Tool in Type of Labor Development and Subsequent Pelvic Floor Diseases?

The objective of our study is to determine the thickness of the pubovisceral fasciculus of the levator ani muscle and the area of the genital hiatus by means of three-dimensional perineal ultrasound, in pregnant women in the 2nd trimester, and to analyze the related maternal, perinatal and postpartum clinical variables. Furthermore, to compare the results of our study with two similar series previously published. An observational, prospective study of pelvic floor ultrasound was carried out, performed at week 20, whose delivery was attended in the obstetrics service of the Hospital General Universitario Gregorio Marañón de Madrid (HGUGM), during the period of August from 2021 to June 2022. Maternal, ultrasound, perinatal and postpartum clinical variables were collected from each participant. During the study period, a total of 54 patients were included in it. The mean gestational age at which the ultrasound was performed was 19.81 ± 0.91 weeks. In relation to the ultrasound variables, the mean thickness of the pubovisceral muscle was 0.87 ± 0.13 cm (95% CI, 0.64-1.38 cm), while, in the plane of minimum dimension of the genital hiatus, the hiatal area at rest was 13.41 ± 3.22 (95% CI, 4.60-18.78) cm². There is a significant correlation between the age of pregnant women (over 35 years of age) and the increase in the area of the genital hiatus (r = 0.295, p = 0.031). 3D ultrasound of the pelvic floor performed at week 20 of gestation can to be an effective, non-invasive, reproducible and cheap tool in the prognosis of the development of labor and of possible subsequent perineal dysfunctions.

Imaging Characteristics of Episiotomy Scars on Translabial Ultrasound: An Observational Study

INTRODUCTION

Episiotomy has been purported to protect the anal sphincter from injury; efficacy is, however, disputed. Correct execution of episiotomy may have substantial implications. We aimed to describe the characteristics of episiotomy scars on translabial ultrasound (TLUS).

METHODS

In this retrospective observational study involving women after repair of obstetric anal sphincter injuries, 76 women with a history of episiotomy were analyzed. Episiotomy scars were assessed on tomographic ultrasound in the transverse plane using volumes acquired on pelvic floor muscle contraction. We measured scar length, depth, and angle relative to a vertical reference line. Episiotomy scars were described as 1) ipsilateral if they started on the same side as the direction of the episiotomy, 2) contralateral if on the opposite side, and 3) mediolateral if the scar began in the midline.

RESULTS

The mean scar angle was 50.5° (SD 14°; range 14.4°-79.3°) while mean scar length was 14.2 mm (SD 4.5; range 5.7-27.5 mm) and depth was 8.4 mm (SD 2.8, range 3.1-18.2 mm). Sixteen (21%) scars were located mediolateral while 32 (42%) were ipsilateral. In 28 (37%) women, the starting point of the episiotomy was located contralateral to the direction of the episiotomy.

CONCLUSION

In this pilot series, the mean angle of episiotomy scars was within the safe zone of 40° to 60°, however, in one-third of cases the cut may have been initially directed toward the sphincter, not away from it. This observation suggests that not all episiotomies are performed optimally.

When to assess residual anal sphincter defect after OASI by ultrasound

OBJECTIVES

Obstetrical anal sphincter injuries (OASIS) are complications of vaginal delivery. Unrepaired anal sphincter after delivery increases the risk of anal incontinence. The aim of our study is to search for residual defect after OASI repair by 4D introital ultrasound (US). We hypothesised that imaging prior to hospital discharge would show the same number of defects as assessment at 3 months.

STUDY DESIGN

This is a retrospective analysis of 138 patients with immediate repair after OASIS. Since 2009, we have been routinely inviting all our patients with OASIS to the perineal clinic for postoperative follow-up. We scheduled the first visit before discharge from hospital and followed up with a second visit after three months. During both visits, patients underwent transperineal 4D ultrasound examination. We provided examination while at rest and during contraction; volumes were saved for further evaluation.

RESULTS

Eighty-one patients (58.7%) completed both exams and were included in the analysis. Residual external anal sphincter defect was found in 17.3% at the first visit versus 13.6% at the second (delayed) visit. We were not able to assess the sphincter in 9.9% at early versus none in the delayed examination. In 9.9%, the residual defect was not confirmed by the second examination, and in 4.9% the residual defect was missed by the first examination.

CONCLUSIONS

In conclusion, we have found that a 3 month scan yields a smaller number of defects than a scan before discharge.

Is age at menarche a predictor of maternal birth trauma?

OBJECTIVE

Age at menarche and the interval between menarche and age at first vaginal birth have been shown to be associated with reproductive performance; however, their association with maternal birth trauma has not been studied. We aimed to determine whether age at menarche, age at first vaginal birth and their interval are associated independently with levator ani muscle (LAM) avulsion and external anal sphincter (EAS) defect.

METHODS

This was a retrospective analysis of the ultrasound volume datasets of 466 vaginally parous patients attending one of two tertiary urogynecological units in Australia. All patients had undergone a standardized interview and clinical examination using the pelvic organ prolapse quantification staging system, followed by four-dimensional translabial ultrasound. Tomographic ultrasound imaging was used to evaluate the LAM for avulsion and the EAS for significant defect.

RESULTS

Of the 466 women analyzed, LAM avulsion was diagnosed in 121 (26.0%) and significant EAS defect in 55 (11.8%). Logistic regression analysis showed no association between age at menarche and LAM avulsion (P = 0.67). Weak but significant associations were noted between LAM avulsion and age at first vaginal birth (odds ratio (OR), 1.070 (95% CI, 1.03-1.11); P = 0.0007) and between LAM avulsion and menarche-to-first-vaginal-birth interval (OR, 1.064 (95% CI, 1.02-1.11); P = 0.0018). No significant associations were noted between significant EAS defect and any of the evaluated variables (all P ≥ 0.49).

CONCLUSIONS

Age at menarche is not predictive of maternal birth trauma i.e. LAM avulsion and EAS residual defect. There was a statistically significant association between LAM avulsion and menarche-to-first-vaginal-birth interval; however, this was not stronger than the previously established association between LAM avulsion and age at first vaginal birth, arguing against any distinct effect of prolonged prepregnancy hormonal stimulation on the biomechanical properties of the pelvic floor. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

The Association of Hiatal Dimensions and Urethral Mobility With Stress Urinary Incontinence

OBJECTIVES

To investigate the association of hiatal area (HA), bladder neck mobility, and urethral mobility during the cough stress test (CST) with stress urinary incontinence (SUI).

METHODS

This was a prospective study of 110 continent and 190 incontinent women using transperineal ultrasound. HA, bladder neck mobility, and the mobility of six points along the urethra (Vectors 1-6) were measured. The cohort was randomly divided at a ratio of 2:1 into a training cohort and a validation cohort. The correlations of HA with bladder neck mobility, urethral mobility, and SUI were tested. The predictive model was yielded by fisher linear discriminant analysis and receiver operating characteristics to assess the parameters' ability to predict SUI.

RESULTS

Valid data were collected from 177 incontinent women and 105 continent women. Significant differences were identified in HA, body mass index (BMI), funneling, bladder neck mobility, and Vectors 1-6 between them. HA was positively correlated to bladder neck mobility. In the training cohort, bladder neck position on Valsalva, Vectors 3, and BMI had the area under curves of 0.74, 0.69, and 0.66 (all P < 0.001); Funneling and Vector 3 had odds ratios of 18.96 and 3.65 (all P < 0.001), for predicting SUI. The predictive model incorporating funneling, Vectors 3, and BMI provided the best performance in predicting SUI in both cohorts.

CONCLUSION

The larger the HA was, the higher the bladder neck mobility. However, it was mid-urethral mobility rather than bladder neck mobility that performed best at predicting SUI.

Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is defined as the descent of one or more of the anterior and posterior vaginal walls, uterus (cervix), or apex of the vagina (vaginal vault or cuff scar after hysterectomy). Although POP can be asymptomatic, if the bulge extends beyond the opening of the vagina, it can have a significant impact on a woman's quality of life. Findings include vaginal bulging toward or through the vaginal introitus that the patient may feel, palpate, or see with a mirror. If a woman is bothered by her prolapse, she should be offered both nonsurgical and surgical treatments.

Pelvic organ prolapse in nulliparae

Background

Pregnancy and childbirth are thought to be the strongest environmental risk factors for pelvic organ prolapse, but prolapse does occur in nulliparae.

Aim

To characterise prolapse in vaginal nulliparae.

Material and methods

This was a retrospective study using archived clinical and imaging data of 368 vaginally nulliparous women seen between 2006 and 2017 at two tertiary urogynaecological centres. Patients underwent a standardised interview, clinical examination and 3D/4D translabial ultrasound. Volume datasets were analysed by the second author, blinded against all clinical data, using post‐processing software on a personal computer. Significant prolapse was defined as Pelvic Organ Prolapse Quantification system stage ≥2 for the anterior and posterior compartment, and stage ≥1 for the central compartment. On imaging, significant prolapse was defined as previously described.

Results

Of 4297 women seen during the inclusion period, 409 were vaginally nulliparous, for whom 368 volume data sets could be retrieved. Mean age was 50 years (17–89) and mean body mass index 29 (16–64). Eighty‐one (22%) presented with prolapse symptoms. On clinical examination, 106 women (29%) had significant prolapse, mostly of the posterior compartment (n = 70, 19%). On imaging 64 women showed evidence of significant prolapse (17%), again mostly posterior (n = 47, 13%). Rectovaginal septal defects were even more common in 69 (19%). On multivariate analysis we found no differences between true nulliparae (n = 184) and women delivered exclusively by caesarean section (n = 184).

Conclusions

Prolapse occurs in vaginal nulliparae, but it has distinct characteristics. Rectocele predominates, while cystocele and uterine prolapse are uncommon. Pregnancy and caesarean delivery seem to have little effect.

Point of care ultrasound in pelvic health: scope of practice, education and governance for physiotherapists

Pelvic health and pelvic floor dysfunction have wide-reaching implications across a range of patient groups. Placing ultrasound imaging into the hands of assessing and treating clinicians (i.e. point of care ultrasound, PoCUS) can provide a step change in clinical effectiveness and efficiency. Pelvic floor dysfunction is managed by one or more members of a multi-disciplinary team that includes physiotherapists. Physiotherapists' involvement includes diagnosis, patient education, identifying shared treatment goals, using rehabilitative strategies and empowering patients through self-management. Drawing upon existing publications in this area and applying framework principles, the authors propose a clinical and sonographic scope of practice for physiotherapists as part of supporting the consolidation and expansion of pelvic health PoCUS. Education and governance considerations are detailed to ensure the robust and safe use of this modality. Alongside empowering the use of ultrasound imaging by clinicians such as physiotherapists in the UK and internationally, we provide clarity to other members of the care pathway and ultrasound imaging professionals.

Effects of yoga on the intervention of levator ani hiatus in postpartum women: a prospective study

[Purpose] This study aimed to explore the application value of yoga intervention in early postpartum recovery of the levator ani muscle hiatus (LAH) area. [Participants and Methods] Females in natural labor from May 2020 to November 2020 in the Third People’s Hospital of Sun Yat-sen University Ultrasound Research Center were prospectively included for a pelvic ultrasound examination. The control group received no intervention. The experimental group received 60-min yoga once a week from week 1 to week 12 postpartum. A pelvic ultrasound examination was performed on the week 6 and week 12 postpartum. The LAH area was measured at rest, during contraction and Valsalva maneuver. [Results] A total of 128 participants who met the inclusion criteria were selected and randomly assigned to the control group (n=66) and the experimental group (n=62) in pre and post intervention design. No significant differences were found in age, parity, body mass index, and fetal weight between the control and experimental groups. Further, no significant difference was observed in the LAH area between the control and experimental groups at rest, during contraction and Valsalva maneuver on the week 6 postpartum. However, the LAH area in experimental group significantly reduced at rest, during contraction and Valsalva maneuver on the week 12 postpartum. The differences of LAH area (date week 6 minus date week 12) in the control group at rest, during contraction and Valsalva maneuver were 0.12 ± 3.12 cm², 0.80 ± 2.29 cm², and 0.80 ± 4.22 cm², while in the control these were 1.95 ± 3.41 cm², 1.39 ± 1.91 cm², and 3.81 ± 5.49 cm², respectively. Compared with control group, the differences of LAH area significantly increased in experimental group at rest and during Valsalva maneuver. [Conclusion] Yoga intervention can help in the recovery of LAH.

Is vaginal laxity an early symptom of pelvic organ prolapse?

INTRODUCTION AND HYPOTHESIS

We aimed to determine whether vaginal laxity (VL) may be an early symptom of pelvic organ prolapse (POP).

METHODS

This was a retrospective observational study including patients referred to a urogynecological clinic owing to symptoms of pelvic floor dysfunction. The interview included inquiry about VL and POP symptoms. Clinical examination and translabial ultrasound (TLUS) were performed to assess for POP and levator hiatal ballooning. Analysis of ultrasound datasets was performed with the reviewer blinded against all other data. Linear regression models were used to evaluate associations between age categories and symptoms.

RESULTS

The analysis included 531 patients. Mean age was 59.7 years (range 17.6-92.0), mean body mass index (BMI) was 29.5 kg/m² (14.7-53.5) and 458 (86%) were vaginally parous. Overall, POP symptoms were reported by 258 patients (49%) and VL by 118 (22%). Significant clinical POP was diagnosed in 384 patients (72%). Levator hiatal ballooning on TLUS was noticed in 56%. VL and POP symptoms showed a divergent association with age (p = 0.02). This trend remained significant after controlling for clinically significant POP (p = 0.01) and levator hiatal ballooning (p = 0.002). Of 384 women with significant objective POP, 231 (60%) reported symptoms of POP. Of 153 women with asymptomatic POP, 7 (5%) reported symptoms of VL.

CONCLUSIONS

With increasing age the prevalence of VL decreases, whereas symptoms of POP increase. However, only very few women with objective POP perceive VL as their only symptom, independent of age at presentation. Therefore, vaginal laxity does not seem to be an early symptom of prolapse.

Levator ani avulsion: a Systematic evidence review (LASER)

BACKGROUND

There is variation in the reported incidence rates of levator avulsion (LA) and paucity of research into its risk factors.

OBJECTIVE

To explore the incidence rate of LA by mode of birth, imaging modality, timing of diagnosis and laterality of avulsion.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CINAHL, AMED and MIDIRS with no language restriction from inception to April 2019.

STUDY ELIGIBILITY CRITERIA

A study was included if LA was assessed by an imaging modality after the first vaginal birth or caesarean section. Case series and reports were not included.

DATA COLLECTION AND ANALYSIS

RevMan v5.3 was used for the meta-analyses and SW SAS and STATISTICA packages were used for type and timing of imaging analyses.

RESULTS

We included 37 primary non-randomised studies from 17 countries and involving 5594 women. Incidence rates of LA were 1, 15, 21, 38.5 and 52% following caesarean, spontaneous, vacuum, spatula and forceps births, respectively, with no differences by imaging modality. Odds ratio of LA following spontaneous birth versus caesarean section was 10.69. The odds ratios for LA following vacuum and forceps compared with spontaneous birth were 1.66 and 6.32, respectively. LA was more likely to occur unilaterally than bilaterally following spontaneous (P < 0.0001) and vacuum-assisted (P = 0.0103) births but not forceps. Incidence was higher if assessment was performed in the first 4 weeks postpartum.

CONCLUSIONS

LA incidence rates following caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively. Ultrasound and magnetic resonance imaging were comparable tools for LA diagnosis.

TWEETABLE ABSTRACT

Levator avulsion incidence rates after caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively.

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.

International Urogynecological Consultation: clinical definition of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This segment of Chapter 1 of the International Urogynecology Consultation (IUC) on pelvic organ prolapse (POP) reviews the literature on the clinical definition of POP with the intent of creating standard terminology.

METHODS

An international group containing nine urogynecologists and one university-based medical librarian performed a search of the literature using pre-specified search terms in PubMed, Embase, and Scopus. Publications were eliminated if not relevant to the clinical definition of POP, and those articles remaining were evaluated for quality using the Specialist Unit for Review Evidence (SURE). The resulting list of articles was used to inform a comprehensive review and creation of the clinical definition of POP.

RESULTS

The original search yielded 31,931 references, of which 167 were used by the writing group. Ultimately, 78 are referenced in the manuscript.

CONCLUSIONS

The clinical definition of POP for this review of the literature is: "anatomical prolapse with descent of at least one of the vaginal walls to or beyond the vaginal hymen with maximal Valsalva effort WITH the presence either of bothersome characteristic symptoms, most commonly the sensation of vaginal bulge, or of functional or medical compromise due to prolapse without symptom bother."

Transperineal pelvic floor ultrasound for analyzing the outcomes of pelvic floor surgery for the treatment of anterior compartment prolapse: A comparative study of transvaginal mesh and native-tissue repair

OBJECTIVE

To compare the outcomes of transvaginal mesh (TVM) and native-tissue repair (NTR) for the repair of anterior compartment prolapse.

METHODS

This retrospective study involved 90 patients with anterior compartment prolapse who underwent pelvic organ prolapse surgery between January 2018 and October 2020. A TVM was used to treat 53 patients and 37 underwent NTR. All patients underwent a standardized interview, clinical examination, and four-dimensional pelvic floor ultrasound (PFUS) before and after the surgery. The primary outcome was anatomic recurrence evaluated by ultrasonic parameters. The secondary outcomes were subjective recurrence and complications.

RESULTS

Subjective recurrence was 9.43% (5/53) for TVM and 16.22% (6/37) for NTR (P = .522). Significant recurrence of prolapse on ultrasound occurred in five patients (9.43%) after TVM and 12 (32.43%) after NTR; there was a significant difference between the TVM and NTR groups (P = .006). In the TVM group, the mesh was visible on ultrasound in each patient. The mesh exposure rate was 1.89% (1/53). The postoperative hiatal area reduction in the TVM group, compared with the NTR group, was statistically significant (5.55 ± 4.71 cm² vs 3.09 ± 5.61 cm² , P = .027). The incidence of de novo stress urinary incontinence was higher in the TVM group (20.75% vs 2.70%, P = .03). After surgery, there were significant differences between the two groups based on bladder descent (12.02 ± 8.64 mm vs 22.41 ± 13.95 mm, P = .000) and urethral rotation angle (25.26 ± 13.92° vs 40.27 ± 23.72°, P = .001).

CONCLUSION

PFUS is effective for evaluating postoperative outcomes. TVM facilitates a better anatomic cure than NTR for anterior compartment prolapse.

Is pelvic floor muscle contractility an important factor in anal incontinence?

OBJECTIVE

Pelvic floor muscle contractility (PFMC) may contribute to anal continence. The aim of this study was to assess the association between clinical and sonographic measures of PFMC and anal incontinence (AI) symptoms, after controlling for anal sphincter and levator ani muscle (LAM) trauma.

METHODS

This was a retrospective study of 1383 women assessed at a tertiary center between 2013 and 2016. All patients underwent an interview, including the St Mark's incontinence score (SMIS) in those who reported AI symptoms, a clinical examination, including assessment of PFMC using the modified Oxford scale (MOS), and four-dimensional translabial ultrasound (TLUS). Sonographic measures of PFMC, i.e. cranioventral shift of the bladder neck (BN) and reduction of anteroposterior (AP) diameter of the levator hiatus, were measured offline using ultrasound volumes obtained at rest and on maximum pelvic floor contraction. The reviewer was blinded to all clinical data.

RESULTS

Of the 1383 patients assessed during the study period, seven were excluded due to missing imaging data, leaving 1376 for analysis. Mean age of the participating women was 55 years and mean body mass index was 29 kg/m² . AI was reported by 221 (16.1%) women, with a mean SMIS of 11.8. Mean MOS grade was 2.3. On TLUS, mean BN cranioventral shift was 5.9 mm and mean AP diameter reduction was 8.1 mm. LAM avulsion and significant external anal sphincter (EAS) defect were diagnosed in 24.8% and 8.7% patients, respectively. On univariate analysis, sonographic measures of PFMC were not associated with AI. Lower MOS grade was associated with symptoms of AI; however, statistical significance was lost on multivariate analysis.

CONCLUSION

Clinical and sonographic measures of PFMC were not significantly associated with AI symptoms after controlling for EAS and LAM trauma. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Artificial intelligence models derived from 2D transperineal ultrasound images in the clinical diagnosis of stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

The aim of the study was to develop artificial intelligence (AI) algorithms using 2D transperineal ultrasound (TPUS) static images to simplify the clinical process of diagnosing stress urinary incontinence (SUI) in practice.

METHODS

The study involved 400 patients in total, including 265 SUI patients and 135 non-SUI patients who underwent a routine clinical evaluation process by urologists and TPUS. They were classified into different groups based on the International Consultation on Incontinence Questionnaire (ICIQ) to assess the impact of inconvenience on patients' lives. Four AI models were developed by 2D TPUS images: Model A (a single-mode model based on Valsalva maneuver images to classify G-0, G-1, and G-2); Model B (a dual-mode model based on Valsalva maneuver and resting state images to classify G-0, G-1, and G-2); Model C (a single-mode model based on Valsalva maneuver images to classify G-2 and G-01); Model D (a dual-mode model based on Valsalva maneuver and resting state images to classify G-2 and G-01). The performance of the four models was evaluated by confusion matrices and the area under the receiver-operating characteristic curve (AUC).

RESULTS

The dual-mode model based on the Valsalva maneuver and resting-state images (Model D) had a higher accuracy of 86.3% and an AUC of 0.922, which was significantly higher than the AUCs of the other three models: 0.771, 0.862, and 0.827.

CONCLUSIONS

The AI algorithm using 2D TPUS static images of the Valsalva maneuver and resting state may be a promising tool in the diagnosis of SUI patients in to relieve clinical processes in practice given its ease of use in clinical applications.

Assessment of levator hiatal area using 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: randomized controlled trial

OBJECTIVES

Deep infiltrating endometriosis (DIE) is associated with chronic pelvic pain, dyspareunia and pelvic floor muscle hypertonia. The primary aim of this study was to evaluate the effect of pelvic floor physiotherapy (PFP) on the area of levator ani hiatus during Valsalva maneuver, assessed using transperineal ultrasound, in women with DIE suffering from superficial dyspareunia.

METHODS

This was a randomized controlled trial of 34 nulliparous women diagnosed with DIE and associated superficial dyspareunia. After an initial clinical examination, all patients underwent three-dimensional/four-dimensional (3D/4D) transperineal ultrasound to measure the levator hiatal area (LHA) at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver, and were asked to rate their pain symptoms using a numerical rating scale (NRS). Eligible women were assigned randomly (1:1 ratio) to no intervention (control group, 17 women) or treatment with five individual sessions of PFP (study group, 17 women). Four months after the first examination, all women underwent a second evaluation of pain symptoms and LHA on transperineal ultrasound. The primary outcome measure was the percentage change in LHA on maximum Valsalva maneuver between the baseline and follow-up examinations. The percentage changes in pain symptoms between the two examinations, including superficial and deep dyspareunia, dysmenorrhea, chronic pelvic pain, dysuria and dyschezia, were also evaluated.

RESULTS

Thirty women, comprising 17 in the study group and 13 in the control group, completed the study and were included in the analysis. The percentage change in LHA on maximum Valsalva maneuver between the two examinations was higher in the study group than in the control group (20.0 ± 24.8% vs -0.5 ± 3.3%; P = 0.02), indicating better pelvic floor muscle relaxation. After PFP treatment, the NRS score for superficial dyspareunia remained almost unchanged in the control group (median change in NRS (Δ-NRS), 0 (interquartile range (IQR), 0-0)) while a marked reduction was observed in the study group (median Δ-NRS, -3 (IQR, -4 to -2); P < 0.01). Moreover, there was a significant difference between the PFP and control groups with regards to the change in chronic pelvic pain (median Δ-NRS, 0 (IQR, -2 to 0) vs 0 (IQR, 0-1); P = 0.01).

CONCLUSIONS

In women with DIE, PFP seems to result in increased LHA on Valsalva maneuver, as observed by 3D/4D transperineal ultrasound, leading to improved superficial dyspareunia, chronic pelvic pain and pelvic floor muscle relaxation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment

INTRODUCTION

The terminology for female and male pelvic floor muscle (PFM) assessment has expanded considerably since the first PFM function and dysfunction standardization of terminology document in 2005. New terms have entered assessment reports, and new investigations to measure PFM function and dysfunction have been developed. An update of this terminology was required to comprehensively document the terms and their definitions, and to describe the assessment method and interpretation of the finding, to standardize assessment procedures and aid diagnostic decision making.

METHODS

This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) Working Group 16, with contributions from recognized experts in the field and external referees. A logical, sequential, clinically directed assessment framework was created against which the assessment process was mapped. Within categories and subclassifications, each term was assigned a numeric coding. A transparent process of 12 rounds of full working group and external review was undertaken to exhaustively examine each definition, plus additional extensive internal development, with decision making by collective opinion (consensus).

RESULTS

A Terminology Report for the symptoms, signs, investigations, and diagnoses associated with PFM function and dysfunction, encompassing 185 separate definitions/descriptors, has been developed. It is clinically based with the most common assessment processes defined. Clarity and user-friendliness have been key aims to make it interpretable by clinicians and researchers of different disciplines.

CONCLUSION

A consensus-based Terminology Report for assessment of PFM function and dysfunction has been produced to aid clinical practice and be a stimulus for research.

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).

Does Vaginal Parity Alter the Association Between Symptoms and Signs of Pelvic Organ Prolapse?

OBJECTIVES

This study aimed to investigate whether the number of vaginal births a woman has alters the association between symptoms and signs of pelvic organ prolapse.

METHODS

In this retrospective study, we investigated data on 1748 women seen between April 2012 and January 2016. To elucidate whether the number of vaginal births is a confounder of this relationship, we used receiver operating characteristic statistics to investigate the association between symptoms and signs of prolapse in women of different vaginal parity.

RESULTS

A higher number of vaginal births was associated with a higher likelihood of symptoms of prolapse for any given degree of prolapse. Multivariate modeling, however, showed this confounding effect to be due to higher vaginal parity in older women (P < .001). Receiver operating characteristic curves obtained for the association between symptoms and signs of prolapse were near identical regardless of whether vaginal parity was included in the modeling. This was true for both clinical and imaging assessments of prolapse.

CONCLUSIONS

Although vaginal childbirth is associated with symptoms of prolapse, the number of vaginal births does not alter the relationship between symptoms and signs of prolapse among individuals presenting to a tertiary care center for evaluation. Previously published limits for "normal" pelvic organ mobility can be used irrespective of vaginal parity.

Reliability of ultrasound imaging of pelvic floor morphology and function among females who have undergone pelvic radiotherapy

AIMS

To investigate the intra- and inter-rater reliability of two-dimensional (2D) transperineal ultrasound imaging (USI) measures of bladder wall thickness (BWT), urethral length (UL), and parameters related to levator plate length (LP) and transient changes in LP during pelvic floor muscle (PFM) contraction, and on Valsalva in women who received radiation therapy (RT) for treatment of pelvic cancer.

METHODS

Twenty women with a history of RT for the treatment of pelvic cancer were assessed independently by two raters on the same day. Five outcomes were assessed for reliability: BWT, UL, and LP at rest (LP-R), during a maximal voluntary contraction of the PFMs (LP-MVC), and during a maximal-effort Valsalva maneuver (LP-MVM). Reliability was determined using intra-class correlation coefficients (ICC) and Bland-Altman analyses. Measurement error was determined using standard error of the measurement (SEM) and minimal detectable difference.

RESULTS

Intra-rater reliability was very good for LP-R, LP-MVC, LP-MVM, and UL (ICC: 0.97 [0.93-0.99], 0.95 [0.88-0.98], 0.84 [0.59-0.94], and 0.96 [0.89-0.98], respectively). Inter-rater reliability was very good for LP-R (ICC: 0.82 [0.55-0.93]), and good for LP-MVC, LP-MVM, and UL (ICC: 0.79 [0.46-0.92], 0.79 [0.49-0.92], and 0.75 [0.36-0.90], respectively). BWT had poor intra- and inter-rater reliability. The variability between measurements was the smallest for LP-R, LP-MVC, and UL for intra-rater assessments, and for LP-R and UL for inter-rater assessments. SEM values for intra-rater assessments were LP-R: 1.5 mm, LP-MVC: 1.84 mm, LP-MVM: 4.33 mm, and UL: 1.16 mm.

CONCLUSIONS

Although these results support the reliability of 2D-transperineal USI for the evaluation of UL and PFM parameters, they do not support its use for the assessment of BWT.

Transperineal ultrasound as a reliable tool in the assessment of membranous urethra length in radical prostatectomy patients

To evaluate the usefulness of transperineal ultrasound (TPUS) as a method of membranous urethra length (MUL) measurement and investigate whether preoperative (MULpre) and postoperative (MULpost) would be associated with the degree and time of urinary continence recovery after laparoscopic radical prostatectomy (LRP). 84 patients who underwent LRP between January 2017 and December 2018 were selected for final analysis. All patients had preoperative and postoperative measurement of MUL in TPUS. Urinary continence was defined as no pad or a safety pad. Recovery of continence was assessed at 1, 3, 6 and 12 months after catheter removal. We prospectively analyzed correlation of MULpre, MULpost and a percent change in membranous urethral length (MULratio) with the urinary continence status. 69 (82%) patients regained continence in the follow-up of 12 months. MULpre, MULpost and MULratio assessed in TPUS were larger in subgroups of patients who regained continence earlier and in the entire continent group. Spearman rank test showed strong correlations between MULpost and MULratio (R-0.6 and R-0.56, respectively, p < 0.0001) with the time to continence recovery in the cumulative 12 months follow-up. TPUS allowed a reliable measurement of MUL before and after LRP. MULpre, MULpost as well as MULratio are related with time to regain continence and recovery rate after LRP. Sparing longest possible sphincteric urethra, with respect to oncological outcomes is a key factor in recovering continence after prostate cancer surgery.

Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy

Urinary incontinence is a common and predictable consequence among men with localized prostate cancer who have undergone radical prostatectomy. Despite advances in the surgical technique, urinary continence recovery time remains variable. A range of surgical and patient-related risk factors contributing to urinary incontinence after radical prostatectomy have been described, including age, BMI, membranous urethral length and urethral sphincter insufficiency. Physical activity interventions incorporating aerobic exercise, resistance training and pelvic floor muscle training programmes can positively influence the return to continence in men after radical prostatectomy. Traditional approaches to improving urinary continence after radical prostatectomy have typically focused on interventions delivered during the postoperative period (rehabilitation). However, the limited efficacy of these postoperative approaches has led to a shift from the traditional reactive model of care to more comprehensive interventions incorporating exercise-based programmes that begin in the preoperative period (prehabilitation) and continue after surgery. Comprehensive prehabilitation interventions include appropriately prescribed aerobic exercise, resistance training and specific pelvic floor muscle instruction and exercise training programmes. Transperineal ultrasonography is a non-invasive and validated method for the visualization of the action of the pelvic floor musculature, providing real-time visual biofeedback to the patient during specific pelvic floor muscle instruction and training. Importantly, the waiting time before surgery can be used for the delivery of comprehensive prehabilitation exercise-based interventions to increase patient preparedness in the lead-up to surgery and optimize continence and health-related quality-of-life outcomes following radical prostatectomy.

Predictors of occult stress urinary incontinence

BACKGROUND

Causes for occult stress urinary incontinence (SUI) are poorly recognised.

AIMS

To explore the mechanisms behind occult SUI. We hypothesised that cystocele type affects the risk of occult SUI.

MATERIALS AND METHODS

We conducted a retrospective, cross-sectional study on 878 consecutive women assessed at a tertiary urogynaecologic clinic between July 2016 and November 2018. The population of this study consisted of 424 women with urodynamic stress incontinence. Women with previous anti-incontinence surgery were excluded. All women underwent a standardised interview, clinical examination and urodynamic testing. Translabial ultrasound was used to categorise cystoceles into Green type II (cystocele with open retrovesical angle) and Green type III (cystocele with intact retrovesical angle). We compared women with overt SUI to those with occult SUI (defined as stress incontinence only observed after prolapse reduction) for demographic characteristics, urodynamic findings and functional anatomy. Predictors for occult SUI were identified with a multivariable logistic regression model.

RESULTS

Of 424 women, 362 (85%) had overt, and 62 (15%) occult SUI. There were 136 (32%) women who had a significant cystocele on imaging; 57 (42%) were classified as type II and 79 (58%) as type III. On multivariable regression, age and cystocele type were significantly associated with occult SUI. Odds for occult SUI was 10.9 times higher with type III (cystocele with an intact retrovesical angle) than with type II cystocele (cystocele with an open retrovesical angle; 95% CI 1.3-90.9).

CONCLUSIONS

Cystocele type affects the risk of occult SUI. Type III cystocele (intact retrovesical angle) associates with occult SUI.

Pelvic floor muscle assessment by digital palpation and translabial ultrasound of women with cervical or endometrial cancer after pelvic radiotherapy: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

We hypothesized that anatomical changes in the pelvic floor muscles (PFM) could be detected using four-dimensional translabial ultrasound (4D TLUS) in patients with cervical (CC) or endometrial cancer (EC) who underwent pelvic radiotherapy (RT) as digital palpation may present sensitivity limitations.

METHODS

This was a cross-sectional study that included 64 women (26 with CC and 38 with EC). PFM function was assessed by digital palpation, grading muscle strength according to the Modified Oxford Scale and by 4D TLUS. Ultrasonographic variables were: levator plate angle, hiatal area, puborectalis muscle thickness, puborectalis strain and levator ani muscle integrity. These variables were also correlated with clinical and sociodemographic data from all these patients. A 5% significance level was adopted.

RESULTS

When assessed by digital palpation, no significant difference was found in PFM strength between women with CC and those with EC (p = 0.747). However, when assessed by 4D TLUS, women with CC presented greater thickening of the left (p = 0.039) and right (p = 0.014) lower portion of the puborectalis muscle during PFM contraction compared to those with EC. After pooling the groups, higher cancer staging (p = 0.028) was associated with smaller narrowing in the symphysis-levator distance, and shorter RT finishing duration (< 60 months) was associated with higher thickening in the left (p = 0.029) and right (p = 0.013) upper portion of the puborectalis muscle during PFM contraction as well as a shorter menopause duration (p = 0.007 and p = 0.002, respectively).

CONCLUSIONS

Anatomical changes in the puborectalis muscle during PFM contraction were detected by 4D TLUS within gynecological cancer patients after pelvic RT.

Does the presence of a true radiological rectocele increase the likelihood of symptoms of prolapse?

INTRODUCTION AND HYPOTHESIS

Posterior compartment prolapse is commonly due to a 'true' rectocele, i.e., a diverticulum of the rectal ampulla. This condition is associated with symptoms of obstructed defecation and may contribute to prolapse symptoms. We tested the hypothesis: 'A true rectocele is an independent predictor of symptoms of prolapse.'

METHODS

This was a retrospective cohort study of patients presenting to a urogynecology unit for symptoms of pelvic floor dysfunction between September 2011 and June 2016. Assessment included a structured interview, POP-Q examination and 4D TLUS. Ultrasound volume data were acquired on Valsalva. Offline measurements were performed by analysis of stored volume data sets at a later date, blinded to all clinical data.

RESULTS

One hundred six patients were excluded because of incomplete data. Of the remainder, Bp was the most distal point on POP-Q in 348. Statistical analysis was performed on this cohort. Mean age was 60 (33-86) years and mean BMI 31 (18-55) kg/m². One hundred fifty-three patients (44%) presented with symptoms of prolapse; 272 were diagnosed with a true rectocele on TLUS. Bp on POP-Q and true rectocele on TLUS were both significantly associated with prolapse symptoms; however, on multivariate analysis the latter became nonsignificant (p = 0.059). Receiver-operating characteristic (ROC) analysis confirmed that the presence of a true rectocele on TLUS did not contribute significantly to symptoms of prolapse (AUC 0.66 for model with rectocele, AUC 0.65 without).

CONCLUSIONS

The presence of a true rectocele on TLUS does not seem to contribute substantially to the manifestation of clinical symptoms of prolapse.

Impact of gestational diabetes on pelvic floor: A prospective cohort study with three-dimensional ultrasound during two-time points in pregnancy

AIM

To evaluate the pelvic floor (PF) biometry using three-dimensional ultrasound (US) at two-time points of gestational in pregnant women with gestational diabetes mellitus (GDM).

METHODS

A prospective cohort study conducted at the Perinatal Diabetes Research Center including 44 pregnant women with GDM and 66 pregnant women without GDM at 24 to 28 weeks of gestation. Three-dimensional transperineal US was performed at 24 to 28 and 34 to 38 weeks of gestation in the lithotomy position at rest. The axial plane of the minimal Levator hiatal dimensions was used to determine Levator ani muscle and Hiatal area (HA) biometry at 24 to 28 and 34 to 38 weeks of gestation.

RESULTS

Of the 110 pregnant women, 100 (90.9%) completed the follow-up at 34 to 38 weeks of gestation. The evaluation by US showed a negative biometric change between the two-time points, during pregnancy in women with GDM; in the HA (β coefficient: estimative of effect in biometric progression according to GDM diagnosis, using the non-GDM group as reference = -6.76; P = .020), anteroposterior diameter (β = -5.07; P = .019), and Levator ani thickness (β = -12.34; P = .005).

CONCLUSIONS

Pregnant women with GDM had a significantly lower than expected percentage of changes in biometry of Levator ani thickness and HA from 24 to 28 to 34 to 38 weeks of gestation when compared with the group of pregnant women without GDM. GDM alters the morphology of PF structures assessed by three-dimension US. This reported complication may be implicated in adverse birth outcomes and may play a role in the development of PF dysfunction.

Three-dimensional ultrasound evaluation of the pelvic floor in postmenopausal women using hormone therapy

OBJECTIVE

To evaluate the three-dimensional (3D) ultrasound characteristics of the pelvic floor muscles (PFM) in two groups of postmenopausal women: users and nonusers of menopausal hormone therapy (MHT).

STUDY DESIGN

Observational, cross-sectional cohort study.

MAIN OUTCOME MEASURES

In this study 226 sexually active heterosexual women, aged 45-60 years with amenorrhea >12 months and without clinical pelvic floor disorders or urinary incontinence were included. Women using MHT ≥ 6 months were classified as systemic users. PFM strength was assessed by digital vaginal palpation and scored on the Modified Oxford Scale. Biometry of the PFM was performed by 3D transperineal ultrasound for evaluation of total urogenital hiatus area, transverse and anteroposterior diameters, and levator ani muscle thickness.

RESULTS

The participants were divided into users (n = 78) and nonusers (n = 148) of MHT. There were no differences in clinical or anthropometric parameters between groups. The mean age was 55 years and the time since menopause was six years in both groups. The mean duration of MHT use was 43.4 ± 33.3 months. Users of MHT had greater levator ani muscle thickness (p = 0.001) and higher PFM strength (p = 0.029) than nonusers. Risk analysis adjusted for age, time since menopause, BMI, parity, and type of delivery showed an association of MHT use with greater levator ani muscle thickness (OR = 2.69; 95% CI 1.42-5.11, p = 0.029), and higher PFM strength (OR = 1.78; 95% CI1.01-3.29, p = 0.046). There was a weak positive correlation between levator ani muscle thickness and duration of MHT use (r = 0.25, p = 0.0002) and PFM strength (r = 0.12, p = 0.043).

CONCLUSIONS

Postmenopausal women using MHT had a greater levator ani muscle thickness associated with higher PFM strength than nonusers.

Ultrasonographic Imaging Features of Female Urethral and Peri-urethral Masses: A Retrospective Study of 95 Patients

The aim of this study was to assess the imaging features of urethral and peri-urethral masses on transvaginal or transperineal ultrasound (US) in a cohort of 95 women. In this retrospective study, medical records of 95 female patients with 98 asymptomatic or symptomatic urethral and peri-urethral masses were retrospectively reviewed. Data regarding patient demographic characteristics, symptoms, signs, imaging features on 2-D and 3-D transvaginal or transperineal US, diagnostic tests and physical and intra-operative findings were extracted. The US imaging features and clinicopathologic characteristics of each urethral or peri-urethral mass were compared. On ultrasound, 39 masses (in 39 patients) were diagnosed as urethral diverticula, which manifested mostly as complex cystic masses (24/39, 61.5%); 35 masses (in 33 patients) were diagnosed as para-urethral cysts, which manifested mostly as simple cystic masses (19/35, 54.3%); 13 hypo-echoic solid masses (in 12 patients) exhibiting blood flow signals on color Doppler imaging were diagnosed as urethral leiomyomas; hypo-echoic or heterogeneous solid masses (in 8 patients) exhibiting blood flow signals on color Doppler imaging were diagnosed as urethral caruncles, including one complicated by malignant transformation; solid masses with mixed echogenicity (in 2 patients) exhibiting blood flow signals on color Doppler imaging were diagnosed as urethral squamous cell carcinoma or adenocarcinoma, and a hypoechoic solid mass (in one patient) with blood-flow signals on color Doppler imaging was diagnosed as urethral condyloma associated with human papillomavirus infection. This study confirmed transvaginal or transperineal 2-D and 3-D ultrasonography to be a valid, non-invasive, cost-effective diagnostic modality for the differential diagnosis of urethral and periurethral masses.

Transperineal Ultrasound Visual Feedback Assisted Pelvic Floor Muscle Physiotherapy in Women With Deep Infiltrating Endometriosis and Dyspareunia: A Pilot Study

A prospective study with the aim to evaluate the effects of pelvic floor physiotherapy was conducted among women with deep infiltrating endometriosis (DIE) and associated dyspareunia. At initial evaluation superficial and deep dyspareunia were assessed using a numerical rating scale, and levator hiatus area (LHA) was assessed with 3-D/4-D transperineal ultrasound. Women underwent five individual sessions of ultrasound visual feedback assisted pelvic floor physiotherapy. One month after the therapy, dyspareunia and LHA were reassessed and compared with pre-therapy data. Pelvic floor physiotherapy seems to improve both superficial and deep dyspareunia and pelvic floor muscle relaxation in women with DIE.