Dr Bruce AllenHorizon Radiology

Acknowledgement to Dr Hans Dietz and Dr Jenny Kruger

Clinical application of Pelvic floor imagingPelvic floor muscles involved in:

Maintenance of continenceSupport of the organs of the pelvisVaginal delivery

Failure of these muscles increases risk of:Urinary and fecal incontinence, Prolapse of the organs of the pelvis, Perineal pain and dyspareunia.

Ultrasound imagingCost effective

Do not need expensive machines to do basic imaging

Ultrasound is highly operator dependant Not difficult to learn

Real time, functional studies easy

MRIExpensiveImages are easier to understandFunctional studies difficult.

2D imaging - Ultrasound

Until recently 2D ultrasound scanning only methodology used define pathology and normal function of pelvic floorAbdominally, transvaginal or translabialDescent of bladder neck, uterus and rectal

ampulla during a valsalva Transperineal ultrasound useful biofeedback

measure for patientsImage is in mid-sagittal plane$12,000 machine.

Translabial 2D Ultrasound

Patient is supine, bladder empty ( or standardized filling)

Knees flexed, feet on the tableTransducer covered in glove/condom for

hygienePlaced fairly firmly on the perineum in the

mid sagittal orientation.

Ultrasound Anatomy

Typical 2D image of the pelvic floor muscles

uret

hra

cranial

MRI: Sag midline, normal anatomy

Bony landmarks20 mins scan timeAnatomy

Pelvic floor functional assessment

Training

Contraction

Valsalva

Pelvic floor muscle contraction

Contraction assess: 1. Narrowing of the hiatus in the AP diameter2. Movement of the bladder neck3. Strength of the PF muscle

Contraction: Bladder neck

Valsalva: BND

Effective valsalva manouevre

Valsalva assess:1.Descent of bladder, uterus, rectum. Urethral rotation.2.Development of cystocele, prolapse or rectocele3.Width of hiatus in the AP diameter

MRI: Valsalva. Cystocoele

Functional:4 min per sequenceValsalvadefaecation (training)

2D imagingMeasurements of bladder neck descent and

urethral rotation.

Ultrasound images showing measurement of bladder neck descent and urethral rotation. Bladder neck descent (BND)= x-r –x-s. (Dietz et al 2004)

2D

Im

ag

ing

Clinical use of 2D ultrasoundStill widely used Bladder, uterine and rectal descent. Bo, K. and M. Sherburn, Evaluation of female pelvic-floor muscle

function and strength. Physical therapy, 2005. 85(3): p. 269-82, Mar.

Abdominal ultrasound

Athanasiou, S., et al., Direct imaging of the pelvic floor muscles using two-dimensional ultrasound: a comparison of women with urogenital prolapse versus controls.BJOG: An International Journal of Obstetrics and Gynaecology, 2007. 114(7): p. 882-888.

Endovaginal probe

Costantini, S., et al., Perineal ultrasound evaluation of the urethrovesical junction angle and urethral mobility in nulliparous women and women following vaginal delivery. Int Urogynecol J Pelvic Floor Dysfunct, 2005. 16(6): p. 455-9.

Transperineal ultrasound

Dietz, H., Pelvic Floor Ultrasound. Current Medical Imaging Reviews, 2006. 2: p. 271-290.

Dietz, H., B. Haylen, and J. Broome, Ultrasound in the quantification of female pelvic organ prolapse. Ultrasound in Obstetrics and Gynecology, 2001. 18: p. 511-514.

3D ultrasound imaging

3D ultrasound widely used in obstetric scanning so equipment is now readily available

$100,000 – $250,000Acquisition of volume images allow

access to the ‘axial’ plane – previously domain of magnetic resonance imaging.

Protocol for 3D pelvic floor imaging • Translabial imaging:

– Imaged supine after voiding– Transducer ‘sits’ on the perineum mid-sagittal

orientation– Mid-sagittal image on the screen– Symphysis pubis reference point – during movement– Methods highly reproducible (Guaderrama, Yang, Dietz ).

3D US pelvic floor imaging – levator hiatus

Voluson 730 expert system. (Dietz et al 2005)

MRI: normal axial anatomy

3D pelvic floor ultrasound – assessing functionLevator hiatus:‘plane of minimal dimensions’

Smallest distance from the inferior edge of the symphysis pubis to the anal rectal angle

Levator hiatal area bounded by the symphysis pubis anteriorly, anal rectal angle posteriorly, puborectalis/ pubococcygeus laterally.

Hiatal area measures pelvic floor functionRestMaximum pelvic floor muscle contractionMaximum valsalva(Training).

Normal 3D Pelvic Floor

A mid-sagittal image. Line indicates plane of minimal dimensions

B corresponding ‘axial’image showing entire levator hiatus

3D imaging: hiatal measurement

Normal Contraction of the hiatus

Ballooning of the hiatus on Valsalva

Avulsion: Ultrasound. Unilateral

Avulsion. MRI. Large unilateral

Avusion: Ultrasound. Bilateral

MRI ………………….……….. Ultrasound

ConclusionsTranslabial ultrasound 2D / 3D /4D

Function and anatomy effective, easy, low cost method for assessment of

the PF Used to confirm/or not the digital diagnosis of PF

dysfunctionBiofeedback training

MRI Anatomy (and function)

Effective valsalva manouevre

Hiatal measurements at rest