World J Urol (2011) 29:615–623 DOI 10.1007/s00345-011-0708-x
TOPIC PAPER
Pelvic floor disorders: role of new ultrasonographic techniques A. P. Wieczorek • A. Stankiewicz • G. A. Santoro • M. M. Woz´niak • M. Bogusiewicz • T. Rechberger
Received: 7 March 2011 / Accepted: 25 May 2011 / Published online: 14 June 2011 Ó Springer-Verlag 2011
Abstract The paper presents the role of various ultrasound modalities in the diagnostics of female pelvic floor disorders (PFD). It describes the use of two/three/fourdimensional transperineal ultrasound and endocavitary transducers, which, up to now, have been used for proctological examinations and prostate cancer brachytherapy. Ultrasonography is the most widely available imaging modality. As a result of technical progress, novel transducers and more sophisticated software have recently been introduced to the market providing more information about the anatomy of pelvic organs. Some features of these transducers, such as higher frequency and multiplanar imaging, enable better visualisation of pelvic floor organs. In-depth knowledge of the technical and physical properties of modern ultrasonography, as well as its advantages and limitations, could provide an integrated approach to imaging of PFD. Technical modalities, the wide availability of ultrasonographic techniques, and an understanding of the imaging possible with modern ultrasonography
A. P. Wieczorek A. Stankiewicz (&) M. M. Woz´niak Pediatric Radiology Department, Children’s Teaching Hospital, Medical University of Lublin, ul. Chodzki 2, 20–093 Lublin, Poland e-mail:
[email protected] G. A. Santoro 3rd Division of General Surgery, Regional Hospital, Piazza Ospedale 1, 31 100 Treviso, Italy M. Bogusiewicz T. Rechberger 2nd Gynecology Department, Teaching Hospital, Medical University of Lublin, ul. Jaczewskiego 8, 20–090 Lublin, Poland
could improve our understanding of PFD and allow better assessment in pre- and post-surgical management. Keywords 2D/3D/4D ultrasound Endoanal/endovaginal ultrasound Pelvic floor disorders Transperineal ultrasound Abbreviations ARA Anorectal angle BND Bladder neck descent BSD Bladder-symphysis distance EAUS Endoanal ultrasound ERUS Endorectal ultrasound EVUS Endovaginal ultrasound FI Fecal incontinence ICS International Continence Society IUGA International Urogynecological Association LAM Levator ani muscle LH Levator hiatus MPR Multiplanar reconstruction MRI Magnetic resonance imaging OD Obstructive defecation PFD Pelvic floor disorders POP Pelvic organ prolapse POP-Q Pelvic organ prolapse quantification system ROI Region of interest RVA Retrovesical angle SP Symphysis pubis SUI Stress urinary incontinence TPUS Transperineal ultrasound TUI Tomographic imaging UI Urinary incontinence US Ultrasound 2D US Two-dimensional ultrasound 3D US Three-dimensional ultrasound 4D US Four-dimensional ultrasound
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Introduction The pelvic floor is a complex, three-dimensional (3D) apparatus, with precise anatomical and functional areas [1– 3] that have been artificially divided by different medical specialties. Female pelvic floor disorders (PFD), such as pelvic organ prolapse (POP), or other morphological abnormalities of the pelvic organs, may lead to disturbances of their function, resulting in urinary incontinence (UI), faecal incontinence (FI) or obstructive defecation (OD). Up to now, there has been no single, comprehensive imaging technique in routine use that is able to show anatomical or functional disorders in all the pelvic floor compartments and explain their causative factors. Proctography and magnetic resonance imaging (MRI), which are considered the most reliable techniques for PFD diagnostics, have many limitations, such as poor accessibility, high cost, the necessity for well-trained personnel and the embarrassment experienced by patients undergoing these examinations. Compared with other imaging modalities, ultrasound (US) imaging is widely available, easy to perform and familiar to many medical specialties. The huge variety of transducers introduced over the last few years, with different physical properties, such as high frequencies over 10 MHz, endocavitary multiplanar approaches, different techniques (2D/3D/4D) and novel post-processing programmes, such as render mode and multiplanar reconstructions, have encouraged specialists working in the pelvic floor area to widen their use of ultrasonography. However, the complex anatomy and function of the pelvic floor organs requires an integrated approach, based on indepth knowledge of the properties and limitations of available US equipment and methods, to achieve the required level of information. It is known that imaging techniques can significantly influence clinical management [4]. Practical application of these methods allows improved morphological assessment of the pelvic floor organs, facilitating a better understanding of the aetiology of PFD. The role of modern US is to reduce inappropriate surgical treatments and reduce the high rate of post-operative failures [5]. The multi-compartmental background and manifestation of PFD may be missed by clinicians who concentrate on only one compartment of the pelvic floor [6]. The wide range of modern US equipment and methods currently available gives clinicians’ easy access to all the pelvic floor structures. A joint report of the ICS/IUGA (International Continence Society/International Urogynecological Association) has presented the terminology in use for female PFD and described some existing US tools that could currently be used for PFD [7].
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In this paper, we present the main characteristics of US modalities used by different clinical specialties for an optimal, integrated approach to PFD problems.
Transperineal ultrasound (TPUS) Methods and equipment Introital US, perineal US and translabial US are all synonymous with TPUS [8]. In this method, the US transducer is placed gently on the perineal area, enabling visualisation of the pelvic floor organs in sagittal, oblique and transverse sections. Convex transducers (2–6 MHz) routinely used for abdominal or obstetric US, or endovaginal (EVUS)/endorectal (ERUS) end-fire endotransducers, may all be used for TPUS. Two-dimensional (2D) TPUS is performed with the patient in the dorsal lithotomy position and does not require any special gynaecological chair, contrast filling or other patient preparation. The patient should feel no discomfort from the bladder volume during the examination. Two-dimensional TPUS (2D-TPUS) Measurements In midsagittal section, 2D TPUS at rest shows the anatomical relationships between the pelvic organs located between the symphysis pubis (SP) and coccyx: the bladder, urethra, vagina and anorectum. Reference measurements can be performed, in order to define the position of these organs. The bladder neck position is defined by the distance between the bladder neck and the lowest margin of the SP; this is called the bladder-symphysis distance (BSD) [8]. As a reference point for this measurement, the horizontal line to the lowest dorsal border of the SP is drawn. The position of the urethra is described by angles: the retrovesical (RVA), which is the angle between the line passing through the lumen of the proximal urethra and the line passing through the trigonal surface of the bladder and the gamma angle (c angle) between the midequitorial line of the SP and the line passing through urethrovesical junction [7]. Clinical relevance In the central compartment, the distance from the lowest margin of the SP to the uterine cervix can be measured [9]. The relevant dimension in the posterior compartment is the anorectal angle (ARA), formed between the posterior rectal wall and the posterior wall of the anal canal.
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Two-dimensional TPUS performed in dynamic mode shows pelvic organ floor displacement. During the Valsalva manoeuvre, bladder neck descent (BND) is measured to assess urethral mobility (Fig. 1). A cut-off of 20 mm has been proposed to define hypermobility and correlates with stress urinary incontinence (SUI) [8, 9]. The values of the RVA and gamma angle allow definition of hypermobility and hyper-rotation of the proximal urethra, which is believed to be pathognomic for UI [10]. The values of RVA are significantly higher in incontinent patients than in continent ones [11]. Motion tracking mode may also be helpful in assessment of the mobility and function of pelvic structures [12]. In some patients with SUI or urge incontinence, 2D TPUS allows visualisation of a funnelling of the internal urethral meatus. The urine leakage can be recorded in colour Doppler mode, acquired in dynamic 2D TPUS in patients with low Valsalva leak point pressure [13]. Two-dimensional TPUS allows definition of abnormal fluid collections, urethral diverticula, Gartner cysts and pathologies of the bladder, such as tumours or ureterocele [13].
From the clinical point of view, the most important role of TPUS is the ability to diagnose POP, such as cystocele, cystourethrocele, uterine/vaginal prolapse or recto/enterocele [14]. For better evaluation of the type and degree of organ descent, TPUS may be also performed with the patient standing [13]. However, staging of POP is often hampered by existing artefacts, especially in patients with multi-compartmental prolapse, which limits the clinical usefulness. This has already been reported by Broekhuis et al. who compared POP quantification (POP-Q), dynamic MRI and TPUS and concluded that the POP staging only correlates in the anterior compartment [14]. A study by Perniola et al., comparing defecation proctography with US in an investigation of defecatory disorders, recommended TPUS as the initial examination or screening method in patients with suspected rectocele and intussusception/ prolapse [15]. Dynamic 2D TPUS may be used to monitor anatomical restoration after surgery [16] and is useful for explaining some causative mechanisms of pathologies occurring ‘de novo’, such as bladder outlet obstruction as a result of too tight positioning of the tape.
Fig. 1 Two-dimensional TPUS, midsagittal section of pelvic organs. (a and b) Normal anatomy. Measurements of the position of pelvic floor organs taken at rest (a) and during Valsalva manoeuvre (b). The bladder symphysis distance (red line) is the distance between the bladder neck (BN) and the lowest margin of the symphysis pubis (SP); the anorectal angle (ARA) is the angle between the posterior rectal wall and the anal canal; the gamma angle (v) is the angle
between the inferior edge of the SP and urethrovesical junction; the retrovesical angle (RVA) is the angle between the proximal urethra and trigonal surface of the bladder and the line passing through the urethral lumen. A anus, B bladder, BN bladder neck R rectum, Vg vagina. (c and d) During Valsalva manoeuvre, cystocele (c) and rectocele (d) can be recognised. Other pelvic floor structures are not clearly visualised due to the presence of prolapse
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A limitation of 2D TPUS is related to the low frequency (2–6 MHz) of the transducers, which provide limited resolution, resulting in poor image quality and, in some cases, a lack of detailed morphological information about the pelvic floor structures. The placement of the transducer on the perineal area may provide false measurements in patients with high-grade prolapse.
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in the transverse section of the pelvic floor, compared to the fixed reference point represented by the SP. Biometric indices (area and diameters) of the levator hiatus (LH) can also be measured. Clinical relevance
Three-dimensional anatomical data can be analysed offline and enriched by post-processing modalities such as render mode, multiplanar reconstruction (MPR) or tomographic imaging (TUI), which enables visualisation of displaced structures of the pelvic floor on the selected levels, by defining the region of interest (ROI). It allows the symmetry or asymmetry of the position of the urethra, vagina, anus and levator ani muscles (LAM) to be assessed,
Many reports have shown that 3D TPUS provides reliable and repeatable measurements of the LH [17, 18] in nulliparous and multiparous patients with prolapse [19]. It is reported that 3D TPUS could be used instead of MRI in the evaluation of static pelvic floor anatomy in patients without POP at rest [20]. Falkert et al. performed 3D TPUS two days after first delivery and showed that women with vaginal delivery had a significantly higher hiatal area and transverse diameter than women after Caesarean section [21]. Three-dimensional TPUS provides evaluation of trauma to the LAM, as well as its distribution in patients with PFD, especially when TUI is applied [22]. Dietz et al. have proposed a diagnosis of a complete avulsion on tomographic pelvic floor US, when the plane with minimal dimensions and two additional cranial planes show an abnormal insertion of the muscle on the pubic rami [22]. Any defect of the LAM may result in an asymmetric position of the urethra, which could also be assessed in the reconstructed coronal plane. The images obtained could lead to a better understanding of the background of clinical complaints. Three-dimensional TPUS can be used for evaluation of the effectiveness of prosthesis implants. It allows analysis of the tension, dislocation and migration of suburethral slings [23] and could be also useful in the morphological visualisation of pelvic floor structures after muscle training [24]. Three-dimensional transducers are larger than those of 2D US, which may result in distortion of the anatomy and
Fig. 2 Three-dimensional TPUS, axial section of pelvic organs. a Normal anatomy. The urogenital hiatus area is marked with a dotted line. A anus, LA levator ani muscle, SP symphysis pubis, U urethra, V vagina. b Transobturator tape is visualised (arrows). c Tomographic
ultrasound imaging (TUI) enables more detailed assessment of the pelvic structures and levator ani morphology. In this patient, the urogenital hiatus is wider and a levator ani defect is seen on the right side (asterisk)
Three-dimensional transperineal ultrasound (3D TPUS) Methods and equipment Three-dimensional US, introduced by Kretz-Technik company (nowadays a part of General Electrics) in the 1990s, was originally designed for obstetric US. Currently, almost all US manufacturers offer 3D modality in their products, not only for obstetrics but also for urology, gynaecology, radiology, paediatrics and other specialties. Automatic, motorised volume transducers have a slightly larger surface area compared to 2D TPUS convex transducers, 4–8 MHz frequency, and a fast computer data analysis, and provide assessment of three perpendicular sections (particularly in the axial section) through pelvic floor anatomy (Fig. 2). Measurements
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false measurements of the pelvic floor structures. Moreover, due to its low resolution and depth of penetration, in some cases, 3D TPUS is unable to provide efficient visualisation of the superficial perineal muscles (bulbospongiosus and ischiocavernosus). In patients with higher-grade POP, the ROI may be too small to include the whole prolapse [19]. Four-dimensional transperineal US (4D TPUS) Methods and equipment The ability to perform simultaneous observation of three sections through the organs that are perpendicular to each other can be enriched by real time (4D US). Measurements This technique may be introduced for a very sensitive and spectacular functional assessment of the pelvic floor structures and their mobility during Valsalva manoeuvre and contraction. Clinical relevance Four-dimensional TPUS could directly indicate functional weakness of the LAM where defects are present. This method can be applied for evaluation of lower-grade prolapse; however, in patients with more severe symptoms of POP, it may not deliver a precise delineation of the anatomical structures. In a study of a group of 17 women, performed by Majida et al., it was only possible to assess the anterior and posterior borders of the LH during Valsalva manoeuvre in 29% of cases. Thus, improvements to this technique are required before it is introduced more widely for diagnosis of POP [17]. However, it is a very good method of archiving and could be used before and after operations in the pelvic floor area for the assessment of outcomes.
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available on the market, and they differ in technical aspects. Those most frequently used are the radial electronic probe (Hitachi Medical Systems, Japan) and the rotational mechanical probe (type 2052 B–K Medical, Herlev, Denmark). These transducers differ in the method of 3D data acquisition: free-hand in the electronic transducer and a motorised automatic system in the mechanical one. By using the 2052 transducer, 3D data are acquired over a distance of 60 mm in 60 s and are composed of 300-aligned transaxial 2D images. The 3D volume can be also archived for off-line analysis [25]. The high frequency (9–16 MHz) and direct contact to the anal canal structures provide an excellent resolution. Automatic motorised 3D acquisition reduces to a minimum the artefacts that appear in free-hand 3D systems. Thus, this method has become a gold standard in proctology and its clinical relevance has been described in many publications [7]. Measurements The normal US anatomy and differences of anal canal morphology between males and females are very well known [25]. Three separate levels are defined, as the muscles of the lower and the upper part are different [25]. High-frequency EAUS enables precise measurement of the anal sphincters and differentiation of their lesions (defects, scarring, thinning, thickening and atrophy) [25] (Fig. 3). Moreover, it is also helpful in the detection of perianal fistulas, especially in visualisation of fistulous tracts after H2O2 injection and renders mode application [26]. Clinical relevance The technical achievements of 360° rotational transducers have encouraged their use for diagnosis of female PFD. The wide range of frequencies allows selection of the optimal frequency for pelvic floor patients. Three-dimensional endovaginal US (3D EVUS)
Endocavitary US High-frequency endoanal US (EAUS)
Axial images of pelvic floor structures obtained by highfrequency (9–16 MHz) 3D EVUS are similar to those obtained in 3D TPUS; however, higher frequency provides better resolution of the organs examined [27].
Methods and equipment Methods and equipment The patient may be scanned in two different positions, either on the left decubitus or in gynaecological position. Endocavitary US transducers, initially using a 2D 360° rotational probe and then developed for 3D acquisition, have been introduced to clinical practice for examination of the anal canal. There are very few transducers currently
EVUS is performed in the dorsal lithotomy position, with the pelvis elevated on the patients’ own fists. No patient preparation is required and no rectal or vaginal contrast is used. The transducer should be inserted into the vagina in a neutral position to avoid excessive pressure on surrounding
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Fig. 3 Three-dimensional, high-frequency US with the use of a 360° rotational transducer. (a and b) Endovaginal US. a Axial and b sagittal plane of normal pelvic floor structures. The levator ani muscle (LAM) thickness can be measured in the axial plane (line). The rhabdosphincter muscle can be assessed in the sagittal plane (arrows); A anus, BN bladder neck, SP symphysis pubis, U urethra. (c and d) endoanal US. c Normal anatomy of the anal canal in the axial plane. EAS external anal sphincter, IAS internal anal sphincter, LM longitudinal muscle, SE subepithelial layer. d External anal sphincter lesion distending from 10 to 2 o’clock. Volume render mode was applied for better visualisation of the lesion and muscle extension
tissues that might distort the anatomy. A stable position should be maintained and there should be no movement during data acquisition. Measurements and clinical relevance For an overall view of the pelvic floor, the SP should be defined and located at the 12 o’clock position. As in 3D TPUS, it is considered the reference point of symmetry of the pelvic organs in the axial plane. Data acquisition starts above the bladder neck and ends beyond the superficial perineal muscles [27]. The pelvic floor structures should be assessed in four axial levels, as reported by Santoro et al. [27]. The axial plane enables evaluation of symmetry/ asymmetry of the urethra and anal canal and allows precise measurements of their diameters. High-resolution 3D EVUS visualises detailed morphology, enabling differentiation of the urethral structures (rhabdosphincter muscle, urethral smooth muscle), defining urethral support (e.g. vaginal sulci) and the surrounding structures [27–29] (Fig. 3). Wieczorek et al. have shown that 3D EVUS provides excellent reliability for measurement of urethral diameters and good reliability for measurement of the rhabdosphincter muscle [29]. It may be also helpful in
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precise assessment of the distribution of urethral abnormalities, such as diverticula or pathological calcifications. Moreover, in the axial plane, the LH and LAM can be assessed [27]. Santoro et al. have reported that this technique allows repeatable measurements of the LH, regardless of medical specialty [30]. Shobeiri et al. [28] have successfully employed 3D EVUS for evaluation of LAM elements and, due to the ability to obtain oblique sections, have defined the localisation of each muscle in the pelvis. The advantage of 3D high-frequency EVUS with a 360° field of view is the ability to obtain good-quality images in all reconstructed sections, and visualisation of the pelvic organs in many planes, reflecting their distorted shape. A single 60 s acquisition allows a 3D cube to be obtained with anatomical data, where all the reference measurements for 2D and 3D TPUS can be taken. High-resolution 360° field of view EVUS could be also helpful in pre- and post-operative assessment of PFD. Tapes and anterior and posterior meshes are clearly visualised, as well as some complications such as abnormal fluid collections, abscesses and haematomas. The ability to assess these structures in oblique planes gives information about their distension, tension and potential displacement.
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Endocavitary US transducers in urology were mainly designed for diagnostics and treatment monitoring (biopsy, brachytheraphy) in the prostate. However, their physical properties, such as high frequency (9–16 MHz), the ability to work in 3D mode and the electronic character of some of these transducers providing colour and spectral Doppler modes, encourages their use in PFD.
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Measurements and clinical relevance
The biplane probe (type 8848, B–K Medical) was originally designed for endoanal use in urology and, in time, appeared to also be very useful in endovaginal examinations. This transducer has linear and transverse arrays and beam formation perpendicular to the examined organs. With a near transverse focal point and high frequency (9–12 MHz), it enables an accurate analysis of the anterior and posterior pelvic floor compartments. Three-dimensional data acquisition in a longitudinal plane can be performed by a motorised 180° rotational mover, while in axial plane, free-hand acquisition is possible by withdrawing the transducer outside the vagina [25].
This transducer provides precise assessment of the morphology of the urethral complex, enabling differentiation of its anatomical and functional parts (intramural part, midurethra, distal urethra) [31, 32] (Fig. 4). Some congenital abnormalities such as dystopic ureters and diverticula can be recognised and precisely evaluated in three sections [8]. Additionally, 2D real-time functional evaluation can be performed during Valsalva manoeuvre. In incontinent patients with no coexisting prolapse, it provides accurate measurements of the urethra, comparable with those obtained in TPUS. However, in patients with high-grade prolapse, the transducer inserted into vagina prevents development of the prolapse, resulting in false measurements of the urethra [33]. Dynamic assessment is also important in posterior compartment disorders, differentiating enterocele from rectocele, and visualising internal intussusception, rectal prolapse and anismus [34]. Another feature of this method is the ability to obtain the data in colour Doppler mode, which provides both 2D and 3D information about the vascular pattern of examined structures (Fig. 4). It is known that vascularity plays an
Fig. 4 Three-dimensional EVUS with the use of a biplane transducer with transverse and linear array. a Axial section of the midurethra allows visualisation of urethral morphology. The rhabdosphincter muscle (long arrows) and pubocervical fascia (short arrows) are seen. U urethra. b and c Midsagittal section of the urethral complex in the patient after intravaginal sling insertion c The tape (arrow) is visualised as a hyperechoic structure with an acoustic shadow
artefact. c Application of colour Doppler mode allows evaluation of the vascular patter of the urethra. B bladder, BN bladder neck, EO external urethral orifice, RS rhabdosphincter, SP symphysis pubis. d Midsagittal view of the posterior compartment with relevant structures. The anorectal angle (ARA) can be measured. The perineal body is visualised (arrow, dotted line). AC anal canal, R rectum, RVS rectovaginal septum
3D EVUS with a biplane 180° rotational transducer Methods and equipment
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important role in maintaining continence and any dysfunction results in UI [35]. Urethral vascularity in nulliparous patients has been described by many authors [32, 36], who have reported that anatomical and functional parts of the urethra present different values of vascular parameters. Further studies are needed to find out the clinical relevance of this observation. The vascular pattern can be also obtained in 3D, which might be useful, for example, in planning surgery.
Discussion Modern ultrasound technologies include a variety of available types of probes, with different frequencies and accesses, starting from the widely known low frequency 2–6 MHz convex transducers used by radiologists or obstetricians, to specialised and sophisticated endocavitary high-frequency equipment designed for urology or proctology. Each type of ultrasound examination has some limitations, resulting from differences in the size, shape and frequency of the transducers. Technical innovations such as 3D or 4D US enrich the quality and range of information obtained. Different types of software give additional abilities of post-processing, allowing for very precise visualisation of the morphology and function of female pelvic anatomy and pelvic floor disorders and their causes. Among alternative methods used in the diagnostics of pelvic floor disturbances, cystocolpoproctography and MRI should be mentioned. Cystocolpoproctography reliably shows the anatomical relations of pelvic floor organs; however, radiation and the necessity of filling the rectum, vagina and bladder with contrast, which is embarrassing for the patient, greatly limit the use of this method. Moreover, the availability of the method is lower than for US, and even in the centres that perform such examinations, dynamic assessment is not always possible. MRI is generally a good method and in many centres is treated as the gold standard, but it also has limitations. These include claustrophobia, low availability, high cost and long duration of the procedure. It is also important to realise that very few centres can perform dynamic evaluation, which is so crucial for proper assessment of pelvic floor disturbances. Evaluation of the images obtained in both cystocolpoproctography and MRI requires highly experienced specialists. On the other hand, US is widely available, relatively cheap, repeatable, fast and easy to perform. Unlike other imaging methods, its main advantage is that it can be performed by the clinician himself, as an extension of clinical examination. Ultrasonography also has limitations. The method is operator dependent and requires good knowledge about the possibilities and usefulness of various transducers and
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anatomical accesses. Artefacts produced (excessive pressure, improper placement of the transducer and physics of the ultrasound beam) may hamper the results, which can be mistakenly interpreted by an inexperienced operator. However, the method can be learnt quickly, enabling good overall evaluation of pelvic floor anatomy, which has already been demonstrated [29]. Development of modern high-frequency, automatic transducers has led to a diminishing number of artefacts, while at the same time allowing quantitative assessment of vascularisation and differentiation of very small anatomical structures [28], which allows correlation of US PF morphology with functional tests such as urodynamics or electromyography to be attempted [37]. Modern US diagnostics may bring into routine clinical practice a range of new information about anatomical disturbances and their influence on PF function. This could be reflected in the choice of the most appropriate treatment. Knowledge about the possibilities of different US techniques might also be useful in post-operative assessment, which could lead to better understanding of the causes of surgical failures, and so reduce their incidence. Further development of modern US modalities requires a multidisciplinary approach and more investigations of new opportunities in the field. Disorders of the complex anatomy and function of the pelvic floor must be assessed and managed by a team that includes a proctologist, gynaecologist, urologist and radiologist, as an abnormality found in one compartment often coexists with disturbances in other compartments, and all of them must be treated holistically, for both medical and ethical reasons. Conflict of interest of interest.
The authors declare that they have no conflict
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