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The use of ultrasound in the evaluation of pelvic organ prolapse
Reviews in Gynaecological Practice 5 (2005) 182–195 www.elsevier.com/locate/rigp
The use of ultrasound in the evaluation of pelvic organ prolapse Christopher Barry a,*, Hans Peter Dietz b,1 b
a James Cook University Clinical School, Townsville Hospital, 10 Hooper St, Townsville, Qld 4810, Australia Western Clinical School, Nepean Campus, University of Sydney, Nepean Hospital, Penrith, NSW 2750 Australia
Received 31 March 2005; accepted 14 June 2005
Abstract Pelvic organ prolapse is a common problem significantly affecting women’s quality of life, particularly in later years. Transperineal, twodimensional ultrasonography can be used for the assessment of female pelvic floor dysfunction for pelvic organ morphology, tissue biomechanics and in vivo properties of prosthetic implants. The role of transperineal ultrasound for the assessment of pelvic organ prolapse is still developing, but with the rapid development of three- and four-dimensional technology may allow dynamic assessment of anatomy in the axial plane. Three-dimensional ultrasound also permits the storage of data volumes for analysis at a later stage, which introduces the ability to independently review images in any plane offline. Further evaluation and research of this imaging tool is required to identify its place in the assessment of women for pelvic organ prolapse and its role in surgical audit. # 2005 Elsevier B.V. All rights reserved. Keywords: Pelvic organ prolapse; Three-dimensional ultrasound; Transperineal ultrasound; Audit; Vaginal prolapse surgery
1. Introduction Studies in the United States of America have suggested that one in nine women will require an operation for pelvic organ prolapse (POP) by the age of 80, and of significant concern is that up to 30% of these women will require reoperation [1]. This implies that either our assessment is less than satisfactory, or our treatment is unsatisfactory. Comparison of therapeutic interventions in the research setting has been difficult due to a lack of standardisation of assessment methods. Initial attempts to quantify POP using clinical assessment utilised the Baden–Walker classification system [2], which allowed the degree of POP to be described and documented as a grading scale of I–IV. This method has never been validated for its reproducibility however. In an attempt to standardise the assessment of pelvic organ descent a pelvic organ prolapse quantification system (POPQ) (Fig. 1) [3] has been developed, which has been validated * Corresponding author. Tel.: +61 7 4796 3588; fax: +61 7 4796 1771. E-mail addresses: [email protected] (C. Barry), [email protected] (H.P. Dietz). 1 Tel.: 61 2 4734 1809; fax: 61 2 4734 3485. 1471-7697/$ – see front matter # 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.rigp.2005.06.004
for both intra- and inter-observer reliability [4], and adopted by the International Continence Society (ICS) [5]. However, in a recent study it was suggested that only 40% of clinicians who have an interest in urogynaecology actually utilise this system on a routine basis, as it is considered by some to be clumsy to use [6]. In addition, this system does not address potential defects of the lateral vaginal support mechanisms, which may or may not be important in the pathogenesis of pelvic organ prolapse [7–9]. The place of two-dimensional ultrasound for the investigation and management of women with gynaecological problems is now well established. Both transabdominal and transvaginal scanning permit the identification of the uterus and adnexae with excellent resolution to direct appropriate management. However, transabdominal ultrasonography provides poor imaging of the lower pelvic structures, particularly the support structures of the vagina and levator muscle group, due to the depth of the tissues from the transducer. Transvaginal ultrasound permits excellent visualisation of the bladder, urethra and the posterior compartment but distorts the pelvis thereby precluding accurate assessment of POP [10]. In an attempt to overcome this, investigators have utilised introital [11],
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Fig. 1. Diagrammatic drawing of ICS POP-Q system.
transperineal and translabial ultrasonography [12,13]. Information can be obtained with no discomfort to the patient as part of a routine pelvic examination. It is therefore possible to improve our understanding of POP using transperineal ultrasound for both clinical and research purposes by adding a further objective measuring system to the ICS POP-Q system. The addition of three-dimensional ultrasonography provides the opportunity for visualisation of the axial plane of the pelvis, improved data storage and therefore independent audit. This review will describe the technology behind threedimensional ultrasonography, compare other imaging modalities and then discuss the information that can be obtained using two-, three- and four-dimensional ultrasonography (US). The future place of this imaging modality for pelvic organ prolapse will also be discussed.
2. Imaging modalities Early attempts to identify and image pelvic organ descent in the female pelvis were initially undertaken using X-ray imaging with contrast, to enable the identification of the axis of the vagina as well as prolapse [14]. More recently imaging with fluoroscopic dynamic cystoproctography (FDC) has permitted additional information to be obtained in women with symptoms as well as signs of POP [15,16]. Evacuatory proctography helps identify both anterior and the much less common posterior rectocele. It is also able to identify intussusception of the sigmoid and rectum. With the addition of peritoneography enteroceles can be identified directly. Dysfunctional defaecation causing anismus can be identified by discoordinated levator relaxation. Attempts to define pelvic organ prolapse using this technique use a distance of between 3 and 6 cm below the pubococcygeal line as representing prolapse [17]. In a number of small studies dynamic cystoproctography seems to identify rectocele and cystocoele better than clinical examination [16,17]. This may be because women are in the sitting position and
therefore have to relax their pelvic floor in order to defaecate, while at the same time bearing down. This is therefore more likely to mimic the symptoms of prolapse than on supine examination. Defects in the posterior compartment may be exaggerated by the fact that the labelled contrast medium abnormally distorts the rectum by its nature and volume. Level I defects, i.e. vault prolapse or uterine prolapse are less easily identified. There is however a paucity of data on normal asymptomatic women. Potential concerns over the use of radiation, expense, complexity and the fact that women find it embarrassing to defecate in front of an X-ray machine have limited the use of this imaging technique to those women with unexplained lower bowel symptoms or for research. The advent of magnetic resonance imaging (MRI) in the last 15 years for the identification of pelvic organ prolapse and pelvic organ dysfunction, has brought previously unparalleled definition, until then only seen on cadaveric dissection [18]. Developments in three-dimensional modelling and fast image acquisition now permit the identification of anatomy in both static and dynamic states [19]. However, the true extent of a prolapse maybe difficult to identify, unless a consistent Valsalva manoeuvre is performed. During an MRI, the patient is supine, in an enclosed room where timing and coaching is critical for correct image acquisition. Machines that permit images to be taken in the sitting position are as yet still very expensive and limited to tertiary centres only [20]. This precludes widespread use for large studies. Studies undertaken in symptomatic and asymptomatic women have been used to help define prolapse on MRI [21]. Prolapse was defined as descent below the sacrococcygeal inferopubic point (SCIPP) of the inferior most part of the prolapsing organ (Fig. 2). Addition of contrast media permits better identification of pelvic organs improving more accurate measurement [22]. The only study comparing independent standardised clinical assessment using the POP-Q studied 20 women with pelvic organ prolapse and 10 asymptomatic volunteer control subjects. There was fair correlation with clinical staging
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also levator hiatal dimensions have been demonstrated following pregnancy [28] and following surgery [29]. Apart from MRI being more expensive and apart from the mentioned problems with data acquisition during manoeuvres, there are also concerns that abdominal straining may move the levator plate relative to the pre-determined axial planes, therefore changing the angle of the image. This is difficult to compensate for with fixed equipment and variable Valsalva efforts.
3. Transperineal technique for ultrasonography
Fig. 2. Mid-sagittal image on MRI of a woman with a cystocele (C) and rectocele (R) on Valsalva. The SCIPP line is shown.
(KAPPA = 0.61). Further analysis suggested that clinical assessment was enhanced by this imaging modality as it identified enterocele more accurately. Singh used a different system to that proposed by Yang using the hymen rather than fixed bony landmarks for reference points, which is more likely to mimic clinical practice [23]. Other measurement systems include the HMO classification, which uses the levator hiatus as a line of reference, and describes not only descent beyond the levator hiatus but also rotation of the levator plate [24]. Further information can be obtained with three-dimensional modelling using sophisticated rendering tools to assess levator size and morphology [25–27]. Changes in the size, shape and nature of the levator muscle complex and
Ultrasound assessment is undertaken with the woman placed in the supine position, having emptied her bladder and bowel if necessary [30]. There have been concerns about examination while supine and whether adequate reproduction of prolapse herniation occurs [31]. A small study looking at the anterior compartment would suggest that there is no difference in the final resting place of the bladder or urethra on maximal Valsalva [32]. The transducer is covered with a powder-free glove or similar latex sheath (non-latex if allergic) prior to the examination and placed on the perineum in the mid-sagittal plane. Ultrasonic jelly is used at both interfaces and the probe pressed firmly but without causing discomfort such that the introitus is covered and no air bubbles are present to interfere with image quality (Fig. 3a). Data volumes are then acquired at rest and on maximum Valsalva, having practiced the manoeuvre a number of times. A mid-sagittal image is obtained as shown in Fig. 3b and c, with diagrammatic representation also shown. Pressure must be released on the transducer head when identifying prolapse as this may reduce the accuracy of
Fig. 3. (a) Represents a schematic diagram of the placement of the transducer for transperineal US; (b) the image obtained in the mid-sagittal plane with the pelvic organs labelled: SP, symphysis pubis; V, vagina; R, rectum; U, urethra; B, bladder; PR, puborectalis; a diagram highlighting the structures visualised.
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measurement. The image should be set for maximal acquisition angle both antero-posterior and laterally which usually equates to 708 and 70–858, respectively. The image should contain the lower part of the symphysis pubis, urethra, bladder upper vault or uterus, rectum, Pouch of Douglas and anorectal junction. The levator ani, i.e. puborectalis and pubococcygeus should also be visible, as may the external anal sphincter. For a complete examination an abdominal and transvaginal scan should be performed to exclude other gynaecological causes that may relate to presenting symptomatology of a prolapse. Using fourdimensional imaging orientation in the sagittal plane can be checked, thus by-passing the normal learning curve for use in two-dimensional mode.
4. Two-dimensional ultrasound Ultrasound has been used for pelvic floor assessment for some considerable time in two-dimensional B mode and more importantly for the assessment of lower urinary tract dysfunction with particular reference to incontinence [33– 35]. Imaging of the lower pelvis can be undertaken using transabdominal, transvaginal, endoanal ultrasound, introital and transperineal/translabial ultrasound. Endoanal ultrasound permits the identification of defects of the internal external anal sphincter, as well as providing information on the morphological features and defects of puborectalis created by trauma associated with childbirth. However, with the discomfort involved, limited depth and spatial orientation together with interference with mobility of the pelvic organs for identifying pelvic organ prolapse, intra-cavitary ultrasound has seen only limited use in pelvic organ prolapse assessment. For the purpose of this discussion, we will therefore concentrate on transperineal/translabial ultrasound and how it can be used to assess pelvic floor integrity.
5. Anterior compartment Imaging of the anterior compartment allows the visualisation of the bladder, urethra and surrounding support structures. This can aid in the diagnosis of vaginal, bladder and urethral pathology, such as Gartner duct cysts, bladder stones, congenital abnormalities, injury/haematoma, diverticula and tumours. Transperineal ultrasonography can add clinical information on bladder neck opening [11,36], mobility [37–39] and incontinence. It appears to provide as much information as videocystourethrography [40,41]. In women complaining of urinary incontinence symptoms, particularly with overactive bladder symptoms, a measurement of bladder wall thickness, which has been shown to correlate with evidence of detrusor instability (OAB) [42], can be added. The biomechanics of pelvic tissues can be quantified by measuring bladder neck descent and urethral rotation.
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Measurement is undertaken by assessing images at rest, on levator contraction and on maximum Valsalva. Attempts to standardise the Valsalva manoeuvre have involved the use of spirometry [39], intra-vaginal pressure transducers [43] and oral pressure measuring devices using a sphygmomanometer [44]. The latter study investigated 80 women undergoing urodynamic investigation and compared maximum Valsalva to a standard rise using a modified sphygmomanometer, and measured intra-abdominal pressure changes. Rises in intra-abdominal pressure were more reproducible and consistent using a sphygmomanometer. Despite this some authors prefer to use maximum Valsalva. Excellent test–retest parameters for measurement of bladder neck mobility using this technique would confirm the validity of this method [45]. However, great care must be taken to avoid reflex contraction of the levator ani, and this is true regardless of whether standardisation for Valsalva pressures is attempted. Measurement of bladder neck mobility is undertaken using a split screen on the ultrasound monitor, and images taken as described. Measurements are taken from the inferoposterior margin of the symphysis pubis, in the midline, and a line drawn to the posterior point of the bladder neck at right angles as shown in Fig. 4. Angles of excursion can then also be measured. Pelvic organ mobility on Valsalva may be a heritable trait [46]. Studies using bladder neck mobility as a criteria of ‘‘at risk’’ women going through childbirth permitted an intervention study for an antenatal exercise program, which identified a better outcome for these women undergoing antenatal pelvic muscle training [47]. The method may also provide a means to identify women at greater risk of POP prior to childbirth. However, criteria for the definition of ‘‘hypermobility’’ vary considerably with bladder neck descent of between 1.2 and 40.2 mm in continent nulliparous women [48]. Once descent exceeds 20 mm there is a strong correlation with USI [49]. The anterior compartment is well suited to ultrasound investigation, as it has excellent contrast characteristics due to the fact that there is always some urine in the bladder. There have been a number of studies looking at POP which demonstrate that prolapse can be identified easily and measured using this technique [50,11,51]. In the largest study to date involving 145 women, there was good correlation when two-dimensional ultrasound using the midsagittal plane when compared with ICS POP-Q assessment and the degree of prolapse [52]. With a correlation coefficient, r = 0.72 for anterior compartment defects (cystocele), this method appears to be as good as clinical evaluation using the ICS POP-Q and would suggest that this method of imaging is sufficiently accurate not only to identify prolapse but also allow quantification. The leading edge of the cystocele, correlating with point Ba on the ICS POP-Q is used as the point of greatest descent. A line is drawn from the inferoposterior margin of the symphysis pubis horizontally and distance above or below this line is
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Fig. 4. (a) A mid-sagittal view showing the bladder neck at rest. Measurements have been taken using on screen callipers as described and (b) the same measurement parameters on Valsalva (bladder neck descent (BND) = 2.95 0.625 = 2.325 cm).
measured Fig. 5. Translabial ultrasound may therefore have a role in confirming clinician’s examination findings or surgical outcome. Other measurements have been suggested using a line between the symphysis pubis and anorectal junction as a reference line for depth of herniation of the prolapsing [51]. Measurements can also be made of the anorectal junction during evacuatory proctosonography and levator contraction. However, the reliability of this measurement technique has not been validated for POP although was in good agreement with evacuatory proctography for the diagnosis of rectoceles and rectal intussus-
ception, with anorectal angles also having a good correlation (Fig. 5). Prosthetic implants are increasingly being used, especially in incontinence surgery, where traditional surgical techniques such as the Burch colposuspension have been largely superseded by permanent, synthetic, porous tapes [53]. These implants can be visualised easily in the anterior compartment on transperineal ultrasound and their mechanical properties studied in vivo, giving clues as to the mechanism of their action [54–57]. With the increasing use of synthetic mesh to improve the results of cystocele and
Fig. 5. (a) 2D image of cystocele with standard measurements and (b) diagram of measurements using perpendicular line from infero-posterior margin of symphysis pubis.
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Fig. 6. (a) Enterocele on Valsalva with fluid at apex; (b) uterine descent with cervix at introitus; (c) rectocele visualised at rest and on Valsalva with measurements of depth and length. Note the rectovaginal septal discontinuity.
Fig. 7. (a) Transducer head demonstrating sweep of motorised micro-array crystals and (b) diagrammatic representation of projection of image in 3D volume.
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rectocele repair [58–60] these implants can also be studied using ultrasound as they generally are hyperechogenic. However, sagittal views of the mesh placed in the anterior or posterior vaginal wall are not as clear as for sub-urethral slings.
6. Central compartment The central compartment can be visualised relatively easy with transperineal ultrasound to identify uterine prolapse and descent measured relative to the urogenital
Fig. 8. (a) 3D ultrasound volume of pelvic floor. Mid-sagittal plane at top left, coronal plane on top right, axial plane bottom left. The bottom right image shows a rendered volume encompassing the pubovisceral muscle; (b) axial plane imaging at rest (left) and on Valsalva (right); (c) diagram of levator hiatus as seen from caudally (U, urethra; V, vagina; R, rectum; PR, puborectalis; IC, ischiococcygeus; C, coccygeus); (d) measurement of antero-posterior, transverse diameters and area of levator hiatus on Valsalva.
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Fig. 8. (Continued ).
or levator hiatus, although vault prolapse may be more difficult to identify due to problems with tissue contrast and differentiation at the top of the vault. In the study quoted above, the uterus was not identified in 18% of cases, but identification improved following the initial pilot study [52].
Correlation was good for descent of the cervix (r = 0.77), with the ultrasound measurement tending to be 2 cm more distal than on ICS grading. Enterocele herniation can be identified easily and appears as a projection of the Pouch of Douglas descending
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into the vagina with or without small bowel [61]. Identification of enterocele formation, which may be anterior or posterior, may help when planning surgical treatment to avoid injury to the bowel, as well as for quantification for research Fig. 6.
7. Posterior compartment The posterior compartment encompasses the rectum and anal canal, and is bounded anteriorly by the rectovaginal septum, inferiorly by the perineal membrane, and superiorly by the uterus or upper vault and Pouch of Douglas. There has been debate as to whether posterior compartment defects are specific fascial disruptions or defects [62], disruption [63] or separation of the levator complex [64] with disruption of level III support of the perineal membrane [65]. It is likely that it is a combination of all or some of these three support mechanisms. In addition, perineal hypermobility may cause pseudorectoceles. Dynamic transperineal ultrasound of the pelvic floor, particularly looking at the rectum and external anal sphincter in a small study of 10 women, identified the different compartments of the female lower pelvis and demonstrated similar findings when the same patients had either endoanal ultrasound or evacuatory proctography [66]. The study was undertaken with patients on their left lateral side, which may have interfered with the Valsalva and contraction of the pelvic muscles. No comparison has been made with patients on the left lateral side versus the supine position. Some women however found it too uncomfortable as contrast medium was used in both the rectal and vaginal cavity, and refused to continue. This suggests that unless it was used in preference to evacuatory proctography it is unlikely the use of rectal contrast would have a place for the routine assessment of women with POP. Excellent images can be obtained without contrast. Two-dimensional ultra-
sound can visualise defects in the rectovaginal septum, which in the mid-sagittal plane appears as a discontinuity of the anterior muscularis layer of the anorectum on Valsalva. The size and depth of this discontinuity can be measured (see Fig. 6). Such findings are be consistent with the theory that true rectoceles are due to a defect or weakness of the fascial covering either in the transverse or longitudinal plane. Studies suggest that up to 10% of nulliparous women have congenital rectovaginal septal defects, which are nearly always asymptomatic [48]. Reproducibility of measurement of rectoceles has not as yet been published. Assessment for rectocele prolapse may provide quantitative comparative data on pre- and postoperative parameters for research. Using on-screen callipers rather than clinical grading, allowing more accurate measurement. Studies are currently ongoing looking at this technique as a tool for assessment. Other features that may be examined include levator contraction [67] and possibly the external sphincter, as well functional emptying of the rectum [66].
8. Three-dimensional imaging 8.1. Technological developments in three-dimensional ultrasonography Development in three-dimensional data acquisition has been progressing since its early years in the 1970s and 1980s [68]. Three-dimensional ultrasound was first performed using freehand or motorised withdrawal techniques, predominantly for intra-cavitary application. Image acquisition can now be achieved by rapid oscillation of a group of elements within the transducer head. As each pixel has a defined location relative to the transducer, a volume of image data can then be reconstructed. These areas are no longer
Fig. 9. (a) Pelvic floor ultrasound in the C or axial plane, possible paravaginal defect and (b) right-sided levator avulsion on MRI (left) and 3D ultrasound (rendered volume, right).
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Fig. 10. (a) Axial view of permanent synthetic mesh overlay for a rectocele. Arrow denotes mesh covering defect; (b) a rendered view of a disrupted/dislocated synthetic, non-absorbable mesh for cystocele repair; (c) a rendered image of an anterior non-absorbable mesh implant using the trans-obturator route; (d) a rendered image of a PIVS (posterior infra-coccygeal vaginal slingoplasty) tape, for vault prolapse.
called pixels but ‘voxels’. Such volumes are normally represented in the three orthogonal planes (A, B and C plane), with the rendered image in the fourth viewing box (Fig. 7). This rendered image represents a semi-transparent representation of all the voxels in an area defined by the user. Software allows image manipulation in all three dimensions, thereby permitting independent analysis at a later stage or review for further studies. Four-dimensional imaging allows the real time acquisition of volumes, which again can be viewed either in
all three orthogonal planes or as the rendered volume. This simplifies correct alignment of the transducer and cine recording of defects of the pelvic floor and provides an exciting capability for dynamic imaging of the pelvis. 8.2. Assessment of the pelvic floor The advent of three-dimensional ultrasound has now provided an imaging modality, which has some of the advantages of MRI, i.e. images in all three planes,
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particularly visualisation in the axial plane. This allows cross-sectional qualitative and quantitative assessment of paravaginal support structures, the levator ani, levator hiatus and urogenital hiatus. In addition, one may also to be able to view the external and internal sphincter complex of the anus at the same time. The levator hiatus is a crucial structure for the female pelvis as it provides passage of the rectum, vagina and urethra and support of the pelvic floor. It therefore also constitutes a potential route for herniation of the pelvic organs. Damage to the levator muscle complex or congenital abnormalities of structure and/ or function may lead to some women developing prolapse later in their life. Specific abnormalities of the attachment of the levator ani or the surrounding fascia have been identified in cadaveric dissection to explain disruption and widening of the levator gap [65,69]. It is believed by some clinicians to be an important factor not only in the development of prolapse but also recurrence of pelvic organ prolapse after surgical treatment [64]. Three-dimensional ultrasound permits assessment of both levator morphology and levator dimensions (Fig. 8). Measurements of the levator muscle thickness and area may not be very repeatable with current technology [70]. However, levator dimensions at rest and more so on Valsalva appear to have a good correlation with greater degrees of prolapse on clinical assessment and good repeatability (intra-class correlation coefficients between 0.7 and 0.82) [71]. Measurements are taken by identifying the plane of minimal hiatal dimensions in the mid-sagittal plane, between the posterior or dorsal aspect of the symphysis pubis and the most anterior or ventral aspect of the puborectalis muscle. The C plane of the volume is then used to identify the plane of minimal dimensions in an oblique axial view and to measure diameters in the coronal and sagittal planes and the hiatal area, as shown Fig. 8. As yet it is not possible to render three-dimensional models of the levator ani using three-dimensional ultrasound, which would permit full morphological assessment as well as qualitative assessment of this muscle group, such as has been undertaken with MRI [27]. Initial studies comparing clinical recurrence and levator dimensions suggest that a wider hiatus on Valsalva may be associated with a higher incidence of recurrence (Barry submitted ANZJOG 2004). The most frequently seen morphological abnormality, avulsion of the anteromedial aspect of the pubovisceral muscle off the pelvic sidewall, seems to be common [71,72] and is clearly due to childbirth (Dietz and Lanzarone, 2005 RANZCOG abstract). Such defects of the pubovisceral muscle seem to be associated with prolapse of the anterior and central compartment rather than incontinence (Steensma and Dietz 2005 IUGA abstract submitted) (Fig. 9). Debate continues with regards to the significance of paravaginal defects and whether they represent disruption of
the endopelvic fascia laterally at the vaginal sulci [73,74], where it attaches to the pelvic sidewall, or whether they reflect disruption of the insertion of the puborectalis/ pubococcygeus complex leading to cystocoele formation [63]. Other workers have suggested that prolapse of the anterior compartment is not simply a midline disruption of fascia but also disruption at the pubocervical fascia or its remnants, in the absence of the uterus, with caudal displacement of the bladder [75]. There are some authors who believe that discrete lateral paravaginal breaks in the fascia result in a higher recurrence of cystocele formation or incontinence [7,73,76,77]. A number of studies have used abdominal scanning to help identify anterior paravaginal defects, but the reliability of this method has been questioned due to problems with image quality and positioning [78–81]. Research using MRI would suggest that defects in the fascia may be visible, but direct identification of fascial tissue is impossible. Clinical examination is also notoriously unreliable [82,83]. Without specific criteria for clinical detection, correlation of imaging, surgical findings or cadaveric dissection this problem will be difficult to resolve. Three-dimensional ultrasound allows dynamic imaging with increasing resolution, as new developments continue. The latest innovation, volume contrast imaging (VCI), enables resolutions close to magnetic resonance imaging standards in all three orthogonal planes, while offering far superior temporal resolution. This opens up new avenues for research in vivo. Research priorities are the validation of this new imaging technique against MRI in both normal controls and symptomatic women, and work on the clinical relevance of the observed morphological abnormalities. Identification of prosthetic implants can be aided by three-dimensional US, to help define changes in pelvic floor anatomy and integrity of the implants (Fig. 10).
9. Conclusion Transperineal ultrasonography is simple to learn, causes minimal discomfort to the patient and can provide useful information on structure and function in those women complaining of symptoms of pelvic floor and bladder dysfunction. The technology is in a state of rapid development. Recent advances permit better resolution and tissue definition, especially in the axial plane. This is particularly helpful in identifying levator muscle anatomy. 3D and 4D ultrasound allows data storage of volumes of information as opposed to single plane images. This permits offline analysis and independent audit. There are still a number of important issues to resolve in regards to its use in clinical practice and as a research tool, but it appears likely that the technique will see more widespread use in the future.
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Practice points Pelvic organ prolapse is a common problem in women. It accounts for a significant number of operations and currently there is an unacceptably high recurrence rate. Two-dimensional translabial/transperineal ultrasound permits simple evaluation of the degree of prolapse along with morphological assessment of the bladder, urethra and rectum. This technique is easy to learn, can be performed with equipment available in virtually all gynaecological units in the developed world, and is well tolerated by the patient. Three-dimensional ultrasound allows imaging of the axial plane, and provides for the collection of volumes of imaging information, which then can be stored or transferred off site, for analysis and interpretation at a later date. Recent innovations such as 4D real-time volume imaging and volume contrast imaging suggest that pelvic floor ultrasound may overtake MRI as the imaging method of choice for pelvic floor dysfunction. In the future identification of specific fascial defects or changes in levator ani, morphology may permit surgery to be tailored more effectively, thereby reducing recurrence rates.
Research agenda Comparison with other imaging modalities and validated clinical assessment. Comparison of surgical and ultrasound findings. Use in surgical audit. Definition of the role of specific morphological abnormalities in the development of symptoms of pelvic floor and lower urinary tract dysfunction.
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[45] Testretest and Interrater Reliability of the Ultrasound Assessment of Bladder Neck mobility. International Urogynecological Association (IUGA), Buenos Aires, Argentina; 2003. [46] Bladder neck mobility is a heritable trait. International Urogynecological Association (IUGA) Conference, Buenos Aires, Argentina; 2003. [47] Reilly E, Freeman R, Waterfield M, Waterfield A, Steggles P, Pedlar F. Prevention of postpartum stress incontinence in primigravidae with increased bladder neck mobility: a randomised controlled trial of antenatal pelvic floor exercises. BJOG 2002;109:68–76. [48] Dietz H, Eldridge A, Grace M, Clarke B. Normal values for pelvic organ descent in healthy nulligravid young Caucasian women. Neurourol Urodyn 2003;22:420–1. [49] Dietz H, Clarke B, Herbison P. Bladder neck mobility and urethral closure pressure as predictors of genuine stress incontinence. Int Urogynecol J 2002;13:289–93. [50] Creighton S, Pearce J, Stanton S. Perineal video ultrasonography in the assessment of vaginal prolapse: early observations. Br J Obstet Gynaecol 1992;99:310–3. [51] Beer-Gabel M, Teshler M, Barzilai N, Lurie Y, Malnick S, Bass D, et al. Dynamic transperineal ultrasound in the diagnosis of pelvic floor disorders: pilot study. Dis Colon Rectum 2002;45(2):239–45 [discussion, pp. 245–8]. [52] Dietz HP, Haylen BT, Broome J. Ultrasound in the quantification of female pelvic organ prolapse. Ultrasound Obstet Gynecol 2001;18(5):511–4. [53] Ward K, Hilton P. A randomized trial of colposuspension and TVT for primary genuine stress incontinence—2 year follow-up. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:S7. [54] Lo T, Wong A, Liang C, Soong Y. Ultrasonographic and urodynamics evaluation after tension-free vaginal tape procedure (TVT). Int Urogynecol J 2000;11:S31. [55] Dietz HP, Wilson PD. The ‘iris effect’: how two-dimensional and three-dimensional ultrasound can help us understand anti-incontinence procedures. Ultrasound Obstet Gynecol 2004;23(3): 267–71. [56] Martan A, Masata J, Svabik K, Halaska M, Voigt P. The ultrasound imaging of the tape after TVT procedure. Neurourol Urodyn 2002;21:322–4. [57] Masata J, Martan A, Kasikova E, Svabik K, Halaska M, Drahoradova P. Ultrasound study of the effect of TVT operation on the mobility of the whole urethra. Neurourol Urodyn 2002;21:286–8. [58] Sand P, Koduri S, Lobel R. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. M J Obstet Gynecol 2001;184:1357–64. [59] Dwyer PL, O’Reilly BA. Transvaginal repair of anterior and posterior compartment prolapse with atrium polypropylene mesh. BJOG Int J Obstet Gynaecol 2004;111(8):831–6. [60] Cervigni M, Natale F. The use of synthetics in the treatment of pelvic organ prolapse. Curr Opin Urol 2001;11(4):429–35. [61] Vierhout ME van der Plas-de Koning YW. Diagnosis of posterior enterocele: comparison of rectal ultrasonography with intraoperative diagnosis. J Ultrasound Med 2002;21(4):383–7. [62] Richardson A. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 1993;36:976–83. [63] Delancey JO. Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet Gynecol 2002;187(1):93–8. [64] Zacharin RF. Pulsion enterocele: review of functional anatomy of the pelvic floor. Obstet Gynecol 1980;55(2):135–40. [65] DeLancey JO. Structural anatomy of the posterior pelvic compartment as it relates to rectocele. Am J Obstet Gynecol 1999;180(4):815–23 [see comment]. [66] Beer-Gabel M, Teshler M, Schechtman E, Zbar AP. Dynamic transperineal ultrasound versus defecography in patients with evacuatory difficulty: a pilot study. Int J Colorectal Dis 2004;19(1):60–7.
C. Barry, H.P. Dietz / Reviews in Gynaecological Practice 5 (2005) 182–195 [67] Dietz H, Jarvis S, Vancaillie T. The assessment of levator muscle strength: a comparison of five different techniques. Int Urogynecol J 2002;13:156–9. [68] Gritzky A, Brandl H. The Voluson (Kretz) technique. In: Merz E, editor. 3-D ultrasound in obstetrics and gynecology. Philadelphia: Lippincott Williams & Wilkins Healthcare; 1998. p. 9–15. [69] Delancey JO, Hurd WW. Size of the urogenital hiatus in the levator ani muscles in normal women and women with pelvic organ prolapse. Obstet Gynecol 1998;91(3):364–8. [70] Steensma AB, Dietz P, Pardey J. The prevalence of major abnormalities of the levator ani in urogynecological patients. Abstract ICS 2004 Paris, 2004. [71] Steensma AB, Dietz H. 3D pelvic floor ultrasound in the assessment of the levator ani muscle complex. Ultrasound Obstet Gynecol 2004;24:258. [72] DeLancey JO, Kearney R, Chou Q, Speights S, Binno S. The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol 2003;101(1):46–53. [73] Richardson AC, Edmonds PB, Williams NL. Treatment of stress urinary incontinence due to paravaginal fascial defect. Obstet Gynecol 1981;57(3):357–62. [74] Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol 1976;126(5):568–73. [75] Shull BL. Pelvic organ prolapse: anterior, superior, and posterior vaginal segment defects. Am J Obstet Gynecol 1999;181(1):6–11. [76] Shull BL, Benn SJ, Kuehl TJ. Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative
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The use of ultrasound in the evaluation of pelvic organ prolapse Christopher Barry a,*, Hans Peter Dietz b,1 b
a James Cook University Clinical School, Townsville Hospital, 10 Hooper St, Townsville, Qld 4810, Australia Western Clinical School, Nepean Campus, University of Sydney, Nepean Hospital, Penrith, NSW 2750 Australia
Received 31 March 2005; accepted 14 June 2005
Abstract Pelvic organ prolapse is a common problem significantly affecting women’s quality of life, particularly in later years. Transperineal, twodimensional ultrasonography can be used for the assessment of female pelvic floor dysfunction for pelvic organ morphology, tissue biomechanics and in vivo properties of prosthetic implants. The role of transperineal ultrasound for the assessment of pelvic organ prolapse is still developing, but with the rapid development of three- and four-dimensional technology may allow dynamic assessment of anatomy in the axial plane. Three-dimensional ultrasound also permits the storage of data volumes for analysis at a later stage, which introduces the ability to independently review images in any plane offline. Further evaluation and research of this imaging tool is required to identify its place in the assessment of women for pelvic organ prolapse and its role in surgical audit. # 2005 Elsevier B.V. All rights reserved. Keywords: Pelvic organ prolapse; Three-dimensional ultrasound; Transperineal ultrasound; Audit; Vaginal prolapse surgery
1. Introduction Studies in the United States of America have suggested that one in nine women will require an operation for pelvic organ prolapse (POP) by the age of 80, and of significant concern is that up to 30% of these women will require reoperation [1]. This implies that either our assessment is less than satisfactory, or our treatment is unsatisfactory. Comparison of therapeutic interventions in the research setting has been difficult due to a lack of standardisation of assessment methods. Initial attempts to quantify POP using clinical assessment utilised the Baden–Walker classification system [2], which allowed the degree of POP to be described and documented as a grading scale of I–IV. This method has never been validated for its reproducibility however. In an attempt to standardise the assessment of pelvic organ descent a pelvic organ prolapse quantification system (POPQ) (Fig. 1) [3] has been developed, which has been validated * Corresponding author. Tel.: +61 7 4796 3588; fax: +61 7 4796 1771. E-mail addresses: [email protected] (C. Barry), [email protected] (H.P. Dietz). 1 Tel.: 61 2 4734 1809; fax: 61 2 4734 3485. 1471-7697/$ – see front matter # 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.rigp.2005.06.004
for both intra- and inter-observer reliability [4], and adopted by the International Continence Society (ICS) [5]. However, in a recent study it was suggested that only 40% of clinicians who have an interest in urogynaecology actually utilise this system on a routine basis, as it is considered by some to be clumsy to use [6]. In addition, this system does not address potential defects of the lateral vaginal support mechanisms, which may or may not be important in the pathogenesis of pelvic organ prolapse [7–9]. The place of two-dimensional ultrasound for the investigation and management of women with gynaecological problems is now well established. Both transabdominal and transvaginal scanning permit the identification of the uterus and adnexae with excellent resolution to direct appropriate management. However, transabdominal ultrasonography provides poor imaging of the lower pelvic structures, particularly the support structures of the vagina and levator muscle group, due to the depth of the tissues from the transducer. Transvaginal ultrasound permits excellent visualisation of the bladder, urethra and the posterior compartment but distorts the pelvis thereby precluding accurate assessment of POP [10]. In an attempt to overcome this, investigators have utilised introital [11],
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Fig. 1. Diagrammatic drawing of ICS POP-Q system.
transperineal and translabial ultrasonography [12,13]. Information can be obtained with no discomfort to the patient as part of a routine pelvic examination. It is therefore possible to improve our understanding of POP using transperineal ultrasound for both clinical and research purposes by adding a further objective measuring system to the ICS POP-Q system. The addition of three-dimensional ultrasonography provides the opportunity for visualisation of the axial plane of the pelvis, improved data storage and therefore independent audit. This review will describe the technology behind threedimensional ultrasonography, compare other imaging modalities and then discuss the information that can be obtained using two-, three- and four-dimensional ultrasonography (US). The future place of this imaging modality for pelvic organ prolapse will also be discussed.
2. Imaging modalities Early attempts to identify and image pelvic organ descent in the female pelvis were initially undertaken using X-ray imaging with contrast, to enable the identification of the axis of the vagina as well as prolapse [14]. More recently imaging with fluoroscopic dynamic cystoproctography (FDC) has permitted additional information to be obtained in women with symptoms as well as signs of POP [15,16]. Evacuatory proctography helps identify both anterior and the much less common posterior rectocele. It is also able to identify intussusception of the sigmoid and rectum. With the addition of peritoneography enteroceles can be identified directly. Dysfunctional defaecation causing anismus can be identified by discoordinated levator relaxation. Attempts to define pelvic organ prolapse using this technique use a distance of between 3 and 6 cm below the pubococcygeal line as representing prolapse [17]. In a number of small studies dynamic cystoproctography seems to identify rectocele and cystocoele better than clinical examination [16,17]. This may be because women are in the sitting position and
therefore have to relax their pelvic floor in order to defaecate, while at the same time bearing down. This is therefore more likely to mimic the symptoms of prolapse than on supine examination. Defects in the posterior compartment may be exaggerated by the fact that the labelled contrast medium abnormally distorts the rectum by its nature and volume. Level I defects, i.e. vault prolapse or uterine prolapse are less easily identified. There is however a paucity of data on normal asymptomatic women. Potential concerns over the use of radiation, expense, complexity and the fact that women find it embarrassing to defecate in front of an X-ray machine have limited the use of this imaging technique to those women with unexplained lower bowel symptoms or for research. The advent of magnetic resonance imaging (MRI) in the last 15 years for the identification of pelvic organ prolapse and pelvic organ dysfunction, has brought previously unparalleled definition, until then only seen on cadaveric dissection [18]. Developments in three-dimensional modelling and fast image acquisition now permit the identification of anatomy in both static and dynamic states [19]. However, the true extent of a prolapse maybe difficult to identify, unless a consistent Valsalva manoeuvre is performed. During an MRI, the patient is supine, in an enclosed room where timing and coaching is critical for correct image acquisition. Machines that permit images to be taken in the sitting position are as yet still very expensive and limited to tertiary centres only [20]. This precludes widespread use for large studies. Studies undertaken in symptomatic and asymptomatic women have been used to help define prolapse on MRI [21]. Prolapse was defined as descent below the sacrococcygeal inferopubic point (SCIPP) of the inferior most part of the prolapsing organ (Fig. 2). Addition of contrast media permits better identification of pelvic organs improving more accurate measurement [22]. The only study comparing independent standardised clinical assessment using the POP-Q studied 20 women with pelvic organ prolapse and 10 asymptomatic volunteer control subjects. There was fair correlation with clinical staging
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also levator hiatal dimensions have been demonstrated following pregnancy [28] and following surgery [29]. Apart from MRI being more expensive and apart from the mentioned problems with data acquisition during manoeuvres, there are also concerns that abdominal straining may move the levator plate relative to the pre-determined axial planes, therefore changing the angle of the image. This is difficult to compensate for with fixed equipment and variable Valsalva efforts.
3. Transperineal technique for ultrasonography
Fig. 2. Mid-sagittal image on MRI of a woman with a cystocele (C) and rectocele (R) on Valsalva. The SCIPP line is shown.
(KAPPA = 0.61). Further analysis suggested that clinical assessment was enhanced by this imaging modality as it identified enterocele more accurately. Singh used a different system to that proposed by Yang using the hymen rather than fixed bony landmarks for reference points, which is more likely to mimic clinical practice [23]. Other measurement systems include the HMO classification, which uses the levator hiatus as a line of reference, and describes not only descent beyond the levator hiatus but also rotation of the levator plate [24]. Further information can be obtained with three-dimensional modelling using sophisticated rendering tools to assess levator size and morphology [25–27]. Changes in the size, shape and nature of the levator muscle complex and
Ultrasound assessment is undertaken with the woman placed in the supine position, having emptied her bladder and bowel if necessary [30]. There have been concerns about examination while supine and whether adequate reproduction of prolapse herniation occurs [31]. A small study looking at the anterior compartment would suggest that there is no difference in the final resting place of the bladder or urethra on maximal Valsalva [32]. The transducer is covered with a powder-free glove or similar latex sheath (non-latex if allergic) prior to the examination and placed on the perineum in the mid-sagittal plane. Ultrasonic jelly is used at both interfaces and the probe pressed firmly but without causing discomfort such that the introitus is covered and no air bubbles are present to interfere with image quality (Fig. 3a). Data volumes are then acquired at rest and on maximum Valsalva, having practiced the manoeuvre a number of times. A mid-sagittal image is obtained as shown in Fig. 3b and c, with diagrammatic representation also shown. Pressure must be released on the transducer head when identifying prolapse as this may reduce the accuracy of
Fig. 3. (a) Represents a schematic diagram of the placement of the transducer for transperineal US; (b) the image obtained in the mid-sagittal plane with the pelvic organs labelled: SP, symphysis pubis; V, vagina; R, rectum; U, urethra; B, bladder; PR, puborectalis; a diagram highlighting the structures visualised.
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measurement. The image should be set for maximal acquisition angle both antero-posterior and laterally which usually equates to 708 and 70–858, respectively. The image should contain the lower part of the symphysis pubis, urethra, bladder upper vault or uterus, rectum, Pouch of Douglas and anorectal junction. The levator ani, i.e. puborectalis and pubococcygeus should also be visible, as may the external anal sphincter. For a complete examination an abdominal and transvaginal scan should be performed to exclude other gynaecological causes that may relate to presenting symptomatology of a prolapse. Using fourdimensional imaging orientation in the sagittal plane can be checked, thus by-passing the normal learning curve for use in two-dimensional mode.
4. Two-dimensional ultrasound Ultrasound has been used for pelvic floor assessment for some considerable time in two-dimensional B mode and more importantly for the assessment of lower urinary tract dysfunction with particular reference to incontinence [33– 35]. Imaging of the lower pelvis can be undertaken using transabdominal, transvaginal, endoanal ultrasound, introital and transperineal/translabial ultrasound. Endoanal ultrasound permits the identification of defects of the internal external anal sphincter, as well as providing information on the morphological features and defects of puborectalis created by trauma associated with childbirth. However, with the discomfort involved, limited depth and spatial orientation together with interference with mobility of the pelvic organs for identifying pelvic organ prolapse, intra-cavitary ultrasound has seen only limited use in pelvic organ prolapse assessment. For the purpose of this discussion, we will therefore concentrate on transperineal/translabial ultrasound and how it can be used to assess pelvic floor integrity.
5. Anterior compartment Imaging of the anterior compartment allows the visualisation of the bladder, urethra and surrounding support structures. This can aid in the diagnosis of vaginal, bladder and urethral pathology, such as Gartner duct cysts, bladder stones, congenital abnormalities, injury/haematoma, diverticula and tumours. Transperineal ultrasonography can add clinical information on bladder neck opening [11,36], mobility [37–39] and incontinence. It appears to provide as much information as videocystourethrography [40,41]. In women complaining of urinary incontinence symptoms, particularly with overactive bladder symptoms, a measurement of bladder wall thickness, which has been shown to correlate with evidence of detrusor instability (OAB) [42], can be added. The biomechanics of pelvic tissues can be quantified by measuring bladder neck descent and urethral rotation.
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Measurement is undertaken by assessing images at rest, on levator contraction and on maximum Valsalva. Attempts to standardise the Valsalva manoeuvre have involved the use of spirometry [39], intra-vaginal pressure transducers [43] and oral pressure measuring devices using a sphygmomanometer [44]. The latter study investigated 80 women undergoing urodynamic investigation and compared maximum Valsalva to a standard rise using a modified sphygmomanometer, and measured intra-abdominal pressure changes. Rises in intra-abdominal pressure were more reproducible and consistent using a sphygmomanometer. Despite this some authors prefer to use maximum Valsalva. Excellent test–retest parameters for measurement of bladder neck mobility using this technique would confirm the validity of this method [45]. However, great care must be taken to avoid reflex contraction of the levator ani, and this is true regardless of whether standardisation for Valsalva pressures is attempted. Measurement of bladder neck mobility is undertaken using a split screen on the ultrasound monitor, and images taken as described. Measurements are taken from the inferoposterior margin of the symphysis pubis, in the midline, and a line drawn to the posterior point of the bladder neck at right angles as shown in Fig. 4. Angles of excursion can then also be measured. Pelvic organ mobility on Valsalva may be a heritable trait [46]. Studies using bladder neck mobility as a criteria of ‘‘at risk’’ women going through childbirth permitted an intervention study for an antenatal exercise program, which identified a better outcome for these women undergoing antenatal pelvic muscle training [47]. The method may also provide a means to identify women at greater risk of POP prior to childbirth. However, criteria for the definition of ‘‘hypermobility’’ vary considerably with bladder neck descent of between 1.2 and 40.2 mm in continent nulliparous women [48]. Once descent exceeds 20 mm there is a strong correlation with USI [49]. The anterior compartment is well suited to ultrasound investigation, as it has excellent contrast characteristics due to the fact that there is always some urine in the bladder. There have been a number of studies looking at POP which demonstrate that prolapse can be identified easily and measured using this technique [50,11,51]. In the largest study to date involving 145 women, there was good correlation when two-dimensional ultrasound using the midsagittal plane when compared with ICS POP-Q assessment and the degree of prolapse [52]. With a correlation coefficient, r = 0.72 for anterior compartment defects (cystocele), this method appears to be as good as clinical evaluation using the ICS POP-Q and would suggest that this method of imaging is sufficiently accurate not only to identify prolapse but also allow quantification. The leading edge of the cystocele, correlating with point Ba on the ICS POP-Q is used as the point of greatest descent. A line is drawn from the inferoposterior margin of the symphysis pubis horizontally and distance above or below this line is
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Fig. 4. (a) A mid-sagittal view showing the bladder neck at rest. Measurements have been taken using on screen callipers as described and (b) the same measurement parameters on Valsalva (bladder neck descent (BND) = 2.95 0.625 = 2.325 cm).
measured Fig. 5. Translabial ultrasound may therefore have a role in confirming clinician’s examination findings or surgical outcome. Other measurements have been suggested using a line between the symphysis pubis and anorectal junction as a reference line for depth of herniation of the prolapsing [51]. Measurements can also be made of the anorectal junction during evacuatory proctosonography and levator contraction. However, the reliability of this measurement technique has not been validated for POP although was in good agreement with evacuatory proctography for the diagnosis of rectoceles and rectal intussus-
ception, with anorectal angles also having a good correlation (Fig. 5). Prosthetic implants are increasingly being used, especially in incontinence surgery, where traditional surgical techniques such as the Burch colposuspension have been largely superseded by permanent, synthetic, porous tapes [53]. These implants can be visualised easily in the anterior compartment on transperineal ultrasound and their mechanical properties studied in vivo, giving clues as to the mechanism of their action [54–57]. With the increasing use of synthetic mesh to improve the results of cystocele and
Fig. 5. (a) 2D image of cystocele with standard measurements and (b) diagram of measurements using perpendicular line from infero-posterior margin of symphysis pubis.
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Fig. 6. (a) Enterocele on Valsalva with fluid at apex; (b) uterine descent with cervix at introitus; (c) rectocele visualised at rest and on Valsalva with measurements of depth and length. Note the rectovaginal septal discontinuity.
Fig. 7. (a) Transducer head demonstrating sweep of motorised micro-array crystals and (b) diagrammatic representation of projection of image in 3D volume.
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rectocele repair [58–60] these implants can also be studied using ultrasound as they generally are hyperechogenic. However, sagittal views of the mesh placed in the anterior or posterior vaginal wall are not as clear as for sub-urethral slings.
6. Central compartment The central compartment can be visualised relatively easy with transperineal ultrasound to identify uterine prolapse and descent measured relative to the urogenital
Fig. 8. (a) 3D ultrasound volume of pelvic floor. Mid-sagittal plane at top left, coronal plane on top right, axial plane bottom left. The bottom right image shows a rendered volume encompassing the pubovisceral muscle; (b) axial plane imaging at rest (left) and on Valsalva (right); (c) diagram of levator hiatus as seen from caudally (U, urethra; V, vagina; R, rectum; PR, puborectalis; IC, ischiococcygeus; C, coccygeus); (d) measurement of antero-posterior, transverse diameters and area of levator hiatus on Valsalva.
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Fig. 8. (Continued ).
or levator hiatus, although vault prolapse may be more difficult to identify due to problems with tissue contrast and differentiation at the top of the vault. In the study quoted above, the uterus was not identified in 18% of cases, but identification improved following the initial pilot study [52].
Correlation was good for descent of the cervix (r = 0.77), with the ultrasound measurement tending to be 2 cm more distal than on ICS grading. Enterocele herniation can be identified easily and appears as a projection of the Pouch of Douglas descending
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into the vagina with or without small bowel [61]. Identification of enterocele formation, which may be anterior or posterior, may help when planning surgical treatment to avoid injury to the bowel, as well as for quantification for research Fig. 6.
7. Posterior compartment The posterior compartment encompasses the rectum and anal canal, and is bounded anteriorly by the rectovaginal septum, inferiorly by the perineal membrane, and superiorly by the uterus or upper vault and Pouch of Douglas. There has been debate as to whether posterior compartment defects are specific fascial disruptions or defects [62], disruption [63] or separation of the levator complex [64] with disruption of level III support of the perineal membrane [65]. It is likely that it is a combination of all or some of these three support mechanisms. In addition, perineal hypermobility may cause pseudorectoceles. Dynamic transperineal ultrasound of the pelvic floor, particularly looking at the rectum and external anal sphincter in a small study of 10 women, identified the different compartments of the female lower pelvis and demonstrated similar findings when the same patients had either endoanal ultrasound or evacuatory proctography [66]. The study was undertaken with patients on their left lateral side, which may have interfered with the Valsalva and contraction of the pelvic muscles. No comparison has been made with patients on the left lateral side versus the supine position. Some women however found it too uncomfortable as contrast medium was used in both the rectal and vaginal cavity, and refused to continue. This suggests that unless it was used in preference to evacuatory proctography it is unlikely the use of rectal contrast would have a place for the routine assessment of women with POP. Excellent images can be obtained without contrast. Two-dimensional ultra-
sound can visualise defects in the rectovaginal septum, which in the mid-sagittal plane appears as a discontinuity of the anterior muscularis layer of the anorectum on Valsalva. The size and depth of this discontinuity can be measured (see Fig. 6). Such findings are be consistent with the theory that true rectoceles are due to a defect or weakness of the fascial covering either in the transverse or longitudinal plane. Studies suggest that up to 10% of nulliparous women have congenital rectovaginal septal defects, which are nearly always asymptomatic [48]. Reproducibility of measurement of rectoceles has not as yet been published. Assessment for rectocele prolapse may provide quantitative comparative data on pre- and postoperative parameters for research. Using on-screen callipers rather than clinical grading, allowing more accurate measurement. Studies are currently ongoing looking at this technique as a tool for assessment. Other features that may be examined include levator contraction [67] and possibly the external sphincter, as well functional emptying of the rectum [66].
8. Three-dimensional imaging 8.1. Technological developments in three-dimensional ultrasonography Development in three-dimensional data acquisition has been progressing since its early years in the 1970s and 1980s [68]. Three-dimensional ultrasound was first performed using freehand or motorised withdrawal techniques, predominantly for intra-cavitary application. Image acquisition can now be achieved by rapid oscillation of a group of elements within the transducer head. As each pixel has a defined location relative to the transducer, a volume of image data can then be reconstructed. These areas are no longer
Fig. 9. (a) Pelvic floor ultrasound in the C or axial plane, possible paravaginal defect and (b) right-sided levator avulsion on MRI (left) and 3D ultrasound (rendered volume, right).
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Fig. 10. (a) Axial view of permanent synthetic mesh overlay for a rectocele. Arrow denotes mesh covering defect; (b) a rendered view of a disrupted/dislocated synthetic, non-absorbable mesh for cystocele repair; (c) a rendered image of an anterior non-absorbable mesh implant using the trans-obturator route; (d) a rendered image of a PIVS (posterior infra-coccygeal vaginal slingoplasty) tape, for vault prolapse.
called pixels but ‘voxels’. Such volumes are normally represented in the three orthogonal planes (A, B and C plane), with the rendered image in the fourth viewing box (Fig. 7). This rendered image represents a semi-transparent representation of all the voxels in an area defined by the user. Software allows image manipulation in all three dimensions, thereby permitting independent analysis at a later stage or review for further studies. Four-dimensional imaging allows the real time acquisition of volumes, which again can be viewed either in
all three orthogonal planes or as the rendered volume. This simplifies correct alignment of the transducer and cine recording of defects of the pelvic floor and provides an exciting capability for dynamic imaging of the pelvis. 8.2. Assessment of the pelvic floor The advent of three-dimensional ultrasound has now provided an imaging modality, which has some of the advantages of MRI, i.e. images in all three planes,
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particularly visualisation in the axial plane. This allows cross-sectional qualitative and quantitative assessment of paravaginal support structures, the levator ani, levator hiatus and urogenital hiatus. In addition, one may also to be able to view the external and internal sphincter complex of the anus at the same time. The levator hiatus is a crucial structure for the female pelvis as it provides passage of the rectum, vagina and urethra and support of the pelvic floor. It therefore also constitutes a potential route for herniation of the pelvic organs. Damage to the levator muscle complex or congenital abnormalities of structure and/ or function may lead to some women developing prolapse later in their life. Specific abnormalities of the attachment of the levator ani or the surrounding fascia have been identified in cadaveric dissection to explain disruption and widening of the levator gap [65,69]. It is believed by some clinicians to be an important factor not only in the development of prolapse but also recurrence of pelvic organ prolapse after surgical treatment [64]. Three-dimensional ultrasound permits assessment of both levator morphology and levator dimensions (Fig. 8). Measurements of the levator muscle thickness and area may not be very repeatable with current technology [70]. However, levator dimensions at rest and more so on Valsalva appear to have a good correlation with greater degrees of prolapse on clinical assessment and good repeatability (intra-class correlation coefficients between 0.7 and 0.82) [71]. Measurements are taken by identifying the plane of minimal hiatal dimensions in the mid-sagittal plane, between the posterior or dorsal aspect of the symphysis pubis and the most anterior or ventral aspect of the puborectalis muscle. The C plane of the volume is then used to identify the plane of minimal dimensions in an oblique axial view and to measure diameters in the coronal and sagittal planes and the hiatal area, as shown Fig. 8. As yet it is not possible to render three-dimensional models of the levator ani using three-dimensional ultrasound, which would permit full morphological assessment as well as qualitative assessment of this muscle group, such as has been undertaken with MRI [27]. Initial studies comparing clinical recurrence and levator dimensions suggest that a wider hiatus on Valsalva may be associated with a higher incidence of recurrence (Barry submitted ANZJOG 2004). The most frequently seen morphological abnormality, avulsion of the anteromedial aspect of the pubovisceral muscle off the pelvic sidewall, seems to be common [71,72] and is clearly due to childbirth (Dietz and Lanzarone, 2005 RANZCOG abstract). Such defects of the pubovisceral muscle seem to be associated with prolapse of the anterior and central compartment rather than incontinence (Steensma and Dietz 2005 IUGA abstract submitted) (Fig. 9). Debate continues with regards to the significance of paravaginal defects and whether they represent disruption of
the endopelvic fascia laterally at the vaginal sulci [73,74], where it attaches to the pelvic sidewall, or whether they reflect disruption of the insertion of the puborectalis/ pubococcygeus complex leading to cystocoele formation [63]. Other workers have suggested that prolapse of the anterior compartment is not simply a midline disruption of fascia but also disruption at the pubocervical fascia or its remnants, in the absence of the uterus, with caudal displacement of the bladder [75]. There are some authors who believe that discrete lateral paravaginal breaks in the fascia result in a higher recurrence of cystocele formation or incontinence [7,73,76,77]. A number of studies have used abdominal scanning to help identify anterior paravaginal defects, but the reliability of this method has been questioned due to problems with image quality and positioning [78–81]. Research using MRI would suggest that defects in the fascia may be visible, but direct identification of fascial tissue is impossible. Clinical examination is also notoriously unreliable [82,83]. Without specific criteria for clinical detection, correlation of imaging, surgical findings or cadaveric dissection this problem will be difficult to resolve. Three-dimensional ultrasound allows dynamic imaging with increasing resolution, as new developments continue. The latest innovation, volume contrast imaging (VCI), enables resolutions close to magnetic resonance imaging standards in all three orthogonal planes, while offering far superior temporal resolution. This opens up new avenues for research in vivo. Research priorities are the validation of this new imaging technique against MRI in both normal controls and symptomatic women, and work on the clinical relevance of the observed morphological abnormalities. Identification of prosthetic implants can be aided by three-dimensional US, to help define changes in pelvic floor anatomy and integrity of the implants (Fig. 10).
9. Conclusion Transperineal ultrasonography is simple to learn, causes minimal discomfort to the patient and can provide useful information on structure and function in those women complaining of symptoms of pelvic floor and bladder dysfunction. The technology is in a state of rapid development. Recent advances permit better resolution and tissue definition, especially in the axial plane. This is particularly helpful in identifying levator muscle anatomy. 3D and 4D ultrasound allows data storage of volumes of information as opposed to single plane images. This permits offline analysis and independent audit. There are still a number of important issues to resolve in regards to its use in clinical practice and as a research tool, but it appears likely that the technique will see more widespread use in the future.
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Practice points Pelvic organ prolapse is a common problem in women. It accounts for a significant number of operations and currently there is an unacceptably high recurrence rate. Two-dimensional translabial/transperineal ultrasound permits simple evaluation of the degree of prolapse along with morphological assessment of the bladder, urethra and rectum. This technique is easy to learn, can be performed with equipment available in virtually all gynaecological units in the developed world, and is well tolerated by the patient. Three-dimensional ultrasound allows imaging of the axial plane, and provides for the collection of volumes of imaging information, which then can be stored or transferred off site, for analysis and interpretation at a later date. Recent innovations such as 4D real-time volume imaging and volume contrast imaging suggest that pelvic floor ultrasound may overtake MRI as the imaging method of choice for pelvic floor dysfunction. In the future identification of specific fascial defects or changes in levator ani, morphology may permit surgery to be tailored more effectively, thereby reducing recurrence rates.
Research agenda Comparison with other imaging modalities and validated clinical assessment. Comparison of surgical and ultrasound findings. Use in surgical audit. Definition of the role of specific morphological abnormalities in the development of symptoms of pelvic floor and lower urinary tract dysfunction.
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