Pelvic floor Ultrasound Basic settings and procedures

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Pelvic flr Ultrasund Basic settings and prcedures HP Dietz, KL Shek, S Chan, R Guzman Rjas This dcument has been prduced by the Special Interest Grup Pelvic Flr Imaging f IUGA.

1 Pelvic flr Ultrasund Basic settings and prcedures HP Dietz, KL Shek, S Chan, R Guzman Rjas This dcument has been prduced by the Special Interest Grup Pelvic Flr Imaging f IUGA. It prvides instructins fr the acquisitin f ultrasund images and 3D/4D data sets btained by translabial imaging, the currently mst widely used methd fr pelvic flr imaging. It is recgnised that sme practitiners use transvaginal and end-anal techniques, t which this text des nt apply. Basic Setup: Ask patient t vid and empty bwel if pssible. Psitin in lithtmy, heels clse t buttcks 4-8 MHz curved array r similar vlume transducer apply a layer f gel befre and after cvering the prbe with a transducer cver/ nn-pwdered glve (r plastic film), avid air bubbles between the prbe and the prbe cver place n intritus, vertically in midline (Fig 1). Ultrasund settings: Maximum aperture (up t 90 degrees) 2 Fcal znes depth 7-9 cm High harmnics, SRI 4-5, CRI 2-3 r similar speckle reductin techniques if available. Figure 1: Transducer placement fr assessment f residual urine, Detrusr Wall Thickness, rgan descent, hiatal area, levatr integrity.

2 1.) 2D image acquisitin Leave prbe n perineum nce placed. Symphysis pubis in left hand crner, n mre than 1 cm frm transducer surface Urethra visible as black stripe t identify midsagittal plane, and the anal canal as tubular structure in the right upper quadrant. Residual urine: tw maximal diameters vertical t each ther, x*y*5.6= residual in ml (x and y measured in cm) Detrusr wall thickness (DWT) measured n dme, three lcatins in the midline, perpendicular t the mucsal surface after bladder emptying with residual <50mls. Split screen: images at rest (left) and n maximal Valsalva >= 6s, (right). Used t measure bladder neck and bladder descent (a,b), retrvesical angle (c,d) urethral rtatin (e,f), (Fig 2). Single screen: image n maximal Valsalva t determine rgan descent (Fig 3). Let the prlapse cme- n pressure n perineum, withut tilting the hand Check fr hyperechgenic structures (slings and meshes) in anterir and psterir vaginal wall. Check fr cystic structures (urethral diverticula, Gartner cysts, nabthian fllicles, uretercele. Figure 2: Split screen fr BND, RVA, urethral rtatin and bladder descent. BSD= bladder neck- symphysis distance, RVA= retrvesical angle, rt= rtatin angle, r= at rest, s= n straining. SP= symphysis pubis, B= bladder, V= vagina, R= rectum.

5-2 cm thickness, green line at tp, place the bx t include the plane f minimal hiatal dimensins (Fig 4).

3 Figure 3: Single screen at maximum Valsalva (>=6s) fr rgan descent. S= symphysis pubis, C= cystcele, U= uterus, R= rectal ampulla. 2) 4D acquisitin fr prlapse/ hiatal area assessment Set acquisitin angle at 85 degrees (r system maximum) 2 split screen with rendered vlume n right, set the regin f interest (the bx shwn in A) t cm thickness, green line at tp, place the bx t include the plane f minimal hiatal dimensins (Fig 4). One may need t rtate the image s that the plane f minimal hiatal dimensins lies within the bx, as in Fig 4. Keep right-hand image symmetrical and in the centre thrughut acquisitin, and keep SP in left- hand image. N pressure n transducer. Avid levatr c-activatin (Fig. 5). Bifeedback teaching if there is levatr cactivatin. Valsalva >= 6 s. Measure hiatal area n rendered vlume (right). Mve the Bx (area f interest) in A fr clear image f the hiatus fr measurement. Use whatever thickness (0.5-2 cm) gives yu the best cntur. Check distance f cntur frm image edge in A and B. Figure 4: 4D acquisitin fr rgan descent and hiatal ballning (85 degree acquisitin angle). The regin f interest (bx in A) is set between symphysis (S) n the left and the levatr ani (LA) n right. B= bladder, U= urethra, R= rectal ampulla, A=anal canal, V= vagina. The dtted cntur in B is the hiatus in the plane f minimal dimensins, the white line in A and B is the minimal hiatal diameter in the midsagittal (anterpsterir) plane.

Fig. 5: Levatr c-activatin r c-cntractin during Valsalva evidenced by a reductin in anterpsterir hiatal diameter (first Valsalva, vertical lines in

) PFMC fr tmgraphic imaging f levatr integrity: Views as abve- make sure symphysis is visible.

4 Fig. 5: Levatr c-activatin r c-cntractin during Valsalva evidenced by a reductin in anterpsterir hiatal diameter (first Valsalva, vertical lines in central images). Frm Oern et al., Ultrasund Obstet Gynecl 2007; 2007; 30: ) PFMC fr tmgraphic imaging f levatr integrity: Views as abve- make sure symphysis is visible. Ask fr PFMC, and make sure the levatr ani muscle remains visible. May need pressure n the perineum. Rtate the A plane t place plane f minimal dimensins (minimal distance frm SP t LA) in middle f bx (Figure 6). Figure 6: PFMC, plane f minimal dimensins placed in centre f bx (regin f interest)

Switch t TUI (tmgraphic ultrasund imaging) in the C (axial) plane and rtate this plane s that the image is upright. Set the interslice interval at 2.5 mm, 8 slices (see Figure 7).

Rate central three slices fr integrity f the insertin f the pubrectalis muscle. When in dubt measure levatr-urethral gap between centre f the urethra and PR insertin (Figure 8).

5 Switch t TUI (tmgraphic ultrasund imaging) in the C (axial) plane and rtate this plane s that the image is upright. Set the interslice interval at 2.5 mm, 8 slices (see Figure 7). May need further adjustment s that the SP in the 3 central slices (i.e.slice 3 t 5 in Fig 7) appear pen (slice 3), clsing (slice 4) and clsed (slice 5) (Figure 7). Rate central three slices fr integrity f the insertin f the pubrectalis muscle. When in dubt measure levatr-urethral gap between centre f the urethra and PR insertin (Figure 8). Limit f nrmal in Caucasians is 2.5 cm. Figure 7: TUI in the C (axial) plane fr assessment f levatr integrity. Slice 1 is the caudal slice, slice 8 is the mst cranial cranial slice. Figure 8: Levatr-urethra gap measurement in the three central TUI slices in a patient with a right- sided avulsin.

4) 4D Acquisitin fr imaging f the anal canal Place transducer transversely ver intritus after reducing aperture t 60 degrees. Apply additinal gel centrally.

6 4) 4D Acquisitin fr imaging f the anal canal Place transducer transversely ver intritus after reducing aperture t 60 degrees. Apply additinal gel centrally. Tilt the prbe twards the canal (see Figure 9 A) s as t btain a transverse view f the anal canal (see Figure 9 B) SRI 3-4, CRI 2-4, high harmnics, +/- VCI Set acquisitin angle at 70 degrees t image the whle length f the anal canal. One fcal zne as clse as pssible t the prbe surface. Figure 9: Transducer placement fr ex-anal imaging f the anal sphincter view transverse plane as A, midsagittal plane as B, and identify the fascial plane separating the EAS frm the levatr ani in the B plane (Figure 10). If the B plane shws hrizntal parallel dark stripes and if thse parallel dark stripes, ie., the internal sphincter, are vertical in the C plane, then the image is prperly centred. ask patient t perfrm PFMC, take care the entire EAS is within the field f visin. Adjust transducer pressure t stay clse withut defrming the ring shape f the sphincter. Select A plane and TUI. Adjust interslice interval t include the entire EAS (see Figure 11). Measure defects by determining defect angle (Figure 12) in slices 2-7.

althugh this defect is nt visible in A. Figure 11: TUI fr assessment f the anal sphincter, asymptmatic nullipara.

7 Figure 10: Identificatin f EAS limits in midsagittal (B) plane. The fascial plane in B (black arrws) identifies the true extent f the EAS. There is a clear deficiency f its ventral aspect (white arrw), which n tmgraphic imaging (examples in Figures 11 and 12) affected 3 ut f 6 slices, althugh this defect is nt visible in A. Figure 11: TUI fr assessment f the anal sphincter, asymptmatic nullipara. The tp left hand image in the midsagittal plane shws placement f the 8 transverse slices, which encmpass the entire EAS frm slice 2 t 7, with the pssible exceptin f the mst superficial part f the subcutaneus EAS.

8 Figure 12: Measurement f EAS defect angle in symptmatic patient >20 years after EAS tear. The images shw a defect f 30 degrees r mre (ne hur n the clck face) in slices 2-6.

9 Further reading: Dietz HP. Pelvic Flr Ultrasund. In: Rizk and Puschek, Ultrasngraphy in Gyneclgy. Cambridge University Press 2013 Dietz HP. Ultrasngraphy. In: Evidence based physitherapy fr the pelvic flr: bridging research and clinical practice. 2 nd Editin. K. B, B. Berghmans, M. van Kampen and S Mrkved Eds. Butterwrth Heinemann Elsevier, 2014 Shek KL, Dietz HP. Imaging f slings and meshes. Australasian Jurnal f Ultrasund in Medicine May 2014; 17 (2): Dietz HP. Pelvic Flr Ultrasund. In: Sngraphy in Obstetrics and Gyneclgy: Principles and Practice. 8th ed. Fleischer AC et al., Mc Graw Hill 2016 Dietz HP. Pelvic Flr Ultrasund: Nrmal Anatmy. In: Merz E. Atlas f 3D/ 4D Ultrasund in Obstetrics and Gyneclgy. Thieme Stuttgart, Dietz HP. Pelvic Flr Ultrasund: Abnrmal findings. In: Merz E. Atlas f 3D/ 4D Ultrasund in Obstetrics and Gyneclgy. Thieme Stuttgart, Shek KL, Dietz HP. Assessment f Pelvic Organ Prlapse: A Review - Ultrasund Obstet Gynecl Gynecl 2016; 48: DOI: /ug

10 Transperineal ultrasund reprt template Date f prcedure: Patient details: Indicatin: Transperineal ultrasund perfrmed: Bladder emptied: YES / NO Residual urine vlume: mls thickness: mm Bladder neck descent n Valsalva: cm Urethral rtatin n Valsalva: degrees supine/standing Detrusr Wall RVA n Valsalva: deg. Cmments: Pelvic Organ measurements (Valsalva) relative t SP: Bladder psitin: mm Uterus/vault: mm Rectal ampulla: mm Entercele: mm Intussusceptin: Rectcele depth: mm Cmments: Mesh r slings: YES/NO If sling present, sling pubis gap measurement: mm Cmments: 3D/ 4D ultrasund: Status f levatr muscle RIGHT: Intact / Partial / Cmplete avulsin LEFT: Intact / Partial / Cmplete avulsin Levatr hiatal area n Valsalva: cm 2 Other: Anal Sphincter Cmplex: Intact / Defects nted: IAS. / 6 EAS... / 6 Findings & Cnclusin:

11 Letter Template Date: Re: Ms was seen fr a Pelvic Flr Ultrasund n. She is suffering frm symptms f. 2D and 3D/4D pelvic flr ultrasund was perfrmed using a system. Findings: 2D: The pstvid residual was ml. The urethra appears. Detrusr wall thickness was mm. N synthetic implants visualised. There was cm f bladder neck descent n Valsalva, with a retrvesical angle and degrees f urethral rtatin. On valsalva, there is descent f the bladder t cm belw the symphysis pubis (SP), the rectal ampulla descends t cm belw the SP, and the rectcele depth measured. The vault/uterus descended t abve/ belw the SP. 3D: The pubrectalis muscle was intact/ shwed an avulsin n the right, and n the left. The levatr hiatal area measured cm 2, which is enlarged/ implies ballning. Mrs was able t perfrm a fair, well crdinated levatr cntractin. Bth EAS and IAS appeared nrmal/abnrmal, with n/ a residual defect in slices. Interpretatin: -cmpartment prlapse against the backgrund f pubrectalis muscle and levatr hiatal area ballning. A plan f management may include I hpe t have been f assistance. Kind regards

Pelvic Floor Ultrasound Imaging. Prof HP Dietz (Sydney) A/Prof KL Shek (Sydney) Dr R Guzman Rojas (Santiago de Chile) Dr Kamil Svabik (Prague)

Pelvic Floor Ultrasound Imaging Workshop IUGA 2015 Nice Faculty: Prof HP Dietz (Sydney) A/Prof KL Shek (Sydney) Dr R Guzman Rojas (Santiago de Chile) Dr Kamil Svabik (Prague) The use of translabial ultrasound