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Must Read Articles About Pelvic Floor Ultrasound —
A Resource Guide


This clinical review presents key articles from the clinical literature that offer practical information to help guide the pelvic floor practitioner in using ultrasound. All featured articles are available through download or by request on the contact form, as indicated. Articles presented in this order:
  1. Urogynecological ultrasound practice: "Updated recommendations on ultrasonography in urogynecology"
  2. Endoanal ultrasound as part of an anal physiologic testing protocol: "Transrectal ultrasound, manometry, and pudendal nerve terminal latency studies in the evaluation of sphincter injuries"
  3. The importance of perineal body measurement in endoanal ultrasound investigation: "Perineal body measurement improves evaluation of anterior sphincter lesions during endoanal ultrasonography"
    Note: scroll down to see a video of how to perform a perineal body measurement during endoanal ultrasound
  4. Comprehensive review of external and endovaginal pelvic floor ultrasound applications with relevant images: "Introital and transvaginal ultrasound as the main tool in the assessment of urogenital and pelvic floor dysfunction: an imaging panel and practical approach"
  5. Using perineal ultrasound for dynamic pelvic floor muscle evaluation and patient biofeedback: "The use of perineal ultrasound to quantify levator activity and teach pelvic floor muscle exercises"
  6. Multi-compartmental pelvic floor ultrasound imaging, describing the use of 2D, 3D, and 4D ultrasound: "State of the art: an integrated approach to pelvic floor ultrasonography"
Endoanal ultrasound, normal female

Endoanal ultrasound, normal female

Transperineal ultrasound, normal female, ARA = ano-rectal angle

Transperineal ultrasound, normal female, ARA = ano-rectal angle

Surgical mesh implant, dysfunctional

Surgical mesh implant, dysfunctional

Updated Recommendations on Ultrasonography in Urogynecology

Tunn R, Schaer G, Peschers U, Bader W, Gauruder A, Hanzal E, Koelbl H, Koelle D, Perucchini D, Petri E, Riss P, Schuessler B, Viereck V. Updated recommendations on ultrasonography in urogynecology. Int Urogynecol J. 2005; 15:236-241.

"Ultrasound is a supplementary diagnostic procedure in urogynecology, which allow documentation of functional and morphologic findings. The patient's history, clinical examination, urodynamic testing, and imaging continue to be the cornerstones of comprehensive urogynecologic work-up."

This article presents a practical, standardized approach to evaluating pelvic floor conditions, using affordable equipment and transducers for the clinical practitioner.

Recommendations distinguish between two techniques based on the type of probe: 1) endocavity ultrasound, specifically endoanal ultrasound (EAUS), using a 2D, 360o probe (10-12.5MHz); and 2) external ultrasound, for transperineal ultrasound (TPUS), using a general purpose probe (3.5-5MHz), or introital ultrasound (IUS), using an end-fire vaginal probe (5-7.5 MHz). The introital approach is noted as particularly convenient as it uses the same probe as for endovaginal ultrasound (EVUS) applications.

This article details recommended standards for the urogynecologist, including image orientation, measurement methods, and examination position. It includes clinical applications for both endocavity and external ultrasound, and describes functional testing and the role of ultrasound in perioperative evalution of patients with surgical mesh implants.

Featured article available through the contact form on this page.

Related article: ICS Recommendations on the evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Download Article >

Transrectal Ultrasound, Manometry, and Pudendal Nerve Terminal Latency Studies in the Evaluation of Sphincter Injuries

Garland B, Hull, T. Int Urogynecol J. 2005; 15:236-241.

"...These tests provide us with an objective evaluation of anal neuromuscular function that would not be otherwise detected on clinical examination."

This article summarizes the techniques for anal testing of patients with fecal incontinence, describing the type of equipment used for each and study interpretation of the following:
  • Transrectal (endoanal) ultrasound: A validated technique that is highly accurate for detecting anal sphincter defects, as determined by a number of studies in the1990's using 2D imaging with a 360o endoanal probe. Images provided show normal and abnormal ultrasound findings.
  • Anal manometry: The use of an anal balloon or specialty catheter to measure sensation, pressures, capacity, and compliance within the anal canal.
  • Pudendal nerve latency: Measurement of terminal latency response of the pudendal nerve.
Download This Featured Article  >

Related articles:
Rottenberg GT, Williams AB. Endoanal Ultrasound, pictoral review. Brit J Radiol. 2002;75: 482-488.

Bartram CI, Sultan AH. Anal endosonography in faecal incontinence. Gut.1995;37(1): 4–6. Download Article >

Deen KI, Kumar D, Williams JG, Olliff J, Keighley MR. Anal sphincter defects. Correlation between endoanal ultrasound and surgery. Ann Surg.1993; 218(2):201–205. Download article >

Abdool Z, Sultan AH, Thakar R. Ultrasound imaging of the anal sphincter complex: a review. Brit J Radiol. 2012; 85:865-875. Download Article >

Perineal Body Measurement Improves Evaluation of Anterior Sphincter Lesions During Endoanal Ultrasonography

Zetterstrom JP, Mellgren A, Madoff RD, Kim DG, Wong WD. Perineal body measurement improves evaluation of anterior sphincter lesions during endoanal ultrasonography. Dis Colon Rectum. 1998; 41:705-713.

"Digital delineation of the perineal body during endoanal ultrasonography improved the visualization of sphincter lesions in the majority of patients. Use of this technique improves visualization of sphincter lesions."

This groundbreaking article transformed the way many colorectal surgeons perform endoanal examinations. By inserting a finger in the vagina and gently holding it against the posterior vaginal wal,l the ability to detect external anal sphincter (EAS) defects was enhanced."The echogenicity of a sphincter defect in EAUS images is variable...by compressing the tissue, a different acoustic impedance is created, and a more hypoechoic image is consequently created."

It was demonstrated that anal injuries to the EAS could be better quantified (such as distinguishing between ruptured sphincter endings and scar tissue). In addition, through the use of the perineal body method, the authors were able to identify a complete rupture of the EAS versus muscle thinning.

Further, the authors stated that it is unusual to have ambiguous findings with imaging the internal anal sphincter (IAS). A discussion of IAS thickness in patients vs. asymptomatic subjects is included.

Finally, this article presented norms for perineal body width, indicating that perineal body measurement of less than 10mm should be considered abnormal.

Featured article available through the contact form on this page.

Related articles:
Woodman PJ, Graney DO. Anatomy and physiology of the female perineal body with relevance to obstetrical injury and repair. Clinical Anatomy. 2002;15: 321-334. Download Article >

Geller EJ, Robinson BL, Matthews CA, Celauro KP, Dunivan GC, Crane AK, Ivans AR, Woodham PC, Fielding JR. Perineal body length as a risk factor for ultrasound-diagnosed anal sphincter tear at first delivery. Int Urogynecol J. 2014; 25:631-636. Download Abstract >

Introital and Transvaginal Ultrasound as the Main Tool in the Assessment of Urogenital and Pelvic Floor Dysfunction: an Imaging Panel and Practical Approach

Tunn R, Petri E. Introital and transvaginal ultrasound as the main tool in the assessment of urogenital and pelvic floor dysfunction: an imaging panel and practical approach. Ultrasound Obstet Gynecol. 2003; 22(2):205-13.

"Female voiding dysfunction, including urge symptoms, recurrent urinary tract infections and urinary incontinence, may occur secondary to morphological and topographical changes of the urogenital organs...Ultrasound has replaced radiography in yielding information on the abnormal morphology of the urogenital organs, which should be taken into account in planning the treatment of urogynecological conditions."

This article provides a comprehensive review of external and transvaginal ultrasound applications for investigating pelvic floor disorders, including 28 ultrasound images showing findings that include urethral diverticulum, suburethral masses, bladder wall edema, sling erosion, and more. Click here for a table of "Sonographic findings of the urogenital organs in urogynecological diseases," reproduced from this article.

 Download This Featured Article >

Related article:
Dietz HP. Ultrasound imaging of the pelvic floor. Part I: two-dimensional aspects.  Ultrasound Obstet Gynecol. 2004; 23:80-92. Download Article >

The Use of Perineal Ultrasound to Quantify Levator Activity and Teach Pelvic Floor Muscle Exercises

State of the Art: An Integrated Approach to Pelvic Floor Ultrasonography

Dietz HP, Wilson PD, Clark B. The use of perineal ultrasound to quantify levator activity and teach pelvic floor muscle exercises. Int Urogynecol J Pelvic Floor Dysfunct. 2001; 12(3):166-8; discussion 168-9.

"Pelvic floor muscle assessment and teaching can be used as an adjunct to the ultrasound assessment of urogynecologic, requiring at most 5 minutes."

In this study, the authors demonstrated that perineal ultrasound is an effective way to assess levator activity, by measuring the displacement of the internal urethral meatus on voluntary contraction. Of the 212 women enrolled in the study, 56 were unable to contract the pelvic floor upon request. Using visual feedback through perineal ultrasound, 32 (57%) of these were successful in contracting their pelvic floor muscles correctly.

The authors concluded that biofeedback for pelvic muscle exercise training was easily understood and readily accepted by women.

Featured article available through the contact form on this page.

Related article:
Thompson JA, O'Sullivan PB, Briffa NK, Neumann P. Assessment of voluntary pelvic floor muscle contraction in continent and incontinent women using transperineal ultrasound, manual muscle testing and vaginal squeeze pressure measurements. Int Urogynecol J. 2006; 17:624-630. Download Article >

Santoro GA, Wieczorek AP, Dietz HP, Mellgren A, Sultan AH, Shobeiri SA, Stankiewicz A, Bartram C. State of the art: an integrated approach to pelvic floor ultrasonography. Ultrasound Obstet Gynecol. 2011; 37:381-396.

"Surgical management of pelvic floor disorders depends on a comprehensive understanding of the structural integrity and function of the pelvic floor. For visualizing this region, ultrasonography has emerged as a procedure that is relatively easy to perform, cost-effective and widely available."

This article presents how to use different ultrasound techniques to create a complete anatomical evaluation of the pelvic floor, in order to gain a better understanding of the causative mechanisms underlying clinical symptoms. The multicompartmental approach to imaging is consistent with urogynecological practice, and the authors contend that visualizing pelvic floor structures from anterior, central, and posterior positions can help reduce the high rate of surgical failures and repeat surgeries.

The following applications and techniques are presented: transperineal ultrasound (TPUS), transvaginal ultrasound (TVS), and endoanal ultrasound (EAUS). The article reviews how the pelvic floor structures can be imaged with each approach, using 2D, 3D, and 4D ultrasound capabilities. Clinical applications discussed include urinary incontinence, fecal incontinence, levator ani injuries, cystocele, rectocele, rectal intussusception, pelvic floor dyssynergy, uterine prolapse, and assessment of mesh implants.

In conclusion, the authors stated,"Imaging findings are already leading to either modification or a choice of specific operative procedures," and postulated that this "integrated" approach to imaging can improve surgical outcomes.

Download This Featured Article >

Related article:
Dietz, HP. Pelvic floor ultrasound in incontinence:what's in it for the surgeon? Int Urogynecol J. 2011; 22:1085-1097.
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Perineal Body Measurement Technique

The video below is an excerpt from the Catalyst™ Clinical Education Video on how to measure the perineal body during an endoanal ultrasound exam. For full screen viewing: click the arrow to begin the video, then click in the lower right hand corner of the viewing screen.

Typical external ultrasound image of the pelvic floor with coordinate system, parallel and vertical to the urethra. A = anterior urethra. P = poster urethra. ARA = ano-rectal angle.

Typical external ultrasound image of the pelvic floor with coordinate system, parallel and vertical to the urethra. A = anterior urethra. P = poster urethra. ARA = ano-rectal angle.

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