dr bruce allen horizon radiology acknowledgement to dr hans dietz and dr jenny kruger
TRANSCRIPT
Dr Bruce AllenHorizon Radiology
Acknowledgement to Dr Hans Dietz and Dr Jenny Kruger
Clinical application of Pelvic floor imagingPelvic floor muscles involved in:
Maintenance of continenceSupport of the organs of the pelvisVaginal delivery
Failure of these muscles increases risk of:Urinary and fecal incontinence, Prolapse of the organs of the pelvis, Perineal pain and dyspareunia.
Ultrasound imagingCost effective
Do not need expensive machines to do basic imaging
Ultrasound is highly operator dependant Not difficult to learn
Real time, functional studies easy
MRIExpensiveImages are easier to understandFunctional studies difficult.
2D imaging - Ultrasound
Until recently 2D ultrasound scanning only methodology used define pathology and normal function of pelvic floorAbdominally, transvaginal or translabialDescent of bladder neck, uterus and rectal
ampulla during a valsalva Transperineal ultrasound useful biofeedback
measure for patientsImage is in mid-sagittal plane$12,000 machine.
Translabial 2D Ultrasound
Patient is supine, bladder empty ( or standardized filling)
Knees flexed, feet on the tableTransducer covered in glove/condom for
hygienePlaced fairly firmly on the perineum in the
mid sagittal orientation.
Ultrasound Anatomy
Typical 2D image of the pelvic floor muscles
uret
hra
cranial
MRI: Sag midline, normal anatomy
Bony landmarks20 mins scan timeAnatomy
Pelvic floor functional assessment
Training
Contraction
Valsalva
Pelvic floor muscle contraction
Contraction assess: 1. Narrowing of the hiatus in the AP diameter2. Movement of the bladder neck3. Strength of the PF muscle
Contraction: Bladder neck
Valsalva: BND
Effective valsalva manouevre
Valsalva assess:1.Descent of bladder, uterus, rectum. Urethral rotation.2.Development of cystocele, prolapse or rectocele3.Width of hiatus in the AP diameter
MRI: Valsalva. Cystocoele
Functional:4 min per sequenceValsalvadefaecation (training)
2D imagingMeasurements of bladder neck descent and
urethral rotation.
Ultrasound images showing measurement of bladder neck descent and urethral rotation. Bladder neck descent (BND)= x-r –x-s. (Dietz et al 2004)
2D
Im
ag
ing
Clinical use of 2D ultrasoundStill widely used Bladder, uterine and rectal descent. Bo, K. and M. Sherburn, Evaluation of female pelvic-floor muscle
function and strength. Physical therapy, 2005. 85(3): p. 269-82, Mar.
Abdominal ultrasound
Athanasiou, S., et al., Direct imaging of the pelvic floor muscles using two-dimensional ultrasound: a comparison of women with urogenital prolapse versus controls.BJOG: An International Journal of Obstetrics and Gynaecology, 2007. 114(7): p. 882-888.
Endovaginal probe
Costantini, S., et al., Perineal ultrasound evaluation of the urethrovesical junction angle and urethral mobility in nulliparous women and women following vaginal delivery. Int Urogynecol J Pelvic Floor Dysfunct, 2005. 16(6): p. 455-9.
Transperineal ultrasound
Dietz, H., Pelvic Floor Ultrasound. Current Medical Imaging Reviews, 2006. 2: p. 271-290.
Dietz, H., B. Haylen, and J. Broome, Ultrasound in the quantification of female pelvic organ prolapse. Ultrasound in Obstetrics and Gynecology, 2001. 18: p. 511-514.
3D ultrasound imaging
3D ultrasound widely used in obstetric scanning so equipment is now readily available
$100,000 – $250,000Acquisition of volume images allow
access to the ‘axial’ plane – previously domain of magnetic resonance imaging.
Protocol for 3D pelvic floor imaging • Translabial imaging:
– Imaged supine after voiding– Transducer ‘sits’ on the perineum mid-sagittal
orientation– Mid-sagittal image on the screen– Symphysis pubis reference point – during movement– Methods highly reproducible (Guaderrama, Yang, Dietz ).
3D US pelvic floor imaging – levator hiatus
Voluson 730 expert system. (Dietz et al 2005)
MRI: normal axial anatomy
3D pelvic floor ultrasound – assessing functionLevator hiatus:‘plane of minimal dimensions’
Smallest distance from the inferior edge of the symphysis pubis to the anal rectal angle
Levator hiatal area bounded by the symphysis pubis anteriorly, anal rectal angle posteriorly, puborectalis/ pubococcygeus laterally.
Hiatal area measures pelvic floor functionRestMaximum pelvic floor muscle contractionMaximum valsalva(Training).
Normal 3D Pelvic Floor
A mid-sagittal image. Line indicates plane of minimal dimensions
B corresponding ‘axial’image showing entire levator hiatus
3D imaging: hiatal measurement
Normal Contraction of the hiatus
Ballooning of the hiatus on Valsalva
Avulsion: Ultrasound. Unilateral
Avulsion. MRI. Large unilateral
Avusion: Ultrasound. Bilateral
MRI ………………….……….. Ultrasound
ConclusionsTranslabial ultrasound 2D / 3D /4D
Function and anatomy effective, easy, low cost method for assessment of
the PF Used to confirm/or not the digital diagnosis of PF
dysfunctionBiofeedback training
MRI Anatomy (and function)
Effective valsalva manouevre
Hiatal measurements at rest