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Phyllis GlancSunnybrook Health Sciences Center

Department Medical Imaging

Associate Professor, University of Toronto

phyllis.glanc@sunnybrook.ca

Pelvic Floor DysfunctionRole of Ultrasound

Special Thank You

• Professor Hans Peter Dietz generously permitted

educational use of images

• Wonderful Sunnybrook staff who have developed a

pelvic floor imaging program.

NO DISCLOSURES

Hello, incontinence helpline - can you hold?

Text

Objectives

• Background

• What are the Issues in Pelvic Floor Dysfunction

Urinary (UI) & Fecal Incontinence (FI)

Pelvic Organ Prolapse (POP)

Levator ani trauma

Post operative - Slings and Things

• Conclusion

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Pelvic Floor Imaging - Choices

• Transperineal ultrasound (TPUS)

• Endoanal ultrasound ( gold standard AS)

• MRI with rectal contrast – dynamic;

defecography ( limited availability)

• Fleuroscopic Techniques - Traditional

• Voiding cystourethrography (VCUG), dynamic

cystoprotography, Fluoroscopic Defecography

TPUS – Why Now?

• US imaging pelvic floor available many years

• Why Now?

• 3D/4D obstetrical image has made

physicians comfortable with the tools

• Improved resolution – MPR – real-time with

cineloops/volumes can review

• Tomographic CT style slices

• Fleuroscopy is out of favor – MRI expensive

Why Bother?

Pelvic Floor Dysfunction

•Affect 50% women by age 50

• 1/10 have surgery by age 70

• 1/3 repeat surgeries

• Pelvic organ prolapse (POP) affect 1/3 PMW

• Societal costs in billions for UI and millions for POP

and AI

•Project huge demand increase service

Pelvic Floor Disorders

•Challenges

• Pelvic floor anatomy complex

• Requires advanced US imaging techniques

• Limited FOV as compared to MRI

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• * Female gender

• ** prolonged 2nd stage labor (vaginal delivery

• Plus

• Increasing age

• Pelvic surgery - especially hysterectomy

• Chronic increased abdominal pressure eg obesity,

weight lifting,

• Poor pelvic support

• Connective tissue disorders, post radiation

Risk Factors Compartments Pelvic Floor

• Anterior - Bladder , urethra

• Central - Uterus-cervix-vagina

• Posterior - Anal sphincter and rectum

Reference Slide

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Level Anterior compartment

Posterior Compartment

1 Highest Bladder base Inferior 1/3 rectum

2 Mid Bladder neck Anorectal junction

3 Low Midurethra Upper 1/3 anal canal Levator Ani Sling-Lateral vagina-Posterior Anal canal-Attach PR anterior

4* Lowest Distal urethra Mid/lower 1/3 anal canal Perineal body & superficial perineal muscles (perineal

muscles, bulbospongiosus, ischiocavernosus ,superficial transverse

* Level measure AP diameter UG hiatus ( pubosymphysis-perineal body distance)

Anatomy Review

Urethra

Uterus

anal canal

rectum

Cervix

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Urinary Incontinece

• Women more susceptible

• Anatomy : Urethra shorter thus less resistance

to outflow when bladder contracts

• Life style Risks: Vaginal Delivery/2nd stage

labor prolonged

Urinary Incontinence• Stress : (SUI) -increase abdominal pressure

(cough, laugh, sneeze) results involuntary loss

urine

• Sphincteric defect / hypermobility urethra

• Urge urinary incontinence (UUI) - detrusor

overactivity ( destrusor thickness > 5mm) or

damage innervation bladder

• Overflow: Leakage

Anterior Compartment: UI & Prolapse

Key role of Ultrasound

• ID position bladder neck / urethra, assess PVR

• Assess UVJ for rotation and descent

-maintain RVA (retrovesical angle > 120

degrees)

• Assess develop cystocele ( if UVJ stable may

kinked urethra and bladder dysfuntion/retention

• Distinguish between cystocele with urethral

hypermobility versus a cystocele without urethral

rotation

Bladder neck remains closed

Hypermobility urethra descends & rotates horizontal

Borderline small cystocele develops

Classic SUI

Rest Strain

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Retrovesical angle now > 120 degrees

Associated SUI Isolated Cystoceles

- Less common

- Bladder neck remains in place

- Voiding dysfunction rather than SUI

- Association with levator ani trauma

Posterior Compartment

• Anal continence - Anorectal angle 90-130 degrees

rest & anorectal junction above or at level PS

• POP with perineal hypermobility - descent rectal

ampulla

• Rectovaginal defect with diverticular outpouching

anterior wall rectum into vagina is rectocele , also

sigmoidocele, enterocele

• Rectal intussception

• Anal sphincter trauma

Posterior Compartment

• EAUS gold standard assess anal sphincter

• Distinguish incontinent patients with intact

anal sphincter vs sphincteric lesions (defect,

scarring, atrophy) 90% sensitivity/specificity

• MRI good big picture/muscles

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• Important to have maximum effort

• Rest normal ARA which is above pubic symphysis

• Valsalva develop rectocele, loss acute ARA, descent rectal

ampulla

• Rectocele measure depth perpendicular to wall expected

contour anterior rectal wall in continuity with AS > 1- 1.5 cm

Development sigmoidocele

Fecal IncontinenceTPUS: Normal AS

Not the Gold Standard

Useful for rapid assessment AS but more importantly bigger

picture thinking puborectalis / levator tears, abnormal RVA

and dev rectocele/enterocele/sigmoidocele

TPUS - Anal Sphincter

Pannu et al Radiographics 2010

Yagel et al., Valsky et al., UOG 2006, 2007

IAS =2-3mm, EAS variable thickness

US sensitivity/specificity muscular defect ~

90%

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TPUS Anal SphincterResults less validated c/w endoanal US

Courtesy Dr. Dietz

PELVIC ORGAN PROLAPSE

Pelvic Organ Prolapse (POP)

• Descent of the pelvic organs beneath a theoretical line between PS and

ARA

• Cystocele – bladder

• Rectocele – anterior wall rectum

• Into widened rectovaginal space is enterocele or sigmoidocele

• Vaginal prolapse or pocidentia (uterus)

• Critical pre surgery to evaluate all compartments

• Also important to recognize only important if clinically symptomatic

Pelvic Organ Prolapse (POP)

• 9% women clinical symptoms

• 30% undergo repeat operation

• Negative impact on quality of life including sexual function

• LA avulsion from pubic bone or pelvic sidewall is associated with

POP

• LA avulsion is associated with vaginal delivery

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MR - Pubococcygeal

line Pelvic Organ Prolapse (Anterior)

• Pelvic Organ Prolapse ( Posterior)

• Line from PS to ARA at rest…..

Pelvic Organ Prolapse (posterior)3D & Volume Rendered Critical

• Dimensions urogenital hiatus

• POP

• Levator Ani Trauma

• Slings and Things

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Display Modes :

MPR/Rendered• MPR/orthogonal display

mode shows cross-sectional planes through the volume in question.

• Imaging planes on 3D US can change either at the time of acquisition or offline at a later time.

• D = standard rendered image of the levator hiatus, with the rendering direction set from caudally to cranially

Courtesy Dr. Dietz

Urogenital Diaphragm• Largest natural hiatus in body

• Mean 16 cm young nullip

• Mean 25 cm overall

• Most caudal layer pelvic floor

• Composed of CT and peroneus muscle run from ischial rami to perineal

body and EAS

• Perineal body is site attachment for endopelvic fascia, UG diaphragm,

bulbocavernosus muscle and puborectalis muscle

Urogenital Hiatus Biometric Indices:

• AP diameter 4.5 -4.8 cm

• laterolateral diameter 3.3 -4.7cm

• hiatal area 11.3 - 12 cm

Functional Assessment

• Valsalva and PFMC allow its functional assessment.

• Ballooning of the hiatus(excessive distensibility of LA)

• increase in hiatal area to > 25 cm2 on Valsalva maneuver

• Generally associated with full pelvic organ prolapse (POP)

Dietz et al and Santoro et al.

Urogenital hiatal ballooning on Valsalva

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Levator Avulsion• Common ( 10-35%) post vaginal delivery

• Forceps triple risk

• Will result

• Reduction contraction strength

• Increased risk prolapse (ant/central) 2-3x

• Increased risk prolapse recurrence post

surgery

• May not affect SUI or FI

Pelvic Floor Musculature

• Levator ani muscles symmetric broad

muscular sheet attached internal surface

pelvis

• Key point maintain constant tone except

during voiding, defecation, Valsalva

• Stretched during vaginal delivery with

maximal strain occuring in most medial

aspect pubococcygues

Levator Ani (LA) Avulsion• Direct signs is the avulsion of LA

• Indirect sign is the disruption of “H”

configuration vagina suggested by posterior

displacement vaginal fornix

Levator ani ( puborectalis) avulsionDietz and Lanzarone, Obstet Gynecol 2005; Dietz et al. IUGJ 2010

Normal

TUI :Right-side levator ani defect measure ~ 2

cm (AP) retraction muscle

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Slings – MeshSuburethral

• Concept:

• Continence maintained at midurethra

instead of the bladder neck

• Failure of the pubourethral ligaments

• Propylene mesh

• pore size minimum 75 microns

• Permit entry macrophages, fibroblasts,

collagen fibres

• Mesh erosion rate ~ 9%

• Bleeding pv 31%

• Pain 13%

• Voiding dysfunction 21%

• PS - Mesh gap in Valsalva < 1cm

• < 7mm increase probability functional obstruction

thus may consider tape division

• 20% mesh arm dislodge - mesh mobile

• Line straight or obtuse, wide gap ? not anchored

• Mesh can fold up into itself, migrate, perforate

Complications

TVT Mesh

• Repair via obturator foramen for anchoring may be

useful for women with levator avulsion injuries to

decrease risk recurrence

TVT (tensionless vaginal tape TOT (Transobturator tape

•Concern re use of mesh in prolapse surgery

• 70,000 such procedures done in the US /yr

•Complications are attracting the attention of lawyers soliciting for class action lawsuits.

•Concern for surgeons if they should stop

• New evidence show that they markedly reduce recurrence rates (Altman et al, NEJM 2011, Wong IUGJ 2011)

Warning: FDA and meshJuly 2011

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• Mesh use in patients at high risk of recurrence is

approriate

• Age (the younger the worse), prolapse stage,

previous failed surgery, levator avulsion

• Inciting factors ( obesity.....)

• Mesh use in patients at low recurrence risk ?

• Newer studies demonstrate higher rate of

treatment success

*Whiteside AJOG 2004, Vakili AJOG 2005, Dietz UOG 2010, Model EJOGRB 2010, Wong IUGJ 2011, Morgan IJGO 2011, Weemhoff IUGJ 2011,

Conclusion: FDA & MESH

Sagittal

Mesh midurethral

level

Harder to obtain

information but

doable

Axial view Relatively straight extending

laterally to insert on

puborectalis/levator ani and

out thru obturator foramen

TOT

Evaluation TOT PS – Mesh Gap – Too wide/high

PROBLEM: Recurrent UI

Mesh high in location

Bladder neck opens wide with stress

although remains fixed high in

position

PS- Mesh Gap – Too Narrow

Problem: Voiding Dysfunction

Typically > 1cm

Typically cut mesh to cure this

Narrow gap < 7mm

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Problem – Post-Operative –

Urinary DysfunctionCut Sling

Courtesy Dr. Dietz

Problem – Post-Operative - PainTomographic Slice

TVT – curve anchoring anterior, deshiscient

Mesh frayed & migrated into vagina.

Rendered Image

TVT – curve anchoring anterior,

the left side is split in two and not obviously anchored, concern

Edges migrated into vagina.

Problem – Post Operative

TVT perforation / migration into urethra

Courtesy Dr. Dietz

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• Pelvic floor disorders common

• Complex area

• Best for POP, LA avulsion defects, hiatal

ballooning, SUI

• Biofeedback pelvic floor contraction

• Does not always correlate well with clinical

symptoms

• More research needed

Conclusion References• State of the art: an integrated approach to pelvic floor ultrasonography. H. P. Dietz3, Ultrasound in Obstetrics & Gynecology 37, 381–396, April 2011

• DeLancey JO. The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment. Am J Obstet Gynecol 2005; 192: 1488–1495.

• Dietz HP, Shek C, Clarke B. Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound. Ultrasound Obstet Gynecol 2005; 25: 580–585.

• Lekskulchai O, Dietz H. Detrusor wall thickness as a test for detrusor overactivity in women. Ultrasound Obstet Gynecol 2008; 32: 535–539.

• Broekhuis SR, Futterer JJ, Hendriks JCM, Barentsz JO, Vierhout ME, Kluivers KB. Symptoms of pelvic floor dysfunction are poorly correlated with findings on clinical examination and dynamic MR imaging of the pelvic floor. Int Urogynecol J 2009; 20: 1169–1174.

• Model A, Shek KL, Dietz HP. Do levator defects increase the risk of prolapse recurrence after pelvic floor surgery? Neurourol Urodyn 2009; 28: 888–889

• Dietz HP, Haylen BT, Broome J. Ultrasound in the quantification of female pelvic organ prolapse. Ultrasound Obstet Gynecol 2001; 18: 511–514.

• Yagel S, Valsky DV. Three-dimensional transperineal ultrasonography for evaluation of the anal sphincter complex: another dimension in understanding peripartum sphincter trauma. Ultrasound Obstet Gynecol 2006; 27: 119–123.

• Dietz HP, Barry C, Lim YN, Rane A. Two-dimensional and three-dimensional ultrasound imaging of suburethral slings. Ultrasound Obstet Gynecol 2005; 26: 175–179.

• Dietz HP, Steensma AB. Posterior compartment prolapse on two-dimensional and three-dimensional pelvic floor ultrasound: the distinction between true rectocele, perineal hypermobility and enterocele. Ultrasound Obstet Gynecol 2005; 26: 73–77.