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Pelvic Diagnosis in Gynecology

Ultrasound imaging of the female perineum: the effect of vaginal delivery on pelvic floor dynamics.
Costantini S, Esposito F, Nadalini C, Lijoi D, Morano S, Lantieri P, Mistrangelo E
Ultrasound Obstet Gynecol. 2005 Dec 30;.

OBJECTIVE: To assess the use of perineal ultrasound in the evaluation of the influence of vaginal delivery on urethral mobility and on the contraction strength of the levator ani muscles. METHODS: This was a prospective observational study of 70 nulliparous women. Each woman underwent perineal ultrasound assessment at 36-38 weeks' gestation and at 1 week and 3 months following delivery. During each examination we assessed: the posterior urethrovesical angle at rest, urethral mobility during Valsalva maneuver and movement of the anorectal angle and levator sling angle during contraction of the levator ani. RESULTS: The urethrovesical angle and the urethral mobility increased significantly after delivery (P < 0.0001). The levator sling excursion decreased proportionally. The anorectal excursion had decreased significantly by the examination 3 months after birth. CONCLUSIONS: Perineal sonography provides objective assessment criteria for urethral mobility and for contraction strength of the levator ani muscles and detects changes in the anatomy and function of the pelvic floor after vaginal delivery. Copyright (c) 2005 ISUOG. Published by John Wiley & Sons, Ltd.

[Value of sonography and MR imaging for the evaluation of deep pelvic endometriosis]
Bazot M, Nassar J, Darai E, Thomassin I, Cortez A, Buy JN, Uzan S, Marsault C
J Radiol 2005 May;86(5 Pt 1):461-7.

Deep pelvic endometriosis may involve the uterosacral ligaments, cul-de-sac of Douglas, vagina, rectum, and occasionally the bladder. Evaluation by physical examination is difficult, and imaging techniques are needed to evaluate the location and extent of endometriosis. In this review, we review the transvaginal and transrectal sonographic and MR imaging features suggestive of deep pelvic endometriosis and their diagnostic value.

Posterior compartment prolapse on two-dimensional and three-dimensional pelvic floor ultrasound: the distinction between true rectocele, perineal hypermobility and enterocele.
Dietz HP, Steensma AB
Ultrasound Obstet Gynecol 2005 Jul;26(1):73-7.

OBJECTIVES: Posterior compartment descent may encompass perineal hypermobility, isolated enterocele or a 'true' rectocele due to a rectovaginal septal defect. Our objective was to determine the prevalence of these conditions in a urogynecological population. METHODS: One hundred and ninety-eight women were clinically evaluated for prolapse and examined by translabial ultrasound, supine and after voiding, using three-dimensional capable equipment with a 7-4-MHz volume transducer. Downwards displacement of rectocele or rectal ampulla was used to quantify posterior compartment prolapse. A rectovaginal septal defect was seen as a sharp discontinuity in the ventral anorectal muscularis. RESULTS: Clinically, a rectocele was diagnosed in 112 (56%) cases. Rectovaginal septal defects were observed sonographically in 78 (39%) women. There was a highly significant relationship between ultrasound and clinical grading (P < 0.001). Of 112 clinical rectoceles, 63 (56%) cases showed a fascial defect, eight (7%) showed perineal hypermobility without fascial defect, and in three (3%) cases there was an isolated enterocele. In 38 (34%) cases, no sonographic abnormality was detected. Neither position of the ampulla nor presence, width or depth of defects correlated with vaginal parity. In contrast, age showed a weak association with rectal descent (r = -0.212, P = 0.003), the presence of fascial defects (P = 0.002) and their depth (P = 0.02). CONCLUSIONS: Rectovaginal septal defects are readily identified on translabial ultrasound as a herniation of rectal wall and contents into the vagina. Approximately one-third of clinical rectoceles do not show a sonographic defect, and the presence of a defect is associated with age, not parity. Copyright (c) 2005 ISUOG. Published by John Wiley & Sons, Ltd.

A new three-dimensional automatic bodymarker system for transvaginal ultrasonography.
Kuwata T, Taniguchi N, Matsubara S, Ono T, Itoh K, Suzuki M
Ultrasound Obstet Gynecol 2005 Jun;25(6):586-91.

OBJECTIVE: To evaluate the accuracy and usefulness of a newly developed three-dimensional automatic bodymarker system for transvaginal ultrasonography. METHODS: A bodymarker system which utilizes an electromagnetic field to specify the probe position was developed. Software was written which enabled the positional information of the probe and the ultrasound image to be simultaneously displayed on a personal computer. The bodymarker was displayed as a three-dimensional graphic model. The differences between the estimated and the actual position-i.e. the error-for both position (x, y and z) and angles (azimuth, elevation and roll) of the probe were measured. The movement of the probe was then evaluated in healthy female volunteers and the comparative time required for ultrasound examination was determined. RESULTS: Both the position and the angles of the probe were accurately shown in the computer display. The errors were 1.0 mm and 0.7 degrees (median) for position and angle, respectively. The system was also shown to work well in healthy female volunteers. Calibration of the new system required only 5.0 seconds, compared with an average of 7.6 seconds for the conventional bodymarker. CONCLUSION: The newly developed three-dimensional automatic transvaginal bodymarker system provides an accurate indication of probe position and its tilting angle. It works well in healthy female volunteers and speeds up the examination time. It may be clinically useful for transvaginal ultrasound examination. Copyright (c) 2005 ISUOG. Published by John Wiley & Sons, Ltd.

Paravaginal defects: a comparison of clinical examination and 2D/3D ultrasound imaging.
Dietz HP, Pang S, Korda A, Benness C. Aust N Z
J Obstet Gynaecol 2005 Jun;45(3):187-90.

Abstract Background: Paravaginal defects are often assumed to be the underlying anatomical abnormality in anterior compartment descent. Neither clinical examination nor ultrasound assessment are generally accepted diagnostic modalities. Aims: To compare clinical examination and translabial 3D ultrasound in the detection of such defects. Methods: Fifty-nine women without previous prolapse or incontinence surgery were seen prospectively. Clinical and ultrasound assessments were carried out in blinded fashion. 3D translabial ultrasound was undertaken after voiding and supine. Volumes were acquired at rest, on Valsalva and on levator contraction. Loss of paravaginal support ('tenting') in the axial plane was taken to signify paravaginal defects. Results: Paravaginal defects were reported clinically in 14 cases on the left (24%), 19 times on the right (32%). Two 3D ultrasound examinations did not yield satisfactory volumes, leaving 57 for analysis. Neither midsagittal nor coronal views yielded data that correlated with clinical assessments. In the axial plane there was absence of tenting at rest in 32/57 (57%) patients, but this did not correlate with clinical findings. Loss of tenting on Valsalva was observed less often (21/57, 37%) and was weakly associated with clinically observed lateral defects (P = 0.036). Conclusions: Pelvic floor ultrasound in midsagittal, axial or coronal planes does not correlate well with clinical assessment for paravaginal defects. This could be due to poor clinical assessment technique or limitations of the ultrasound method. On the other hand, paravaginal defects may be uncommon or clinically irrelevant. On present knowledge, the paravaginal defect has to be regarded as an unproven concept.

Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound.
Dietz HP, Shek C, Clarke B.
Ultrasound Obstet Gynecol 2005; 25:580-5.

Until recently, magnetic resonance was the only imaging method capable of assessing the levator ani in vivo. Three-dimensional (3D) ultrasound has recently been shown to be able to demonstrate the pubovisceral muscle. The aim of this study was to define the anatomy of the levator hiatus in young nulliparous women with the help of 3D ultrasound. METHODS: In a prospective observational study, 52 nulligravid female Caucasian volunteers (aged 18-24 years) were assessed by two-dimensional (2D) and 3D translabial ultrasound after voiding whilst supine. Pelvic organ descent was assessed on Valsalva maneuver. Volumes were acquired at rest and on Valsalva maneuver, and biometric indices of the pubovisceral muscle and levator hiatus were determined in the axial and coronal planes. RESULTS: In the axial plane, average diameters of the pubovisceral muscle were 0.4-1.1 cm (mean 0.73 cm). Average area measurements were 7.59 (range, 3.96-11.9) cm2. The levator hiatus at rest varied from 3.26 to 5.84 (mean 4.5) cm in the sagittal direction, and from 2.76 to 4.8 (mean 3.75) cm in the coronal plane. The hiatus area at rest ranged from 6.34 to 18.06 (mean 11.25) cm(2) increasing to 14.05 (6.67-35.01) cm(2) on Valsalva maneuver (P = 0.009). There were significant correlations between pelvic organ mobility and hiatus area at rest (P = 0.018 to P < 0.001) and on Valsalva maneuver (all P < 0.001). CONCLUSIONS: Biometric indices of the pubovisceral muscle and levator hiatus can be determined by 3D ultrasound. Significant correlations exist between hiatal area and pelvic organ descent. These data provide support for the hypothesis that levator ani anatomy plays an independent role in determining pelvic organ support.

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
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):236-41. Epub 2004 Oct 16.

Ultrasound is a supplementary, indispensable diagnostic procedure in urogynecology; perineal, introital, and endoanal ultrasound are the most recommended techniques. The position and mobility of the bladder neck can be demonstrated. In patients undergoing diagnostic work-up for urge symptoms, ultrasound occasionally demonstrates urethral diverticula, leiomyomas, and cysts in the vaginal wall. These findings will lead to further diagnostic assessment. The same applies to the demonstration of bladder diverticula, foreign bodies in the bladder, and bullous edema. With endoanal ultrasound, different parts of the sphincter ani muscle can be evaluated. Recommendations for the standardized use of urogenital ultrasound are given.

A new vaginal speculum for pelvic organ prolapse quantification (POPQ).
Diokno AC, Borodulin G
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan 21;.

The purposes of this study were to introduce a new vaginal speculum, describe the technique of using the new speculum in identifying and measuring the severity of pelvic organ prolapse (POP), and present results of a pilot study comparing the new speculum to the conventional instruments used in performing POP quantification (POPQ). The new speculum has retractable upper and lower blades marked in centimeters. POPQ was performed with one instrument using the new speculum and multiple instruments performing the conventional technique. Twenty-two patients underwent POPQ-11 using the new speculum and 11 using conventional instruments. The duration of the procedure and the level of discomfort were assessed. The POPQ method using the new speculum is described. Preliminary experience with the new speculum showed that the length of examination is significantly shorter (p<0.001) and the comfort level is better than with the conventional technique (p=0.088). A new vaginal speculum with adjustable blades simplifies POPQ. Preliminary testing suggests potential savings in procedure time and reduction in patient discomfort.