Pelvic Floor Dysfunction and Imaging - SD

Introduction

Hi, I am Dolores Pretorius.

I'm a professor of radiology at uc, San Diego,
and I'm gonna talk to you this morning about pelvic floor
dysfunctioning and imaging.

I'm talking about pelvic floor dysfunction and imaging.

And my disclosures are
that I've had some software support from both Phillips
and ge, and I've also done some lecturing.

Objectives

The objectives of this talk are to review the anatomy
of the pelvic floor to review the sonographic findings
for fecal and urinary incontinence
and to demonstrate pupil ect, avulsion
and sphincter tears, urinary incontinence, a**l continence,
and pelvic organ prolapse are all part
of pelvic floor disorders.

Prevalence of Pelvic Floor Disorders

One or more pelvic floor disorders was found in 37%
of community dwelling women.

When I read that, I wondered,
what's a community dwelling woman?

That is someone who is not in a nursing home.
So people like you and me walking around.

So in this study, there were 4,000 plus
women from Kaiser who were from 25 to 84 years old,
and they were just randomly identified by age.

And 37% had one
or more pelvic disorders, 15% were stress incontinence,
13% overactive bladder, 6% organ prolapse,
and 25% had a**l incontinence.

Causes of Fecal Incontinence

What are the causes of fecal incontinence?

Muscle damage from childbirth is probably number one.
It's possibly related to being u forceps,
being used at delivery and app
episiotomies, being done at delivery.

But not everything is related to childbirth.
Some are hemorrhoidal surgeries, pelvic tumors, a**l sex,
nerve damage from childbirth, again,
from long-term constipation,
stroke nerve degeneration from diabetes,
which we have a lot of today.

Multiple sclerosis, loss
of storage capacity from radiation treatments
and inflammatory bowel disease, diarrhea,
and pelvic floor dysfunction, decreased squeeze pressure,
impaired a**l sensation, rectal prolapse, and rectus seals.

Diagnosis of Pelvic Floor Disorders

How do we diagnose these things?

There are indices of different questionnaires,
and probably the most popular one is called the fei,
which is the Fecal Incontinence Severity Index.

And this little questionnaire has questions on the
types of leakage, whether it's gas, mucus,
liquid stool, or solid stool.

And the frequency of how often these happen,
do they happen one to three times per month,
one time a week, et cetera.

You get a score based on your answers,
and if you're greater than four, you're considered
to have fecal incontinence.

Available Tests

What are the tests that we have available
to diagnose these types of abnormalities?

First, a**l manometry is used where they test the pressures
of the rectum when you do these squeeze mechanisms.

A**l rectal sonography using 2D endo a**l
and 3D defecography using barium studies,
proct sigmoidoscopy to look at the area
and a**l electromyography.

Treatments for Pelvic Floor Disorders

What types of treatments do we have available?

There's dietary changes, there's medications, there's
bowel training.

And then lastly, there's surgery.

Anatomy of the Pelvic Floor

This isn't an anatomical diagram of sort
of like a cartoon of,
but the muscles that you need to know about.

First off, the synthesis.

Pubis is a very important landmark
for us in identifying this region.

Then we have the urethra, then the vagina,
then the rectum, and then the muscles.

Now, this is the pubal rec muscle here,
but you can see there's a ileal coia,
a anterior sacral coga ligament.

And many people reference these as the levator anai.

And so you'll find in the literature many different terms,
but these muscles do come back here
to the sacrum posteriorly.

Performing Ultrasound Studies

How do we do these studies?

We do them with a patient lying in the lithotomy position.

If we have stirrups
and we're in a lab where there are a tables
with stirrups, then we use stirrups.

If there's no stirrups,
then we let the legs fall against the bed rails
that we keep up with a pillow against them.

And then the legs falling across.

Transducers Used

There's two types of transducers that are being used.

One is the 3D transvaginal probe, which is a five
to nine megahertz probe with a condom of course,
and that gives you better resolution.

But the four to six curva,
linear transabdominal probes sitting on the perineum gives
you a broader based window to the hiatus.

The transducer is placed on the perineum near the
introitus on the perineal body.

And if you don't know where that
is, you'll know in a few minutes.

It's very important to use a light touch
as the transducer pressure thins out the external sphincter
and can cause you to think
that there's a defect when there isn't one.

So in contrast to most of ultrasound where we push in the
pelvic floor, we want to lift up.

Dynamic Information

The dynamic information is very important.

When you're doing pelvic floor work, we look at it both
with resting and with squeeze.

And most of our tears of the internal
and external sphincter are much more obvious on our
patients where we contract and bear down.

Then when we have the resting state,
we generally have the patient hold their breath.

You would think that it's far enough away from the lungs
that it wouldn't impact it,
but image resolution is everything when
you're trying to decide these.

And some studies are being performed
with four d ultrasound in order to see the movement
of the pelvic floor.

3D Multiplanar Imaging

Here's a diagram with the transducer sitting right on
top of the introitus.

We do put in manometry catheters for research purposes,
but this won't be done on a routine basis.

There's the window of what we're gonna look at
and then we kick out a orthogonal planer image
where we have three perpendicular planes looking at that.

We also in our lab, have looked at the pressures,
but that's basically been done for the research purposes
to understand what we're looking at.

Here is the basic 3D
multiplanar picture that we take.

We start in the sagittal plane
and acquire here with the a**l canal
and then the rectum coming down.

And then we have the transverse image off
to our right in box b
with the pubal erectus muscle there.

And then we have our coronal picture through the a**l canal.

Now if we take a slice down here near the a**l angle,
we will get a nice picture of the pubal erectus, this white
sling, and then the internal
a**l sphincter is the black.

And then on the lower part, we can see here
that the perineal body sits right on top of the a**l canal.

And you can also see the pupil rec muscle
in the internal sphincter.

The rectum is down here
and there is again the perineal body right there.

If we go more approximately in the anus,
then you will see the black ring again is the internal
sphincter and the white ring is the external sphincter.

Now this is just another diagram of the same thing,
the perineal body right up here.

And here's our ring of our a**l canal.

And we did some measurements here just to see
what normal measurements were.

And once again, the black ring is the internal,
the white ring is the external.

I like this picture from Dr.
Timor Tricia's paper
because it kind of has a nice picture of the a**l canal right here and showing that if you are more distal here in the a**l canal,
then it looks more like this.

And if you're more proximal there near the angle,
then it looks more like this.

MRI Comparison

The MRI is also helpful.

This was a 21-year-old that was having
probably asymptomatic, maybe it was
a volunteer, I'm not sure.

But notice how thin these muscles are that are
drawn out here in this cartoon
of the internal sphincter versus the pubic.

And notice that the external sphincter has a little cup here
that it comes around and it says,
called the superficial part of the external sphincter
that cups around there.

But notice how thin these are.

Now, maybe part of that is
because of the coils that are in here
pressing everything out.

But that's true for the endo a**l ultrasound as well.

That's one of the reasons we really like 3D.

Ultrasound is we don't have to put anything
inside the rectum.

Mucosal Star and Abnormal Findings

Here we have a beautiful picture from Timor Trish
who coined this, the mucosal scar star in the
middle of the a**l canal.

And I really like that the mucosal star
because it ends up being quite helpful
to us when we have abnormalities.

Here's an abnormal star
and notice right here that you can see
that being pulled up to the anterior part,
which is where the tear is.

And notice this normal
for comparison down here in the bottom right corner,
how smooth and round it is in comparison to
how this is moving up in the star in this patient
with a fourth degree tear.

Research Techniques

Now we did originally our research looking at using
Photoshop to help us move along
and we found the pupil rec muscle
and watched it in the internal sphincter and the external
and saw how it changed over distance
as it went towards the a**l verge.

But then our companies
helped us develop these multis slice
or parallel slice techniques that you can see
that the external sphincter is coming in right here.

There it is the external
and now the internal begins to come in right in here.

And as you go along you see here's some more of
that external right there.

And then once again, we're seeing both.

Now at the a**l verge you can see that you have more
of the external sphincter
and then at the midpoint you have the
internal and the external.

And then as we get towards the a**l rectal junction,
we have just a little tiny bit of the external
and much more of the internal.

So that's the normal progression.

Now, when we started using thick slice, we found
that we could actually see these sphincters better.

And so whether you use a small narrow volume
or thick slice, whatever VCI, whatever the company is using
that you're using, you will get better pictures.

Now the measurement of
that thick slice I think is not very reproducible from one
piece of equipment to another.

And on one equipment we would use a thick slice
that was like 10 and another, we'd use it as one millimeter
and they looked very similar to us.

So I'm not sure how the thick slices are working
for the companies, but I don't think
that they're exactly what they say.

Here you can see disruption of
that mucosal star going into
that internal sphincter right now
and probably going into the external as well.

And you can see that on this rendered picture as well
as right here where that is another picture
of a sphincter damage as you see going up here.

And notice that KY shows us that the
external sphincter may look a little bit thicker right
where it is when we have a tear here in the internal
that you can get thinning of that internal there
and you can get thickening on the
opposite side of the rupture.

They called it the half moon sign.

And then once again, the mucosal star
is abnormal here.

Now, when you do thick slice imaging,
the left hand column here, these are all normal.
The right hand column here are all abnormal.

It ends up that it's not so hard to decide
that it looks normal to you.

It's these abnormals
that you don't know exactly what's abnormal.

Is it just the internal?
Is it the internal and the external?

Here you have the entire rectum is a very thin
little bit of internal sphincter.

And here again, you have it being pulled up anteriorly.

And so there's clearly an internal tear.

Is there an external tear?
You'd have to go up and down to make that decision,
but just like ultrasound
and other places, there's lots of artifacts
and just by tipping it a little bit,
you make it look abnormal.

But notice that the mucosal star is not really
being pulled up here.

And when you just rotate your transducer a little bit,
you see that it's really totally normal.

Now when you look at this anatomic diagram
of the a**l canal, I think it's important to realize
that the pubal rec is closer to the a**l angle
and that the external sphincter is closer
to the verge and the
internal sphincter overlaps the two other muscles.

So when you look at multis slice going through these,
that's an important thing to know.

Technique for Pelvic Floor Imaging

The technique
for the pelvic floor is a little bit different. Before
we tip downward.

Now we tip outward and we take a high frequency probe
and we place it on the perineum
and we acquire volumes
that we can see the an synthesis PUIs anteriorly
and the a**l canal and rectum posteriorly.

Pelvic Hiatus Diagram

Here's another diagram of the pelvic hiatus.

It's not quite perfect,
but it's reasonable that we have this pupil erectus muscle
coming up to the region of the synthesis PUIs
and fanning out with its muscle fibers.

It's not one little point, it's along the entire
part of the pelvis.

The pelvis, notice again the urethra, the vagina
and the rectum.

Here is the trans perineal view
or the urogenital hiatus it's been called.

And you can see the pupil rectal recile muscle.

You can see the urethra, the vagina, and the a**l canal.

And this is a diagram
that I think helps you just go along and follow that.

I think this Mr.
Diagram is very nice to show you
that this pupil erectus muscle, what it looks like here
and that it's right off the edge again.

And then when you correlate with the 3D
and you get the planer information,
here's the pupil erectus very nicely
with the synthesis pubis up here
and then the urethra, the vagina, and the rectum.

And then when we do that thick slice
or narrow volume view,
you can see the pupil rec muscles coming out.

A**l canal, vagina, yeah.

And the urethra up, this is how you do it.

You acquire sagittal
and then you rotate this box C so that it's upright.

Then you move the cursor up to
where you think the synthesis pubis is going to be here.

So that here is our synthesis pubis
and then we rotate it on that
that the cursor is on the synthesis pubis over here
and we rotate it so that we can get that in one plane.

That plane is very important.

I'm gonna go back and show you
that clip much more slowly now that you have the concept so
that you can see how to do it yourself.

First you acquire in the sagittal plane right here.

So here's the a**l canal, here's the rectum,
the synthesis pubis has
to be over here in the left part of the image.

So we went back and forth, back
and forth till we could see it.

Then we have our angle coming right down the region of
where the vagina's gonna be.

So we've acquired we're we swept it.

Now we're gonna zoom just a little bit box C.

We're gonna rotate it up so that we're gonna get in that
pelvic hiatus view.

Okay, so now we're there, now we're going to watch this dot,
we're going to move that dot until it goes up.

And now as we're moving it up here, we're looking in box A
and we're seeing until we get the synthesis pubis.

Now we are in the synthesis pubis right here.

There's the synthesis pubis.

So now we're going to move the cursor in
that plane from here up so that we know where exactly
where the there you go.

We grab it, we move it up to the tip of
where the synthesis is.

That is the tip of the synthesis pubis.

And that is the same in all three planes.

So it's right over here and it's right down here.

So now we have this here
and we need to rotate box B so that it is parallel
so we can get this angle.

So watch, now we're going to rotate it
like a record player in the Z axis.

There we go. Because now we are in
this plane with the angle.

It's right here with the
cursor from the synthesis pubis located from box A.

Now I know that you can replay that on your tapes
or whatever, but the idea is now we have a perfectly
reproducible plane that we are everyone across the world is
using to make our decisions about this.

So when you think of it, the yellow line is the urethra,
the pink is the vagina and the orange is the a**l canal.

Okay? And this is the angle we're looking for.

We're looking for the synthesis pubis to the retro, I mean
to the a**l angle right there, a**l canal angle.

And then if we put these measurements on,
here is the vagina again, here is the a**l canal
and here is the urethra.

Measurements and Research

Now we did measurements in our research, measuring areas,
perimeters, all types of things, volumes.

But what panned out
is the best is the anterior posterior length of the heus.

And it actually is very simple.

There we go from the synthesis pubis where we put that to
the anterior part of the pubal erectus
and we do it with rest and we do it with squeeze.

And you tend to be able to make your calls
of your abnormals best on your squeeze images.

Scoring System

Here's some pictures of a scoring of what was developed
for MRI and we're using it with ultrasound as well.

And this is a normal pelvic hiatus with,
we count it as zero because it's normal.

Nice normal here.

Here's another just a little different nice normal pupil
erectile muscle here on this image, this side looks normal,
but this side just looks a little asymmetric
and it doesn't look as tight.

This one looks thinner on this side on,
so we got a score of one, this one scored a two
'cause you just really can't quite see it.

And this one scores a two on both sides as well
because of the we can't see that pubal ect very melt
asymmetry is important when you're looking at these in order
to help you make the differential.

Vagina Shape and Dynamic Assessments

The shape of the vagina is also something
that we became aware of.

We put a balloon in
and we increased it with different sizes just to see
what the area looked like.

And you might think this is really just
research, and indeed it is.

But look at this clip really helped us
understand what was happening.

This is the vagina filled a balloon in the vagina.

Here's the synthesis pubis over here,
and here is our a**l canal
with our a**l rectal angle right here.

That is why we want to the line to go from the synthesis
to the angle because that's where we contract
when we do that squeeze mechanism.

MRI and Movement

MRI has been used to look at the pelvic floor
with at rest and at squeeze,
and you can see the diameter changes,
the same angle changes.

And we know that on MRI,
that the pelvic floor is moving in multiple directions.

It's not just a simple vertical direction or
contraction in an anterior posterior direction,
but indeed it is a vector.

It goes up in a vector type position
and we've been trying to figure out how to measure that.

But the rectum
and the whole buttocks moves when you squeeze,
so you can't keep in the same direction.

Valsalva Maneuver Study

Dr. Deets did this study looking at how we
move our lator muscles with Val Salva
and he took 50 nulo pairs, women who are 36
to 38 weeks pregnant.

And he did the pelvic hiatus pictures with
and without Val Salva.

He taught them how to do a Val Salva.

And he found that only 22 outta 50
decrease their hial diets like they were supposed to
for a Val Salva maneuver.

11 out of 50 were able to decrease it
after a secondary instruction.

But you can see
that basically many women cannot val salva correctly.

That means that we have to teach people
how to do this better.

Here we have a picture on the left of at rest
where you can see the nice pupil rec muscle
and then on the first Val Salva, it doesn't really,
it decreases instead of increasing.

And then when we get an optimal Val Salva,
we get our maximum extent here.

I think this was very important in confirming
what many women already knew that we didn't really know how
to do our v Salva maneuvers appropriately.

We weren't doing our Kegels in a way
that was actually helping us strengthen our pelvic floors.

We just didn't know how.

There are physical therapists that help
and can put their hands in your pelvis
and watch your muscles, feel your muscles
and tell you what you're doing right and wrong.

And in France, every pregnant woman has a has appointment
with a PT person to help them do their kegel afterwards.

And maybe this would decrease some
of our pelvic floor incontinence if we knew how to do this.

Posterior Compartment Assessment

The posterior compartment is also something in that we use for fecal incontinence
that we can not only assess the sphincters,
but we can also look for other abnormalities such
as rectus seals and intussusception.

And these things can be detected on ultrasound.

Here you have at rest the defecography showing
what the rectum looks like going into the a**l canal
versus with squeeze.

And you can see that that angle changes.

That's why everyone's interested in this angle being 90
degrees here versus one 15 degrees here.

So there is some degree of correlation with what this means.

Here is a rectus seal that you can see going up here
that correlates with this defecography with the rectus seal,
a blossoming out of the rectum which certainly
comes with people who have problems
with fecal incontinence.

Now this line from the synthesis pubis over to the rectum,
it's that same important line.

We can look for cysto seals, uterine prolapse
and rectus seals and even intra seals come down here
and penetrate in.

And these can be important for therapy.

Prolapse Examples

Here we have a patient at rest
and here's the urethra coming down
and then here we have a Val Salva.

And look what happens to that bladder
that it funnels down into the tissues.

And that is a cysto seal.

Here we have a patient who's had first degree uterine descent
after a birch copal suspension, which is one
of the surgeries they do for urinary incontinence.

And you can see that here we are at rest with the bladder.

And then here we are
with the bladder coming down towards the cervix.

Here's a rectocele, another rectocele,
there's the rectum, I mean the a**l canal
and then the rectum coming out and there it is
and here it was at rest.

So that's what we look for to find a rectus seal.

Now there are slightly different appearances
for interal versus rectocele,
an inal which is from the small bowel peristalsis.

And there can be fat or momentum in it
and it usually is more homogeneous
or nearly iso coic, whereas the rectocele is filled
with stool and it often has a lot
of hyper echogenicity within it with di distal shadowing.

So here is a typical interal
and here's a typical rectocele in a patient
that you don't see it at rest,
but you do see it at Valsalva.

Here's a ur urethral diverticulum that you know,
now you know where the urethra is
and here is that diverticulum.

And sometimes these are more easily seen on the valve
salva again and they can simulate a cysto
or ur cysto urethra seal even though it's really a
diverticulum of the bladder neck.

Stress Urinary Incontinence

What can I tell you about stress urinary incontinence?

This is work that I've taken from the literature.

I have to tell you, I haven't done a lot
of work on the bladder itself.

I've spent most of my research time looking
at the posterior compartment.

But different people are looking at the bladder
for mo mobility and for funneling,
and people are developing ranges for normal motion
of the bladder neck.

So here we have the
bladder neck right here in this patient at rest.

And you can see once again the synthesis pubis the
a**l canal over here.

And here we have first Val Salva and then optimal Val Salva
and how much more descent there is after that.

Anterior Compartment Evaluation

The anterior compartment is where we evaluate
for urinary incontinence and Valki talks about the height
and the distance from the bladder neck
and how far we go
and also the posterior urethral vesicle angle
in the pelvic floor.

And these are numbers that they have developed at
what the angle should be approximately at rest
and at Val Salva.

But we don't really have the abnormal numbers yet
developed to figure this out.

The 2D ultrasound parameters are encouraging
and we think 3D numbers would be even better,
but they need to be correlated with clinical standards
and dynamic studies, which hasn't been done yet.

So here we have the normal pelvic floor again
and here's one of these angles, one of these distances
that they're looking at in order
to try to figure this out.

Now here is a normal
with the pubal erect muscle on either side
and then here is a avulsion with this pulling off here
and you see this ballooning out of the vagina.

And this retro, the space right
behind the vagina here in the region of where
that avulsion has taken place.

Now this is another picture of a avulsion
with the asymmetry that we see
when we have an avulsion off the side.

This is a patient that has detachment
and the question is, is it artifact or is it real?

And this one is really just artifact.

You can make a defect just
by being a little bit off axis as you rotate.

So you need to be able to rotate back and forth
and try to get the normal picture
before you're confident that it's abnormal.

Surgical Interventions

We do have different types of tape
and surgical things that have been put in to try
to help us for incontinence.

Here's a nice normal picture of tension free vaginal tape
and here's one that's kinked
or broken underneath the urethra.

Here another a tension-free vaginal tape
that you can see right here.

It looks kind of like the stitches that we see
with our C-section scars.

And there it is on Vel Salva as well.

So it is in place, it's in the place, right place.

And here's one called microplastic injectable.

That is a nice normal appearance of that
from the literature.

Conclusion

The pelvic floor I think has,
these are some articles that you can look up if you'd like,
that I think are excellent editorial
or review articles to give you an idea
of what's going on in the literature.

And I hope that was helpful to you.

And thank you very much.