1. Jennifer Kruger1 Hans Peter Dietz2,
Pelvic floor imaging
Jennifer Kruger1 Hans Peter Dietz2,
2Department of Obstetrics and Gynaecology University of Sydney, Sydney, Australia
1Department of Sport and Exercise Science, University of Auckland, Auckland, New Zealand
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2. Outline Pelvic floor imaging in general 2D imaging
General use of 3D ultrasound
3D pelvic floor imaging
Pelvic floor function
Research of pelvic floor (pf) function in elite nulliparous athletes using 3D ultrasound.
Possible clinical implications

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Introduction
Ultrasound imaging of pelvic floor available for many years
Lack of ionizing radiation
Ease of use
Cost effectiveness
Recently - capable of imaging in multiple planes, 3D images, ‘real time’ property.
These proved useful particularly obstetrics, gynaecology, paediatrics and cardiology
I N T R O D U C T I O N
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2D imaging
Previously 2D/B mode ultrasound scanning used define pathology and normal function of pelvic floor.
Abdominally, intravaginal or transperineal.
Function assessed:
Descent of bladder, uterus and rectal ampulla during a valsalva manouevre.
Images in the mid-sagittal plane.
Still widely used.
2D Imaging
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2D imaging
Measurements of bladder neck descent and urethral rotation.
2D Imaging
Ultrasound images showing measurement of bladder neck descent and urethral rotation. Bladder neck descent (BND)= x-r –x-s. (Dietz et al 2006)
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3D ultrasound imaging
Use of 3D ultrasound popularised by obstetric scanning.
Volume images of the fetus
Some suggestion improves diagnostic capabilities
Cleft palate
Spinal defects
Gynaecological pathologies
Quantify volumes in urethra and paravaginal supports
Anal canal anatomy and mammography
3D IMAGING
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7. Obstetric imaging

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3D pelvic floor imaging
Recent advances in 3D/4D transperineal ultrasound imaging suitable for visualisation of pelvic floor muscles.
3D Pelvic floor imaging
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3D pelvic floor imaging
Display mode on ultrasound machine shows multiplanar images in sagittal, coronal and axial view and a rendered volume image.
Volume image is the integration of 2D sectional images.
Acquisition of multiplanar images allow access to the axial plane – previously domain of magnetic resonance imaging.
3D PELVIC FLOOR IMAGING
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3D pelvic floor imaging
3D Pelvic floor imaging
A standard acquisition screen of pelvic floor imaging as captured with a Voluson 730 expert system. The orthogonal views are seen at the top left (A plane), top right (B plane), and bottom left (C plane). The bottom right image shows a rendered volume image of the entire levator hiatus. (Dietz et al 2006)
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11. 3D pelvic floor imaging – assessing function
Unique plane of acquisition for levator hiatal area:
‘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 function
Rest
Maximum pelvic floor muscle contraction
Maximum valsalva
3D PELVIC FLOOR IMAGING
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3D imaging
3D PELVIC FLOOR IMAGING
A mid-sagittal image. Line indicates plane of minimal dimensions
B corresponding axial image showing entire levator hiatus ( dotted area)
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13. Protocol for 3D pelvic floor imaging
Transperineal imaging:
GE Kretz Voluson 730 Expert ( similar)
Wide angle of acquisition (85°) curved array volume transducer 8-4MHz.
Imaged supine after voiding
Transducer ‘sits’ on the perineum mid-sagittal orientation
Mid-sagittal/Axial image on the screen
Symphysis pubis reference point – during movement
Evaluation post processing – proprietary software
Methods highly reproducible (Guaderrama 2005, Yang 2006, Dietz 2006 )
3D PELVIC FLOOR IMAGING
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14. Hiatal area on valsalva
3D PELVIC FLOOR IMAGING
Courtesy H.P Dietz
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15. ‘Ballooning’ of hiatus
3D PELVIC FLOOR IMAGING
Courtesy H.P Dietz
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16. Pelvic floor muscle contraction
3D PELVIC FLOOR IMAGING
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18. Introduction
Preliminary evidence women in long term high impact sport (HIFIT) athletes
Poor progress in labour (Kruger 2006)
Increased incidence of stress incontinence (Bo 2004)
Previous research demonstrated increased cross-sectional area of levator-ani muscle in HIFIT women (Kruger 2006)
Stress incontinence more prevalent in high impact sports (Eliasson 2002, Nygaard 1997 )
Association between bladder neck descent, hiatal area on valsalva and pelvic floor dysfunction

19. Aims
Use transperineal 3D ultrasound to characterise the pelvic floor muscle function in HIFIT women and compare it to an age-matched control group.
Investigate pelvic organ descent in both groups during a valsalva manouevre to determine if there is an association with urinary stress incontinence.

20. Methods 24 HIFIT athletes;22 age matched controls
Transperineal ultrasound using published protocol
Questionnaire determine symptoms of
Incontinence
Prolapse
Bowel dysfunction
Imaging using GE Kretz Voluson 730/730 Expert with 7-4MHz transducer
Volumes acquired at rest, pfmc, and valsalva
Most effective of 3 manoeuvres used for evaluation

21. Results All data normally distributed
Mean age 28.5 and 27.6yrs for HIFIT and controls
All asymptomatic for prolapse
Incidence of SUI in the athletes and controls
3 HIFIT – SUI – only
1 HIFIT – UI - only
2 Controls- SUI & UI
Significant differences levator hiatal area on valsalva and BND between groups. HIFIT group higher values for both parameters + increased pubovisceral muscle diameter
None of the other measured parameters different

22. Results

23. Results
1=Hifit
2=Control
* HIFIT

24. Conclusions HIFIT women differ in several aspects of pf function
> Area of levator hiatus on valsalva
No association between hiatal area on valsalva and SUI - was an association with BND. Caution very small numbers
Importance of BN position during raised intra abdominal pressure
Incidence of SUI in HIFIT – ‘overflow phenomenon’ or may be due to
? Changes in the connective tissue.
Incidence of SUI in athletes in keeping with that of the general population (10%) (Bo 2006)

25. Possible clinical implications
Pf muscle function determined by ultrasound
May be a method to aid in ‘risk assessment’ for labour.
Better advise women on the likely obstetric impact of long term, high impact sport.
Development of SUI in athletes during competition – etiology unknown but likely to resolve when sport is stopped (Nygaard 1999)

26. Thank-you for your attention