The Relationship between Pelvic Examination and Ultrasound Finding in Patient with Pelvic Floor Dysfunction

Abstract

In Pelvic examination, the POPQ system is an objective, site-specific system for describing and staging pelvic organ prolapse (POP) in women to create a “topographic” map of the vagina. Ultrasound is capable of identifying different compartmental defects of the pelvic floor. On ultrasonography, there are three methods for the quantification of POP: determining position by 1 distance and 1 angle (polar coordinate), by 2 distances ( orthogonal coordinate), or by measuring the height of pelvic organ with reference to a horizontal line drawn at the lower border of symphysis pubis. The differences between resting and stress bladder neck angles yield the rotational angle, which represents urethral or bladder neck mobility in a similar way as the Q-tip test. There are no definite values of normal bladder neck descent or urethral mobility. Although the positions of the bladder neck in patients with stress incontinence are lower than those of continent women, there is an overlap between these two groups. Nevertheless, urethral mobility was reported to be related to grade of incontinence. The levatorani muscles play an important role in supporting pelvic organs and maintaining normal pelvic floor function. Palpation through the vagina or rectum helps in assessing pelvic floor squeeze strength and levator muscle thickness. Guidelines have been published by the International Continence Society to assess pelvic floor musculature tone. Women with poor pelvic floor muscle function may benefit from pelvic physical therapy. On ultrasonography, the function of levatorani muscle has been assessed indirectly by the displacement of pelvic structures (e.g. bladder neck or bladder base) on its contractions. The bladder and urethra moves upwards and ventrally during pelvic floor contractions. Correlations between shift of bladder neck and palpation/perineometry have been shown to be good. During straining, the bladder neck may move in a semicircular fashion with the tip of the symphysis pubis as the center (rotational descent), or move downward along the urethral axis (sliding descent). On ultrasonography, the occurrence of bladder neck funneling suggests poor urethral closure pressure. In addition to stress incontinence, bladder neck funneling may also be found in women with urge incontinence. It does not occur in normal continent women unless the bladder is full. Enteroceles are often difficult to recognize by clinical examination, but are easily detected by perineal or introital ultrasound. The imaging of the cervix and the vaginal apex may be incomplete with the presence of large rectoceles, and the extent of pelvic floor relaxation may be underestimated because of transducer pressure and without the help of sim speculum. Levator avulsion, detachment of puborectalis muscle from its insertion, and hiatal (levator ani compelx) overdistensibility, are two risk factors associated with POP.