Transperineal Ultrasound Imaging Research Articles

Differences in activation of pelvic floor muscles in response to electrical stimulation in men using different electrode montages

Objective:To measure contraction of the striated urethral sphincter, bulbocavernosus and puborectalis muscles with transperineal ultrasound imaging in response to electrical stimulation with three electrode montages. Materials and methods:Electrical stimulation was applied via anal, perineal and perineal-to-suprapubic electrode montages in ten healthy men. Induced pelvic landmark displacement was recorded with transperineal ultrasound imaging. Threshold current to evoke contraction of each muscle and maximum displacement was identified from displacement of relevant landmarks. outcomes were compared between landmarks and montages. Results:Contraction of all muscles (identified from landmark displacement) could be evoked with each electrode montage. Contraction of puborectalis was evoked in less men than the sphincter for the perineal montage. Threshold current was lower for the anal montage than either perineal montage and lower for contraction of the sphincter than puborectalis. Conclusion:Although electrical stimulation can evokes contraction of all pelvic floor muscles tested, differences in frequency of contraction and threshold imply different electrode montages may have different clinical applications. A perineal montage biases contraction to the sphincter and bulbocavernosus.

Direction-guided and multi-scale feature screening for fetal head–pubic symphysis segmentation and angle of progression calculation

Transperineal ultrasound imaging in the mid-sagittal plane can potentially enable the objective quantification of the level of fetal head descent in the birth canal by measuring the angle of progression (AoP). Specifically, the AoP is defined as the angle between a straight line drawn along the longitudinal axis of the pubic symphysis and a line drawn from the inferior edge of the pubic symphysis to the leading edge of the fetal head. However, the process of outlining contours and measuring AoP on ultrasound images is complex and tedious, often leading to misjudgments by physicians. In response to this challenge, we propose the fetal head–pubic symphysis segmentation network (FH-PSSNet) for automatic AoP measurement. The FH-PSSNet model is based on an encoder–decoder framework, incorporating a dual attention module, a multi-scale feature screening module and a direction guidance block. The encoder extracts the relevant features and learns the global feature correlation through a dual attention module, while the decoder utilizes skip connections to preserve spatial information. Additionally, a multi-scale feature screening module with attention mechanism is proposed to extract global contextual information, enhancing object localization. Within the decoder, a dual-branch structure generates both direction information and initial segmentation features. Finally, a direction guidance block corrects the initial segmentation features to refine the segmentation results. Experiments on two datasets demonstrate the effectiveness of the proposed method. Compared to existing approaches, our model showcases competitive performance. The FH-PSSNet significantly improves automatic segmentation and AoP measurement, reducing errors and aiding sonographers in clinical settings.

The acute effects of running on pelvic floor morphology and function in runners with and without running-induced stress urinary incontinence

Introduction and hypothesisThe aim of this study was to examine the impact of a single running session on pelvic floor morphology and function in female runners, and to compare those with and without running-induced stress urinary incontinence (RI-SUI).MethodsThis cross-sectional, observational study involved two groups: female runners who regularly experienced RI-SUI (n = 19) and runners who did not (n = 20). Pelvic floor muscle (PFM) properties were assessed using intravaginal dynamometry during maximal voluntary contractions (MVC) and during passive tissue elongation. The morphology of the pelvic floor was assessed at rest, during MVC and during maximal Valsalva maneuver (MVM) using 2D and 3D transperineal ultrasound imaging before and after a running protocol. Mixed-effects ANOVA models were used to compare all outcomes between groups and within-groups, including the interaction between group and time. Effect sizes were calculated.ResultsNo changes in PFM function assessed using intravaginal dynamometry were observed in either group after the run. Significant and large within-group differences were observed on ultrasound imaging. Specifically, the area and antero-posterior diameter of the levator hiatus were larger after the run, the bladder neck height was lower after the run, and the levator plate length was longer after the run (p ≤ 0.05). At the peak MVM and MVC, the bladder neck height was lower after the run than before the run (p ≤ 0.05). No between-group differences were observed for any outcomes.ConclusionsRunning appears to cause transient strain of the passive tissues of the female pelvic floor in runners both with and without RI-SUI, whereas no concurrent changes are observed in PFM contractile function.

Pelvic floor muscle length changes with breathing in males: A preliminary report

The study aimed to identify whether pelvic floor muscles modulate length with breathing, and if any length changes induced by breathing relate to abdominal cavity displacement and intra-abdominal pressure. To investigate these relationships, displacement of pelvic landmarks that related to pelvic floor muscle length using transperineal ultrasound imaging, breath volume, intra-abdominal pressure, abdominal and ribcage displacement, and abdominal and anal sphincter muscle electromyography were measured during quiet breathing and breathing with increased dead-space in ten healthy men. Pelvic floor muscle landmark displacement modulated with ribcage motion during breathing. This relationship was stronger for: i) motion of the urethrovesical junction (puborectalis muscle length change) than the mid-urethra landmark (striated urethral sphincter muscle length change), and ii) dead-space breathing in standing than dead-space breathing in supine or quiet breathing in standing. In most (but not all) participants, the urethrovesical junction descended during inspiration and elevated during expiration. Striated urethral sphincter length changes during the respiratory cycle was independent of intra-abdominal pressure. In summary, breathing involves pelvic floor muscle length changes and is consistent with the role of these muscles during respiration to aid maintenance of continence, lung ventilation and/or provision of support to the abdominal cavity. Clinicians who train pelvic floor muscles need to be aware that length change of pelvic floor muscles is expected with breathing.

Association between sonographic sling location and success of surgery for stress urinary incontinence.

To determine the relationship between the clinical outcome of suburethral sling surgery for stress urinary incontinence and sling location on ultrasound examination. This was a retrospective study of patients diagnosed with stress urinary incontinence who were treated with a suburethral sling by a single surgeon between January 2009 and October 2016. Four-dimensional volumes acquired on transperineal ultrasound at least 3 months postoperatively were analyzed and the gap between the sling and symphysis pubis (sling-pubis gap (SPG)) on Valsalva maneuver was measured. Continence was assessed on a cough stress test at follow-up. A total of 378 patients were included, with a mean follow-up of 14.3 months. The success rate of sling surgery was 89.4%. The mean ± SD SPG on Valsalva maneuver was 12.0 ± 2.5 mm in women who were clinically continent at follow-up and 14.1 ± 2.8 mm in those with failed surgery (P < 0.001). A shorter SPG on transperineal ultrasound imaging after suburethral sling surgery is associated with cure of stress urinary incontinence. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Pelvic Floor Muscle Function and Its Relationship with Post-Prostatectomy Incontinence

ObjectivesPost-prostatectomy incontinence (PPI) is a common condition, but the underlying mechanisms are not completely understood. Transperineal ultrasound (TPUS) assessment of voluntary pelvic floor muscle (PFM) function may be associated with PPI. This study investigates the relationship between PPI and pre- and postoperative displacement of anatomical landmarks related to PFM function.MethodsThis was a prospective longitudinal cohort study of 40 patients undergoing robotic-assisted radical prostatectomy (RARP) by a high-volume single surgeon. All patients underwent PFM training pre- and postoperatively. TPUS was used to obtain sagittal images of pelvic structures during maximal voluntary PFM contractions: (1) preoperatively, (2) 3 weeks postoperatively, and (3) 6 weeks postoperatively. TPUS images were analyzed to calculate displacement of anatomical landmarks associated with activation of striated urethral sphincter (SUS), bulbocavernosus muscle (BC), and puborectalis muscle (PR). Continence was assessed at 3 and 6 weeks postoperatively, defined as use of ≤ 1 pad/day. The relationship of continence to the displacement of SUS, BC, and PR was analyzed.ResultsSUS, BC, and PR displacement decreased significantly 3 weeks postoperatively (P = 0.042, P = 0.002, P &lt; 0.001, respectively). Continent men exhibited significantly greater SUS displacement (median, 5.13 mm) than incontinent men (median, 3.90 mm) 3 weeks postoperatively (P = 0.029). Between 3 and 6 weeks following RARP, there was significant increase in SUS, BC, and PR displacement (P = 0.003, P = 0.030, P &lt; 0.001, respectively).ConclusionsA significant decrease in PFM function occurs following RARP, with a subsequent recovery of postoperative PFM function between 3 and 6 weeks post-procedure in men who undergo PFM training. SUS activation was significantly greater in continent patients compared to incontinent patients at 3 weeks following RARP.

Automated segmentation and measurement of the female pelvic floor from the mid-sagittal plane of 3D ultrasound volumes.

Transperineal ultrasound (TPUS) is a valuable imaging tool for evaluating patients with pelvic floor disorders, including pelvic organ prolapse (POP). Currently, measurements of anatomical structures in the mid-sagittal plane of 2D and 3D US volumes are obtained manually, which is time-consuming, has high intra-rater variability, and requires an expert in pelvic floor US interpretation. Manual segmentation and biometric measurement can take 15 min per 2D mid-sagittal image by an expert operator. An automated segmentation method would provide quantitative data relevant to pelvic floor disorders and improve the efficiency and reproducibility of segmentation-based biometric methods. Develop a fast, reproducible, and automated method of acquiring biometric measurements and organ segmentations from the mid-sagittal plane of female 3D TPUS volumes. Our method used a nnU-Net segmentation model to segment the pubis symphysis, urethra, bladder, rectum, rectal ampulla, and anorectal angle in the mid-sagittal plane of female 3D TPUS volumes. We developed an algorithm to extract relevant biometrics from the segmentations. Our dataset included 248 3D TPUS volumes, 126/122 rest/Valsalva split, from 135 patients. System performance was assessed by comparing the automated results with manual ground truth data using the Dice similarity coefficient (DSC) and average absolute difference (AD). Intra-class correlation coefficient (ICC) and time difference were used to compare reproducibility and efficiency between manual and automated methods respectively. High ICC, low AD and reduction in time indicated an accurate and reliable automated system, making TPUS an efficient alternative for POP assessment. Paired t-test and non-parametric Wilcoxon signed-rank test were conducted, with p<0.05 determining significance. The nnU-Net segmentation model reported average DSC and p values (in brackets), compared to the next best tested model, of 87.4% (<0.0001), 68.5% (<0.0001), 61.0% (0.1), 54.6% (0.04), 49.2% (<0.0001) and 33.7% (0.02) for bladder, rectum, urethra, pubic symphysis, anorectal angle, and rectal ampulla respectively. The average ADs for the bladder neck position, bladder descent, rectal ampulla descent and retrovesical angle were 3.2mm, 4.5mm, 5.3mm and 27.3°, respectively. The biometric algorithm had an ICC>0.80 for the bladder neck position, bladder descent and rectal ampulla descent when compared to manual measurements, indicating high reproducibility. The proposed algorithms required approximately 1.27 s to analyze one image. The manual ground truths were performed by a single expert operator. In addition, due to high operator dependency for TPUS image collection, we would need to pursue further studies with images collected from multiple operators. Based on our search in scientific databases (i.e., Web of Science, IEEE Xplore Digital Library, Elsevier ScienceDirect and PubMed), this is the first reported work of an automated segmentation and biometric measurement system for the mid-sagittal plane of 3D TPUS volumes. The proposed algorithm pipeline can improve the efficiency (1.27 s compared to 15 min manually) and has high reproducibility (high ICC values) compared to manual TPUS analysis for pelvic floor disorder diagnosis. Further studies are needed to verify this system's viability using multiple TPUS operators and multiple experts for performing manual segmentation and extracting biometrics from the images.

Reliability and Reproducibility of Analyzing 3D Transperineal Ultrasound Volumes Obtained in the First Phase of Labor - A Pilot Study.

The aim of this study was to investigate the reliability and reproducibility of transperineal ultrasound (TPUS) in the initial phase of labor. As TPUS is a common method, it could supplement vaginal palpation and even replace it in certain situations. In addition, we used a 4-dimensional method for the assessment of cervical effacement. 54 women in labor were included and underwent TPUS. The resulting images from the acquired 4D volumes were evaluated after the examination for the first time and a second time after 21 days. The measured values were cervical length, dilatation and effacement, the angle of progression (AoP), and head-perineum distance. 54 patients were examined. TPUS images were unable to be evaluated in 12 patients because of cervical dilatation of more than 5 cm or poor image quality. Thus, 42 measurements were included. The concordance correlation coefficients according to Lin are satisfactory overall, with one exception for cervical effacement. The accuracy component of cervical length (CCCLin: 0.93; accuracy: 1.00), dilatation (CCCLin: 0.93; accuracy: 1.00), and AoP (CCCLin: 0.87; accuracy: 1.00) is excellent and still high for the head-perineum distance (CCCLin: 0.89; accuracy: 0.96) and cervical effacement (CCCLin: 0.77; accuracy: 0.97). TPUS is a valuable noninvasive tool with good diagnostic accuracy for the AoP, cervical length, and dilatation. Our study provides support for the use of TPUS to complement a vaginal examination. It should not replace a digital examination but should serve as a suitable alternative method for monitoring labor progression in the future.

Advances and Applications of Transperineal Ultrasound Imaging in Female Pelvic Floor Dysfunction

Advances and Applications of Transperineal Ultrasound Imaging in Female Pelvic Floor Dysfunction

A framework for computing angle of progression from transperineal ultrasound images for evaluating fetal head descent using a novel double branch network.

Background: Accurate assessment of fetal descent by monitoring the fetal head (FH) station remains a clinical challenge in guiding obstetric management. Angle of progression (AoP) has been suggested to be a reliable and reproducible parameter for the assessment of FH descent. Methods: A novel framework, including image segmentation, target fitting and AoP calculation, is proposed for evaluating fetal descent. For image segmentation, this study presents a novel double branch segmentation network (DBSN), which consists of two parts: an encoding part receives image input, and a decoding part composed of deformable convolutional blocks and ordinary convolutional blocks. The decoding part includes the lower and upper branches, and the feature map of the lower branch is used as the input of the upper branch to assist the upper branch in decoding after being constrained by the attention gate (AG). Given an original transperineal ultrasound (TPU) image, areas of the pubic symphysis (PS) and FH are firstly segmented using the proposed DBSN, the ellipse contours of segmented regions are secondly fitted with the least square method, and three endpoints are finally determined for calculating AoP. Results: Our private dataset with 313 transperineal ultrasound (TPU) images was used for model evaluation with 5-fold cross-validation. The proposed method achieves the highest Dice coefficient (93.4%), the smallest Average Surface Distance (6.268 pixels) and the lowest AoP difference (5.993°) by comparing four state-of-the-art methods. Similar results (Dice coefficient: 91.7%, Average Surface Distance: 7.729 pixels: AoP difference: 5.110°) were obtained on a public dataset with >3,700 TPU images for evaluating its generalization performance. Conclusion: The proposed framework may be used for the automatic measurement of AoP with high accuracy and generalization performance. However, its clinical availability needs to be further evaluated.

Comparison of diagnostic criteria for significant anal sphincter defects between endoanal and transperineal ultrasound.

To evaluate the agreement between three-dimensional endoanal ultrasound (EAUS) and four-dimensional transperineal ultrasound (TPUS) in measuring anal sphincter defect angle. This was a secondary analysis of the PERINEAL study, which evaluated the effect of perineal wound infection on anal sphincter integrity. Women were reviewed once a week, until their perineal wound had healed or for up to a maximum of 16 weeks. At each visit, both EAUS and TPUS (the latter at rest and on maximum pelvic floor muscle contraction (PFMC)) were performed to evaluate the presence of external (EAS) and internal(IAS) anal sphincter defect and measure the defect size. The largest angle size of a defect at the same sphincter level was analyzed. A defect was deemed significant if it was > 30°. Kappa coefficient (κ), intraclass correlation coefficient and standard error of measurement (SEM) were calculated, using EAUS as the reference standard. In 73 women scanned at weekly intervals, a total of 250 EAUS and 250 TPUS scans were performed. An EAS defect was found in 55 (22.0%) EAUS images and 47 (18.8%) TPUS images. An IAS defect was found in 26 (10.4%) images on both modalities. There was excellent agreement (κ = 0.87) between TPUS and EAUS in diagnosing the presence of an EAS defect and perfect agreement (κ = 1.00) in diagnosing the presence of an IAS defect. TPUS performed at rest had poor and moderate agreement with EAUS in measuring EAS and IAS defect size, respectively, with respective SEMs of ± 16.1° and± 27.9°. TPUS performed during maximum PFMC had poor and moderate agreement with EAUS in measuring EAS and IAS defect size, respectively, with respective SEMs of ± 16.5° and± 26.4°. Based on the SEMs, if the diagnostic cut-off of 30° for defect size on TPUS was used, an incorrect diagnosis of significant EAS defect could occur in approximately 9-36% of women and an incorrect diagnosis of a significant IAS defect could occur in approximately 4-15% of women, using EAUS as the reference. This is the first study to compare directly anal sphincter defect angle measurements obtained on EAUS and TPUS. A cut-off angle of 30° should not be used for the diagnosis of a significant residual anal sphincter defect during TPUS examination. Further research is required to determine the optimal defect cut-off angle for TPUS. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The relationship between pre- and postprostatectomy measures of pelvic floor muscle function and development of early incontinence after surgery.

The aim of this study is to investigate (i) whether pelvic floor muscle (PFM) shortening can be enhanced by provision of training focused on striated urethral sphincter (SUS) with feedback before prostatectomy, (ii) whether PFM shortening during voluntary efforts and coughing before and after prostatectomy differs between men who do and do not report symptoms of urinary incontinence 1 month after prostatectomy, and (iii) the relationship between severity of incontinence after prostatectomy and features of pelvic floor function (muscle shortening) and urethral length before and after prostatectomy. Sixty men referred for preoperative PFM training before radical prostatectomy participated. The International Continence Society Male Short Form questionnaire was used to quantify continence status. Transperineal ultrasound (US) imaging was used to record pelvic displacements related to activation of striated urethral sphincter, bulbocavernosus (BC) and puborectalis muscles during cough, "natural" voluntary contraction following pamphlet instruction, and trained voluntary contraction after formal physiotherapist instruction including US feedback. Pelvic floor displacements following training differed between continent and incontinent men; continent participants demonstrated increased SUS shortening after training (compared with "natural"), but no difference was observed between trained and "natural" contractions for incontinent participants. Motion at ano-rectal junction during cough was reduced following surgery, but voluntary and involuntary activation of SUS or BC was not consistently affected by surgery. Participants' capacity to improve function of the SUS with training appears related to postprostatectomy continence outcome.

Multitask Deep Neural Network for the Fully Automatic Measurement of the Angle of Progression.

The angle of progression (AoP) for assessing fetal head (FH) descent during labor is measured from the standard plane of transperineal ultrasound images as the angle between a line through the long axis of pubic symphysis (PS) and a second line from the right end of PS tangentially to the contour of the FH. This paper presents a multitask network with a shared feature encoder and three task-special decoders for standard plane recognition (Task1), image segmentation (Task2) of PS and FH, and endpoint detection (Task3) of PS. Based on the segmented FH and two endpoints of PS from standard plane images, we determined the right FH tangent point that passes through the right endpoint of PS and then computed the AoP using the above three points. In this paper, the efficient channel attention unit is introduced into the shared feature encoder for improving the robustness of layer region encoding, while an attention fusion module is used to promote cross-branch interaction between the encoder for Task2 and that for Task3, and a shape-constrained loss function is designed for enhancing the robustness to noise based on the convex shape-prior. We use Pearson's correlation coefficient and the Bland–Altman graph to assess the degree of agreement. The dataset includes 1964 images, where 919 images are nonstandard planes, and the other 1045 images are standard planes including PS and FH. We achieve a classification accuracy of 92.26%, and for the AoP calculation, an absolute mean (STD) value of the difference in AoP (∆AoP) is 3.898° (3.192°), the Pearson's correlation coefficient between manual and automated AoP was 0.964 and the Bland-Altman plot demonstrates they were statistically significant (P < 0.05). In conclusion, our approach can achieve a fully automatic measurement of AoP with good efficiency and may help labor progress in the future.

Anatomical identification of ischial spines applicable to intrapartum transperineal ultrasound based on magnetic resonance imaging of pregnant women

Objective Intrapartum transperineal ultrasound is considered useful in judging fetal head descent; however, the inability to detect ischial spines on ultrasound images has been a drawback to its legitimacy. The current study aimed to determine the anatomical location of ischial spines, which can be directly applied to intrapartum transperineal ultrasound images. Method Based on magnetic resonance imaging (MRI) of 67 pregnant women at 33+2 [31+6-34+0] weeks gestation (median [interquartile range: IQR]), we calculated the angle between the pubic symphysis and the midpoint of ischial spines (midline symphysis-ischial spine angle; mSIA), which is theoretically equivalent to the angle of progression at fetal head station 0 on ITU, by determining spatial coordinates of pelvic landmarks and utilizing spatial vector analysis. Furthermore, we measured symphysis-ischial spine distance (SID), defined as the distance between the vertical plane passing the lower edge of the pubic symphysis and the plane that passes the ischial spines. Results As a result, mSIA was 109.6° [105.1–114.0] and SID 26.4 mm [19.8–30.7] (median, [IQR]). There was no correlation between mSIA or SID and maternal characteristics, including physique. Conclusions We established a novel method to measure the components of the pelvic anatomy by analyzing the three-dimensional coordinates of MRI data and identified the anatomical location of ischial spines which can be applied to ultrasound images. Our results provide valuable evidence to enhance the reliability of intrapartum transperineal ultrasound in assessing fetal head descent by considering the location of ischial spines.

Is there a role for transperineal ultrasound imaging of the anal sphincter immediately after primary repair of third degree tears?

ObjectiveWhen obstetric anal sphincter injuries are identified, it is crucial that the defects are repaired appropriately to achieve a better outcome. Although the presence of an intact anal sphincter is not the sole mechanism for maintaining continence, and not all women with an anal sphincter defect are symptomatic, there is an association between sphincter defects and anal incontinence. Our aim was to evaluate whether transperineal ultrasound (TPUS) is useful in assessing anal sphincter integrity immediately following primary repair of obstetric anal sphincter injuries (OASIs). Study DesignThis is a prospective observational study of women who sustained OASIs during their first vaginal delivery. Three dimensional (3D) TPUS was performed immediately after repair of OASIs to identify anal sphincter defects. A repeat TPUS was performed 12 weeks following repair. Results21 women sustained OASIs of whom 20 (95%) attended follow up. Eight (40%) had a grade 3a tear and 12 (60%) a 3b tear.8/20 (40%) women had residual external anal sphincter (EAS) defects identified by TPUS immediately after repair. Of these eight defects, six (75%) persisted at 12 weeks postpartum. No new defects were seen at follow up among the twelve women in whom no defect was seen immediately following the repair.Six residual EAS defects were found at 12 weeks postpartum. An EAS defect at 12 weeks postpartum was associated with anal incontinence (p = 0.04). Women with 3b tears were more likely to have anal incontinence (AI) and residual sonographic EAS defects when compared with 3a tears but this was not statistically significant. ConclusionsWomen who had no TPUS defect detected immediately following primary repair of OASIs, remained as such at 12 weeks postpartum. Of those in whom a defect was seen immediately after repair, it persisted in 75% of cases at 12 weeks. We believe that the value of TPUS immediately after repair appears to be limited and would need to be defined if it were to be considered for routine practice. Further research on its role immediately after repair of major tears (Grade 3C/4) is needed. In addition, performing ultrasound would require widespread training of obstetricians to develop expertise. This highlights the importance of adequate training of obstetricians in OASI repair.

Anorectal Anatomy and Function.

Anatomy of pelvic floor muscles has long been controversial. Novel imaging modalities, such as three-dimensional transperineal ultrasound imaging, MRI, and diffusion tensor imaging, have revealed unique myoarchitecture of the external anal sphincter and puborectalis muscle. High-resolution anal manometry, high-definition anal manometry, and functional luminal imaging probe are important new tools to assess anal sphincter and puborectalis muscle function. Increased understanding of the structure and function of anal sphincter complex/pelvic floor muscle has improved the ability to diagnose patients with pelvic floor disorders. New therapeutic modalities to treat anal/fecal incontinence and other pelvic floor disorders will emerge in the near future.

Pelvic Floor Mobility measured by Transperineal Ultrasound Imaging in Women with and without Urgency and Frequency Predominant Lower Urinary Tract Symptoms.

Women with urgency/frequency predominant lower urinary tract symptoms (UF-LUTS) may have elevated pelvic floor muscle (PFM) position at rest and limited mobility with PFM contraction and bearing down, but this has not been quantified. To compare PFM position and mobility using transperineal ultrasound (TPUS) at rest, maximal PFM contraction (perineal elevation), and bearing down (perineal descent) in women with and without UF-LUTS. We hypothesized that women with UF-LUTS would demonstrate elevated resting position and decreased excursion of pelvic landmarks during contraction and bearing down as compared to women without UF-LUTS. Case-control study. Women with UF-LUTS were matched 1:1 on age, body mass index and vaginal parity to women without UF-LUTS. TPUS videos were obtained during 3 conditions: rest, PFM contraction, and bearing down. Levator plate angle (LPA) and puborectalis length (PR length), were measured for each condition. Paired t-tests or Wilcoxon signed rank tests compared LPA and PR length between cases and controls. 21 case-control pairs (42 women): Women with UF-LUTS demonstrated greater LPA at rest (66.8 ± 13.2 degrees vs 54.9 ± 9.8 degrees; P=0.006), and less PR lengthening from rest to bearing down (0.2 ± 3.1 mm vs 2.1 ± 2.9 mm; P=.03). Women with UF-LUTS demonstrated more elevated (cranioventral) position of the PFM at rest and less PR muscle lengthening with bearing down. These findings highlight the importance of a comprehensive PFM examination and possible treatment for women with UF-LUTS to include PFM position and mobility.

Breech progression angle: new feasible and reliable transperineal ultrasound parameter for assessment of fetal breech descent in birth canal.

To assess the feasibility and reliability of transperineal ultrasound in the assessment of fetal breech descent in the birth canal, by measuring the breech progression angle (BPA). Women with a singleton pregnancy with the fetus in breech presentation between 34 and 41 weeks' gestation were recruited. Transperineal ultrasound images were acquired in the midsagittal view for each woman, twice by one operator and once by another. Each operator measured the BPA after anonymization of the transperineal ultrasound images. BPA was defined as the angle between a line running along the long axis of the pubic symphysis and another line extending from the most inferior portion of the pubic symphysis tangentially to the lowest recognizable fetal part in the maternal pelvis. Each operator was blinded to all other measurements performed for each woman. Intra- and interobserver reproducibility of BPA measurement was evaluated using the intraclass correlation coefficient (ICC). To investigate the presence of any bias, intra- and interobserver agreement was also analyzed using Bland-Altman analysis. Student's t-test and Levene's W0 test were used to investigate whether a number of different clinical factors had an effect on systematic differences and homogeneity, respectively, between BPA measurements. Overall, 44 women were included in the analysis. BPA was measured successfully by both operators on all images. Both intra- and interobserver agreement analyses showed excellent reproducibility in BPA measurement, with ICCs of 0.88 (95% CI, 0.80-0.93) and 0.83 (95% CI, 0.71-0.90), respectively. The mean difference between measurements was 0.4° (95% CI, -1.4 to 2.2°) for intraobserver repeatability and -0.4° (95% CI, -2.6 to 1.8°) for interobserver repeatability. The upper limits of agreement were 12.0° (95% CI, 8.9-15.1°) and 13.6° (95% CI, 9.9-17.3°) for intra- and interobserver repeatability, respectively. The lower limits of agreement were -11.2° (95% CI, -14.3 to -8.1°) and -14.4° (95% CI, -18.2 to -10.7°) for intra- and interobserver repeatability, respectively. No systematic difference between BPA measurements was found on either intra- or interobserver agreement analysis. None of the clinical factors examined (maternal body mass index, maternal age, gestational age at the ultrasound scan and parity) showed a statistically significant effect on intra- or interobserver reliability. BPA represents a new feasible and highly reproducible measurement for the evaluation of fetal breech descent in the birth canal. Future studies assessing its usefulness in the prediction of successful external cephalic version and breech vaginal delivery are needed. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Changes in pelvic floor morphometry and muscle function after multimodal physiotherapy for gynaecological cancer survivors suffering from dyspareunia: a prospective interventional study

ObjectiveTo investigate the changes in pelvic floor morphometry and muscle function after multimodal pelvic floor physiotherapy treatment in gynaecological cancer survivors suffering from painful intercourse (dyspareunia). DesignProspective interventional study. SettingThree university hospitals. ParticipantsThirty-one gynaecological cancer survivors with dyspareunia. InterventionThe treatment consisted of 12 weekly sessions of physiotherapy combining education, pelvic floor muscle exercises with biofeedback, manual therapy and home exercises. Main outcome measuresWomen were assessed at baseline and post-treatment. Pelvic floor morphometry was evaluated at rest and on maximal contraction by measuring bladder neck position, anorectal and levator plate angles as well as levator hiatal dimensions with three-dimensional/four-dimensional transperineal ultrasound imaging. Pelvic floor muscle function was evaluated by measuring passive forces (muscle tone measure), flexibility, stiffness, strength, coordination and endurance with an intra-vaginal dynamometric speculum. ResultsSignificant changes in pelvic floor morphometry and muscle function were found post-treatment. The parameters assessing the changes from rest to maximal contraction significantly improved (e.g., mean change of levator hiatal area narrowing 14%, 95% CI 11–18, Cohen’s d effect size 1.48)), supporting the hypothesis of decreased muscle tone and improved muscle contractility following treatment. Women also presented with a significant decrease in tone (mean change -0.4N, 95% CI −0.7 to −0.1, Cohen’s d effect size 0.57) and stiffness (mean change −0.1N/mm, 95% CI −0.2 to −0.1, Cohen’s d effect size 0.59), as well as significant improvements in flexibility (mean change 9.0mm, 95% CI 5.8–12.2, Cohen’s d effect size 1.08), coordination (mean change 3 rapid contractions, 95% CI 2–4, Cohen’s d effect size 0.85) and endurance (mean change 683%*s, 95% CI 388–978, Cohen’s d effect size 0.90). ConclusionOur findings suggest significant improvements in pelvic floor morphometry and muscle function after a multimodal physiotherapy treatment in gynaecological cancer survivors with dyspareunia. These effects may represent key treatment mechanisms to reduce dyspareunia, supporting the rationale for multimodal physiotherapy in this population. Clinical trial registration number (ClinicalTrials.gov)NCT03935698.

The influence of prostatectomy and body position on location and displacement of pelvic landmarks with pelvic floor muscle contraction

To compare pelvic floor muscle (PFM) anatomy and function (i) between pre- and post-prostatectomy in standing, and (ii) between sitting and standing postprostatectomy. Thirty-two men scheduled to undergo a prostatectomy volunteered to participate. Transperineal ultrasound imaging was used to visualize five anatomical pelvic landmarks that have been validated to reflex anatomy and activity of PFMs (pubic symphysis, anorectal junction [ARJ], mid-urethra [MU], bulb of penis [BP], and urethrovesical junction [UVJ]). Both before and after prostatectomy, participants performed three submaximal PFM contractions in sitting and/or standing positions while ultrasound data were recorded. Postprostatectomy the UVJ location was more caudal and dorsal, the ARJ (puborectalis) vector was longer, the BP was more ventral than preprostatectomy, and these landmarks moved less ventrally with contraction. After prostatectomy, the MU, BP, and ARJ were more ventral in standing than sitting. The UVJ was more caudal and elevated more with contraction in standing than sitting after prostatectomy. These data demonstrate differences in the anatomy and mechanics of PFMs post- versus pre-prostatectomy, and between sitting and standing positions postprostatectomy. Findings are consistent with surgical changes to the bladder and urethral anatomy. Reduced passive support for the urethra and bladder are likely to may contribute to differences between standing and sitting postprostatectomy.