September 28 30, 2018 · Pelvic Floor‐Fleischer Different perspectives to PFD‐ palpation vs....

Course Director

September 28-30, 2018

Pelvic Floor ‐Fleischer

2D/3D Transperineal Sonographyof

Pelvic Floor Disorders:Clinical and Imaging Perspectives

Arthur C. Fleischer, MD

Vanderbilt U Med Ctr

Depts of Radiology and Ob/Gyn

Disclosures/Acknowledgements

• I’m not an astronaut, but people think I’m “spacey” at times

• Thanks to H. Dietz for the permission to use some selected images and videoclips

• Line drawings c/o Ahuja

US Anatomy‐Amirsis, 2007

Objectives

• Provide an overview of the role of 2D/3D TPS in pelvic floor disorders

• Demonstrate the 2D/3D TPS normal and abnormal findings and how to optimize imaging‐especially dynamic aspects

• Stimulate thought and discussion


Gravity vs Pelvic Floor

Pelvic Floor Disorders (PFD)*(*Haggard, JAMA 2008, Luber, Am J O/G, 2001)

• Affect up to 50% of postmenopausal women

• Of these, 10‐20% will be symptomatic

• Of affected women, 1 in 10 will have surgery

• Over next 30 years, there is a projected 45%

increase in demand for imaging/clinical management/surgery of PFD

Pelvic Floor Disorders‐Risk Factors

• Female, age, parity

• S/P hysterectomy, other pelvic surgeries

• ? chronic increased intraabdominal pressure

• Ethnicity/genetic factors• Increased risk for Hispanics

• Increased in Marfan’s syndrome

• Decreased risk for African Americans


Pelvic Floor Disordersand what you can visualize with TPS

• Stress urinary incontinence– Funneling of internal urethral meatus on Valsalva or at rest

– Retrovesical angle gr than 120 degrees on Valsalva

– Bladder neck descent gr than 3 mm on Valsalva

• Pelvic organ prolapse– Movement of pelvic organs below reference line

– (TPS more subjective than MR POPS)

• Fecal incontinence– Thinning/disruption of int/ext anal sphincters

TPS for Pelvic Floor Disorders, cont’d.

• Post op assessment of prolapse and/or incontinence surgery complications

2D/3D TPS affords DYNAMIC DEPICTION of tape/mesh including

Tensionless Vaginal Tape (TVT),

Transobturator Tape (TOT) (Monarc),

Perigee, Apogee

Injected bulking agents (Mastopatique)

Pelvic Floor Disorders‐Mechanisms• Weak, torn, or thinned pelvic muscles, ligaments, fascia associated with birth/surgical trauma lead to…

• Loss of pelvic organ support which contributes to…

• Pelvic organ mobility and prolapse leading to…pelvic pain/pressure, urinary incontinence/retention, fecal incontinence/retention/constipation

• Multiple factors‐multiple compartments‐multiple symptoms


c/o C. Zimmerman, MD)

3 Compartments‐ANTERIOR: bladder, urethraMIDDLE: vagina, uterus

POSTERIOR: rectum, anus

ANTERIOR‐urinary bladder

and urethra

MIDDLE‐uterus/cervix

POSTERIOR‐rectum/anus

PELVIC FLOOR DISORDERS as depicted on TRANSPERINEAL US:COMPARTMENT CLASSIFICATIONS


PUL=pubourethral ligament; ATFP=arcus tineus fascia pelvis;USL=uterosacral ligament

1=CYSTOCELE2=UTERINE PROLAPSE3/4=RECTOCELE

Cystocele

Rectocele


Cystocele vs Rectocele

Uterine prolapse

Rectoceleand

Uterine Prolapse

Enterocele,Rectocele,

andUterine Prolapse

USUALLY PFDs areMulti‐COMPARTMENTAL


TPS of the pelvic diaphragmin the midline sagittal plane

3D Model of Pelvic Floor (Luo, J A J O/G, 205:391, 2011)


PELVIC DIAPHRAGM MUSCLES-frontal view

Purple=levatorBlue=obturatorBrown=pyriformus

PELVIC DIAPHAGM MUSCLES-back view

Purple=levatorsBrown=pyriformisBlue=obturator

Pelvic diaphragm‐side view

Purple=levatorBrown=pyriformis


Different perspectives to PFD‐palpation vs. imaging

Imaging of Pelvic Floor Disorders

• Transperineal Sonography (TPUS)‐2D, 3D, 4D or “live 3D”, Transvaginal Sonography (TVS), Endoanal Sonography (EAUS)

• Magnetic Resonance Imaging (MRI)

• Voiding Cystourethrography (VCUG)

• Fluoroscopic Defecography

• Colonic transit studies

Advantages of TPS(over MR, Fluoroscopy)

• No ionizing radiation, dynamic

• Cheaper

• Easier on patient, examiner

• Can visualize TVT, slings, meshs


Anatomy of the Pelvic Diaphragm*

Vesalius, 1623

*Warning‐It’s complicated

• Levator ani muscles

• Pubovisceral

“complex” mm

– Puborectalis m

– Pubococcygeus m

• Endopelvic fascia

• Ligaments

Pelvic Diaphragm(as viewed from below)

equivalent to reconstructed (virtual) AXIAL PLANE



Select transducer/probeaccording to area of interest

• Small, confined places (vagina)

– Use tightly curved convex array (TVS)

• Relatively flat, open surfaces (perineum)– 2D linear array– 3D curvilinear with mechanical sector

– 4D (Matrix array) small footprint electronic/phased array sector

– Think of using different surgical instruments relative to desired function

2D US transducer

Image Orientation


TPS of pelvic diaphragmin the midline sagittal plane

TPS of Pelvic Diaphragmin the midline sagittal

plane‐as displayed on screen

Side‐by‐side comparisonof acquistion vs display of TPS

acquistion display


TPS of Pelvic Floor‐midline sagittal

bb

v

r

Transvaginal US

3D of Pelvic Floor with TV probe

Shobeiri, S


3D Transperineal US

Rendered axial plane

Standard acquisition screen of 3D Transperineal Sonography

Midsaggital Coronal

Axial plane


Axial 3D TPS of normal Transobturator Tape (TOT)

REMEMBER: AXIAL PLANE TPS IS RECONSTRUCTEDVIRTUAL‐CAN BE DONE IN REALTIME, TOO

Matrix array transducer/probe

48



Terms used to describe Transperineal Sonography of

Pelvic FloorTechnique‐

2D linear array, convex linear (transvaginal probe)3D (“hybrid” probe)

Scan planessagittalaxialcoronal

Pelvic Floor Structures‐Urethra

• Vagina• Uterus• Rectum/anus• Levator ani muscles

TPS and Anatomy/Orientation/“Field of View”


2D Transperineal US‐Normal Anatomy using

Standard ProbesUrethra/BladderCervix/UterusRectum/AnusPelvic Floor


2D Transperineal Sonography of Pelvic Floor Anatomy,

cont’d.High Resolution 2D US

of the urethra,

Anal sphincters



Vesalius, 1623*Warning‐It’s even more

complicated

DYNAMIC Anatomy of thePelvic Floor*


Dynamic Measurements of Bladder Neck

at Rest and with Valsalva

Descent (N=less than 30 mm)Retrovesicular angle (N=b/w 90 and

120 degrees)


Rest Strain down


Dynamic changes with straining

Quantifying bladder neck descent

Bladder neck descent


Color and spectral Doppler US

Urethra and vagina



Axial 2D Transperineal US‐using TVS probe

Anal canal

Internal and external sphnitchters


3D TPS‐Volume rendered

VaginaUrethra

Rectum/anusPelvic floor muscles



3D volume rendered TPS

Pelvic Floor



Uterine prolapse

TPS reference line for determining PROLAPSE


MR‐Pubococcygeal Line (PCL)

MR‐PCL H and M lines(H=hiatal, 5 cm; M=mid, 2 cm)

Cystocele‐(MR=Q tip test)


Rectocele(during defecation)

TPS Technique

• Supine or erect• 2D‐TPS, 3D‐TPS, 3D‐TUI• Transperineal curvilinear transducer

– 4 MHz or more, 5 cm footprint or more– cover with glove, apply minimal pressure– speckle reduction/post processing

• Image at rest and Valsalva (strain)‐cineloop• Measure change with Valsalva

– Bladder neck descent (N=less than 30 mm)– Retrovesical angle (N=90‐120 degrees)– Hiatal area (N=less than 25 cc)

Transducer placement on perineum Schematic representation of imaging in midsaggital plane

Transducer placement for trans‐labial/perineal sonography (TPS)


Limitations of TPS

• Multicompartment disease

• Operator dependant

• Limited field of view

• Standards‐MR can assess/quantify prolapse

– By POP‐Q (pelvic organ prolapse quantification)

• Equipment variations

3 Compartments‐ANTERIOR: bladder, urethraMIDDLE: vagina, uterus

POSTERIOR: rectum, anus

Normal Pelvic Floor DynamicsAs Depicted with 3D TPS


Dynamic 3D TPS‐normalsagittal and axial ONLY

TPS with a 2D US transducer=aka‐simple, “straightforward” apps

Rest Valsalva

Pelvic floor ultrasound in the midsagittal plane at rest and maximal Valsalva with arrow identifying inferior margin of symphysis pubis, ie,

point of reference for measurement of bladder neck position (*)

Determination of bladder neck mobility


Cystourethrocele with intact retrovesical angle

Rest Valsalva

Cystourethrocele associated with urinary stress incontinence and good voiding function. Retrovesical angle on Valsalva is at about 180 degrees, and bladder neck is lowest point of bladder.

Cystocele with intact retrovesical angleRest Valsalva

Isolated cystocele associated with prolapse and voiding dysfunction rather than stress incontinence. Retrovesical angle on Valsalva is at 90‐120 degrees, and bladder base is lower than

bladder neck.

TPS reference line


Rectocele Perineal hypermobility Rectal intussusception

All 3 conditions can manifest as clinical rectocele and are impossible to distinguish on examination

Clinical “Rectocele”s

3D Transperineal US



Midsaggital Coronal

Axial plane


Normal Pelvic Floor Dynamics

Anterior urethral diverticulumon 3D TPS

Orthogonal planes clearly illustrate location and extent of diverticulum

RectocoeleAnd

Uterine Prolapse

Enterocele, Rectocoeleand

Uterine Prolapse

Lacerated perineum


Levator hiatus in the plane of minimal dimensions

Normal narrow hiatus Moderate ballooning in parous patient

Severe ballooning in patient with bilateral avulsion and 3 compartment

prolapse

Hiatal area measurements illustrating range of findings that may be obtained in women with symptoms of lower urinary tract dysfunction and pelvic organ prolapse.

Rectocele Perineal hypermobility Rectal intussusception

All 3 conditions can manifest as clinical rectocele and are impossible to distinguish on examination

2DTPS reference line

Rectocele on 3D transperineal USMidsaggital Coronal

Axial Axial plane rendered volume

A and B show rectocele to be typically located at the anorectal junction and symmetrical. C and D illustrated that it occupies a very substatial part of levator hiatus


Tensionless Vaginal Tape (TVT)

Tensionless Vaginal Tape

c/o Von Theobald


Tensionless Vaginal Tape (TVT)

Sagittal cineloop of TOT


Axial 3D TPS of normal Transobturator Tape (TOT)

Suburethral slings as seen on TPS –midsagittal plane

Transretzius (A) and transobturator (C) slings are essentially indistinguishable.

Both are echogenic and located dorsal to midurethra.

Suburethral slings as seen on 3D TPS – axial plane

The distinction between slings is quite obvious in the axial plane. In B, a tension‐free vaginal tape (TVT) is curving ventrally toward symphysis pubis, whereas in D, a Monarc tracks

laterally toward insertion of puborectalis muscle and obturator

foramen.


Cineloop‐normal TVT

Mesh “Mishaps”

• ? Location‐? “contraction” or “retraction”

– Mesh did not remain flat but folded upon itself during implantation or immediately after closure

– ? Dislodgement of anchoring arms

– TPS can provide dynamic assessment of mesh

(polypropylene) implants (MRI can’t)

Mesh prior to insertion


TPS of mesh in soft tissue phatom(c/o J. Steer, VMS IV)

3D‐TPS of folded mesh

Cineloop‐folded mesh


Migrated TVT

Normal TVT‐cineloop

Patient after TVT division due to de novo urgency,urge incontinence, and chronic mild obstruction

Midsaggital plane. Arrow indicates most likely tape

location, but tape is invisible in this plane.

Coronal (B) and axial (C) views with 2 free tape

ends (arrows).

Axial plane rendered volume also

demonstrates gap between 2 tape ends.


Tiny enterocele s/p TOT‐Long

Tiny enterocele s/p TOT‐tv

sagittal

coronal


Axial 3D TPS

Sagittal-straining

Coronal-straining


Anterior and posterior compartment mesh implants

Patient is s/p successful Perigee (P) and Apogee (A) implantation. Midsaggital plane (A) demonstrates absence of prolapse on Valsalva, despite severe levator ballooning

evident in the axial plane (B) in this patient with bilateral avulsion injury.

Rectocele & Cystoceles/p rectocele rx

Patient with large rectocele (C, imaged here before full development of large rectocele to improve visualization) who developed cystocele (D) 6

months after successful defect‐specific rectocele repair.

Cystocele/Rectoceles/p Perigee placement

Patient with large cystocele (A) who developed rectocele (B) 6 months after successful Perigee anterior compartment mesh (which is invisible

due to shadowing from air‐filled rectocele).


Right‐sided avulsion of the puborectalis muscle

Clinical appearance Axial TPS Axial MR

Delivery‐related levator trauma as seen on exploration of large

vaginal tear after vaginal delivery.

As imaged on 3D TPS. As imaged on MR.

Rendered volume (axial plane) of typical unilateral avulsion

Prior insertion of muscle (long arrow), now completely devoid of any hyperechogenic tissue, and retracted

puborectalis muscle (short arrow).

Quantification of trauma on multislice/tomographic ultrasound imaging

(TUI)

Typical right‐sided levator defect (*) measuring about 2 cm (dorsoventral) width and at least 1.75 cm in (craniocaudal) depth as it is apparent in all 8 slices


Retained mesh/abscess

Tract post removal

Dynamic 2D and 3D TPS‐Illustrative cases

Adapted from Dietz, HP

Pelvic Floor Sonography

In Sonography in O/G, MGH, 7 e

2011

(www.sonobook7e.com)


Cystocele/Failed TO mesh

Normal TVT

Rectocele/Enterocele


3D Transperineal US



Midsaggital Coronal

Axial plane

Cystocele/Rectal intussception


Cystocele/Rectocele/Avulsions

TPS of Pelvic Floor Disorders‐CONCLUSIONS

• Pelvic floor disorders are a common and complex problem

• Transperineal Sonography affords real time (dynamic) imaging as well as 3D/4D and can visualize tape/slings/mesh

• TPS enables better understanding of the dynamics and potential treatment of pelvic

floor disorders

References*(*=used with permission)

Dietz HP. Pelvic floor ultrasound: a review. Am J Ob Gyn. 2010;202(4):321‐34.* Dietz HP, Hoyte, LP, Steensma, AB Atlas of Pelvic

Floor Ultrasound N.Y. Springer Pub, 2008*Lee, W Fleischer, AC SonoLibrary: McGraw‐Hill,

2011*Fleischer, AC Toy, E Lee, W Manning, F Romero, R

Sonography in Ob/Gyn: Principles and Practice7th ed., N.Y. McGraw‐Hill Pub, 2011*

Ahuja, A Imaging Anatomy‐US Amirsys, 2007*Leyendecker, J Abdominal and Pelvic MRI N.Y. Springer‐

Verlag, 2011*Santoro, G et al State of art: an integrated approach to pelvic floor US

Ultra O/G 37: 381‐396, 2011


Additional References

• Dietz, HP Hoyte, L, Steensma, A ATLAS of PELVIC FLOOR US N.Y. Springer 2008

• Shobeiri, S PRACTICAL PELVIC FLOOR US N.Y. Springer 2014

• Theobald, P Zimmerman, C Davilla, G NEW TECHNIQUES in GENITAL PROLAPSE SURGERY N.Y. Springer 2011

• Pretorius, D Sonoworld, 2011

Special Thanks to• Carl W. Zimmerman, MD Vanderbilt

• Hans Peter Dietz, MD, PhD U. of Sydney

• Wesley Lee, MD Wm Beaumont Hosp.

• Murray A Freedman, MD‐Medical College of Ga

• John Bobbitt; Vera Merriweather‐Vanderbilt Med Ctr

• Aditi Desai, VMS IV; Annie Liu, VMS IV

• CWI Sonographers‐Sandra Crabtree, RDMS; Mitzi Devore, RDMS, Jan Herndon, RDMS; Stephanie Perry, RDMS; Stephanie Smith, RDMS

Special Thanks to

• Dan Biller, MD; Renee Ward, MD; Karen Gold, MD; Andy Norman, MD; Trent Rice, MD‐Ob/Gyn VUMC

• Rochelle Andreotti, MD; Sara Harvey, MD; Stephanie Kurita, MD; James Green, MD;James Andrews, MD; Glynis Sacks, MD; Alice Hinton, MD Christine Dove, MD‐Tammy Hoyt, MD‐Radiology (Women’s Imaging‐‐ VUMC and CWI)

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September 28 30, 2018 · Pelvic Floor‐Fleischer Different perspectives to PFD‐ palpation vs....

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