Pelvic floor imaging

Jennifer Kruger1 Hans Peter Dietz2,

1Department of Sport and Exercise Science, University of Auckland, Auckland, New

Zealand

THE UNIVERSITY OF AUCKLANDDEPARTMENT OF SPORT AND EXERCISE SCIENCE

2Department of Obstetrics and Gynaecology University of Sydney, Sydney, Australia

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

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

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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.

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2D imaging

Measurements of bladder neck descent and urethral rotation.

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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

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Obstetric imaging

3D pelvic floor imaging

Recent advances in 3D/4D transperineal ultrasound imaging suitable for visualisation of

pelvic floor muscles.

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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.

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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)

UNIVERSITY OF AUCKLANDDEPARTMENT OF

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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

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THE UNIVERSITY OF AUCKLANDDEPARTMENT OF SPORT AND EXERCISE SCIENCE

3D 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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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 )

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THE UNIVERSITY OF AUCKLANDDEPARTMENT OF SPORT AND EXERCISE SCIENCE

Hiatal area on valsalva

Courtesy H.P Dietz

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‘Ballooning’ of hiatus3

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Courtesy H.P Dietz

Pelvic floor muscle contraction3

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THE UNIVERSITY OF AUCKLANDDEPARTMENT OF SPORT AND EXERCISE SCIENCE

THE UNIVERSITY OF AUCKLANDDEPARTMENT OF SPORT AND EXERCISE SCIENCE

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

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.

Methods

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

Results

HIFIT ± SD(n=24)

Controls ±SD(n=22)

P value

Levator hiatal area at rest [cm2] 12.71 ± 2.49 12.77 ± 2.43 0.72

Levator hiatal area on PFMC [cm2] 10.59 ± 1.71 9.72 ± 2.11 0.2

Levator hiatal area on Valsalva [cm2] 21.53 ± 9.98 14.91 ± 7.18 0.01*

Pubovisceral muscle diameter [cm] 0.96 ± 0.17 0.70 ± 0.11 <0.01*

Bladder descent on Valsalva [mm] 22.70 ± 7.85 15.10 ± 10.20 0.03*

Uterine position on Valsalva [mm] 22.70 ± 17.15 28.70 ± 16.90 0.31

Rectal position on Valsalva [mm] 1.04 ± 17.38 5.37 ± 11.36 0.35

Results

Hiatal area and Bladder Neck descent in HIFIT and controls

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HIATAL AREA ONVALSALVA

BND

Relationship between BND and Hiatal area in SUI women

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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)

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)

Thank-you for your attention