Pelvic floor imaging Jennifer Kruger 1 Hans Peter
- Slides: 26
Pelvic floor imaging Jennifer Kruger 1 Hans Peter Dietz 2, 1 Department of Sport and Exercise Science, University of Auckland, New Zealand 2 Department of Obstetrics and Gynaecology University of Sydney, Australia THE UNIVERSITY OF AUCKLAND DEPARTMENT OF SPORT AND EXERCISE SCIENCE
Outline n Pelvic floor imaging in general n 2 D imaging n General use of 3 D ultrasound n 3 D pelvic floor imaging n n n Pelvic floor function Research of pelvic floor (pf) function in elite nulliparous athletes using 3 D ultrasound. Possible clinical implications
Introduction INTRODUCTION n n n Ultrasound imaging of pelvic floor available for many years n Lack of ionizing radiation n Ease of use n Cost effectiveness Recently - capable of imaging in multiple planes, 3 D images, ‘real time’ property. These proved useful particularly obstetrics, gynaecology, paediatrics and cardiology THE UNIVERSITY OF AUCKLAND DEPARTMENT OF SPORT AND EXERCISE SCIENCE
2 D imaging 2 D Imaging n Previously 2 D/B mode ultrasound scanning used define pathology and normal function of pelvic floor. n n Abdominally, intravaginal or transperineal. Function assessed: n n n Descent of bladder, uterus and rectal ampulla during a valsalva manouevre. Images in the mid-sagittal plane. Still widely used. THE UNIVERSITY OF AUCKLAND DEPARTMENT OF SPORT AND EXERCISE SCIENCE
2 D imaging Measurements of bladder neck descent and urethral rotation. 2 D Imaging n Ultrasound images showing measurement of bladder neck descent and urethral rotation. Bladder neck descent (BND)= x-r –x-s. (Dietz et al 2006) THE UNIVERSITY OF AUCKLAND DEPARTMENT OF SPORT AND EXERCISE SCIENCE
3 D ultrasound imaging n 3 D IMAGING n n n Use of 3 D ultrasound popularised by obstetric scanning. n Volume images of the fetus Some suggestion improves diagnostic capabilities n Cleft palate n Spinal defects Gynaecological pathologies n Quantify volumes in urethra and paravaginal supports Anal canal anatomy and mammography THE UNIVERSITY OF AUCKLAND DEPARTMENT OF SPORT AND EXERCISE SCIENCE
Obstetric imaging
3 D pelvic floor imaging Recent advances in 3 D/4 D transperineal ultrasound imaging suitable for visualisation of pelvic floor muscles. 3 D Pelvic floor imaging n THE UNIVERSITY OF AUCKLAND DEPARTMENT OF SPORT AND EXERCISE SCIENCE
3 D pelvic floor imaging 3 D PELVIC FLOOR IMAGING n Display mode on ultrasound machine shows multiplanar images in sagittal, coronal and axial view and a rendered volume image. n Volume image is the integration of 2 D sectional images. n Acquisition of multiplanar images allow access to the axial plane – previously domain of magnetic resonance imaging. UNIVERSITY OF AUCKLAND DEPARTMENT OF
3 D Pelvic floor imaging 3 D 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 AUCKLAND DEPARTMENT OF
3 D pelvic floor imaging – assessing function 3 D PELVIC FLOOR IMAGING n n 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 n Levator hiatal area bounded by the symphysis pubis anteriorly, anal rectal angle posteriorly, puborectalis/pubococcygeus laterally. n Hiatal area measures – pelvic floor function n Rest n Maximum pelvic floor muscle contraction n Maximum valsalva n THE UNIVERSITY OF AUCKLAND DEPARTMENT OF SPORT AND EXERCISE SCIENCE
3 D PELVIC FLOOR IMAGING 3 D imaging A mid-sagittal image. Line indicates plane of minimal dimensions B corresponding axial image showing entire levator hiatus ( dotted area) UNIVERSITY OF AUCKLAND DEPARTMENT OF
Protocol for 3 D pelvic floor imaging 3 D PELVIC FLOOR IMAGING n Transperineal imaging: n GE Kretz Voluson 730 Expert ( similar) n Wide angle of acquisition (85°) curved array volume transducer 8 -4 MHz. n Imaged supine after voiding n Transducer ‘sits’ on the perineum mid-sagittal orientation n Mid-sagittal/Axial image on the screen n Symphysis pubis reference point – during movement n Evaluation post processing – proprietary software n Methods highly reproducible (Guaderrama 2005, Yang 2006, Dietz 2006 ) THE UNIVERSITY OF AUCKLAND DEPARTMENT OF SPORT AND EXERCISE SCIENCE
3 D PELVIC FLOOR IMAGING Hiatal area on valsalva n Courtesy H. P Dietz THE UNIVERSITY OF AUCKLAND DEPARTMENT OF SPORT AND EXERCISE SCIENCE
3 D PELVIC FLOOR IMAGING ‘Ballooning’ of hiatus Courtesy H. P Dietz THE UNIVERSITY OF AUCKLAND DEPARTMENT OF SPORT AND EXERCISE SCIENCE
3 D PELVIC FLOOR IMAGING Pelvic floor muscle contraction THE UNIVERSITY OF AUCKLAND DEPARTMENT OF SPORT AND EXERCISE SCIENCE
THE UNIVERSITY OF AUCKLAND DEPARTMENT OF SPORT AND EXERCISE SCIENCE
Introduction n n Preliminary evidence women in long term high impact sport (HIFIT) athletes n Poor progress in labour n Increased incidence of stress incontinence (Kruger 2006) (Bo 2004) Previous research demonstrated increased crosssectional area of levator-ani muscle in HIFIT women (Kruger 2006) n Stress incontinence more prevalent in high impact sports (Eliasson 2002, Nygaard 1997 ) n Association between bladder neck descent, hiatal area on valsalva and pelvic floor dysfunction
Aims n Use transperineal 3 D ultrasound to characterise the pelvic floor muscle function in HIFIT women and compare it to an age-matched control group. n Investigate pelvic organ descent in both groups during a valsalva manouevre to determine if there is an association with urinary stress incontinence.
Methods 24 HIFIT athletes; 22 age matched controls Most effective of 3 manoeuvres used for evaluation Transperineal ultrasound using published protocol Questionnaire determine symptoms of Volumes acquired at rest, pfmc, and valsalva • Incontinence • Prolapse • Bowel dysfunction Imaging using GE Kretz Voluson 730/730 Expert with 7 -4 MHz transducer
Results n n n All data normally distributed Mean age 28. 5 and 27. 6 yrs for HIFIT and controls All asymptomatic for prolapse Incidence of SUI in the athletes and controls n 3 HIFIT – SUI – only n 1 HIFIT – UI - only n 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
Results 1=Hifit 2=Control * HIFIT
Conclusions n HIFIT women differ in several aspects of pf function n > Area of levator hiatus on valsalva n No association between hiatal area on valsalva and SUI - was an association with BND. Caution very small numbers n Importance of BN position during raised intra abdominal pressure n Incidence of SUI in HIFIT – ‘overflow phenomenon’ or may be due to n n ? Changes in the connective tissue. Incidence of SUI in athletes in keeping with that of the general population (10%) (Bo 2006)
Possible clinical implications n n 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)
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