Objective To develop and validate a pictorial chart that documents ultrasound examination of the anal sphincter.Design A new pictorial chart (Liverpool Ultrasound Pictorial Chart [LUPIC]) depicting the normal anatomy of the anal sphincter was developed.Methods To validate LUPIC, two observers documented the findings of 296 endoanal scans. Reliability was assessed between observers using kappa agreement for presence and position of sphincter defects. To validate the use of LUPIC by different observers, a video of ten endoanal ultrasound scans was reviewed by our local expert (gold standard). Seven clinicians underwent test-retest analysis. Kappa agreement was calculated to assess intra-observer and gold standard versus observer agreement for the overall presence of sphincter defects and compared with the gold standard. Complete agreement for the position and level of sphincter defects was assessed for the five abnormal scans.Main outcome measures Excellent agreement between the two observers was found for the presence (kappa 0.99), position and level of external anal sphincter defects documented using LUPIC. The intra-observer and gold standard versus observer kappa values of experienced clinicians (A-E) showed good agreement for the overall presence of sphincter defects. Complete agreement for the position and level of sphincter defects was found in 23 of 35 (66%) observations.Conclusions LUPIC is designed and validated method of documenting anal sphincter injury diagnosed by endoanal ultrasound. Standardisation of endoanal ultrasound findings by using LUPIC may help correlate the degree of damage with patient symptoms.

Oral communication abstracts Although this injury can be assessed clinically and visualized by 3DTUS or MRI, we are far from understanding the significance and prognostic value of these findings. Objectives: 3DTUS assessment of LA in women with different risk for pelvic floor (PF) trauma to establish the role of LA injury as a link between vaginal delivery and subsequent PF disorders. Methods: In this prospective observational study 4 groups (276 patients) were evaluated by 3DTUS; PF volume datasets were analyzed offline. Main outcome measure was U/S defect of pubovisceral muscle. Group 1 (control): 35 nulliparous gravidae evaluated days-weeks before delivery; Group 2 (average risk for LA injury): 170 primiparous women evaluated 24-72 hours after vaginal delivery; Group 3 (high risk): 34 primiparous women with III-IV • sphincter tears, evaluated during follow up visit 2-20mo after delivery; Group 4 (very high risk):37 patients referred to urogynecological clinic for evaluation before PF surgery. 20 assessments were performed by two investigators for evaluation of interobserver agreement. Results: Scanning with adequate stored volumes was possible in 97% of cases. Interobserver agreement was 0.69 (Cohen's kappa) showing good agreement. In all Group 1 subjects LA was visualized intact. U/S signs of LA avulsion injury were present in 17.6, 50 and 73% of patients from Groups 2, 3 and 4 respectively (P < 0.05) and bilateral in 3.3, 17.6 and 41% of affected patients respectively (P < 0.05). Conclusions: 3DTUS is an effective method for evaluation of LA injury. U/S LA defect was only seen in parous women and increased in frequency in women with PF complaints. This fact underlines the link between vaginal birth as an etiological factor for LA trauma, and LA trauma as a predisposing factor to PF disorders. Bilateral LA trauma may have greater importance in later urogynecological complaints.