Total pelvic floor ultrasound for pelvic floor defaecatory dysfunction: a pictorial review

Abstract

Total pelvic floor ultrasound is used for the dynamic assessment of pelvic floor dysfunction and allows multicompartmental anatomical and functional assessment. Pelvic floor dysfunction includes defaecatory, urinary and sexual dysfunction, pelvic organ prolapse and pain. It is common, increasingly recognized and associated with increasing age and multiparity. Other options for assessment include defaecation proctography and defaecation MRI. Total pelvic floor ultrasound is a cheap, safe, imaging tool, which may be performed as a first-line investigation in outpatients. It allows dynamic assessment of the entire pelvic floor, essential for treatment planning for females who often have multiple diagnoses where treatment should address all aspects of dysfunction to yield optimal results. Transvaginal scanning using a rotating single crystal probe provides sagittal views of bladder neck support anteriorly. Posterior transvaginal ultrasound may reveal rectocoele, enterocoele or intussusception whilst bearing down. The vaginal probe is also used to acquire a 360°cross-sectional image to allow anatomical visualization of the pelvic floor and provides information regarding levator plate integrity and pelvic organ alignment. Dynamic transperineal ultrasound using a conventional curved array probe provides a global view of the anterior, middle and posterior compartments and may show cystocoele, enterocoele, sigmoidocoele or rectocoele. This pictorial review provides an atlas of normal and pathological images required for global pelvic floor assessment in females presenting with defaecatory dysfunction. Total pelvic floor ultrasound may be used with complementary endoanal ultrasound to assess the sphincter complex, but this is beyond the scope of this review.

Accuracy of integrated total pelvic floor ultrasound compared to defaecatory MRI in females with pelvic floor defaecatory dysfunction

“…All scans were performed in the lithotomy position. 18 The entire sonographic assessment took approximately 15 min per patient.…”

“…Anterior and posterior views were acquired while asking the patient to perform three manoeuvres: cough, squeeze and strain. 18 Transperineal scanning was performed using a conventional curved-array probe (6 MHz). The transducer was rested on the perineum to obtain mid-sagittal views and the patient was asked to cough, squeeze and strain.…”

“…Ultrasound: the protrusion of the anterior rectal wall with impingement onto the perineal body on anterior transvaginal scanning 18 ( Figure 1b) and the bulge of the anterior rectal wall into the vagina on transperineal scanning [distance beyond the perineal body ($1 cm significant) 17,[19][20][21] ( Figure 1c)]. …”

“…24 Posterior transvaginal scanning: the presence of bowel between the rectum and probe (Figure 3b). 18 Transperineal scanning: graded according to the maximal descent of the small bowel in relation to the vagina-the cranial third (Grade I), the middle third (Grade II) and the caudal third (Grade III) ( Figure 3c). 25 Cystocoele MRI: the descent of the bladder below the pubococcygeal line (Grade I descent ,3 cm, Grade II descent 3-6 cm and Grade III .…”

Imaging the pelvic floor

“…Integrated total pelvic floor ultrasound is becoming the standard of care, along with the multidisciplinary team approach to the evaluation and treatment of pelvic floor dysfunction [20][21][22].…”