Echografie van de Bekkenbodem

1. Echografie van de Bekkenbodem A.B. Steensma Erasmus Medical Centre Rotterdam (NL) and UZ Gasthuisberg, Leuven (B)

4. In fact- the problems are NOT visible to the naked eye- what’s visible is only their effect on gross anatomy and (sometimes) function. It’s time to look INTO the tissues. Most doctors do- why not us?

5. 2D Transperineal Ultrasound

6. Technique transperineal (labial) ultrasound • Supine position • After voiding • Midsagittal view • 3.5 – 6 /4 – 8 MHz Curved array probe • 70˚ angle of the probe • Volumes obtained at • rest/contraction/valsalva • 2D/3D/4D(real time) imaging

7. Why use fancy equipment for problems that are evident to the naked eye? • Incontinence • Prolapse • Levator function • Implants • Levator defects

8. Anatomical Findings • Anterior Compartment • Central Compartment • Posterior Compartment

9. Investigation

12. POP- Q / Symptoms

13. POP- Q

14. Histograms for bladder descent in mm (left) in asymptomatic (grey) and symptomatic women (black) and receiver operator curve for bladder descent as a test for symptomatic prolapse (right). Lines define proposed cut-offs. Histograms for rectal descent in mm (left) in asymptomatic (grey) and symptomatic women (black) and receiver operator curve for rectal descent as a test for symptomatic prolapse (right). Lines define proposed cut-offs.

15. POP – Q/ Symptoms • Good correlations between POP–Q and transperineal US for anterior compartment (r = 0.77) and central compartment (r = 0.72) • Descent of the bladder to >=10 mm below the symphysis pubis on transperineal US imaging, and descent of the rectum to >= 15 mm below this line are proposed as cut-offs for the ultrasonic diagnosis ‘significant prolapse’ on the basis of ROC characteristics. Dietz HP, IUGA& ICS 2006

16. 3D/4D Ultrasound

17. Volume Ultrasound of the Pelvic Floor • 2D pelvic floor imaging provides useful information and is changing clinical practice in Urogynaecology. However, there are obvious limits. • 3D volume ultrasound overcomes some of those limits as it now allows visualization of the transverse or axial plane.

18. Technique • Same as with 2D, only with 85˚ angle • CRI • SRI • Volume Cineloop 4D real time • VCI • TUI

19. Banana Split – Multiplanar (Orthogonal) Display mid sagittal coronal . . A B rendered volume axial C

20. mid sagittal coronal rendered volume axial

21. Normal

22. Rectocele

23. VCI Bilateral Avulsion (contraction)

24. VCI Bilateral Avulsion (valsalva)

25. Clinical symptoms

26. Defecography versus 3D/4D ultrasound for detecting central/posterior compartment prolapse abnormalities Colpo cystodefecography 3D/4D VCI Ultrasound

27. 3D/4D US versus Defecography

28. Quantification of Defects:Tomographic Ultrasound Imaging(TUI)

29. Levator hiatus

30. 0/0 0/0

31. 8/0

32. Levator defects (1) • Prevalence: 24.1% in parous women • Significant correlations between total defect width and • hiatal area on Valsalva (r=0.4, P= 0.005), • ICS POPQ grading for cystocele (P= 0.02), • cystocele descent on ultrasound (P= 0.014).

33. Levator defects (2) • Significant association pelvic floor muscle contraction • Significant association with anal sphincter injuries • Significant association with age at 1st delivery

34. Maternal age at first vaginal delivery and levator defects age

35. Conclusion • Objective assessment of pelvic floor function • Reproducible • Teaching • Epidemiology • Research

36. Conclusion • Maternal Age at 1st Delivery • Not just the presence of defects, but also their width and depth, are associated with symptoms and signs of prolapse, especially of the anterior compartment. • And also with the quality of pelvic floor contraction and sphincter injuries • 1st Diagnostic tool for detecting central and posterior compartment anatomic abnormalities

37. Conclusion “Missing link” between anatomical abnormalities and pelvic organ prolapse symptoms