Version May 2024
INTRODUCTION — Ultrasound is a widely available tool that can provide real-time diagnostic information at the point of care. Pelvic floor ultrasound (PFUS), one application of ultrasound technology, can help evaluate women with a variety of pelvic floor disorders.
This topic will discuss applications for PFUS, available technology, and the technique for performing these studies. Related content on use of ultrasound in general obstetrics and gynecology is presented separately. (See "Overview of ultrasound examination in obstetrics and gynecology".)
CLINICAL APPLICATIONS — Transvaginal and transabdominal ultrasound have been used for decades to visualize the uterus and adnexa for gynecologic pathology, including leiomyoma, ovarian cysts, and endometriomas. Pelvic floor ultrasound (PFUS) provides unique visualization of pelvic muscles and related structures, which can be useful for the evaluation of women with vaginal mesh complications, fecal incontinence, urinary symptoms, and symptoms related to postpartum changes, among others (table 1) [1-8]. Several organizations consider PFUS the reference standard for assessing pelvic floor and anal sphincter injury.
PELVIC FLOOR ANATOMY — Pelvic floor ultrasound (PFUS) can visualize deep pelvic support structures, including the muscles of the levator ani complex, urogenital hiatus, and minimal levator hiatus. The minimal levator hiatus is the shortest distance between the pubic symphysis and the levator plate [9]. The correlation of PFUS findings, both normal and abnormal, with the patient's symptoms, has the potential to improve treatment outcomes because the clinician can more effectively target the underlying anatomic problem.
●Pelvic floor muscles – The levator ani muscles and the associated fascial layer surround pelvic organs like a funnel to form the pelvic diaphragm, also called the pelvic floor (figure 1) [10]. The main components of the levator ani complex include the puborectalis, pubococcygeus, and iliococcygeus [9,11,12]. The levator ani fibers converge behind the rectum to form the levator plate. A detailed discussion of pelvic floor anatomy is available elsewhere. (See "Surgical female urogenital anatomy".)
The baseline tonic activity of the levator ani muscles keeps the minimal levator hiatus closed by compressing the urethra, vagina, and rectum as they exit through this opening [13]. With contraction, the levator plate elevates to form a horizontal shelf over which pelvic organs rest.
●Pelvic muscle abnormalities – Deficiency, defects, or tearing of any portion of the levator ani results in weakening or altered function of the levator plate and prolapse of pelvic organs [14]. When the muscles are damaged by a tear or complete separation from their attachments, the pelvic floor sags downward over time, and the organs move abnormally through the urogenital hiatus. Different patterns of levator ani injury can result in different types of clinical presentations. Clinicians may use PFUS findings to inform treatment options, including the selection of surgical procedures, although supporting data are limited [15].
CONDITIONS FOR EVALUATION — Common conditions that are evaluated with pelvic floor ultrasound (PFUS) include levator ani detachment, levator ani deficiency, vaginal cysts and masses, vaginal synthetic mesh complications, obstetric anal sphincter injury (OASIS), accidental bowel leakage, and voiding dysfunction.
Levator ani detachment — Levator ani injury is common after vaginal delivery (figure 2), with up to 24 percent of women having demonstrable muscle injury on postpartum ultrasound. Associated hematomas typically resolve within the first four postpartum months [16-18]. Women with persistent detachment or muscle deficiency may present with a combination of continued pain, pressure, urinary retention, and/or vaginal bulge. The bulge symptoms and pain may worsen with prolonged standing. While some surgeons offer repair of symptomatic detached levator ani muscles [19], standardized surgical approaches and outcomes data are lacking.
Ultrasound can confirm levator ani detachment with evidence of wide separation of the levator plate from the pubic symphysis (image 1) and minimal or no anterior and upward movement of the levator plate with attempted pelvic floor contractions (image 2). A levator plate lift/rest ratio is significantly higher in women with functional muscle strength. All patients with a lift of 30 percent or greater compared with the resting position as visualized by endovaginal ultrasound (EVUS) are considered to have functional muscle strength [20]. The levator plate lift/rest ratio is calculated as the position at Kegel (lift) divided by the levator plate position at rest (lift/rest x 100).
Levator ani deficiency and muscle strength scales are moderately negatively correlated. Among patients with normal morphology or the most severe muscle deficiency, levator ani deficiency scores can identify most patients with functional or nonfunctional muscle strength scores, respectively. In a study of 77 women with pelvic floor dysfunction, of women diagnosed with almost total muscle loss by PFUS, 70 percent had nonfunctional muscle strength scores whereas, in patients with normal anatomy or minimal deficiency (scores of 0 to 4), nearly 90 percent had functional muscle strength scores. The Modified Oxford scale (MOS) scores were categorized as nonfunctional (scores 0 to 1) and functional (scores 2 to 5) [21].
Mechanisms of levator ani injury are discussed in detail separately. (See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse", section on 'Mechanisms of pelvic floor injury'.)
Previous studies have reported that women with pelvic organ prolapse have decreased muscle fiber number and function, a higher apoptosis pace, and disorganization of smooth muscular fibers [22,23]. These variables may explain why one woman has adequate connective tissue strength to compensate for muscle injury, and thus she never develops prolapse, while another woman with less muscle injury but weaker connective tissue develops prolapse with aging.
Detailed discussions of OASIS, pelvic organ prolapse, and incontinence (both urinary and fecal), which collectively impact hundreds of millions of women globally, are presented separately [24].
●(See "Obstetric anal sphincter injury (OASIS)".)
●(See "Female urinary incontinence: Evaluation", section on 'Epidemiology' and "Female urinary incontinence: Evaluation".)
●(See "Fecal incontinence in adults: Etiology and evaluation".)
Vaginal synthetic mesh complications — PFUS can be particularly useful in evaluating complications related to the highly echogenic polypropylene mesh used in midurethral slings and pelvic organ prolapse repair. In women with prior mesh placement, postsurgical symptoms may relate to incorrect initial mesh placement and/or changes in mesh since implantation. Ultrasound can visualize the current mesh position and shape as well as assess for mesh contraction (ie, shrinkage) and migration [3,6,25]. Based on 2D dynamic perineal ultrasound studies of transobturator incontinence slings, successful sling surgery is associated with ultrasound findings of concordant urethra and sling movement, midurethral location (50th percentile), and deformability of the sling on dynamic assessment (flat at rest, curving into a C-shape with Valsalva) [26].
PFUS can be used to evaluate post-mesh insertion symptoms including abnormal postsurgical pain, persistent urinary incontinence, and new onset urinary retention. Accurate localization of vaginal mesh is important before planning mesh removal or revision as both procedures can result in significant morbidity [27,28].
●Pain – Some women experience significant pain related to, or exacerbated by, synthetic mesh placement for pelvic organ prolapse (eg, anterior and/or posterior mesh-based colporrhaphy) or urinary incontinence. Ultrasound can identify the location and shape of mesh as well as provide feedback on the mesh's association with the patient's pain or symptoms, which is particularly important for women with multiple synthetic meshes. As an example, in a woman who developed severe pain after mesh-based anterior colporrhaphy and midurethral mesh sling, ultrasound evaluation identified both mesh implants and confirmed that the anterior colporrhaphy mesh was the source of her pain (with palpation from the ultrasound probe), likely because it was abutting the vagina and had contracted (image 3) [29,30].
For women suspected of having an abscess, hematoma, or seroma as the source of their pain, ultrasound imaging can visualize and characterize these postoperative fluid collections (image 4).
●Persistent urinary incontinence – An incorrectly located midurethral sling is one cause of persistent postoperative incontinence. Midurethral slings can be located too cephalad (proximal) (image 5), too caudad (distal) (image 6), or outside of the pressure zone relative to the desired midurethral location (image 7). In measuring the urethra with ultrasound, the vesicourethral junction is the 0th percentile, and the external urethral meatus is the 100th percentile. The mid-sling location is measured from the vesicourethral junction, and this measurement is divided by the total length of the urethra. For example, a sling that measures 2 cm from the urethrovesical junction under a 4 cm urethra is placed in 2 cm/4 cm, or 50th percentile length of the urethra. When the midurethral sling is not in the correct location, repeat midurethral sling placement is a treatment option. (See "Stress urinary incontinence in females: Persistent/recurrent symptoms after surgical treatment".)
Inadequate sling tension can also contribute to persistent urinary incontinence (see bullet below).
●Postoperative urinary retention – The midurethral slings are intended to be "tension free" at rest (ie, lie flat and parallel to the urethra) but flex (ie, become C-shaped) with Valsalva to provide continence. Inadequate sling tension with Valsalva can result in persistent urinary incontinence while excessive sling tension at rest can cause urinary retention. PFUS can indirectly evaluate sling tension, using the shape and mobility of the sling as proxies for direct tension measurement [26]. On 2D perineal ultrasound, the sling can be identified as a hyperechoic structure lying suburethrally. The shape of the sling at rest and the deformability of the sling from resting position to maximal Valsalva and back are recorded in the cineloop film. The dynamic change in the shape of the tape is used to categorize three types of sling deformability [26]:
•Desired sling tension – The sling lies parallel to the urethral lumen at rest (flat or slightly curved in shape along its width) and deforms to a C-shape when the patient performs maximal Valsalva (image 8 and image 9).
•Inadequate sling tension – The sling lies parallel to the urethral lumen at rest and remains parallel to the urethral lumen during maximal Valsalva (image 8). The tape does not deform to a C-shape with Valsalva as desired.
•Excessive sling tension – The sling does not lie parallel to the urethral lumen at rest but remains C-shaped along its width at both rest and during maximal Valsalva (image 9).
The types of synthetic mesh, their use in treating urinary incontinence or prolapse, and mesh-related complications are presented in detail separately.
●(See "Transvaginal synthetic mesh: Use in stress urinary incontinence (SUI)".)
●(See "Transvaginal synthetic mesh: Use in pelvic organ prolapse".)
●(See "Transvaginal synthetic mesh: Complications and risk factors".)
●(See "Transvaginal synthetic mesh: Management of exposure and pain following pelvic surgery".)
Obstetric anal sphincter injury (OASIS) — PFUS can be used in the diagnosis of OASIS and levator ani injury, which typically cause anal incontinence and pelvic pain with prolapse, respectively.
Discussions of OASIS and evaluation of anal sphincter laceration are discussed in detail separately.
●(See "Obstetric anal sphincter injury (OASIS)".)
Accidental bowel leakage — For women with accidental bowel leakage (also referred to as fecal incontinence), endoanal ultrasound (EAUS) is well established in identifying normal anatomy, anal sphincter tear, and perianal fistula (image 10 and image 11) [31,32]. Another approach is to initially evaluate these women with PFUS using a perineal approach, which may be better tolerated by some women and has good negative predictive value if normal anatomy is visualized, and then proceed with EAUS imaging only if the first study is abnormal [31,33,34]. (See 'Endoanal' below.)
Detailed discussion of fecal incontinence is presented separately. (See "Fecal incontinence in adults: Etiology and evaluation" and "Endorectal endoscopic ultrasound (EUS) in the evaluation of fecal incontinence".)
Voiding dysfunction — PFUS is used in women with voiding dysfunction to evaluate for urethral diverticulum and to monitor injection of urethral bulking agents.
Suspected urethral diverticulum — Evaluation for urethral diverticulum is typically performed in women with symptoms of postvoid dribbling, dysuria, dyspareunia, and/or a suburethral vaginal mass. Imaging has evolved from older-contrast studies to magnetic resonance imaging (MRI) techniques based on small observational studies [35-41]. PFUS can also diagnose a urethral diverticulum and provide information about diverticulum characteristics that is helpful in planning surgical treatment (number, location and size, description of ostium, presence of urinary stones within the lumen). The image demonstrates a left sagittal view of a urethral diverticulum, which appears as a septated fluid-filled mass around the urethra (image 12). Differentiation of a urethral diverticulum from a Skene's gland or a Gartner duct cyst is generally achieved based on their location. A urethral diverticulum is generally midurethral. A Skene's gland is located caudal and close to the external urethral meatus. By contrast, a Gartner duct cyst is always cephalad and can be periurethral, perivesical, lateral to the vaginal wall, or embedded in the rectovaginal septum and may track in a retroperitoneal direction, which makes its resection difficult. Differentiation of Gartner duct cysts is important for surgical planning as they can be very deep. Imaging a complex urethral diverticulum before surgery is important because it can wrap around the urethra, be multilobular, septated with internal growth, and can be associated with adenocarcinoma in 5 percent of cases [42]. (See "Urethral diverticulum in females".)
Guidance during bulking treatments for stress urinary incontinence — PFUS can be used to guide injection of bulking agents for the treatment of stress urinary incontinence. (See "Stress urinary incontinence in females: Persistent/recurrent symptoms after surgical treatment", section on 'Periurethral injection therapy'.)
The authors use EVUS to image the urethra before and after injection of urethral bulking agents and to assess agent placement. The normal placement of a urethral bulking agent is at three and nine o'clock relative to the urethra (image 13). A small study that assessed placement of urethral bulking agents with 3D EVUS imaging reported that, although the bulking agent was most often found at 3- and 9-o'clock positions as intended, the distance from the urethrovesical junction was highly variable after an uncomplicated, office-based transurethral injection [25]. Of note, 41 percent of women did not form the characteristic spheres post injection and instead had significant spread of the bulking agent either toward the bladder neck or the distal urethra (image 14). Based on this study, the authors regularly perform EVUS after injection of a urethral bulking agent and reinject the agent, as needed, to fill any gaps in coverage.
Pelvic organ prolapse — In women with pelvic organ prolapse who are planning surgery, the authors perform PFUS to refine surgical counseling and recurrence risk estimates. While physical examination provides information on prolapse stage and genital hiatus size [43], both of which are risk factors for prolapse recurrence, only ultrasound and MRI are able to evaluate levator ani disruption, which appears to contribute a three- to fourfold increased relative risk for cystocele recurrence after anterior colporrhaphy (image 15) [44-46]. The authors find this information helpful during preoperative counseling for prolapse recurrence risk.
Other — PFUS can be used to provide biofeedback during pelvic floor muscle exercise and to quantify pelvic floor muscle change in response to training [47,48]. PFUS can also help identify patients unlikely to benefit from pelvic floor muscle training, such as women with bilateral levator ani detachment (image 2), who are unable to adequately contract the muscles and therefore unlikely to improve with pelvic floor strengthening. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management".)
CONTRAINDICATIONS — There are no absolute contraindications to pelvic floor ultrasound. However, patients must be able to consent to the procedure [8]. The procedure is generally avoided in patients with an open wound or severe vulvovaginal pain or discomfort.
TECHNOLOGY — Choice of ultrasound probe and technique is based on equipment availability, the sonographer's technical ability, and the user's knowledge and experience with interpretation of imaging results. Pelvic floor ultrasound examinations should be performed only when there is a valid medical reason. The lowest possible ultrasonic exposure settings are used that gain the necessary diagnostic information.
●Two-dimensional ultrasound (2D) – Two-dimensional ultrasound provides images that are in real time and grey scale. Two-dimensional imaging can be helpful for dynamic quantification of pelvic organ prolapse, assessment of pelvic floor function in physical therapy, visualization of bladder neck mobility in stress urinary incontinence, and the initial screening for vaginal cysts and mesh. The basic equipment and procedure for 2D sonography is discussed separately. (See "Overview of ultrasound examination in obstetrics and gynecology", section on 'Patient preparation'.)
●Three- and four-dimensional ultrasound (3D or 4D) – Three-dimensional sonography refers to a 2D static display of 3D data that are generated by computer stacking of 2D images. Four-dimensional sonography refers to 3D images that can be viewed in real time. Both 3D and 4D ultrasound can be used to evaluate the deep pelvic structures including the levator ani muscles and the pelvic floor hiatus. The details of these advanced ultrasound techniques are discussed separately.
In the authors' experience, deep pelvic floor structures are best evaluated with 3D endovaginal or endoanal imaging. During the post-processing of volumes, the 3D static images are rotated in the three orthogonal planes: coronal, sagittal, and transverse. The visualization of the hiatal structures is enhanced by tomographic function. The volume is sliced with predetermined thickness to visualize structures at different levels. We analyze the 3D volumes with no gaps, and this produces a smooth image without the need for slicing. The rendering function optimizes the visualization of the specific anatomy (image 16).
TECHNIQUE
Preparation and patient positioning — The authors discuss the diagnostic procedure prior to obtaining informed consent. It is helpful to educate patients that activities such as talking and body movements may necessitate repeat imaging in order to obtain optimal scans and thus are to be minimized if possible. The steps and purpose of the examination should be explained to the patient throughout the study.
During scanning, it is important to keep the scanning hand and elbow steady to minimize motion in the probe. The sonographer's own knees or a cushion can be used to stabilize the probe while the other hand runs the controls on the console. Warm gel is placed on the transducer, which is then covered. Additionally, gel is applied to the perineum and introitus to allow for improved signal transmission.
The probes used for pelvic floor imaging (with the exception of transabdominal probes used in locations other than the perineum) require high-level disinfection between each patient. Thus, after each use, transducers are cleaned and disinfected according to manufacturer recommendations, local policies, and the country's standards. We use the American Institute of Ultrasound in Medicine (AIUM) recommendations for high-level disinfection. Additional details related to the set-up and performance of ultrasound are presented separately. (See "Overview of ultrasound examination in obstetrics and gynecology", section on 'Patient preparation'.)
In the United States, most pelvic floor ultrasound (PFUS) examinations are performed with the woman in either dorsal lithotomy or modified lithotomy position (ie, with a cushion placed under buttocks and lower extremities in frog-legged position). In other countries, examination is performed in lateral or prone positions depending on the type of examination table or cultural preferences. It is also possible to perform PFUS with a patient standing, which can be especially useful in patients who have difficulty performing dynamic maneuvers, such as pelvic contraction or Valsalva, in the supine position.
Probe placement — One can perform ultrasound evaluation using a combination of available probes, including a curved surface probe and an endocavitary probe [31,49-52]. A comparison of the various techniques is presented in the table (table 2). The anatomic location of the PFUS probe is based upon the structures to be visualized. Various approaches can be combined, as needed, based on the patient's presenting symptoms and findings. It is important to emphasize that, regardless of the modality chosen (pPFUS versus iPFUS versus EVUS versus EAUS), all modalities start with a 2D perineal/introital dynamic scanning followed by 3D/4D ultrasound of pelvic floor structures as outlined below. The probes are inserted with care to minimize patient discomfort. Some patients prefer to insert the probes themselves and then have the clinician perform the study.
Perineal (pPFUS) — Perineal PFUS (pPFUS) can be performed with either a curved array 2D/3D/4D mechanical or matrix transducer probe that is placed on the perineum and/or vulva (table 2). Both pPFUS and introital PFUS are used to assess for pelvic organ prolapse, levator ani evulsion, and levator ani dysfunction (table 3). The types of sonography are described above. (See 'Technology' above.)
The authors first orient the images by identifying the relevant landmarks, the pubic symphysis and levator plate (table 4). The evaluation begins with a 2D dynamic overview of the pelvic floor in midsagittal view. The probe is placed longitudinally for visualization of the bladder neck, urethra, urethrovesical junction, and levator muscles. The authors also document the presence of bladder neck funneling, a rectocele, enterocele, cystocele, and/or intussusception [31]. The probe is then placed transversely for assessment of the anal canal and sphincters.
Additionally, this view is used to observe pelvic floor mobility during pelvic floor maneuvers such as pelvic floor contraction and Valsalva. The Valsalva maneuver is performed at the conclusion of the examination because if air moves into the lower rectum, it can obscure the images. These maneuvers demonstrate if the patient has pelvic floor awareness (ie, can purposefully perform pelvic muscle contractions). Generally, an asymptomatic patient has a strong resting tone, and the levator ani muscles lift slightly on the images [21]. By contrast, a woman with a weak pelvic floor can lift the levator plate toward the pubic symphysis and constrict the pelvic floor outlet but cannot maintain a normal resting position (image 17).
Introital (iPFUS) — Introital PFUS (iPFUS) is typically performed with a 2D endovaginal ultrasound endfire probe, which is the same probe used for general gynecologic examinations (table 2). However, the probe is placed at the vaginal introitus (picture 1), rather than fully into the vagina, or on the perineum, if needed for PFUS. As with pPFUS, iPFUS probes are 2D/3D/4D but generally with higher resolutions. The structures visualized with iPFUS and pPFUS are similar; typically, the uterus and adnexa are better visualized with iPFUS (table 3). (See 'Technology' above.)
The probe obtains 2D views of the pelvic floor. As with pPFUS, the anatomic landmarks are the pubic symphysis and levator plate (table 4). The authors orient to probe cranially to assess for pelvic organ prolapse (including cystocele and rectocele), levator ani anatomy and function, and periurethral anatomy (including urethral funneling and midurethral mesh, if present). For women with stage III or IV prolapse, the tissue is reduced to facilitate scanning. The probe is oriented posteriorly to visualize the anal sphincter structures.
Endovaginal — For endovaginal ultrasound (EVUS), an endocavitary transducer (linear array 360 3D side-fire linear or radial array 2D/360 3D transducer) is inserted into the vagina to visualize the urethra, bladder neck and bladder, levator ani muscles, anal canal, and anal sphincters (table 2 and table 5). For women with advanced prolapse, 3D EVUS may be ideal as the side-fire probe reduces the prolapse when it is placed into the vagina. In contrast with the iPFUS, in which a probe that can be used vaginally is placed in the introitus between the labia, the EVUS probe is placed fully in the vagina. The typical EVUS probe is well tolerated by patients; it is less than 2 cm in diameter, advances no more than 6 cm into the vaginal canal, and is held still while the image is obtained. EVUS with a 3D probe is associated with much less discomfort than traditional endovaginal gynecologic ultrasound examination of the uterus and ovaries.
To perform EVUS, the probe is first inserted vaginally to view the anterior compartment structures. The anatomic landmark is the vesicourethral junction (table 4). As the probe is advanced, the vesicourethral junction is to the left of the screen and the pubic symphysis to the right, which results in a full-length 2D view of the urethra, and midurethral sling (if present), that can be measured and recorded (image 18). After completion of bladder imaging, the probe is rotated to view the posterior structures. The distance from the probe to the levator plate is measured at rest and with voluntary contraction (ie, squeeze) to assess the resultant reduction in the anorectal canal (image 19) [20]. Since the probe is less than 2 cm in diameter and is held still during imaging, there is minimal pressure on the tissue, and thus the anatomic distances are insignificantly impacted by the presence of the probe. Once these dynamic endovaginal measurements are obtained, a 3D volume is obtained, and the internal mechanism of the probe obtains a 360-degree volume of the pelvic floor. The 3D volume can be reviewed at any orientation desired. For example, the axial rotation of the 3D volume will bring to view the levator ani complex and the minimal levator hiatus (the smallest muscular hiatus for the fetus to pass through during vaginal birth) (table 2).
Endoanal — For endoanal ultrasound (EAUS), an endocavitary transducer (linear or radial array 360 2D/3D side-fire transducer) is placed in the endoanal canal to visualize both the external and internal anal sphincters (table 2). The same probe type is used for 3D EVUS and 3D EAUS in pelvic floor practices. EAUS is the reference standard for evaluation of anal sphincter complex [34,53]. EAUS is indicated if an anal sphincter irregularity is noted with any of the other ultrasound imaging modalities or in women with accidental bowel leakage [54].
To perform EAUS, the probe is inserted through the anus without the need for prior preparations such as an enema, and the probe, which is at most 2 cm in diameter, is gently advanced to the cephalad edge of the U-shaped sling of the levator plate (ie, puborectalis sling) (figure 1). Next, a 3D volume is obtained that encompasses the anal sphincter complex. In the image (image 20), the anal sphincter complex is visualized in axial plane.
During endoanal 3D imaging, the newer probes not only visualize the anal sphincter complex but also visualize the entire levator ani muscle, which can provide insight into pathophysiology of anal incontinence (image 21) [21]. However, if levator ani avulsion (ie, complete detachment of the puborectalis and pubococcygeus) is suspected, the author prefers the introital, perineal, or endovaginal approaches because, in the presence of avulsion, the endoanal probe is farther from the normal muscle attachment site on the pubic bone and therefore difficult to view. For these women, EVUS will provide clearer images (image 1). (See 'Levator ani detachment' above.)
Of note, this imaging should be painless. Women who experience pain may have deep infiltrating endometriosis of the rectum, internal hemorrhoids, fissures, or colitis, depending on the associated symptoms. The patient should be instructed to notify the examiner of any undue pain and discomfort at any point during the examination so the examination can be stopped.
●(See "Endometriosis: Clinical manifestations and diagnosis of rectovaginal or bowel disease".)
●(See "Anal fissure: Clinical manifestations, diagnosis, prevention".)
●(See "Clinical manifestations, diagnosis, and prognosis of Crohn disease in adults".)
●(See "Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults".)
SUMMARY AND RECOMMENDATIONS
●Clinical rationale – Pelvic floor ultrasound (PFUS) provides unique visualization of pelvic muscles and related structures, which can be useful for the evaluation of women with synthetic transvaginal mesh complications, fecal incontinence, urinary symptoms, and symptoms related to childbirth, among others (table 1). (See 'Clinical applications' above.)
●Visualized anatomy – PFUS can visualize deep pelvic support structures, including the muscles of the levator ani complex, urogenital hiatus, and minimal levator hiatus. Clinicians may use PFUS findings, both normal and abnormal, along with the patient's symptoms and physical examination to select appropriately targeted treatments. (See 'Pelvic floor anatomy' above.)
●Common clinical conditions for PFUS imaging– Common conditions that are evaluated with PFUS include levator ani detachment, levator ani deficiency, vaginal cysts and masses, vaginal synthetic mesh complications, obstetric anal sphincter injury (OASIS), accidental bowel leakage, and voiding dysfunction.
•Levator ani detachment – While levator ani injury is common after vaginal delivery (figure 2), most will resolve within the first postpartum year. Women with persistent detachment or muscle deficiency may present with a combination of continued pain, urinary retention, and/or vaginal bulge. PFUS can confirm levator ani detachment with evidence of wide separation of the levator plate from the pubic symphysis (image 1) and minimal or no anterior and upward movement of the levator plate with attempted pelvic floor contractions (image 2). (See 'Levator ani detachment' above.)
•Synthetic transvaginal mesh – PFUS can be particularly useful in evaluating complications related to the highly echogenic polypropylene mesh used in midurethral slings and pelvic organ prolapse repair because it can visualize mesh position and shape. PFUS can be helpful in the evaluation of mesh-related postsurgical pain, persistent urinary incontinence, and new onset urinary retention. (See 'Vaginal synthetic mesh complications' above.)
•Obstetric injury – PFUS can be used in the diagnosis of OASIS and levator ani injury, which typically cause anal incontinence and pelvic pain with prolapse, respectively. (See 'Obstetric anal sphincter injury (OASIS)' above.)
•Accidental bowel leakage – For women with accidental bowel leakage (also referred to as fecal incontinence), endoanal ultrasound can identify normal anatomy, anal sphincter tears, and perianal fistula (image 10 and image 11). (See 'Accidental bowel leakage' above.)
•Voiding dysfunction – PFUS is used in women with voiding dysfunction to evaluate for urethral diverticulum, monitor injection of urethral bulking agents, or determine the location of a sling. (See 'Voiding dysfunction' above.)
•Pelvic organ prolapse – While not routinely used by all pelvic floor surgeons, the authors perform PFUS in women with pelvic organ prolapse who are planning surgery to refine surgical counseling and recurrence risk estimates. However, the additive value of ultrasound in this setting is still being evaluated, and other experts may not use PFUS in these women. (See 'Pelvic organ prolapse' above.)
●Considerations for imaging – Choice of ultrasound probe and technique is based on equipment availability, the sonographer's technical ability, and the user's knowledge and experience with interpretation of imaging results. PFUS examinations should be performed only when there is a valid medical reason. The lowest possible ultrasonic exposure settings are used that gain the necessary diagnostic information. Options include 2D, 3D, and 4D studies. (See 'Technology' above.)
●Approach to imaging – One can perform ultrasound evaluation using a combination of available probes; the selection of probe type and anatomic placement are based upon the structures to be visualized. All modalities start with a 2D perineal/introital dynamic scanning followed by 3D/4D ultrasound of pelvic floor structures. A comparison of the various techniques is presented in the table (table 2). (See 'Probe placement' above.)
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