Andrzej Paweł Wieczorek

State of the art: an integrated approach to pelvic floor ultrasonography

Surgical management of pelvic floor disorders depends on a comprehensive understanding of the structural integrity and function of the pelvic floor. For visualizing this region, ultrasonography has emerged as a procedure that is relatively easy to perform, cost‐effective and widely available. In this review, pelvic floor ultrasonography, including two‐dimensional (2D), three‐dimensional (3D) and 4D imaging as well as transvaginal, endoanal and transperineal techniques, is discussed from a global and multicompartmental perspective, rather than using a compartmentalized approach. The role of the different sonographic modalities in the major disorders of the pelvic floor—urinary and fecal incontinence, pelvic organ prolapse and obstructed defecation syndrome—is evaluated critically. Copyright

High-resolution three-dimensional endovaginal ultrasonography in the assessment of pelvic floor anatomy: a preliminary study

Introduction and hypothesisOur aim was to evaluate the morphological characteristics of the female pelvic floor that may be further elucidated with three-dimensional endovaginal ultrasonography (3D-EVUS).MethodsA consecutive series of 20 nulliparous females underwent 3D-EVUS. Measurements were determined according to pre-established criteria. Descriptive statistics and Spearman’s correlation test were performed.ResultsThe levator hiatus (LH) was measured in the oblique plane parallel to the pubovisceral muscle. A positive correlation was found between LH area and age (p = 0.03). The anteroposterior diameter of the urogenital hiatus, measured in the axial plane tilted from the symphysis pubis to the ischiopubic rami, correlated with LH area (p = 0.008). No urethral rotations were observed in the coronal plane. Significant correlations were found among urethral parameters. Mean anal sphincter measurements were comparable to previously reported magnetic resonance imaging and ultrasound measurements.Conclusions3D-EVUS allows measurements of key pelvic floor structures in planes that cannot be determined by conventional imaging modalities.

Interobserver and interdisciplinary reproducibility of 3D endovaginal ultrasound assessment of pelvic floor anatomy

Introduction and hypothesisThe study aims were to evaluate (1) the interobserver and (2) the interdisciplinary repeatability of levator hiatus, urethral thickness, and anorectal angle measurements using three-dimensional endovaginal ultrasound (3D-EVUS).MethodsTwenty-seven nulliparous asymptomatic females were imaged with 3D-EVUS. Analyses were conducted off-line from stored 3D volumes by six readers (two radiologists, two urogynecologists, and two colorectal surgeons) using a standardized technique. Reproducibility was determined using the interclass correlation coefficients (ICC).ResultsThe overall interobserver repeatability for levator hiatus dimensions was good to excellent (ICC, 0.655–0.889), for urethral thickness was good (ICC, 0.624), and for anorectal angle was moderate (ICC, 0472). The interdisciplinary repeatability for levator hiatus indices was good to excellent (ICC, 0.639–0.915), for urethral thickness was moderate to good (ICC, 0.565–0.671), and for anorectal angle was fair to moderate (ICC, 0.204–0.434).Conclusions3D-EVUS yields reproducible measurements of levator hiatus dimensions and urethral thickness in asymptomatic nulliparous women.

3-D high-frequency endovaginal ultrasound of female urethral complex and assessment of inter-observer reliability

OBJECTIVES Assessment of the urethral complex and defining its morphological characteristics with 3-dimensional endovaginal ultrasonography with the use of high frequency rotational 360° transducer. Defining inter-observer reliability of the performed measurements. MATERIALS AND METHODS Twenty-four asymptomatic, nulliparous females (aged 18-55, mean 32 years) underwent high-frequency (12MHz) endovaginal ultrasound with rotational 360° and automated 3D data acquisition (type 2050, B-K Medical, Herlev, Denmark). Measurements of the urethral thickness, width and length, bladder neck-symphysis distance, intramural part of the urethra as well as rhabdosphincter thickness, width and length were taken by three investigators. Descriptive statistics for continuous data was performed. The results were given as mean values with standard deviation. The relationships among different variables were assessed with ANOVA for repeated measures factors, as well as T-test for dependent samples. Intraclass correlation (ICC) was calculated for each parameter. Intra- and interobserver reliability was assessed. Statistical significance was assigned to a P value of <0.05 (two-tailed). RESULTS Excellent reliability was observed for urethral measurements (length, width, thickness and volume) (ICC>0.8) and good reliability for rhabdosphincter measurements (ICC>0.6) between all three investigators. CONCLUSIONS Advanced EVUS provides detailed information on anatomy and morphology of the female urethral complex. Our results show that 360° rotational transducer with automated 3D acquisition, currently routinely used for proctological scanning is suitable for the reliable assessment of the urethral complex and can be applied in a routine diagnostics of pelvic floor disturbances in females.

Uterus and ovary hernia of the canal of Nuck

Hernia of the canal of Nuck is a rare condition occurring in female infants. The canal of Nuck is a portion of the processus vaginalis of the peritoneum within the inguinal canal. The processus vaginalis is an evagination of parietal peritoneum of the embryonic lower anterior abdominal wall that passes into the inguinal canal. Normally, it loses its connection with the peritoneal cavity, but when it fails to close a hydrocele or hernia may result. We present a 2-month-old girl with a palpable movable mass in the right inguinal region. Ultrasonography revealed a hernia containing uterus and ovary. Ultrasonography is the examination of choice in female infants with a pathological mass in the groin. Its availability and accuracy facilitate diagnosis and proper surgical treatment.

Pelvic floor disorders: role of new ultrasonographic techniques

The paper presents the role of various ultrasound modalities in the diagnostics of female pelvic floor disorders (PFD). It describes the use of two/three/four-dimensional transperineal ultrasound and endocavitary transducers, which, up to now, have been used for proctological examinations and prostate cancer brachytherapy. Ultrasonography is the most widely available imaging modality. As a result of technical progress, novel transducers and more sophisticated software have recently been introduced to the market providing more information about the anatomy of pelvic organs. Some features of these transducers, such as higher frequency and multiplanar imaging, enable better visualisation of pelvic floor organs. In-depth knowledge of the technical and physical properties of modern ultrasonography, as well as its advantages and limitations, could provide an integrated approach to imaging of PFD. Technical modalities, the wide availability of ultrasonographic techniques, and an understanding of the imaging possible with modern ultrasonography could improve our understanding of PFD and allow better assessment in pre- and post-surgical management.

Testicular adrenal rest tumors in boys with congenital adrenal hyperplasia: 3D US and elastography – Do we get more information for diagnosis and monitoring?

BACKGROUND Testicular adrenal rest tumors (TART) are the nodular testicular lesions deriving from the adrenal remnant tissue reported in boys and men with congenital adrenal hyperplasia. Until now, the diagnostics of TART have been based on a combination of clinical features, imaging methods (primarily two dimensional ultrasound--2D US), response of the foci to glycocorticosteroid (GCS) therapy and exclusion of the neoplastic process. Application of 2D US supplies however a limited range of information about the volume, demarcation, structure and vascularization of the lesions. OBJECTIVE To define whether the use of 3D US, power Doppler and elastography changes the algorithm of the diagnostics and monitoring or treatment of TART. MATERIAL AND METHODS In this study, modern ultrasound techniques such as 3D US and elastography were introduced in two boys with TART. RESULTS The 3D power Doppler option gives the opportunity for accurate assessment of the volume of testes and adrenal tissue foci and their vascularization. Sonographic elastography allows the assessment of stiffness of adrenal tissue areas compared to normal testis parenchyma. CONCLUSION The use of these modern techniques enables more adequate and advanced diagnostics, and more precise monitoring of the effects of treatment in patients with TART.

The differences in testicular volumes in boys 8-36 months old with undescended, retractile and hydrocele testis — Usefulness of scrotal screening ultrasound

PURPOSE The aim of the study was quantitative and qualitative assessments of scrotal abnormalities diagnosed in boys 8 to 36 months old during ultrasound screening and estimation if these abnormalities influence testes volume. MATERIALS AND METHODS High frequency scrotal ultrasound was performed in 1448 patients aged 8-36 months as additional exam during screening ultrasound program for children including cervical and abdominal ultrasound. The mean age of examined boys was 17 months. For further analysis the children were divided in 5 age groups. RESULTS The abnormalities in scrotal ultrasound were found in 20.1% of boys. Undescended, cryptorchid testes were found in 4.8% of patients, mobile testicle in 7.6% and hydrocele in 2.8%. The volume of undescended testes was statistically lower than volume of the descended testes in 3 youngest groups of boys (p=0.003-0.011). The volume of mobile testicles did not increase with age, while in patients with hydrocele the testicular volume decreased with age. CONCLUSION Scrotal screening ultrasound performed in boys up to 3 years old may deliver information about the number and type of existing pathologies as well as their influence on the testicular volume. The volume of the pathological testes was lower than the volume of the normal ones. Improper growth of testes may potentially have important clinical implication for the function of testes in the future.

Pelvic Floor Disorders

In 2010 GA Santoro, AP Wieczorek, and CI Bartram edited a comprehensive new textbook entitled Pelvic Floor Disorders Imaging and Multidisciplinary Approach to Management. This work is published by Springer and contains contributions from many of the most renowned International pelvic physicians and surgeons. The work presents a special emphasis on the role of diagnostic imaging. Pelviperineology is pleased to announce that we will be publishing a series of articles highlighting the different sections of this landmark book in the months to come. It goes without saying that this innovative work is a completely new approach covering the diagnosis and management of pelvic problems in one comprehensive volume. This approach enables the reader to develop a sound understanding of the pathophysiology of pelvic disease seen through the window provided by the latest imaging techniques. It highlights the importance of the imaging of pelvic floor disorders especially with the advent of new innovative technologies in many areas. This work covers both diagnosis and management. The decision how to treat should arise from a comprehensive understanding of the physiopathology of the relevant disorders and identifying where any anatomical defects are located using the techniques that are so clearly described This is a multidisciplinarity book. It is written by urologists, colorectal surgeons, gynecologists and physiotherapists and supports the concept that the approach to the pelvic floor and pelvic floor disorders should be multidisciplinary. The International Society for Pelviperineology through our journal is proud to support this work and commend it to our readers. We hope you enjoy the forthcoming articles and will be motivated to obtain your own copy of the book. BRUCE FARNSWORTH drbruce505@yahoo.com.au

Use of uroflow parameters in diagnosing an overactive bladder—Back to the drawing board

The aim of our study was to analyze whether uroflowmetry parameters are helpful in diagnosing overactive bladder (OAB). The working hypothesis was that the flow curves of patients with OAB symptoms would appear as a sharp peak flow rate with a short duration and high amplitude, lasting only for a short period during urgency sensation, followed by reduced urine flow. We introduced a new parameter called flow index (FI) defined as an average divided by maximal urine flow rates as a potential marker for diagnosing OAB.