2016-02-15
Special Thank You
Pelvic Floor Dysfunction • Professor Hans Peter Dietz generously permitted Role of Ultrasound educational use of images
Phyllis Glanc • Wonderful Sunnybrook staff who have developed a Sunnybrook Health Sciences Center pelvic floor imaging program. Department Medical Imaging Associate Professor, University of Toronto [email protected]
NO DISCLOSURES Objectives
• Background • What are the Issues in Pelvic Floor Dysfunction Text . Urinary (UI) & Fecal Incontinence (FI) . Pelvic Organ Prolapse (POP) . Levator ani trauma . Post operative - Slings and Things Hello, incontinence helpline - can you hold? • Conclusion
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Pelvic Floor Imaging - Choices TPUS – Why Now?
• US imaging pelvic floor available many years • Transperineal ultrasound (TPUS) • Why Now? • Endoanal ultrasound ( gold standard AS) • 3D/4D obstetrical image has made • MRI with rectal contrast – dynamic; physicians comfortable with the tools defecography ( limited availability) • Improved resolution – MPR – real-time with Fleuroscopic Techniques - Traditional • cineloops/volumes can review • Voiding cystourethrography (VCUG), dynamic cystoprotography, Fluoroscopic Defecography • Tomographic CT style slices • Fleuroscopy is out of favor – MRI expensive
Why Bother? Pelvic Floor Disorders
Pelvic Floor Dysfunction •Affect 50% women by age 50 • 1/10 have surgery by age 70 •Challenges • 1/3 repeat surgeries • Pelvic floor anatomy complex • Pelvic organ prolapse (POP) affect 1/3 PMW • Requires advanced US imaging techniques • Societal costs in billions for UI and millions for POP and AI • Limited FOV as compared to MRI •Project huge demand increase service
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Risk Factors Compartments Pelvic Floor • * Female gender • ** prolonged 2nd stage labor (vaginal delivery • Plus • Increasing age Pelvic surgery - especially hysterectomy • • Anterior - Bladder , urethra • Chronic increased abdominal pressure eg obesity, weight lifting, • Central - Uterus-cervix-vagina • Poor pelvic support • Posterior - Anal sphincter and rectum • Connective tissue disorders, post radiation
Reference Slide Anatomy Review Level Anterior Posterior Compartment compartment Urethra 1 Highest Bladder base Inferior 1/3 rectum anal canal 2 Mid Bladder neck Anorectal junction
3 Low Midurethra Upper 1/3 anal canal Levator Ani Sling -Lateral vagina -Posterior Anal canal rectum -Attach PR anterior
4* Lowest Distal urethra Mid/lower 1/3 anal canal Perineal body & superficial perineal muscles (perineal Uterus muscles, bulbospongiosus, Cervix ischiocavernosus ,superficial transverse
* Level measure AP diameter UG hiatus ( pubosymphysis-perineal body distance) 11
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Urinary Incontinece Urinary Incontinence • Stress : (SUI) -increase abdominal pressure (cough, laugh, sneeze) results involuntary loss • Women more susceptible urine
• Anatomy : Urethra shorter thus less resistance • Sphincteric defect / hypermobility urethra to outflow when bladder contracts • Urge urinary incontinence (UUI) - detrusor • Life style Risks: Vaginal Delivery/2nd stage overactivity ( destrusor thickness > 5mm) or labor prolonged damage innervation bladder
• Overflow: Leakage
Anterior Compartment: UI & Prolapse Bladder neck remains closed Hypermobility urethra descends & rotates horizontal Key role of Ultrasound Borderline small cystocele develops
• ID position bladder neck / urethra, assess PVR
• Assess UVJ for rotation and descent -maintain RVA (retrovesical angle > 120 degrees)
• Assess develop cystocele ( if UVJ stable may kinked urethra and bladder dysfuntion/retention Rest Strain • Distinguish between cystocele with urethral hypermobility versus a cystocele without urethral rotation Classic SUI
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Retrovesical angle now > 120 degrees Associated SUI Isolated Cystoceles
- Less common - Bladder neck remains in place - Voiding dysfunction rather than SUI - Association with levator ani trauma
Posterior Compartment Posterior Compartment
• Anal continence - Anorectal angle 90-130 degrees rest & anorectal junction above or at level PS • EAUS gold standard assess anal sphincter • POP with perineal hypermobility - descent rectal ampulla • Distinguish incontinent patients with intact anal sphincter vs sphincteric lesions (defect, • Rectovaginal defect with diverticular outpouching scarring, atrophy) 90% sensitivity/specificity anterior wall rectum into vagina is rectocele , also sigmoidocele, enterocele • MRI good big picture/muscles • Rectal intussception
• Anal sphincter trauma
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• Important to have maximum effort
• Rest normal ARA which is above pubic symphysis
• Valsalva develop rectocele, loss acute ARA, descent rectal Development sigmoidocele ampulla
• Rectocele measure depth perpendicular to wall expected contour anterior rectal wall in continuity with AS > 1- 1.5 cm
Fecal Incontinence TPUS - Anal Sphincter TPUS: Normal AS Not the Gold Standard
IAS =2-3mm, EAS variable thickness Useful for rapid assessment AS but more importantly bigger US sensitivity/specificity muscular defect ~ picture thinking puborectalis / levator tears, abnormal RVA 90% Pannu et al Radiographics 2010 and dev rectocele/enterocele/sigmoidocele Yagel et al., Valsky et al., UOG 2006, 2007
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TPUS Anal Sphincter Results less validated c/w endoanal US
PELVIC ORGAN PROLAPSE
Courtesy Dr. Dietz
Pelvic Organ Prolapse (POP) Pelvic Organ Prolapse (POP)
• Descent of the pelvic organs beneath a theoretical line between PS and ARA • 9% women clinical symptoms • Cystocele – bladder • 30% undergo repeat operation • Rectocele – anterior wall rectum • Negative impact on quality of life including sexual function • Into widened rectovaginal space is enterocele or sigmoidocele • LA avulsion from pubic bone or pelvic sidewall is associated with • Vaginal prolapse or pocidentia (uterus) POP
• Critical pre surgery to evaluate all compartments • LA avulsion is associated with vaginal delivery
• Also important to recognize only important if clinically symptomatic
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MR - Pubococcygeal line Pelvic Organ Prolapse (Anterior)
3D & Volume Rendered Critical Pelvic Organ Prolapse (posterior)
• Pelvic Organ Prolapse ( Posterior) • Dimensions urogenital hiatus • Line from PS to ARA at rest….. • POP • Levator Ani Trauma • Slings and Things
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Display Modes : Urogenital Diaphragm MPR/Rendered • Largest natural hiatus in body • MPR/orthogonal display Mean 16 cm young nullip mode shows cross- • sectional planes through the volume in question. • Mean 25 cm overall • Imaging planes on 3D US can change either at the time of acquisition or offline at a later time. • Most caudal layer pelvic floor • D = standard rendered • Composed of CT and peroneus muscle run from ischial rami to perineal image of the levator body and EAS hiatus, with the rendering • Perineal body is site attachment for endopelvic fascia, UG diaphragm, direction set from caudally bulbocavernosus muscle and puborectalis muscle to cranially
Courtesy Dr. Dietz
Urogenital hiatal ballooning on Valsalva Urogenital Hiatus Biometric Indices: • AP diameter 4.5 -4.8 cm • laterolateral diameter 3.3 -4.7cm • hiatal area 11.3 - 12 cm
Functional Assessment • Valsalva and PFMC allow its functional assessment. • Ballooning of the hiatus(excessive distensibility of LA) • increase in hiatal area to > 25 cm2 on Valsalva maneuver • Generally associated with full pelvic organ prolapse (POP)
Dietz et al and Santoro et al.
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Levator Avulsion Pelvic Floor Musculature • Common ( 10-35%) post vaginal delivery • Forceps triple risk • Levator ani muscles symmetric broad • Will result muscular sheet attached internal surface pelvis • Reduction contraction strength • Key point maintain constant tone except • Increased risk prolapse (ant/central) 2-3x during voiding, defecation, Valsalva • Increased risk prolapse recurrence post • Stretched during vaginal delivery with surgery maximal strain occuring in most medial • May not affect SUI or FI aspect pubococcygues
Levator ani ( puborectalis) avulsion Levator Ani (LA) Avulsion Dietz and Lanzarone, Obstet Gynecol 2005; Dietz et al. IUGJ 2010 • Direct signs is the avulsion of LA • Indirect sign is the disruption of “H” configuration vagina suggested by posterior displacement vaginal fornix Normal
TUI :Right-side levator ani defect measure ~ 2 cm (AP) retraction muscle
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Slings – Mesh Complications Suburethral • Mesh erosion rate ~ 9%
• Concept: • Bleeding pv 31% TVT Mesh • Continence maintained at midurethra • Pain 13% instead of the bladder neck • Voiding dysfunction 21% • Failure of the pubourethral ligaments • PS - Mesh gap in Valsalva < 1cm • < 7mm increase probability functional obstruction • Propylene mesh thus may consider tape division • pore size minimum 75 microns • 20% mesh arm dislodge - mesh mobile • Permit entry macrophages, fibroblasts, • Line straight or obtuse, wide gap ? not anchored collagen fibres • Mesh can fold up into itself, migrate, perforate
Warning: FDA and mesh July 2011 •Concern re use of mesh in prolapse surgery • 70,000 such procedures done in the US /yr
•Complications are attracting the attention of TVT (tensionless vaginal tape TOT (Transobturator tape lawyers soliciting for class action lawsuits. • Repair via obturator foramen for anchoring may be useful for women with levator avulsion injuries to Concern for surgeons if they should stop decrease risk recurrence • • New evidence show that they markedly reduce recurrence rates (Altman et al, NEJM 2011, Wong IUGJ 2011)
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Conclusion: FDA & MESH • Mesh use in patients at high risk of recurrence is approriate TOT • Age (the younger the worse), prolapse stage, previous failed surgery, levator avulsion • Inciting factors ( obesity.....) Sagittal Axial view Mesh midurethral Relatively straight extending • Mesh use in patients at low recurrence risk ? level laterally to insert on Harder to obtain puborectalis/levator ani and • Newer studies demonstrate higher rate of information but out thru obturator foramen treatment success doable
*Whiteside AJOG 2004, Vakili AJOG 2005, Dietz UOG 2010, Model EJOGRB 2010, Wong IUGJ 2011, Morgan IJGO 2011, Weemhoff IUGJ 2011,
Narrow gap < 7mm
Evaluation TOT PS- Mesh Gap – Too Narrow PS – Mesh Gap – Too wide/high Problem: Voiding Dysfunction PROBLEM: Recurrent UI Typically > 1cm Mesh high in location Typically cut mesh to cure this Bladder neck opens wide with stress although remains fixed high in position
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Problem – Post-Operative – Problem – Post-Operative - Pain Urinary Dysfunction Tomographic Slice Cut Sling
TVT – curve anchoring anterior, deshiscient Mesh frayed & migrated into vagina. Courtesy Dr. Dietz
Rendered Image Problem – Post Operative
TVT perforation / migration into urethra
TVT – curve anchoring anterior, the left side is split in two and not obviously anchored, concern Courtesy Dr. Dietz Edges migrated into vagina.
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Conclusion References
• State of the art: an integrated approach to pelvic floor ultrasonography. H. P. Dietz3, Ultrasound in Obstetrics & Gynecology 37, 381–396, April 2011 • Pelvic floor disorders common • DeLancey JO. The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment. Am J Obstet Gynecol 2005; 192: 1488–1495. • Dietz HP, Shek C, Clarke B. Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor • Complex area ultrasound. Ultrasound Obstet Gynecol 2005; 25: 580–585. • Lekskulchai O, Dietz H. Detrusor wall thickness as a test for detrusor overactivity in women. Ultrasound Obstet Gynecol 2008; 32: 535–539. • Broekhuis SR, Futterer JJ, Hendriks JCM, Barentsz JO, Vierhout ME, Kluivers KB. Symptoms of pelvic floor dysfunction are • Best for POP, LA avulsion defects, hiatal poorly correlated with findings on clinical examination and dynamic MR imaging of the pelvic floor. Int Urogynecol J 2009; 20: 1169–1174. ballooning, SUI • Model A, Shek KL, Dietz HP. Do levator defects increase the risk of prolapse recurrence after pelvic floor surgery? Neurourol Urodyn 2009; 28: 888–889 • Dietz HP, Haylen BT, Broome J. Ultrasound in the quantification of female pelvic organ prolapse. Ultrasound Obstet • Biofeedback pelvic floor contraction Gynecol 2001; 18: 511–514. • Yagel S, Valsky DV. Three-dimensional transperineal ultrasonography for evaluation of the anal sphincter complex: another dimension in understanding peripartum sphincter trauma. Ultrasound Obstet Gynecol 2006; 27: 119–123. • Dietz HP, Barry C, Lim YN, Rane A. Two-dimensional and three-dimensional ultrasound imaging of suburethral slings. • Does not always correlate well with clinical Ultrasound Obstet Gynecol 2005; 26: 175–179. • Dietz HP, Steensma AB. Posterior compartment prolapse on two-dimensional and three-dimensional pelvic floor symptoms ultrasound: the distinction between true rectocele, perineal hypermobility and enterocele. Ultrasound Obstet Gynecol 2005; 26: 73–77. • More research needed
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