Three-Dimensional Transperineal Ultrasound Assessment of the Anal Sphincter Immediately After Vaginal Birth: An Exploratory Study.

OBJECTIVES: To assess the feasibility of acquiring adequate transperineal ultrasound (TPUS) volumes of the anal sphincter (AS) immediately after vaginal birth, the reproducibility of its measurements, and detecting defects therein. METHODS: Secondary analysis of TPUS volumes of the AS, acquired immediately after vaginal birth with a transversely oriented convex probe. Two independent experts ranked off-line image quality as "inadequate," "adequate," or "ideal" using the Point-of-Care Ultrasound Image Quality scale. On "adequate" and "ideal" quality volumes, the length of the external AS at 6 and 12 o'clock, and the volume of the external and internal AS were measured. Additionally, volumes were screened for AS defects on tomographic ultrasound imaging. Subsequently, we rated the intra- and interrater agreement on those findings. RESULTS: Of 183 volumes, 162 were considered "adequate" or of "ideal" quality (88.5%). Reasons for "inadequacy" were shadow artifacts (16/21), poor resolution (3/21), incomplete acquisition (1/21), or aberrant AS morphology (1/21). The intrarater reliability of two-dimensional (2D) and three-dimensional (3D) measurements was excellent, whereas interrater reliability was fair to good for 2D measurements and good for 3D measurements. In those tomographic ultrasound imaging (TUI) sequences including AS defects, the intra- and interrater reliability of the defect measurement were excellent [intraclass correlation coefficient (ICC) = 0.92 (0.80-0.94)] and moderate [ICC = 0.72 (0.63-0.79)]. In this cohort, there were only few (4/48; 8.3%) AS defects. However, grading them was poorly reproducible between experts. CONCLUSION: TPUS of the AS immediately after vaginal birth yields adequate image quality and allows for reproducible measurements. In the few patients with AS defects, there was good agreement on the presence, but it was poor for the extent of defects.

Immediate postpartum assessment of the anal sphincter by endovaginal ultrasound: a new technical approach.

INTRODUCTION AND HYPOTHESIS: In this study we described a new technical approach to adapt endovaginal ultrasound scanning of the anal sphincter complex to the immediate postpartum period. METHODS: We analyzed the clinical and ultrasonographic examinations of 18 primiparous women presenting deep perineal tears with potential or clearly identified lesions of the anal sphincter. Potential anal sphincter lesion was defined as a second degree perineal tear extending close to the anal sphincter with exposition of its capsule or muscular fibers. We reported interesting ultrasonographic images explaining our technique in a video. RESULTS: We reported clinical and ultrasonographic features in nine cases of grade 2, four cases of grade 3a, four cases of grade 3b and one case of grade 3c perineal tears. The ultrasonographic examination confirmed the intact state of the anal sphincter complex in all patients with clinical grade 2 tears except one in which a grade 3b lesion was detected. We were not able to identify external anal sphincter lesions on ultrasound in any of the patients with clinical grade 3a tears. In patients with clinical grade 3b tears, the ultrasound confirmed the external anal sphincter lesion in all cases, but revealed additional involvement of the internal anal sphincter in 1 case (grade 3c). CONCLUSION: Immediate postpartum endovaginal ultrasound could be a promising technique to improve the management of perineal traumas after vaginal delivery.

Breech progression angle: new feasible and reliable transperineal ultrasound parameter for assessment of fetal breech descent in birth canal.

OBJECTIVE: To assess the feasibility and reliability of transperineal ultrasound in the assessment of fetal breech descent in the birth canal, by measuring the breech progression angle (BPA). METHODS: Women with a singleton pregnancy with the fetus in breech presentation between 34 and 41 weeks' gestation were recruited. Transperineal ultrasound images were acquired in the midsagittal view for each woman, twice by one operator and once by another. Each operator measured the BPA after anonymization of the transperineal ultrasound images. BPA was defined as the angle between a line running along the long axis of the pubic symphysis and another line extending from the most inferior portion of the pubic symphysis tangentially to the lowest recognizable fetal part in the maternal pelvis. Each operator was blinded to all other measurements performed for each woman. Intra- and interobserver reproducibility of BPA measurement was evaluated using the intraclass correlation coefficient (ICC). To investigate the presence of any bias, intra- and interobserver agreement was also analyzed using Bland-Altman analysis. Student's t-test and Levene's W0 test were used to investigate whether a number of different clinical factors had an effect on systematic differences and homogeneity, respectively, between BPA measurements. RESULTS: Overall, 44 women were included in the analysis. BPA was measured successfully by both operators on all images. Both intra- and interobserver agreement analyses showed excellent reproducibility in BPA measurement, with ICCs of 0.88 (95% CI, 0.80-0.93) and 0.83 (95% CI, 0.71-0.90), respectively. The mean difference between measurements was 0.4° (95% CI, -1.4 to 2.2°) for intraobserver repeatability and -0.4° (95% CI, -2.6 to 1.8°) for interobserver repeatability. The upper limits of agreement were 12.0° (95% CI, 8.9-15.1°) and 13.6° (95% CI, 9.9-17.3°) for intra- and interobserver repeatability, respectively. The lower limits of agreement were -11.2° (95% CI, -14.3 to -8.1°) and -14.4° (95% CI, -18.2 to -10.7°) for intra- and interobserver repeatability, respectively. No systematic difference between BPA measurements was found on either intra- or interobserver agreement analysis. None of the clinical factors examined (maternal body mass index, maternal age, gestational age at the ultrasound scan and parity) showed a statistically significant effect on intra- or interobserver reliability. CONCLUSIONS: BPA represents a new feasible and highly reproducible measurement for the evaluation of fetal breech descent in the birth canal. Future studies assessing its usefulness in the prediction of successful external cephalic version and breech vaginal delivery are needed. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Assessment of levator hiatal area using 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: randomized controlled trial.

OBJECTIVES: Deep infiltrating endometriosis (DIE) is associated with chronic pelvic pain, dyspareunia and pelvic floor muscle hypertonia. The primary aim of this study was to evaluate the effect of pelvic floor physiotherapy (PFP) on the area of levator ani hiatus during Valsalva maneuver, assessed using transperineal ultrasound, in women with DIE suffering from superficial dyspareunia. METHODS: This was a randomized controlled trial of 34 nulliparous women diagnosed with DIE and associated superficial dyspareunia. After an initial clinical examination, all patients underwent three-dimensional/four-dimensional (3D/4D) transperineal ultrasound to measure the levator hiatal area (LHA) at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver, and were asked to rate their pain symptoms using a numerical rating scale (NRS). Eligible women were assigned randomly (1:1 ratio) to no intervention (control group, 17 women) or treatment with five individual sessions of PFP (study group, 17 women). Four months after the first examination, all women underwent a second evaluation of pain symptoms and LHA on transperineal ultrasound. The primary outcome measure was the percentage change in LHA on maximum Valsalva maneuver between the baseline and follow-up examinations. The percentage changes in pain symptoms between the two examinations, including superficial and deep dyspareunia, dysmenorrhea, chronic pelvic pain, dysuria and dyschezia, were also evaluated. RESULTS: Thirty women, comprising 17 in the study group and 13 in the control group, completed the study and were included in the analysis. The percentage change in LHA on maximum Valsalva maneuver between the two examinations was higher in the study group than in the control group (20.0 ± 24.8% vs -0.5 ± 3.3%; P = 0.02), indicating better pelvic floor muscle relaxation. After PFP treatment, the NRS score for superficial dyspareunia remained almost unchanged in the control group (median change in NRS (Δ-NRS), 0 (interquartile range (IQR), 0-0)) while a marked reduction was observed in the study group (median Δ-NRS, -3 (IQR, -4 to -2); P < 0.01). Moreover, there was a significant difference between the PFP and control groups with regards to the change in chronic pelvic pain (median Δ-NRS, 0 (IQR, -2 to 0) vs 0 (IQR, 0-1); P = 0.01). CONCLUSIONS: In women with DIE, PFP seems to result in increased LHA on Valsalva maneuver, as observed by 3D/4D transperineal ultrasound, leading to improved superficial dyspareunia, chronic pelvic pain and pelvic floor muscle relaxation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Assessment of the angle of progression and distance perineum-head in the prediction of type of delivery and duration of labor using intrapartum ultrasonography.

OBJECTIVE: To evaluate the relevance of the angle of progression (AOP) and head-perineum distance (HPD) for predicting the type of delivery and duration of the second stage of labor using intrapartum ultrasonography. METHODS: In total, 221 women in labor with a single gestational sac at ≥37 weeks of gestation and fetuses in cephalic presentation underwent two-dimensional ultrasonography by transperineal route for measurements of AOP and HPD. Correlations between the type of delivery (vaginal or surgical (cesarean section and forceps)), duration of the second stage of labor, and fetal and maternal characteristics were assessed. AOP and HPD variables were separately studied in the first and second stages of labor. Multivariate logistic regression was followed in stages to identify the predictors for the surgical delivery outcome - stepwise forward method. RESULTS: In total, 153 (69.2%) women underwent vaginal deliveries, 7 (3.2%) underwent forceps deliveries, and 61 (27.6%) underwent cesarean deliveries. AOP was a statistically significant parameter in first and second stages of labor (107.8 ± 12.1° versus 100.8 ± 13.7°; p = .017), with an inverse correlation with the occurrence of vaginal delivery. HPD was a statistically significant parameter in the second stage of labor (3.42 ± 0.84 cm versus 4.17 ± 0.54 cm; p < .003), with a direct correlation with the occurrence of surgical delivery. The value of AOP that optimized the curve was 129.9° with 85% specificity and 63% sensitivity for the vaginal delivery endpoint. The value of HPD that optimized the curve was 4.3 cm with 69% specificity and 89% sensitivity for the surgical delivery endpoint. In the first phase, the variables defining the type of delivery were the following: height, body mass index, and AOP. In the second phase, the variables defining were the following: height, labor analgesia, HPD, and position of the fetal occiput. CONCLUSION: AOP and HPD determined by intrapartum ultrasonography were associated with duration of labor, which may aid in predicting the type of delivery in association with clinical parameters.

Transperineal ultrasound assessment of fetal head elevation by maneuvers used for managing umbilical cord prolapse.

OBJECTIVE: To assess objectively the degree of fetal head elevation achieved by different maneuvers commonly used for managing umbilical cord prolapse. METHODS: This was a prospective observational study of pregnant women at term before elective Cesarean delivery. A baseline assessment of fetal head station was performed with the woman in the supine position, using transperineal ultrasound for measuring the parasagittal angle of progression (psAOP), head-symphysis distance (HSD) and head-perineum distance (HPD). The ultrasonographic measurements of fetal head station were repeated during different maneuvers, including elevation of the maternal buttocks using a wedge, knee-chest position, Trendelenburg position with a 15° tilt and filling the maternal urinary bladder with 100 mL, 300 mL and 500 mL of normal saline. The measurements obtained during the maneuvers were compared with the baseline measurements. RESULTS: Twenty pregnant women scheduled for elective Cesarean section at term were included in the study. When compared with baseline (median psAOP, 103.6°), the knee-chest position gave the strongest elevation effect, with the greatest reduction in psAOP (psAOP, 80.7°; P < 0.001), followed by filling the bladder with 500 mL (psAOP, 89.9°; P < 0.001) and 300 mL (psAOP, 94.4°; P < 0.001) of normal saline. Filling the maternal bladder with 100 mL of normal saline (psAOP, 96.1°; P = 0.001), the Trendelenburg position (psAOP, 96.8°; P = 0.014) and elevating the maternal buttocks (psAOP, 98.3°; P = 0.033) gave modest elevation effects. Similar findings were reported for HSD and HPD. The fetal head elevation effects of the knee-chest position, Trendelenburg position and elevation of the maternal buttocks were independent of the initial fetal head station, but that of bladder filling was greater when the initial head station was low. CONCLUSIONS: To elevate the fetal presenting part, the knee-chest position provides the best effect, followed by filling the maternal urinary bladder with 500 mL then 300 mL of fluid, respectively. Filling the bladder with 100 mL of fluid, the Trendelenburg position and elevation of the maternal buttocks have modest effects. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Transperineal ultrasound assessment of maternal pelvic floor at term and fetal head engagement.

OBJECTIVES: To evaluate the association between pelvic floor dimensions in nulliparous women at term and fetal head engagement, as assessed by transperineal ultrasound. METHODS: This was a prospective observational study of nulliparous women at term. Before the onset of labor, transperineal ultrasound was used to measure the anteroposterior diameter (APD) of the levator hiatus and the angle of progression (AoP) at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver (before and after visual feedback). We assessed the correlation between pelvic floor static and dynamic dimensions (levator hiatal APD and levator ani muscle coactivation) and AoP, which is an objective index of fetal head engagement. RESULTS: In total, 282 women were included in the analysis. Among these, 211 (74.8%) women had a vaginal delivery while 71 (25.2%) had a Cesarean delivery. AoP was narrower in the Cesarean-delivery group at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva, whereas no differences in levator hiatal APD were found between the two groups. We found a negative correlation between levator hiatal APD at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva and the duration of the second stage of labor. There was a positive correlation between AoP and levator hiatal APD on maximum Valsalva maneuver after visual feedback (r = 0.15, P = 0.01). Women with levator ani muscle contraction on Valsalva maneuver (i.e. coactivation), both pre and post visual feedback, had a narrower AoP at rest and on maximum Valsalva. After visual feedback, women with levator ani muscle coactivation had a longer second stage of labor than did those without (80.8 ± 61.4 min vs 62.9 ± 43.4 min (P = 0.04)). CONCLUSIONS: Smaller pelvic floor dimensions and levator ani muscle coactivation are associated with higher fetal head station and with a longer second stage of labor in nulliparous women at term. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Utility of 2D-ultrasound in pelvic floor muscle contraction and bladder neck mobility assessment in women with urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Assessment of pelvic floor muscle (PFM) contraction and bladder neck (BN) mobility in women with stress urinary incontinence (SUI) is essentially clinical. Ultrasound is increasingly used as a method for evaluating BN mobility and PFM contraction, but has not been standardized. The aim of this study was to review ultrasound technics and parameters that might be relevant for PFM contraction and BN mobility assessment in women with urinary incontinence (UI). METHODS: We reviewed articles indexed in the MEDLINE database between 1988 and 2018 and selected articles which had a cohort of women with UI who had undergone functional 2D-ultrasound evaluation of PFM or BN mobility. RESULTS: Transperineal ultrasound provides a panoramic view of the pelvic organs without modifying the anatomical relationship between the urethra and surrounding structural landmarks. One of the measurements used to assess urethral mobility is bladder neck descent (BND), which has been shown to be extremely reliable. Measuring the anteroposterior diameter (APD) of the urogenital levator hiatus can also reliably quantify PFM contraction in women. The more recently developed technique of elastography could be an additional useful non-invasive method for measuring periurethral striated muscle stiffness. CONCLUSIONS: Several ultrasound parameters such as BND, anorectal angle displacement and periurethral stiffness as measured by elastography are relevant for investigating UI in women undertaking pelvic floor muscle training. Our hypothesis is that these ultrasound parameters can be correlated with urinary symptoms and clinical contraction assessment. They need to be validated for clinical use.

CT assessment of the quality of omentoplasty and its implications for perineal wound healing.

PURPOSE: This study was designed to examine the impact of an omentoplasty and its quality on pelviperineal morbidity after abdominoperineal resection (APR) for rectal cancer. METHODS: This was a retrospective single-centre study of consecutive patients undergoing APR for primary or recurrent rectal cancer between 2000 and 2018. Quality of omentoplasty was categorised (sufficient vs insufficient) based on postoperative CT scans. Main study endpoints were perineal wound healing and perineal hernia. RESULTS: This study included 100 patients: 16 with a sufficient omentoplasty, 16 with an insufficient omentoplasty, and 68 without omentoplasty. Rate of pelviperineal complications within 30 days was 44%, 69% and 64% (P = 0.283), and delayed wound healing at 3 months was 19%, 54% and 27%, respectively (P = 0.109). Sufficient omentoplasty was not significantly associated with less delayed healing in multivariable analysis (OR 0.597; 95% CI 0.149-2.397). An insufficient omentoplasty demonstrated significantly higher rates of delayed healing at 6 months (46% vs 14%; P = 0.016) and chronic perineal sinus at 12 months (31% vs 3%; P = 0.008) compared with no omentoplasty. CONCLUSION: This relatively small series suggest that even a sufficient omentoplasty, as determined by postoperative imaging, does not reduce pelviperineal morbidity after APR for rectal cancer. The methodology of CT-based assessment of an omentoplasty as well as the correlation with postoperative outcomes has to be validated in future studies.

Pre-Induction Transperineal Ultrasound Assessment for the Prediction of Labor Outcome.

OBJECTIVE: To examine (1) the concordance of manual and automated para-symphyseal angle of progression (psAOP) measurements, (2) the repeatability of psAOP, head-symphysis distance, head-perineum distance, and sonographic cervical dilatation, and (3) the value of transperineal ultrasound (TPU) in predicting induction of labor (IOL) outcome. METHODS: We performed a prospective study in 308 women with singleton pregnancies undergoing IOL at term. Logistic regression analysis was used to determine which maternal factors, Bishop score, method of IOL, and TPU parameters were significant predictors of cesarean section (CS) and CS due to no progress (CS-NP). RESULTS: There was vaginal delivery in 225 (83.0%) and CS in 46 (17.0%) cases. The intra-class correlation coefficient between manual and automated psAOP was 0.866, but automated psAOP was 4.6° wider than manual measurement. All TPU parameters had an inter-observer intra-class correlation coefficient > 0.800. Significant independent prediction of CS and CS-NP was provided by maternal factors, previous vaginal delivery, and psAOP. There was no improvement in area under the receiver-operating characteristic curve with the addition of psAOP to maternal factors. CONCLUSIONS: All TPU parameters are reproducible. Comparing the three TPU parameters for fetal head station, only psAOP is a significant independent predictor of CS; however, it is unlikely to be useful in predicting IOL outcome.

The feasibility and accuracy of ultrasound assessment in the labor room.

Objective: Vaginal examination is widely used to assess the progress of labor; however, it is subjective and poorly reproducible. We aim to assess the feasibility and accuracy of transabdominal and transperineal ultrasound compared to vaginal examination in the assessment of labor and its progress. Methods: Women were recruited as they presented for assessment of labor to a tertiary inner city maternity service. Paired vaginal and ultrasound assessments were performed in 192 women at 24-42 weeks. Fetal head position was assessed by transabdominal ultrasound defined in relation to the occiput position transformed to a 12-hour clock face; fetal head station defined as head-perineum distance by transperineal ultrasound; cervical dilatation by anterior to posterior cervical rim measurement and caput succedaneum by skin-skull distance on transperineal ultrasound. Results: Fetal head position was recorded in 99.7% (298/299) of US and 51.5% (154/299) on vaginal examination (p < .0001 1 ). Bland-Altman analysis showed 95% limits of agreement, -5.31 to 4.84 clock hours. Head station was recorded in 96.3% (308/320) on vaginal examination (VE) and 95.9% (307/320) on US (p = .79 1 ). Head station and head perineum distance were negatively correlated (Spearman's r = -.57, p < .0001). 54.4% (178/327) of cervical dilatation measurements were determined using US and 100% on VE/speculum (p < .0001). Bland-Altman analysis showed 95% limits of agreement -2.51-2.16 cm. The presence of caput could be assessed in 98.4% (315/320) of US and was commented in 95.3% (305/320) of VEs, with agreement for the presence of caput of 76% (p < .05). Fetuses with caput greater than 10 mm had significantly lower head station (p < .0001). Conclusions: We describe comprehensive ultrasound assessments in the labor room that could be translated to the assessment of women in labor. Fetal head position is unreliably determined by vaginal examination and agrees poorly with US. Head perineum distance has a moderate correlation with fetal head station in relation to the ischial spines based on vaginal examination. Cervical dilatation is not reliably assessed by ultrasound except at dilatations of less than 4 cm. Caput is readily quantifiable by ultrasound and its presence is associated with lower fetal head station. Transabdominal and transperineal ultrasound is feasible in the labor room with an accuracy that is generally greater than vaginal examinations.

Assessment of pelvic floor muscle contractility: digital palpation versus 2D and 3D perineal ultrasound.

PURPOSE: The aim of our study was to investigate 2D and 3D ultrasound assessment of pelvic floor muscle contractility as an objective non-invasive diagnostic tool in urogynecologic patients. METHODS: Patients from our urogynecological outpatient clinic were examined clinically by a single investigator including digital palpation as well as 2D and 3D perineal ultrasound. Muscle contractility was graded according to the modified Oxford Score and ultrasound images were saved for later analysis. Stored images were evaluated offline by another investigator blinded to all clinical data at a later stage. Bladder neck distance from pubic symphysis and symphysis-levator distance were measured in 2D at rest and during maximal pelvic floor muscle contraction. Hiatal area at the level of minimal hiatal dimensions as a 3D ultrasound parameter was measured at rest and during maximal pelvic floor muscle contraction, too. Spearman's rho was used to calculate statistical correlation between ultrasound parameters and digital assessment. RESULTS: A total of 114 patients were examined in our study. We found a significant correlation between modified Oxford Score and 2D ultrasound parameters of elongation of bladder neck length (Spearman's rho 0.292, p = 0.002) and reduction of symphysis-levator distance (Spearman's rho 0.0.301, p = 0.001), respectively. In addition, we detected a statistical significant correlation of modified Oxford Score and reduction of hiatal area in 3D ultrasound (Spearman's rho 0.458, p < 0.001), too. CONCLUSIONS: In this study, we found a significant correlation of subjective digital assessment of pelvic floor muscle strength with 2D and 3D ultrasound parameters as an objective diagnostic tool.

Evaluation of sonographic assessment of the progress of labor.

OBJECTIVE: To evaluate the practical application of intrapartum sonographic assessment of the progress of labor. MATERIAL AND METHODS: Eighty three full-term pregnant women who delivered at the Obstetrics and Gynecology Department were enrolled into this study. Transperineal ultrasonographic examinations were conducted with a convex transducer at the onset of active labor, yielding mid-sagittal and coronal images. Three parameters were measured: 1) the angle between the long axis of the symphysis pubis and the line joining its lowest margin to the contour of the fetal head (angle of progression); 2) the distance between the presenting point and the line perpendicular to the symphysis pubis and passing through its lowest margin; 3) the fetal head-perineum distance. The relationship between measurement results and the period from examination to delivery was also analyzed. RESULTS: There were 73 vaginal deliveries and 10 women underwent a cesarean section due to failure to progress. The two groups (vaginal vs. cesarean delivery) differed significantly in terms of the angle of progression (131 vs. 110 degrees, respectively p<0.01) and the distance between the presenting point and the infrapubic line (34 vs. 20 mm, respectively p<0.01). The inter-group difference in fetal head-peritoneum distances (53 and 61 mm, respectively) was noticeable but non-significant (p>0.05). The study also demonstrated a relationship between all three of the measured values and the time to second labor phase completion. CONCLUSIONS: Ultrasonography may be useful in assessing the progress of labor as well as in predicting or early diagnosis of abnormal fetal head descent.

Agreement between two- and three-dimensional transperineal ultrasound methods for assessment of fetal head-symphysis distance in active labor.

OBJECTIVES: To assess the intermethod agreement between two-dimensional (2D) and three-dimensional (3D) transperineal ultrasound methods in measuring a new index of fetal head station (the fetal head-symphysis distance (HSD)) in active labor, and to assess potential factors that may affect their agreement. METHODS: HSD was measured by transperineal ultrasound in 86 women in active labor, once using a 2D and once using a 3D technique. 2D images were acquired first in 43 cases and 3D images were acquired first in the other 43 women. Intermethod agreement between 2D and 3D methods was analyzed by means of intraclass correlation coefficient (ICC) and Bland-Altman analysis. In addition, potential factors affecting the intermethod reproducibility were investigated including fetal occiput position, order of acquisition, fetal head station, stage of labor, maternal body mass index and use of epidural analgesia, using the ANOVA test to check for systematic bias and Levene's test for homoscedasticity. RESULTS: Good agreement was demonstrated between 2D and 3D measurements of HSD (ICC, 0.949 (95% CI, 0.914-0.984)). No evidence of systematic difference was shown between the two methods (average difference ± SD = 0.03 ± 2.29 mm; P = 0.888). The only factor that had a significant effect on systematic difference between 2D and 3D methods was order of acquisition (P = 0.042); the first observation was higher regardless of the method used. Fetal head station had a significant effect on the homogeneity between the two methods (P = 0.004) with a better 2D-3D agreement obtained at lower head stations (SD of differences: 1.63 vs 2.59 mm). CONCLUSIONS: There is very good agreement between 2D and 3D methods of assessing HSD. Agreement is better in lower fetal head stations.

Transperineal perineal ultrasound versus magnetic resonance imaging in the assessment of perianal Crohn's disease.

BACKGROUND: To assess the accuracy of transperineal ultrasound (TPUS), in comparison with magnetic resonance imaging (MRI), in classifying perianal Crohn's disease (CD) according to Parks' classification and the American Gastroenterological Association criteria. METHODS: Fifty-nine consecutive patients with confirmed or suspected perianal CD underwent TPUS and MRI within 10 days. An independent expert surgical evaluation, which took into account proctological and MRI findings, was used as the gold standard. Fistulae and perianal disease were classified according to Parks' classification and American Gastroenterological Association criteria, respectively. RESULTS: Forty-six patients showed 64 fistulae (9 intersphincteric, 34 transsphincteric, 2 suprasphincteric, 9 extrasphincteric, and 10 anovaginal) and 23 abscesses were also found. Fifty-one of 54 perianal fistulae (per-lesion sensitivity: 94.4%) and 9 of 10 anovaginal fistulae (sensitivity: 90.0%) were detected and 58 were correctly classified by TPUS (sensitivity: 90.6%; positive predictive value: 93.4%). Overall, TPUS correctly detected and classified the fistulae in 89% of patients and the agreement for classifying perianal fistulae between TPUS and MRI was excellent (K value: 0.783). In contrast, 11 of 23 abscesses were correctly diagnosed by TPUS (sensitivity: 47.8%); although 14 abscesses were diagnosed by TPUS, only 11 were confirmed by MRI (positive predictive value: 78.6%). Overall, TPUS correctly detected and classified fistulae and associated abscesses in 67.3% of patients. Agreement between MRI and TPUS in discriminating simple (15) and complex (29) perianal disease was fairly good (K value: 0.57). CONCLUSIONS: TPUS is a simple and accurate diagnostic method for classifying perianal fistulae in CD and could be used for the preliminary assessment and follow-up of perianal CD.

A novel three-dimensional dynamic anorectal ultrasonography technique for the assessment of perineal descent, compared with defaecography.

AIM: The purpose of the study was to describe a novel three-dimensional dynamic anorectal ultrasonography technique (dynamic 3-DAUS) for assessment of perineal descent (PD) and establishment of normal range values, comparing it with defaecography. Secondarily, the study compares the ability of the two techniques to identify various pelvic floor dysfunctions. METHOD: A prospective study was undertaken in 29 women (mean age 43 years) with obstructed defecation disorder. All patients underwent defaecography and dynamic 3-DAUS and the results were compared. Lee kappa coefficients (K) were used. RESULTS: On defaecography, PD > 3 cm was detected in 12 patients. On dynamic 3-DAUS, 10 of these patients had PD > 2.5 cm. Seventeen had normal PD on defaecography and PD ≤ 2.5 cm on dynamic 3-DAUS (K 0.85). Normal relaxation was observed in 10 patients and anismus in 14 with both techniques (K 0.65). Both techniques identified five patients without rectocele, two with grade I rectocele (K 0.89 and 1.00, respectively) and 10 with grade II and nine with grade III (K 0.72 and 0.77, respectively). Rectal intussusception was identified in six patients on defaecography. These were confirmed on dynamic 3-DAUS in addition to the identification of another seven cases indicating moderate agreement (K 0.46). Enterocele/sigmoidocele grade III was identified in one patient with both techniques, indicating substantial agreement (K 0.65). CONCLUSION: Dynamic 3-DAUS was shown to be a reliable technique for the assessment of PD and pelvic floor dysfunctions, identifying all disorders and confirming findings from defaecography.

Agreement and reliability of pelvic floor measurements during contraction using three-dimensional pelvic floor ultrasound and virtual reality.

OBJECTIVES: Virtual reality is a novel method of visualizing ultrasound data with the perception of depth and offers possibilities for measuring non-planar structures. The levator ani hiatus has both convex and concave aspects. The aim of this study was to compare levator ani hiatus volume measurements obtained with conventional three-dimensional (3D) ultrasound and with a virtual reality measurement technique and to establish their reliability and agreement. METHODS: 100 symptomatic patients visiting a tertiary pelvic floor clinic with a normal intact levator ani muscle diagnosed on translabial ultrasound were selected. Datasets were analyzed using a rendered volume with a slice thickness of 1.5 cm at the level of minimal hiatal dimensions during contraction. The levator area (in cm(2)) was measured and multiplied by 1.5 to get the levator ani hiatus volume in conventional 3D ultrasound (in cm(3)). Levator ani hiatus volume measurements were then measured semi-automatically in virtual reality (cm(3) ) using a segmentation algorithm. An intra- and interobserver analysis of reliability and agreement was performed in 20 randomly chosen patients. RESULTS: The mean difference between levator ani hiatus volume measurements performed using conventional 3D ultrasound and virtual reality was 0.10 (95% CI, - 0.15 to 0.35) cm(3). The intraclass correlation coefficient (ICC) comparing conventional 3D ultrasound with virtual reality measurements was > 0.96. Intra- and interobserver ICCs for conventional 3D ultrasound measurements were > 0.94 and for virtual reality measurements were > 0.97, indicating good reliability for both. CONCLUSION: Levator ani hiatus volume measurements performed using virtual reality were reliable and the results were similar to those obtained with conventional 3D ultrasonography.

Interobserver repeatability of three- and four-dimensional transperineal ultrasound assessment of pelvic floor muscle anatomy and function.

OBJECTIVE: To evaluate the interobserver repeatability of measurement of the pubovisceral muscle and levator hiatus, and the position of related organs, during rest, muscle contraction and Valsalva maneuver using three- and four-dimensional (3D and 4D) transperineal ultrasound. METHODS: Seventeen women were included in the study. The position and dimensions of the pubovisceral muscle and levator hiatus in patients at rest and during contraction and Valsalva were determined from stored 3D and 4D ultrasound volumes. Analyses were conducted offline by two observers blinded to the clinical data and to each others' measurements. RESULTS: Measurements of levator hiatal dimensions at rest demonstrated intraclass correlation coefficient (ICC) values of 0.92 to 0.96. The ICC values for pubovisceral muscle thickness at rest varied between good and very good (ICC, 0.61-0.93), regardless of plane. During contraction, the ICC values for all measured parameters were very good, varying between 0.61 and 0.92. Measurement of the transverse diameter of the levator hiatus during the Valsalva maneuver showed good reliability (ICC, 0.86), but assessment of the anterior and posterior borders of the levator hiatus was only possible in 29% of cases. CONCLUSIONS: 3D and 4D transperineal ultrasound measurement of the pubovisceral muscle and levator hiatus is reliable in women with no or minor symptoms of prolapse at rest and during contraction. The technique for recording during the Valsalva maneuver requires improvement if it is to be useful in the diagnosis of pelvic organ prolapse.

Ultrasound assessment of fetal head-perineum distance before induction of labor.

OBJECTIVES: To evaluate fetal head-perineum distance measured by ultrasound imaging as a predictive factor for induction of labor, and to compare this distance with maternal factors, the Bishop score and ultrasound measurements of cervical length, cervical angle and occiput position. METHODS: The study included 275 women admitted for induction of labor. The fetal head-perineum distance was measured by transperineal ultrasound imaging as the shortest distance from the outer bony limit of the fetal skull to the skin surface of the perineum. Cervical length and angle was measured by transvaginal ultrasound examination, and fetal head position was assessed by transabdominal ultrasound imaging. The Bishop score was assessed without knowledge of ultrasound measurements. Receiver-operating characteristics (ROC) curves were used for evaluation of the probability of a successful vaginal delivery. The time from induction to delivery was tested using Cox regression analysis with ultrasound measurements, parity and body mass index (BMI) as possible predictive factors. RESULTS: Areas under the ROC curve for prediction of vaginal delivery were 62% (95% CI, 52-71%) for fetal head-perineum distance (P = 0.03), 61% (95% CI, 51-71%) for cervical length (P = 0.03), 63% (95% CI, 52-74%) for cervical angle (P = 0.02), 61% (95% CI, 52-70%) for Bishop score (P = 0.03) and 60% (95% CI, 51-69%) for BMI (P = 0.05). The Cesarean delivery rate was 22% among nulliparous and 5% among parous women (P < 0.01). Parity, fetal head-perineum distance, cervical length and cervical angle were contributing factors predicting vaginal delivery within 24 h in a Cox regression model. Occiput posterior position had no significant predictive value. CONCLUSIONS: Fetal head-perineum distance measured by transperineal ultrasound examination can predict vaginal delivery after induction of labor, with a predictive value similar to that of ultrasonographically measured cervical length and the Bishop score. However, we judge none of these methods used alone to be good enough in a clinical setting.

Three-dimensional transperineal ultrasonography of the pelvic floor: improving visualization for new clinical applications and better functional assessment.

OBJECTIVE: With increasing awareness of the scope of pelvic floor disorders has come development and introduction into clinical practice of new imaging techniques, with increasing importance of ultrasonography. Complex pelvic floor anatomy, the conceptual difficulty in the basics of some pelvic floor disorders, and the uneven standardization of ultrasonographic techniques were the impetuses of this review. The purpose of this study was to review the basic anatomy of the pelvic floor and the transperineal ultrasonographic evaluation technique and to provide an overview of the current clinical use of 3-dimensional transperineal ultrasonography in the evaluation of the anterior and posterior pelvic floor compartments. METHODS: A literature review illustrated with index cases from our center was conducted. RESULTS: Ultrasonography has been widely applied to evaluation of the anterior and posterior compartments of the pelvic floor. Three-dimensional ultrasonography has a role in improving pelvic floor assessment. CONCLUSIONS: Three-dimensional transperineal ultrasonography has been applied to evaluation of normal and pathologic pelvic floor anatomy. Practical application, through well-designed and sufficiently powered clinical studies, will establish the association between the clinical presentations of dysfunction with ultrasonographic findings.