[Cystocele and perineal ultrasound : Comparison of reliability and patient satisfaction]. / Zystozele und perinealer Ultraschall : Vergleich von Reliabilität und Patientenzufriedenheit.

BACKGROUND: Pelvic organ prolapse is a common medical finding. The use of perineal ultrasound for diagnosis of cystoceles is gaining in importance. OBJECTIVES: The purpose of this work was to test whether perineal ultrasound can be used to diagnose a cystocele before surgery and for follow-up examination. Furthermore, patient satisfaction during speculum examination and perineal ultrasound was compared. MATERIALS AND METHODS: 33 women with cystocele were examined before and after anterior colporrhaphy. Symptoms and satisfaction were documented with questionnaires. RESULTS: Ultrasound measurements of both examiners were correlated before and after colporrhaphy. Also, the degree of cystocele and ultrasound were correlated during Valsalva after surgery. There was no clear relation between typical symptoms of the cystocele and ultrasound measurements. The patient's comfort is higher during ultrasound than during speculum examination (r = 0.45; p = 0.04. t = 4,418; p < 0.01). CONCLUSION: The results of the perineal ultrasound are reproducible before and after colporrhaphy. Patients prefer ultrasound to the speculum examination. A sonographic scale of the cystocele would extend the use of perineal ultrasound.

Off-label use of misoprostol for labor induction in Germany: a national survey.

OBJECTIVE: Misoprostol is safe and effective for labor induction in viable pregnancies. Little is known about the prevalence of off-label use of misoprostol, and the reasons for using or not using misoprostol for labor induction. As such, a national survey was conducted in Germany to assess reliable data about the use of misoprostol in clinical practice. STUDY DESIGN: A prospective study was performed in 2013 using a standardized survey questionnaire. All registered departments of obstetrics and gynecology in Germany were targeted. RESULTS: Out of 783 questionnaires, 542 (69%) were returned. Three hundred and fifty-five (66%) respondents reported that they use misoprostol for labor induction in viable term pregnancies, and 183 (34%) respondents reported that they never use misoprostol for this indication. The most common reasons given for using misoprostol in labor induction were: effectiveness (40%), good patient acceptance (35%), established/well proven in clinical practice (35%) and cost-effectiveness (32%). The most common reasons given for not using misoprostol were lack of licence (off-label use, 69%) and uncertainty of the legal situation (27%). CONCLUSION: Although misoprostol is not licensed in Germany for obstetric indications, the vast majority of respondents (66%) reported that they use misoprostol for labor induction. The main reasons for not using misoprostol for labor induction in Germany are legal concerns rather than lack of scientific evidence. Cost-effective medications with evidence-based effectiveness and safety should be supported by a clear statement from national medical societies.

[Transperineal ultrasound to measure cervical length of pregnant women in general and in particular with cervical insufficiency - a comparison of transabdominal and transperineal ultrasound as alternatives to transvaginal ultrasound]. / Der transperineale Ultraschall zur Messung der Cervixlänge bei Schwangeren im Allgemeinen und im Besonderen bei Cervixinsuffizienz - Ein Vergleich des transabdominalen und transperinealen Verfahrens als Alternativen zum transvaginalen Verfahren.

PURPOSE: To investigate the feasibility of measuring cervical length by transabdominal and transperineal ultrasound as alternatives to transvaginal ultrasound. MATERIALS AND METHODS: 33 pregnant women with and 28 without cervical insufficiency at 16 to 35 weeks of gestation were examined by an experienced examiner (DEGUM II) and the cervical length was measured twice at an interval of 6 months. Comparability, reliability and comfort of the patients during the examinations were taken for statistical analysis. RESULTS: There is poor agreement between transabdominal and transvaginal ultrasound (Lin's rho = 0.578), whereas transperineal ultrasound shows high correlation (Lin's rho = 0.922) to the measurements obtained transvaginally, a preference referring to the comfort scale and good reliability (ICC = 0.949). When regarding sub-groups (pregnant women with and without cervical insufficiency), transperineal ultrasound shows better results than transabdominal ultrasound. However, small cohort sizes affect the statistical validity. CONCLUSION: Transabdominal ultrasound cannot be recommended to measure cervical length. Besides providing exact measurements, transperineal ultrasound avoids contact between the cervix and the probe, is better accepted by patients and offers a simplified examination. This method is a good alternative to transvaginal ultrasound. Due to minor inaccuracies of the method, we recommend this technique only for patients with a cervix longer than 2.5 cm. For further analysis concerning patients with cervical insufficiency, large-scale studies should be performed.

Evaluation of established and new reference lines for the standardization of transperineal ultrasound.

OBJECTIVES: To examine the performance of a new reference line for the assessment of pelvic organ descent by transperineal ultrasound. METHODS: We compared our newly proposed reference line, between two hyperechoic contours of the symphysis pubis (Line 3), with the horizontal reference line proposed by Dietz and Wilson (Line 1) and the central pubic line proposed by Schaer et al. (Line 2). Ultrasound volumes of 94 women obtained in routine clinical practice were analyzed. The perpendicular distance from the reference lines to the internal sphincter and the most dependent part of the bladder base was measured for volumes obtained at rest, on pelvic floor muscle contraction, on Valsalva maneuver and during coughing. Measurements were repeated 4 months later by the same examiner. Rates of assessment were calculated, and intrarater reliability was evaluated using Bland-Altman plots and intraclass correlation coefficients. RESULTS: Line 2 had to be excluded from reliability analysis because of an assessment rate of only 12%, whereas Lines 1 and 3 could be assessed in 100% of volumes. The intrarater repeatability of Lines 1 and 3 was shown to be very similar. CONCLUSION: In this comparison of three potential reference lines for the assessment of pelvic organ descent by transperineal ultrasound, the central pubic line was shown to be inferior owing to poor visibility in our volumes. Inter-rater reliability analysis and validation studies are required to confirm our results.

[Imaging diagnostics of the male pelvic floor]. / Bildgebende Diagnostik des männlichen Beckenbodens.

The understanding of the female pelvic floor during the last 20 years was very much influenced by the new techniques of sonographic and magnetic resonance imaging (MRI). Functional imaging of the male pelvic floor is, however, still in its infancy. In analogy to ultrasound examinations of the female pelvic floor, perineal ultrasound can be also be applied to men. The mobility of the proximal urethra, scarring of the bladder neck or implanted suburethral meshes can be easily visualized. Studies on healthy men provide information about different muscular structures during micturition. Morphology and function of the external sphincter can be visualized with transrectal or intraurethral ultrasound and also with a perineal approach. Using functional MRI the complex interactions of bladder, urethra, external sphincter and pelvic floor muscles can be evaluated. Functional MRI is so far not generally available but enables a better understanding of the function of the male pelvic floor. Imaging of the male pelvic floor makes a substantial contribution for improving surgical procedures for male incontinence in the future.

[Perineal ultrasound for diagnostics of male stress incontinence: comparative study on the application of urogynecological standards for men and women]. / Die Perinealsonographie zur Diagnostik der männlichen Belastungsinkontinenz : Eine Vergleichsstudie zur Anwendbarkeit von urogynäkologischen Standards bei Mann und Frau.

BACKGROUND: The diagnostic options for persistent urinary incontinence following prostatectomy are limited despite incidence numbers of up to 40%. Perineal ultrasound, which is already well established in urogynecology to quantify urethral mobility, can also be used for the diagnostics of incontinence in men. The present study investigated whether there is a difference in reproducibility concerning the quantification of urethral mobility between men and women. MATERIAL AND METHODS: A total of 27 men and 27 women aged 65-85 years participated in the study. All underwent perineal ultrasound examination following standardized criteria under the three conditions of rest, contraction and a Valsalva maneuvre. Ultrasound images were taken under each condition and given to two independent examiners for evaluation. For all conditions it was recorded which of the three reference points for the quantification of urethral mobility, the urethra, internal urethral meatus and the base of the urinary bladder, could be assessed. The results were compared by means of a coefficient of agreement (p0) and the difference of the results between the two groups was validated for statistical significance using Student's t-test. RESULTS: At a t-value of 1.58 (p=0.154) there were no significant differences in the reproducibility in visualizing the three sonographic reference points, the urethra, internal urethral meatus and the base of the urinary bladder, between men and women. CONCLUSIONS: Using perineal ultrasound for quantification of urethral mobility in the diagnostics of incontinence in men after prostatectomy is just as reproducible in men as in women. For both sexes the technique is comfortable and pain-free due to the non-invasive nature. Perineal ultrasound is a cheap, non-invasive and reproducible diagnostic procedure which can be recommended for the evaluation of incontinence and the selection of a suitable surgical procedure also in men.

[Using contrast inversion to extend the diagnostic value of perineal ultrasound for urethral and paraurethral pathologies]. / Die Kontrastumkehr als Methode zur Optimierung der perinealen Ultraschalldiagnostik bei urethralen und paraurethralen Pathologien.

PURPOSE: The aim of our study was to show how using contrast inversion extends the diagnostic value of perineal ultrasound, in particular with regard to paraurethral pathologies. MATERIALS AND METHODS: To assess the practical value of contrast inversion in the daily routine, 42 women with urinary incontinence underwent perineal ultrasound examination. Pictures were converted to contrast inversion and then checked for the visibility of sonographic reference points for urogynecological measurements (urethra, meatus urethrae internus, vesical base) by two independent evaluators both in B-mode and contrast inversion. Visibility was compared using a coefficient of agreement. The results were then tested for significance. In addition, in our clinical routine we detected several paraurethral pathologies (e. g. paraurethral abscess, glandula paraurethralis, urethral diverticulum), each being presented in B-mode and contrast inversion. RESULTS: There was no significant difference between contrast inversion and B-mode with regard to the reproducibility of visibility of the three sonographic reference points. Contrast inversion was superior for depicting paraurethral pathologies and postoperative anatomical findings. CONCLUSION: With respect to routine evaluation, the two modes do not reveal any significant difference. For the sonographic evaluation of paraurethral pathologies, contrast inversion provides better contour sharpness than B-mode, suggesting a higher diagnostic value for ambiguous anatomical settings. The nature of contrast inversion nevertheless facilitates misinterpretations and requires frequent comparison with B-mode pictures. In conclusion, we propose contrast inversion as an initial screen and a refinement to established diagnostic methods, such as MRI and voiding cysturethrography, not as their substitute.