Atlas of Pelvic Floor Ultrasound: An Illustrated Textbook for Pelvic Floor Specialists

Additionally, diastasis recti may have an impact on pelvic stabilization. In 2007, >60% of patients with diastasis recti were found to exhibit concurrent pelvic floor dysfunction (PFD) (18). In contrast, a prospective study published in 2017 revealed no association between diastasis recti and PFD (19). However, neither of these studies applied ultrasound to measure IRD, which may have led to a less precise result.

The group of PFD conditions includes defecation, urination, sexual activity disorders, POP, and pelvic cavity pain (30). Diastasis recti and PFD are both common conditions in pregnant and postnatal women. The abdominal wall muscle, pelvic fascia, and pelvic floor muscles collectively form the abdominal-pelvic cavity, which is an anatomical entity. Therefore, it is clinically imperative to examine the relationship between PFD and diastasis recti to develop clear guidelines for postpartum rehabilitation. Spitznagle et al. (18) published a retrospective study in 2007 in which only vaginal palpation was used to examine the strength of the pelvic floor muscles; they also did not use ultrasound to measure the IRD. In 2017, Bø et al. (19) conducted a prospective cohort study examining 300 postpartum women. Specifically, pelvic floor muscle strength was assessed using vaginal manometry, whereas the IRD was determined using the simple approach of palpation.

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Pelvic floor ultrasonography is a safe and convenient method that can be used to evaluate anatomical and functional changes in the pelvic floor dynamically. It has been highly recommended to assess urinary dysfunction, anal incontinence, POP, protruding vaginal mass, and chronic pelvic pressure/discomfort (30). This study used ultrasound to assess the IRD and PFD, possibly generating more accurate and objective results than those in the studies discussed above. Our results revealed that there was no clear correlation between diastasis recti and PFD in early postpartum females. Additionally, there were no significant differences in the IRD values between participants with clinical symptoms and asymptomatic ones.

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The pelvic floor is a dome-shaped muscular sheet separating the pelvic cavity above from the perineal region below. This cavity encloses the pelvic viscera - bladder, intestines, and uterus(in females).[1]

The parietal and visceral fascia is continuous where organs penetrate the pelvic floor. They thicken to form the arcus tendinous, arches of fascia running adjacent to the viscera from the pubis to the sacrum.

Perineal Body - a fibromuscular structure located between the vagina/testicles and the anus, attaching to the sides of the ischiopubis rami by the deep transverse perineal muscle. It is known as the central tendon of the pelvis because many pelvic floor structures intersect with the perineum at this structure.

If your quality of life suffers due to voiding dysfunction or pelvic pain, Casa Colina Hospital and Centers for Healthcare can help. The Voiding Dysfunction & Pelvic Pain Program combines expertise in musculoskeletal function with specialized treatments and equipment to strengthen the pelvic floor and improve pelvic alignment. We work with patients at their comfort level on these sensitive disorders, with the goal of achieving improved bowel/bladder function and decreased pain.

In the Section of Urogynecology and Reconstructive Pelvic Surgery, our physicians pioneered a number of innovative techniques for the diagnosis and treatment of urinary and fecal incontinence, pelvic organ prolapse and other pelvic floor disorders. Our department was one of the first in the country to establish a fellowship in the board approved specialty of Female Pelvic Medicine and Reconstructive surgery. This rigorous fellowship has trained many leaders in the field.

Our division specializes in minimally invasive techniques for the treatment of pelvic floor disorders, which includes urinary incontinence, accidental bowel leakage, pelvic organ prolapse (prolapsed bladder, uterus, or rectum), and pelvic floor dysfunction. For urinary incontinence, we offer the tension free vaginal tape (TVT), and transobturator (TOT) vaginal tapes, urethral bulking injections, as well as Botox bladder injections, and sacral neuromodulation for overactive bladder. To treat pelvic organ prolapse, we offer outpatient laparoscopic and robotic-assisted sacral colpopexy, vaginal reconstruction with native tissue repair or mesh implantation, and explantation of vaginal mesh. We also perform vaginal laser therapy for vaginal atrophy and for vulvar skin conditions such as lichen sclerosus.

The primary approach to a patient presenting for the first time with faecal incontinence or constipation with difficult defecation should be to exclude serious underlying pathology (such as colorectal malignancy and IBD)8. In patients with symptoms refractory to first-line therapies such as lifestyle modification and optimization of stool consistency, it is justifiable to proceed with evaluation of anorectal structure, motor and sensory function9,10. The selection of appropriate investigations is often guided by the clinical history and examination. Such an evaluation should focus on determining the duration, type and severity of the patient's symptoms as well as identification of risk factors for symptom onset11. Epidemiological studies have identified a number of such risk factors, including increasing age, elevated BMI and presence of diarrhoea12,13. In women, obstetric injury is particularly relevant14,15,16 owing to the risk of damage to the pelvic floor, anal sphincters and pudendal nerves during the second stage of labour17,18. In men, iatrogenic injury to the sphincter complex secondary to anal surgery is a factor in up to 59% presenting for assessment19, and coexistent benign perianal disease (such as haemorrhoids, fistula-in-ano and radiation proctitis) is also common20. In all patients, particular attention should be paid towards symptoms of other anorectal complaints (for example, faecal incontinence in a patient presenting with constipation) as data increasingly suggest that both faecal incontinence and evacuation disorders commonly coexist21. Also, anorectal evaluation begins with a carefully performed digital rectal examination that can reveal several abnormalities, including dyssynergia, weak anal sphincters, sphincter defects and faecal impaction15,22.

The IAPWG steering committee (E.V.C., S.M.S., H.H., M.F. and S.S.R.) was appointed by the International Working Group for Disorders of Gastrointestinal Motility and Function. Under the guidance of the steering committee, the authors performed focused literature reviews in the following areas: anorectal manometry (ARM), anorectal neurophysiology, endoanal ultrasonography, pelvic floor ultrasonography, rectal sensory testing, balloon expulsion and defecography. Consensus was achieved through careful evaluation and discussion of available literature as well as expert agreement when recommendations lacked supporting evidence.

Study performance. Although not expected to be fully diagnostic, a digital rectal examination should be performed before intubation to provide an overview of anorectal and pelvic floor structure and function to exclude faecal loading, stricture, bleeding and pain. Checking a patient's understanding of instructions such as 'squeeze' and 'push' is also helpful. Studies are typically performed in the left lateral position, and any lubricant to aid probe placement should be non-anaesthetising. The probe is then positioned ensuring that the sensors span the distal rectum to beyond the anal verge. Both conventional and high-resolution techniques can use either water-perfused or solid-state technology for data collection, and detailed description of hardware and software setup and catheter design is described elsewhere35.

Clinical utility. A number of contemporary and historical studies have demonstrated differences in manometric findings between healthy volunteer and patient groups. Several clinically relevant features have been observed. Sphincter hypotonia (low anal resting pressure), although of low sensitivity, is associated with passive faecal incontinence44,45,46,47,48,49 (Fig. 2a), whereas sphincter hypertonia (high anal resting pressure) can be a feature of anal fissure50,51,52 or constipation53. Sphincter hypocontractility (impaired ability to voluntarily contract the anal sphincter) is associated with faecal incontinence, particularly faecal urgency45,54, and poor propulsion (impaired rectal force during push), dyssynergia (paradoxical anal sphincter contraction during push) (Fig. 2b) and pelvic floor akinesia (failure of movement of the pelvic floor)55,56,57 have been noted in patients with evacuatory dysfunction. An absent rectoanal inhibitory reflex is classically seen in Hirschsprung disease58; however, abnormal responses can also be observed in patients with faecal incontinence59 and constipation60 and after anorectal surgery61. 2ff7e9595c