PMRS webinar series. I'm Dr. Pam Fairchild. I'll be moderating today's webinar. Today's webinar is how to incorporate pelvic floor ultrasound into your practice and is presented by Dr. Abha Shabari. Dr. Shabari will present for 45 minutes. The last 15 minutes of the webinar will be dedicated to questions and answers. Please feel free to put your questions in the Q&A box below. Dr. Shabari is the Vice Chair of Gynecologic Self-Specialties and Professor of OBGYN, Medical Education and Bioengineering at Inova. Dr. Shabari attained his bachelor's degree from the University of Washington, medical degree from Tufts University and completed his residency and fellowship at Louisiana State University in New Orleans. He is the Director of the NAFC Designated National Center of Excellence, Continence Care at Inova, ICS and Iyuga Research Scholar Program, a multidisciplinary Inova-George Mason University pelvic floor investigation group. Dr. Shabari has a master's degree from the University of Washington, medical education and bioengineering and a master's degree from the University of Washington, ultrasound of pelvic floor investigation and therapeutics, UP-FIT. Finally, he has authored more than 200 articles in scientific journals and many chapters for textbooks standard to the field of gynecology, urogynecology and medical device development. Myself, I use this textbook all the time for pelvic floor ultrasound reference. The webinar has been live streamed. You can use the Q&A feature of the Zoom webinar to ask any of the questions you'd like to ask. The chat feature should be for any technological issues you have. Our OGS moderator will be monitoring that and is happy to help if you have issues. So without further ado, we'll let Dr. Shabari get started. Welcome. Thank you, Pam. And thank you, the audience for attending this webinar. I have no relevant financial relationships to disclose. This webinar is intended to assist you in understanding basic pelvic floor ultrasound instruments and really understand the ARUM parameters and indications for pelvic floor ultrasound and how to achieve ARUM accreditation of pelvic floor ultrasound in your practice. So the reason I mentioned ARUM so much is because we worked on a document, joint document for standardization of the pelvic floor ultrasound terminology that was sponsored by OGS, ACR, AU and SRU and ARUM. And we are going to go through that. It's a good document for you to refer to. We are going to really stress on why you need imaging as a urogynecologist and why we advocate ultrasound and why we advocate for you to do it the way that I'm going to talk about. Really when we talk about indications for pelvic floor ultrasound, any of the indications that you have in your chart sheet for most part pertains to performing an ultrasound. Anal incontinence, which is long established indication, obstructive defecation, voiding dysfunction, pain, dyspironia, levator and I defects, pelvic organ prolapse, perineal cysts, urethral hypermobility, incontinence, vaginal cysts and masses, levator and I muscle assessment after childbirth, obstetric perineal injury, anal sphincter injury, pelvic and vaginal pain after synthetic implants and meshes and bulking agents, vaginal discharge or bleeding after pelvic floor surgery are all indications for performing a pelvic floor ultrasound. Why do we want to use imaging at all in general? Well, because we are reconstructive surgeons. We are trying to reconstruct anatomy because we understand reconstructing anatomy would translate into better motion and function. So how can we reconstruct the anatomy if all that we are looking at is just the vaginal skin that is coming at us? We need to understand what's behind that skin and understand the pathophysiology and correct the other defects that are concomitantly present. Why do we advocate ultrasound? Well, because ultrasound just have come a long, long way. It has great image quality. It has rapidly developed. It's pretty much standard now and it's very much evidence-based. There are no contraindications except when the patients are unable to consent to the procedure and in situations that it would breach infection control protocols and guidelines, such as if the patient has an open wound or severe vaginal pain or discomfort. There are some basic structures that we want to visualize on the ultrasound that we start. When we start, the pubic symphysis, the urethra, bladder, and the vagina, and the uterus, if possible, and the anal canal and the levator plate are the main things that we'll be looking at on a 2D ultrasound, on a simple 2D ultrasound. And when we move into 3D ultrasound, we want to ascertain the integrity of the insertion of the levator and eye muscles into pubic symphysis, get the dimensions of the pelvic floor, and we may need to use more than scanning approach to achieve this end. For all these modalities, we ask the patients to use the bathroom before they go to the room, and by the time they are situated on the bed, they have enough urine in their bladder to undergo ultrasound, enough urine in their bladder to undergo ultrasound, and we just utilize the normal lithotomy position. Any gas in the lower rectum may distort the images, so having the patient use the bathroom beforehand may be very useful. In terms of terminology, we had to standardize this. The first one is perineal pelvic floor ultrasound, and we are going to go through this. This is where you get an abdominal transducer that is meant for looking at the baby, and you apply it to the perineum to look at the baby. Introidal pelvic floor ultrasound uses an endovaginal transducer that is 3D, and you put it on the vaginal introitus or vulva or perineum, and you do the same thing that you will be doing with the perineal pelvic floor ultrasound. Endovaginal ultrasound, EVUS, and endoanal ultrasound, EAUS, they use spatial endocavitory transducers that are automated to obtain 360-degree images. When we look at the different modalities that you see here, on one axis you can see that we have 2D perineal ultrasound here, and the 2D perineal ultrasound is really good at looking at pelvic organ prolapse. When you get a bit fancier and you use a 3D perineal pelvic floor ultrasound, then that can be used for urinary incontinence, bulking agents, mesh slings, et cetera, and also for anal sphincter integrity and avulsion. 3D anal and 3D vaginal ultrasound help you see all of these issues that we have talked about and really evaluate the rest of these modalities, and it would probably give you a much better resolution than using the 3D perineal ultrasound. 3D anal echodefacography is really good for visualizing interception. So perineal pelvic floor ultrasound is used with, again, this kind of transducer that you're very familiar with, and the transducer is designed to look at the abdomens. Your images that you're going to obtain are going to be upside down, as if the patient is standing on their head, which is not anatomic, but that's how the images are displayed. You would have the pubic symphysis here, urethral bladder, and the vaginal and uterus. So this is what your images would look like, again, as if the patient is standing on their head with the patient's front being here and patient's back being here. So this is the pubic symphysis here, and that is the levator plate right there. And then you have the bladder, urethra, vagina, and then the anal canal. So obviously with this kind of modality that you can see here is a 2D modality, and we use it to ask the patient to valsalva, cough, and bear down. And if you see that the bladder is coming to the introitus that would signal to you that the patient has a cystocyte, versus this is a patient here that does not have a cystocyte. There are various angles and such described that I'm not really going to go over. They're good for research purposes. Once you are done with your 2D imaging, you press on the 3D button on your machine, and that's going to obtain a 3D volume for you. With the 3D volume, you are going to obtain the minimal levator hiatus. And then with the perineal pelvic floor ultrasound terminology, when you have the three central images demonstrating defect, then you would say there is an avulsion. And again, because the perineal pelvic floor ultrasound, the transducers are meant to look at the surface. They're very good at looking at probably the puborexalis, which is the muscle that is looking right at you, but they cannot see the muscles that are behind that. You may manage to see some of them, but the clarity would be lost. You can use your transducer, just twist it a little to look at the perineal and the posterior compartment images to look at the anal sphincter. And you can see the anal sphincter here. And again, the same way, if you're seeing any defect in the anal sphincter that you see here, then you would say that there's an anal sphincter defect present. And this patient here, you can see she has normally anal sphincter, external anal sphincter. You can do the same maneuvers with a 3D endovaginal probe that you can see here. You can apply it to the vulva or perineum and then obtain exact same images that you obtained before. A lot of people like this methodology much better because the endovaginal transducers tend to be much higher resolution and better frequency for this purpose. So you get, again, the same sort of image and you're going to obtain your 3D and you're going to twist the probe to look at the perineal body and anal sphincter and you get the same sort of images as we discussed. How about endoluminal ultrasound? Why should we be using that? So we have done studies where we have shown that the endovaginal ultrasound is at least equivalent to the MRI. And here is the same patient here with an MRI and her ultrasound side-by-side. And you can see on the ultrasound, you can literally see every single muscle fiber in her levator and a muscle here. And when you cut off and look at it here, you can see all of the muscle fibers line by line very clearly. And this is not what you're seeing in the MRI image here. So we advocate endovaginal ultrasound because of high resolution, because you can do it quickly at the bedside and gets just amazing images. However, the way we do this, we use all the probes that are available to us. We use a 2D probe to obtain important information about the pelvic floor mobility. We apply the 2D probe to the vulvar area. And what we do in our terminology, we actually display our images on the screen as if the patient is standing in an anatomic position. And you have to just change the setting of your machine to look at the images this way. So again, what you have is pubic symphysis, bladder, urethra, uterus, vagina, and rectum that you'll be looking at. And we are going to go over that. So here we have a 2D transducer applied to the patient's vaginal area. And without doing anything, you can see that the patient has her bladder here right against the probe. And if you look at the pubocervical faro-muscularis, you see it ends there and it ends here. So theoretically, if you just go suture these two ends together, you have taken care of her systocele. So she does have a systocele to begin with. We know that already. But you can ask her to valsalva. And what you would see here is that as she bears down, I just froze the screen. You see now, even though her anal canal is intact, there's an interocele sliding behind her vaginal canal and coming to the opening to the probe. And here's the interocele coming here. And as she stops bearing down, the interocele sucks back up. You have your anal canal and you're back to where you started. So you could go potentially and do sacrocopal boxeondyspation and totally miss this posterior compartment defect. This is another patient. So what you see here is that she has a posterior mesh. And the people used to put these here and think that it would take care of all their problems. And you see, even though she has a piece of mesh there, she has all this stool just sitting in her vaginal, in the rectal area, pressing on the vaginal area. When we ask the same patient to bear down, you know, what happens is that she bears down and the mesh again collapses even more and all of the rectum collects in there. Incidentally, with this patient, when we examined her, she did not demonstrate a rectocele the way that you would imagine that you would see it normally. This is another patient, intact bladder, intact rectum, and she does have a prolapse coming at us, but with the content of the prolapse, we know that this is a sigmoidosyl looking at us. Once we are done with our vaginal scanning, we just use our vaginal probe and we insert the vaginal probe inside the vagina. And we tell the patient at this point that this is very different with the vaginal exams they have had before, because the probe is literally the size of your finger and you're putting it gently inside the vagina and you're not pushing it around or manipulating it in any way. Most often the patients, you know, get very bored with this because we are not moving the probe or doing anything threatening to them. But during this examination, it's very important to also to tell them, because they get nervous, please don't talk and, you know, don't move the field, so to speak. So you put the probe inside the vagina gently and you advance it until you see the vesicoureterial junction. With this probe that we use, the crystals are lined along the anterior part of the probe right here, where I'm drawing for you. And the ultrasound rays are looking straight up this way, so you're looking at the bladder. When we push the 3D button, these transducers will turn 360 degree and it's going to give you a 3D volume. But right now we are very interested in the 2D imaging of the urethra. So what we do, we are going to look at the urethra, we are going to measure the patient's urethra. If you want to look at the vascularity, we can use the Doppler function and look at that area as well. In some situations, that's very useful. And then we can look at the structures around the urethra. We have done histological comparison of the urethra to the ultrasound and really layer by layer, you would see exact same things that you would see on the ultrasound and you would see it on the histology as well. We do some functional imaging anteriorly, we press the probe posteriorly, so we are not obstructing the urethra and we ask the patient to cough. And you can see here, she's bearing down and coughing and you can see the urethra is mobile, but the continence mechanism and the muscles around it are preventing it from opening up. You can actually see urethral funneling and the length of the urethra itself give you a clue into the integrity of the urethral structures. A normal urethral would be three and a half to four centimeters and most incontinent patient would have a urethral less than three centimeters. You turn the probe at this point posteriorly, the crystals would be looking posterior and looking at posterior images and you're looking at the anorectal canal now. And again, you look at the structures here, these have been authenticated and they correlate with the histology very well. What we do, we measure the distance from the probe to the levator plate here at rest and we ask the patient to squeeze and we measure that distance as well. And this difference in the distance and the squeeze of the levator plate has been correlated very well with the pelvic floor strength. And if the patient has defecatory dysfunction, we generally ask them to bear down to look at the levator plate motion and see if there's interception or not. So this is the histology we talked about. Again, you can see layer by layer, you can see the subcutaneous and the main part of anal sphincter, the internal anal sphincter, rectovaginal septum is clearly seen in superficial transverse perineum. And as I said, you would ask the patient here to squeeze their muscles. We do dynamic imaging here, the patient is bearing down and you can see when the patient bears down, the rectum comes down and when we tell them to squeeze, then her, right here, as we tell her to squeeze, her levator plate goes up and squeezes the pelvic floor short, so to speak. So that's the dynamic imaging of the posterior compartment. At this point, we push the 3D button and as we discussed, the crystals inside the transducer, the probe are going to turn 360 degree and get you a 3D volume. You can look at the 3D volume in the conventional manner that you're used to with MRI. There is axial coronal sagittal views that you can look at. And there's a very elegant desktop software that we use to do this. But really to do this, where you're going to lose the advantage of the 3D software that you're using. And I'm going to demonstrate that for you. So with the pelvic floor muscles, you can go axially and look at these structures as if you're looking at MRI. And if you just march up, you can see the superficial transverse perinei. Right above that, you will see the puboinalis fibers here. Puboperinealis fibers come to view. And as you go further up, you would see puboperinealis and puboinalis marching up. And then eventually the puborectalis will come to view. And then as you go up, you would have the pubococcygeus and ileococcygeal fibers crawling sandwiched inside the puborectalis fibers. So to speak. And you can see all of those in axial view, just like in the MRI. But as I said, you would lose the advantage of the 3D ultrasound because the beauty of 3D ultrasound is that your muscles are not traveling up and down in axial plane. You know, they're zigzagging all over the place and you can actually change your plane to look at these muscles individually. And we are going to demonstrate that. One of the objectives is to obtain the minimal levator hiatus. And minimal levator hiatus is the smallest dimension that the baby has to go through this muscular hiatus. And we have shown in our cadaveric studies that the muscles that are most medial to the minimal levator hiatus are the pubococcygeal fibers. So it's really literally impossible to injure your puborectalis fibers without injuring your pubococcygeal fibers first. So really, because the 3D vaginal ultrasound is so precise in visualizing these problems, we don't really use the term avulsion as much as other people do. Avulsion is when the pubococcygeus and puborectalis are torn together. We precisely say, for example, pubococcygeus is injured or puborectalis is injured, or both of them are injured on right or left and how much. But we can use the term avulsion if all of these muscles were gone, but you, again, you can be much more precise. So what I wanted to show you is basically just, this is a 3D ultrasound here that, let me see, I probably need to make it a smaller, yeah. So this is a 3D volume and let's work on it together. Right off the bat, what you're going to see here is the, you're going to see the vagina here. You can see the urethra there and then the anal canal right there. First thing that you're going to see is the superficial transverse perinei going around. This is the internal anal sphincter and right around it you have your anal sphincter fibers, external anal sphincter fibers. So that you want to always make sure that you have included those structures into your 3D volume. And then what you do, you just need to march up and as you march up, you would see that your puboperinealis fibers start showing themselves here and then the puboanalis fibers are starting to show themselves here, right there. And what I was saying about losing your advantage is that I'm just looking at this at the axial view and I'm telling you what it is. In reality, I'm calling puboanalis because it starts from the pubic bone and go to the anal canal. So if I'm really interested in looking at this structure, I can actually just twist my volume and sort of go and look at all these all together. So you can see the fibers are following themselves to the pubic bone. So let me just see. Okay, so our goal is to march up and find our pubic arch first. So once, if you're looking at the minimal levator hiatus, so that's our pubic arch, you see it's coming together. And then we want to see the shortest distance between the pubic bone and the levator plate. So we need to go up and the way we really do that is that we come mid-sagittally and we look at it this way and we say okay that this is this line that I have drawn for you here already. This is the shortest distance from the pubic bone to the levator plate. Therefore, that is my minimal levator hiatus and that's where I would obtain my measurement. I'm just going to move a little because I drew it already for you. So that would be our minimal levator hiatus. The other thing that I have done for you here already, so you can see, I have drawn out your puborectalis fibers that are still existing here and I have drawn out for you the pubococcygeal fibers that are lining the minimal levator hiatus on both sides and like there. And then what we have also laterally are the your puborectalis fibers that we have outlined here. Right, so when we talk about avulsion, we can really talk about injury to these muscles, right, when they get disrupted in this area on either side or both sides. That's what you would call avulsion, but you really don't need to use that terminology, you can just say what is injured and where it is injured. So as you go up, you just need to remember your anatomy that your puborectalis, we are looking at this in axial view, your puborectalis starts disappearing and your pubococcygeus turns into more and more fibers of the ileococcygeal fibers and it just sort of continues upward. And then you can look at all this in any way you want, you can come in chronal view to look at the urethra, a very useful view, say if you're looking at the slings or such, you can go further down, go through the vaginal canal and look at the rectal canal, again very important for defecator dysfunction and so on and so forth. So a lot to look at and a lot to appreciate. If your patient has a fecal incontinence, anal sphincter injury, or you do have another reason to to image the anal canal, the next thing that you want to do, you can take the probe out and insert it gently into the rectum. It helps if you ask the patient to bear down as you're introducing the probe inside the anal canal. Again, it's the size of a finger and should not be painful if the patient says it's painful or bothersome to them, you need to stop and do not proceed. Your goal is not to hurt the patient. So we know that in endoanal ultrasound is the gold standard for imaging of the anal sphincter, and what we advocate is that when we are doing in the vaginal ultrasound, the perineal ultrasound, if we see an anal sphincter that is intact, we really don't see a need for doing endoanal imaging, but if we cannot clearly see the anal sphincter on the endovaginal imaging or perineal imaging, we think we are obligated to do an endoanal imaging. Let me, okay. So one important thing is that you need to have a permanent recorder for examination and your interpretation. You need to, anytime you are doing vaginal ultrasound, anal ultrasound, you need to insert those images in your files, in your electronic medical records, and you need to create an official interpretation of your ultrasound findings in order to be paid for your work. And we went through this already, why this is important. The equipment that we use is a 2D perineal ultrasound probe and a 3D pelvic floor probe that has a high frequency and high resolution. When you compare the pelvic floor probe to the old long endoanal probe for endoanal imaging, you see that we get the exact same images with both of the probes. The pelvic floor probe actually changes the image to look more like MRI-ish, you know, it has better resolution and easier to see the structures with it. And we are going to go over that. So one thing I'm going to do for you is that, let me see if I can find it. So we are going to open a 3D file. So this is what your files look like. And I think this is your, the, for the same patient that we just saw. This is her anal ultrasound. So you see the bar down there is opening. That's because I have a thousand applications open on my computer. It generally is much faster. So this is what you get. You are not seeing much, but you can adjust the color and the density right here so you can see better. You can see the volume, you can just turn it any way that you want. It's really intuitive and easy to use. One thing that we don't do, we don't change our specification from vaginal to anal. We use exact same dimensions and we just use that for anal imaging. If you want to, you can use different colors to view it, but we just normally just use the normal white. So as we are going in here, I can zoom in for you a little so you can see better. But you can see as we go into the anal canal, the superficial part of the anal sphincter is coming to view. And this is the, the sort of the main part of the anal, external anal sphincter. You are not seeing any internal anal sphincter yet. And you can see the anal sphincter fibers just as if you're looking at a really high resolution endoanal MRI. So we go in, you can start seeing the internal anal sphincter fibers here. And then you are seeing the external anal sphincter fibers here, right. And as we go in further, the next thing that you are seeing here in your images are, are superficial transverse perinei fibers going side to side here. You see that a straight line. When I remove my color, you would see those hypoechoic areas. And then if we go in further, superficial transverse perinei sort of finishes. You can see some more fibers of it here. And as it, as it finishes, you sort of end up with the U-shaped part of the anal sphincter. So this is the incomplete part of the external anal sphincter. And if you look at this here, you would say, oh, there's a defect there. When they're in reality, there is no defect. This is anatomically supposed to be like that. So as we go in further, you see that the fibers start changing their directions. The same U fibers that are sort of hanging there are starting to sort of point upward. And you can see here, one thing I haven't pointed out to you is like here, you can actually see the vagina, the smiley face like in H format. And this is the urethra that you see there. And you're seeing the pubic bone coming to view. And the other thing that you're seeing now here is this is your levator plate, so to speak. So, so you're at the level of the levator plate here. And we are so these are the muscles that you're looking at. And then as you go further up, you're looking at the pubococcygeal fibres. If you get the same image and turn it sideways, you would see the levator plate. So obviously, you can look at the anal sphincter from side. This is a posterior compartment, the posterior part of it and anterior part of it. And again, as we are going, you can see the U part of the anal sphincter. And as we go a bit further here, this is your puborectalis fibers. And as we go a bit further here, that would be pubococcygeal and neococcygeal fibres. So cool stuff. Looking at the anal sphincter is just not looking at the anal sphincter. There is a lot more than just anal sphincter there that you need to look at. We obtain images of all the things that we have looked at. And one thing that I didn't show you is that we do obtain dynamic images. Like here, you can see basically the the transperineal image when we are asking the patient to cough and bear down. And also here you can see endovaginal ultrasound. Oops, it's not cooperating for some reason. Yeah, so here you can see endovaginal ultrasound with the levator plate and we are asking the patient to squeeze and bear down. So you can do those things as well, but I'm not going to go into it in great detail because of in the interest of time. So when we talked about documentation, this is what we took out of our documentation, out of our EMR. Basically we are looking at, we did the ultrasound for parity-related changes as the indication. We are documenting the perineal imaging and 3D endovaginal imaging. You can see we have language for sling and mesh in case the patient has it and intussusception here. The other thing we haven't talked about, we also score the levator anoid deficiency score, which is an indicator of levator atrophy. And we do indicate avulsion injury, yes and no. But really when you do the levator anoid deficiency score, you really don't need to do the avulsion because the scores will tell you all the story and we get the MLH measurement and levator plate descent angle that we didn't go through. Endoanal imaging has its own template and then we need to document if you spend time with the patient to talk to them about the findings, which you always do. You need to say that you spent 15 minutes talking to them face to face and another maybe 15 minutes that you spent performing the ultrasound in order to get paid for what you did. So sometimes if you do a GYN ultrasound at the same time, you can also document GYN ultrasound, but you cannot do it with the pelvic floor probe. But we do have ultrasound sitting side by side and sometimes we do this. In terms of payments, the payments you get paid for your endovaginal imaging and the endoanal imaging and also for 3D interpretation, you need to use the codes. For you to be certified by AIUM, there is a strict criteria where you send a basically certain number of 3D ultrasounds that you have performed. And those guidelines are on the AIUM website for under the practice parameters for performance of ultrasounds. And then you, we were the first program in the country that in the world that got certification from the AIUM in female pelvic floor imaging. So in conclusion, this has been an introductory lecture on how to incorporate ultrasound into your practice. To do this literally professionally, you need to do a lot of these. And what I would advocate for you to do is first use whatever ultrasound machine you have available to you. A 2D probe in your hand can give you a lot of information and you get used to using ultrasound. And then using your vaginal probes that are lying around your clinic may be helpful as well. Your eyes really just need to get used to all that black and white fuzzy picture that you're looking at and make sense of it. And when you get good at it, you can use the type of technology that we have shown you. One thing that I would advocate for you if you are a graduating fellow and looking at a job, it's really much easier to negotiate in the beginning that you want an ultrasound machine. And if you, and then get it in the beginning and rather than after you start, they wouldn't get it for you. But you need to do the first 30 ultrasounds that you do should be pretty much normal ultrasounds. Do not get patients with prolapse or injury or mesh and expect to see things. You really need to see normal and whatever else that after that, if you see things and you say, well, geez, I am used to seeing this structure, but it's not there now, then you know there is injury or there are issues. So these are my references. I really want to thank you for dialing in and paying attention to this very interesting lecture. Thank you. Okay. Thank you, Dr. Shaberi. We have 15 minutes for questions. You can submit your questions into the Q&A box now. And I see that one is coming in into the chat. It is, do you have any experience on visualizing somatic nerve entrapment or demonstrating the sciatic prudential tracing? Pudendal, I'm wondering? Pudendal, yeah. We have done ultrasounds and we have looked at, we have been able to visualize the sacrospinous ligament and sacrotuberous ligament and we can deduce where the pudendal nerve is. But, you know, we do not see the nerves themselves. A question that I had, you know, is when you operationalize this in your clinic, because it sounds like for your practice, you're doing this in the majority of patients. Is that correct? We, it seemed like all the patients end up getting an ultrasound sooner or later. Yeah. You know, is that, is it as like a separate visit or if you identify it at the time, is it something like, okay, I think you would benefit from this. Let's go ahead and do it. And if so, are physicians doing all of the imaging or do you have techs that are doing the images and then you're reading later? Those are very good questions. So basically, what we did was, first of all, the physicians are doing these procedures. We used to have an ultrasonographer who was very, very good, but it turned out that you really have to be a clinician and a sonographer at the same time. And it's hard to find that kind of experience. And so we went back to doing the ultrasounds ourselves and we really view it as if a cardiologist is using their stethoscope or an ophthalmologist is using their ophthalmoscope. It's just something that we have to do ourselves. And we, if I see a patient and I have time on my schedule to see them, I'm going to do the ultrasound. I'm going to do the ultrasound. If I see a patient and I have time on my schedule to see them for an ultrasound, I would do it right off the bat. We have a very good mechanism where the front staff are screening the patients while they're calling and while they're getting an appointment. If somebody is calling for, I don't know, recurring UTIs, we don't want to, quote unquote, waste a 45 minute slot for that. So what if they have issues with prolapse, mesh, postpartum issues, they are scheduled into a slot where they can get their ultrasound during the same setting. Great. So we have another Q&A question, which is, which companies produce these probes in North America? What are our options if looking at making a request to the organization or purchasing one ourselves? Yeah. So the perineal probes are your, you know, I don't want to name name of companies, but I guess I have to. But, you know, your GE, Philips, whatever, you know, the whatever machine that you're using for your imaging the baby is what you can use. If you have a GYN probe, a 3D GYN probe, definitely you can use that for in total, probably for ultrasonography. For the endovaginal ultrasonography, they are, like Hitachi has, Hitachi Aloka has an endovaginal probe that is, that is not 3D. You can create 3D with it, but it's like a manual 3D. You have to pull it back and it's not reliable because it's not automated. There are other companies, like Halo has another machine that is video based and lower, and I don't have much experience with it. But I know some people who were calling me saying they were not seeing what they needed to see. And the one that we are using, it is pretty much the standard to the industry, which is the BK Ultrason. And, you know, the, in terms of when you compare the cost of a machine that MFM uses compared to the cost of these things, it's really nothing. They're still expensive, but it is what it is. If you want quality, and if you want to see the kind of images that I have shown you, you probably want to get a better image, better. I would say too, we also use the BK at Michigan. It's a, it's a pretty nice device and worth an investment if you're going to do a lot of this ultrasound, I think. We have a couple more questions here. Oh, go ahead, Aba. No, I totally agree with you. I think it's one of those things that more you see, more you use it, more you see, and more you see, more you incorporate it into your practice where it actually changes your management of patients. Exactly. So the next question is, do you store the volumes in your medical records or just the post-processing images? And then does your ultrasound automatically upload the image to your medical record? There is that capability to, depending on your, on your system, to upload them to your EMR, depending what EMR you're using. We use it for research purposes. So we actually have a research sonographer who transfer them from the machine to our server. So all of our 3D volumes are kept on server forever and ever. And because these are actually pretty hefty 3D volumes, they occupy a lot of space. And so you need lots of space on your server. But we do include images into our EMR because, again, for billing purposes, you do need images incorporated. The next question is, is there any correlation from the pelvic floor sonogram findings with POPQ staging? Yeah, I think there is publication about that in terms of correlation and such. I, you know, you use ultrasound not to replicate your POPQ staging. You're using ultrasound to see, to look at the muscles and get additional information. So POPQ is what it is. You know, when, when the patient bears down, I can see the skin coming at me, whether it's, you know, bladder skin or rectal skin. But what I'm interested in is really not replicating my POPQ stages, but I'm interested in seeing when they bear down, is there something sneaking into that area where I thought it was bladder? Is there rectum there or interception or such? And the next question is, how successful are you in getting reimbursed for the ultrasounds? We are very successful. Otherwise, our administrator would come and ask us to stop doing it. So, yeah, we, one part of it that I should caution you about is the 3D post-processing of it. You have, that's, that can be a sticky area where some insurance companies may not cover it. We know which ones cover and which ones don't cover. For example, if you use it on a Medicaid patient, they probably are going to throw all your charges out altogether. So for those patients, I just do whatever I did, 3D vaginal, 3D anal, and sorry, endo-anal ultrasound and the vaginal ultrasound, but I won't code for a 3D. But some other ones that are more generous, we do click on the 3D rendering as well. I think to dovetail on that question, I had a question about as far as the AIUM certification, and if you think that is necessary to be performing this in your practice, I think it certainly gives you a little bit of credibility. But do you think it's necessary? Is it something that we should all be seeking out if we're doing it? And what resources does AIUM provide as far as assistance with, you know, I know for like fetal ultrasound, they have like minimum documentation standards, like this is what you need to see for this to be billed as this. And I'm wondering what resources we have for this. Yeah, they have in their document, they have made that very clear on what is that you need to get certified. And I think in places probably like yours or mine, it may not be an issue if you are doing an ultrasound. But in some places it gets very sticky and political that why are you doing ultrasound? I mean, I'm a radiologist or I'm a colorectal surgeon, and you're doing, you know, what I'm supposed to be doing, even if they don't know how to do it, quite honestly, at some point. But so sometimes the physicians really feel like they need to have this certificate to show their administration that they are allowed to do this. And this is more of an issue, you know, a lot of times in probably organizations where the urogynecologist is going into that environment as a new provider, and they haven't had that before, where, you know, colorectal surgeons and GYN and radiologists and whoever are sort of trying to make do and they have a process going and all of a sudden urogynecologist walks in and say, I can do everything and I can do the ultrasound as well. The next question we have is, what is the repeatability for assessment of the injury to the levator ani muscles? Could you repeat that? What is the repeatability for assessment of the injury? So, I think what they're asking is, you know, if you see an injury once and someone else looks at the same pelvic floor, are they going to see the same injury? So, is it consistent? Yeah, I think if I look at it and you look at it, Pam or John Delancey look at it, we see the same thing. So, I think it has to do with the operator and understanding of the anatomy, because what the ultrasound is doing, it's not really tricking you, it's just putting a very high resolution probe inside the vagina to look at all these structures. So, the anatomy is what it is. If there is injury, you see it. If there is not injury, you don't see it. Yeah, I think the challenge is learning to read grayscale, like you had said in your talk, you know, you have to look at a whole bunch of images and it starts to look not so gray anymore. Yeah, and again, it's one of those things that I know what I'm looking at. If I look at it again tomorrow, I would see the same thing. But for your eyes, it needs to get used to it and, you know, you need to become very good at it. When you get to that stage, you know, all of us are going to see the same thing. Great. Well, it looks like we've addressed all the questions. On behalf of AUGS, I'd like to thank Dr. Chaberi for this excellent talk and everyone for joining us today. Our next FPMRS webinar is going to be held on August 18th. It will also be at 7 p.m. Eastern Time and you can visit the AUGS website to sign up. And thanks everyone so much for participating today. Have a great evening. Thanks, Dr. Chaberi. Thank you so much.

pelvic floor ultrasound

medical practice

webinar

Dr. Abha Shabari

types of pelvic floor ultrasound

indications

anatomy

2D and 3D ultrasound probes

training and certification