Welcome to today's AUGS webinar. I am Colleen McDermott, the moderator for today's session. Before we begin, I would like to share that we will be taking questions at the end of the webinar, but you can submit them at any time by typing them into the question box on the left-hand side of the event window. Today's webinar is entitled Essentials of Pelvic Floor Ultrasound in Pelvic Floor Disorders, presented by Dr. Milena Weinstein and Lieshan Quiroz. Dr. Weinstein will be starting off. She is an assistant professor at Harvard Medical School and board certified in both OB-GYN and FPMRS. Dr. Weinstein earned her medical degree from the University of California Los Angeles David Geffen School of Medicine, where she stayed for her OB-GYN residency. She completed her FPMRS fellowship at the University of California San Diego School of Medicine. She is currently and attending at Massachusetts General Hospital, where she is the program director for the FPMRS fellowship program, research director, and co-chair of Pelvic Floor Disorder Center. Thank you, Dr. Weinstein. Please start us off. Good evening, everybody, and thank you for tuning in. I'm excited to talk about the pelvic floor ultrasound tonight. So, what I'd like to do is cover some of the basics of the pelvic floor ultrasound indications in the parameters that are developed by, well, the American Institute of Ultrasound of Medicine is working on right now, and I will cover only a non-luminal ultrasound of pteroidal and perineal, and we'll also talk about assessments of different parts of the pelvic floor. So, without further ado, I do believe that, you know, the reason why ultrasound is important is that pelvic floor disorders are really, have really varied manifestations, and it is important to have this multimodal approach to diagnostics and treatment, and ultrasound, it's sort of obvious, provides a tool that doesn't have any radiation, it's pretty accessible to many providers, and it does create a three-dimensional ability to visualize this 3D structures in the pelvis. Recently, I was privileged to be a part of a very, very interesting group of people who were working with American Institute of Ultrasound of Medicine developing these parameters for pelvic floor ultrasound, which is exciting because it's been used for a long time, but there hasn't really been any sort of standardization to how this is done. So, these parameters are not quite ready for prime time, but they're going through enough development stages that some of these things I'm going to show are actually part of this group development, and the first thing is, obviously, talking about the clinical indications. I grouped these into different categories, which you can see here. So, obviously, we can use the ultrasound to assess different parts of the pelvic floor, different signs and symptoms, as well as some of the specific situations that have to do with assessing postpartum pelvic floor muscles, injury related to postpartum condition, as well as post-surgical assessments, including, of course, assessment of synthetic implants and some other symptoms related to potential post-surgical complications. So, how do we do this? So, let's kind of dive in and talk about the two different modalities that I will cover, which is perineal ultrasound and entroid ultrasound. So, perineal ultrasound is ultrasound that is done using an abdominal transducer, and that is placed on the perineum, and it can be placed on perineum as well as the labia and the introitus. And the real difference between perineal and entroid ultrasound is that entroidal ultrasound uses an endovaginal transducer that's placed at the introitus, but also can be placed on perineum and on the labia to visualize the structures that are needed. And we're going to start off talking about visualizing some pelvic floor structures of the pelvic floor hiatus. And for this, we use, in a case of a perineal ultrasound, the abdominal probe is oriented transversely, and it's placed on the perineum sort of facing essentially cranially towards the patient's head. And similar things can be done with an endovaginal probe, again placing it on perineum and orienting towards the cranially. I will mainly though show the images of the entroidal ultrasound, so that's the technique that I use, but I will also include some perineal ultrasound images. So, let's see if some of this animation works. So, when we place the ultrasound transducer and image the pelvic floor hiatus, what we see is sort of this essential first picture, which we're going to discuss in the next few slides, is visualization of the hiatal structure. So, this is essentially a mid-sagittal view. And to orient you, what I have here is, and the top panel is essentially the anatomy slide that I downloaded off the web, and turn it upside down. And the reason I did that is because when we use the ultrasound at the perineum or entroidus, what we see really is this upside down view. And what we have here is anatomy showing the pubic symphysis. We can see the urethra and the bladder. This patient has a pretty empty bladder, so we can barely see it. We can see the vagina and the cervix. We can also see the anus and the rectum. And then we see the anorectal angle formed by the pelvic floor muscles. So, this is sort of the orientation of mid-sagittal view. I do think that the most exciting thing, though, about three-dimensional ultrasound and visualization of all the pelvic floor structures in 3D is actually seeing a transverse view. So, before we go into the transverse view, I just want to show the anatomy here. And this is the picture from essentially looking inside the pelvis. But the transverse view, which is also called an axial view, is as though it would cut the patient straight through. So, that anatomy can be also seen on the 3D ultrasound. And the way we do this is starting with the mid-sagittal view, which again shows the urethra and the bladder, the vagina, the anal canal. And three-dimensional imaging lets us look kind of through that image. So, if I connect the ultrasound, if I connect the pelvic symphysis to the anorectal angle here, the picture that will appear on ultrasound would look like this. And that is the axial transverse view. And to get oriented, again, there's a pubic synthesis at the top, the cross-section of the urethra, the cross-section of the vagina, which actually has this very characteristic butterfly shape, or some people call it a smiley face, and the cross-section of the anal canal. And these structures are surrounded by the levator ani muscles, which is sort of the exciting part about seeing this transverse view. So, to get even more detailed into how this ultrasound is visualized, when we take the ultrasound, when we do the imaging, we have this sort of orientation of all these planes. So, all these planes, and so the mid-sagittal plane we've already seen before, the axial plane we've already seen before. So, mid-sagittal is cutting kind of through the middle, kind of right-to-left, and axial view cutting kind of straight across. The coronal view is actually essentially the third dimension to this. And in this particular picture, there's actually not a lot of anatomy seen on the coronal view. But to kind of understand what's happening in these images, is these images are all connected to each other. And what connects them is this spot, which is called a dot marker. So, that's the same spot in all those images, and they're in 3D orientation to each other. And again, I'm going to orient it to the anatomy, the pubic symphysis, the urethra, the bladder, the vatina, and then the anorectum. So, in order for me to actually see better that three-dimensional anatomy, what I can do here is take this sort of what we call a thick slice, which is essentially integrated view through what's called an area of interest. And this area of interest is also called plane of minimal dimensions, and that's kind of the smallest dimension between the pubic symphysis and an anorectal angle. And that's where, well, at least the pubertalis, but some of the levator anti-muscles can be seen. And when I do that, I see a sort of what's called a rendered image, and that's an integrated image. And again, the same anatomy can be seen, and then we can see much more defined levator anti-muscles here. Why is it important? Well, there are a lot of interesting literature that's come out in the last decade or so that talks about injury to the levator anti-muscles. And I like this computer modeling and this schematics that shows one of the potential mechanisms of injury, which is considered the primary mechanism, is the avulsion of the muscle. So, essentially, these levator anti-muscles can get avulsed off their attachment points. And what that can look like when we look at it on the ultrasound is it can look like the muscle is completely, well, the whole hiatus, I should say, completely asymmetric, the muscle gets thinned out. And in this particular example, when the patient performs a straining maneuver, there's even more distortion of that hiatus to that one side, which is shown with those arrows. I have a couple more examples of sort of the same concept, again, showing some normal anatomy with the, each of these images is obviously separate women, but these women have absolutely normal looking hiatus and levator anti-muscles. And there are examples of women who have a lot of trauma along both of their muscles and a lot of asymmetry and what also some people call ballooning of the levator hiatal muscles, which can be seen on those images with blue arrows. So, kind of shifting gears a little bit, since I started talking about dynamic images, one of the other parameters that the American Institute of Ultrasound Medicine mentioned here is that there is a lot of interesting potential things that can be done with ultrasound using dynamic images. So, I'm showing an example of somebody who is, again, imaging of the mid-sagittal plane, and we've already been oriented to this where we can see the bladder, the urethra, and the anorectum. And then this same patient, when she strains, we can see that there's quite a bit of sort of shift in the anterior vagina and the bladder, showing the prolapse in the systocele. There is also funneling of the urethra and almost rotation of the urethra, and that's shown with a star. So, another example of this can be seen in, and by the way, this also patient has some descent of her cervix as well. So, another example of this is seen in this patient who is also straining, and here we can see both descent of the anterior vaginal wall, the systocele, as well as the descent of the rectal impula, i.e. the rectocele. Now, is there a way to actually quantify and measure this? There is a system that's been described to sort of describe how we can quantify these measurements. It's not sort of quite well finalized in terms of how well it correlates with our clinical assessment, but the system implies that what we want to do is draw a line through the inferior portion of the pubic symphysis and then look at and draw perpendicular lines to each of the structures that are shown here to be descending, and here the C stands for the systocele, and then these are uterine prolapse, as well as the rectal impula plyarops, or rectocele. So, I'm going to shift gears and talk about the next parameter, which is evaluation of the anorectum, and the way this is done is a little bit different. So, using the same transducers for perineal and entroital, but the orientation has to be different since we want to orient the transducers actually towards the anal canal. So, when we do that for the perineal ultrasound, we can see that there is, we can actually get this three-dimensional image with cross section of the anorectum, and we can actually create this multi-slice image, which slices the anorectum throughout, and similarly, we can do the same thing using the entroital ultrasound. So, let's look at it a little bit closer. So, I show some normal anatomy here, and this is a patient who, or a woman, who has had this imaging done. So, you can see the distal anal canal, which essentially starts showing disappearance of the internal anal sphincter. Internal anal sphincter is shown as a kind of a darker circle, the inner darker circle. The outside, kind of more mixed, kind of white and gray, mixed heterogenic kind of looking sphincter, that's the external sphincter. And when we kind of look along the cross section of the anal canal and come to the proximal anal canal, we can actually start seeing the puborectalis muscle as the anterior portion of the internal anal sphincter disappears. And that's a pretty normal anatomy as we expect to see this. The nice thing about it is the imaging that's done with placing the probe perineally can actually show definition of the sphincter without sort of introducing an interluminal ultrasound. And one of those potential definitions is actually definition of the inside of the anal canal and the anal mucosa as well. So, I'm going to shift gears and just bring up a couple examples of the potential pathology that can be seen here or rather sort of clinical use of the ultrasound. So, we do use ultrasound in many different ways and one of them is to visualize the surgical implants. So, I have examples of the surgical implants here with the slings. And the cool thing about the ultrasound is the slings are very hyper-echoic. So, they're very bright on the imaging and they can be seen with the arrows here. So, on the retropubic, we can see the retropubic sling that actually is a very normal positioning of a retropubic sling around the urethra. And on the trans-optorotis sling, this patient happens to have a little asymmetry to that, but that is also the positioning we can see around the urethra. And using this technique, we can also assess the positioning, the symmetry, as well as location along the urethra. My other example of sort of a clinical use of an ultrasound is looking at the even cooler anatomy here. This is the patient with a urethral diverticulum. So, let's kind of try to get oriented here so we can see the sort of this urethral diverticulum is shown in 3D in each of those images. So, there's the mid-sagittal view of a diverticulum and we can actually see the urethra and the bladder. And coronal view, we essentially see a cross-section of this from a perpendicular view. And when we look at the axial view, we see some more interesting things come up here. So, this patient has some stones in her diverticulum and they appear this really cool bright structures. As well as we can see actually a connection between the diverticulum itself and the urethra. So, that's another really interesting way we can use this ultrasound. And when the American Institute of Ultrasound Medicine described the parameters, there's certainly some situations for which we use this for patients depending on what the symptoms are. And obviously, what we see is the pathology. So, to summarize what we covered so far is we talked about the difference between the perineal and entroital ultrasound and some of the indications. And we reviewed the outline of the parameters that are created by American Ultrasound Medicine, by the way, in collaboration with some of the national international societies. Namely, the principles of the pelvic floor imaging using three-dimensional imaging as well as evaluating the anorectum and evaluating the dynamic assessment. I thank you for your time and if you have any questions, I think we're going to say those to the end and you can put them in a question box for the moderator for later. Thank you, Dr. Weinstein, that was excellent. And again, if anybody has any questions, please type them in now so we can address them at the end of the session. So, now we are going to turn over to Dr. Lishen Quiroz. She is an associate professor at the University of Oklahoma Health Sciences and is board certified in Obstetrics and Gynecology and FPMRS. She earned her undergraduate degree at Brown University and received her Doctor of Medicine from the University of Southern California Keck School of Medicine. She completed her postgraduate training in Obstetrics and Gynecology at the University of Miami Jackson Memorial Hospital and a fellowship in FPMRS at the John Hopkins University. She is currently fellowship director and chief of the division of FPMRS at the University of Oklahoma Health Sciences. Thank you, Dr. Quiroz. Hello, everyone. Good evening and thank you for tuning in to this ultrasound webinar. I am going to try to take over this next set of slides over here and I have no disclosures that are relevant. So, the objectives for the second half of this talk will be to review the clinical indications for this what we're calling multi-compartmental pelvic floor ultrasound and that is in line with the AIUM parameters that will eventually be distributed once the document is finalized. We're also going to review the technique, equipment, and 3D post-processing of some of these images. The 3D post-processing specifically can be a very important advantage of this kind of technology but it can also be something that is highly independent on the operator. We're also going to go over some case scenarios to show you some cool pictures. So, in talking about our objectives, we need to talk and discuss why imaging, why ultrasound, and how does it help. And the more that we think about some of the indications, the longer this list becomes. I feel like it's a very useful tool. It's going to provide us another way of addressing or examining questions which don't yet have a very good answer within pelvic floor disorders. The more that you use this tool, the more that you'll find uses for it, and the more that you'll see that it's something that can be easily incorporated into clinical practice. And so, advantages to ultrasound, as Dr. Weinstein included, will include the absence of ionizing radiation, its relative ease of use, minimal discomfort to the patient, cost-effectiveness, and relative short time required to be able to acquire it. It's got wide availability and the availability to perform 3D and 4D assessments. So, in going forward with a multi-compartmental approach, we're first going to talk about performing a 2D standard maneuver using a concave probe to perform the 3D, the initial 2D imaging. So, this is going to be standard maneuvers of squeeze and valsalva performed. Subsequent to that, a 3D volume acquisition is used by placing an endovaginal probe in the vaginal area. So, this is done in order to obtain then a 3D cue that will then be acquired, and the 3D post-processing will take place on a laptop or desktop using the proprietary software. The patient is usually in the dorsal lithotomy position, and the probe is placed in a neutral position in the pelvis. Lastly, we have the placement of an endoanal probe, which will also be used for volume acquisition of anal sphincter complex if the anal rectal or colorectal symptoms are present. So, moving on to 3D ultrasound, it's important to remember that all of the three, you know, different compartments of the pelvic floor, and I would like to thank Dr. Chauvery for sharing some of these slides originally with me from some of his anatomy studies. Really, when we talk about the different areas of the compartment, we're talking about really anteriorly, we have basically a room of the bladder outlet, and we have the urethra and periurethral structures. Then you have the vaginal canal, and laterally you have the borders of the levator and eye muscles, and anteriorly and posteriorly, the fibromuscular layers, and then lastly, the anal canal. And so, as we've gone forward in trying to validate what we see and to understand the complexity of all of these different compartments, we note that from the different histological and anatomical dissection studies, that we've been able to then validate our visualization of these different structures using 3D ultrasound. And so, I'm going to be using some of the different nomenclature that we use when we talk about 3D ultrasound, and at the end of obtaining your 3D ultrasound, your endocarpitary ultrasound, you're going to end up with a 3D cube, and then you're ready for your 3D post-processing. I'm going to be using terms such as axial, and that'll include basically this kind of view, and when we talk about an axial view, we're just talking about this kind of plane. Next, we're going to also talk about a sagittal view, which is basically a side-wave view, and you're going to hear terms such as coronal view, which means that we're looking basically from above. I wanted to quickly give you a reference as to what we mean with these kinds of different nomenclatures. These are some pictures of the different probes that we utilize in some of the 3D ultrasound and the luminary ultrasound, and some of the probes that are coming up are going to be slightly differently named, but I wanted to provide some of these for you for your reference. So really, this multi-compartmental scanning takes about five minutes to do, starting out, as we said, with first the transperineal 2D functional imaging, then the endovaginal 360 imaging, and lastly, endoanal 360 imaging, if appropriate. So starting up with the transperineal exam, this is going to slightly differ from some of the images that Dr. Weinstein showed you earlier, in that you just need to turn these images upside down a second. To reorient you, what you see here in the anterior part is going to be basically the pubic symphysis, the bladder, and the vaginal canal over here, and then over here on the left, you have the posterior area with the rectum. And so by placing the endocarpitary probe, you actually end up with a 3D image that will end up giving you a 3D cube, and what I'm showing you over here is just to start orienting you, is that anteriorly, you're going to have the pubic symphysis. Over here, you're going to have the area of the urethra. The probe is located in the vagina, so that's where you have this perfectly round circle over here, and that's why I've labeled it V. Posteriorly, you're going to have the rectal canal. Now, whenever these were being validated initially, and we were starting to use some of these different technologies, our group validated the visualization of the levator and anus muscle divisions. We were able to confirm that we were seeing, what we were seeing, by first performing these ultrasounds in the liparous patients, then in fresh frozen cadavers, and then the muscles were then tagged, and they were allowed for the muscles to then be dissected out. And we then were able to describe, in a really elegant study, to allow us to visualize in great detail of the levator ani muscles that had only been previously visualized in that greater detail by Dr. Delancey and his group in Michigan. So, other aspects were to establish the different parameters and the measurements in normal patients outside of pathologic, outside of pathology and pelvic floor disorders. And so, we started to ask different questions, such as this age of visualize, does age alone affect the visualization of the levator ani muscles? And the answer to that was that it did not, which was consistent with what was seen in MRI studies. Then the next step was to then talk about how we can use and actually start rating the degrees of levator ani defects or damage that can happen after a childbirth. So, this is an example of an axial view of an ultrasound image. What you see is the pubic symphysis labeled anteriorly. Then subsequently, underneath, you have the urethra over here. Then we have the vaginal probe. And what you see on the right are basically the levator ani muscle subdivisions labeled for you. This shows an example of a normal levator ani muscle. And you see that this is a fairly symmetric scan. What you'll see in the following slide is a levator ani muscle defect being shown. And one of the, even without great knowledge of how to, how this is described or rated, you already begin to see that there is a lack of symmetry on one side versus the other. The next step was to establish whether this kind of rating and levator ani deficiency score correlates with pathology. And we were able to also, to be able to correlate pretty well that the severity score did correlate with a greater severity of prolapse. Of course, the next step after that was also to add and to be able to describe in detail the structures of the anterior and posterior compartments. Again, to establish being able to visualize those structures in normal women, as well as being able to, you know, visualize different areas, different areas that were then we could describe in different pathologic pelvic floor disorders. So, to orient you one more time, we are now looking at a sagittal view. And what we see here is it's labeled for you bladder. This whole area that I'm pointing out to over here is the urethra. Then we have the probe is in the middle. We have the rectum posteriorly. And lastly, underneath here, this is highlighting the levator plate. What I'm pointing out to you right there is a cross section basically of a form material. And in this case, it was two separate sling sections that were being identified in this patient. So, the identification of synthetics, as Dr. Weinstein also spoke about, is one of the great advantages of this kind of technology. So, we've been able to talk about how this, the patterns, for example, of some of these, some of these mesh synthetics can correlate with, basically, and be associated with symptoms. So, that's been something that was also recently published. So, in really, in essence, everyone wants to know how is this going to help me clinically? I know that we have great studies and we continue to use it, and we continue to find very creative ways of asking questions, but how is this going to help you? So, there are many questions that we all have. Is there a sling or mesh? Is there a foreign body? The symptoms are not correlating with the exam. This is something that happens quite often. There's remaining pain post-mesh removal, or there's a bulge. Is it a cyst or a mass? Are we talking about a combination of different bulges? Or we need additional imaging secondary to what we know, right, whether it's fecal incontinence or obstructive defecation. Or there's some asymmetry to the entrance of the vagina. Are we talking about her having spasm on one side, or are we talking about a levator A9 damage? So, those are all, you know, the more we sit down and talk about these questions, the more questions we come up with. And so, this is an example of a bulge that's present in someone that has previously had a Laforte coprocliasis, for example. So, as you can imagine, this is the kind of situation in which we need all the help we can get when examination itself has, you know, limitations. So, this kind of technology can help us provide answers to questions. It can help provide location of the foreign body. It can help give you an idea whether there's anything remaining or any calcifications that can be actually guiding you towards some answers as to why there's remaining pain or discomfort. Sometimes there are women that have a history of some kind of quote-unquote bladder lift. There is no operative report present, and you just don't know exactly what was done. And this actually can help you give you some answers. There's, as we said, sometimes prolapse that can be a lot more complex than meets the eye. Definitely, with cysts, masses, characteristics, and real-time localization, these can be actually done in the operating room, and needle localization can actually be utilized in order to be able to locate the specific area of dissection. And so, the next step that I'm going to go over into a little bit of detail with you all is about the 3D manipulation. And so, the next step that I have for you right here is, and I don't know, I think something just moved. Okay, here we go. So now, I'm actually manipulating this view, and what you can see over here is that I'm going into the actual 3D cube in an axial view. So, I'm pointing out where the probe is, and then as we go on in, then we begin to see those familiar structures that I pointed out earlier. I'm pointing out to the urethra and the pubic symphysis, and we are able to go in and out and actually delineate the different structures that we've been talking about. Laterally, as you can see right here, is basically the levator and eye muscle, okay? What the pointer is leading towards right now is also the clear visualization of a sling. We're going to turn this cube now and go to the sagittal image, and we're going to slowly go in sagittally, and this is an example of the beautifully detailed anatomy you can see of these insertion of the levator and eye muscles that I pointed out as we were going in. So laterally, now we have a clear view of the bladder and the urethra, and what we are going to do is to be able to specifically measure the length of the urethra, so in this case, the urethra is 43.8 millimeters, and we're locating that first sling at 26.4 millimeters distal to the urethral vesicle junction, so we're able to give you that amount of detail in that measurement. If you are unsure as to what exactly it is that you're measuring, you can actually turn it around and see that, indeed, that area does correlate with what you were visualizing as that sling that we were trying to get a clearer view at. Now you can go ahead and extend it, extend that cube again, and then you can rotate that around, and by going and going in from the top, extending that whole view, you can then go in and get that coronal view that we were mentioning earlier, so you can also have another view of whether that is associated with any asymmetry or whether you were concerned of having additional areas that you wanted a closer look to. Now you have this 3D cube, and this is part of what this 3D post-processing can allow you to do. So now that we have all of this information under our belt, I wanted to review a couple of cases from actual clinical practice. So first, we have a 62-year-old who was scheduled to undergo a robotic hysterectomy with a GYN oncology service. She endorsed a history of prior possible mesh placement, and she had some frequency urgency, and I was asked, since she was kind of urgently taken to the operating room, whether I would do anything for her, any evaluation-wise, and I think what I mentioned at that point is that the least that I would do is a cystoscopy, giving her history of mesh, and previously, having had that history with her irritated voiding symptoms. So on cystoscopy, what we saw was basically this mesh erosion, or actually this exposure in the erosion in the bladder. Now once we were able to, there was some difficulty obtaining greater detail as to what she had done, and the next thing that we did, of course, after she, you know, healed from her GYN oncology surgery was to then get a 3D ultrasound. Now to orient you, we are looking at the sagittal view, and what we see on here is that we have the bladder, probe, and the rectum, then we have visualized a foreign body right there, and then we also see another foreign body right there, and so she actually had a combination of both, a sling and a mesh kit. Now it's important for us to know that in the absence of operative reports, we need to kind of sort this out. We need to figure out whether that mesh that we saw in the bladder is from a, it was coming from a sling or from the mesh kit, and what we saw was that upon further manipulation of the cube, you can kind of see that the actual arm that was in the bladder is also visualized on the ultrasound. So going back, what we see is that we have this anterior vaginal mesh kit being done, and we actually see that arm in the bladder. Okay, this is an oblique view of that, and you can clearly see that there's continuity between that mesh and whatever, you know, the rest of the mesh that's in the bladder. So the second case, I'll briefly go over with you, is a 45-year-old with a history of a sling removal, and now this was done at an outside or out-of-state clinic. Now she presents with a history of severe inguinal and vaginal pain. Now she has been in six months of physical therapy and is failing any other kind of management. An ultrasound then reveals that although she does have a history of a sling revision, she has still a left arm of that sling in place, and actually palpation of that area did correlate with where the tenderness was coming from. What I showed previously was the axial view, and what I'll show you right now is the sagittal view of that same kind of synthetic material, and really, synthetic material cannot hide from this kind of technology. It's been very interesting to continue to utilize it in this age just because it's been such a useful tool. So lastly, I'll talk about basically endoanal ultrasound and imaging, and I'll quickly share with you the history of this 44-year-old with a history of fecal incontinence with well-formed stools, history of forceps seven years ago, has really undergone physical therapy, biofeedback, stool bulking, and overall has poor tone on exam. Let's take a step back and talk about how you would do an endoanal ultrasound, and what I mentioned to you earlier is that this is basically what we would do and continues to be the gold standard for evaluation of the enol rectal canal. Now, whenever this is placed in, it's placed in about anywhere from about four to six centimeters in, but what I want to display to you is that what you're going to see over here on this initial level one mentioned over here really is the higher limit, the upper limit of where you are, your area of interest. The puborectalis muscle that's visualized on these images over here is your upper margin, and any areas that are of interest, such as the anal sphincter complex, are going to be distal to the visualization of this muscle right here. Now, what you will visualize on these two, specifically level two, which is coming back at about this area right here, is that you're going to visualize this external anal sphincter ring being shown as a hyperechoic ring and a hypoechoic ring of the internal anal sphincter in continuity, okay? Lastly, you're going to still be able to see some external anal sphincter as you continue to go and withdraw the probe or actually move on to the images that are closer to the entrance of the interrectal canal. What you'll get to see in this image is, and remember, from the get-go, this image is in the endorectal, it's an endoanal ultrasound. You do not see the pubic symphysis or urethra. You only see one image right now, and you're only seeing the endoanal canal. What I want to orient you to is that the probe is visible in the center, and what you then see is a continuous hypoechoic ring going all around the probe, followed by an external anal sphincter defect visualized just right there. I want you to go back a couple of times now that you can train your eyes. I want you to then squint a little bit and hone in how you can visualize that clearly, and then you can evaluate and visualize this external anal sphincter defect. Lastly, I was hoping to do this for you real quick, which is also this visualization of these different images of the 3D cube with the endoanal imaging. What you'll tend to see up higher above is this puberectalis muscle, and we are looking at an axial view. The puberectalis muscle is clearly visualized from side to side. Then we are coming more distally, and that is when you'll begin to see that formation and the lack of continuity in that hypoechoic image, okay? So, there is an external anal sphincter defect present here. You are able to measure the degree of that, I mean, how big that is by measuring an angle of view over here. And from quickly visualizing that, you can see that the angle of that degree is from approximately about the 11 o'clock to 2 o'clock position, going along with about a 60-degree view. Remember that you can turn this around, and you can actually confirm where you are, go anteriorly, posteriorly. And now you're going down into the coronal view of this image, and in that way, you're able to see the continuity of the muscle. And in instances in which a patient has had either anal bulking or an anal sling, you'll be able to visualize that quite clearly as well. So, in summary, the clinical use can vary and we'll continue to expand that list as we continue to do more exciting research and utilize this technique. The high resolution and pre- and postoperative assessment of pelvic floor disorders is going to be something that we need to continue to address and study. It's an excellent tool for visualization of the patient's condition. It's a great tool for visualization of pathology, especially secondary to pelvic floor disorders that are not clearly delineated. And as far as slings and anterior and posterior meshes, they are clearly visualized with ultrasounds. It's very useful for visualization of collections, abscesses, hematomas, fistulas, and we will continue to do more studies to talk about the impact of the clinical use with lavator NI imaging. I want you all to know that I also placed here my email account, and I want to make sure that you will realize that I will be available for any additional questions, either now or feel free to email me. I will also be at Augsburg in Chicago. Thank you. Thank you, Dr. Quiroz. That was a very interesting talk and amazing images. We now have a few minutes for questions. So once again, you can submit your questions in the questions box on the left-hand side of the window. We've already got a few questions up. So we'll start off. Two people have asked what machine you are both using for your ultrasound. So this is Leishen Quiroz. So I am using the BK, one of the BK machines. So I think that currently there is, you know, the Profocus and Ultrafocus. Those are the two of the ones that are most commonly used. So it's the BK machine that I'm currently using for my imaging. Elena? Yes, and I use the GE equipment platform with an endovaginal transducer, which has 3D capabilities as well. Yeah. And that might lead us into the next question, which was how do you make a decision to perform transperineal versus intravaginal ultrasound? And do you think one is better over the other for particular indications? So I can answer my version of that as well. So, you know, I think that in my training and what we've done so far has always been to always do the 2D dynamic assessment because with endoluminal ultrasound, you can be limited by the probe if you are trying to evaluate the dynamic maneuver of the pelvic floor. So the first step for using this kind of approach for the multi-compartmental approach really is to start with a 2D dynamic approach. That is putting a probe on the introitus and then assessing for, you know, squeeze and passava and evaluating the movement of the pelvic floor. That's always followed by some kind of endoluminal assessment. So in my experience and the kind of approach that I do, then I always do both. Yeah. And this is Milena. I, you know, clearly I think a lot of this for many people who do this is also equipment dependent. So obviously, if you have access to BK and perineal ultrasound, it actually makes sense to do both. Absolutely. But I think the limitation of a lot of, you know, people around the world who do this is they may have access to one or the other platform. And for me, I also actually trained using the platform that had the endovaginal transducer with a 3D. And by the way, I also start with a 2D assessment and then move to the 3D assessment as well as dynamic assessments. But I don't, and I actually have very limited access now to an endoluminal technology because it's a completely different machine. So I think a lot of time, and I think there's quite limited research out there to say which one is better. That's the, you know, and some of it is what you're used to and what you train your eye to see and what you're really trying to visualize, which is, I think, a whole other thing is what, you know, what are you after? It is true that Alicia mentioned that endoanal ultrasound is still a gold standard for assessment of the anal sphincter, for example. But you can see images of the anal canal, very nice images of the anal canal using the perineal. So it is, there's some also variability of what are you trying to visualize with an ultrasound. Okay, great. And just to lead into another question, how long did it take both of you to learn how to do the multicartmental pelvic floor ultrasound? And do you feel that something like a workshop is enough training? So that is a good question. I think that the workshop is definitely the best place to start. I think that after the workshop, there is going to be probably some additional time to continue to train your eyes with the technology. And just like with any kind of assessment, like if you remember how you were, you know, when you're learning to use the robot or anything like that, that initial intense training needs to then be followed by implementation and practice on a fairly close basis. I mean, if you do a workshop and then you don't see an image for two years, it may be more difficult. But I think that a workshop is definitely the best place to start. And then after that, start doing them and try to train your eyes. I think that all of us that work with this technology are very open to being reached out to and to, you know, to mentor people through the learning process, because we're all very motivated to have this kind of technology be more widely implemented and used by more of us. We'll be able to collaborate better if it's, you know, if more of us are able to use it and utilize it in a clinically useful way. But definitely a workshop is a really good place to get started and to make connections with the people that you're going to then, you know, ask to continue to mentor you through the growth of this process. Yeah, I agree completely. I think the workshop is an excellent place to start. But just so that the audience also knows that, you know, the parameters that I worked with American Institute of Ultrasound and Medicine, one of the things that this incredible organization does is once they approve the parameters, they actually start putting out training modules. So it is all about training your eye, but I think training modules can help with that because they sort of identify the right things you want to look at. They look at normal and abnormal. And so some of that can help, especially if, you know, the frequency, because you want to take the, you know, you want to take the training, but then you want to actually continue doing that in your clinical practice. Otherwise, you know, you kind of like it's, you know, you don't use it, lose it. So I think having also some access to some other modalities like the training modules could be a really helpful way to do it. I agree. Okay, great. We have questions pouring in here. So can the speakers discuss their selection for their imaging choice for urethral diverticulum? Do you think that 3D pelvic ultrasound is ready to replace MRI for this diagnosis? This is Milena. I showed the nice picture of the urethral diverticulum, and quite honestly, I did get an MRI of that patient as well, only because I know, and it was a very impressive diverticulum to be perfectly honest. But I do think that, you know, this is where kind of this exciting part about this technology is as we move forward is seeing more actually doing some studies to have a comparison and reliability studies and, you know, have buy-in from different organizations that, you know, have ability to sort of make this as a broader accessible technique that I think it may replace MRI. And it's not that we're trying to get rid of MRI, but, you know, a lot of places it's hard to access it. And you also, you know, you also need somebody who knows how to do the urethral MRI. Whereas if you take an ultrasound in your own office and look at the urethra, once you know normal anatomy, it's actually not that hard. So I do think that it has a future. It's just not quite ready for prime time. You know, and, you know, just to echo some of what Dr. Weinstein also said, I mentioned earlier that really this 3D pulse processing and ultrasound is one of the great advantages, but it's one of the things that you actually need to learn how to do. And so I feel at this point that I can clearly visualize every millimeter of the urethra with this ultrasound. And however, I know that it's important to teach the correct protocol and technique. I think it's going to be operator dependent to answer that. I think that in the right hand, it can easily replace, I mean, MRI. I think it eventually will get there as more and more people become more, you know, comfortable with this kind of technology. I think that ultrasound is incredibly valuable for visualizing this and urethral diverticulum as well as, you know, any kind of other pathology of the urethra or bladder neck or anything like that. I mean, we see it with such great resolution. And not only that, the beauty of that is that we're, you know, for some of us, we have the ability to take this kind of technology to the operating room and be able to tag some of these, you know, some of what we see and actually measure it real time instead of saying, you know, we had an MRI done a month ago and, you know, now the urethra's drained some and now things may be a little different. So, we're able to, not everyone has that same kind of access, but I'm just letting you know that there is that possibility to be able to re-image them right before you do that surgery and, you know, talk about, you know, whether there's interim growth or anything like that. So, I do think that it does provide a great advantage whenever it's available. In some institutions, and I would feel like in ours, it could easily replace MRI. I don't get any MRIs for these kinds of things unless I am very confused by the ultrasound images. So, I completely understand why we wouldn't have that as backup. There's been a few questions about whether or not you think 3D imaging with ultrasound is eventually going to replace 2D imaging, you know, particularly in general gynecology when people are just looking at the uterus and ovaries. And then next, do you think 2D ultrasound will one day be antiquated in the near future? Well, they kind of exist together. This is Melina. I mean, they, you know, each platform has at least for, I know the interluminal is a little bit different, but for the 3D, each probe can exist in 2D, 3D, and actually 4D, which we didn't even discuss. So, I don't think it's antiquated for kind of a quick look, because a lot of three-dimensional ultrasound, you do have to do the post-processing, which I didn't really talk on my part only because it's pretty complex. But that's the part, that's where I think the highest learning curve, by the way, speaking of the learning curve, is really figuring out how to post-process and find what you are, you know, what you want in that volume of data that you're getting. So, but I don't think it's going to be antiquated. It's just going to exist together. Okay. One interesting question. Somebody missed the beginning of the talk and asked if you reviewed the location of the midrithral sling and how it related to failure, which I don't think you completely went through, but do you have any comments on that? I'll give a quick comment on that. There have been many times in which we are able to visualize that the sling is clearly nowhere near the midrithra, and that death usually goes along with, you know, whether failure or failure in addition to pain, for example, that sometimes is a worse combination. But we are definitely able to then see, oh, this is, you know, definitely, you know, within like five millimeters of the urethral meatus instead of the midrithra, or whether it's one centimeter above the UVJ, how could this ever work? We've had those moments, and we've seen that kind of correlation with specific sling location and failure, just to answer that question quickly. Yeah, good. And one last question, I think, since we're running over time now. How well is apical descent visualized with the ultrasound? And do you think that it can be helpful in showing apical contribution to a visually anteriorly dominant prolapse? I think that's more, I mean, unless we want to take this, I think it's more for me. I do think it's actually, especially when the prolapse is a little confusing, it's good to look with an ultrasound. It certainly gives a little bit idea, I think it's a little, quite honestly, I think it's a little bit harder with when you have a uterus and a cervix, it's easier. I mean, I think everything is a little bit easier with an ultrasound when you have kind of that more defined structure. I think it is a tiny bit harder when you have a vault because you can't really know exactly where the top of the vagina is when you look with an ultrasound, but you can certainly visualize bowel, etc. So, it has sort of possibilities for sure. I think, unfortunately, so far, the studies that look at some of the parameters of how you measure the prolapse with ultrasound and how you do it clinically, just because the reference planes are different. So, it's hard to sort of make these parallels, but you can certainly see things clearer with an ultrasound for the apex. I agree. Ultrasound can be incredibly useful. I showed that picture of that lady with a bulge that really had, I mean, a bulge that came out like plus five, and she had a previous Laporte. So, that was a very interesting challenge because you have no idea what you're seeing. What are you looking at? And so, ultrasound in that specific case was incredibly useful. I didn't have time to show the images that came with that lady, but those are examples those are examples of where you definitely gain some additional perspective by having some imaging available to you. Interesting. And one last question, because I think this is pertinent and a lot of people are thinking about it. Are these procedures reimbursable as urogynecologists? So, Alicia, I'll take this, actually, because the idea of the new parameters. So, American Institute of Ultrasound and Medicine is actually kind of the body that also kind of qualifies you to do the ultrasound. So, once they put out the parameters, I think the next step is the billing code. So, there's going to be a specific hope. It's not coming next month, but I think over the next six months to a year, we may even have a billing code. I.e. we will actually have, because right now it's billable in ways that isn't really what it is, because it's just the parameters don't exist. But they're coming. Great. Well, thank you, everyone. These are great talks tonight, and thank you, everybody, for contributing your questions. And a special thanks to both Dr. Weinstein and Dr. Quiros for all the work they did. On behalf of AUGS Education and Scientific Committees, I would like to thank both of you and everyone for coming. Our next webinar will be entitled, A Gynecologist's Role in Identifying and Responding to Human Trafficking, which will be presented by Julia Guinness-Montan on August 15th. So, thank you, everyone, and good night.

AUGS webinar

Pelvic floor ultrasound

Pelvic floor disorders

Dr. Milena Weinstein

Dr. Lieshen Quiroz

Basics of pelvic floor ultrasound

Clinical indications

Assessment of pelvic floor structures

Visualization of levator ani muscles

3D post-processing