Okay, I'm going to go ahead and get started. Good evening, everyone. Welcome to the Augsburg Organicology webinar series. I'm Dr. Hamadi, I'm the moderator for today's webinar, entitled Incorporating Pelvic Floor Ultrasound into Your Practice. Just some last minute reminders before I introduce our speaker for tonight, Dr. Shoubary. The presentation will run around 45 minutes. The last 15 minutes of the webinar will be dedicated to the questions and answers. Before we begin, I'd like to review some housekeeping items. So the webinar is being recorded and live streamed. A recording of the webinar will be made available in the Augs eLearning portal. Please use the question and answer feature of the Zoom webinar to ask any of the speaker's questions. We will answer them at the end of the presentation and use the chat feature if you have any technical issues. Our staff will be monitoring the chat and can assist. So moving forward, I will introduce our speaker, Dr. Shoubary. He is the Inova Health System Chief of Benign Gynecology, a professor of obstetrics and gynecology, medical education, and the Affiliate Biomedical Engineering Faculty at George Mason University. Inova Fairfax Gynecology is ranked top 10 by U.S. World News. Dr. Shoubary is an international authority in pelvic floor ultrasonography, medical device development, and robotics. He obtained his bachelor's degree from the University of Washington, medical doctorate from Tufts University, MBA from Brandeis University. He completed his residency and fellowship at Tulane and Louisiana State University. He pioneered the discipline of endovaginal pelvic floor ultrasonography and believes this skill should be a core competency for urogynecologists. Dr. Shoubary has established Inova NAFC Center of Excellence for Continence, an integrated FBMRS fellowship, an IUGA-ICS-sponsored fellowship program, the Pelvic Floor Investigation Group, the Ultrasound of Pelvic Floor Investigation and Translation Group. He has received numerous research and educational awards, including the APGO Award. He is a frequently invited national and international speaker. He has served on many research and program committees, grant reviews, manuscript reviews, and national and international society leaderships. He has authored more than 200 articles in scientific journals and chapters for textbooks standard to medical device development, imaging, and robotics. He is the editor of the second edition of the textbook Practical Pelvic Floor Ultrasonography and the editor of the textbook Innovation and Evolution of Medical Devices. His local strategic priorities are to further Inova's mission of delivering the best possible healthcare to the population it serves through research, education, and patient advocacy. His national and international strategic priorities are establishing standards in the evaluation and management of patients with pelvic floor injury after childbirth. And without further ado, Dr. Shoubary, thank you so much for taking the time to join us tonight. Good night, everyone, and thank you for having me. So we are going to talk about how to incorporate pelvic floor ultrasound into your pelvic floor practice. And in advance, I should apologize about my hat. I just got out of the OR, and I'm not quite sure what my hair looks like, so I'm going to keep my hat on. So I have no relevant financial relationships to disclose. I do consulting work for many different companies, but none of them are relevant to this talk. This webinar is intended to assist you to understand basics of pelvic floor ultrasound instrumentation. To do this, we are going to overview the ARUM parameters for performing pelvic floor ultrasound and what it takes to get accreditation from ARUM in performing pelvic floor ultrasound. So this is a document that I worked on and I led probably starting in 2018, bringing various societies together to standardize the terminology that we use for pelvic floor ultrasound because it was just very confusing what modality people were actually referring to. So we are going to use this document as our guide. Basically, for the ultrasound, we are going to explore why we are going to be using imaging at all, why ultrasound is the best modality for you, and why we want to perform multi-compartmental ultrasound, which means that why is that we don't stick with one type of ultrasound at all. The clinical indications for ultrasound, pelvic floor ultrasound specifically, are really pretty much everything on your chart sheet. Signs and symptoms could be anal incontinence, which is a very popular abstract identification, voiding dysfunction, pelvic pain and dyspareunia, levator ani deficiency and pelvic floor muscle wasting, pelvic organ prolapse, perineal cysts and masses, ureteral hypermobility associated with urinary incontinence, vaginal cysts and masses, such as ureteral diverticulum. Also, postpartum assessment of levator ani muscle is very useful. Obstetric perineal injury and anal sphincter injury, post-surgical assessments, such as pelvic or vaginal pain after synthetic implants, whether it's mesh or ureteral bulking agents, and also for vaginal discharge or bleeding after pelvic floor surgery. Why do we use imaging at all? Well, because we are reconstructive surgeons. Our job is to reconstruct anatomy to the way that it is supposed to be, because this is going to create motion and motion creates function. Why do we want to use ultrasound? Because ultrasound has just amazing image quality. It's a rapidly developing field and it's highly evidence-based. During this talk, I would be stressing on endovaginal ultrasound, because the quality of that type of ultrasonography is really outstanding. There are no contraindications to perform ultrasound, except where the patient is unable to consent to the procedure, or if there are situations where there is a breach of inpatient control guidelines. If the patient has pain, they have open wounds or sores in the vulvovaginal area. Specifications of examination include visualizing basic structures that you need to see. We are going through these, but basically you need to see the pubic symphysis, uretera, bladder, vagina. Uterus sometimes is seen, anal canal needs to be seen, levator plate and function integrity of the insertion of levator adeni, and various insertion points, dimensions of levator hiatus, and you may need to use more than one scanning approach to identify all the relevant structures. The patients are endorsedly taught in position, so the way it happens in our office is that they will be on a normal examination table. During the same time that we do the examination, we spend another three minutes to perform our ultrasound. Really no special preparation is necessary. Approaches to performing pelvic floor ultrasound can be varied, and it depends on the equipment that you have available to you. Most of the institutions have a lot of obstetric ultrasound machines sitting around, so this is most often available, and this modality is called perineal pelvic floor ultrasound. This is when you use an abdominal transducer, and that is meant to look at the baby's surface area for the most part, and you place it on the perineum area or vulva area to perform your ultrasound. Conversely, you may want to do entroidal pelvic floor ultrasound. Again, you have a machine sitting there with a 3D endovaginal probe, and endovaginal probes tend to be higher resolution than the abdominal probes, so rather than putting these inside the vagina where you need to visualize the uterus, you put it on the vulva or the perineum and use it for 3D imaging, 4D imaging of pelvic floor. The modalities that we use in our clinic is the endovaginal ultrasound, otherwise known as EVUS, which is a specialized endocarpatory transducer that is inserted into the vagina to obtain the 3D images, and the images from this modality are outstanding because it basically gets an image every 0.2 or 0.3 degrees, even 0.1 degrees, so you can have anywhere from 2,000 to 3,000 images that are coalesced together to create your 3D volume, so it's very high definition. Endovaginal imaging is performed with the same transducer. If you need to do it, you just use the same transducer and use it directly. In terms of developing expertise in performing ultrasound, you can basically see the different ultrasound modalities on the bottom, and then you can see the various pelvic floor disorders on the left side, and you can see that as the complexity of the ultrasound increases, you will be able to do more and more complicated ultrasonography, so, for example, levatorinid deficiency is something that pretty much can be seen by 3D endovaginal ultrasound, but if you're interested in obstructive defecation and interception, you're probably best served by performing a modality that is called 3D anal echodeficography, which we are not even going to talk about here, it is so specialized. In your office, if you just have a 2D probe, you can easily see a lot of pelvic organ prolapse and vaginal cyst masses and maybe some mesh elements as well. To perform a 2D assessment, which is common to all modalities, we put the probe on the vulvar area, so we do the same thing during endovaginal ultrasound, we do a quick scanning before we put our endovaginal probe in. Now, the way that the abdominal ultrasound probes are designed, they are designed to look at the baby, so the images that you see on the screen for you are disorienting because it is as if the patient is upside down, standing on their head, and this gets a little getting used to. Again, the images are upside down, and there are various measurements that have been described from bladder angles, so on and so forth, really don't have much clinical utility, and they are basically for the realm of research. And I will tell you why that is as we go forward. Once you find the shortest distance between the pubic bone and the levator plate, as you can see here, you can obtain your 3D images, and this is something that we can show you. So this is your pubic bone here, the probe is sitting here, and this is the rectal canal, and this is the levator plate here. So what you want to do, you want to basically get the shortest distance between the levator plate and pubic bone, and that's where you engage your 3D ultrasound to obtain the minimal levator hiatus as you see here. And the image that you see here by the abdominal ultrasound placed on the perineal area is very much representative of what you get on a perineal ultrasound. You would see the borders of the muscle that is looking at you, which is for the most part the puborectalis muscle. And the way you look at this is just like looking at an MRI, there are different slices that you look at, and when you don't see a connection of the muscle to the pubic bone, you say there is an avulsion. The problem with this modality is that it is really looking at your puborectalis muscle, which is not the whole of the levator ani muscle, and it just shows the connection to the pubic bone, which is of interest, but it's again not the whole levator ani muscle. You can turn your probe sideways to look at the anal-sphincter complex as you see here, and this is a good modality if you just have a 2D probe in hand, you can easily look at anal-sphincter complex. When I was a resident at LSU in, I don't know, I'm not going to date myself, in 1990-something, this is the probe I used to do my initial studies, and it worked quite well. And these are the kind of images you may get if you do a 3D ultrasound. To do introidal pelvic floor ultrasound, as I said, you just get the probe, you put it on the perineum or between the vulva, and you have to use ample gel for all of these modalities, and then you really get the same sort of images. Again, here you would get your pubic symphysis here, levator plate, anal canal, vagina, that's the ureter and that's the bladder here. And again, you get an inside, sort of upside-down image of what we described earlier. Again, you engage your 3D volume, you see that introidal pelvic floor ultrasound gives you slightly better ultrasound images compared to the perineal, that is, used abdominal probe. And you can, again, turn the same probe sideways and look at the anal sphincter, and if you engage the 3D volume, you would see the 3D images of anal sphincter, which are reasonably good if the patients have intact anal sphincter. In our practice, if the patient has symptoms of fecal incontinence or perineal defect, or if we see defect on the ultrasound, we automatically do an endoanal ultrasound. Why do we prefer endovaginal ultrasound? Because, as I said, in this modality, you're using specialized probe that is placed inside the vagina. It's 16 megahertz, very high fidelity. And when you look at the images here, you can actually see, like, literally every single muscle fiber inside the levator and eye muscle. And when you get the same patient and you look at the MRI, you see this is the MRI image that you get, which is nowhere close to comparison when you put it side by side with the endovaginal ultrasound. So even though the studies haven't been shown, the studies we have done have shown equivalency in our mind and in our hands, and the vaginal ultrasound far surpasses MRI. If you don't have ultrasound available, MRI is definitely the best next choice for you. In the same patient, again, you can see that she has a vaginal mass here and the same vaginal mass is seen here in her MRI as well. And you can look at it in many different ways. So this is the machine that we use. We always use the 2D perineal to scan the pelvis for prolapse. And when we orient our images on this screen, our preset is as if the patient is in normal standing position. So our images on the screen would look like this. And if I show it to you, when we ask the patient to bear down like here, you would see she has actually a resting prolapse to begin with. So this is her pubic bone here, and then her levator plate is way out here somewhere. So if you just draw a line from here to here, you would see that her bladder in resting position is surpassing the hymen. And this line, the distance between the pubic bone to the top of the levator plate, roughly corresponds to where the hymen is. So she has a resting cyst to seal, and then she has colon passing this area, that's anal sphincter. So she has a sort of a resting rectocele as well. So if we just continue with our video, and you keep your eye on these red areas that I drew, you can see that as the patient contracts, all of the structures go back where they belong. So right now she's bearing down, filling up her rectocele. When she squeezes her muscles, then her bladder reduces in size. The levator plate comes up here. And so that's the basis for asking our patients the key goals to keep their pelvic floor muscles strong. When we look at patients, again, you see here is a patient with a posterior mesh, and you can see she just has stool sitting in her rectum here. That's her pubic bone, bladder is up there, urethra is here. But it's not normal to have a stool sitting in your rectum all the time. And you see that the mesh hasn't really helped this problem because the mesh doesn't really help her levator and that muscle, which is the problem with this patient. If you ask the same patient to bear down, you can see that the mesh collapses and she has further filling of her whole pelvis here. So she has, you can see the rectal canal here, but then she has this stuff that are filling up also her pelvis. So it's just not a simple rectocele, it's levator and eye deficiency and issues with the levator that will not be corrected with a vaginal mesh procedures here. You can tell the difference between a sigmoidoscele and a rectocele just by the content of what's in there. And remember all of what I showed you so far, you're doing it with a very simple, fairly available 2D probe that is in any OB-GYN office. So one issue with the current status of urogynecology is that you're like cardiologists before they discover the stethoscope. And your stethoscope is ultrasound. If you don't know how to perform ultrasound, you need to start somewhere. You need to pick any ultrasound machine that you have close by. First, it would look like really fuzzy black and white images, but just like parsons, right? Remember when you were in medical school and they gave you a stethoscope and you really couldn't hear anything and just with practice, you got better. So use what you have available to you. Once we are done with the perineal ultrasound, we would go to the vaginal scanning. And in this picture, you see that, actually in the background, I have a perineal pelvic floor ultrasound machine sitting side by side next to our endovaginal machine. And at this point, this is many years ago, I was doing scans just to make sure that we were having the better modality. And after we did about a hundred of these, we stopped using the other machine. For the endovaginal ultrasound, the probe is literally the size of your pinky. Shouldn't be that big. Shouldn't create any discomfort for the patient. Most patients really sort of are lying there and we encourage them to be on their phone because they're not being bothered by the examination. The probe is very cool. The way it is designed is that the crystals are all lined up right here anteriorly where the probe is. And once you put it inside the vagina, you're going to look anteriorly at your pubic symphysis here and the urethra here and the bladder there. And then what you do after that is that you're going to engage your 3D to go 360 degrees to get you your 3D volumes. So once we have the probe inside the vagina, we can use Doppler. We have a large number of patients with genital mutilation. We look at their clitoral blood flows, et cetera. We measure the length of the urethra. If they have a sling, we can clearly see that measure the length of the location of sling in relation to the urethra. And using an endovaginal ultrasound like this is way superior to any other modality because it straightens out your urethra and you can see exactly where the sling is at. The other thing with this modality is that when we did this, I don't know, 20 years ago, we did it right and we did it really from ground up where we got cadaveric specimen. We did histological slides of the urethra and the bladder and compared them to the ultrasound. And you can see with ultrasound, you can see levator, sorry, trigonal plate, trigonal ring, longitudinal and circular sphincter of the urethra. So you can see a lot in the patients. When you look at the patient, you can ask them to cough. This is a very normal patient and you can see she has normal coaptation of her urethra. But at the same time, we have done studies that shows the patients have funneling demonstrated. The patient who have funneling demonstrated during ultrasound, they actually have ISD. So it's again, very correlative. Once you turn your probe around, you can look again, the crystals are looking posteriorly and this time what you see is your perineal body, levator plate here and the anal canal here. And we are going to go through that as well. The first thing that we do once the probe is inside the vagina is we measure the distance from probe to the levator plate that you see here. And then we ask the patient to squeeze and we see if that distance changed or not. So in this patient, she goes from 22.6 to 18.4 millimeters. A resting of above 20 is generally the borderline for having laxity of the levator and eye muscles. And so at the resting position, she's at 22, she can go up to 18.4 in this case. And again, the studies we have done have shown that this is very reliable, repeatable in terms of measuring pelvic floor muscle strength. Again, we have done the histologic studies looking at the posterior compartment. It's very cool, you can see all the different layers of the anal sphincter, superficial transverse perinei, internal anal sphincter, rectovaginal septum, all of them are seen on the ultrasound. When you do posterior imaging, you can ask the patient to bear down like in this instance, and you can see that she's going to bear down and her whole anal canal collapses. The levator that is down here sort of falls down. And as soon as we ask the patient to squeeze her muscles, you see that now what happened was, let me see if I can find it, so yeah, right here, you can see that the levator plate goes up here and the anal canal narrows down. So just imagine yourself again like the cardiologist who is listening to the heartbeat and this is the heartbeat of the pelvis. You need to look at the pelvis, you need to see how it functions. Once you are done with the anterior imaging, posterior imaging, you engage your 3D volume. And as I said, the crystals, you don't need to do anything fancy, you just keep your probe there. The crystals turn inside the probe and then they will give you the 3D volume. So to start with, you can look at the images in traditional views, axial, coronal, sagittal, and the software would give you the ability to do that. Having said that, that's very outdated way of looking at structures. Your muscles are not simply going up and down in your body or left and right. They are going in various different angles, especially the levator and the muscles. They are very complex and you need to be able to change your planes and this modality here is not going to help you to change your plane. When we started doing this, I was very confused by the terminology that they were using in the meetings when they reported perineal ultrasound and they were showing different words that really didn't have much meaning for me. I am an anatomist and I'm very exact on what needs to be used. So to start with, we did a cadaveric study. This was in about 2006 to 2008, we were doing this. Where we did cadaveric study, we put needle in all of these different muscles, dissected them down and we identified what are all these black and white shadows that you see on the endovaginal ultrasound. And because back then, well, even now, people just were so used to look at images axially and coronally and sagittally, we didn't want to blow their minds. So we just showed the images in axial plane and showed them the different structures that could be seen. And this was published in 2009 in the Green Journal. And then we went on to really demonstrate the other parameters and compare these two MRIs showing that at least they were equivalent because people really did not believe that this was better than the MRI, which in our mind it is. So what I'm going to do now, I'm going to just show you a typical ultrasound, right? So this is for a patient that we did ultrasound on. We're just going to go to the photo viewer and we just show you the sequence. So you see here, this is from her 2D perineal. We are measuring the 2D perineal image. And then we asked her to squeeze or after this maybe cough to see whether she has prolapse. She has no prolapse. So this is our quick scanning of the pelvis. Then we do the endovaginal imaging that I told you about. Here we have measured the urethra, as you can see here. And we have done the measurement in two lines because the urethra is not straight. And then we add them up and that gives us the whole urethral length. And then, let's see if it loads. Yep. Okay. And then we do the posterior imaging at rest and at a squeeze. So with this patient, you see she's fairly healthy, but I'm guessing her resting distance from the probe to the elevator plate is 16.6 millimeters. And you see, when we ask her to squeeze, it barely moves close to 16.1 millimeters. So what you need to remember is that basically the, the resting tone of the pelvic floor is tension, right? So the only time that you relax your muscles is when you're having sex or peeing or pooping. So this is normal that she's not moving her muscles. And just to orient you to this image again, the probe is in here. This is her perineal body. This is the internal anal sphincter here, anal canal. This is the elevator plate here. And then we are measuring from the probe to the elevator plate. So, just going over the sequences and then we obtain our measurements and record any, any important findings. So I'm going to just close this. How about the 3D volume? The 3D volume is this green cube and I'm going to double click on it to open it. You can see that this is a pretty hefty, hefty volume. It's, you know, so you need quite a bit of memory to open it up and my computer is just slowly opening it up. My computer is a little sleepy. They just did an update on it and confused it. But so, here we go. Yeah, okay. So the 3D volume opened up here. You should be able to see it now. So, so you can see, this is our 3D volume. And you look at the, these images, every time I look at them and I've been doing them, doing this for, I don't know, 20 some years now, it just blows my mind, the image quality. So you can see, this is the vagina. This is where the clitoris would be, but you don't see it right now. Anus is sort of coming to view. If you just look at these quickly, you can see here, like your bulbous spongiosis fibers on this side, I don't see it as well. The, and then we are just going to go in, right? I'm going to show you how I look at this. And right off the bat here, you're going to see the superficial transverse perineal fibers here. You see that? So that's your STP. And I can color it more, but I don't have a lot of time to color things. I'm not going to do it. But underneath it here, you can see the anal sphincter is coming to view, right? Cool. You can see here a little bit of her Bartland gland here that is not full. It's not pathologic. So we're going to leave it alone. And we are going to just keep going through our journey. You see against superficial transverse perineal and anal sphincter, and then anal sphincter, superficial transverse perineal. So in this patient, obviously, when I look at this, there's no reason for me to do an endoanal ultrasound on her, right? So if you do an endovaginal and anal sphincter is intact, you really don't need to do an endoanal. So as we are going in, you can see the vascularity comes through. And then one thing you want to look at, just look at this structure here. I'm going to show you. So you don't see it very well, but this is the ends of the puboperinealis muscles. And if you look right behind this triangular area, these are the ends of the puboanalis muscles. So these are the things that you need to know in terms of understanding the pelvic floor support. At the same time here, we are getting very close to the perineal membrane. So this is literally the area where the perineal membrane is coming to view. And that's another thing that we need to be mindful of in terms of support. As we go in further, so you know, you are going to, for example, say Chauvet is making things up and showing us all these structures that don't exist, but really this is not rocket science. If it goes from point A to point B is like AB muscle, right? So we just call this puboanalis muscle. So we have to expect it that it should go from the pubic bone to the anus. So we are going to turn it around there a little and twist our plane and go like that, right? So the muscle that I showed you, now you see the whole entirety of this muscle here. So now you see the whole puboanalis as it's coming from the back of the pubic bone, attaching itself to the, basically pulling the anus up. And so all of these muscles can be traced to their original insertion point and we can clearly see them. So as we go in, the first thing we want to do, just don't worry about looking at the levator adenine muscles, go to the pubic bone. You want to find the pubic bone, and again, totally disregard the muscles that you see here. Now you can see the vagina, you can see the anus, you can see the urethra. But what we want to do, we want to turn sideways, and we are going to ask ourselves the question, we are going to say, what's the shortest distance between the pubic bone, which is here, and the levator plate? So we can just put that line there and say, that's our shortest distance, and we can go in there. I'm going to take that off, and I'm going to actually use my measurement tool, if I can find it. So I'm just going to put this here, and I'm going to say, this is my, so this is the whole ultrasound software itself that I'm using now, and I'm going to turn my plane into that line that I drew, right? Because we are trying to find the shortest distance between the pubic bone and the levator plate, which is the shortest distance where the baby's body and head will come through, right? And then we extend it out, and we are going to say, this is our minimal levator hiatus. If we want to adjust it a little, we can, you know, if I can, but this is the line that I had drawn. So at this point, if I want to get the minimal levator hiatus, my measurement tool is missing somewhere. Oh, I see. I have three screens here, it's going to this. So it gives you this measurement tool, and I'm going to go and find my minimal levator hiatus. We want to go inside the levator ani muscle along the investing fascia of the vagina. So that's what we are going to do. We're just going to go and double click it. I went a little fast, but her minimal levator hiatus is 8.04 centimeters square. And I didn't want to do that, okay. Then I'm going to just do the anterior posterior diameter, which is okay. And then left and right diameter, which is really not that useful for most parts. So this gives us our MLH, gives us the borders of our MLH. Now, this is a very important point of reference. So if a patient has levator injury, and for example, if we came and saw this patient and her levator just came to here, and there was no connection, obviously we cannot get the MLH because there are no lateral borders. But what we do, we still come and put a make-believe circle here, because that's going to become our point of reference. And the reason it becomes our point of reference is that the, that's another thing that really got me confused is that when they talked about MLH, they just kept saying it was surrounded by puberic thalus. So we published this in the British Journal, where we showed that most of your muscles that surround the MLH are actually pubococcygeus. So if you want to draw those, I can show them to you. So these fibers here, these are your pubococcygeal fibers right there. And it comes to here. Okay. And then what you, I can see it better on this side, so I'm painting it there. Versus these muscles, you see you're not seeing the whole thing, the pink one, that's your puberic thalus. And the reason you don't see the puberic thalus is because puberic thalus is coming towards you. Most people erroneously think that puberic thalus is attached to the pubic bone. It is true. A portion of it is attached to the pubic bone somewhere, but most of it is probably about, I don't know, 70% of it is attached to the arterial internus. So this is your puberic thalus, that's your pubococcygeus. And then on this side, I don't see that as well. I'm not going to try. They have to change the plane. Not going to do that. I'm going to get away with my drawings. So now that we have established where our MLH is, by definition, we say anything that is towards the head as we go up, is mostly pubococcygeus. So you can see pubococcygeal fibers. And so you can see pubococcygeal. Oopsie, I just entered it. That's my MLH, so yeah, okay. So now that we are past that, we are going to say, okay, this is my pubococcygeal fibers here. And then as we go cephalad, these fibers, you see that they're going to get smaller and smaller. And as we go up, they get narrower and narrower and become mostly very thin sheet of muscle. And these become your ileococcygeal fibers, right? So you can see that's ileococcygeal fibers. And you can still see, if you pay attention, you can see like pubococcygeal fold inside where the ileococcygeus is as well. They're the same muscles, but they're attaching to different areas, right? But this is mostly ileococcygeus. And when we go more cephalad, you would see again more of the ileococcygeus. And then, you know, it sort of cuts off. And then when we come back towards us, we find our MLH again. Where is my MLH here? So if I come towards the feet and I come out about a centimeter out, exclusively the fibers that you see here are puborectalis, right? And if you look at the fibers here, they have attachment to the, really, arterial internist fibers, not as much to the muscle itself. And then here they have fibers that are mostly pubococcygeus attached. Here is the puborectalis. So hopefully everybody see that. You see that vein there. Again, this is literally a puborectalis hiatus. So when you do perineal ultrasound, you're looking at this. And this is obsecuring everything behind it. It's obsecuring the pubococcygeus, ileococcygeus. So what you need to remember is that you can literally never have puborectalis injury without pubococcygeus injury. The baby's body will tear through that, will tear through the pubococcygeus before it gets to the puborectalis. So then the other thing that we want to do, I'm running out of time, but you're having so much fun. So I'm gonna continue. So when we turn this way and we look at it, we do a measurement called levator plate descent angle. So if we just look at the line that we drew, which is our MLH, and draw a line towards this plane, we can say that, you know, we have a negative angle. This is about, I don't see my own numbers. Minus 7.9 degrees Cephalon. So basically we don't, when we look at the levator plate, we can see that, we can see that like the, I don't know where this is. When we look at the levator plate, your levator plate can be right under the pubic symphysis. It could be step flat to the pubic symphysis. And this happens in normal people. But if your levator plate is caudate to the pubic symphysis, if it's below it, like where I drew the last line, that's definitely pathologic. And that has a positive degree. And we see it in patients who have levator injuries. Let me just clean all this up. Okay. So basically this is going to be your 3D volume. You can definitely come and look at it from coronal view. We do it a lot of times. You can see the urethra here, the urethral sphincter muscle, wrapped up my sphincter muscle around it. As we go down, you actually see the muscles here in coronal view. And as we go down, you see the anal canal. So I'm going to close this and go back to the presentation. So the presentation, you can use the same probe in the anally as I told you, like literally every 30 vaginal ultrasound that we do, we may do one endoanal ultrasound. When you do ultrasound, you want to get a permanent record. You need to have a report to get paid for it. You need to have quick text and so on and so forth that we actually have a formula that we use. I'm not really going through the endoanal ultrasound, not very interesting. If you see a complete donut, it's an intact muscle. If you don't see the donut, there is a defect. I think at this point, because we have about a few minutes left, I'm going to try to answer some questions if that's okay with people. I'm going to do that. Thank you so much, Dr. Shouberi. Comments from the crowd, exceptional presentation. We have a couple of questions for you. The first one, great images and presentation, Dr. Shouberi. Can you comment on first part of the question, the American Institute of Ultrasound and Medicine Credentialing, how do we get someone to review our studies if we don't have anyone locally to review them? And number two, how are you building coding these studies in the office? So those are really great questions. I think, let me go from top to bottom and look at these. How common is intussusception rectus in combination? Are there any specific symptoms beyond severe chronic constipation? So the intussusception and chronic constipation are really difficult problems. And one thing that we didn't go through was that when you have intact levator adenine muscles, your intact levator adenine muscles literally creates a funnel, like the stool is not sitting inside the rectum, right? And then as the colon, descending colon fills up and the stool comes down, there's a sampling mechanism where the muscles relax and the stool traverses. When you don't have the intact levator adenine muscles, because there's levator adenine deficiency or some sort of levator adenine defect, that funnel literally opens. So rather than having a straight funnel and then opening on top, the funnel is opening right at the anal sphincter. And we showed some of those images, just even with the 2D ultrasound where the stool is just sitting there. In my mind, intussusception, rectal prolapse, all of those are a lot of times manifestation of the anal levator adenine issues that we have. We do see them infrequently in patients who have intact levator adenine muscles, but they have Ehlers-Danlos syndrome or something else. Going to the next question, Chris is asking about the AOM credentialing. How do we get someone to review our studies if we don't have anyone locally? My understanding, Chris, was that they actually do that for you, that they do have reviewers. So if you have difficulty with that, just let me know. I can address that with the AIUM. And in terms of ultrasound, I'm an expert in the individual ultrasound. So we literally have never, ever, never had any problem getting paid for an ultrasound. And I think what I'm going to do, if you don't mind, Sarah, I'm just going to share my screen again. I know it's such a pain. So I'm going to share this. Sure, there we go. So this is, we have, this is our form that pops up in our EPIC, right? And then everything is written and we document what we have. And in our EPIC, the indication is actually the diagnosis for the patient that automatically builds up here. So whatever the reason is for this. And then we score the levator adenine muscles. We have levator adenine deficiency score and the avulsion score. And then we have the MLA, so on and so forth. But this is our documentation. If we do endo-renal imaging, we document it. If we do echocardiography, then we document it as well. And we document how much time we spent with the patients. So we charge both for an ultrasound and we also charge for an E&M visit because ultrasound is like, I did ultrasound for you, go talk to your provider and they're going to talk to you about the results. That's not what we do. We are spending 15 minutes doing ultrasound and another 15 minutes talking to the patient about it or sometimes even longer. And we want to get paid for both of them. And then in terms of the codes and the reimbursement, they're paying fairly healthy RVUs and such. So again, we have not had any problem. We just use our normal codes. So that's, let me look at the next question. And the bilingual, again, have never had any problem. You want to tell me the next question, Sarah? Sure. Great images and appreciate all of your contributions in this field. Do you do ultrasound on all patients? If not, what criteria do you use to determine which patients get ultrasound? If I could do ultrasound on all my patients, I would do ultrasound on my patients, right? So I think even a normal ultrasound tells you that a patient is normal. So it's again, just like putting a stethoscope on somebody's chest and saying, yes, you have a normal heartbeat. We did ultrasound on you and it was normal. And remember again, in my hand, when I do ultrasound, it literally takes me three minutes to do the actual ultrasound for the patient. So rather than giving the patient the runaround to go get imaging somewhere else or somebody else interprets it, we see the patients, we have the results for them right away. And we spend a lot of time just educating them about their issues. Having said that, doing ultrasounds for pelvic organ prolapse is, as we have done the studies, as the pelvic organ prolapse progresses, you would see less and less levatory muscles. So we have found it useful in patients who have maybe stage two or maybe stage three pelvic organ prolapse because all of the stage four patients have no visible muscle. And the way that I use it, and we haven't done really the studies, is that what makes sense to me is that 50% of your support comes from your muscles, 50% of your support comes from your ligaments. And if your muscles are intact and I go and do a sacral copepixy on you, I have reconstructed your ligaments. I can assuredly tell you that I have constructed your ligaments and you should have good outcome. Versus if we do ultrasound for you and you don't have any muscles and we see this all the time, we go and do sacral copepixy and reconstruction, but the patients still come back with prolapse symptoms. Like, and you look inside the vagina and you're like, everything is up. And when you ultrasound them, you see that like all the bowel and everything is going into that empty space where the muscles used to be. And it still gives them this pressure symptom, so to speak, and defecator dysfunction and constipation and so on and so forth. So for managing expectations in early stage two, sorry, in stage two and early stage three, I would advocate that stage four is probably doesn't help too much. Sorry, this is the point that you need to make up for a question, but I'm not asking any more questions. Actually, we're right on time. It's 9 p.m., so I'm gonna just conclude. On behalf of the Oggs, I'd like to thank Dr. Shabir and everyone for joining us today. Be sure to register for our upcoming webinars on October 26th. We have the congenital genitourinary anomalies and the role of the urogynecologist, November 15th, functional anatomy of the lower urinary system, and December 21st, just the season for good laxation, how to more effectively treat individuals with chronic constipation. Dr. Shabir, thank you so much for this excellent presentation. We really appreciate you taking the time. Thank you, Sarah, for having me. Just one last plug I need to put there. I just, you know, we do a lot of ultrasound for patients with levator injury, and for those fellows who are interested, we actually have an Instagram account. If you go to Dr. S.A. Shabir, I have a lot of answers that I've posted for the patients, but I think the fellows may appreciate that as well. Again, thank you for having me. Thank you. Good night. Thank you. Good night, everyone. Good night. Good night.

pelvic floor ultrasound

clinical practice

ultrasound modalities

endovaginal ultrasound

image quality

urogynecology practice

pelvic organ prolapse

anal incontinence

levator ani deficiency

reconstructive surgery