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Penrith, Australia

Dietz H.P.,Sydney Medical School Nepean
Ultrasound in Obstetrics and Gynecology

Objective: The rectovaginal septum (RVS) is described as a layer of connective tissue separating the anorectum from the vagina. RVS defects are thought to be responsible for rectocele formation. This study attempted to visualize the RVS with transvaginal three-dimensional (3D) ultrasound. Methods: Fifty-two women were interviewed and underwent clinical examination and pelvic floor ultrasound examination. Two-dimensional (2D) translabial imaging was used to assess for rectocele on maximal Valsalva maneuver. Transvaginal volume ultrasound data were archived and analyzed 6-9 months later, by an observer blinded to clinical data. 3D volumes were assessed for the presence of a hyperechoic layer between the vaginal muscularis and internal anal sphincter/anorectal muscularis. Data were analyzed relative to clinical findings, symptoms and the 2D ultrasound diagnosis of a rectocele. Results: Forty-six volume ultrasound datasets could be analyzed.On clinical examination, 20 women were found to have a rectocele (≥ Stage 2). On translabial ultrasound there were 28 (61%) women with true rectocele i.e. pocketing of the rectal ampulla. On 3D ultrasound a hyperechogenic layer between vaginal and anorectal muscularis was identified in all but one patient. Gaps in this layer were identified in 10 (22%) women. There were no consistent associations between clinical findings of posterior compartment descent or sonographically detected rectocele and RVS thickness or extent, or the finding of a gap in the RVS on 3D imaging. Conclusions: The RVS may be identifiable with static transvaginal 3D ultrasound, but this method does not seem to yield any information that correlates with clinical or translabial 2D ultrasound findings of posterior vaginal wall prolapse. Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd. Source

Dietz H.P.,Sydney Medical School Nepean
Nature Reviews Gastroenterology and Hepatology

Female pelvic floor dysfunction encompasses a range of morbidities, including urinary incontinence, female pelvic organ prolapse, anal incontinence and obstructed defecation. Patients often present with symptoms covered by several specialties including gastroenterology, colorectal surgery, urology and gynecology. Imaging can therefore bring clinicians from multiple specialties together by revealing that we frequently deal with different aspects of one underlying problem or pathophysiological process. This article provides an interdisciplinary imaging perspective on the pelvic floor. Modern pelvic floor imaging comprises defecation proctography, translabial and endorectal ultrasound, and static and dynamic MRI. This Perspectives focuses on the potential use of translabial ultrasound, including 3D and 4D applications, for diagnosis of pelvic floor disorders. Over the next decade, pelvic floor imaging will most likely be integrated into mainstream diagnostics in obstetrics and gynecology and colorectal surgery. Using imaging to facilitate communication between different specialties has the potential to greatly improve the multidisciplinary management of complex pelvic floor disorders. © 2012 Macmillan Publishers Limited. All rights reserved. Source

Dietz H.P.,Sydney Medical School Nepean | Mann K.P.,University of Sydney
International Urogynecology Journal and Pelvic Floor Dysfunction

Introduction and hypothesis: This study was undertaken to investigate the relationship between symptoms of prolapse and International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) measurements in order to establish optimal cutoffs for predicting prolapse symptoms using receiver operator characteristic (ROC) statistics. Methods: This was a retrospective study using 764 archived data sets of patients seen for symptoms of lower urinary tract and pelvic floor dysfunction between March 2011 and November 2012. Main outcome measure was symptoms of prolapse. Explanatory parameters were Ba, C, and Bp as defined by the ICS POP-Q. Patient age, body mass index (BMI), previous hysterectomy or incontinence/prolapse surgery, and vaginal parity were tested for a confounding effect on the relationship between ICS POP-Q measurements and symptoms of prolapse. Results: Optimal cutoffs for predicting prolapse symptoms were defined as follows: Ba = -0.5 (sensitivity 69 %, specificity 71 %), C =-5 (sensitivity 67 %, specificity 64 %), Bp = -0.5 (sensitivity 63 %, specificity 62 %). ROC statistics resulted in an area under the curve of 0.768 for Ba [confidence interval (CI) 0.729-0.807), for C of 0.724 (CI 0.672-0.776), and for Bp of 0.686 (CI 0.639-0.733). Conclusion: Our findings suggest that the ICS POP-Q staging system requires revision. Prolapse of the anterior and posterior vaginal wall of < -1 should probably be regarded as normal. On the other hand, stage 1 uterine prolapse as currently defined seems highly relevant. © 2014 The International Urogynecological Association. Source

Dietz H.P.,Sydney Medical School Nepean
Journal of Minimally Invasive Gynecology

The assessment of pelvic organ prolapse has to date been limited to the clinical evaluation of surface anatomy. This is clearly insufficient. As a result, imaging of pelvic floor function and anatomy is moving from the fringes to the mainstream of obstetrics and gynecology. This is mainly due to the realization that pelvic floor trauma in labor is common, generally overlooked, and a major factor in the causation of pelvic organ prolapse. Modern imaging methods such as magnetic resonance and 3-dimensional ultrasonography have enabled us to diagnose such abnormalities reliably and accurately, most commonly in the form of an avulsion of the puborectalis muscle off its insertion on the os pubis. However, ultrasonography has other advantages in the assessment of pelvic organ prolapse, most notably in the differential diagnosis of posterior compartment prolapse, which can be due to at least 5 different conditions. In this review I will try to summarize the methods of prolapse and pelvic floor assessment by translabial ultrasonography and to describe the most common abnormalities and their consequences. This article will not deal with magnetic resonance imaging because I consider this technology to be of limited clinical utility due to technical restrictions, expense, and access issues. © 2010 AAGL. Source

Dietz H.P.,Sydney Medical School Nepean
International Urogynecology Journal and Pelvic Floor Dysfunction

In the interest of progress and in order to avoid conflict of interest, guidelines and standardisation documents should be published anonymously, and they should undergo a mandatory review process by peers every few years. © 2011 The International Urogynecological Association. Source

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