Donald School Journal of Ultrasound in Obstetrics and Gynecology

Register      Login

VOLUME 17 , ISSUE 3 ( July-September, 2023 ) > List of Articles


Three-dimensional/Four-dimensional Pelvic Floor Ultrasound

Hans P Dietz

Keywords : Avulsion, Birth trauma, Four-dimensional ultrasound, Levator ani, Obstetric anal sphincter injury, Pelvic organ prolapse, Ultrasound

Citation Information : Dietz HP. Three-dimensional/Four-dimensional Pelvic Floor Ultrasound. Donald School J Ultrasound Obstet Gynecol 2023; 17 (3):248-269.

DOI: 10.5005/jp-journals-10009-1984

License: CC BY-NC 4.0

Published Online: 30-09-2023

Copyright Statement:  Copyright © 2023; The Author(s).


Ultrasound is the primary imaging method in gynecology, and it is also widely used in urology and colorectal surgery. This makes the modality increasingly popular in the imaging assessment of pelvic floor anatomy, a field all three specialties are routinely involved with. This development is long overdue, especially as pathophysiology and etiology of most pelvic floor conditions are still poorly understood. The advent of three-dimensional (3D) ultrasound allows access to the axial plane and arbitrarily definable parasagittal and oblique planes which has greatly facilitated the assessment of the levator ani muscle, the anal sphincter, and of paraurethral abnormalities such as urethral diverticula. At least as importantly, four-dimensional (4D) ultrasound enables the observation of function in the form of maneuvers such as cough, Valsalva, and pelvic floor muscle contraction.

  1. Dietz H. Female Urology and Urogynaecology. Informa Healthcare; 2006.
  2. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89(4):501–506. DOI: 10.1016/S0029-7844(97)00058-6
  3. Smith FJ, Holman CD, Moorin RE, et al. Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstet Gynecol 2010;116(5):1096–1100. DOI: 10.1097/AOG.0b013e3181f73729
  4. Dietz HP, Wilson PD. The influence of bladder volume on the position and mobility of the urethrovesical junction. Int Urogynecol J Pelvic Floor Dysfunct 1999;10(1):3–6. DOI: 10.1007/pl00004011
  5. Dietz H, Steensma A. Dimensions of the levator hiatus in symptomatic women. Ultrasound Obstet Gynecol 2005;26(4):369–370.
  6. Svabík K, Shek KL, Dietz HP. How much does the levator hiatus have to stretch during childbirth? BJOG 2009;116(12):1657–1662. DOI: 10.1111/j.1471-0528.2009.02321.x
  7. Dietz H. Classifying major delivery-related pelvic floor trauma. Int Urogynecol J 2006;17(S2):S124–S125.
  8. Dietz H. Exoanal imaging of the anal sphincters. J Ultrasound Med 2018;37(1):263–280. DOI: 10.1002/jum.14246
  9. Dietz HP, Velez D, Shek KL, et al. Determination of postvoid residual by translabial ultrasound. Int Urogynecol J 2012;23(12):1749–1752. DOI: 10.1007/s00192-012-1769-0
  10. Lekskulchai O, Dietz HP. Detrusor wall thickness as a test for detrusor overactivity in women. Ultrasound Obstet Gynecol 2008;32(4):535–539. DOI: 10.1002/uog.5370
  11. Lekskulchai O, Dietz HP. Is detrusor hypertrophy in women associated with voiding dysfunction? Aust N Z J Obstet Gynaecol 2009;49(6):653–656. DOI: 10.1111/j.1479-828X.2009.01070.x
  12. Dietz HP. Pelvic floor ultrasound in incontinence: what's in it for the surgeon? Int Urogynecol J 2011;22(9):1085–1097. DOI: 10.1007/s00192-011-1402-7
  13. Guichard P, Gillor M, Dietz H. Imaging of urethral diverticula by 4D—translabial ultrasound. Int Urogynecol J 2018;29(S1).
  14. Eisenberg VH, Chantarasorn V, Shek KL, et al. Does levator ani injury affect cystocele type? Ultrasound Obstet Gynecol 2010;36(5):618–623. DOI: 10.1002/uog.7712
  15. Dietz HP, Korda A. Which bowel symptoms are most strongly associated with a true rectocele? Aust N Z J Obstet Gynaecol 2005;45(6):505–508. DOI: 10.1111/j.1479-828X.2005.00486.x
  16. Rodrigo N, Shek KL, Dietz HP. Rectal intussusception is associated with abnormal levator ani muscle structure and morphometry. Tech Coloproctol 2011;15(1):39–43. DOI: 10.1007/s10151-010-0657-1
  17. Dietz HP, Steensma AB. Posterior compartment prolapse on two-dimensional and three-dimensional pelvic floor ultrasound: the distinction between true rectocele, perineal hypermobility and enterocele. Ultrasound Obstet Gynecol 2005;26(1):73–77. DOI: 10.1002/uog.1930
  18. Dietz HP. Can the rectovaginal septum be visualized by transvaginal three-dimensional ultrasound? Ultrasound Obstet Gynecol 2011;37(3):348–352. DOI: 10.1002/uog.8896
  19. Guzman Rojas R, Kamisan Atan I, Shek KL, et al. The prevalence of abnormal posterior compartment anatomy and its association with obstructed defecation symptoms in urogynecological patients. Int Urogynecol J 2016;27(6):939–944. DOI: 10.1007/s00192-015-2914-3
  20. Guzmán Rojas R, Kamisan Atan I, Shek KL, et al. Defect-specific rectocele repair: medium-term anatomical, functional and subjective outcomes. Aust N Z J Obstet Gynaecol 2015;55(5):487–492. DOI: 10.1111/ajo.12347
  21. Sultan AH. Anal incontinence after childbirth. Curr Opin Obstet Gynecol 1997;9(5):320–324.
  22. Stoker J, Rociu E, Bosch JL, et al. High-resolution endovaginal MR imaging in stress urinary incontinence. Eur Radiol 2003;13(8):2031–2037. DOI: 10.1007/s00330-003-1855-2
  23. Peschers UM, DeLancey JO, Schaer GN, et al. Exoanal ultrasound of the anal sphincter: normal anatomy and sphincter defects. Br J Obstet Gynaecol 1997;104(9):999–1003. DOI: 10.1111/j.1471-0528.1997.tb12056.x
  24. Van Gruting I. Can transperineal ultrasound replace endoanal ultrasound for the detection of analsphincter defects? Int Urogynecol J 2017;27(S1):S51–S52.
  25. Shek KL, Guzman-Rojas R, Dietz HP. Residual defects of the external anal sphincter following primary repair: an observational study using transperineal ultrasound. Ultrasound Obstet Gynecol 2014;44(6):704–709. DOI: 10.1002/uog.13368
  26. Turel FD, Langer S, Shek KL, et al. Medium- to long-term follow-up of obstetric anal sphincter injury. Dis Colon Rectum 2019;62(3):348–356. DOI: 10.1097/DCR.0000000000001297
  27. Guzmán Rojas RA, Shek KL, Langer SM, et al. Prevalence of anal sphincter injury in primiparous women. Ultrasound Obstet Gynecol 2013;42(4):461–466. DOI: 10.1002/uog.12481
  28. Roos AM, Thakar R, Sultan AH. Outcome of primary repair of obstetric anal sphincter injuries (OASIS): does the grade of tear matter? Ultrasound Obstet Gynecol 2010;36(3):368–374. DOI: 10.1002/uog.7512
  29. Andrews V, Sultan AH, Thakar R, et al. Occult anal sphincter injuries—myth or reality? BJOG 2006;113(2):195–200. DOI: 10.1111/j.1471-0528.2006.00799.x
  30. Dietz H, Pardey J, Murray H. Maternal birth trauma should be a key performance indicator of maternity services. Int Urogynecol J 2015;26:29–32.
  31. Dietz HP. Pelvic floor ultrasound in prolapse: what's in it for the surgeon? Int Urogynecol J 2011;22(10):1221–1232. DOI: 10.1007/s00192-011-1459-3
  32. Chantarasorn V, Shek KL, Dietz HP. Sonographic appearance of transobturator slings: implications for function and dysfunction. Int Urogynecol J 2011;22(4):493–498. DOI: 10.1007/s00192-010-1306-y
  33. Shek KL, Rane A, Goh J, et al. Imaging of the Perigee transobturator mesh and its effect on stress incontinence. Ultrasound Obstet Gynecol 2007;30(4):446. DOI: 10.1002/uog.4362
  34. Dietz HP, Erdmann M, Shek KL. Mesh contraction: myth or reality? Am J Obstet Gynecol 2011;204(2):173.e1–173.e4. DOI: 10.1016/j.ajog.2010.08.058
  35. Svabík K, Martan A, Masata J, et al. Ultrasound appearances after mesh implantation—evidence of mesh contraction or folding? Int Urogynecol J 2011;22(5):529–533. DOI: 10.1007/s00192-010-1308-9
  36. Wong V, Shek KL. The mesh debate: transvaginal anterior anchored mesh should not be abandoned. Aust N Z J Obstet Gynaecol 2017;57(1):105–107. DOI: 10.1111/ajo.12589
  37. Shek KL, Wong V, Lee J, et al. Anterior compartment mesh: a descriptive study of mesh anchoring failure. Ultrasound Obstet Gynecol 2013;42(6):699–704. DOI: 10.1002/uog.12577
  38. Gainey HL. Post-partum observation of pelvic tissue damage. Am J Obstet Gynecol 1943;46:457–466.
  39. DeLancey J. Levator ani muscle structure and function in women with prolapse compared to women with normal support. Neurourol Urodyn 2003;22(5):542–543.
  40. Dietz HP, Lanzarone V. Levator trauma after vaginal delivery. Obstet Gynecol 2005;106(4):707–712. DOI: 10.1097/01.AOG.0000178779.62181.01
  41. Turel F, Caagbay D, Dietz HP. The prevalence of major birth trauma in Nepali women. J Ultrasound Med 2018.
  42. Dietz HP, Wilson PD, Milsom I. Maternal birth trauma: why should it matter to urogynaecologists? Curr Opin Obstet Gynecol 2016;28(5):441–448. DOI: 10.1097/GCO.0000000000000304
  43. Dietz HP, Shek C. Validity and reproducibility of the digital detection of levator trauma. Int Urogynecol J Pelvic Floor Dysfunct 2008;19(8):1097–1101. DOI: 10.1007/s00192-008-0575-1
  44. Dietz HP, Shek KL. Levator defects can be detected by 2D translabial ultrasound. Int Urogynecol J Pelvic Floor Dysfunct 2009;20(7):807–811. DOI: 10.1007/s00192-009-0839-4
  45. Dietz HP. Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol 2007;29(3):329–334. DOI: 10.1002/uog.3951
  46. Adisuroso T, Shek KL, Dietz HP. Tomographic ultrasound imaging of the pelvic floor in nulliparous pregnant women: limits of normality. Ultrasound Obstet Gynecol 2012;39(6):698–703. DOI: 10.1002/uog.10124
  47. Dietz HP, Bernardo MJ, Kirby A, et al. Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound. Int Urogynecol J 2011;22(6):699–704. DOI: 10.1007/s00192-010-1329-4
  48. Zhuang RR, Song YF, Chen ZQ, et al. Levator avulsion using a tomographic ultrasound and magnetic resonance-based model. Am J Obstet Gynecol 2011;205(3):232.e1–232.e8. DOI: 10.1016/j.ajog.2011.03.052
  49. Pilzek A, Shek C, Guzman Rojas RA, et al. Recurrence after prolapse surgery: does partial avulsion matter? Ultrasound Obstet Gynecol 2013;42(S1):37–38. DOI: 10.1002/uog.12687
  50. Dietz HP, Abbu A, Shek KL. The levator-urethra gap measurement: a more objective means of determining levator avulsion? Ultrasound Obstet Gynecol 2008;32(7):941–945. DOI: 10.1002/uog.6268
  51. Dietz H, Pattillo Garnham A, Guzmán Rojas R. Diagnosis of levator avulsion: is it necessary to perform TUI on pelvic floor muscle contraction? Ultrasound Obstet Gynecol 2017;49:252–256.
  52. Shek KL, Dietz HP. The effect of childbirth on hiatal dimensions. Obstet Gynecol 2009;113(6):1272–1278. DOI: 10.1097/AOG.0b013e3181a5ef23
  53. Dietz HP, Shek C. Levator avulsion and grading of pelvic floor muscle strength. Int Urogynecol J 2008;19(5):633–636. DOI: 10.1007/s00192-007-0491-9
  54. Dietz HP, Steensma AB. The prevalence of major abnormalities of the levator ani in urogynaecological patients. BJOG 2006;113(2):225–230. DOI: 10.1111/j.1471-0528.2006.00819.x
  55. Dietz HP, Simpson JM. Levator trauma is associated with pelvic organ prolapse. BJOG 2008;115(8):979–984. DOI: 10.1111/j.1471-0528.2008.01751.x
  56. Friedman T, Eslick GD, Dietz HP. Risk factors for prolapse recurrence: systematic review and meta-analysis. Int Urogynecol J 2018;29(1):13–21. DOI: 10.1007/s00192-017-3475-4
  57. Dietz HP, Shek C, De Leon J, et al. Ballooning of the levator hiatus. Ultrasound Obstet Gynecol 2008;31(6):676–680. DOI: 10.1002/uog.5355
  58. Dietz HP, Shek C, Clarke B. Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound. Ultrasound Obstet Gynecol 2005;25(6):580–585. DOI: 10.1002/uog.1899
  59. Dietz HP, Wong V, Shek KL. A simplified method for determining hiatal biometry. Aust N Z J Obstet Gynaecol 2011;51(6):540–543. DOI: 10.1111/j.1479-828X.2011.01352.x
  60. Dietz HP, Stankiewicz M, Atan IK, et al. Vaginal laxity: what does this symptom mean? Int Urogynecol J 2018;29(5):723–728. DOI: 10.1007/s00192-017-3426-0
  61. Dietz H. Ultrasound imaging of the pelvic floor. Part I: two-dimensional aspects. Ultrasound Obstet Gynecol 2004;23(1):80–92. DOI: 10.1002/uog.939
  62. Dietz HP. Sonography in Obstetrics and Gynecology: Principles and Practice. McGraw Hill; 2017.
  63. Dietz H. Atlas of 3D/4D Ultrasound in Obstetrics and Gynecology. Thieme; 2018.
  64. Dietz HP, Zhang X, Shek KL, et al. How large does a rectocele have to be to cause symptoms? A 3D/4D ultrasound study. Int Urogynecol J 2015;26(9):1355–1359. DOI: 10.1007/s00192-015-2709-6
  65. Dietz HP. Female pelvic organ prolapse—a review. Aust Fam Physician 2015;44(7):446–452.
  66. Shek KL, Zazzera VD, Atan IK, et al. The evolution of transperineal ultrasound findings of the external anal sphincter during the first years after childbirth. Int Urogynecol J 2016;27(12):1899–1903. DOI: 10.1007/s00192-016-3055-z
  67. Dietz HP, Gillespie AV, Phadke P. Avulsion of the pubovisceral muscle associated with large vaginal tear after normal vaginal delivery at term. Aust N Z J Obstet Gynaecol 2007;47(4):341–344. DOI: 10.1111/j.1479-828X.2007.00748.x
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.