Hans Peter Dietz

Introduction and Hypothesis Maximum urethral closure pressure (MUCP) is a measure of urethral quality and is associated with urodynamic stress incontinence (USI). A confounder of this relationship is pelvic organ prolapse (POP). We investigated the effect of prolapse reduction on MUCP and its association with USI. Methods We carried out an observational study using data sets of 1992 women seen at a tertiary urogynaecological centre in 2017–2024. All had undergone a questionnaire, POPQ examination and translabial ultrasound. MUCP was obtained after bladder emptying, at rest and during POP reduction. USI was rated mild, moderate, marked or severe. Associations between MUCP/MUCP on prolapse reduction and USI were tested using nominal regression. Nagelkerke R² were used to compare association strength. Results Of 1992 women seen for urodynamic testing, 1737 had MUCP obtained at rest and POP reduction. Most complained of stress urinary incontinence (72.8%), and 7% reported splinting to void. On clinical examination, 82.8% had significant prolapse. USI was diagnosed in 61.9%, detrusor overactivity in 22.6% and voiding dysfunction in 31.9%. Mean MUCP was 39.1 cm H₂O at rest (standard deviation [SD] 18.2) and 33.9 (SD 17.6) on prolapse reduction (p < 0.001). This reduction was greater in women reporting splinting (p = 0.004) and weakly associated with Ba (p < 0.001), C (p < 0.001 and Bp (p = 0.02). MUCP at rest and MUCP on prolapse reduction were significant predictors of USI and USI grading (all p < 0.001). MUCP on prolapse reduction was not markedly superior to MUCP at rest in the association with USI grading (Nagelkerke R² = 0.14 and 0.13 respectively). Conclusions Symptoms of splinting and objective prolapse on POPQ predict a lower MUCP on prolapse reduction. However, as the latter does not significantly increase predictive value, prolapse reduction is probably unnecessary in clinical practice.

Objectives: Obstetric anal sphincter injury is a common complication of childbirth and the primary etiological factor for anal incontinence in young women. On endoanal ultrasound, a significant defect of the external anal sphincter (EAS) has arbitrarily been defined as a gap of greater than 30° in its hyperechogenic ring structure. This study was designed to validate a cut‐off value for defining a significant EAS defect on tomographic exoanal imaging. Methods: This was a retrospective study involving women attending a tertiary urogynecological unit between January 2015 and December 2021. Analysis was limited to premenopausal women to reduce confounders. The assessment included obtaining the St Mark's incontinence score and visual analog scale (VAS) bother score of anal incontinence, and performance of four‐dimensional transperineal exoanal ultrasound. Tomographic ultrasound imaging (TUI) was used to evaluate the EAS; offline analysis was performed at a later date, with the assessor blinded against all other clinical data. The primary measure to assess EAS defects was defect angle. Associations between this parameter and anal incontinence, VAS bother score and St Mark's score were estimated using univariable logistic or linear regression models. Receiver‐operating‐characteristics (ROC)‐curve analysis was performed to determine the optimal cut‐off value of the EAS defect angle for defining a significant defect. Results: A total of 915 premenopausal women were seen during the study period. Ultrasound volumes of the anal canal were missing in 64 women and one patient was excluded due to muscular dystrophy, leaving 850 women included in the analysis. The mean age was 42 (range, 18–56) years and the mean body mass index was 29 (range, 16–57) kg/m ² at assessment. Anal incontinence was reported by 133 (16%) women, with a median St Mark's score of 10 (interquartile range, 6–14) and a mean VAS bother score of 6.6 (range, 0–10). On TUI, six slices were scored per patient (total of 5100 assessments). EAS defects were seen in 111 (13%) patients and 368 slices, with an average defect angle of 32° (range, 2–155°) and a mean maximum defect angle of 67° (range, 14–167°). Average defect angle showed the strongest correlation with anal incontinence, St Mark's score and VAS bother score (all P < 0.001). ROC‐curve analysis suggested a cut‐off of 30° for the definition of a significant EAS defect. Conclusion: In premenopausal women, EAS defects on TUI were associated significantly with all investigated measures of anal incontinence. Average defect angle was the best predictor of anal incontinence and enabled ROC‐curve analysis. The 30° defect angle criterion empirically used for endoanal ultrasound seemed to be valid as a cut‐off for the diagnosis of significant anal sphincter defect on exoanal imaging. © 2026 International Society of Ultrasound in Obstetrics and Gynecology.

Introduction and Hypothesis The levator hiatus is an important determinant of pelvic organ prolapse and prolapse recurrence after surgery. Manufacturers are now offering automatic determination of hiatal dimensions. Methods This was an observational study using data sets of 437 women attending a urogynaecological unit in 2024 and 2025. All had 4D pelvic floor ultrasound using a Voluson E 22 system with SonoPelvic™ software. Data sets obtained on Valsalva were used for automated measurements. Manual measurements were performed later on stored data sets blinded against all other data. For statistical analysis we employed ICC and Bland Altman plots. Patients in whom measurements differed by ≥20% were reviewed. Results The 437 women seen during the study period presented with stress urinary incontinence (n = 304), urgency urinary incontinence (n = 334) and symptoms of pelvic organ prolapse (n = 229). Automated measurements yielded a mean of 25.45 (4.08–64.76) cm², whereas manual hiatal area measurements provided a mean of 26.8 (6.97–65.7) cm² (Pearson’s correlation 0.59, p < 0.0001). The difference between individual measurements was statistically nonsignificant on t test. A direct comparison was possible in 425, with 80/425 (19%) showing a discrepancy of ≥20%. These were reviewed separately by the authors and found to be due to loss of symphysis pubis (n = 20) or anorectal angle (n = 35) or both (n = 10) in higher stages of prolapse. Conclusion Automated analysis by the current version of SonoPelvic™ shows a strong correlation with manual measurements, except in women with highly abnormal pelvic organ support. The software is under continuous development for which several recommendations are made.

Ultrasound imaging has been the most important diagnostic technique in Obstetrics and Gynaecology for well over a generation. However, while it is entirely dominant in Obstetrics, this is less obvious in Gynaecology. Urogynaecology or pelvic floor medicine remains a Cinderella subject even within Gynaecology, and imaging still has only a niche existence in Urogynaecology. The latter is partly due to a lack of equipment and sometimes of reimbursement, partly due to the strong surgical orientation of the subspecialty, and partly due to simple human inertia. In regard to birth trauma, political factors such as natural childbirth ideology with its denial of maternal birth trauma, and pressure on Caesarean section rates, have delayed the utilisation of pelvic floor ultrasound, despite its obvious potential in clinical audit and practice improvement. The origins of ultrasound imaging in Urogynaecology go back nearly 50 years to a time when B mode realtime sonographic imaging using solid-state curved array transducers had just become ubiquitous in Obstetrics, impacting on antenatal care worldwide. Pelvic floor ultrasound is now changing both intrapartum care and Urogynaecology, but much work remains to be done. This contribution tries to chronicle the evolution of pelvic floor ultrasound from its inception in the mid-1980s until the present day.

Stress urinary incontinence (SUI) is a common condition characterized by involuntary urine leakage during physical exertion, affecting up to 50% of women over 40 years of age globally and significantly impacting their quality of life. Treatment options include both nonsurgical and surgical approaches, with synthetic midurethral slings being the most widely used surgical technique. While clinical history, physical examination, and urodynamic studies remain the cornerstone of SUI evaluation, ultrasound has gained increasing prominence as a complementary imaging modality. It is cost-effective and provides real-time assessment of both anatomical and functional aspects of the lower urinary tract. Notably, ultrasound also enables detailed evaluation of sling positioning and function, as well as identification and management of postoperative complications. This article aims to review the role of ultrasound in assessing synthetic slings, encompassing both preoperative planning and postoperative follow-up.

Objective: To compare a standardized interslice interval of 2.5 mm against individualized interslice intervals for exoanal sphincter imaging, in the prediction of anal incontinence, visual analogue scale (VAS) bother score of anal incontinence and St Mark's incontinence score. Methods: This was a cross‐sectional study of 1342 women seen between December 2017 and May 2021 for symptoms of pelvic floor dysfunction. All women underwent an interview, including St Mark's score and VAS bother score for anal incontinence, as well as tomographic exoanal sphincter imaging. Tomographic coronal plane slices were obtained by a sonographer blinded to all clinical data, first using individualized interslice intervals of 1.5–4.5 mm and then a second time using an interval of 2.5 mm, performed successively to ensure blinding. Multivariable ordinal and linear regression were employed to assess the association of ‘significant residual defects’ of the EAS with symptoms of anal incontinence, St Mark's score and VAS bother score of anal incontinence. Cohen's κ was used to determine agreement between the two methods. Results: Of 1342 women seen during the inclusion period, ultrasound volume data were missing in 211 and information on anal incontinence was missing in three, leaving 1128 complete datasets for analysis. Anal incontinence was reported by 253 (22.4%) women, with a mean St Mark's score of 11 (range, 1–22) and a mean VAS bother score of 6 (range, 0–10). Individualization of interslice intervals resulted in a mean ± SD interval of 2.7 ± 0.5 mm (range, 1.5–4.5 mm). There were 429 (38.0%) women who had at least one abnormal external anal sphincter (EAS) slice, and a ‘significant residual defect’ of the EAS was diagnosed in 138 (12.2%). Reanalysis using a standardized interval of 2.5 mm resulted in abnormal EAS slices in 461 (40.9%) women, with ‘significant residual defects’ in 134 (11.9%) women. Of the 1128 women, only 28 (2.5%) were classified differently when a 2.5‐mm interval was used; agreement between the two methods was high (κ = 0.88). The unadjusted and adjusted models for individualized and standardized interslice intervals did not differ significantly for association with anal incontience. Conclusion: A standardized interslice interval of 2.5 mm does not seem to be less valid for the diagnosis of ‘significant residual EAS defect’ than individualized interslice intervals. This will help to simplify automated analysis of sphincter imaging. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Objective: To evaluate the validity of two‐dimensional (2D) oblique parasagittal ultrasound imaging to assess levator ani muscle avulsion. Methods: This was a cross‐sectional prospective study of women attending a tertiary urogynecological service between February 2021 and August 2022. All women underwent a standardized interview, pelvic organ prolapse quantification (POP‐Q) assessment and four‐dimensional transperineal ultrasound. 2D oblique parasagittal ultrasound imaging was performed by rotating the transducer 10–20° from the midline to line up the main transducer axis with the fiber direction of the puborectalis muscle, followed by a full parasagittal sweep of the hiatus at rest. Postprocessing of archived ultrasound volume data was performed at a later date, blinded to all other data. Findings were compared with levator ani assessment results obtained previously using three‐dimensional tomographic ultrasound imaging (TUI). Diagnosis of levator ani avulsion on TUI and oblique parasagittal imaging was analyzed for associations with pelvic organ prolapse (POP). Results: The datasets of 484 women were analyzed. Mean age was 58 (range, 16–94) years, mean body mass index was 30 (range, 17–65) kg/m ² and mean parity was 2.6 (range, 0–8). POP symptoms were reported by 278 (57%) women. Clinically and sonographically significant POP was found in 385 (80%) and 350 (72%) women, respectively. Levator ani avulsion was diagnosed in 77 (16%) women on TUI and in 90 (18.6%) women on oblique parasagittal ultrasound imaging, with fair agreement between the two methods (Cohen's kappa of 0.365). There were significant associations between levator ani avulsion on 2D ultrasound imaging and POP diagnosis on clinical examination (odds ratio (OR), 2.88 (95% CI, 1.34–6.18); P = 0.005) and on ultrasound (OR, 2.92 (95% CI, 1.53–5.55); P = 0.001), but these associations were much stronger for TUI ( P < 0.001 for both). Conclusion: There was limited agreement between tomographic and oblique parasagittal ultrasound diagnosis of levator ani muscle avulsion. The latter technique has some validity for levator ani assessment but is clearly less valid than TUI. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.