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  1. Ballooning: enlargement of the levator hiatus to 25 cm2 or more on Valsalva.

  2. Bladder neck descent: the extent of caudal movement of the bladder neck on maximal Valsalva, relative to the symphysis pubis.

  3. Detrusor wall thickness: thickness of the bladder wall, measured at less than 50-mL bladder volume at the dome, from leading edge (mucosa) to leading edge (peritoneum).

  4. Funneling: opening of the bladder neck on Valsalva.

  5. Levator avulsion: detachment of the puborectalis muscle from its insertion on the pelvic sidewall (inferior pubic ramus).

  6. Levator hiatus: the plane of minimal hiatal dimensions between symphysis pubis and inferior pubic rami anteriorly and the puborectalis loop laterally and posteriorly.

  7. True rectocele: diverticulum of the anterior rectal wall, which is defined by a 90-degree discontinuity of the anterior rectal wall at the junction of the anal canal and rectal ampulla, resulting in a herniation of rectal contents into the vagina on Valsalva.

It has taken over 20 years for imaging to develop as a mainstream diagnostic tool in the investigation of female pelvic organ prolapse, urinary and fecal incontinence, and defecation disorders. Physicians have been slow in realizing that clinical assessment alone is a very inadequate tool to assess pelvic floor function and anatomy. Our examination skills are poor, focusing on surface anatomy rather than true structural abnormalities, and recurrence after pelvic reconstructive surgery is common.1 The uptake of pelvic floor ultrasound by clinicians has varied substantially from one specialty to another, with gynecologists having a major advantage over urologists and colorectal surgeons due to the fact that an entire generation of OB/GYN specialists has now grown up with ultrasound imaging. Sonography is an accepted component of any clinical assessment in both obstetrics and gynecology, so why should it be any different in urogynecology and female urology?

In theory, clinical assessment skills could be improved to such a degree as to make imaging unnecessary in many cases. However, this clearly is not the case at present, and it is unlikely to happen unless we allow imaging techniques to demonstrate what (and where) the actual problems are. To give just one example: the missing link between vaginal childbirth and prolapse—major levator trauma in the form of avulsion of the anteromedial aspects of the puborectalis muscle off the pelvic sidewall2,3—is palpable, but palpation of levator trauma requires considerable skill and teaching,4,5, and 6 preferably with imaging confirmation. Certainly, diagnosis by imaging is more reproducible than diagnosis by palpation,6 and easier to teach. And suspected levator trauma or abnormal distensibility ("ballooning") are by no means the only reason to perform pelvic floor imaging (Table 40-1).


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