Real-Time Ultrasound

Ultrasound imaging can be used to assess and treat many pelvic health conditions. Real-Time Ultrasound (RTUS) can be used during treatments to provide real time feedback to both the patient and physical therapist.

Ultrasound is used in pelvic floor physical therapy to:

  • Evaluate and diagnose the function of the pelvic floor and core muscles.
  • Provide visual feedback during treatment
  • Improve patients sensory awareness of the pelvic floor and core

What this means for our patients is that with the use of RTUS, we are able to observe whether your pelvic floor muscles are contracting or relaxing efficiently. We can also see if there is synergy with your core and postural muscles. We can then use this information to determine how this may contribute to your symptoms.

During treatment sessions we can use RTUS to provide visual feedback to re-educate the appropriate muscle action. As the sensory awareness increases RTUS can be used less and less until functional control of the muscle is restored.

There are three main areas where ultrasound can help in pelvic floor therapy:

  • Strengthening of pelvic floor muscles:
  • Urinary or fecal incontinence
  • Prolapse
  • Relaxation of pelvic floor muscles:
  • Constipation, anismus, ano-rectal dyssynergia
  • Difficulty initiating urination, weak or intermittent flow
  • Pelvic pain
  • Training of core and postural muscle synergy with pelvic floor muscles:
  • Diastasis Recti
  • Low back pain and pelvic girdle pain:
  • Sacroiliac joint
  • Pubic symphysis dysfunction

Specifically ultrasound can be used for:

RTUS allows us to observe the effect produced by the contraction of the pelvic floor muscles as it relates to the movements of the organs in the pelvic cavity. A contraction of the pelvic floor produces a movement of the organs in the upwards and forwards direction that prevents incontinence.

When we are training the pelvic floor muscles to rehabilitate in cases of urinary incontinence, the ultrasound probe is placed on the lower abdomen and doesn’t require the patient to be undressed. This allows us to observe the effect of the contraction of the pelvic floor muscles on the bladder. We can diagnose if the patient is able to activate the muscles to elevate the bladder, or if, on the contrary, there is a bearing down on the bladder with no lift of the pelvic floor muscles. This would result in excessive pressure and possibly, leakage of urine. We can also observe the pelvic floor during breathing and with functional activities (standing or lifting).

Observation of pelvic floor muscles, provided by a transperineal view, can provide feedback regarding the ability of the muscles of the pelvic floor to relax. For individuals with difficulty with bowel movements or initiating urination, this can be helpful to teach relaxation of the pelvic floor muscles.

A transperineal view can be useful in functional constipation. For ‘recto-anal dyssinergia’ the external anal sphincter and/or the puborectalis muscles contract when they should relax to allow stool to pass during defecation. The coordination of these muscles can be observed and treated using RUSI.

Diastasis rectus abdominis (DRA) is the separation of the muscle bellies of the rectus abdominis from the midline (linea alba). It is common during and after pregnancy. In DRA, the abdominal muscles are unable to generate the appropriate force to protect the spinal column and pelvis from compressive forces. The abdomen bulges outwards as a result.

RTUS is used to:

  • Visualize of the linea alba and measure the separation 
  • Use visual feedback to re-educate abdominal muscle contraction
  • Understand in what cases plastic surgery may be indicated

An individual may seek treatment for symptoms of incontinence, incomplete emptying of the bladder, “pressure” or a “sense of bulging” that may be worse with exercise, lifting or towards the end of the day.

With transperineal ultrasound we can observe the position of the organs at rest and during an increase of intra-abdominal pressure, if we ask the patient to bear down, to see what may happen when the person strains, coughs or as a result of gravity and muscle weakness.

 

References:

  • Yoshida et al. Differences in motor learning of pelvic floor muscle contraction between women with and without stress urinary incontinence: Evaluation by transabdominal ultrasonography. Neurourol Urodyn. 2017 Jan;36(1):98-103. https://www.ncbi.nlm.nih.gov/pubmed/26352786. Accessed 27 Sep. 2018.
  • Thompson & O’Sullivan. Levator plate movement during voluntary pelvic floor muscle contraction in subjects with incontinence and prolapse: a cross-sectional study and review. Int Urogynecol J Pelvic Floor Dysfunct. 2003 Jun;14(2):84-8. https://www.ncbi.nlm.nih.gov/pubmed/12851748. Accessed 27 Sep. 2018.
  • Bø et al. Transabdominal ultrasound measurement of pelvic floor muscle activity when activated directly or via a transversus abdominis muscle contraction. Neurourol Urodyn. 2003;22(6):582-8. https://www.ncbi.nlm.nih.gov/pubmed/22925244. Accessed 27 Sep. 2018.
  • Lee & Hodges. Behavior of the Linea Alba During a Curl-up Task in Diastasis Rectus Abdominis: An Observational Study. J Orthop Sports Phys Ther. 2016 Jul;46(7):580-9. https://www.ncbi.nlm.nih.gov/pubmed/27363572. Accessed 27 Sep. 2018.
  • Whittaker et al. Comparison of the sonographic features of the abdominal wall muscles and connective tissues in individuals with and without lumbopelvic pain. J Orthop Sports Phys Ther. 2013 Jan;43(1):11-9. https://www.ncbi.nlm.nih.gov/pubmed/23160368. Accessed 27 Sep. 2018.