 Hello everybody, I am Dr. Alpena Zushi, I am a consultant sonologist practicing at Malad Shubha Diagnostic Centre. I have been practicing since the last 26 years and my main area of interest is obstetrics and gynaic ultrasound. So today in the series of gynaic workshops, we will be talking about the pelvic floor imaging. So when you start doing a pelvic floor imaging, your probe has to be on the perineum, the patient is in the lithotomy position and a transducer, a convex transducer. We have used a volume transducer here. The volume transducer is kept over the perineum and then the image is acquired. So if you see this image, this is a 4 images which are seen but if you make it a single image, you will see that there is, this is a pubic symphysis, this is the bladder. Then if you just walk through it, you will start seeing the urethra. So now you are seeing the urethra here. This is the bladder, the bladder is almost empty. This echogenic kind of a line which you see around that is the sphincter. Then this is the vagina, vagina is always collapsed and this particular portion is the anus and this is the rectum. So this is a recto anal angle. This is a curvature which you see the rectum and then this portion which is devoid of any stools is the anus. So we go back to the image of 4 and since this was acquired really well, you can literally see the 4D image, I mean the volume rendered image which is seen pretty well. So here what are the landmarks? What you see is this entire thing is called a pelvic hiatus. This is the urethra. This smiley kind of a face or smiling picture what you see is the vagina. This is the collapsed vagina and this is the anal canal. This will be the posterior most portion. So this entire thing will be a pelvic hiatus and here there will be a pubic symphysis which is seen. So this is a basic image and then there are certain measurements which are very useful. So here since we are using a mind ray Resona 7 system, it has again some auto calculations. If you can see it on the image, you can just give two inputs. One is the urethra and one is the posterior most portion of the pelvic hiatus and then if you see it has given you the calculations automatically. This is the first calculation if you see is the AP diameter. So this is the AP diameter of the pelvic hiatus. The second measurement it has taken is the lateral diameter and it is this particular lateral diameter. Then it has calculated the area or the circumference. So this is the area which has calculated. So again if you this we have done it at rest. So if you take the measurements of the pelvic floor at rest or while doing the valsalvas or while doing an active pelvic contraction, the measurements are going to be little bit different. When the woman is contracting the pelvic floor, these dimensions are going to be little less in size and when the woman is performing a valsalvas it is going to be little more the measurements are going to be on the higher side as compared to the measurements at rest. So this is where you see the area and circumference. These measurements normally do not exceed more than 20. LUG is the levator urethra gap. If you see this pelvic hiatus, here this narrow small portion what you see it is lined by the levator ni muscle. So this is the lateral moose portion of the levator ni and this is the urethra. So from urethra to levator. So this is the distance which you take as a levator urethra gap. This usually is 2 centimeters and as you can see here it is 1.9 and 2.1 centimeters on right and left side. So these measurements are within normal range. So in case if there is a pelvic organ prolapse, if there is a levator ni tear then you will see that there will be this distance which might get increased if there is a tear somewhere here. If there is a tear on this side then this particular distance will be increased. So this is the importance of doing the measurements. So it is not mandatory to do these measurements all the time. If you are just looking at the pelvic organ prolapse but one should know these measurements to give the accurate reporting. The another approach what can be used is kind of slicing through the images. If you can see this is almost like a CT scan or MRI section it is called eye page in this different systems will have a different kind of name to it. But as you can see here this is taking the different slices through the pelvic floor and then there are certain protocols to be followed about the depth of this or where you keep these slices and then if you see in fact here you will see the levator ni if there is a tear properly and then you will see whether it is what is the extent of that tear. If you see the tear in more than 2 slices more than 3 slices then you know that levator ni tear is more extensive than if you see it in only 2 sections or in 1 section. So this is another way of looking at the pelvic floor which is the different slices as if you are seeing a MR image of the pelvic floor. So this was another patient who had a pelvic organ prolapse. So in fact if you will see now this image which is the volume rendered image is looking little ugly because there was a vaginal prolapse there was a uterine prolapse and then you can you are not seeing that smiley face here the urethra is seen here. So what you can do is you can try and make this image little better by doing some adjustments of the size and the position of this and as you can see here now the urethra and the posterior portion is seen better. You can at least imagine that there is some pelvic hiatus kind of a structure which is seen this is the urethra here and if you compare it with the previous slide you will understand that this pelvic hiatus is really roomy. It has much more area of the circumference than what we saw previously. So if here again we go to that smart pelvic calculations and give it two points where the urethra is and then again it will calculate automatically and if you will see that these measurements have gone the measurement which is seen of the area and the circumference is everything is more if you see that it was coming to around the circumference is coming to around 22 the area and the circumference if you see the levator urethra gap also is little increased because the hiatus is wide and then when you see that this distance is considerably more 2.9 you can you know really suspect that there may be a levator anion tear and then you can do these slicing through that and then try and see if there is a levator anion tear also along with it or not.