Lewis Chan1 , Tom Jarvis2 , Stuart Baptist3 and Vincent Tse1
(1)
Department of Urology, Concord Repatriation General Hospital, Sydney, NSW, Australia
(2)
Department of Urology, Prince of Wales Hospital, Barker Street, Randwick, NSW, 2031, Australia
(3)
Sydney Sports and Orthopaedic Physiotherapy Group, Level 1, 139 Macquarie Street, Sydney, NSW, 2000, Australia
Lewis Chan (Corresponding author)
Email: lewis.chan@sswahs.nsw.gov.au
Tom Jarvis
Email: tomjarvis@ozdoctors.com
Stuart Baptist
Email: stuartbaptist@ssop.com.au
Vincent Tse
Email: vincent.tse@sydney.edu.au
Electronic supplementary material
The online version of this chapter (doi: 10.1007/978-3-319-04310-4_4) contains supplementary material, which is available to authorized users.
Ultrasound imaging is often performed in the assessment of the male patient with lower urinary symptoms (LUTS) and voiding dysfunction. The male pelvis can be imaged by transabdominal, transperineal and transrectal approaches (Fig. 4.1). Urologists have a long history of performing transrectal ultrasound in the diagnosis and treatment of prostate cancer and this aspect of imaging is beyond the scope of this book. This chapter will focus on the application of transabdominal and transperineal ultrasound in the assessment of voiding dysfunction in the male patient.
Fig. 4.1
(a) Transabdominal ultrasound scan of pelvis. (b) Transperineal ultrasound scan. (c) Transrectal ultrasound scan (intracavity transducer)
Transabdominal Ultrasound
Transabdominal ultrasound of the pelvis can assist in the evaluation of bladder outlet obstruction, measurement of bladder volume, post-void residual, prostate volume, ureteric jets (Fig. 1.20) and other bladder pathology such as tumours or stones.
Technique of Transabdominal Ultrasound
The examination is easily performed using 2D ultrasound equipment and a curved transducer for abdominal scanning (for example, a 2–5 MHz transducer). It is important to identify the pubic symphysis and place the transducer above this level and angulate the transducer appropriately to avoid loss of field of view caused by shadowing behind the pubic bone (Fig. 4.2). Common measurements in the male patient with voiding dysfunction include pre and post void residual volumes (Fig. 4.3), prostate volume (Fig. 4.4), bladder wall thickness and intravesical prostatic protrusion (Fig. 4.5). The scanning technique is detailed in Tips 4.1.
Fig. 4.2
Transabdominal ultrasound image of male pelvis (sagittal plane). It is important to identify the pubic symphysis and angulate the transducer appropriately to avoid loss of view caused by acoustic shadowing behind the pubic bone (arrow)
Fig. 4.3
Postvoid residual urine volume measurement. Ultrasound images of bladder in sagittal and transverse planes showing elevated residual urine and prostatomegaly
Fig. 4.4
Prostate volume measurement. Transabdominal ultrasound images of prostate in sagittal (left image) and transverse planes (right image)
Fig. 4.5
Measurement of intravesical prostatic protrusion (B) as a perpendicular line from the bladder base (A), and bladder wall thickness (C)
Transperineal Ultrasound
The male pelvis can also be imaged via the perineum. This approach (Fig. 4.6) has an emerging role in the evaluation of the pelvic floor in post-prostatectomy incontinence (see Cases 2 and 3). It also provides satisfactory imaging of the prostate for the measurement of prostate volume (which may be more acceptable than a transrectal route) given the difficulty in imaging the apex of the prostate for accurate volume measurement by the transabdominal route [1]. Transperineal ultrasound can also be used to image the prostate to guide biopsies in patients who have undergone abdominal-perineal (AP) excision of the rectum and thus are unable to have transrectal ultrasound. The scanning technique is detailed in Tips 4.2.
Fig. 4.6
Transducer placement for transperineal ultrasound in the male patient. The scrotum is lifted cephalad to allow placement of the transducer against the perineum
Applications of Pelvic Floor Ultrasound in Physiotherapy
Two useful applications for ultrasound imaging in the physiotherapy management of the urological patient are for stress urinary incontinence (SUI) post radical prostatectomy (RP) and in men presenting with chronic pelvic pain syndrome (CPPS).
Stress Urinary Incontinence (SUI)
Pelvic floor muscle strengthening has long been advocated for men as an intervention aimed at improving continence recovery post RP. Transperineal ultrasound gives a very clear field of view of the Anorectal junction (ARJ), Bulbar penile crus, and urethra. The striated urethral sphincter (SUS) can also be viewed (Fig. 4.7)
Fig. 4.7
Transperineal ultrasound imaging for pelvic floor muscle strengthening feedback
Prior to any kind of strength training accurate isolation of the correct muscles must first be achieved. Our aim is to reduce the dominant posterior levator ani action (anal component) of the pelvic floor contraction and instead educate the patient on a more anterior penile and SUS lift sensation.
Verbal cues are given to elicit less anterosuperior motion at the ARJ and more posterior slide of the SUS (a sensation of testicular vertical lifting) and an anterior slide of the bulbar penile crus (a sensation of penile indrawing – as if ceasing urination produced by the bulbocavernosus muscle).
The combination of posterior SUS motion and anterior bulbocavernosus contraction causes increasing urethral closure pressure and is therefore considered to be vital in improving continence outcomes [8].
Once evidence of high quality motor control is observed on ultrasound using verbal cueing then the patient may be encouraged to continue with a progressive hypertrophy program designed to further increase urethral closure pressure under progressive loads and functional movement patterns.
Male Chronic Pelvic Pain Syndrome (CPPS)
Also called Chronic Prostatitis, Proctalgia Fugax and Pudendal Neuraligia (amongst other names) this painful condition can often baffle the most experienced clinicians as there is often very little clinical evidence of an organic dysfunction. Cystoscopy, urinalysis, urodynamic and blood tests are often all within normal limits. The patient is often frustrated and frightened and is almost always in a state of high stress and anxiety.
Often the only clinical feature is an abnormally high anal sphincter tone and excessive discomfort during digital rectal examination (even though the prostatic tissue may feel within normal limits).
In these cases pelvic floor hypertonicity may be a contributing and perpetuating factor in this disabling condition.
Transabdominal ultrasound scanning can be a useful tool in evaluating bladder base rise/fall on contraction and release of pelvic floor contractions. Hypertonicity can be seen as a poor bladder base rise on volitional pelvic floor muscle activation and a slow return to a more rested/relaxed state following cessation of pelvic floor muscle activity (Fig. 4.8).
Fig. 4.8
Ultrasound of bladder base rise/fall on contraction and release of pelvic floor muscles
Relaxation of the pelvic floor musclulature can be taught whilst observing the bladder base during respiration. Hypertonic pelvic floors have a tendancy to prevent bladder base descent during inspiration. By giving patients cues to ‘release tension’ in the pelvic floor during the inspiratory phase of respiration (as intra-abdominal pressure increases) increased excursion of the bladder base in a caudad direction may be observed on ultrasound.
Continued practice of effective pelvic floor relaxation may be crucial in assisting in restoring normal pelvic floor tone to the patient with CPPS.
Cases
The following cases illustrate applications of pelvic floor ultrasound in assessment of the male patient with voiding dysfunction.
Case 1 Voiding Dysfunction
A 65-year-old man presented with reduced urinary flow, frequency, nocturia and a sensation of incomplete bladder emptying (Fig. 4.5, Video 4.1).
Comments
The images demonstrate prominent intra-vesical protrusion of the prostate. Various ultrasound imaging parameters have been investigated for the evaluation of bladder outlet obstruction in addition to functional parameters such as uroflow and pressure-flow urodynamic studies. These ultrasound measurements include prostate volume, post-void residual (PVR) urine measurement, bladder wall thickness and measurement of intravesical protrusion of the prostate. Prostate volume and residual urine has poor correlation with urodynamic outlet obstruction and the role of bladder wall thickness is controversial [2, 3]. Of all these parameters, the degree of intravesical protrusion of the prostate (Fig. 4.5) appears to have the best correlation with outlet obstruction [4].
Other ultrasound features of bladder outlet obstruction include trabeculation (Fig. 4.9), the presence of bladder diverticulum (Fig. 4.10) and presence of bladder calculi. Bladder calculi can generally be distinguished from calcified bladder tumours by tilting the patient and re-imaging in the decubitus position as calculi are mobile within the bladder (Fig. 4.11).
Fig. 4.9
Trabeculation of bladder wall with saccules in a male patient with chronic bladder outlet obstruction
Fig. 4.10
Bladder diverticulum. Transverse image of the bladder in a male patient with bladder outlet obstruction and a right sided bladder diverticulum (arrow)
Fig. 4.11
Bladder calculus. Decubitus image of bladder demonstrating echogenic calculus (arrow) with posterior acoustic shadowing. Prostate (p)
Ultrasound can also be employed as the imaging modality for urodynamic studies in certain circumstances. Transabdominal imaging during the filling phase of urodynamics allows detection of bladder trabeculation, intravesical prostatic protrusion and upper urinary tract assessment. Upper urinary tract dilatation may indicate effect of outlet obstruction or reflux (Fig. 4.12). However, it is generally not possible to image the urethra during voiding. A protocol for ultrasound imaging during urodynamic study is included in Tips 4.3.
Fig. 4.12
(a) Sagittal image of kidney (obtained during ultrasound urodynamics) in a patient with bladder outlet obstruction and reduced detrusor compliance demonstrating dilatation of collecting system during bladder filling. The hydronephrosis resolved post voiding (b)
Case 2 Post Prostatectomy Incontinence
A 65-year-old male presented with persisting severe urinary incontinence 18 months after a radical prostatectomy. He has tried pelvic floor (Kegel) exercises with little improvement (Fig. 4.13 and Video 4.2).
Fig. 4.13
Sagittal transperineal ultrasound image of patient with urinary incontinence post radical prostatectomy. Bladder (b), pubic symphysis (ps), urethra (bulbar) (u), external sphincter (arrow)
Comments
Pelvic floor ultrasound in the assessment of post-prostatectomy incontinence
Although urge incontinence is the most common type of incontinence in men and usually occurs in the setting of an overactive bladder, stress incontinence may occur following prostate surgery and is of increasing importance due to the popularity of radical prostatectomy as treatment for prostate cancer.
Urinary incontinence occurring after radical prostatectomy has a reported incidence of 2–60 % with a median of 10–15 %. The reported rates vary according to the definition of incontinence and the methods of evaluation (such as questionnaires, interviews by clinician vs independent reviewer). Risk factors identified include advanced age, stage of disease and previous radiation therapy. The surgical approach to radical prostatectomy (retropubic, perineal, laparoscopic/robotic) does not appear to be a significant factor [5].
Urodynamic evaluation is important to identify the underlying pathophysiology in patients with post- prostatectomy incontinence prior to consideration of surgical treatment. Although sphincteric incompetence/deficiency is the main cause of the incontinence in more than two thirds of patients, detrusor overactivity or poor compliance may be present in 40–60 % [6]. With an increasing number of treatment options for mild to moderate stress incontinence available, identification and management of associated detrusor dysfunction may therefore influence the ultimate choice of surgical treatment.
Transperineal ultrasound may be used as an alternative mode of imaging during urodynamics and can replace fluoroscopy. Dynamic transperineal 2D imaging allows assessment of the bladder, bladder neck beaking (Video 4.2) and urethral mobility. The clinician can also assess pelvic floor contractions and the success of a pelvic floor muscle (Kegel) exercise program which is commonly prescribed for patients with post prostatectomy incontinence (Video 4.3). MRI and ultrasound studies have shown that there is little urethral mobility/hypermobility in patients with post prostatectomy incontinence (unlike female stress incontinence) [7], (Fig. 4.14) so it is acceptable to perform perineal ultrasound with the patient lying comfortably in a supine position with legs slightly flexed and abducted (Fig. 4.6)- see Tips 4.2.
Fig. 4.14
Transperineal ultrasound images of patient with urinary incontinence post radical prostatectomy, at rest (left) and on Valsalva (right) demonstrating minimal urethral descent (B). The urethrovesical anastomosis/bladder neck at rest (A)
It is easier to assess bladder, bladder neck and urethral morphology during dynamic scanning with some urine in the bladder (ideally more than 100–150 ml). In practice, however, many patients with severe incontinence void frequently to reduce bladder volume and hence amount of stress incontinence. They may be unable to retain significant amount of urine for ultrasound assessment (video 4.2).
In trouble-shooting patients with a urinary prosthesis such as artificial urinary sphincter, ultrasound is useful to measure volume of fluid in the reservoir to detect leakage of fluid from the system (Fig. 4.15).
Fig. 4.15
Transabdominal ultrasound image of the pressure regulating balloon of an artificial urinary sphincter (AMS 800). The arrow indicates position of the tubing
Case 3 Post Prostatectomy Incontinence: Failed Male Sling
A 67-year-old male who underwent transobturator synthetic sling for incontinence post radical retropubic prostatectomy still requires the use of three medium pads per day. Preoperative urodynamic studies showed normal bladder capacity and a 24-h pad weight was 400 g. The patient reported initial improvement post-operatively but had significant deterioration in his continence at 3 weeks. Transperineal ultrasound scan was performed to assess sling position in this patient with early sling failure (Video 4.5).
Comments
Dynamic scanning: The evolving role of transperineal ultrasound in evaluation of male slings
There has been increasing use of transobturator slings in the treatment of post-prostatectomy stress urinary incontinence (Fig. 4.16). Three year data demonstrates these slings to be safe and effective in mild to moderate post-prostatectomy incontinence [8]. Whilst the exact mechanism of action of these slings remains unclear, transperineal ultrasound studies of male slings have demonstrated the phenomenon of ‘dynamic compression’ of the urethra (Fig. 4.17a, b, Video 4.4) with coughing and Valsalva that may be a mechanism of action apart from direct compression of the urethra. As synthetic slings are easily visualised on ultrasound, there is an evolving role in the use of dynamic transperineal ultrasound imaging to evaluate patients with failed slings (also see Tips 4.2)
Fig. 4.16
Male trans-obturator sling (Advance sling- image courtesy of American Medical Systems)
Fig. 4.17
Sagittal transperineal ultrasound images of AdVance sling at rest (a) and on coughing (b) demonstrating dynamic compression of the urethra. Bladder (b), pubic symphysis (ps), urethra (bulbar) (u), sling (arrow)
In this patient the transperineal ultrasound images (Fig. 4.18, Video 4.5) showed that there was displacement/malposition of the sling causing early sling failure. The patient subsequently had a successful re-do sling procedure (Fig. 4.19).
Fig. 4.18
Transperineal ultrasound image during Valsalva in patient with early failure post Advance sling showing malposition and lack of urethral compression (arrow). Urethra (bulbar) (u)
Fig. 4.19
Transperineal ultrasound image in patient who underwent re-do AdVance XP sling (green arrow) following early failure due to malpositioning
Tips 4.1 Easy Steps to Performing Bladder Ultrasound
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Tips 4.2 Technique of Transperineal Imaging of the Male Pelvic Floor
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Tips 4.3 Imaging Protocol for Ultrasound Urodynamics in Males
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