Ultrasound is a very quick,
inexpensive, non - radiation, less uncomfortable exam, being well accepted by the patient,
allowing also the dinamic study of the lower urinary tract 1,4,6,7,8; as the evaluation of the anatomical alterations
and specially the bladder neck mobility 3,4,6,9, being able to be done by abdominal way (Fig. 2), transvaginal,
or transperineal (Fig.4).
The abdominal way becomes limited to this exam in very obese patients, carriers of genital
prolapse or with a large capacity bladder, by the distance of the transducer and the
examined area 1,6 of all those ways of
access most authors prefer the transvaginal because of where it is localized which permit
a better and more adequate image definitions and because of the lesser discomfort they
provoke if compared to the transrectal way 1,4,7,8,10. Other authors profess transperineal way
because it does not interfere in the strain movement 2,3,5.
So interference does not occur in the
evaluation by transvaginal way ( mobility of the transducer to effort), the introduction
professes this until the maximum of 1.0 cm. of the vaginal vestibulum 1,6 (Fig. 5).
The standarization of the exam is extremely important for the reproductability of the
same, being essential that the way is exactly defined when the measurement and similar
instructions are given to women for the effort that is made in the Valsalva maneuver. It
is necessary to force around 30 cm H20; which is possible for all women 9.
The ultrasound obeys the following sequence and standarization: 1,8,9. The vesical volume recomended is between 200
and 300 ml. there is no significant difference between the proclaimed volume or larger
vesical repletion, not being recomended to do the study with an empty bladder 9.
The exam may be done in orthostatic position,
sitting or lying; not having significant alteration between them. Though it is recomended
the gynecological position which is the least uncomfortable 9.
The transducer is covered by a preservative and
lubrified with gel, being then introduced at the maximum of about 1.0cm. of vaginal
The ultrasound technician identifies the
structures (urethra, bladder, bladder neck and pubic symphysis) measuring the distance
between the bladder neck and the pubic symphysis in rest and during effort to evaluate the
amplitude of the displacement of the bladder neck in milimeters (Fig.6 A/B).
If the bladder displaces but remains above the pubic
symphysis the amplitude of the displacement is the substraction of these measurements, but
if it displaces below the pubic symphysis, the result will be the addition of these
It is observed that if the amplitude of the displacement of the utethrovesical function
(UVJ) was the same or larger than 1.0cm. in an incontinent woman and less than 1.0cm. in a
continent woman 1,4,7,9,10. In 95% of the women with incontinence, the
urethrovesical junction was below the pubic symphysis to effort.
The neck mobility is verified besides the opening or not of the proximal urethra (Fig.8), the
urethrovesical angle and most rarely the presence of non inhibited contractions of the
detrusor that deform the vesical contours 11. The deficiency of the sphincterian urethral
function may be suggested when the opening of the urethra in the mild urethra is bigger
than 5mm 1.
Nowadays this ultrasound evaluation technique is used to verify the anatomical position of
UVJ before and after the surgical correction, noting that the success of surgery was in
relation with this preoperative situation and with the new positioning of these structures
in the postopertative 3,4,5,8.
Other authors 8,12 used a endorectal US
to evaluate the success of the surgical correction in the immediate postoperative. It was
observed that of the 40 post-colposuspension patients that were studied, 29 of them had a
better clinical improvement (symptomatic) and anatomical and 11 of them persisted with the
same complaints. These last patients had an inadequate position of the vesical neck in the
postoperative, but this is not the only responsible factor for the surgical failure. The
anatomical restructure of the entirety should be taken in account, concluding that the
endovaginal US is a simple method to investigate premature/late results of the
postoperative of SUI.
Other authors attained a comparation between continent and incontinent women in the pre
and postoperative of colposuspension and concluded that in continent women the position of
the bladder neck was above the pubic symphysis on the contrary of the incontinent 4,8. Associated to SUI they also observed that the
position of the UVJ was below the pubic symphysis, besides the lowering of the bladder
neck with stress 4, 8.
Evaluating the successful postoperative, the bladder neck was noted more elevated in
relation to the pubis and during stress the opening of the neck, but a significant falling
does not occur 4, 8.
Among all the available methods for this evaluation the US shows itself more acceptable,
non invasive, less uncomfortable and produces adequate anatomical images.
Some authors 2,12 used the transrectal
US during the operative act of colposuspension. It helps in the identification and
measurement of the posterior urethro-vesical angle, identifying adequate suspension during
surgery, furthering better results and preventing complications, once that the urinary
retention in the postoperative is attributed to excessive suspension of the vaginal
walls,overelevating the urethovesical junction and the bladder neck.
The help of the US in the surgery act helps to make prophylaxy of these complications.