Objective Three-/four-dimensional translabial ultrasound (TLUS) is gaining popularity for the assessment of anal sphincter trauma, although repeatability data are lacking. This study aimed to determine the repeatability of tomographic ultrasound imaging (TUI) on TLUS for the diagnosis of external anal sphincter (EAS) trauma and compare the performance of a novice with that of an experienced investigator.Methods This was a retrospective study of archived ultrasound datasets of patients who presented with symptoms of pelvic floor dysfunction and were examined twice between 2012 and 2016 at an average interval of 260 (range, 1-1100) days. All volumes were obtained using a GE Medical Systems Voluson 730 Expert or E8 ultrasound system. Post-processing of volumes was performed independently by two investigators, one with over 1 year's experience and another with no prior experience in using TUI, who were blinded to clinical data, each other's results and the results obtained at the first timepoint. Significant trauma on EAS was diagnosed if four of the six TUI slices showed a defect of ≥ 30 • . Intra-and interobserver agreement were determined using Cohen's kappa (κ) and intraclass correlation coefficients.Results During the study period, 105 women underwent two TLUS assessments of the anal sphincter. Of these, 103 patients with ultrasound volumes available for both timepoints were included in the analysis. The novice investigator demonstrated average repeatability for assessment of significant EAS trauma and single-slice defect (κ, 0.30 and 0.22, respectively) despite relatively high agreement between measurements obtained at the two timepoints (84.5% and 79.3%, respectively). The experienced investigator demonstrated good to very good repeatability for significant EAS trauma and single-slice defect (κ, 0.91 and 0.78, respectively) between the Correspondence to: two assessments, which equates to 98.1% and 94.7% agreement, respectively. ConclusionThe repeatability of TLUS measurements for diagnosis of EAS trauma seems to be very good when imaging is undertaken with state-of-the-art equipment and the analysis is performed by an experienced observer; however, the performance of a novice investigator is much poorer.

BackgroundPelvic organ prolapse (POP) is a common chronic health issue. Pessary rings are used for conservative management. To date, there is little evidence on objective anatomical findings as predictors of successful ring pessary management.AimTo determine any association between history, clinical and four‐dimensional translabial ultrasound (TLUS)/pelvic floor ultrasound examination and pessary success.Materials and MethodsFrom November 2013 to November 1015, all new patients presenting with symptomatic prolapse to a tertiary urogynaecological unit underwent an assessment including interview, clinical examination, that is, International Continence Society POPQ (pelvic organ prolapse quantification) and TLUS. Women with symptomatic prolapse were offered conservative management with a ring pessary. Those who agreed had a ring inserted that day. Successful trial of pessary use was defined as continued use for at least three months. Retrospective analysis of imaging data was performed blinded to other data. Statistical analysis was performed to assess the relationship between history, examination and imaging and pessary success.ResultsOf 525 patients seen during the inclusion period, 177 had symptomatic prolapse. One hundred and twenty‐eight were offered a pessary, 89 accepted. Five had incomplete data, leaving 84. Forty‐ Two (50%) were still using the pessary at a three‐month follow‐up. Predictors associated with failure included being pre‐menopausal (P = 0.031), a previous hysterectomy (P = 0.051), increasing genital hiatus and perineal body (Gh + Pb) (P = 0.013), posterior compartment prolapse (P = 0.027) and a larger hiatal area on Valsalva on TLUS (P = 0.049). Pre‐menopausal status (P = 0.003), increasing Gh + Pb (P = 0.011) and previous hysterectomy (P = 0.001) remained significant on multivariate analysis.ConclusionsA history of previous hysterectomy is a predictor of pessary failure as are Gh+Pb on Valsalva and premenopausal status.

Objectives-Exoanal 4-dimensional translabial ultrasound (TLUS) is increasingly used to image the anal sphincter. The aim of this study was to define the limits of normality for assessment of external and internal anal sphincters with TLUS.Methods-This study was a retrospective analysis using data sets of nulliparous women seen antenatally. All women had a 4-dimensional TLUS examination at a mean gestational age AE SD of 36 AE 0.7 (range, 32.9-37.3) weeks. Anal sphincter biometry, including external anal sphincter (EAS) length and thickness, EAS proximal rotational asymmetry, and internal anal sphincter thickness, was assessed blinded against other data.Results-A test-retest series showed good repeatability (intraclass correlation coefficients, 0.619-0.849) of all parameters. The mean age of the women (n = 111) was 30.9 (range, 18.8-40.5) years. None reported anal incontinence. On tomographic imaging, none showed anal sphincter defects. The mean EAS length was 17.5 (range, 8.4-34.8) mm, being shorter dorsally at 16.4 (range, 7.0-32.7) mm versus 18.7 (range, 7.5-36.9) mm ventrally (P < .001). The ventral EAS reached farther cranially by 0.8 AE 2.5 (range, -4.8-5.1) mm on average. The mean EAS thickness was 3.4 (range, 2.0-5.8) mm, being thicker dorsally than ventrally (P < .001).Conclusions-Anal sphincter biometry can be assessed with good repeatability by TLUS. The EAS seems longer ventrally. Asymmetry of the EAS could result in a false-positive diagnosis of defects in women in whom the ventral EAS terminates more caudally than its dorsal aspect, which seems uncommon. Hence, the likelihood of a false-positive diagnosis of substantial defects of the EAS using the published method seems low.

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