[ clinical commentary ]

Jackie L. Whittaker, PT, FCAMT1 • Judith A. Thompson, Dip PT, Post-grad Dip PT, PhD2
Deydre S. Teyhen, PT, PhD, OCS3 • Paul Hodges, PhD, MedDr, BPhty (Hons)4

Rehabilitative Ultrasound Imaging

of Pelvic Floor Muscle Function

I
t is well accepted that the pelvic floor muscles, specifically the is to provide an understanding of cur-
levator ani, provide an important contribution to the continence rent applications, the available quanti-
tative and qualitative information, the
mechanism.17,18 However, there is growing evidence from
associated limitations, and to show how
biomechanical models,65 as well as neurophysiological40,76,77 and rehabilitative ultrasound imaging can be
epidemiological28,66,78 studies, that this muscle group also plays an incorporated as a form of biofeedback
important role in postural control of the lumbopelvic region. Both during rehabilitation. Furthermore, as
low back pain (LBP) and urinary incontinence (UI) are prevalent the compilation and comparison of data
depends on consistency of measurement
physical ailments,42,90 and clinical experts Ultrasound imaging is a potential tool techniques, this commentary highlights
have long alluded to their empirical asso- that has been used to evaluate the mor- considerations for measurement accuracy
ciation. In a recent epidemiological study, phology7,52 and certain components of and interpretation and provides generic
Smith et al78 determined that disorders the function24,27,67,81,82,86 of these muscles. guidelines for future investigation based
of continence are more strongly related Specifically, ultrasound imaging has been upon international consensus.80
to frequent LBP than obesity and levels shown to be more specific than intravagi-
of physical activity, while Eliasson et al28 nal palpation for measurement of the lift- QUANTITATIVE EVALUATION
found that 78% of women with LBP re- ing action of the pelvic floor muscles on

U
port concurrent UI. As such, there is a the bladder neck31 and base,20,31 and it ltrasound imaging has been
need for physical therapists to have ac- provides information about the support- used to measure the morphology7,52
cess to tools that accurately evaluate the ing function of the pelvic floor muscles of the pelvic floor muscles. It has
various aspects of pelvic floor muscle during various maneuvers.20,57,85 also been used to measure the impact of
function (elevating and occlusion func- As the use of rehabilitative ultra- pelvic floor muscle contraction or increase
tions, as well as neuromuscular control, sound imaging for assessment of pelvic in intra-abdominal pressure (straining,
strength, and endurance) both in labora- floor muscles function is a relatively new cough, sneeze, or leg-raising task) on
tory and clinical environments. procedure, the goal of this commentary the bladder from a variety of approaches
(transperineal and transabdominal; Fig-
t Synopsis: This commentary provides an tion. Furthermore, as the ability to compile and ure 1), planes (sagittal and transverse),
overview of the current concepts and evidence re- compare existing evidence depends on the degree and positions.6,22,27,57,61,67,76,83,84,96 The
lated to rehabilitative ultrasound imaging of pelvic of similarity in methodology by investigators, this transperineal approach (placement of
floor (levator ani) function. As this is an emerging commentary highlights points of consideration the ultrasound transducer in a sagittal
topic, the goal is to provide a basic understand- and provides guidelines, as well as an agenda, for
plane along the midline of the perineum)
ing of ultrasound imaging applications related future investigation. J Orthop Sports Phys Ther
2007;37(8):487-498. doi:10.2519/jospt.2007.2548 is considered advantageous to the trans-
to levator ani function: the available quantitative
abdominal approach, as both the pubic
and qualitative information, the limitations, as t Key Words: levator ani, sonography,
symphysis and the proximal junction of
well as how ultrasound imaging can be incorpo- therapeutic exercise, transabdominal ultrasound
rated as a form of biofeedback during rehabilita- imaging, transperineal ultrasound imaging the bladder neck and urethra are includ-
ed within the field of view and can serve
1
 MPhil/PhD Candidate, School of Health Professions and Rehabilitation Sciences, University of Southampton, Highfield Campus, Southampton, UK; Physical Therapist, Whittaker
Physiotherapy Consulting, White Rock, BC, Canada 2 Lecturer, School of Physiotherapy, Curtin University of Technology, Perth, Western Australia; Physical Therapist, Body logic Physiotherapy,
Shenton Park, Western Australia. 3 Assistant Professor, US Army-Baylor University Doctoral Program in Physical Therapy, San Antonio, TX; Director, Center for Physical Therapy Research,
Fort Sam Houston, TX; Research Consultant, Spine Research Center and the Defense Spinal Cord and Column Injury Center, Walter Reed Army Medical Center, Washington, DC. 4 NHMRC
Centre of Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia. The opinions or
assertions contained here in are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Army, Air Force, or Defense.
Address correspondence to Jackie Whittaker, Whittaker Physiotherapy Consulting, #101, 12761 16th Ave, White Rock, BC, Canada V4A 1N2. E-mail: J.L.Whittaker@soton.ac.uk

journal of orthopaedic & sports physical therapy | volume 37 | number 8 | august 2007 | 487
 [ clinical commentary
as points of reference. Furthermore, the
transperineal approach provides a direct
view of the levator ani, facilitating study of
its morphology.52 Recently, there has been
renewed interest in the transabdominal
approach, as it is a noninvasive method31
that can provide clinicians with novel
information about some components of
pelvic floor muscle function. Comparing
sagittal transperineal and transabdomi-
nal approaches during pelvic floor muscle
contraction, straining, and an abdominal
curl in a group of women with inconti-
nence and continent controls, Thomp-
son et al83,84 demonstrated that, although
a divergence in bladder base (observed
with transabdominal ultrasound imag-
ing) and bladder neck motion (observed
with transperineal ultrasound imaging)
occurred in 15% of the subjects, there
was a significant correlation between
measurements across the tasks.
Measurement Protocols for Bladder
Base, Bladder Neck, and Anorectal Angle
Motion
Rehabilitative ultrasound imaging ap-
plications aimed at assessing pelvic floor
muscle function generally employ a stan-
dard medical ultrasound imaging system
used in conjunction with a 3.5- to 5.0-
MHz curved array transducer (40-mm
Ultrasound
transducers
Trans
abdominal Pubic symphysis
Urethra
Bladder
neck
Uterus
Base Trans
perineal
Rectum Vagina
Sacrum
FIGURE 1. Comparison of transperineal and trans-
abdominal ultrasound. Note the different transducer
locations and regions of the bladder where movement
is visualized (bladder base for transabdominal and
bladder neck for transperineal). Reproduced with per-
mission of International Urogynecology Journal.84
488 | august 2007 | volume 37 | number 8 | journal of orthopaedic & sports physical therapy
footprint) to generate 2-dimensional
brightness mode (b-mode) images of the
structures of interest. This convention is
reflected in the following section; how-
ever, emerging applications that use mo-
tion-mode (m-mode) to investigate the
endurance or ability to sustain an elevat-
ing contraction and the application of 3-
dimensional imaging techniques for the
evaluation of the pelvic floor21 are being
developed.
Transperineal Ultrasound Imaging
Transperineal ultrasound imaging pro-
vides a sagittal plane view of the junction
between the bladder neck and proximal
urethra, the anorectal angle (ARA), as
well as the pubic symphysis, which serves
as a fixed bony landmark from which
measurements can be made (Figures 1
and 2). The technique for evaluation of
bladder neck and ARA motion during
pelvic floor muscles contraction and Val-
salva maneuver are well established.20,59-
61,73,74
As measurements of bladder neck
and ARA mobility can be influenced by
a variety of factors, including bladder
filling, subject and transducer position,
measurement sites, and verbal instruc-
tions,22,26,53,74 consistent methodology
must be employed.
Transperineal ultrasound imaging is
most commonly performed with the sub-
ject in a dorsal lithotomy position with
A B
Urethra
PS
Bladder
FIGURE 2. (A) Transperineal ultrasound image of the bladder (reproduced with permission of International Urogyne-
cology Journal84). (B) Labeled outline of the transperineal image. Abbreviation: PS, pubic symphysis.
]
the hips flexed, the knees slightly abduct-
ed, and the lumbar spine in neutral.20 If
circumstances demand, the technique
can also be performed in standing22 or
sitting over a toilet chair47; however, care
must be taken when comparing images/
measures made in different positions.
The ultrasound transducer is placed in
the midline of the perineum, in the sag-
ittal plane, after covering it with ultra-
sound gel followed by a nonpowdered
surgical glove or plastic wrap for hygienic
reasons, and further gel. The labia may
need to be parted to obtain a clearer im-
age, which should include the pubic sym-
physis, the urethra and bladder neck, the
vagina, the cervix, rectum, and anal ca-
nal. For the assessment of bladder neck
movement during pelvic floor muscle
contraction and functional maneuvers, a
measurement of the bladder neck rela-
tive to the pubic symphysis is taken using
a standardized method (Figure 3).61,74 As
the bladder neck and proximal urethra
exhibit greater mobility when the blad-
der is nearly empty, bladder filling should
be specified.26 With transperineal ultra-
sound imaging, voiding prior to evalua-
tion is preferable.20
Verbal instructions that have been
used to encourage contraction of the pel-
vic floor muscles include “draw in and
lift the pelvic floor muscles while breath-
ing normally.”83 Instructions that have
Urethra
PS
Bladder
Cranial
been used to encourage an increase in
intra-abdominal pressure via a Valsalva
maneuver (a forced expiration against a
closed glottis) include “strain downwards
with maximal effort.”83
Transabdominal Ultrasound Imaging
Transabdominal ultrasound imaging of
the bladder and pelvic floor was originally
described by White92 for the investigation
of women with stress UI. However, the
technique was abandoned in favor of the
transperineal approach, due to the inabil-
ity of transabdominal imaging to consis-
tently provide a view of the bladder neck,
which is a common point of investigation
for women with incontinence. The trans-
abdominal approach (both sagittal and
transverse planes) has received renewed
interest, as it is a relatively noninvasive
method to provide clinicians with novel
information about some components of
pelvic floor muscle function, as well as
serving as source of biofeedback when
retraining the pelvic floor muscles.27
Transabdominal ultrasound imaging is
used to assess the lifting aspect of a pel-
vic floor muscle contraction by observa-
tion of movement of the bladder base as
a marker for pelvic floor muscle activity
during voluntary pelvic floor muscle con-
tractions.9,57,75,86 As with the transperineal
approach, measurements of bladder base
mobility, assessed transabdominally, can
be influenced by a variety of factors, in-
cluding bladder filling, subject and trans-
ducer position, measurement sites, and
verbal instructions.
Transabdominal ultrasound imaging
can be performed in the supine, crook-
lying (supine with hips and knees flexed),
sitting, and standing positions.9,31,75,84,86
Reliability data have been reported for
images gathered in crook lying75,84; how-
ever, it has yet to be established for the
other positions. Standardization of test-
ing positions is critical, including the
posture of the lumbar spine, as coactiva-
A B
tion between the pelvic floor muscles and
abdominal muscles varies with degree
of lumbar lordosis72 and may affect the
displacement of the bladder base. Fur-
thermore, the amount of bladder base
displacement is influenced by subject po-
sition. For example, Frawley et al31 dem-
onstrated that a voluntary contraction
of the pelvic floor muscles, viewed with
transabdominal (sagittal) ultrasound im-
aging, resulted in greater displacement of
the bladder base in standing than in the
supine (P = .003) and sitting (P = .001)
positions. A further consideration is the
importance of testing pelvic floor muscle
function in a variety of positions, as sub-
jects who are unable to elevate the blad-
der base in supine lying may be able to do
so in standing.31
For sagittal plane transabdominal
ultrasound imaging of the bladder base,
the ultrasound transducer is placed in
BN

Bladder
PFM
contraction
Bladder
neck

Rest

Cranial
Valsalva
Pubic
Symphysis FIGURE 4. (A) Ultrasound transducer placement for sagittal ultrasound imaging of the bladder using the transab-
dominal approach. (B) A sagittal ultrasound image of the bladder. Reprinted from Ultrasound Imaging for Rehabili-
tation of the Lumbopelvic Region: A Clinical Approach, by Whittaker,94 with permission from Elsevier. Abbreviation:
y-axis (mm) BN, bladder neck.

A B

Bladder

FIGURE 3. Transperineal ultrasound assessment of

MPFS
bladder neck position at rest, during a pelvic floor
muscle contraction and Valsalva. The measurement
graph for calculation of vector length during Valsalva
is shown. The displacement is measured by calculat-
Right
ing a vector from the resting position (x1y1) to the
position at the end of the maneuver (x2y2), using the FIGURE 5. (A) Ultrasound transducer placement for transverse ultrasound imaging of the bladder. (B) A transverse
following formula: vector length a2 = b2 + c2, where b ultrasound image of the urinary bladder and midline pelvic floor structures using the transabdominal approach. Re-
= y1 – y2 and c = x1 – x2. Reproduced with permission printed from Ultrasound Imaging for Rehabilitation of the Lumbopelvic Region: A Clinical Approach, by Whittaker,94
of International Urogynecology Journal.84 with permission from Elsevier).

journal of orthopaedic & sports physical therapy | volume 37 | number 8 | august 2007 | 489
 [ clinical commentary
a midline sagittal orientation immedi-
ately superior to the pubic symphysis
on the lower abdomen. The angle of the
transducer is manipulated until it points
posterior and inferior to the symphysis
pubis (towards the posteroinferior re-
gion or base of the bladder), allowing
for a clear image of the bladder and the
proximal aspect of its neck (Figure 4).
The marker on the transducer, which in-
dicates the left side of the screen, should
be oriented towards the patient’s head.
For transverse plane transabdominal
ultrasound imaging of the bladder base,
the transducer is placed in a transverse
orientation, across the midline of the
abdomen, immediately superior to the
pubic symphysis. The angle of the trans-
ducer is manipulated until it is approxi-
mately 60° from the vertical and aimed
towards the base of the bladder (Figure
5). It is recommended that the marker on
the transducer (indicating the left side of
the display screen) is oriented according
to standard radiological convention (eg,
towards the right side of the supine sub-
ject)15; however, this may not always be
appropriate in clinical situations when
assessing dynamic functional activities.
The angle of the ultrasound transducer
should be adjusted until there is a clear
image of the bladder and midline pelvic
floor structures (urethra, perineal body,
rectum, etc). A key consideration in accu-
rately interpreting bladder base motion
with the transabdominal approaches is
consistency of transducer position with
respect to the bony pelvis. Abdominal
muscle activity during functional tasks,
inappropriate bracing of the abdominal
muscles during voluntary contraction of
the pelvic floor muscles,83 and increases
in intra-abdominal pressure are associ-
ated with a potential for the transducer
to be pushed outward. This outward
motion increases the distance from the
transducer to the bladder base and may
be misinterpreted as bladder descent. In
these circumstances, the manual inward
pressure of the transducer must be ma-
nipulated such that its position is main-
tained. Inclusion of the pubic symphysis
490 | august 2007 | volume 37 | number 8 | journal of orthopaedic & sports physical therapy
in the transabdominal image by adjust-
ment of the transducer angle can provide
a landmark to assist with this control.
The most commonly reported marker
for the bladder base is the region of the
posteroinferior bladder wall ( junction
of the hyper and hypoechoic structures)
(Figure 1), which demonstrates the great-
est displacement during the event being
investigated (pelvic floor muscle contrac-
tion or Valsalva maneuver). It is impor-
tant to note that with sagittal applications
involving increases in intra-abdominal
pressure (eg, Valsalva maneuver) this site
has been shown to be less reliable. To ob-
tain a clear image of the posteroinferior
bladder wall the bladder must contain
sufficient fluid. This can be accomplished
by a standardized bladder-filling protocol,
which involves asking the subject to void
1 hour before testing, then to drink 450
to 500 ml of water and to not void until
after the test.58,84 It is important to note
that unlike other abdominal ultrasound
scans, such as those associated with in-
trauterine fetal imaging, where the blad-
der needs to be near full capacity to serve
as an acoustic window, overfilling in this
situation may confound the assessment
process by increasing the resting activity
of the pelvic floor muscles.
Reliability
Reliability of Transperineal Ultrasound
Imaging  The position and mobility of
the bladder neck have been reported to
be reliable when assessed with transperi-
neal ultrasound imaging.20 The reference
points used to generate this measure-
ment are either the central axis or infe-
rior margin of the symphysis pubis and
the junction of the proximal urethra with
the bladder.20 This methodology has been
shown to have good intra and interrater
reliability (ICC, 0.76-0.98) for the mea-
surement of bladder neck movement dur-
ing a pelvic floor muscle contraction and
Valsalva maneuver.19,61,74
Although measurement techniques
used in the aforementioned investiga-
tions show good reliability, it is important
to note that this is influenced by the skill
]
of the operator, the degree of standard-
ization of the performance of task by the
subject/patient, as well as factors that af-
fect the mobility of the bladder (bladder
filling,26 catheterization, and patient po-
sition22,53,75). For instance, some women,
particularly those who are nulliparous,
find it difficult to perform an effective
Valsalva maneuver20 and therefore it is
difficult to compare the strength and the
quality of a maximal effort. Although in-
vestigators have attempted to standardize
the degree of Valsalva maneuver41,46 by ei-
ther directly monitoring intra-abdominal
pressure during the effort41 or by moni-
toring rectal and intravesical (bladder)
pressure while patients blew into a mod-
ified sphygmomanometer,46 these tech-
niques may represent different actions
and may result in different patterns and
levels of pelvic floor muscle activity.71 Fur-
thermore, attempts to limit the amount
of effort during a Valsalva maneuver may
limit the amount of bladder descent ob-
served.20 Therefore, it is important to
consider that the method of the Valsalva
maneuver may affect reliability and that
the technique of the Valsalva maneuver
must be specified.
Reliability of Transabdominal Ultra-
sound Imaging  Transabdominal ultra-
sound imaging is primarily used to assess
the lifting aspect of a pelvic floor muscle
contraction by observation of movement
of the bladder base as a marker for pel-
vic floor muscle activity during voluntary
pelvic floor muscle contraction.9,57,75,86 The
technique has also been used to assess the
amount of movement at the bladder base
during various functional maneuvers that
increase intra-abdominal pressure, such
as the Valsalva maneuver, an abdomi-
nal curl-up, and lower extremity lifting
tasks.56,57,83,84 Good intrarater and interra-
ter reliability for measurement of bladder
base displacement (transverse and sagit-
tal views) during a pelvic floor muscle
contraction (ICC, 0.81-0.88),76 as well
as good intrarater reliability (transverse
view) during functional, active, straight-
leg raise testing (ICC, 0.98),57 have been
reported. In contrast, Thompson et al83,84
reported only moderate reliability for the
measurement of bladder base displace-
ment (sagittal view) during an abdominal
curl-up (ICC, 0.53) and Valsalva maneu-
ver (ICC, 0.51). This is likely explained by
the difficulty in maintaining a consistent
transducer position when the abdominal
wall is stiffened or displaced outward dur-
ing contraction of the abdominal muscles
or an increase in intra-abdominal pres-
sure, and may limit the use of this view
during these postural tasks.
Although both the transverse and
sagittal transabdominal views have good
reliability for assessment of bladder base
movement during pelvic floor muscle
contraction, the transverse view may
provide additional information about the
symmetry of the contraction based on the
symmetry of the bladder base movement.
However, the clinical significance of this
measure has not been assessed. It is im-
portant to note that movement of the
bladder base during pelvic floor muscle
contraction may only be visible in 1 plane
in some individuals, and therefore the use
of both views is recommended.
Interpretation of Pelvic Floor
Displacement
Motion of the pelvic floor is dependent
on a range of factors that complicate the
interpretation of ultrasound imaging.
Two main issues require consideration:
intra-abdominal pressure and the start-
ing position of the pelvic floor. Increased
intra-abdominal pressure due to contrac-
tion of the diaphragm and abdominal
muscles directly opposes the elevation
of the bladder base during a pelvic floor
muscle contraction. Consequently, el-
evation of the bladder base may not be
evident during functional tasks that in-
volve activation of the abdominal and
diaphragm muscles, despite increased
activity of the pelvic floor muscles, if the
increase in intra-abdominal pressure
prevents shortening of the pelvic floor
muscles. It has been suggested in specific
populations that increased intra-abdomi-
nal pressure may overcome the contrac-
tion of the pelvic floor muscles and lead
journal of orthopaedic & sports physical therapy | volume 37 | number 8 | august 2007 |
to caudal displacement of the bladder
base.57 During voluntary contraction of
the pelvic floor muscles, some women
activate abdominal muscles in addition
to the pelvic floor muscles, with a resul-
tant caudal displacement of the bladder
base.81 Thus consideration of the activity
of the other muscles that surround the
abdominal cavity and the associated in-
crease in intra-abdominal pressure must
be considered during ultrasound imaging
evaluation of pelvic floor displacement.
Motion of the pelvic floor also depends
on its starting position, which is depen-
dent on preexisting pelvic floor muscle
activity and the laxity of the myofascial
system. For instance, if the bladder base
is already elevated due to resting activ-
ity of the pelvic floor muscles, further
elevation may not occur when the pelvic
floor muscles are contracted voluntarily
or during a functional task. Similarly,
decreased laxity of the myofascial sys-
tem could maintain the bladder base in
an elevated position. Conversely, greater
laxity may result in a more caudal start
position and therefore greater potential
for motion. Thus the amount of blad-
der base elevation seen with ultrasound
imaging is dependent on a number of
interdependent factors that are likely to
complicate the interpretation of pelvic
floor muscle function. Furthermore, the
amount of elevation is not likely to be di-
rectly correlated with pelvic floor muscle
activity except in very specific situations
in which the pelvic floor muscles contract
from rest with no concurrent activity of
abdominal or diaphragm muscles.
For these reasons, clinical assess-
ment requires diligent inquiry as well as
the amalgamation of information from
a range of assessment tools, including a
detailed history, digital palpation, evalu-
ation of abdominal muscle activity, and
changes in breathing as well as ultrasound
imaging. Ultimately, it is the opinion of
the authors that, due to the interplay of
the above-mentioned factors, the ability
to generate accurate, reliable, and mean-
ingful measurements with transperineal
and transabdominal ultrasound imaging
of the bladder and pelvic floor structures
requires specialized training, diligent in-
quiry, and considerable experience.
Validity of Transperineal and Transab-
dominal Ultrasound Imaging
Magnetic resonance imaging (MRI) and
indwelling electromyography (EMG)
have been used to establish the validity
of ultrasound with respect to measure-
ment of the morphology (using MRI)
and activation (using EMG) of other
muscles, including the transversus ab-
dominis37,39,49 and lumbar multifidus.38,45
No studies have described the relation-
ship between the amount of EMG activ-
ity of the pelvic floor muscles and pelvic
floor elevation. However, as mentioned
above, it is likely that this relationship
would be affected by the complex inter-
relationship between elevation, intra-
abdominal pressure, start position, and
preexisting myofascial laxity. Several
MRI studies have investigated the be-
havior of the pelvic floor muscles during
voluntary contraction and straining in
both continent and incontinent popula-
tions,8,14,29 and have provided data that
are consistent with the findings of ul-
trasound imaging. Using MRI with sub-
jects in a supine position, Christensen et
al14 reported on bladder wall movement
during a voluntary pelvic floor muscle
contraction in continent females. They
specifically reported that the greatest
amount of motion (mean 6 SD, 7.0 6
2.8 mm) occurs at the posteroinferior
region of the bladder wall (bladder base),
and that this displacement is most easily
observed from the sagittal plane. Bo et
al8 reconfirmed the elevating function of
the pelvic floor muscles through dynamic
MRI in a seated position and measured
the inward motion of the bladder base
(10.8 6 6.0 mm) in a group consisting of
both continent and incontinent women.
Furthermore, these authors demonstrat-
ed a mean outward motion of 19.1 6 7.4
mm associated with straining. Although
not directly compared, these values are
within the range measured with transab-
dominal ultrasound imaging. 9,75
491
 [ clinical commentary
Comparison of Transperineal and Trans-
abdominal Ultrasound Imaging
As indicated above, transperineal ultra-
sound imaging has advantages over the
transabdominal approach, as it allows
visualization of the junction between the
proximal urethra and bladder neck, as
well as providing a fixed bony landmark
from which all measurement can be
made, thus increasing the reliability for
comparisons between subjects. However,
the transperineal technique requires ex-
tensive training, interpretation of trans-
perineal images necessitates experience,
transducer location is more invasive and
may interfere with some functional ma-
neuvers, and measurement is complex
and time consuming.
By comparison, transabdominal ul-
trasound imaging is a relatively easy
technique to learn, measurements and
image interpretation are less com-
plex, and transducer placement does
not restrict movement of the lower ex-
tremities, which has been argued to be
important for assessment of people with
lumbopelvic pain.57 Furthermore, trans-
abdominal ultrasound imaging is totally
noninvasive (the patient does not need
to undress), which may be important in
specific populations where internal ex-
amination may not be desirable (eg, chil-
dren, adolescents, men, victims of sexual
abuse, and some ethnic groups). This
technique provides an alternative source
of biofeedback when learning pelvic floor
muscle exercises in individuals who are
reluctant to undergo internal examina-
tion. This may overcome a major barrier
to some patients seeking professional
help for incontinence. However, trans-
abdominal ultrasound imaging does not
always allow for direct visualization of
the bladder neck, requires a moderately
full bladder (which may be difficult in
women with a reduced functional blad-
der capacity or bladder urgency), and
may be difficult in individuals with dense
abdominal scar tissue.84 Furthermore,
movement of the bladder base does not
always reflect movement at the bladder
neck.84 As mentioned above, descent of
492 | august 2007 | volume 37 | number 8 | journal of orthopaedic & sports physical therapy
the bladder base only indicates that there
has been an increase in distance between
it and the transducer. This can reflect ei-
ther an actual descent of the bladder wall
or outward movement of the abdominal
wall. One other possible disadvantage
of the transabdominal approach is the
difficulty of visualizing the bladder in
obese individuals.92 However, this did
not prove to be a limitation in a study by
Thompson et al,83,84 in which the blad-
der base was visualized in all subjects,
despite a body mass index range of 17 to
39 kg/m2.
Comparison of Ultrasound Imaging With
Other Methods of Pelvic Floor Muscle
Assessment
As mentioned earlier, it is important to
consider that interpretation of bladder
base or neck displacement observed with
ultrasound imaging requires integra-
tion with the information attained from
other methods of assessment due to the
range of factors that influence their mo-
tion. Although ultrasound imaging does
provide valuable and previously unavail-
able information, it does not allow for de-
finitive assessment of clinically important
information, such as resting pelvic floor
muscle activity, myofascial laxity, pelvic
floor muscle strength, abdominal activa-
tion strategy (eg, excessive bracing), or
other important subjective information
such as the presence of pain. Although
the amount of bladder neck (transperine-
al ultrasound imaging) and bladder base
(transabdominal ultrasound imaging)
movement during a pelvic floor muscle
contraction has been shown to correlate
with pelvic floor muscle strength (assessed
by manual muscle testing and perineom-
etry),27,82,83 there have been some find-
ings to the contrary.75 Precaution should
be taken with the interpretation of larger
displacements, as they do not necessar-
ily represent a more forceful contrac-
tion. For instance, a larger lift may result
from either a forceful pelvic floor muscle
contraction or increased fascial laxity. In
contrast, a small lift observed during a
voluntary pelvic floor muscle contraction
]
may indicate either a weak contraction or
high pelvic floor muscle resting activity.
Furthermore, transabdominal ultrasound
imaging does not allow direct assessment
of the perineal area or vaginal wall sup-
port. Consequently, the information that
it provides must be considered in light of
findings attained through traditional as-
sessment, including digital examination
when possible.
Muscle Morphology and Structural
Assessment  In addition to its ability to
provide information about pelvic floor
muscle (levator ani) function through
the analysis of bladder neck and blad-
der base motion, ultrasound imaging
has been used to quantify the thickness
of the levator ani,7,52 measure residual
bladder volume,34 investigate uterovagi-
nal prolapse20,64 and new surgical proce-
dures,25,91 as well as detect paravaginal
defects48,55 and space-occupying lesions
(cysts, fibroids). Applications related
to quantification of the thickness of the
levator ani or residual bladder volumes
have a direct relevance to physical thera-
pists. For instance, Bernstein et al7 used
a transperineal ultrasound imaging to as-
sess the reliability of pelvic floor muscle
thickness measurements at rest and dur-
ing contraction in 9 healthy, young (25-
38 years of age) females. Although the
methodology is poorly described, they re-
ported a mean (6SD) resting thickness of
9.4 6 0.8 mm and contracted thickness
of 11.5 6 1.1 mm, which represented an
increase of 23% 6 8%. In a more recent
study, Morkved et al52 investigated the
relationship between pelvic floor muscle
strength (vaginal squeeze pressure) and
increased thickness of the pelvic floor
muscles (transperineal ultrasound imag-
ing) in both continent and incontinent
women. They determined that the con-
tinent group (n = 71) had significantly
thicker muscles at rest (P = .018) and
with contraction (P = .006), and they
demonstrated higher mean increments in
muscle thickness (P = .021) between the
resting and contracted states. Moreover,
a moderate to good correlation between
measurements of pelvic floor muscle
strength and muscle thickness (r = 0.703)
was demonstrated.
Specialized radiological training is re-
quired for evaluation of tissue pathology.
Further, the diagnosis of a paravaginal
defect, uterovaginal prolapse, fibroid, or
cyst via an imaging study is challenging
and, in the case of the paravaginal defect,
a controversial undertaking.20,54 Further-
more, such investigations are beyond the
scope of practice and training of physical
therapists. However, if therapists employ
ultrasound imaging in this region they
must be prepared to handle suspicions of
such findings in a timely and professional
manner. It is recommended that physi-
cal therapists ensure that all patients are
aware of the scope of practice of physi-
cal therapists with respect to the use of
ultrasound imaging, and that all patients
provide consent prior to ultrasound im-
aging examination, enabling the thera-
pist to contact the patient’s physician if a
questionable structure is identified dur-
ing the ultrasound imaging examination.
For instance, Stokes et al79 recommend
the use of a consent form that clearly
states that the purpose of the rehabilita-
tive ultrasound imaging evaluation is to
examine muscle function and is not in-
tended for the identification of other pa-
thology. Further, if during the course of
study a questionable finding is identified,
the information is to be passed onto the
patient’s physician in a timely manner.
QUALITATIVE EVALUATION
T
he use of ultrasound imaging
to analyze the effect of a muscle
contraction is complex. Although
changes in static architectural parame-
ters (eg, position of the bladder base) can
contribute some elements of the story,
this analysis does not take into account
the timing of a contraction, or its influ-
ence on other structures (eg, tension in
the endopelvic fascia). As alteration in
the neuromuscular control of the pelvic
floor muscles and abdominal muscles
have been reported in individuals with
dysfunctions such as stress UI,5,16,77 it is
journal of orthopaedic & sports physical therapy | volume 37 | number 8 | august 2007 |
imperative that methods to assist in the
detection of these changes are devel-
oped. It is likely that detailed evaluation
of qualitative components of changes in
the pelvic floor muscles, bladder base, etc,
may provide additional insight to aid in
the interpretation of pelvic floor muscle
function. Qualitative analysis of rest-
ing characteristics and dynamic features
that occur with muscle contraction or
increased intra-abdominal pressure may
provide additional insight when added to
the measurement of quantitative parame-
ters. For instance, important information
that may assist in the clinical interpreta-
tion of a neuromuscular strategy may be
provided by analysis of the following: the
resting shape of the bladder; factors sug-
gesting simultaneous abdominal splinting
versus a lift of the bladder base; phasic
versus sustained lifting of the bladder base
with a pelvic floor muscle contraction;
return of the bladder base to its starting
position once a pelvic floor muscle con-
traction ceases; or motion of the bladder
with a task (such as an active straight-leg
raise) that loads the region. Although
components of qualitative analysis have
been proposed by several authors,68,93,94
these factors have not been adequately
examined in the peer-reviewed literature.
Current analysis is based on clinical inter-
pretation and extrapolation of related and
emerging evidence. Further investigation
is required to evaluate the validity and
psychometric properties of these analyses.
However, it may be possible to combine
the applications outlined above with tra-
ditional assessment findings and a knowl-
edge of the neuromuscular mechanisms
that underlie postural control of the trunk
and continence. This may enable analysis
of the neuromuscular strategy employed
by an individual at rest, during a task that
loads the region, or during a pelvic floor
muscle contraction and correlate this
to various qualitative features observed
with ultrasound imaging (Table). For in-
stance, one might be able to determine if
an individual can produce and maintain
a coordinated isometric contraction of the
pelvic floor muscles and sustain it during
limb-loading activities, as well as to spec-
ulate on resting activity of the pelvic floor
muscles and the ability of the endopelvic
fascia to transmit tension.94 Although this
reasoning appears to have clinical util-
ity, it is speculative and requires further
investigation.
TREATMENT: ULTRASOUND
IMAGING AND BIOFEEDBACK
TRAINING
T
he real-time information pro-
vided by ultrasound imaging has
been proposed as a possible source
of biofeedback that can be valuable dur-
ing re-education of the pelvic floor mus-
cles and lateral abdominal wall muscles
in individuals with incontinence,27,36 and
possible low back and pelvic girdle pain.
This section describes the role of biofeed-
back in pelvic floor muscle training, pres-
ents the unique benefits of ultrasound
biofeedback in comparison to more tradi-
tional biofeedback devices, and outlines
basic gaps in the current knowledge base
with respect to these topics.
Nonoperative care of individuals with
SUI has been advocated since the late
1940s when Kegel reported that 90%
of 455 patients treated with pelvic floor
muscle training improved.43,44 In a more
recent systematic review, as part of the
Cochrane Database, the widespread use
of pelvic floor muscle training as a first-
line conservative management strategy
for women with stress, urge, or mixed
urinary incontinence has been advocat-
ed.35 Although pelvic floor muscle train-
ing has success rates reported between
21% to 84%,2 investigators have found
that between 25% to 57% of individuals
with incontinence or bladder prolapse
have difficulty performing a proper pel-
vic floor muscle contraction when only
verbal and/or tactile cueing is provid-
ed.10,27,81,86 As improper performance of a
pelvic floor muscle contraction may ac-
tually facilitate urine leakage,10,81 pelvic
floor muscle training augmented with a
biofeedback device that ensures accuracy
of contraction may decrease the number
493
 [ clinical commentary ]
Qualitative Transabdominal and Transperineal Ultrasound Imaging Features Associated
With Analysis of Pelvic Floor Function and the Possible Insights That They Provide 94

Point of Consideration Contribution to PFM Analysis*

Shape, size, and symmetry of bladder at rest May assist in detection of PFM resting activity, residual bladder volume, and the possibility of a PVD or
encroaching structure (eg, cyst)
Resting relationship of bladder and pelvic floor height May assist in detection of increased PFM resting activity or as an early indicator of prolapse
Caudodorsal motion of bladder with an ASLR May assist in the detection of factors that contribute to inappropriate bladder descent, such as insufficient
PFMs, delayed activation of the PFMs, fascial laxity, and/or a motor control strategy that employs unsuitable
increases in IAP57
Dorsal motion of bladder with an ASLR May assist in detection of competent PFM activation in association with a motor control strategy that employs
inappropriate increases in IAP resulting from abdominal splinting
Lateral shift or rotation of bladder with an ASLR May assist in detection of either a unilateral insufficiency of the PF, or excessive unilateral activation of the
oblique abdominals
Observable PFM contraction during an ASLR May assist in the detection of an effective PFM
Change in shape of the bladder with an ALSR May assist in the detection of a motor control strategy that employs excessive increases in IAP
Caudal encroachment of bladder with PFM contraction May suggest some degree of voluntary control over the PFMs
Cranioventral motion of bladder with PFM contraction May suggest some degree of voluntary control over the PFMs
Abdominal encroachment of bladder with PFM May suggest a lack of voluntary control over the PFMs
contraction
Caudodorsal motion of bladder with PFM contraction May suggest a lack of voluntary control over the PFMs. Bladder base depression has been associated with
increased activity of the upper abdominal and chest wall muscles85
Observable relaxation of the PFM after PFM contraction May suggest some degree of voluntary control over the PFMs. Difficulty returning to the rest position or a slow
return may indicate over active PFMs
Abbreviations: ASLR, active straight-leg raise; IAP, intra-abdominal pressure; PF, pelvic floor (muscles and associated fascial support system); PFM, pelvic
floor muscle (levator ani); PVD, paravaginal defect; TA, transabdominal; QTA, qualitative transabdominal; TP, transperineal.
*Appropriate interpretation of these qualitative features must take into account findings attained through traditional assessment, including where possible
internal digital examination, and requires appropriate ultrasound imaging training and an understanding of the neuromuscular mechanisms associated
with postural control of the trunk and the continence mechanism.

of individuals that do not respond to con-
servative care.
Biofeedback training has been advo-
cated as an adjunct during the training
of a proper pelvic floor muscle contrac-
tion in people with “poor ability to con-
tract or perceive contraction of the pelvic
floor muscles, weak, injured, and edema-
tous muscles, or altered neuromuscular
control resulting in delayed or inconsis-
tent activation.”87,88 However, traditional
biofeedback training utilizing surface
or intravaginal EMG and pressure peri-
nometry has demonstrated mixed suc-
cess.2,11,35,51 Several cohort studies have
shown a decrease in the number of leak-
age accidents resulting in leakage per
week, the cost of protective garments, and
an increase in strength and endurance of
the pelvic floor muscles when biofeedback
training was included as an adjunct to
pelvic floor muscle exercises.1,2,4,11,12 More
specifically, Burgio et al11 and Morkved et
al51 found a 19% to 25% increase in suc-
cess rates when individuals participated
in an augmented biofeedback training
program compared to a control group.
However, the results are more equivocal
when assessed using systematic reviews
of randomized control trials. Two recent
reviews by the Cochrane Database35 and
the International Continence Society96
were unable to determine the benefit of
augmented biofeedback training (pri-
marily employing pressure perinometry
and EMG) for the pelvic floor muscles.
However, methodological problems with-
in the original studies were cited. A key
issue is that biofeedback may not lead to
a substantially better outcome when it is
applied in a blanket manner to all indi-
viduals, but may be effective when used
with a specific subset of patients who
have particular difficulty learning how to
activate the pelvic floor muscles.
The use of ultrasound imaging as a
source of biofeedback is relatively new
and may be advantageous in comparison
to traditional biofeedback training de-
vices (eg, pressure perinometry or EMG).
Although all of these devices provide im-
mediate visual feedback during a pelvic
floor muscle contraction, both pressure
perinometry and EMG can increase with
either an elevating or a straining pelvic
floor muscle contraction.85 In contrast,
ultrasound imaging can provide real-time
visual information about the direction of
pelvic floor movement during a pelvic
floor muscle contraction, straining ma-

494 | august 2007 | volume 37 | number 8 | journal of orthopaedic & sports physical therapy
neuver,82,83 or functional task (eg, active
straight-leg raise test).57 Furthermore,
traditional biofeedback techniques are
susceptible to measurement error due to
crosstalk from lower extremity muscle ac-
tivity (eg, gluteus maximus, hamstrings,
and adductors), while assessment of pelvic
floor elevation with ultrasound imaging is
not.62 It is important to point out that the
crosstalk from lower extremity muscles
may be a result of either the intensity or
technique employed by subjects when
contracting their pelvic floor muscles (eg,
subjects asked to perform strong contrac-
tions likely coactivated the limb muscles
with the pelvic floor muscles) and not a
shortcoming of the biofeedback device
itself, as a recent investigation address-
ing this problem has shown.40 As with all
pelvic floor muscle biofeedback devices,
substitution patterns associated with ab-
dominal and chest wall muscle activity
may confound interpretation and contrib-
ute to measurement error. For instance, a
recent study identified increased activity
of these muscles in individuals with both
UI and LBP, highlighting that they need
to be monitored concurrently.78,81 One
further consideration is that, due to the
noninvasive nature of transabdominal
ultrasound imaging, measurement error
associated with poor patient compliance
and apprehension, as seen with the more
invasive traditional methods, may be
minimized.
Beyond the advantages highlighted
above, ultrasound biofeedback training
can assist some individuals in performing
an effective pelvic floor muscle contrac-
tion in a relatively short time. In a study
of 212 women, Dietz et al27 reported that
26% of subjects (n = 56) were unable
to perform a proper pelvic floor muscle
contraction; but 57% of these subjects
(32 individuals) were successful after
5 minutes of training with ultrasound
biofeedback. In a smaller study (n = 13),
62% of incontinent women identified to
be depressing the pelvic floor when at-
tempting to perform an elevating pelvic
floor muscle contraction (transabdomi-
nal ultrasound imaging) were able to
journal of orthopaedic & sports physical therapy | volume 37 | number 8 | august 2007 |
perform an elevating contraction within
1 biofeedback session.81
As with any form of biofeedback, the
optimal protocol and feedback schedule,
as well as the subgroup(s) of patients that
would receive the greatest benefit from
training with ultrasound biofeedback,
must be determined.50 As ultrasound
biofeedback training is relatively new,
many of these concepts have not been in-
vestigated. Considerations of biofeedback
during specific phases of motor learning,
timing (immediate versus delayed), the
type (knowledge of results or perfor-
mance), and amount of feedback need
to be determined. Furthermore, how to
match the specific needs of a patient (def-
icits of strength, endurance, or timing) to
an appropriate ultrasound biofeedback
training protocol needs to be investi-
gated.30,69,70 The use of treatment-based
subgroups aimed at determining patients
who would most benefit from the addition
of ultrasound biofeedback training dur-
ing a pelvic floor muscle training protocol
may prove valuable. This type of classifi-
cation scheme has been demonstrated to
be beneficial in the treatment of patients
with low back pain13,32,33 and may serve
as a template for further research in the
development of a treatment-based clas-
sification system for UI.
In addition to the use of ultrasound
biofeedback of pelvic floor muscle con-
traction in patients with incontinence,
this technique may be useful for the reha-
bilitation of pelvic floor muscle function
in people with low back and pelvic pain.
Although early data suggest dysfunction
of the pelvic floor muscles in a subset of
people with pain in this region57,66 and pel-
vic floor muscle training has been advo-
cated as a component of the rehabilitation
of trunk muscle control,68,72 further work
is required to determine whether this ap-
proach is effective in this population.
In conclusion, there appears to be
agreement among investigators that a
proportion of the population who require
pelvic floor muscle training are unable to
perform the exercise properly when only
verbal and/or tactile cueing are provid-
ed.27,84 Further, there is initial evidence to
suggest that ultrasound biofeedback may
be beneficial in the assessment and initial
training of the pelvic floor muscles and
could potentially increase the proportion
of the population with these conditions
who received benefit from exercise man-
agement of pelvic floor dysfunction.27
Although current evidence for the use
of ultrasound biofeedback in pelvic floor
muscle training is limited, there is emerg-
ing evidence to suggest that ultrasound
biofeedback training of other trunk
muscles is valuable.36,89 More research is
needed and in particular it must be de-
termined if ultrasound biofeedback can
positively influence motor learning and
clinical outcomes.
RESEARCH AGENDA
U
ltrasound imaging can be used
to assess the morphology of the
pelvic floor muscles and associated
structures.7,20,52,54 It also provides a means
to measure the supporting function of the
pelvic floor muscles through the objective
dynamic assessment of a voluntary pelvic
floor muscle contraction that results in
elevation of the bladder neck or bladder
base, and the mobility of the bladder base
and neck during maneuvers than increase
intra-abdominal pressure. Ultrasound
imaging has the advantage of provision
of real-time information, thereby provid-
ing instantaneous visual feedback to both
the client and therapist, and is more clini-
cally accessible and affordable than MRI.
Furthermore, transabdominal ultrasound
imaging has been found to be more sensi-
tive than digital palpation for the detec-
tion of an elevating pelvic floor muscle
contraction.31 In a study by Dietz et al,23
4-dimensional transperineal ultrasound
imaging (eg, real-time 3-dimensional im-
aging) was found to be more sensitive for
detection of defects in the levator ani than
digital palpation. Although asymmetries
of the bladder base have been observed
using conventional 2-dimensional trans-
abdominal ultrasound imaging, there is
a need for further studies that correlate
495
 [ clinical commentary
the findings of digital palpation and 4-
dimensional ultrasound imaging to those
with conventional ultrasound imaging.
With regard to treatment, ultrasound
biofeedback has been shown to be useful
in clinical situations to teach an elevat-
ing pelvic floor muscle contraction.27,81
However, it is not yet known if inclusion
of ultrasound biofeedback in pelvic floor
muscle training regimens improves clini-
cal outcomes. Further, it is unclear at this
point in time if ultrasound biofeedback
is more useful in certain populations (eg,
subjects with poor proprioception).
As yet, there is not consensus regard-
ing useful ultrasound imaging measure-
ments, thus the clinical significance of
the findings remains unclear. For exam-
ple, depression of the pelvic floor while
attempting to perform an elevating
contraction has been observed in both
continent and incontinent women.82,84
Furthermore, no significant difference
in the degree of bladder neck elevation
has been identified between the cohorts
of women with and without incontinence
who were able to perform a contraction
of the pelvic floor muscles.82 In a study
by Thompson et al,83 differences between
measurements of bladder neck mobil-
ity in continent and incontinent women
were more significant during functional
maneuvers than measurements of blad-
der neck elevation during voluntary pel-
vic floor muscle contractions. In addition,
Barbic et al5 demonstrated that increased
bladder neck mobility during coughing
is associated with delayed pelvic floor
muscle activation and symptoms of
stress UI. This indicates the importance
of inclusion of functional evaluation in
pelvic floor muscle assessment. Further
investigation is required to compare ul-
trasound imaging with EMG to assess
the activation patterns of the pelvic floor
muscles and abdominal muscles during
various maneuvers and between diverse
cohorts. Furthermore, it is likely that
more sophisticated measurement tech-
niques, such as that described by Peng et
al,60 which permit more accurate map-
ping of the anorectal angle, as well as the
496 | august 2007 | volume 37 | number 8 | journal of orthopaedic & sports physical therapy
insights provided by color Doppler 3- and
4-dimensional ultrasound imaging,21 are
also likely to influence our understanding
of the pelvic floor muscles and how they
function.
In summary, rehabilitative ultrasound
imaging has provided novel access to
the structure and behavior of the pelvic
floor muscles and their influence on as-
sociated structures. This access has lead
to the development of valid and reliable
measurement techniques and clinical
applications, highlighted the importance
of functional evaluation, and served as
a foundation for theories. However, as
indicated throughout, there is consider-
able work that must still be done to deter-
mine the clinical utility and significance
of these insights.
CONCLUSION
T
he literature indicates that the
pelvic floor muscles (levator ani)
play a role in both the continence
mechanism as well as postural control of
the lumbopelvic region and that there is
an emerging need for physical therapists
to have access to tools capable of accu-
rately evaluating the various aspects of
their function. Rehabilitative ultrasound
imaging is one potential tool. The goal of
this commentary is to amalgamate the
existing literature regarding the use of
rehabilitative ultrasound imaging with
respect to pelvic floor muscle function,
as well as to provide guidelines for future
research. t
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