Practical Pelvic Floor Ultrasonography
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Practical Pelvic Floor Ultrasonography
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Preface
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Contents
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Contributors
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1. Pelvic Floor Anatomy
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Introduction
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Support of the Pelvic Organs: Conceptual Overview
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Practical Anatomy and Prolapse
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Overview
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Apical Segment
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Anterior Compartment
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Perineal Membrane (Urogenital Diaphragm)
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Posterior Compartment and Perineal Membrane
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Lateral Compartment and the Levator Ani Muscles
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Endopelvic Fascia and Levator Ani Interactions
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The Levator Plate
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Nerves
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Summary
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2. 2D/3D Endovaginal and Endoanal Instrumentation and Techniques
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Introduction
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2D Perineal and 2D/3D Endovaginal and Endoanal Ultrasound Imaging
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The 2D Probes
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The 3D Endocavitary High-Resolution Probes
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BK 3D Viewer Software
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Multicompartmental Ultrasonographic Techniques
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Patient Positioning
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2D Perineal Functional Pelvic Floor Ultrasound (PFUS)
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2D/3D Endovaginal Anterior Compartment Imaging
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2D/3D Endovaginal Posterior Compartment Imaging
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3D 360° Endovaginal Imaging (EVUS)
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3D 360° Endoanal Imaging
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Summary
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3. Instrumentation and Techniques for Perineal and Introital Pelvic Floor Ultrasound
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Introduction
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Perineal Pelvic Floor Ultrasonography (pPFUS)
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2D pPFUS
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3D/4D pPFUS
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GE 4D View Software
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2D/3D/4D Introital Pelvic Floor Ultrasonography iPFUS
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iPFUS Orientation and Optimization
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PFUS and Pelvic Floor Disorders
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Pelvic Floor Biometry with PFUS
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iPFUS and pPFUS: Pelvic Floor (Levator) Hiatus and Pelvic Floor Musculature
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Anal Sphincter Complex and Anal Canal pPFUS and iPFUS
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iPFUS and pPFUS in the Evaluation and Treatment of Urinary Incontinence
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iPFUS and pPFUS and Pelvic Organ Prolapse
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Summary
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4. Perineal Pelvic Floor Ultrasound: Applications and Literature Review
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Introduction
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Lower Urinary Tract Dysfunction and Anterior Compartment Pathologies
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Residual Urine and Detrusor Wall Thickness
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Stress Urinary Incontinence
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Pelvic Organ Prolapse
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Anterior Compartment
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Central Compartment
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Posterior Compartment
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The Anal Sphincter
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Synthetic Implants
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Mid-urethral Slings
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Mesh Implants for Pelvic Organ Prolapse
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Anterior Compartment Meshes
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Posterior Compartment Meshes
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The Levator Ani
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Summary
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5. 3D Endovaginal Ultrasound Imaging of Levator Ani Muscles
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Introduction
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Imaging Modalities for Endovaginal Imaging
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3D EVUS Technique for Levator Ani Imaging
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Clinical Applications
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Levator Ani Injury
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LAD: Levator Ani Deficiency Score
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Scoring System
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Changes of Levator Ani with Aging
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Levator Plate Descent Angle and Minimal Levator Hiatus
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Conclusions and Future Research
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6. 3D Endovaginal Ultrasound Imaging of Levator Ani Trauma
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Introduction
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Prevalence of Pelvic Floor Trauma Following Vaginal Delivery
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Risk Factors
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Anatomy
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Supportive Structures of the Pelvic Floor that can be Injured
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Puboanalis/Puboperinealis Fibromuscularis
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Puborectalis
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Pubococcygeus
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Iliococcygeus
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3D Endovaginal Ultrasound Technique for Levator Ani Imaging in Postpartum Patients
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Reliability and Reproducibility of Ultrasound Studies in Postpartum Patients
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Levator Ani Deficiency Score as a Measure of Levator Ani Injury and Atrophy
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3D EVUS LAM Scoring System
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Clinical Relevance of the Scoring System
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Introduction to the Pathophysiology and Types of Skeletal Muscle Injuries
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Types of Levator Ani Injuries During Vaginal Birth
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Subgroup Analysis: Bilateral Injury Compared to Unilateral Injury
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Subgroup Analysis: Avulsion Compared to Pubococcygeus Injury
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Therapeutic Strategies
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RICE
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Physiotherapy
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NSAIDs
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Biological Repair
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Operative Treatment
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Reported Techniques for Levator Ani Muscle Repair
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Conclusions
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7. Endovaginal Urethra and Bladder Imaging
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Introduction
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Equipment, Technology, and Methodology
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Patient Position
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Patients Preparation
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Methodology
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BK 2050/2052/20R3 Anorectal 3D Transducer
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BK 8848 Endocavity Biplane Transducer
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Sagittal Section
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Axial Section
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BK 8838 3D ART Transducer
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Vascular Render Mode and Maximum Intensity Projection
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Urinary Bladder
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Anatomy of Female Urethra and Bladder
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Ultrasound Morphology
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Urethral Vascularity
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Clinical Applications of Urethral Ultrasound
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Conclusions and Future Research
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3D Endovaginal Ultrasound
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3D EVUS in Interventional Treatment
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Future Applications and Directions of Development
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8. 2D/3D Transperineal and 3D Endovaginal Imaging of the Posterior Compartment
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Introduction
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Techniques, Literature Review, and Sonographic Anatomy
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Transperineal Ultrasound 2D/3D Static and Dynamic Imaging
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Rectocele
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Enterocele
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Rectal Intussusception
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Endovaginal 2D/3D Static Imaging
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Axial Plane
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Sagittal Plane
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Coronal Plane
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Endovaginal 2D Dynamic Imaging
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Biomechanics of Evacuation
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Dynamic Posterior Compartment Ultrasound Measurements of Rectal Hypermobility/Folding
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Clinical Applications of Static 3D Endovaginal Ultrasound
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Rectocele
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Enterocele
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Intussusception
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Pelvic Floor Dyssynergy
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Simplified Diagnostic Algorithm to Assess Obstructed Defecation Symptoms
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Other Findings in the Posterior Pelvic Floor Compartment
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Conclusions
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9. Endovaginal Imaging: Vaginal Mesh and Implants
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Introduction
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Pelvic Floor Anatomy as it Relates to the Design and Development of Vaginal Mesh Kits
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Anterior Compartment
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Posterior Compartment and Perineal Membrane
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History and Type of Vaginal Mesh
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Ultrasonographic Findings of Mesh
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Mesh Complications and Ultrasonographic Findings
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Mesh Contraction
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Mesh Exposure and Extrusion
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Urinary Tract or Lower Gastrointestinal Tract Compromise or Perforation
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Musculoskeletal Structure: Pain, Lump, Decreased Elasticity, and Sinus Tract Formation
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Summary
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10. Endovaginal Imaging: Slings
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Introduction
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Multicompartment Endovaginal Imaging in the Visualization of Slings
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3D Imaging of Retropubic (Pubovaginal and Midurethral) and Transobturator Slings
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Technical Details of Performing 3D EVUS to Visualize Slings
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180° Scan of the Anterior Compartment
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360° Scan
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Manipulation of the 3D Data Volume to Trace the Intrapelvic Course of Slings, Retropubic, and Transobturator
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2D Dynamic Functional Assessment of the Slings
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2D Dynamic Functional Assessment of Slings and Its Correlation with Outcome
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Deformability of the Sling
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Location of the Sling on Maximal Valsalva
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Concordance of Urethral Movement with the Sling During Maximal Valsalva
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2D Dynamic Assessment of Deformability of Different Sling Types
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Diagnosis and Planning of Future Treatment in the Case of Failed Sling Surgery
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Unknown Sling Type and Preoperative Scanning in Case of a Failed Sling
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Determining the Location of a Failed Sling
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Planning of Treatment in Patients with Complicated Treatment History
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Diagnosis of Tape Erosion/Extrusion
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Planning of Treatment in Patients with Voiding Dysfunction Following Sling Surgery
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Slings and the Overactive Bladder
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Comparison of Transperineal and Endovaginal Ultrasound in the Imaging of Slings
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Anatomic Path of Transobturator Slings and Its Association with Pelvic Pain
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Conclusions and Future Research
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11. 2D/3D Ultrasound Imaging of Urethral Bulking Materials
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Introduction
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Potential of Multicompartmental Ultrasound in Visualizing Periurethral Distribution of Bulking Agents: Why Bother?
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Technical Details of Performing 3D EVUS to Visualize Urethral Bulking Agents
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Ultrasonographic Parameters of Bulking Agent Injection
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Ideal Site of Injection
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Periurethral Distribution of MPQ
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Location of the Bulkamid Periurethral Bulking Material
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Location of the Injection Plus Periurethral Distribution
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Conclusion
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12. Endovaginal Imaging: Pelvic Floor Cysts and Masses
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Introduction
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3D EVUS Technique
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Bartholin Gland Cyst/Abscess
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3D EVUS Appearance of Bartholin Gland Cyst
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Skene Gland Cyst/Abscess
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3D EVUS Appearance of Skene Gland Cyst
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Urethral Diverticulum
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3D EVUS Appearance of Urethral Diverticulum
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Gartner Duct Cyst
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3D EVUS Appearance of Gartner Duct Cyst
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Leiomyoma of Vagina
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3D EVUS Appearance of Leiomyoma
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Malignant Vaginal Masses
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3D EVUS Appearance of Malignant Vaginal Masses
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Rectovaginal Septum Endometrioma
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3D EVUS Appearance of Rectovaginal Septum Endometrioma
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Vaginal Seroma and Hematoma
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3D EVUS Appearance of Vaginal Seroma and Hematoma
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Conclusions and Key Points
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13. Endoanal Ultrasonographic Imaging of the Anorectal Region
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Introduction
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Ultrasonographic Techniques
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Endosonographic Anatomy of the Normal Anal Canal
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Endosonographic Anatomy of the Rectum
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Clinical Application of 3D Endoanal/Endorectal Ultrasound
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Fecal Incontinence
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Obstructed Defecation and Posterior Vaginal Wall Prolapse
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Perianal Abscesses and Fistulas
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14. Endoanal Imaging of Anorectal Cysts and Masses
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Endometriosis
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Deep Endometriosis
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Perianal Endometriosis
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Presacral Neoplasia
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Rare Tumors
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Rectal Leiomyoma
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Gastrointestinal Stromal Tumors (GIST)
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Rectovaginal Septum Tumors
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Cystic Vaginal Lesion
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Prostatic Cyst Lesion
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Benign Urethral Lesion
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Lymphocele
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15. Role of Ultrasound in the Evaluation and Management of Obstetric Anal Sphincter Injuries
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Introduction
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Diagnosis of Obstetric Anal Sphincter Injuries
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Endoanal Ultrasound
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Transperineal Ultrasound
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OASI Follow-Up
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Pelvic Floor Symptoms Evaluation
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Physical Examination
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Anal Testing
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Physical Therapy Interventions After OASI
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Mode of Delivery in Future Pregnancies
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Conclusions
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16. Strategies to Reduce Severe Perineal Lacerations
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Introduction
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Overview of the Sections
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Sections
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Risk Factors for Perineal Trauma During Childbirth
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Episiotomy
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Operative Vaginal Delivery
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Persistent Occiput Posterior Position
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Fetal Birth Weight
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Induction and Augmentation
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Length of Second Stage
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Regional Anesthesia
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Maternal Familial Factors
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The Safe Passages Program
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Perineal Massage
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Induction of Labor
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Warm Compresses (Fig. 16.1)
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Coaching of Maternal Pushing
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Delivery Position (Fig. 16.2)
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Perineal Support (Figs. 16.3, 16.4, and 16.5)
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Use of Episiotomy
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Shoulder Dystocia Strategies
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Operative Vaginal Deliveries
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Repair of Perineal Lacerations (Figs. 16.6 and 16.7)
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Outcomes of the Simulation Training
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Summary
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17. Ultrasound-Augmented Clinical Examination and Intraoperative Pelvic Floor Ultrasonography
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Introduction
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Clinical Pain Mapping in Mesh Patients
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Intraoperative Ultrasound-Guided Botox of the Pelvic Floor
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Intraoperative Ultrasound-Guided Sling Release
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Intraoperative Ultrasound-Guided Repair of Levator Ani Tears
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Intraoperative Assessment of Uterine and Vaginal Mullerian Anomalies
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Intraoperative Assessment of Uterine Fibroids
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Conclusions and Future Research
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18. Ultrasound Imaging in Pelvic Health Physical Therapy
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Introduction
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Physical Therapist Utilization of Rehabilitative Ultrasound Imaging
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Scope of Practice in Pelvic Health
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Clinical Diagnosis Versus Functional Assessment
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Pressure System Management
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Instrumentation and Approaches for the Pelvic Health Physiotherapist
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Instrumentation
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2D Ultrasound in Physiotherapy
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Equipment Preparation
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Patient Preparation
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Scanning Planes and Approaches
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Scanning Modes
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Clinical Applications of Ultrasound Imaging in Pelvic Floor Physiotherapy
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Imaging Techniques for Assessment and Training of the Pelvic Floor
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2D Transabdominal Versus 2D Perineal Pelvic Floor Ultrasound Imaging
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Patient Positioning
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Transabdominal Ultrasound Approach
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Scan Technique
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TAUS Anatomy: Tissue Morphology and Morphometry
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TAUS Observing Motor Control Strategies: Voluntary and Involuntary
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TAUS Training Motor Control Strategies: Voluntary and Involuntary
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Perineal Pelvic Floor Ultrasound (pPFUS) Approach
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Scan Technique
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pPFUS Anatomy: Tissue Morphology and Morphometry
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pPFUS Observing Pelvic Floor Behaviors: Voluntary and Involuntary
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pPFUS: Training Motor Control Strategies—Voluntary and Involuntary
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US Research Within the Field of Physiotherapy
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Summary
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19. Emerging Imaging Technologies and Techniques
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Ultrasound Shear Wave Elasticity Imaging
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Acoustic Radiation Force Impulse and Shear Wave Elasticity Imaging (ARFI and SWEI) of the Cervix and Uterus
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Photoacoustic Imaging of Ovarian Tissue and the Cervical Canal
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Tactile Imaging of the Female Pelvic Floor
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Summary
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20. Patient-Specific Studies of Pelvic Floor Biomechanics Using Imaging
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Introduction
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Patient-Specific 3D Reconstruction of the Female Pelvic Floor
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Constitutive Material Properties of the Pelvic Floor
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Future Outlook
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Automated Segmentation of Pelvic Floor Structures
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Quantitative Ultrasound Imaging
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Conclusion
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21. Case Studies
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Index













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