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• W2071778897 abstract "Disruption of the anal sphincter and its consequences in obstetric patients has been discussed earlier in this issue1. We report here on the use of a 15–7-MHz linear ‘small parts’ transducer. Sixteen women in two groups were scanned. Group I consisted of 10 women without complaints pertaining to malfunction of the anal sphincter. Five were nulligravida and five had had one or two deliveries with or without episiotomies. Group II consisted of six women who reported incontinence of flatus or overt loss of stool. One of these six women passed stool through the vagina and was suspected to have a postpartum rectovaginal fistula. All women were scanned with a HDI 5500 (Phillips/ATL, Bothell, WA, USA) ultrasound machine equipped with a 15–7-MHz linear small parts transducer (Figure 1a). This small probe, with a footprint of 3.5 cm, was inserted into a prelubricated plastic probe cover and placed on the fourchette in a transverse and/or longitudinal (sagittal) fashion (Figure 1b). To overcome the narrow rectangular field of view generated by the small parts transducer (Figure 2), the ‘panoramic’ sweep feature of the ultrasound machine was used to produce a wider, extended view of the pelvic floor anatomy (Figure 3). The panoramic view is obtained by a slow, continuous and fluid movement of the transducer's footprint along its longitudinal axis following the tight curving contour of the fourchette. The ‘developing’ image on the monitor will aid in obtaining the optimal image using the optimal sweep speed and plane. One may have to acquire several images to achieve the best. The transducer. (a) The 15–7-MHz high-frequency linear ‘small parts’ and vascular ultrasound probe with a footprint of 3.5 cm. (b) The position of the probe to obtain a transverse image of the anal sphincter. Images of the normal anal sphincter obtained using the 15–7-MHz linear transducer; note their high resolution and detail. (a) Transverse ultrasound image of the anal sphincter showing the sonolucent internal sphincter muscle (IS) and the hyperechoic external sphincter muscle (ES). (b) Line drawing corresponding to (a). (c) Moving the transducer slightly lateral of the median plane, an image of the ‘parasagittal’ plane indicated in (a) is obtained. (d) A median (sagittal) image of the rectum and the anal sphincter obtained at the level of the ‘median’ line indicated in (a). (e) Line drawing corresponding to (d). Images of a normal sphincter mechanism created using the extended view sweep mode. (a) A sweep in the median plane. (b) Line drawing depicting the anatomy seen in (a). (c) A sweep in the transverse plane. (d) Line drawing depicting the anatomy seen in (c). ES, external sphincter muscle; IS, internal sphincter muscle. Clear images of the sonolucent internal, and the echogenic external, sphincters were obtained in both transverse and longitudinal planes (Figure 2). On transverse planes, the levator ani muscle could be seen on both sides, ‘below’ the sphincter mechanism (Figure 3c and d). As expected, in Group I the sphincter anatomy in the transverse and longitudinal planes was visible and normal. The ‘mucosal star’ created by the folds of the empty rectal lumen was also seen easily in the low transverse plane. All patients belonging to Group II clearly showed disrupted sphincter anatomy, as expected, between 11 and 2 o'clock. In one of the patients with fecal incontinence disruption of the anatomy between 11 and 3 o'clock on the transverse image was visible, displaying an area with mixed echogenicity, swirling patterns, and the total lack of the two sphincters in that area (Figure 4). The panoramic or extended-view images in this case were clear and enabled a thorough evaluation of the pathology. Images of the anal sphincter in a patient with fecal incontinence. After her last delivery of a 4.5-kg baby, a fourth-degree laceration was repaired. (a) On the median (sagittal) image there is disruption of the internal (IS) and external (ES) sphincter muscles. The planes of images (b) and (c) are indicated. (b) The high-transverse section shows a thin internal sphincter muscle from about 11 to 2 o'clock. (c) The low-transverse section shows a disruption of both sphincter muscles between 11 and 3 o'clock (arrows). (d) A sweep in the median (sagittal plane) shows the damaged area of the sphincters outlined by the dotted line. (e) The sweep in the transverse plane depicts the extensively damaged area surrounded by the dotted line. Note the deformed shape of the mucosal star. Imaging the anal sphincter unit requires a very high-frequency transducer. Different tissues present different degrees of sound-wave attenuation. Higher transducer frequencies provide better resolution of the tissues closer to the transducer, improving resolution while decreasing penetration. The terms ‘focal point’ or ‘focal range’ of transducers require explanation: the lower the transducer frequency, the further the focal point will be from the transducer tip, while the focal range of the probe will generally be wider. Conversely, the higher the frequency, the closer the focal point will be to the tip of the transducer. The focal range of a high-frequency probe is narrowed significantly. For example: a probe with a frequency of 4 MHz typically has a focal range of 4–18 cm, with its focal point at 9–10 cm; an 8-MHz probe typically has a focal range of 3–10 cm with its focal point at 5 cm, and a probe of 15 MHz may have a focal range of 0.5–5 cm with its focal point at 2 cm. These extremely high-frequency transducers are used in vascular imaging2-4, ophthalmology5, 6, neurology7, orthopedic surgery8, and in imaging organs such as the thyroid9-12, breast13, 14, testicles and prostate15. In scanning the anal sphincter mechanism it is imperative to use high-frequency probes as the region of interest is extremely close (about 2 cm) to the transducer. Clearly, using a 15–7-MHz probe with an effective focal range of 0.5–5 cm will provide an exceptionally clear image of the close-up anatomy or pathology that it is required to depict. Small parts or vascular transducers are available on most ultrasound machines and their use is easy to master. The application of the panoramic image presents an added advantage. Since the endoanal ultrasound technique using circular, rotary probes is unavailable to most obstetricians and gynecologists, we suggest the following two options: first, use a simple and available transvaginal probe to achieve excellent-quality sphincter imaging. Second, to further enhance the image resolution, use a 15–7-MHz linear, small parts transducer." @default.
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• W2071778897 title "The use of a 15-7-MHz ?small parts? linear transducer to evaluate the anal sphincter in female patients" @default.
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• W2071778897 doi "https://doi.org/10.1002/uog.1826" @default.
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