Stress urinary incontinence (SUI) is one of the most common disorders of the female pelvic floor and significantly affects the quality of life, sexual function, work performance, and psychological well-being of millions of women worldwide. Traditionally, its diagnosis and management have been based on a combination of clinical symptoms, physical examination, and, in some cases, urodynamic studies. Urethral support depends on a complex ligament and fascial system that includes, among other structures, the pubourethral and the urethropelvic ligaments, whose integrity is fundamental for urinary continence. Although MRI is considered the gold standard for ligament assessment (Ashton-Miller & DeLancey), recent studies have shown that 4D transperineal ultrasound (TPUS) offers comparable diagnostic correlation and dynamic advantages (Shobeiri et al., Dietz). The emerging hypothesis is that functional ultrasound can visualize the urethral support ligaments, identify the integrity and injured structures, and correlate these findings with the pathophysiology of stress urinary incontinence (SUI).
Objective
The objective of this study is to validate the identification and integrity of the pubourethral and periurethral urethral support ligaments using TPUS and MRI, and the possibility of making personalized surgery decisions for stress urinary incontinence (SUI) based on anatomic failure.

This pilot study included 10 women: 5 healthy nulliparous women and 5 women with urinary incontinence. All patients first underwent transperineal ultrasound (TPUS) and were subsequently referred to the radiology department, without identifying whether they were healthy or incontinent, for MRI. Both studies were performed with the patient at rest. Urethral support ligaments visualization, pubourethral and periurethral were compared between TPUS and MRI, to classify the integrity and unilateral or bilateral avulsion.

Pubourethral and periurethral ligament injury on both TPUS and MRI is determined by the loss of continuity of their fibers and that can be unilateral or bilateral. In all healthy patients, the integrity of both ligaments was identified on both ultrasound and MRI. All patients with stress urinary incontinence (SUI) showed loss of continuity of the ligament fibers on both ultrasound and MRI; 3 bilaterally and 2 unilaterally.

When compared to MRI, it demonstrated equal or superior diagnostic accuracy because the ligamentous structures are very small and can be observed more precisely with high-resolution ultrasound. These findings are an original contribution to urogynecology and position the TPUS as standardized study for objective and easy pre-surgical personalized mapping and post-surgical outcome assessment with the possibility for the patient to view the results on the monitor in real time.

Today we need to move towards precise medicine based on personalized assessment. The TPUS is a highly effective, reproducible, and cost-effective study for assessing pelvic floor dysfunction. It helps us diagnose SUI based on individual variability. The ability to detect loss of ligamentous continuity via ultrasound shifts the paradigm from generic treatments toward precision surgical planning tailored to the patient’s specific anatomical failure.

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Katarzyna J. Macura, MD, PhD et al, MR Imaging of the Female Urethra and Supporting Ligaments in Assessment of Urinary Incontinence: Spectrum of Abnormalities,. RadioGraphics 2006