Acute cowperitis, which was previously known as a common complication of sexually transmitted infections (STIs), is now commonly associated with bacterial urinary tract infections, particularly Escherichia coli. Patients often have a history of STIs, and the symptoms resemble other male accessory gland infections (MAGIs). Recent cases associated with sepsis have been managed with percutaneous drainage and/or surgery. We present a case of acute cowperitis with sepsis and an abscess in the right small gland. The diagnosis was made using transperineal ultrasound, and the patient was successfully treated only with a long-term antibiotic therapy.

Obstetric anal sphincter injuries are frequently missed and carry a significant risk for the development of anal incontinence. Immediate postpartum endoanal ultrasound increases identification of these injuries but is rarely employed. We hypothesize that endovaginal ultrasound could be a feasible and easily available alternative sonographic tool to improve early diagnosis of anal sphincter tears.
We conducted a prospective experimental study including 160 primiparous women. Shortly after vaginal delivery, patients underwent clinical and sonographic perineal examinations. We analyzed the feasibility of anal sphincter assessment by endovaginal ultrasound and its potential contribution in the early diagnosis of anal sphincter injuries.
Sonographic assessment of the anal sphincter was analyzable for 136 patients (85.0%). Causes of non-analyzability included air artifacts (6.9%), lack of distinction between the external anal sphincter and surrounding tissues (9.4%) and distortion artifacts (9.4%). Patients in the non-analyzable ultrasound subgroup were less likely to have delivered in a dorsal lithotomy position (62.5% vs. 85.3 %) and more likely to have had an episiotomy (33.3% vs. 14.0%), and their risk of sphincter injury was more frequently classified as \"improbable\" on clinical examination (91.7% vs. 61.0%). Ultrasounds were analyzable for 96.4% of patients clinically reported as having \"possible\" or \"certain\" sphincter injuries. The incidence of anal sphincter injury was 16.9% for clinical observation and 20.0% with associated sonographic examination.
Endovaginal ultrasound could be used as a complementary tool in assessment of the anal sphincter in high-risk patients. Its feasibility and easy availability make this technique a promising tool for improving the management of anal sphincter tears.

Intestinal ultrasound (IUS) is a non-invasive and accurate tool to assess inflammatory bowel disease. The ECCO-ESGAR guideline recommends the use of IUS for the assessment of disease activity and complications in Crohn\'s disease (CD). In addition, an increasing body of evidence suggests the use of IUS as alternative to colonoscopy in monitoring CD and in assessing disease activity of ulcerative colitis. Early responsiveness of IUS findings by the first weeks of treatment and the advantage to perform the procedure in real time may dramatically change frequency of the assessment of treatment response in the future and speed up the clinical decision-making process. Development of validated and reproducible sonographic scores to measure disease activity and therapeutic response and spread of knowledge of IUS remain relevant issues for the future in which current researchers and the International Bowel Ultrasound (IBUS) Group are actively engaged.

OBJECTIVE: In this study we described a new technical approach to adapt endovaginal ultrasound scanning of the anal sphincter complex to the immediate postpartum period.
METHODS: We analyzed the clinical and ultrasonographic examinations of 18 primiparous women presenting deep perineal tears with potential or clearly identified lesions of the anal sphincter. Potential anal sphincter lesion was defined as a second degree perineal tear extending close to the anal sphincter with exposition of its capsule or muscular fibers. We reported interesting ultrasonographic images explaining our technique in a video.
RESULTS: We reported clinical and ultrasonographic features in nine cases of grade 2, four cases of grade 3a, four cases of grade 3b and one case of grade 3c perineal tears. The ultrasonographic examination confirmed the intact state of the anal sphincter complex in all patients with clinical grade 2 tears except one in which a grade 3b lesion was detected. We were not able to identify external anal sphincter lesions on ultrasound in any of the patients with clinical grade 3a tears. In patients with clinical grade 3b tears, the ultrasound confirmed the external anal sphincter lesion in all cases, but revealed additional involvement of the internal anal sphincter in 1 case (grade 3c).
CONCLUSIONS: Immediate postpartum endovaginal ultrasound could be a promising technique to improve the management of perineal traumas after vaginal delivery.

To present the characteristics of women attending a tertiary urogynecology pelvic floor scan clinic with mid-urethral sling (MUS) complications and examine the association between patient symptoms and findings on two-dimensional (2D) perineal and three-dimensional (3D) endovaginal ultrasound.
This was a cross-sectional study of all women with MUS complications referred to a specialist pelvic floor ultrasound clinic between October 2016 and October 2018. Detailed history was obtained regarding their symptoms and time of onset. All patients underwent 2D perineal and 3D endovaginal ultrasound assessment. The association between patient symptoms and ultrasound findings was evaluated using logistic regression analysis. Only symptomatic women with a single MUS, without other pelvic floor mesh, prior mesh excision or bulking agents, were included in the regression analysis.
A total of 311 women with a history of MUS surgery were seen during the study period. Vaginal and/or non-vaginal pain was reported by 80% of patients and this was the primary presenting complaint in 59% of the patients. One-third of the patients reported symptoms starting within 4 weeks after surgery. The data of 172 patients were included in the regression analysis. MUS position within the rhabdosphincter was significantly associated with voiding dysfunction (odds ratio (OR), 10.6 (95% CI, 2.2-50.9); P = 0.003). Voiding dysfunction was highest in those with C-shaped MUS both at rest and on Valsalva maneuver (OR, 3.2 (95% CI, 1.3-7.6); P < 0.001). MUS position in the distal third of the urethra was significantly associated with a higher rate of recurrent urinary tract infection (OR, 2.9 (95% CI, 1.3-6.3); P = 0.01).
Pelvic floor ultrasound can provide insight into the position and shape of the MUS, which could explain some patient symptoms and guide management or surgical planning. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The objective of this study was to evaluate our technique of ultrasonography and robotic-assisted sacrocervicopexy with pubocervical fascia reconstruction (u-RALS-PFR) versus standard robotic-assisted laparoscopic sacrocervicopexy (s-RALS) in the treatment of patients with symptomatic apical/anterior vaginal prolapse. A retrospective analysis was done using the data in two community hospitals. Thirty women presented with symptomatic vaginal apical prolapse and desired minimally invasive surgery (video): (a) standard robotic-assisted laparoscopic sacrocervicopexy (s-RALS) (n = 15) or (b) ultrasound and robotic-assisted sacrocervicopexy with pubocervical fascia reconstruction (u-RALS-PFR) (n = 15) were eligible to participate. All participants underwent a standardized evaluation, including a structured urogynecologic history and physical examination with pelvic organ prolapse quantitative staging. There was longer operating room time in the u-RALS-PFR group compared with the s-RALS group (average difference 35 min); however, sacral promontory dissection time was less in the u-RALS-PFR (average difference of 15 min). The anterior/posterior vaginal dissection and mesh tensioning time was longer in the u-RALS-PFR, as expected. There was only one surgical and anatomic failure (7%) in the s-RALS group after 6 months of surgery (POP Q = Aa + 1, Ba0, Ap-2, Bp-3, C-7). Our technique of ultrasonography and pubocervical fascia reconstruction during RALS appears to be feasible and safe. It aims to improve anterior and apical support, minimize the use of mesh and improve visualization during surgery. u-RALS-PFR approach will add some additional time during surgery but may provide better outcomes.

This article represents part 3 of the EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound (GIUS). It provides an overview of the examination techniques recommended by experts in the field of endorectal/endoanal ultrasound (ERUS/EAUS), as well as perineal ultrasound (PNUS). The most important indications are rectal tumors and inflammatory diseases like fistula and abscesses in patients with or without inflammatory bowel disease (IBD). PNUS sometimes is more flexible and convenient compared to ERUS. However, the technique of ERUS is quite well established, especially for the staging of rectal cancer. EAUS also gained ground in the evaluation of perianal diseases like fistulas, abscesses and incontinence. For the staging of perirectal tumors, the use of PNUS in addition to conventional ERUS could be recommended. For the staging of anal carcinomas, PNUS can be a good option because of the higher resolution. Both ERUS and PNUS are considered excellent guidance methods for invasive interventions, such as the drainage of fluids or targeted biopsy of tissue lesions. For abscess detection and evaluation, contrast-enhanced ultrasound (CEUS) also helps in therapy planning.

The Valsalva maneuver is normally accompanied by relaxation of the levator ani muscle, which stretches around the presenting part, but in some women the maneuver is accompanied by levator ani muscle contraction, which is referred to as levator ani muscle coactivation. The effect of such coactivation on labor outcome in women undergoing induction of labor has not been previously assessed.
The aim of the study was to assess the effect of levator ani muscle coactivation on labor outcome, in particular on the duration of the second and active second stage of labor, in nulliparous women undergoing induction of labor.
Transperineal ultrasound was used to measure the anteroposterior diameter of the levator hiatus, both at rest and at maximum Valsalva maneuver, in a group of nulliparous women undergoing induction of labor in 2 tertiary-level university hospitals. The correlation between anteroposterior diameter of the levator hiatus values and levator ani muscle coactivation with the mode of delivery and various labor durations was assessed.
In total, 138 women were included in the analysis. Larger anteroposterior diameter of the levator hiatus at Valsalva was associated with a shorter second stage (r = -0.230, P = .021) and active second stage (r = -0.338, P = .001) of labor. Women with levator ani muscle coactivation had a significantly longer active second stage duration (60 ± 56 vs 28 ± 16 minutes, P < .001). Cox regression analysis, adjusted for maternal age and epidural analgesia, demonstrated an independent significant correlation between levator ani muscle coactivation and a longer active second stage of labor (hazard ratio, 2.085; 95% confidence interval, 1.158-3.752; P = .014). There was no significant difference between women who underwent operative delivery (n = 46) when compared with the spontaneous vaginal delivery group (n = 92) as regards anteroposterior diameter of the levator hiatus at rest and at Valsalva maneuver, nor in the prevalence of levator ani muscle coactivation (10/46 vs 15/92; P = .49).
Levator ani coactivation is associated with a longer active second stage of labor.

OBJECTIVE: An adequate pelvic floor muscle contraction (PFMC) elevates the bladder neck (BN) and stabilizes it during increased intra-abdominal pressure (IAP). A maximal PFMC may increase the IAP and thereby prevent BN elevation. The aim of this study was to assess BN elevation during submaximal and maximal PFMC and their achievable duration.
METHODS: We recruited 68 women with stress urinary incontinence and 14 vaginally nulliparous continent controls who were able to perform a PFMC on vaginal palpation. Women were upright and performed a maximal PFMC as long as possible, followed by a submaximal PFMC, controlled by vaginal electromyogram (EMG). BN position was measured with perineal ultrasound, IAP and urethral pressure with a microtip catheter, and breathing with a circular thorax sensor.
RESULTS: A submaximal PFMC elevated the bladder neck 4 mm in continent and incontinent women (p = 0.655) and 4.5 vs. 5 mm during maximal PFMC (0.528). Submaximal PFMC was maintained significantly longer than a maximal PFMC (33 vs 12 s) with no difference between groups. A maximal PFMC resulted in BN descent in 29% of continent and 28% of incontinent women, which was not observed during submaximal PFMC. Breathing was normal in 70% of continent and 71% of incontinent women during submaximal PFMC but stopped completely in 21 and 50%, respectively, during maximal PFMC (p = 0.011). IAP increase was significantly greater with maximal PFMC in both groups (24 vs. 9.6 cmH2O and 17 vs. 9 cmH2O, respectively).
CONCLUSIONS: Submaximal PFMC are sufficient to elevate the bladder neck, can be maintained longer, and breathing was not influenced.

Urachal cyst is difficult to diagnose and is a rare malformation and the authors report a case in a 10-month old boy. The malformation was associated with posterior urethral valve and simple surgical treatment was successful.
The authors emphasize the contribution of perineal ultrasound in the diagnosis of associated posterior urethral valves.
Le kyste de l\'ouraque est de diagnostic difficile et constitue une malformation rare dont les auteurs rapportent un cas chez un garçon de 10 mois. La malformation était associée à une valve de l\'urètre postérieur et sa cure chirurgicale très simple a été couronnée de succès.
Ils insistent sur l\'apport de l\'échographie par voie périnéale dans le diagnostic associé des valves de l\'urètre postérieur.