Invest Clin 66(2): 147 - 156, 2025 https://doi.org/10.54817/IC.v66n2a02

Corresponding author: Xuekui Pan. Department of Ultrasound, Huzhou Maternal and Child Health Hospital,

Huzhou 313000, Zhejiang Province, China. E-mail: panxkhmchh@csc-edu.cn

Value of ultrasound shear wave elastography

and gray-scale ultrasonography for assessing

the bladder neck status of women with

stress urinary incontinence.

Huaying Shan, Jingying Fei, Hua Chu, Mingsong Liu, Yan Lu and Xuekui Pan

Department of Ultrasound, Huzhou Maternal and Child Health Hospital, Huzhou,

Zhejiang Province, China.

Keywords: bladder neck; elastography; stress urinary incontinence; ultrasonography.

Abstract. We aimed to investigate the value of ultrasound shear wave elas-

tography (US-SWE) and gray-scale ultrasonography for assessing the bladder

neck status of patients with stress urinary incontinence (SUI). Seventy-two

puerperal women with SUI treated from February 2022 to September 2023

were selected as a research group, while another 50 healthy pregnant women

receiving physical examination in the same period were selected as a control

group. US-SWE and gray-scale ultrasonography were performed for all subjects.

The height, length, circumference and area of the perineal body at rest and

the maximum, as well as the thicknesses and elastic moduli of anterior and

posterior lips of the bladder neck, were compared. At the maximum Valsalva

maneuver (VM), the research group had higher height, smaller length and area,

and shorter circumference of the perineal body than those of the control group

(p<0.05). Maternal SUI was positively correlated with the height of the peri-

neal body (r>0, p<0.05) but negatively correlated with the length, circumfer-

ence and area of the perineal body and the elastic moduli of anterior and poste-

rior lips of the bladder neck (r<0, p<0.05). The elastic moduli of the anterior

and posterior lips of the bladder neck and the height, length, circumference,

and area of the perineal body at the maximum VM were valuable for assessing

maternal SUI. US-SWE and gray-scale ultrasonography parameters are closely

related to maternal SUI, and the risk of maternal SUI can be assessed early by

the bladder neck status.

148 Shan et al.

Investigación Clínica 66(2): 2025

Valor de la elastografía ultrasónica de onda cortante y de la

ecografía en escala de grises para evaluar el estado del cuello

vesical de mujeres con incontinencia urinaria de esfuerzo.

Invest Clin 2025; 66 (2): 147 – 156

Palabras clave: cuello vesical; elastografia; incontinencia urinaria de esfuerzo;

ultrasonografía.

Resumen. Nuestro objetivo fue investigar el valor de la elastografía ultrasó-

nica de onda cortante (US-SWE) y la ecografía en escala de grises para evaluar

el estado del cuello vesical de pacientes con incontinencia urinaria de esfuerzo

(IUE). Setenta y dos mujeres puerperales con IUE tratadas entre febrero de 2022

y septiembre de 2023 fueron seleccionadas como grupo de investigación, mien-

tras que otras 50 mujeres embarazadas sanas que recibieron examen físico en el

mismo período fueron seleccionadas como grupo control. A todos los sujetos se

les realizó eco de US-SWE y escala de grises. Se compararon la altura, longitud,

circunferencia y área del cuerpo perineal en reposo y el máximo, así como los

espesores y los módulos elásticos de los labios anterior y posterior del cuello ve-

sical. En el momento de la maniobra de Valsalva máxima (VM), el grupo de inves-

tigación tuvo mayor altura, menores longitud y área y menor circunferencia del

cuerpo perineal que el grupo control (p<0,05). La IUE materna se correlacionó

positivamente con la altura del cuerpo perineal (r>0, p<0,05), pero negativa-

mente con la longitud, circunferencia y área del cuerpo perineal y los módulos

elásticos de los labios anterior y posterior del cuello vesical (r<0, p<0,05). Los

módulos elásticos de los labios anterior y posterior del cuello vesical y la altura,

longitud, circunferencia y área del cuerpo perineal en el VM máximo fueron valio-

sos para evaluar la IUE materna. Los parámetros de ecografía de US-SWE y escala

de grises están estrechamente relacionados con la IUE materna, y el riesgo de

IUE materna se puede evaluar tempranamente por el estado del cuello vesical.

Received: 20-08-2024 Accepted: 15-04-2025

INTRODUCTION

Maternal stress urinary incontinence

(SUI) is a common pelvic floor dysfunction

in postpartum women, mainly because the

postpartum pelvic floor fascia is too weak to

support the bladder and maintain the ure-

thral closure pressure. SUI does not threat-

en the life safety of puerperae. However, pa-

tients are highly prone to leakage of urine

when the intra-abdominal pressure increases

due to sneezing, laughing, coughing and ex-

ercise, which, if not treated promptly, may

lead to eczema, local skin ulceration, vagi-

nitis and urinary system diseases. Moreover,

negative emotions, such as inferiority and

anxiety, may be produced from all kinds of

embarrassment, affecting the patient’s men-

tal health 1,2. Female pelvic floor dysfunction

is related to perineal injury and abnormal

bladder neck status. Therefore, it is crucial

to detect perineal injury and bladder neck

elasticity to diagnose and treat maternal

SUI3,4. Characterized by non-invasiveness,

simple operation and repeatability, ultraso-

nography is commonly used in clinical prac-

Assessment of bladder neck for stress urinary incontinence 149

Vol. 66(2): 147 - 156, 2025

tice. In particular, gray-scale ultrasonogra-

phy can record the internal echo of tissue

and process the echo into gray-scale images

to accurately display the structure and shape

of the examination site. Besides, ultrasound

shear wave elastography (US-SWE) can ob-

jectively quantify tissue hardness and accu-

rately monitor tissue elasticity 5,6. Based on

this, US-SWE and gray-scale ultrasonogra-

phy were performed in this study to analyze

their values for assessing the bladder neck

status of patients with SUI.

PATIENTS AND METHODS

Subjects

A power analysis was conducted using

G*Power software for the two-tailed indepen-

dent-samples t-test, assuming a moderate ef-

fect size (Cohen’s d = 0.5), a significance

level of α = 0.05, and 80% power. Using the

equation n = 2 × [(Z1-α/2 + Z1-β)/d]2 (with

Z1-0.05/2 ≈ 1.96 and Z1-0.20 ≈ 0.84), n ≈ 63 par-

ticipants per group was obtained. With 72

puerperae with SUI and 50 healthy controls

enrolled, the post hoc analysis confirmed an

overall power of approximately 0.78-0.80,

supporting the adequacy of our sample sizes

to detect clinically significant differences.

Seventy-two puerperae with SUI treated in

our hospital from February 2022 to Sep-

tember 2023 were selected as the research

group, while another 50 healthy pregnant

women receiving the physical examination

in the same period were selected as the con-

trol group.

Inclusion and exclusion criteria

Inclusion criteria were as follows: (1)

puerperae who met the diagnostic criteria

for maternal SUI in the research group 7, (2)

those with a single pregnancy, (3) those aged

22-35 years old, and (4) those who and whose

families signed the informed consent form.

Exclusion criteria involved: (1) subjects

with a history of constipation or chronic

cough, (2) those with a history of pelvic

surgery, (3) those with a history of urinary

incontinence before pregnancy, (4) those

complicated with urinary system diseases,

(5) those complicated with pelvic organ pro-

lapse, pelvic tumor or other diseases that

can lead to pelvic function impairment, (6)

those with infection or neurogenic urinary

incontinence, (7) those with a history of

bladder or urethral diseases, (8) those who

took hormone drugs within the past six

months, or (9) those unable to cooperate in

the study due to mental illness or communi-

cation disorders.

Examination apparatus

Mindray Resona 8S Diagnostic Ultra-

sound System (China) equipped with an ab-

dominal probe SC5-1U (frequency: 1-5 MHz)

and a superficial probe L14-5WU (frequency:

5-14 MHz) or Mindray Neuwa R9 Diagnostic

Ultrasound System (China) equipped with

an abdominal probe SC6-1U (frequency: 1-6

MHz) and superficial probes L15-3WU (fre-

quency: 3-15 MHz) and DE10-3WU (frequen-

cy: 3-10 MHz) was used.

Examination methods and processes

Before examination, the subject was

instructed to empty the bladder. First, gray-

scale ultrasonography was performed on the

subject in the lithotomy position, and the ul-

trasonic probe was placed in the perineal body

at a depth of 3-4 cm on the anorectal median

sagittal plane to display the perineal body (a

high-echo wedge-shaped muscular tissue) with

the bottom facing upward and the tip facing

downward. Then, the morphology, peripheral

conditions and internal echo of the perineal

body were observed, and its height, length, and

circumference area at rest and at the maxi-

mum Valsalva maneuver (VM) were measured.

Afterwards, the ultrasonic probe was adjusted

to make the beam perpendicular to the anorec-

tum, and the image was continuously enlarged

by gain regulation. When the long axis of the

bladder neck became deformed, the image was

frozen, and the thicknesses of the anterior and

posterior lips of the bladder neck were mea-

sured. In addition, in the STE mode, the sam-

150 Shan et al.

Investigación Clínica 66(2): 2025

pling frame was placed at an appropriate depth,

and its size was adjusted so the sampling frame

could completely cover the bladder neck, with

a measurement range of 100 kPa. The stable

images with no mosaics and color loss were fro-

zen and saved. Then, a circle with a diameter

of 3 cm and uniform color was selected as the

region of interest. The elastic moduli of the

anterior and posterior lips of the bladder neck

were measured three times by Q-BOX, and the

average value was taken. All examinations were

performed by the same sonographer with more

than three years of experience.

Outcome evaluation

The height, length, circumference and

area of the perineal body at rest and the

maximum VM were compared between the

two groups. Comparisons were also made on

the thicknesses and elastic moduli of the an-

terior and posterior lips of the bladder neck.

Statistical analysis

SPSS 23.0 software was used for statisti-

cal analysis. Measurement data (the height,

length, circumference and area of the peri-

neal body, and the thicknesses and elastic

moduli of anterior and posterior lips of the

bladder neck) were described by (mean ±

standard deviation) and subjected to the t-

test. Count data were described by percent-

age and subjected to the chi-square test. The

point-biserial correlation test analyzed the

correlations of maternal SUI with US-SWE

and gray-scale ultrasonography parameters.

The assessment values of US-SWE and gray-

scale ultrasonography parameters were ana-

lyzed using receiver operating characteristic

(ROC) curves, p<0.05 was considered statis-

tically significant.

RESULTS

Baseline clinical data

Age, pre-pregnancy body mass index,

gestational age, fetal birth weight, parity

and delivery mode were comparable between

the two groups (p>0.05) (Table 1).

Height, length, circumference and area

of the perineal body at rest

There were no significant differences in

the height, length, circumference and area

of the perineal body at rest between the two

groups (p>0.05) (Table 2).

Height, length, circumference and area

of the perineal body at the maximum

Valsalva maneuver

At the maximum VM, the research

group had higher height, smaller length and

area, and shorter circumference of the peri-

neal body than those of the control group

(p<0.05) (Table 3).

Table 1. Clinical Data Baseline.

Variable Research group

(n=72)

Control group

(n=50) Statistical p

Age ( ± SD, year) 29.04±3.92 28.69±4.12 t=0.475 0.636

Pre-pregnancy BMI ( ± SD, kg/m2)22.54±1.18 22.37±1.32 t=0.745 0.458

Gestation age ( ± SD, weeks) 39.52±0.96 39.46±0.91 t=0.347 0.729

Fetal birth weight ( ± SD, g) 3156.28±493.14 3112.09±502.36 t=0.483 0.630

Parity ( ± SD, times) 1.42±0.49 1.35±0.43 t=0.815 0.417

Delivery mode

[n (%)]

Natural delivery 46 (63.89) 32 (64.00) χ2=0.048 0.977

Cesarean section 21 (29.17) 15 (30.00)

Conversion to cesarean

section

5 (6.94)

3 (6.00.)

Assessment of bladder neck for stress urinary incontinence 151

Vol. 66(2): 147 - 156, 2025

Thickness and elastic moduli of anterior

and posterior lips of the bladder neck

The elastic moduli of the anterior and

posterior lips of the bladder neck were small-

er in the research group than those in the

control group (p<0.05), while the thickness-

es of the anterior and posterior lips of the

bladder neck had no significant difference

between the two groups (p>0.05) (Table 4).

Correlations of maternal SUI with US-

SWE and gray-scale ultrasonography

parameters

Maternal SUI was positively correlated

with the height of the perineal body (r>0,

p<0.05) but negatively correlated with the

length, circumference and area of the peri-

neal body and the elastic moduli of anterior

and posterior lips of the bladder neck (r<0,

p<0.05) (Table 5).

Assessment values of US-SWE and gray-

scale ultrasonography parameters for

maternal SUI

ROC curves were plotted by using US-

SWE parameters (elastic moduli of the ante-

rior and posterior lips of the bladder neck)

and gray-scale ultrasonography parameters

(height, length, circumference and area of

the perineal body at the maximum VM) that

differed between research group and control

group as test variables, and the incidence

of maternal SUI as a state variable (1=Yes,

0=No). The results revealed that the elas-

tic moduli of anterior and posterior lips of

the bladder neck and the height, length,

circumference and area of the perineal body

at the maximum VM were valuable for as-

sessing maternal SUI (areas under the ROC

curves: 0.765, 0.667, 0.809, 0.800, 0.828

and 0.833). The predictive value was optimal

when their cut-off values were 7.630 mm,

16.850 mm, 13.305 mm, 3.070 cm, 26.205

kPa and 22.010 kPa, respectively (Table 6

and Fig. 1).

DISCUSSION

The dynamic balance and muscle func-

tion of pelvic floor support structures are

the main factors controlling normal urina-

tion. Once such balance is destroyed and

Table 2. Height, length, circumference and area of the perineal body at rest.

Group Height (mm) Length (mm) Circumference (mm) Area (cm2)

Research (n=72) 8.42±1.12 16.06±2.16 10.26±1.14 2.41±0.79

Control (n=50) 8.29±1.29 16.49±2.03 10.34±0.93 2.53±0.65

t0.592 1.108 0.410 0.886

p 0.555 0.270 0.682 0.378

Data are expressed as  ± SD.

Table 3. Height, length, circumference and area of the perineal body at the maximum

Valsalva maneuver.

Group Height (mm) Length (mm) Circumference (mm) Area (cm2)

Research (n=72) 8.09±1.23 16.58±2.12 12.86±1.11 2.66±0.81

Control (n=50) 6.87±1.34 18.21±2.64 14.15±0.96 3.52±0.60

t5.194 3.774 6.665 6.386

p 0.000 0.000 0.000 0.000

Data are expressed as  ± SD.

152 Shan et al.

Investigación Clínica 66(2): 2025

muscle function is impaired, it is difficult

to maintain the urethral closure pressure,

resulting in SUI 8,9. Transvaginal ultrasonog-

raphy is commonly used for the clinical diag-

nosis of SUI, and observation of the perineal

body and bladder neck status at rest and the

maximum VM by gray-scale ultrasonography

play an important auxiliary role in diagnos-

ing SUI 10. US-SWE can detect soft tissue

hardness, quantitatively assess muscle elas-

ticity and reflect muscle strength 11. Zhao et

al. found that the state of urethral striated

muscle can be quantitatively assessed by US-

SWE, which had important significance in

diagnosing and treating SUI in females 12.

In the case of muscle damage of the

perineal body, the support capacity declines,

resulting in pelvic floor dysfunction 13. The

urethral sphincter of females is mainly com-

posed of circular smooth muscle fibers sur-

rounding the bladder neck. Pregnancy and

childbirth may alter the bladder neck status

and thus impair its function, so the patients

cannot consciously store urine 14. Therefore,

imaging is necessary to measure relevant

parameters of the perineal body and blad-

der neck. The gray-scale ultrasonic probe

placed in the vagina emits ultrasonic waves

to surrounding tissues, and gray-scale im-

ages are obtained, by which doctors can ob-

serve the height, length, circumference and

area of the perineal body. US-SWE reflects

the changes in morphology and hardness of

the bladder neck in real-time, thereby indi-

rectly reflecting the degree of damage to the

neck15,16. In this study, at the maximum VM,

the research group had higher height, small-

er length and area, and shorter circumfer-

ence of the perineal body than those of the

control group, suggesting that the param-

eters of the perineal body at the maximum

VM of SUI patients were inferior to those of

healthy pregnant women.

Moreover, the elastic moduli of ante-

rior and posterior lips of the bladder neck

were smaller in the research group than

those in the control group, indicating that

the bladder neck of SUI patients was less

elastic than that of healthy pregnant wom-

en. During childbirth, the perineal body

is passively expanded, and the mobility of

the posterior wall of the bladder and tri-

gonum vesicae accordingly increases with

rising abdominal pressure, which may lead

to the shortening of the perineal body and

loose closure of the bladder neck 17,18. In

the third trimester of pregnancy, the pelvic

floor muscles are directly pulled and com-

pressed, resulting in pelvic floor muscle

dysfunction. During childbirth, the perineal

body is exceptionally pulled (up to 200%) as

the fetus passes through the birth canal,

so SUI and other pelvic floor dysfunction

diseases occur easily 19,20.

We herein found that maternal SUI

was positively correlated with the height of

the perineal body but negatively correlated

with the length, circumference and area of

the perineal body and the elastic moduli of

the anterior and posterior lips of the blad-

Table 4. Thickness and elastic moduli of the anterior and posterior lips of the bladder neck.

Group Thickness of anterior

lip (mm)

Elastic modulus

of anterior lip (kPa)

Thickness of

posterior lip (mm)

Elastic modulus of

posterior lip (kPa)

Research

(n=72) 4.42±0.59 24.68±4.16 5.13±0.76 19.37±3.78

Control

(n=50) 4.38±0.61 30.72±4.97 5.09±0.84 25.22±5.49

t0.363 7.278 0.274 6.974

p 0.717 0.000 0.785 0.000

Data are expressed as  ± SD.

Assessment of bladder neck for stress urinary incontinence 153

Vol. 66(2): 147 - 156, 2025

Table 5. Correlations of maternal SUI with US-SWE and gray-scale ultrasonography parameters.

Group Height Length Circumference Area Elastic modulus of

the anterior lip

Elastic modulus of

the posterior lip

Group - 0.430/0.000 -0.326/0.000 -0.518/0.00 -0.501/0.000 -0.553/0.00 -0.538/0.000

Height 0.430/0.000 - -0.210/0.020 -0.297/0.001 -0.256/0.004 -0.309/0.001 -0.268/0.003

Length -0.326/0.000 -0.210/0.020 - 0.257/0.004 0.180/0.048 0.332/0.000 0.213/0.018

Circumference -0.518/0.00 -0.297/0.001 0.257/0.004 - 0.172/0.058 0.356/0.000 0.294/0.001

Area -0.501/0.000 -0.256/0.004 0.180/0.048 0.172/0.058 - 0.298/0.001 0.304/0.001

Elastic modulus

of anterior lip

-0.553/0.00

-0.309/0.001

0.332/0.000

0.356/0.000

0.298/0.001

0.323/0.000

Elastic modulus

of posterior lip

-0.538/0.000

-0.268/0.003

0.213/0.018

0.294/0.001

0.304/0.001

0.323/0.000

The values are represented as r/p; the point-biserial correlation test was used.

Table 6. Assessment value of US-SWE and gray-scale ultrasonography parameters for maternal SUI.

Variable AUC Standard

error p

95%CI Cut-off

value Sensitivity Specificity Youden

index

Lower

limit

Upper

limit

Height 0.765 0.045 0.000 0.678 0.852 7.630 mm 0.780 0.653 0.433

Length 0.667 0.051 0.002 0.566 0.768 16.850 mm 0.660 0.528 0.188

Circumference 0.809 0.040 0.000 0.732 0.887 13.305 mm 0.800 0.681 0.481

Area 0.800 0.039 0.000 0.724 0.877 3.070 cm 0.780 0.681 0.461

Elastic modulus of the anterior lip 0.828 0.038 0.000 0.753 0.903 26.205 kPa 0.860 0.667 0.527

Elastic modulus of the posterior lip 0.833 0.040 0.000 0.755 0.911 22.010 kPa 0.800 0.764 0.564

154 Shan et al.

Investigación Clínica 66(2): 2025

der neck. As indicated by the ROC curve

analysis, the elastic moduli of the anterior

and posterior lips of the bladder neck and

the height, length, circumference and area

of the perineal body at the maximum VM

were valuable for assessing maternal SUI.

The perineal body is the ultimate line of

defense against pelvic floor dysfunction

and plays an important role in supporting

the urethra. Morphological changes of the

perineal body affect its support to the va-

gina and urethra, resulting in cystocele and

rectocele, and ultimately SUI 21. When the

bladder neck is less elastic, and the mus-

cle is weak in contraction, it is difficult to

control urine, thereby effectively increasing

the risk of SUI22. Therefore, patients with

postpartum SUI are recommended to re-

ceive hot compress and massage to relieve

local muscle dysfunction, take anus-lifting

exercises to improve muscle relaxation, and

undergo medication and surgery to restore

the anatomical structure of local tissues if

necessary, aiming to ameliorate the prog-

nosis.

Nevertheless, this study is limited.

First, the ultrasound technique may have

variabilities. Second, this is a single-cen-

ter study with a small sample size. Third,

a subgroup analysis of patients whose ul-

trasound varies considerably was not con-

ducted. Hence, further multicenter studies

with larger sample sizes must confirm our

findings.

In conclusion, US-SWE and gray-scale

ultrasonography parameters are closely re-

lated to maternal SUI, and the risk of mater-

nal SUI can be assessed early by the bladder

neck status. US-SWE may be recommended

in cases with higher-risk factors, such as a

history of multiple pregnancies or advanced

maternal age, where monitoring the elastic-

ity and perineal body status of the bladder

neck can provide valuable insights into SUI

development.

ACKNOWLEDGEMENTS

None.

Funding

This study was financially supported by

Grant No. 2022GYB31.

Conflicts of interest

The authors declare they have no con-

flicts of interest.

ORCID numbers of authors

• Xuekui Pan (XP):

0009-0008-0275-4099

• Huaying Shan (HS):

0009-0006-4354-0893

• Jingying Fei (JF):

0009-0003-9619-6887

• Hua Chu (HC):

0009-0004-7455-6703

• Mingsong Liu (ML):

0009-0002-6541-0732

• Yan Lu (YL):

0009-0006-8693-3750

Fig. 1. ROC curves of US-SWE and gray-scale ultra-

sonography parameters for assessing mater-

nal SUI.

Sensitivity

ROC curve

1 - Specicity

Assessment of bladder neck for stress urinary incontinence 155

Vol. 66(2): 147 - 156, 2025

Participation of each author

HS, XP designed this study and pre-

pared this manuscript; JF, HC, ML, YL per-

formed this study and analyzed the data. All

authors have approved the submission and

publication of this paper.

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