# Rehabilitative Ultrasound Imaging as Visual Biofeedback in Pelvic Floor Dysfunction: A Narrative Review

## TL;DR

Rehabilitative Ultrasound Imaging (RUSI) helps patients visualize and improve pelvic floor muscle control, leading to better outcomes in pelvic floor dysfunction treatment.

## Contribution

This review highlights RUSI as a promising visual biofeedback tool for pelvic floor rehabilitation with evidence of improved muscle control and patient outcomes.

## Key findings

- RUSI-guided training improves pelvic floor muscle function in postpartum women and men after prostate surgery.
- Ultrasound biofeedback enables 57% of patients who cannot contract muscles with verbal cues to achieve correct contractions.
- RUSI outcomes are comparable to or better than other biofeedback methods, though more research is needed.

## Abstract

Pelvic floor dysfunction can cause urinary incontinence, pain, and difficulty coordinating the pelvic floor muscles. Many people struggle to learn these muscle contractions using verbal instructions alone. Rehabilitative Ultrasound Imaging (RUSI) provides real-time visual feedback that helps patients see how their pelvic floor muscles move, making training easier and more effective. Research shows that RUSI-guided exercises improve muscle control, reduce symptoms, and increase patient confidence across different groups, including postpartum women and men after prostate surgery. Although RUSI is promising, its use is limited by equipment costs, the need for specialized clinician training, and a lack of standardized protocols. More high-quality studies are needed to confirm its advantages over other biofeedback methods and to guide wider clinical adoption.

Background: Pelvic floor dysfunction, more prevalent in women but affecting both genders, impairs sphincter control and sexual health, and causes pelvic pain. Pelvic floor muscle (PFM) training is the first-line treatment for urinary incontinence, supported by robust evidence. Rehabilitative ultrasound imaging (RUSI) serves as a visual biofeedback tool, providing real-time imaging to enhance PFM training, motor learning, and treatment adherence. Aim: This narrative review evaluates the role and efficacy of RUSI in pelvic floor rehabilitation. Method: A comprehensive search of PubMed, Cochrane, and MEDLINE was conducted using keywords related to pelvic floor rehabilitation, ultrasound, and biofeedback, limited to English-language publications up to July 2025. Systematic reviews, meta-analyses, and clinical trials were prioritized. Results: Transperineal and transabdominal ultrasound improve PFM function across diverse populations. In post-prostatectomy men, transperineal ultrasound-guided training enhanced PFM contraction and reduced urinary leakage. In postpartum women with pelvic girdle pain, transabdominal ultrasound-guided biofeedback combined with exercises decreased pain and improved function. Ultrasound-guided pelvic floor muscle contraction demonstrated superior performance compared to verbal instruction. Notably, 57% of participants who were unable to contract the pelvic floor muscles with verbal cues achieved a correct contraction with ultrasound biofeedback, and this approach also resulted in more sustained improvements in PFM strength. Compared to other biofeedback modalities, RUSI demonstrated outcomes that are comparable to or superior to those of alternative methods. However, evidence is limited by a lack of standardized protocols and randomized controlled trials comparing RUSI with other modalities. Conclusions: RUSI is an effective visual biofeedback tool that enhances outcomes of PFM training in pelvic floor rehabilitation. It supports clinical decision-making and patient engagement, particularly in cases where traditional assessments are challenging. Further research, including the development of standardized protocols and comparative trials, is necessary to optimize the clinical integration of this method and confirm its superiority over other biofeedback methods.