Imaging of the lower urinary tract was first described in 1928, followed by bead chain cystourethrography in the 1940s and video cystourethrography when fluoroscopy was introduced in 1970s. In recent decades there is an increasing interest in lower urinary tract and pelvic floor imaging amongst urogynaecologists and pelvic floor surgeons. This may be attributed by the fact that female pelvic floor dysfunction involves multifactorial aetiology and pathophysiology, which are still poorly understood. Imaging has a great potential to enhance both research and clinical management in this field. To date this potential is still underutilised.

With advances in medical imaging, imaging of the lower urinary tract and pelvic floor can be achieved by various techniques such as X-ray, computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (either endovaginal, translabial/transperineal or endoanal). Although MRI and CT provide high quality imaging, they are limited by cost and accessibility. Surgical management of pelvic floor disorders depends on a comprehensive understanding of the structural integrity and function of the pelvic floor. Ultrasonography (especially transperineal and translabial approach) has emerged as a procedure that is relatively easy to perform, cost-effective and widely available, thus generally superior for pelvic floor imaging.

Its clinical utility in the management of incontinent women and those with pelvic organ prolapse is well documented in the literature. These include diagnostic work-up, pre-operative investigations, dealing with treatment failure and post-operative complications. Ultrasound including two-dimensional (2D), three-dimensional (3D) and 4D imaging provide information on residual bladder volume, detrusor wall thickness, and bladder neck mobility, and in assessing pelvic organ prolapse as well as levator ani function and integrity. It is equivalent to other imaging modalities in diagnosing conditions as diverse as urethral diverticulum, rectal intussusception and levator ani trauma. Assessment of levator integrity facilitates patient selection for prolapse mesh augmented pelvic reconstructive surgery by identifying those at high risk of recurrence. It also allows evaluation of obstructed defecation and fecal incontinence, and visualisation of modern slings and mesh implants dynamically. Birth trauma to the levator ani muscle which seems to be the central aetiological factor for pelvic organ prolapse and recurrence is easily diagnosed by pelvic floor ultrasound. Similarly, delivery-related trauma to the external and internal anal sphincter is central to the aetiology of anal incontinence in women is easily diagnosed using either endo- or exoanal (translabial or perineal) ultrasound.