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

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.