Pelvic floor ultrasound in functional assessment and rehabilitation: current applications and standardization challenges

Introduction: Pelvic floor ultrasound has evolved over the past 2 decades from a predominantly anatomical imaging modality into a tool supporting functional assessment and rehabilitation. Its capability of visualizing pelvic floor structures in real time during contraction, relaxation, coughing, and straining has expanded its role beyond structural diagnosis and into physiotherapy practice. Aim: This narrative review aimed to examine the role of pelvic floor ultrasound in functional assessment and rehabilitation, with particular emphasis on ultrasound‑derived functional parameters and challenges related to standardization. Methods: Relevant literature was identified through searches of the PubMed, Scopus, and Web of Science databases, focusing on pelvic floor muscle function, rehabilitative ultrasound imaging, biofeedback, physiotherapy applications, and emerging ultrasound technologies. Results: Current evidence supports the transition of ultrasound from static anatomical imaging toward dynamic assessment of pelvic floor muscle performance. Commonly reported functional parameters include bladder neck mobility, pelvic floor elevation, levator hiatus dimensions, and hiatal reduction during contraction. Among these, levator hiatus dynamics appear to provide particularly meaningful information on the integrated mechanical effect of levator ani activation. Ultrasound may also support biofeedback, motor learning, individualized exercise instruction, and monitoring of treatment‑related changes. Emerging approaches, including shear‑wave elastography, automated image analysis, and artificial intelligence–assisted assessment, can make measurements less dependent on manual interpretation. Conclusions: Despite recent advances, functional pelvic floor ultrasound remains limited by heterogeneity in acquisition protocols, task instructions, outcome measures, and reporting methods. Future research should focus on consensus‑based protocols, core functional outcomes, structured reporting, and clinically meaningful reference values.