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Introduction and hypothesis Conventional defecography and MRI defecography can be requested as an additional test for diagnosing and differentiating the type of posterior compartment prolapse and/or obstructive defecation disorders. The objective of this study was to determine the added value of conventional defecography, conventional defecography and MRI defecography for clinical decision-making on treatment for patients with posterior compartment prolapse. Methods Four gynecologists were asked to fill in their treatment plan per patient for 32 cases for three different steps. Step 1 consisted of information on the anamnesis and physical examination (POP-Q). Step 2 consisted of Step 1, including conventional defecography (group A) or MRI defecography (group B). In Step 3, all gynecologists received the information on Step 1 including both conventional defecography and MRI defecography. Data analysis solely focused on the assessment of changes in the gynecological treatment plan of the posterior compartment. Results After Step 2 a change in treatment plan occurred in 37% and 48% of the women in groups A and B, respectively. Accordingly, after Step 3 (including all imaging data), a change in treatment plan occurred in 19% and 52% of the women in groups A and B, respectively. A change within the surgery group (when a different type of surgery was selected) was seen for a total of 11 cases in group A and 20 in group B in all steps combined. Conclusions Both conventional defecography and MRI defecography had an large effect on the treatment plan for patients with posterior compartment prolapse. The dedicated added value of the imaging modality individually cannot be concluded yet.

Objective To develop recommendations that can be used as guidance for standardized approach regarding indications, patient preparation, sequences acquisition, interpretation and reporting of magnetic resonance imaging (MRI) for diagnosis and grading of pelvic floor dysfunction (PFD). Methods The technique included critical literature between 1993 and 2013 and expert consensus about MRI protocols by the pelvic floor-imaging working group of the European Society of Urogenital Radiology (ESUR) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) from one Egyptian and seven European institutions. Data collection and analysis were achieved in 5 consecutive steps. Eighty-two items were scored to be eligible for further analysis and scaling. Agreement of at least 80 % was defined as consensus finding. Results Consensus was reached for 88 % of 82 items. Recommended reporting template should include two main sections for measurements and grading. The pubococcygeal line (PCL) is recommended as the reference line to measure pelvic organ prolapse. The recommended grading scheme is the “Rule of three” for Pelvic Organ Prolapse (POP), while a rectocele and ARJ descent each has its specific grading system. Conclusion This literature review and expert consensus recommendations can be used as guidance for MR imaging and reporting of PFD. Key points • These recommendations highlight the most important prerequisites to obtain a diagnostic PFD-MRI. • Static, dynamic and evacuation sequences should be generally performed for PFD evaluation. • The recommendations were constructed through consensus among 13 radiologists from 8 institutions.

INTRODUCTION:Pelvic floor disorders are prevalent in women. Sarcopenia, or age-related muscle mass loss, may be a contributing factor. We aimed to investigate the association between sarcopenia, as measured by the psoas muscle index (PMI), and pelvic floor and anal sphincter function in women with evacuation disorders.METHODS:We conducted a retrospective analysis of data from women who underwent magnetic resonance defecography and high-resolution anorectal manometry. As an indicator of overall muscle mass measurement, PMI was computed at the L4 level.RESULTS:Women with evacuation disorders who had magnetic resonance imaging diagnosis of sarcopenia (98/264; 37.1%), were older and had lower body mass index (P < 0.001), with comparable rates of parity and pelvic surgery. There was a significant association between diminished PMI and decreased anal resting (P < 0.001) and squeeze (P < 0.001) pressures, as well as increased levator hiatus length (P = 0.004), descent (P = 0.01), and anorectal angle (P = 0.002). Patients with sarcopenia were more likely to have anal hypotension and hypocontractility (P < 0.001), and increased levator hiatus laxity measurements (P < 0.05), associated with lower obstructive defecation scores (9 vs 11, P = 0.003), and higher Wexner fecal incontinence scores (8 vs 4, P = 0.03). Sarcopenia was an independent risk factor of anal hypotension and hypocontractility, levator enlargement, and exaggerated levator hiatus descent.DISCUSSION:Sarcopenia significantly affects anal sphincter function and pelvic floor dynamics in women with evacuation disorders, serving as a risk factor of anal hypotension/hypocontractility and levator laxity. These findings highlight the need for integrated approaches in managing pelvic floor disorders, taking into account the role of muscle mass and strength in treatment strategies.

INTRODUCTION:The natural history of rectal intussusception (RI) is poorly understood. We hypothesized that decline in pelvic floor integrity and function leads to increasing RI grades.METHODS:Retrospective analysis of a registry of patients with defecatory disorders with high-resolution anorectal manometry and magnetic resonance defecography was performed. Association of risk factors on increasing RI grades was assessed using logistic regression.RESULTS:Analysis included a total of 238 women: 90 had no RI, 43 Oxford 1-2, 49 Oxford 3, and 56 Oxford 4-5. Age (P = 0.017), vaginal delivery (P = 0.008), and prior pelvic surgery (P = 0.032) were associated with increased Oxford grades. Obstructive defecation symptoms and dyssynergic defecation were observed at relatively high rates across groups. Increased RI grades were associated with less anal relaxation at simulated defecation yet, higher rates of normal balloon expulsion (P < 0.05), linked to diminished anal sphincter. Indeed, increased RI grades were associated with worsening fecal incontinence severity, attributed to higher rates of anal hypotension. Levator ani laxity, defined by increased levator hiatus length and its excessive descent at straining, was associated with increasing RI grades, independent of age, history of vaginal delivery, and pelvic surgeries and could independently predict increased RI grades. Concurrent anterior and posterior compartments, and visceral prolapse were associated with higher Oxford grades.DISCUSSION:Our data suggest that decline in pelvic floor integrity with abnormal levator ani laxity is associated with increased RI grades, a process that is independent of age, history of vaginal deliveries, and/or pelvic surgeries, and perhaps related to dyssynergic defecation.

To develop an automated grading model for rectocele (RC) based on radiomics and evaluate its efficacy. This study retrospectively analyzed a total of 9,392 magnetic resonance imaging (MRI) images obtained from 222 patients who underwent dynamic magnetic resonance defecography (DMRD) over the period from August 2021 to June 2023. The focus was specifically on the defecation phase images of the DMRD, as this phase provides critical information for assessing RC. To develop and evaluate the model, the MRI images from all patients were randomly divided into two groups. 70% of the data were allocated to the training cohort to build the model, and the remaining 30% was reserved as a test cohort to evaluate its performance. First, the severity of RC was assessed using the RC MRI grading criteria by two independent radiologists. To extract and select radiomic features, two additional radiologists independently delineated the regions of interest (ROIs). These features were then dimensionality reduced to retain only the most relevant data for the analysis. The radiomics features were reduced in dimension, and a machine learning model was developed using a Support Vector Machine (SVM). Finally, receiver operating characteristic curve (ROC) and area under the curve (AUC) were used to evaluate the classification efficiency of the model. The AUC (macro/micro) of the model using defecation phase images was 0.794/0.824, and the overall accuracy was 0.754. The radiomics model built using the combination of DMRD defecation phase images is well suited for grading RC and helping clinicians diagnose and treat the disease.

The pelvic floor is composed of a network of muscles, ligaments, and fasciae, which provide active and passive support for the pelvic organs. Impairment of these pelvic floor elements can result in a variety of functional abnormalities and single or multicompartment organ prolapse. Knowledge of normal pelvic floor anatomy can aid the radiologist in understanding the complex nature of pelvic floor dysfunction and is important for comprehensive image interpretation. This article provides an overview of normal anatomy of the pelvic floor as seen on magnetic resonance imaging, ultrasound, and fluoroscopic studies performed in the evaluation of pelvic floor function.

Magnetic resonance (MR) defecography, including both static and dynamic phases, is frequently requested by gastroenterologists and colorectal surgeons for planning the treatment of obstructive defecation syndrome and pelvic organ prolapse. However, reports often lack key information needed to guide treatment strategies, making management challenging and, at times, controversial. It has been hypothesized that using structured radiology reports could reduce missing information. In this paper, we present a structured MR defecography template report that includes nine key descriptors of rectal evacuation. The effectiveness and acceptability of this template are currently being assessed in Italy through a national interdisciplinary study.

Introduction and Hypothesis The objective was to elucidate the clinical utility of two reference lines, the pubosacrococcygeal joint line (PCL jnt ) and pubococcygeal joint line (PCL cc ), in the quantitative diagnosis of pelvic organ prolapse (POP) and pelvic floor laxity. Methods A retrospective analysis of magnetic resonance defecography (MRD) in patients with stage II or above POP was conducted. POP and pelvic floor relaxation were quantitatively assessed using both PCL jnt and PCL cc as reference lines. Further research, point-to-point correlation analysis was performed between the pelvic organ prolapse quantification (POP-Q) system and MRD to investigate the discrepancies between the two reference lines. Results There was no significant statistical difference in the degree of cystocele and H line between the PCL jnt and PCL cc groups ( p  > 0.05). Nevertheless, significant differences in the degree of uterine prolapse and M-line between the two groups were observed ( p  = 0.00). Both the PCL jnt and PCL cc reference lines demonstrated better correlation with POP-Q, and the PCL cc exhibited slightly higher correlation coefficients than the PCL jnt . Conclusions The results revealed significant moderate correlations between both reference lines and key POP-Q landmarks. Both PCL jnt and PCL cc can be utilized for interpreting MRD images and diagnosing POP for anterior wall and uterine prolapse.

Purpose Utilize magnetic resonance defecography (MRD) to analyze the primary pelvic floor dysfunctions in patients with stress urinary incontinence (SUI) associated with pelvic organ prolapse (POP), and in SUI patients with asymptomatic POP. Method We performed MRD in both SUI and POP subjects. As a primary analysis, the functional MR parameters were compared between the isolated POP and POP combined SUI groups. As a secondary analysis, the functional MR data were compared between the POP combined SUI and the SUI with asymptomatic POP (isolated SUI) groups. Results MRD noted the main characteristics of SUI combined moderate or severe POP, including the shorter closed urethra length (1.87 cm vs. 2.50 cm, p  < 0.001), more prevalent urethral hypermobility (112.31° vs. 85.67°, p  = 0.003), bladder neck funneling (48.28% vs. 20.51%, p  = 0.020), lower position of vesicourethral junction (2.11 cm vs. 1.67 cm, p  = 0.030), and more severe prolapse of the posterior bladder wall (6.26 cm vs. 4.35 cm, p  = 0.008). The isolated SUI patients showed the shortest length of the closed urethra (1.56 cm vs. 1.87 cm, p  = 0.029), a larger vesicourethral angle (153.80° vs. 107.58°, p  < 0.001), the more positive bladder funneling (84.85% vs. 48.28%, p  = 0.002) and a special urethral opening sign (45.45% vs. 3.45%, p  < 0.001). Conclusions Patients with SUI accompanying POP primarily exhibit excessive urethral mobility and a shortened urethral closure. SUI patients with asymptomatic POP mainly show dysfunction of the urethra and bladder neck, characterized by the opening of the urethra and bladder neck and a shortened urethral closure.

BackgroundWe aimed to determine the anorectal physiological factors associated with rectocele formation.MethodsFemale patients (N = 32) with severe constipation, fecal incontinence, or suspicion of rectocele, who had undergone magnetic resonance defecography and anorectal function tests between 2015 and 2021, were retrospectively included for analysis. The anorectal function tests were used to measure pressure in the anorectum during defecation. Rectocele characteristics and pelvic floor anatomy were determined with magnetic resonance defecography. Constipation severity was determined with the Agachan score. Information regarding constipation-related symptoms was collected.ResultsMean rectocele size during defecation was 2.14 ± 0.88 cm. During defecation, the mean anal sphincter pressure just before defecation was 123.70 ± 67.37 mm Hg and was associated with rectocele size (P = 0.041). The Agachan constipation score was moderately correlated with anal sphincter pressure just before defecation (r = 0.465, P = 0.022), but not with rectocele size (r = 0.276, P = 0.191). During defecation, increased anal sphincter pressure just before defecation correlated moderately and positively with straining maneuvers (r = 0.539, P = 0.007) and defecation blockage (r = 0.532, P = 0.007). Rectocele size correlated moderately and positively with the distance between the pubococcygeal line and perineum (r = 0.446, P = 0.011).ConclusionIncreased anal sphincter pressure just before defecation is correlated with the rectocele size. Based on these results, it seems important to first treat the increased anal canal pressure before considering surgical rectocele repair to enhance patient outcomes.