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Pelvic Floor Dysfunction in Females

Variant: 1   Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Fluoroscopy cystocolpoproctography Usually Appropriate ☢☢☢
MR defecography Usually Appropriate O
US pelvis transperineal May Be Appropriate O
MRI pelvis dynamic maneuvers without defecation May Be Appropriate O
US pelvis transabdominal Usually Not Appropriate O
US pelvis transrectal Usually Not Appropriate O
US pelvis transvaginal Usually Not Appropriate O
Fluoroscopy voiding cystourethrography Usually Not Appropriate ☢☢
MRI pelvis without and with IV contrast Usually Not Appropriate O
MRI pelvis without IV contrast Usually Not Appropriate O
CT pelvis with IV contrast Usually Not Appropriate ☢☢☢
CT pelvis without IV contrast Usually Not Appropriate ☢☢☢
CT pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 2   Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
Fluoroscopy voiding cystourethrography Usually Appropriate ☢☢
US pelvis transperineal May Be Appropriate O
US pelvis transvaginal May Be Appropriate O
Fluoroscopy cystocolpoproctography May Be Appropriate ☢☢☢
MR defecography May Be Appropriate O
MRI pelvis dynamic maneuvers without defecation May Be Appropriate O
US pelvis transabdominal Usually Not Appropriate O
US pelvis transrectal Usually Not Appropriate O
MRI pelvis without and with IV contrast Usually Not Appropriate O
MRI pelvis without IV contrast Usually Not Appropriate O
CT pelvis with IV contrast Usually Not Appropriate ☢☢☢
CT pelvis without IV contrast Usually Not Appropriate ☢☢☢
CT pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 3   Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US pelvis transrectal Usually Appropriate O
Fluoroscopy cystocolpoproctography Usually Appropriate ☢☢☢
MR defecography Usually Appropriate O
US pelvis transperineal May Be Appropriate O
MRI pelvis dynamic maneuvers without defecation May Be Appropriate (Disagreement) O
MRI pelvis without and with IV contrast May Be Appropriate O
US pelvis transabdominal Usually Not Appropriate O
US pelvis transvaginal Usually Not Appropriate O
Fluoroscopy voiding cystourethrography Usually Not Appropriate ☢☢
MRI pelvis without IV contrast Usually Not Appropriate O
CT pelvis with IV contrast Usually Not Appropriate ☢☢☢
CT pelvis without IV contrast Usually Not Appropriate ☢☢☢
CT pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 4   Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MR defecography Usually Appropriate O
MRI pelvis dynamic maneuvers without defecation Usually Appropriate O
MRI pelvis without and with IV contrast Usually Appropriate O
US pelvis transperineal May Be Appropriate O
US pelvis transvaginal May Be Appropriate O
Fluoroscopy voiding cystourethrography May Be Appropriate ☢☢
MRI pelvis without IV contrast May Be Appropriate O
US pelvis transabdominal Usually Not Appropriate O
US pelvis transrectal Usually Not Appropriate O
Fluoroscopy cystocolpoproctography Usually Not Appropriate ☢☢☢
CT pelvis with IV contrast Usually Not Appropriate ☢☢☢
CT pelvis without IV contrast Usually Not Appropriate ☢☢☢
CT pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢

Panel Members
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging.
Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging.
A. CT Pelvis
Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging.
B. Fluoroscopy Cystocolpoproctography
Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging.
C. Fluoroscopy Voiding Cystourethrography
Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging.
D. MR Defecography
Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging.
E. MRI Pelvis Dynamic Maneuvers without Defecation
Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging.
F. MRI Pelvis
Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging.
G. US Pelvis Transabdominal
Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging.
H. US Pelvis Transperineal
Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging.
I. US Pelvis Transrectal
Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging.
J. US Pelvis Transvaginal
Variant 2: Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging.
Variant 2: Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging.
A. CT Pelvis
Variant 2: Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging.
B. Fluoroscopy Cystocolpoproctography
Variant 2: Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging.
C. Fluoroscopy Voiding Cystourethrography
Variant 2: Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging.
D. MR Defecography
Variant 2: Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging.
E. MRI Pelvis Dynamic Maneuvers without Defecation
Variant 2: Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging.
F. MRI Pelvis
Variant 2: Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging.
G. US Pelvis Transabdominal
Variant 2: Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging.
H. US Pelvis Transperineal
Variant 2: Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging.
I. US Pelvis Transrectal
Variant 2: Female. Urinary dysfunction (involuntary leakage of urine, or frequent urination, or urgency, straining to void, incomplete voiding, splinting, or digital maneuvers to void). Initial imaging.
J. US Pelvis Transvaginal
Variant 3: Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging.
Variant 3: Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging.
A. CT Pelvis
Variant 3: Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging.
B. Fluoroscopy Cystocolpoproctography
Variant 3: Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging.
C. Fluoroscopy Voiding Cystourethrography
Variant 3: Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging.
D. MR Defecography
Variant 3: Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging.
E. MRI Pelvis Dynamic Maneuvers without Defecation
Variant 3: Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging.
F. MRI Pelvis
Variant 3: Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging.
G. US Pelvis Transabdominal
Variant 3: Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging.
H. US Pelvis Transperineal
Variant 3: Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging.
I. US Pelvis Transrectal
Variant 3: Female. Defecatory dysfunction (incontinence of stool or liquid or gas, straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate). Initial imaging.
J. US Pelvis Transvaginal
Variant 4: Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging.
Variant 4: Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging.
A. CT Pelvis
Variant 4: Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging.
B. Fluoroscopy Cystocolpoproctography
Variant 4: Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging.
C. Fluoroscopy Voiding Cystourethrography
Variant 4: Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging.
D. MRI Defecography
Variant 4: Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging.
E. MRI Pelvis Dynamic Maneuvers without Defecation
Variant 4: Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging.
F. MRI Pelvis
Variant 4: Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging.
G. US Pelvis Transabdominal
Variant 4: Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging.
H. US Pelvis Transperineal
Variant 4: Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging.
I. US Pelvis Transrectal
Variant 4: Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging.
J. US Pelvis Transvaginal
Summary of Recommendations
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
References
1. Sung VW, Hampton BS. Epidemiology of pelvic floor dysfunction. Obstet Gynecol Clin North Am. 2009; 36(3):421-443.
2. Nygaard I, Bradley C, Brandt D. Pelvic organ prolapse in older women: prevalence and risk factors. Obstet Gynecol. 2004; 104(3):489-497.
3. Maglinte DD, Kelvin FM, Fitzgerald K, Hale DS, Benson JT. Association of compartment defects in pelvic floor dysfunction. AJR. 1999; 172(2):439-444.
4. Morgan DM, DeLancey JO, Guire KE, Fenner DE. Symptoms of anal incontinence and difficult defecation among women with prolapse and a matched control cohort. Am J Obstet Gynecol. 2007; 197(5):509 e501-506.
5. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008; 300(11):1311-1316.
6. Gomelsky A, Penson DF, Dmochowski RR. Pelvic organ prolapse (POP) surgery: the evidence for the repairs. BJU Int. 2011; 107(11):1704-1719.
7. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997; 89(4):501-506.
8. Ashok K, Petri E. Failures and complications in pelvic floor surgery. World J Urol. 2012; 30(4):487-494.
9. Nygaard I, Chai TC, Cundiff GW, et al. Summary of Research Recommendations From the Inaugural American Urogynecologic Society Research Summit. Female Pelvic Med Reconstr Surg. 2011; 17(1):4-7.
10. Bitti GT, Argiolas GM, Ballicu N, et al. Pelvic floor failure: MR imaging evaluation of anatomic and functional abnormalities. Radiographics : a review publication of the Radiological Society of North America, Inc 2014;34:429-48.
11. Kelvin FM, Hale DS, Maglinte DD, Patten BJ, Benson JT. Female pelvic organ prolapse: diagnostic contribution of dynamic cystoproctography and comparison with physical examination. AJR. 1999; 173(1):31-37.
12. Vanbeckevoort D, Van Hoe L, Oyen R, Ponette E, De Ridder D, Deprest J. Pelvic floor descent in females: comparative study of colpocystodefecography and dynamic fast MR imaging. Journal of Magnetic Resonance Imaging. 9(3):373-7, 1999 Mar.
13. Siegmann KC, Reisenauer C, Speck S, Barth S, Kraemer B, Claussen CD. Dynamic magnetic resonance imaging for assessment of minimally invasive pelvic floor reconstruction with polypropylene implant. Eur J Radiol. 2011; 80(2):182-187.
14. Showalter PR, Zimmern PE, Roehrborn CG, Lemack GE. Standing cystourethrogram: an outcome measure after anti-incontinence procedures and cystocele repair in women. Urology. 58(1):33-7, 2001 Jul.
15. Pannu HK, Scatarige JC, Eng J. Comparison of supine magnetic resonance imaging with and without rectal contrast to fluoroscopic cystocolpoproctography for the diagnosis of pelvic organ prolapse. J Comput Assist Tomogr. 2009; 33(1):125-130.
16. Dobben AC, Terra MP, Deutekom M, et al. The role of endoluminal imaging in clinical outcome of overlapping anterior anal sphincter repair in patients with fecal incontinence. AJR. 2007; 189(2):W70-77.
17. Maglinte DD, Hale DS, Sandrasegaran K. Comparison between dynamic cystocolpoproctography and dynamic pelvic floor MRI: pros and cons: Which is the "functional" examination for anorectal and pelvic floor dysfunction? Abdom Imaging. 2013;38(5):952-973.
18. Murad-Regadas SM, Regadas FS, Rodrigues LV, Silva FR, Soares FA, Escalante RD. A novel three-dimensional dynamic anorectal ultrasonography technique (echodefecography) to assess obstructed defecation, a comparison with defecography. Surgical Endoscopy. 22(4):974-9, 2008 Apr.
19. Regadas FS, Haas EM, Abbas MA, et al. Prospective multicenter trial comparing echodefecography with defecography in the assessment of anorectal dysfunction in patients with obstructed defecation. Dis Colon Rectum. 2011; 54(6):686-692.
20. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J. 2010; 21(1):5-26.
21. Colaiacomo MC, Masselli G, Polettini E, et al. Dynamic MR imaging of the pelvic floor: a pictorial review. Radiographics. 2009; 29(3):e35.
22. Maglinte DD, Bartram CI, Hale DA, et al. Functional imaging of the pelvic floor. Radiology. 2011; 258(1):23-39.
23. Faucheron JL, Barot S, Collomb D, Hohn N, Anglade D, Dubreuil A. Dynamic cystocolpoproctography is superior to functional pelvic MRI in the diagnosis of posterior pelvic floor disorders: results of a prospective study. Colorectal Disease. 16(7):O240-7, 2014 Jul.
24. Wu YR, Christie AL, Lavelle RS, Alhalabi F, Khatri G, Zimmern PE. Bladder Prolapse Configuration on Baseline Standing Cystogram Can Predict Anterior Vaginal Wall Suspension Procedure Outcomes. Urology. 103:73-78, 2017 May.
25. Kumar NM, Khatri G, Christie AL, Sims R, Pedrosa I, Zimmern PE. Supine magnetic resonance defecography for evaluation of anterior compartment prolapse: Comparison with upright voiding cystourethrogram. European Journal of Radiology. 117:95-101, 2019 Aug.Eur J Radiol. 117:95-101, 2019 Aug.
26. Arif-Tiwari H, Twiss CO, Lin FC, et al. Improved Detection of Pelvic Organ Prolapse: Comparative Utility of Defecography Phase Sequence to Nondefecography Valsalva Maneuvers in Dynamic Pelvic Floor Magnetic Resonance Imaging. Current Problems in Diagnostic Radiology. 48(4):342-347, 2019 Jul - Aug.
27. Bhan SN, Mnatzakanian GN, Nisenbaum R, Lee AB, Colak E. MRI for pelvic floor dysfunction: can the strain phase be eliminated?. Abdom Radiol. 41(2):215-20, 2016 Feb.
28. Flusberg M, Sahni VA, Erturk SM, Mortele KJ. Dynamic MR defecography: assessment of the usefulness of the defecation phase. AJR. 2011; 196(4):W394-399.
29. Khatri G, Kumar NM, Xi Y, et al. Defecation versus pre- and post-defecation Valsalva maneuvers for dynamic MR assessment of pelvic floor dysfunction. Abdom Radiol (NY) 2019.
30. Bertschinger KM, Hetzer FH, Roos JE, Treiber K, Marincek B, Hilfiker PR. Dynamic MR imaging of the pelvic floor performed with patient sitting in an open-magnet unit versus with patient supine in a closed-magnet unit. Radiology. 2002; 223(2):501-508.
31. Fiaschetti V, Pastorelli D, Squillaci E, et al. Static and dynamic evaluation of pelvic floor disorders with an open low-field tilting magnet. Clin Radiol. 68(6):e293-300, 2013 Jun.
32. Iacobellis F, Brillantino A, Renzi A, et al. MR Imaging in Diagnosis of Pelvic Floor Descent: Supine versus Sitting Position. Gastroenterology research & practice. 2016:6594152, 2016.
33. Tumbarello JA, Hsu Y, Lewicky-Gaupp C, Rohrer S, DeLancey JO. Do repetitive Valsalva maneuvers change maximum prolapse on dynamic MRI? Int Urogynecol J. 2010; 21(10):1247-1251.
34. Lin FC, Funk JT, Tiwari HA, Kalb BT, Twiss CO. Dynamic Pelvic Magnetic Resonance Imaging Evaluation of Pelvic Organ Prolapse Compared to Physical Examination Findings. Urology. 119:49-54, 2018 Sep.
35. Al-Najar MS, Ghanem AF, AlRyalat SAS, Al-Ryalat NT, Alhajahjeh SO. The usefulness of MR defecography in the evaluation of pelvic floor dysfunction: our experience using 3T MRI. Abdominal Radiology. 42(9):2219-2224, 2017 09.
36. Rentsch M, Paetzel C, Lenhart M, Feuerbach S, Jauch KW, Furst A. Dynamic magnetic resonance imaging defecography: a diagnostic alternative in the assessment of pelvic floor disorders in proctology. Diseases of the Colon & Rectum. 44(7):999-1007, 2001 Jul.
37. el-Sayed RF, Morsy MM, el-Mashed SM, Abdel-Azim MS. Anatomy of the urethral supporting ligaments defined by dissection, histology, and MRI of female cadavers and MRI of healthy nulliparous women. AJR. 2007; 189(5):1145-1157.
38. Berger MB, Kolenic GE, Fenner DE, Morgan DM, DeLancey JOL. Structural, functional, and symptomatic differences between women with rectocele versus cystocele and normal support. American Journal of Obstetrics & Gynecology. 218(5):510.e1-510.e8, 2018 05.
39. Morgan DM, Umek W, Stein T, Hsu Y, Guire K, DeLancey JO. Interrater reliability of assessing levator ani muscle defects with magnetic resonance images. Int Urogynecol J Pelvic Floor Dysfunct. 2007; 18(7):773-778.
40. Lammers K, Futterer JJ, Inthout J, Prokop M, Vierhout ME, Kluivers KB. Correlating signs and symptoms with pubovisceral muscle avulsions on magnetic resonance imaging. American Journal of Obstetrics & Gynecology. 208(2):148.e1-7, 2013 Feb.
41. Beets-Tan RG, Morren GL, Beets GL, et al. Measurement of anal sphincter muscles: endoanal US, endoanal MR imaging, or phased-array MR imaging? A study with healthy volunteers. Radiology. 2001; 220(1):81-89.
42. Huebner M, Margulies RU, DeLancey JO. Pelvic architectural distortion is associated with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2008; 19(6):863-867.
43. Larson KA, Luo J, Guire KE, Chen L, Ashton-Miller JA, DeLancey JO. 3D analysis of cystoceles using magnetic resonance imaging assessing midline, paravaginal, and apical defects. Int Urogynecol J. 2012; 23(3):285-293.
44. Lienemann A, Anthuber C, Baron A, Kohz P, Reiser M. Dynamic MR colpocystorectography assessing pelvic-floor descent. Eur Radiol. 1997; 7(8):1309-1317.
45. Lakeman MM, Zijta FM, Peringa J, Nederveen AJ, Stoker J, Roovers JP. Dynamic magnetic resonance imaging to quantify pelvic organ prolapse: reliability of assessment and correlation with clinical findings and pelvic floor symptoms. International Urogynecology Journal. 23(11):1547-54, 2012 Nov.
46. Torricelli P, Pecchi A, Caruso Lombardi A, Vetruccio E, Vetruccio S, Romagnoli R. Magnetic resonance imaging in evaluating functional disorders of female pelvic floor. Radiologia Medica. 103(5-6):488-500, 2002 May-Jun.
47. Abdul Jalil SS, Guzman Rojas R, Dietz HP. Does it matter whether levator avulsion is diagnosed pre- or postoperatively?. Ultrasound in Obstetrics & Gynecology. 48(4):516-519, 2016 Oct.
48. Albrich SB, Welker K, Wolpert B, et al. How common is ballooning? Hiatal area on 3D transperineal ultrasound in urogynecological patients and its association with lower urinary tract symptoms. Archives of Gynecology & Obstetrics. 295(1):103-109, 2017 Jan.
49. Notten KJB, Vergeldt TFM, van Kuijk SMJ, Weemhoff M, Roovers JWR. Diagnostic Accuracy and Clinical Implications of Translabial Ultrasound for the Assessment of Levator Ani Defects and Levator Ani Biometry in Women With Pelvic Organ Prolapse: A Systematic Review. [Review]. Female Pelvic Medicine & Reconstructive Surgery. 23(6):420-428, 2017 Nov/Dec.
50. Dietz HP. Pelvic floor ultrasound: a review. Am J Obstet Gynecol. 2010; 202(4):321-334.
51. Perniola G, Shek C, Chong CC, Chew S, Cartmill J, Dietz HP. Defecation proctography and translabial ultrasound in the investigation of defecatory disorders. Ultrasound Obstet Gynecol. 31(5):567-71, 2008 May.
52. Steensma AB, Oom DM, Burger CW, Schouten WR. Assessment of posterior compartment prolapse: a comparison of evacuation proctography and 3D transperineal ultrasound. Colorectal Dis. 2010; 12(6):533-539.
53. Beer-Gabel M, Assoulin Y, Amitai M, Bardan E. A comparison of dynamic transperineal ultrasound (DTP-US) with dynamic evacuation proctography (DEP) in the diagnosis of cul de sac hernia (enterocele) in patients with evacuatory dysfunction. International Journal of Colorectal Disease. 23(5):513-9, 2008 May.
54. Dietz HP, Kamisan Atan I, Salita A. Association between ICS POP-Q coordinates and translabial ultrasound findings: implications for definition of 'normal pelvic organ support'. Ultrasound Obstet Gynecol. 47(3):363-8, 2016 Mar.
55. Lone FW, Thakar R, Sultan AH, Stankiewicz A. Accuracy of assessing Pelvic Organ Prolapse Quantification points using dynamic 2D transperineal ultrasound in women with pelvic organ prolapse. International Urogynecology Journal. 23(11):1555-60, 2012 Nov.
56. Dietz HP, Steensma AB. Posterior compartment prolapse on two-dimensional and three-dimensional pelvic floor ultrasound: the distinction between true rectocele, perineal hypermobility and enterocele. Ultrasound Obstet Gynecol. 2005; 26(1):73-77.
57. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourology & Urodynamics. 21(2):167-78, 2002.
58. Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. Urinary Incontinence in Women: A Review. [Review]. JAMA. 318(16):1592-1604, 2017 Oct 24.
59. Cassado Garriga J, Pessarrodona Isern A, Rodriguez Carballeira M, et al. Three-dimensional translabial ultrasound assessment of urethral supports and the urethral sphincter complex in stress urinary incontinence. Neurourology & Urodynamics. 36(7):1839-1845, 2017 Sep.
60. Walsh LP, Zimmern PE, Pope N, Shariat SF, Urinary Incontinence Treatment Network. Comparison of the Q-tip test and voiding cystourethrogram to assess urethral hypermobility among women enrolled in a randomized clinical trial of surgery for stress urinary incontinence. Journal of Urology. 176(2):646-9; discussion 650, 2006 Aug.
61. Dumoulin C, Tang A, Pontbriand-Drolet S, Madill SJ, Morin M. Pelvic floor morphometry: a predictor of success of pelvic floor muscle training for women with stress and mixed urinary incontinence. International Urogynecology Journal. 28(8):1233-1239, 2017 Aug.
62. Pontbriand-Drolet S, Tang A, Madill SJ, et al. Differences in pelvic floor morphology between continent, stress urinary incontinent, and mixed urinary incontinent elderly women: An MRI study. Neurourology & Urodynamics. 35(4):515-21, 2016 Apr.
63. Morgan DM, Umek W, Guire K, Morgan HK, Garabrant A, DeLancey JO. Urethral sphincter morphology and function with and without stress incontinence. J Urol. 2009; 182(1):203-209.
64. Tasali N, Cubuk R, Sinanoglu O, Sahin K, Saydam B. MRI in stress urinary incontinence: endovaginal MRI with an intracavitary coil and dynamic pelvic MRI. Urol J. 2012; 9(1):397-404.
65. Tunn R, Goldammer K, Neymeyer J, Gauruder-Burmester A, Hamm B, Beyersdorff D. MRI morphology of the levator ani muscle, endopelvic fascia, and urethra in women with stress urinary incontinence. Eur J Obstet Gynecol Reprod Biol. 2006; 126(2):239-245.
66. Dietz HP.. Pelvic floor ultrasound in incontinence: what's in it for the surgeon?. [Review]. International Urogynecology Journal. 22(9):1085-97, 2011 Sep.
67. Tunn R, Petri E. Introital and transvaginal ultrasound as the main tool in the assessment of urogenital and pelvic floor dysfunction: an imaging panel and practical approach. [Review] [54 refs]. Ultrasound Obstet Gynecol. 22(2):205-13, 2003 Aug.
68. Wlazlak E, Surkont G, Shek KL, Dietz HP. Can we predict urinary stress incontinence by using demographic, clinical, imaging and urodynamic data?. Eur J Obstet Gynecol Reprod Biol. 193:114-7, 2015 Oct.
69. Torella M, De Franciscis P, Russo C, et al. Stress urinary incontinence: usefulness of perineal ultrasound. Radiologia Medica. 119(3):189-94, 2014 Mar.
70. Bergman A, Vermesh M, Ballard CA, Platt LD. Role of ultrasound in urinary incontinence evaluation. Urology. 33(5):443-4, 1989 May.
71. Bergman A, McKenzie CJ, Richmond J, Ballard CA, Platt LD. Transrectal ultrasound versus cystography in the evaluation of anatomical stress urinary incontinence. British Journal of Urology. 62(3):228-34, 1988 Sep.
72. Richmond DH, Sutherst JR. Burch colposuspension or sling for stress incontinence? A prospective study using transrectal ultrasound. British Journal of Urology. 64(6):600-3, 1989 Dec.
73. Richmond DH, Sutherst JR. Clinical application of transrectal ultrasound for the investigation of the incontinent patient. British Journal of Urology. 63(6):605-9, 1989 Jun.
74. Kuhn A, Genoud S, Robinson D, et al. Sonographic transvaginal bladder wall thickness: does the measurement discriminate between urodynamic diagnoses?. Neurourology & Urodynamics. 30(3):325-8, 2011 Mar.
75. Zacharakis D, Grigoriadis T, Pitsouni E, Domali E, Protopapas A, Athanasiou S. Ultrasonographic Evaluation of the Urethral Rhabdosphincter Morphology in Female Patients With Urodynamic Stress Incontinence. Female Pelvic Medicine & Reconstructive Surgery. 23(4):267-271, 2017 Jul/Aug.
76. Digesu GA, Robinson D, Cardozo L, Khullar V. Three-dimensional ultrasound of the urethral sphincter predicts continence surgery outcome. Neurourology & Urodynamics. 28(1):90-4, 2009.
77. Bharucha AE, Wald A, Enck P, Rao S. Functional anorectal disorders. Gastroenterology. 2006; 130(5):1510-1518.
78. Bharucha AE, Wald AM. Anorectal disorders. Am J Gastroenterol. 2010; 105(4):786-794.
79. Rao SS, Ozturk R, Laine L. Clinical utility of diagnostic tests for constipation in adults: a systematic review. Am J Gastroenterol. 2005; 100(7):1605-1615.
80. Videlock EJ, Lembo A, Cremonini F. Diagnostic testing for dyssynergic defecation in chronic constipation: meta-analysis. Neurogastroenterol Motil. 25(6):509-20, 2013 Jun.
81. Agachan F, Pfeifer J, Wexner SD. Defecography and proctography. Results of 744 patients. Dis Colon Rectum. 1996; 39(8):899-905.
82. Altringer WE, Saclarides TJ, Dominguez JM, Brubaker LT, Smith CS. Four-contrast defecography: pelvic "floor-oscopy". Dis Colon Rectum. 1995; 38(7):695-699.
83. Harvey CJ, Halligan S, Bartram CI, Hollings N, Sahdev A, Kingston K. Evacuation proctography: a prospective study of diagnostic and therapeutic effects. Radiology. 1999; 211(1):223-227.
84. Halligan S, Malouf A, Bartram CI, Marshall M, Hollings N, Kamm MA. Predictive value of impaired evacuation at proctography in diagnosing anismus. AJR. 2001; 177(3):633-636.
85. Piloni V, Fioravanti P, Spazzafumo L, Rossi B. Measurement of the anorectal angle by defecography for the diagnosis of fecal incontinence. International Journal of Colorectal Disease. 14(2):131-5, 1999 Apr.
86. Reiner CS, Tutuian R, Solopova AE, Pohl D, Marincek B, Weishaupt D. MR defecography in patients with dyssynergic defecation: spectrum of imaging findings and diagnostic value. Br J Radiol. 84(998):136-44, 2011 Feb.
87. Elshazly WG, El Nekady Ael A, Hassan H. Role of dynamic magnetic resonance imaging in management of obstructed defecation case series. Int J Surg. 2010; 8(4):274-282.
88. Ratz V, Wech T, Schindele A, et al. Dynamic 3D MR-Defecography. Rofo: Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin. 188(9):859-63, 2016 Sep.
89. Foti PV, Farina R, Riva G, et al. Pelvic floor imaging: comparison between magnetic resonance imaging and conventional defecography in studying outlet obstruction syndrome. Radiol Med (Torino). 118(1):23-39, 2013 Feb.
90. Hetzer FH, Andreisek G, Tsagari C, Sahrbacher U, Weishaupt D. MR defecography in patients with fecal incontinence: imaging findings and their effect on surgical management. Radiology. 2006; 240(2):449-457.
91. Dobben AC, Terra MP, Deutekom M, et al. Anal inspection and digital rectal examination compared to anorectal physiology tests and endoanal ultrasonography in evaluating fecal incontinence. Int J Colorectal Dis. 2007; 22(7):783-790.
92. Lam TJ, Mulder CJ, Felt-Bersma RJ. Critical reappraisal of anorectal function tests in patients with faecal incontinence who have failed conservative treatment. Int J Colorectal Dis. 2012; 27(7):931-937.
93. Murad-Regadas SM, Karbage SA, Bezerra LS, et al. Dynamic translabial ultrasound versus echodefecography combined with the endovaginal approach to assess pelvic floor dysfunctions: How effective are these techniques?. Techniques in Coloproctology. 21(7):555-565, 2017 Jul.
94. Sultan AH, Kamm MA, Talbot IC, Nicholls RJ, Bartram CI. Anal endosonography for identifying external sphincter defects confirmed histologically. Br J Surg. 1994; 81(3):463-465.
95. Gold DM, Halligan S, Kmiot WA, Bartram CI. Intraobserver and interobserver agreement in anal endosonography. Br J Surg. 1999; 86(3):371-375.
96. Santoro GA, Wieczorek AP, Dietz HP, et al. State of the art: an integrated approach to pelvic floor ultrasonography. Ultrasound Obstet Gynecol. 2011; 37(4):381-396.
97. Cazemier M, Terra MP, Stoker J, et al. Atrophy and defects detection of the external anal sphincter: comparison between three-dimensional anal endosonography and endoanal magnetic resonance imaging. Dis Colon Rectum. 2006; 49(1):20-27.
98. West RL, Dwarkasing S, Briel JW, et al. Can three-dimensional endoanal ultrasonography detect external anal sphincter atrophy? A comparison with endoanal magnetic resonance imaging. Int J Colorectal Dis. 2005; 20(4):328-333.
99. Abdool Z, Sultan AH, Thakar R. Ultrasound imaging of the anal sphincter complex: a review. Br J Radiol. 2012; 85(1015):865-875.
100. Rousset P, Deval B, Chaillot PF, Amara N, Buy JN, Hoeffel C. MRI and CT of sacrocolpopexy. AJR. 2013; 200(4):W383-394.
101. Abed H, Rahn DD, Lowenstein L, Balk EM, Clemons JL, Rogers RG. Incidence and management of graft erosion, wound granulation, and dyspareunia following vaginal prolapse repair with graft materials: a systematic review. Int Urogynecol J. 2011; 22(7):789-798.
102. Haylen BT, Freeman RM, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint terminology and classification of the complications related to native tissue female pelvic floor surgery. Int Urogynecol J. 2012; 23(5):515-526.
103. Haylen BT, Freeman RM, Swift SE, et al. An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint terminology and classification of the complications related directly to the insertion of prostheses (meshes, implants, tapes) & grafts in female pelvic floor surgery. Int Urogynecol J. 2011; 22(1):3-15.
104. van Geelen JM, Dwyer PL. Where to for pelvic organ prolapse treatment after the FDA pronouncements? : A systematic review of the recent literature. Int Urogynecol J. 2013; 24(5):707-718.
105. Alvarez J, Cvach K, Dwyer P. Complications in pelvic floor surgery. Minerva Ginecol. 2013; 65(1):53-67.
106. Chermansky CJ, Winters JC. Complications of vaginal mesh surgery. Curr Opin Urol. 2012; 22(4):287-291.
107. Khatri G, Carmel ME, Bailey AA, et al. Postoperative Imaging after Surgical Repair for Pelvic Floor Dysfunction. [Review]. Radiographics. 36(4):1233-56, 2016 Jul-Aug.
108. Macura KJ, Genadry RR, Bluemke DA. MR imaging of the female urethra and supporting ligaments in assessment of urinary incontinence: spectrum of abnormalities. [Review] [26 refs]. Radiographics. 26(4):1135-49, 2006 Jul-Aug.
109. Carr LK, Herschorn S, Leonhardt C. Magnetic resonance imaging after intraurethral collagen injected for stress urinary incontinence. J Urol. 1996; 155(4):1253-1255.
110. Schuettoff S, Beyersdorff D, Gauruder-Burmester A, Tunn R. Visibility of the polypropylene tape after tension-free vaginal tape (TVT) procedure in women with stress urinary incontinence: comparison of introital ultrasound and magnetic resonance imaging in vitro and in vivo. Ultrasound Obstet Gynecol. 2006; 27(6):687-692.
111. Schofield ML, Higgs P, Hawnaur JM. MRI findings following laparoscopic sacrocolpopexy. Clin Radiol. 2005; 60(3):333-339.
112. Staack A, Vitale J, Ragavendra N, Rodriguez LV. Translabial ultrasonography for evaluation of synthetic mesh in the vagina. Urology. 83(1):68-74, 2014 Jan.
113. Graf CM, Kupec T, Stickeler E, Goecke TW, Meinhold-Heerlein I, Najjari L. Tomographic Ultrasound Imaging to Control the Placement of Tension-Free Transobturator Tape in Female Urinary Stress Incontinence. BioMed Research International. 2016:6495858, 2016.
114. Eisenberg VH, Steinberg M, Weiner Z, et al. Three-dimensional transperineal ultrasound for imaging mesh implants following sacrocolpopexy. Ultrasound Obstet Gynecol. 43(4):459-65, 2014 Apr.
115. Hegde A, Nogueiras M, Aguilar VC, Davila GW. Dynamic assessment of sling function on transperineal ultrasound: does it correlate with outcomes 1 year following surgery?. International Urogynecology Journal. 28(6):857-864, 2017 Jun.
116. Larson K, Scott L, Cunningham TD, Zhao Y, Abuhamad A, Takacs P. Two-Dimensional and Three-Dimensional Transperineal Ultrasound Findings in Women With High-Pressure Voiding After Midurethral Sling Placement. Female Pelvic Medicine & Reconstructive Surgery. 23(2):141-145, 2017 Mar/Apr.
117. Takacs P, Larson K, Scott L, Cunningham TD, DeShields SC, Abuhamad A. Transperineal Sonography and Urodynamic Findings in Women With Lower Urinary Tract Symptoms After Sling Placement. Journal of Ultrasound in Medicine. 36(2):295-300, 2017 Feb.
118. Wen L, Shek KL, Dietz HP. Changes in urethral mobility and configuration after prolapse repair. Ultrasound in Obstetrics & Gynecology. 53(1):124-128, 2019 Jan.
119. Manonai J, Rostaminia G, Denson L, Shobeiri SA. Clinical and ultrasonographic study of patients presenting with transvaginal mesh complications. Neurourology & Urodynamics. 35(3):407-11, 2016 Mar.
120. Hegde A, Smith AL, Aguilar VC, Davila GW. Three-dimensional endovaginal ultrasound examination following injection of Macroplastique for stress urinary incontinence: outcomes based on location and periurethral distribution of the bulking agent. International Urogynecology Journal. 24(7):1151-9, 2013 Jul.
121. Yang JM, Yang SH, Huang WC, Tzeng CR. Matched-pair analyses of resting and dynamic morphology between Monarc and TVT-O procedures by ultrasound. European Journal of Obstetrics, Gynecology, & Reproductive Biology. 169(2):402-7, 2013 Jul.
122. Rautenberg O, Kociszewski J, Welter J, Kuszka A, Eberhard J, Viereck V. Ultrasound and early tape mobilization--a practical solution for treating postoperative voiding dysfunction. Neurourology & Urodynamics. 33(7):1147-51, 2014 Sep.
123. Javadian P, Quiroz LH, Shobeiri SA. In Vivo Ultrasound Characteristics of Vaginal Mesh Kit Complications. Female Pelvic Medicine & Reconstructive Surgery. 23(2):162-167, 2017 Mar/Apr.Female pelvic med. reconstr. surg.. 23(2):162-167, 2017 Mar/Apr.
124. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.
Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.