MRI diagnosis of pelvic organ prolapse compared with clinical examination

Assessment of pelvic organ prolapse with the Pelvic Inclination Correction System: defining the normal range and threshold to pathology

PURPOSE

To define the normal range and threshold values for pathologic prolapse on MRI using the PICS line and assess its correlation with the pubococcygeal line (PCL).

METHODS

This prospective, IRB-approved study included 20 nulliparous volunteers and 18 prolapse patients (POP-Q Stage ≥ 2). Organ positions (bladder, cervix, anorectal junction) relative to PICS and PCL were measured on dynamic MRI. Differences in organ position were compared. Receiver-operating characteristic (ROC) analysis was performed to identify cutoff values for prolapse using the PICS line. The correlation between PICS and PCL measurements was tested with Spearman's rank correlation.

RESULTS

In volunteers, median bladder and cervix positions measured to the PICS at rest were - 2.7 cm and - 5.3 cm compared to - 1.9 cm and - 2.7 cm in patients (p < 0.001). During straining, bladder and cervix were at - 0.9 cm and - 3.2 cm in volunteers versus + 2.5 cm and + 2.5 cm in patients (p < 0.001). Correlation was strong for PICS and PCL measurements for all three compartments (δ = 0.883-0.970, p ≤ 0.001). AUCs of PICS for the anterior and middle compartment were 0.98 (95% confidence interval [CI] 0.96-1.00, p < 0.001) and 0.96 (95% CI 0.89-1.00, p < 0.001) for differentiating patients from healthy volunteers. AUC for the posterior compartment was 0.76 (95% CI 0.57-0.96, p = 0.034).

CONCLUSION

PICS measurements reliably differentiate patients from volunteers in the anterior and middle compartment. Future studies need to identify a reliable threshold for the posterior compartment. PICS and PCL measurements are strongly correlated.

Pubococcygeal Line Versus H-line as MR Defecography Reference for Bladder Descent

INTRODUCTION AND HYPOTHESIS

Magnetic resonance defecography imaging techniques have been used widely to study pelvic floor function and diagnose pelvic organ prolapse (POP). The aim of this study was to investigate the diagnostic accuracy of the H-line to detect bladder descent compared with the current landmark, the pubococcygeal line (PCL).

METHODS

In this retrospective cohort study, patients who underwent MR defecography in our medical center and were diagnosed with moderate to severe cystocele by radiological measurements were recruited. One rest image and one maximum evacuation image for each subject were used for the following measurements: bladder base perpendicular distance from the genital hiatus (GH), indicative of clinically significant bladder descent, PCL as the current radiological reference line, and the H-line, or minimal levator hiatus line, indicative of pelvic floor muscle and connective tissue support. Subjects were categorized as having clinically significant cystocele if the "bladder base" reached within 1 cm or lower of the GH (stage II or higher cystocele). A comparison was performed to assess differences and predictive capabilities of the reference lines relative to the GH measure.

RESULTS

Seventy subjects were included, 30 with clinically significant bladder descent based on distance to GH. Women with bladder descent were older (64.0 ± 11.8 vs 51.2 ± 15.6, p < 0.001), had increased parity (3 [1-7] vs 2 [0-5], p = 0.009), and had a bladder that descended lower than the H-line at rest (1.9 ± 0.5 vs 2.2 ± 0.4, p = 0.003) and evacuation (-2.4 ± 1.6 vs -0.7 ± 1.1, p < 0.001). Multivariate regression analysis confirmed that age, length of the H-line at evacuation, the perpendicular distances between the H-line and the lowest bladder point at rest, and the PCL to the lowest bladder point at evacuation significantly correlated with bladder descent. Receiver operating characteristic analysis was used to identify a measurement threshold to diagnose clinically significant cystocele for both measurements, bladder base to the H-line: -1.2 (80.0, 72.5) area under the curve (AUC) 0.82, and bladder base PCL: -3.3 (77.8, 79.5) AUC 0.86.

CONCLUSION

Our data support the application of using the minimal levator hiatus plane and specifically the H-line as a reliable landmark to diagnose bladder descent using MR defecography imaging.

Comparison of Dynamic Magnetic Resonance Defecography With Clinical Examination in Diagnosing Pelvic Floor Dysfunction: An Observational Study

BACKGROUND

Pelvic floor dysfunction (PFD) is frequently reported in both sexes. Dynamic magnetic resonance defecography (DMRD) is the preferred modality, mainly due to its superiority and complementary role in clinical examination. However, studies from the perspective of Indian patients are scarce and mostly restricted to females. Thus, we assessed the diagnostic performance of DMRD in patients with PFD and correlated the findings with those on clinical examination.

MATERIALS AND METHODS

This prospective, observational study involved 57 adult patients of either sex, presenting with pelvic floor symptoms (PFS) and diagnosed with PFD. Initially, the patients underwent clinical examination, and diagnosis was recorded. Subsequently, the patients were subjected to DMRD. The findings were correlated with the Pearson "r" correlation coefficient.

RESULTS

A significantly greater proportion of patients had involvement of multiple compartments (36 vs. 12, p<0.001), cystocele (23 vs. 8, p=0.002), and rectal prolapse (25 vs. 14, p=0.030) on DMRD than clinical examination, while there was no significant difference regarding uterine prolapse (p=0.789). Grading of cystocele and rectal prolapse as well as diagnosis of enterocele/peritoneocele, rectocele, and intussusception could be done only with DMRD. DMRD had a strong and significant correlation with clinical examination regarding cystocele (r=0.943, p=0.003), uterine prolapse (r=0.972, p=0.001), and rectal prolapse (r=0.951, p=0.001).

CONCLUSIONS

DMRD demonstrated significantly better performance in the diagnosis of multiple compartment involvement, cystocele, and rectal prolapse. DMRD and clinical examination were significantly correlated regarding the diagnosis of cystocele, uterine prolapse, and rectal prolapse. Thus, DMRD provides information, in addition to the clinical examination, and should be used in symptomatic patients.

Defining mechanisms of recurrence following apical prolapse repair based on imaging criteria

BACKGROUND

Prolapse recurrence after transvaginal surgical repair is common; however, its mechanisms are ill-defined. A thorough understanding of how and why prolapse repairs fail is needed to address their high rate of anatomic recurrence and to develop novel therapies to overcome defined deficiencies.

OBJECTIVE

This study aimed to identify mechanisms and contributors of anatomic recurrence after vaginal hysterectomy with uterosacral ligament suspension (native tissue repair) vs transvaginal mesh (VM) hysteropexy surgery for uterovaginal prolapse.

STUDY DESIGN

This multicenter study was conducted in a subset of participants in a randomized clinical trial by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Overall, 94 women with uterovaginal prolapse treated via native tissue repair (n=48) or VM hysteropexy (n=46) underwent pelvic magnetic resonance imaging at rest, maximal strain, and poststrain rest (recovery) 30 to 42 months after surgery. Participants who desired reoperation before 30 to 42 months were imaged earlier to assess the impact of the index surgery. Using a novel 3-dimensional pelvic coordinate system, coregistered midsagittal images were obtained to assess study outcomes. Magnetic resonance imaging-based anatomic recurrence (failure) was defined as prolapse beyond the hymen. The primary outcome was the mechanism of failure (apical descent vs anterior vaginal wall elongation), including the frequency and site of failure. Secondary outcomes included displacement of the vaginal apex and perineal body and change in the length of the anterior wall, posterior wall, vaginal perimeter, and introitus of the vagina from rest to strain and rest to recovery. Group differences in the mechanism, frequency, and site of failure were assessed using the Fisher exact tests, and secondary outcomes were compared using Wilcoxon rank-sum tests.

RESULTS

Of the 88 participants analyzed, 37 (42%) had recurrent prolapse (VM hysteropexy, 13 of 45 [29%]; native tissue repair, 24 of 43 [56%]). The most common site of failure was the anterior compartment (VM hysteropexy, 38%; native tissue repair, 92%). The primary mechanism of recurrence was apical descent (VM hysteropexy, 85%; native tissue repair, 67%). From rest to strain, failures (vs successes) had greater inferior displacement of the vaginal apex (difference, -12 mm; 95% confidence interval, -19 to -6) and perineal body (difference, -7 mm; 95% confidence interval, -11 to -4) and elongation of the anterior vaginal wall (difference, 12 mm; 95% confidence interval, 8-16) and vaginal introitus (difference, 11 mm; 95% confidence interval, 7-15).

CONCLUSION

The primary mechanism of prolapse recurrence following vaginal hysterectomy with uterosacral ligament suspension or VM hysteropexy was apical descent. In addition, greater inferior descent of the vaginal apex and perineal body, lengthening of the anterior vaginal wall, and increased size of the vaginal introitus with strain were associated with anatomic failure. Further studies are needed to provide additional insight into the mechanism by which these factors contribute to anatomic failure.

International Urogynecological Consultation: clinical definition of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This segment of Chapter 1 of the International Urogynecology Consultation (IUC) on pelvic organ prolapse (POP) reviews the literature on the clinical definition of POP with the intent of creating standard terminology.

METHODS

An international group containing nine urogynecologists and one university-based medical librarian performed a search of the literature using pre-specified search terms in PubMed, Embase, and Scopus. Publications were eliminated if not relevant to the clinical definition of POP, and those articles remaining were evaluated for quality using the Specialist Unit for Review Evidence (SURE). The resulting list of articles was used to inform a comprehensive review and creation of the clinical definition of POP.

RESULTS

The original search yielded 31,931 references, of which 167 were used by the writing group. Ultimately, 78 are referenced in the manuscript.

CONCLUSIONS

The clinical definition of POP for this review of the literature is: "anatomical prolapse with descent of at least one of the vaginal walls to or beyond the vaginal hymen with maximal Valsalva effort WITH the presence either of bothersome characteristic symptoms, most commonly the sensation of vaginal bulge, or of functional or medical compromise due to prolapse without symptom bother."

Magnetic resonance imaging to evaluate anterior pelvic prolapse: H line is the key

INTRODUCTION

The aim of the study is to compare clinical staging of anterior pelvic prolapse with magnetic resonance imaging (MRI) staging, using the pubococcygeal line (PCL), the midpubic line (MPL), and the H line as reference lines. Moreover, we aim to analyze interrater reliability of each reference line.

MATERIAL AND METHODS

Forty-two women with pelvic organ prolapse (POP) symptoms were studied using the pelvic organ prolapse quantification on physical examination. Two different observers calculated anterior POP using the three MRI reference lines, retrospectively. Agreement between MRI and clinical staging was estimated using Pearson correlation for the quantitative measurements and kappa index for the stages. Interrater reliability was estimated using the intraclass correlation coefficient (ICC).

RESULTS

Correlation between physical examination and the H line was high by both observers (r = 0.86 and r = 0.76, p < 0.01). The correlation was lower using MPL (r = 0.76 and r = 0.65, p < 0.01). The results of comparing MRI staging and physical examination were: κ = 0.618 and κ = 0.602 for the H line, κ = 0.273 and κ = 0.267 for MPL and κ = -0.105 and κ = -0.140 for PCL. The results of interrater reliability were: ICC of 0.968 for the H line, ICC of 0.788 for MPL, and ICC of 0.737 for PCL.

CONCLUSION

Anterior POP staging using MRI H line as a reference presents a better agreement with clinical staging than PCL or MPL. The H line has better interrater reliability. The H line could replace the current lines.

Dynamic magnetic resonance imaging following native tissue vaginal reconstructive surgery; a prospective study

INTRODUCTION AND HYPOTHESIS

To describe the impact of native tissue vaginal reconstruction on pelvic anatomy using dynamic magnetic resonance imaging.

METHODS

This prospective single-cohort observational study involved women undergoing native tissue reconstruction with intraperitoneal vaginal vault suspension for pelvic organ prolapse. Concomitant procedures such as hysterectomy, midurethral sling, and anterior or posterior colporrhaphy were allowed. Enrolled participants underwent dynamic pelvic imaging pre- and postoperatively. Radiographic and anatomic measurements were compared. Secondary outcomes included validated patient questionnaires.

RESULTS

Fourteen participants were included in the analysis. The mean age was 62 years; all participants were Caucasian. Most participants had stage III pelvic organ prolapse. Significant improvements were noted in several radiographic measurements. The average H-line (representing levator hiatus width) with straining maneuvers improved following surgery (7.2 cm preoperatively vs. 6.6 cm postoperatively, p = 0.015). The average M-line (representing levator muscular descent) improved significantly with both straining (4.0 cm preoperatively vs. 3.0 cm postoperatively, p < 0.001) and defecatory maneuvers (6.2 cm preoperatively vs. 5.2 cm postoperatively, p = 0.001). The average size of cystocele improved from 5.6 cm (moderate) preoperatively to 0.7 cm (absent descent) postoperatively (p < 0.001). The average descent of the vaginal apex with defecation preoperatively was 3.0 cm (moderate) and 0 cm (absent descent) postoperatively (p = 0.003). Posterior compartment descent with defecation did not change following surgical intervention (5.8 cm preoperatively vs. 5.2 cm postoperatively, p = 0.056). Pelvic Organ Prolapse Quantification measurements improved in all compartments, and Pelvic Floor Distress Inventory-20 scores improved significantly following surgery (102 preoperatively vs. 30 postoperatively, p < 0.001).

CONCLUSIONS

Native tissue reconstruction with intraperitoneal vaginal vault suspension resulted in significant anatomic improvements, as defined by physical examination and dynamic magnetic resonance imaging.

Relevance of open magnetic resonance imaging position (sitting and standing) to quantify pelvic organ prolapse in women

INTRODUCTION

In pelvic organ prolapse (POP), posture and gravity impact organ position and symptom severity. The advanced magnet configuration in open magnetic resonance imaging (MRO) allows patients to be imaged when sitting and standing, as well in a conventional supine position. This study evaluated if sitting and standing MRO images are relevant as a means of improving quantification of POP because they allow differences in organ position not seen on supine imaging to be identified.

METHODS

Forty women recruited from a university urogynecology clinic had MRO imaging (0.5 T scanner) with axial and sagittal T2-weighted pelvic scans obtained when sitting, standing, and supine. Pelvic reference lines were used to quantify the degree of POP, and the relevance of imaging position on the detection of POP compared.

RESULTS

Images from 40 participants were evaluated (20 with POP and 20 asymptomatic controls). Our results indicate that the maximal extent of prolapse is best evaluated in the standing position using H line, M line, mid-pubic line, and perineal line as reference lines to determine POP.

CONCLUSIONS

MRO imaging of symptomatic patients in a standing position is relevant in the quantification of POP. Compared with supine images, standing imaging identifies that greater levels of downward movement in the anterior and posterior compartments occur, presumably under the influence of posture and gravity. In contrast, no appreciable benefit was afforded by imaging in the sitting position, which precluded use of some reference lines due to upward movement of the anorectal junction.

Practical guide to dynamic pelvic floor MRI

Pelvic floor dysfunction encompasses a spectrum of functional disorders that result from impairment of the ligaments, fasciae, and muscles supporting the pelvic organs. It is a prevalent disorder that carries a lifetime risk over 10% for undergoing a surgical repair. Pelvic floor weakness presents as a wide range of symptoms, including pain, pelvic pressure or bulging, urinary and fecal incontinence, constipation, and sexual dysfunction. A correct diagnosis by clinical examination alone can be challenging, particularly in cases involving multiple compartments. Magnetic resonance imaging (MRI) allows noninvasive, radiation-free, high soft-tissue resolution evaluation of all three pelvic compartments, and has proved a reliable technique for accurate diagnosis of pelvic floor dysfunction. MR defecography with steady-state sequences allows detailed anatomic and functional evaluation of the pelvic floor. This article provides an overview of normal anatomy and function of the pelvic floor and discusses a practical approach to the evaluation of imaging findings of pelvic floor relaxation, pelvic organ prolapse, fecal incontinence, and obstructed defecation.

LEVEL OF EVIDENCE

5 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1155-1170.

Vaginal delivery-related changes in the pelvic organ position and vaginal cross-sectional area in the general population

PURPOSE

Evaluate the effect of vaginal delivery on pelvic organ positions and vaginal cross-sectional areas.

METHODS

MRI of 119 premenopausal women were grouped according to the number of deliveries. The distances from the three 3-reference points (bladder, uterus, and rectum) to two 2-lines (pubococcygeal-line (PCL) and midpubic-line (MPL)), length of H- and M-lines and vaginal cross-sectional area were compared between the groups.

RESULTS

With increasing parity, distance from the rectum to PCL tended to increase (nullipara vs. bipara; p<0.01). Vaginal cross-sectional area was larger in bipara and tripara than in nullipara (p<0.01).

CONCLUSIONS

Rectal position is more caudally located and vaginal cross-sectional area is larger in bipara than in nullipara.

Magnetic resonance defecography versus clinical examination and fluoroscopy: a systematic review and meta-analysis

BACKGROUND

Magnetic resonance defecography (MRD) allows for dynamic visualisation of the pelvic floor compartments when assessing for pelvic floor dysfunction. Additional benefits over traditional techniques are largely unknown. The aim of this study was to compare detection and miss rates of pelvic floor abnormalities with MRD versus clinical examination and traditional fluoroscopic techniques.

METHODS

A systematic review and meta-analysis was conducted in accordance with recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were accessed. Studies were included if they reported detection rates of at least one outcome of interest with MRD versus EITHER clinical examination AND/OR fluoroscopic techniques within the same cohort of patients.

RESULTS

Twenty-eight studies were included: 14 studies compared clinical examination to MRD, and 16 compared fluoroscopic techniques to MRD. Detection and miss rates with MRD were not significantly different from clinical examination findings for any outcome except enterocele, where MRD had a higher detection rate (37.16% with MRD vs 25.08%; OR 2.23, 95% CI 1.21-4.11, p = 0.010) and lower miss rates (1.20 vs 37.35%; OR 0.05, 95% CI 0.01-0.20, p = 0.0001) compared to clinical examination. However, compared to fluoroscopy, MRD had a lower detection rate for rectoceles (61.84 vs 73.68%; OR 0.48 95% CI 0.30-0.76, p = 0.002) rectoanal intussusception (37.91 vs 57.14%; OR 0.32, 95% CI 0.16-0.66, p = 0.002) and perineal descent (52.29 vs 74.51%; OR 0.36, 95% CI 0.17-0.74, p = 0.006). Miss rates of MRD were also higher compared to fluoroscopy for rectoceles (15.96 vs 0%; OR 15.74, 95% CI 5.34-46.40, p < 0.00001), intussusception (36.11 vs 3.70%; OR 10.52, 95% CI 3.25-34.03, p = 0.0001) and perineal descent (32.11 vs 0.92%; OR 12.30, 95% CI 3.38-44.76, p = 0.0001).

CONCLUSIONS

MRD has a role in the assessment of pelvic floor dysfunction. However, clinicians need to be mindful of the risk of underdiagnosis and consider the use of additional imaging.

[Assessment before surgical treatment for pelvic organ prolapse: Clinical practice guidelines]

INTRODUCTION

The issue addressed in this chapter of recommendations is: What is the clinical and para-clinical assessment to achieve in women with genital prolapse and for whom surgical treatment has been decided. What are the clinical elements of the examination that must be taken into account as a risk factor of failure or relapse after surgery, in order to anticipate and evaluate possible surgical difficulties, and to move towards a preferred surgical technique?

MATERIAL AND METHODS

This work is based on a systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane Database of Systemactic Reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement [AP]).

RESULTS

It suits first of all to describe prolapse, by clinical examination, helped, if needed, by a supplement of imagery if clinical examination data are insufficient or in case of discrepancy between the functional signs and clinical anomalies found, or in case of doubt in associated pathology. It suits to look relapse risk factors (high grade prolapse) and postoperative complications risk factors (risk factors for prothetic exposure, surgical approach difficulties, pelvic pain syndrome with hypersensitivity) to inform the patient and guide the therapeutic choice. Urinary functional disorders associated with prolapse (urinary incontinence, overactive bladder, dysuria, urinary tract infection, upper urinary tract impact) will be search and evaluated by interview and clinical examination and by a flowmeter with measurement of the post voiding residue, a urinalysis, and renal-bladder ultrasound. In the presence of voiding disorders, it is appropriate to do their clinical and urodynamic evaluation. In the absence of any spontaneous or hidden urinary sign, there is so far no reason to recommend systematically urodynamic assessment. Anorectal symptoms associated with prolapse (irritable bowel syndrome, obstruction of defecation, fecal incontinence) should be search and evaluated. Before prolapse surgery, it is essential not to ignore gynecologic pathology.

CONCLUSION

Before proposing a surgical cure of genital prolapse of women, it suits to achieve a clinical and paraclinical assessment to describe prolapse (anatomical structures involved, grade), to look for recurrence, difficulties approach and postoperative complications risk factors, and to appreciate the impact or the symptoms associated with prolapse (urinary, anorectal, gynecological, pelvic-perineal pain) to guide their evaluation and their treatment. © 2016 Published by Elsevier Masson SAS.

Prevalence of dynamic magnetic resonance imaging-identified pelvic organ prolapse in pre- and postmenopausal women without clinically evident pelvic organ descent

Background Dynamic magnetic resonance imaging (dMRI) is an imaging tool that can be used to evaluate and stage pelvic organ prolapse (POP). Greater understanding of the incidental detection of POP in asymptomatic patients is needed. Purpose To evaluate the prevalence of dMRI-detected POP in pre-and postmenopausal women who were imaged for reasons unrelated to pelvic floor dysfunction. Material and Methods A total of 227 women who had diagnoses that did not include POP underwent abdominal/pelvic dMRI. Patients with a positive gynecological examination for or a clinical history of POP ( n = 11), hysterectomy ( n = 4), or gynecologic-oncology surgery ( n = 2) were excluded, as well as patients who were unable to strain during MRI ( n = 11). A total of 199 patients without visible prolapse were enrolled in the study. An H-line, M-line, pubococcygeal line (PCL), and mid-pubic line (MPL) were used to detect and grade prolapse. Results The prevalence of dMRI-identified POP was higher in postmenopausal subjects. The PCL led to a greater frequency of prolapse detection than the MPL. The frequency of middle compartment descent was similar regardless of whether the PCL or MPL was used as a reference line. There was a higher incidence of prolapse in the posterior compartment. Using an H-line and PCL as references, the anterior and posterior compartments were found to significantly differ between pre- and postmenopausal subjects. The MRI parameters that were used to define POP were not correlated with parity, vaginal birth, BMI, or fetal birth weight. With respect to the MPL, age was correlated with both the presence of an elongated H-line and with descent. Conclusion Dynamic MRI identified incidental pelvic organ prolapse in asymptomatic patients. The prevalence of dMRI-detected POP was higher in postmenopausal women without visible prolapse. These findings suggest the need for further studies to identify how to modify the currently used dMRI thresholds for postmenopausal women.

Quantitative assessment of new MRI-based measurements to differentiate low and high stages of pelvic organ prolapse using support vector machines

INTRODUCTION AND HYPOTHESIS

The objective of this study was to quantitatively assess the ability of new MRI-based measurements to differentiate low and high stages of pelvic organ prolapse. New measurements representing pelvic structural characteristics are proposed and analyzed using support vector machines (SVM).

METHODS

This retrospective study used data from 207 women with different types and stages of prolapse. Their demographic information, clinical history, and dynamic MRI data were obtained from the database. New MRI measurements were extracted and analyzed based on these reference lines: pubococcygeal line (PCL), mid-pubic line (MPL), true conjugate line (TCL), obstetric conjugate line (OCL), and diagonal conjugate line (DCL). A classification model using SVM was designed to assess the impact of the features (variables) in classifying prolapse into low or high stage.

RESULTS

The classification model using SVM can accurately identified anterior prolapse with very high accuracy (>0.90), and apical and posterior prolapse with good accuracy (0.80 - 0.90). Two newly proposed MRI-based features were found to be significant in the identification of anterior and posterior prolapse: the angle between TCL and MPL for anterior prolapse, and the angle between DCL and PCL for posterior prolapse. The overall accuracy of posterior prolapse identification increased from 47% to 80% when the newly proposed MRI-based features were taken into consideration.

CONCLUSIONS

The proposed MRI-based measurements are effective in differentiating low and high stages of pelvic organ prolapse, particularly for posterior prolapse.

ACR Appropriateness Criteria pelvic floor dysfunction

Pelvic floor dysfunction is a common and potentially complex condition. Imaging can complement physical examination by revealing clinically occult abnormalities and clarifying the nature of the pelvic floor defects present. Imaging can add value in preoperative management for patients with a complex clinical presentation, and in postoperative management of patients suspected to have recurrent pelvic floor dysfunction or a surgical complication. Imaging findings are only clinically relevant if the patient is symptomatic. Several imaging modalities have a potential role in evaluating patients; the choice of modality depends on the patient's symptoms, the clinical information desired, and the usefulness of the test. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions; they are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals, and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.