BACKGROUND: Patient selection is extremely important in obstructed defecation syndrome (ODS) and rectal prolapse (RP) surgery. This study assessed factors that guided the indications for ODS and RP surgery and their specific role in our decision-making process using a machine learning approach.
METHODS: This is a retrospective analysis of a long-term prospective observational study on female patients reporting symptoms of ODS who underwent a complete diagnostic workup from January 2010 to December 2021 at an academic tertiary referral center. Clinical, defecographic, and other functional tests data were assessed. A supervised machine learning algorithm using a classification tree model was performed and tested.
RESULTS: A total of 400 patients were included. The factors associated with a significantly higher probability of undergoing surgery were follows: as symptoms, perineal splinting, anal or vaginal self-digitations, sensation of external RP, episodes of fecal incontinence and soiling; as physical examination features, evidence of internal and external RP, rectocele, enterocele, or anterior/middle pelvic organs prolapse; as defecographic findings, intra-anal and external RP, rectocele, incomplete rectocele emptying, enterocele, cystocele, and colpo-hysterocele. Surgery was less indicated in patients with dyssynergia, severe anxiety and depression. All these factors were included in a supervised machine learning algorithm. The model showed high accuracy on the test dataset (79%, p < 0.001).
CONCLUSIONS: Symptoms assessment and physical examination proved to be fundamental, but other functional tests should also be considered. By adopting a machine learning model in further ODS and RP centers, indications for surgery could be more easily and reliably identified and shared.

OBJECTIVE: Defecation disorders can occur as a consequence of functional or structural anorectal dysfunctions during voiding. The aims of this study is to assess the prevalence of structural (SDD) vs functional (FDD) defecation disorders among patients with clinical complaints of obstructive defecation (OD) and their relationship with patients\' expulsive capacity.
METHODS: Retrospective study of 588 patients with OD studied between 2012 and 2020 with evacuation defecography (ED), and anorectal manometry (ARM) in a subgroup of 294.
RESULTS: 90.3% patients were women, age was 58.5±12.4 years. Most (83.7%) had SDD (43.7% rectocele, 45.3% prolapse, 19.3% enterocele, and 8.5% megarectum), all SDD being more prevalent in women except for megarectum. Functional assessments showed: (a) absence of rectification of anorectal angle in 51% of patients and poor pelvic descent in 31.6% at ED and (b) dyssynergic defecation in 89.9%, hypertonic IAS in 44%, and 33.3% rectal hyposensitivity, at ARM. Overall, 46.4% of patients were categorized as pure SDD, 37.3% a combination of SDD+FDD, and 16.3% as having pure FDD. Rectal emptying was impaired in 66.2% of SDD, 71.3% of FDD and in 78% of patients with both (p=0.017).
CONCLUSIONS: There was a high prevalence of SDD in middle-aged women with complaints of OD. Incomplete rectal emptying was more prevalent in FDD than in SDD although FDD and SDD frequently coexist. We recommend a stepwise therapeutic approach always starting with therapy directed to improve FDD and relaxation of striated pelvic floor muscles.

Patients with chronic constipation (CC) usually complain of mild to severe symptoms, including hard or lumpy stools, straining, a sense of incomplete evacuation after a bowel movement, a feeling of anorectal blockage, the need for digital maneuver to assist defecation, or reduced stool frequency. In clinical practice, healthcare providers need to check for \'alarm features\' indicative of a colonic malignancy, such as bloody stools, anemia, unexplained weight loss, or new-onset symptoms after 50 years of age. In the Seoul Consensus on the diagnosis and treatment of chronic constipation, the Bristol stool form scale, colonoscopy, and digital rectal examination are useful for objectively evaluating the symptoms and making a differential diagnosis of the secondary cause of constipation. If patients with CC improve to lifestyle modification or first-line therapies, the effort to determine the subtypes of CC is usually not considered. On the other hand, if conventional therapeutic strategies fail, diagnostic testing needs to be considered to distinguish between the different subtypes of functional constipation (normal-transit constipation, slow transit constipation, or defecatory disorder) because these subtypes of constipation have different therapeutic implications and a correct diagnosis is critical. In the Seoul consensus, physiological testing is recommended for patients with functional constipation who have failed to respond to treatment with available laxatives (for a minimum of 12 weeks and recommended a therapeutic regimen) or who are strongly suspected of having a defecatory disorder. The Seoul consensus contains statements of physiological testing, including balloon expulsion test, anorectal manometry, defecography, and colon transit time.

OBJECTIVE: 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.
METHODS: 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.

BACKGROUND: Radiographic imaging of the abdomen and pelvis plays an important role in the diagnosis and management of ileal pouch disorders with modalities including CT, MRI, contrasted pouchography, and defecography.
OBJECTIVE: To perform a systematic review of the literature and describe applications of cross-sectional imaging, pouchography, defecography, and ultrasonography.
METHODS: PubMed, Google Scholar, and Cochrane database.
METHODS: Relevant articles on endoscopy in ileal pouches published between January 2003 and June 2023 in English were included on the basis of Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
METHODS: Main abdominal and pelvic imaging modalities and their applications in the diagnosis of ileal pouch disorders were included.
METHODS: Accuracy in characterization of ileal pouch disorders.
RESULTS: CT is the test of choice for the evaluation of acute anastomotic leaks, perforation, and abscess(es). MRI of the pelvis is suitable for the assessment of chronic anastomotic leaks and their associated fistulas and sinus tracts, as well as for the penetrating phenotype of Crohn\'s disease of the pouch. CT enterography and magnetic resonance enterography are useful in assessing intraluminal, intramural, and extraluminal disease processes of the pouch and prepouch ileum. Water-soluble contrast pouchography is particularly useful for evaluating acute or chronic anastomotic leaks and outlines the shape and configuration of the pouch. Defecography is the key modality to evaluate structural and functional pouch inlet and outlet obstructions. Ultrasonography can be performed to assess the pouch in experienced IBD centers.
CONCLUSIONS: This is a qualitative, not quantitative, review of mainly case series and case reports.
CONCLUSIONS: Abdominopelvic imaging, along with clinical and endoscopic evaluation, is imperative for accurately assessing structural, inflammatory, functional, and neoplastic disorders. See video from symposium .

OBJECTIVE: 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.
CONCLUSIONS: 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.

Sigmoidocele, which is a type of obstructed defecation syndrome (ODS), is a peritoneal hernia of the pelvic floor that has been seldom studied individually. This study investigated the anatomic characteristics of sigmoidocele based on imaging features.
This retrospective cohort population comprised adult patients with ODS who underwent defecography between December 2017 and July 2020. Sigmoidocele was classified based on existing criteria. Novel radiological parameters including the vertical distance descended by the sigmoid colon from rest to maximum straining (RMS) and from the inferior border of the sigmoid colon to the superior border of the rectum at maximum straining (MSR) were measured.
Among 275 patients with sigmoidocele, 251 (91.6%) were female. The mean age was 51.53±12.99 years. We classified 26, 205, and 44 cases as grades I, II, and III, respectively. Patients with more severe sigmoidocele had greater sigmoid colon mobility (RMS: 19.13±8.54 mm, 34.45±14.51 mm, and 48.70±20.05 mm for grades I, II, and III, respectively; p < 0.001) and more pronounced compression of the rectum by the sigmoid colon at maximum straining (MSR: 35.23±8.44 mm, 26.33±13.29 mm, and 15.18±18.00 mm, respectively; p < 0.001). We regrouped the patients based on sigmoid colon alignment. Type L patients had the most severe constipation.
Our study presents a novel sigmoidocele classification. The anatomic appearance and location of the herniated sigmoid colon observed using fluoroscopy during defecation may help improve the clinical awareness of ODS caused by sigmoidocele.

BACKGROUND: 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.
CONCLUSIONS: 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.

BACKGROUND: Magnetic resonance defecography (MRD) plays a central role in diagnosing pelvic floor functional disorders by visualizing the entire pelvic floor along with pelvic organs and providing functional assessment of the defecation process. A shared understanding between radiology and surgery regarding indications and interpretation of findings is crucial for optimal utilization of MRD.
OBJECTIVE: This review aims to explain the indications for MRD from a surgical perspective and elucidate the significance of radiological findings for treatment. It intends to clarify for which symptoms MRD is appropriate and which criteria should be followed for standardized results. This is prerequisite to develop interdisciplinary therapeutic approaches.
METHODS: A comprehensive literature search was conducted, including current consensus guidelines.
RESULTS: MRD can provide relevant findings in the diagnosis of fecal incontinence and obstructed defecation syndrome, particularly in cases of pelvic floor descent, enterocele, intussusception, and pelvic floor dyssynergia. However, rectocele findings in MRD should be interpreted with caution in order to avoid overdiagnosis.
CONCLUSIONS: MRD findings should never be considered in isolation but rather in conjunction with patient history, clinical examination, and symptomatology since morphology and functional complaints may not always correlate, and there is wide variance of normal values. Interdisciplinary interpretation of MRD results involving radiology, surgery, gynecology, and urology, preferably in the context of pelvic floor conferences, is recommended.
UNASSIGNED: HINTERGRUND: Die Magnetresonanz-Defäkographie (MRD) hat durch die Darstellung des gesamten Beckenbodens mitsamt den Beckenorganen und als funktionelle Untersuchung des Stuhlentleerungsakts eine zentrale Rolle in der Diagnostik der Beckenbodenfunktionsstörungen. Ein gemeinsames Verständnis zwischen Radiologie und Chirurgie über Indikation und Befunderhebung ist von immenser Bedeutung, um die MRD bestmöglich einzusetzen.
UNASSIGNED: Diese Übersichtsarbeit soll die Indikationen der MRD aus chirurgischer Sicht erläutern und darlegen, welche Bedeutung die radiologischen Befunde für die Behandlung haben. Es soll verdeutlicht werden, bei welchen Symptomen die MRD sinnvoll ist und welchen Kriterien Durchführung und Befundung folgen sollten, um standardisierte Befunde zu erhalten. Dies ist Voraussetzung, um interdisziplinäre Therapiekonzepte entwickeln zu können.
METHODS: Es erfolgte eine umfassende Literaturrecherche unter Einbezug aktueller Consensus-Guidelines.
UNASSIGNED: Die MRD kann in der Diagnostik der Stuhlinkontinenz und Stuhlentleerungsstörung relevante Befunde liefern und ist insbesondere beim Beckenbodendeszensus, der Enterozele, der Intussuszeption und der Beckenbodendyssynergie das Diagnostikum der Wahl. Rektozelenbefunde in der MRD sollten zurückhaltend interpretiert werden, um Überdiagnosen zu vermeiden.
CONCLUSIONS: MRD-Befunde können nie isoliert, sondern nur in Zusammenschau mit Anamnese, Untersuchung und Leidensdruck bewertet werden, da Morphologie und funktionellen Beschwerden nicht immer korrelieren und die Varianz der Normwerte groß ist. Die Interpretation der MRD sollte interdisziplinär (Radiologie, Chirurgie, Gynäkologie, Urologie) und idealerweise im Rahmen von Beckenbodenkonferenzen erfolgen.

BACKGROUND: Dynamic magnetic resonance imaging (MRI) of the pelvic floor plays a key role in imaging complex pelvic floor dysfunction. The simultaneous detection of multiple findings in a complex anatomic setting renders correct analysis and clinical interpretation challenging.
OBJECTIVE: The most important aspects (anatomy of the pelvic floor, three compartment model, morphological and functional analysis, reporting) for a successful clinical use of dynamic MRI of the pelvic floor are summarized.
METHODS: Review of the scientific literature on dynamic pelvic MR imaging with special consideration of the joint recommendations provided by the expert panel of ESUR/ESGAR in 2016.
RESULTS: The pelvic floor is a complex anatomic structure, mainly formed by the levator ani muscle, the urethral support system and the endopelvic fascia. Firstly, morphological changes of these structures are analysed on the static sequences. Secondly, the functional analysis using the three compartment model is performed on the dynamic sequences during squeezing, straining and defecation. Pelvic organ mobility, pelvic organ prolapse, the anorectal angle and pelvic floor relaxation are measured and graded. The diagnosis of cystoceles, enteroceles, rectoceles, the uterovaginal as well as anorectal decent, intussusceptions and dyssynergic defecation should be reported using a structured report form.
CONCLUSIONS: A comprehensive analysis of all morphological and functional findings during dynamic MRI of the pelvic floor can provide information missed by other imaging modalities and hence alter therapeutic strategies.
UNASSIGNED: HINTERGRUND: Die dynamische Magnetresonanztomographie (MRT) des Beckenbodens hat sich als maßgebliche Bildgebung bei komplexer Beckenbodendysfunktion etabliert. Die Analyse und klinische Interpretation sind aufgrund der Vielzahl möglicher, simultan erfasster Befunde und der komplexen Anatomie herausfordernd.
UNASSIGNED: Die wichtigsten Aspekte (Anatomie des Beckenbodens, 3‑Kompartimente-Modell, morphologische und funktionelle Analyse, Befundbericht) zur erfolgreichen klinischen Anwendung der dynamischen Beckenboden-MRT werden dargestellt.
METHODS: Recherche und Zusammenfassung der wissenschaftlichen Literatur zur dynamischen Beckenboden-MRT unter besonderer Berücksichtigung der Expertenempfehlungen der ESUR/ESGAR (European Society of Urogenital Radiology/European Society of Gastrointestinal and Abdominal Radiology) von 2016.
UNASSIGNED: Der Levator-ani-Komplex, der urethrale Stützapparat und die endopelvine Faszie stellen die zentralen Bestandteile des Beckenbodens dar. Diese werden bezüglich typischer Strukturveränderungen in den statischen Sequenzen zunächst morphologisch evaluiert. Im 3‑Kompartimente-Modell folgt die funktionelle Analyse der dynamischen Sequenzen mit Bestimmung der Beckenorganmobilität und des Beckenorganprolapses (zur pubokokzygealen Linie), des anorektalen Winkels sowie der Beckenbodenrelaxation (durch H‑ und M‑Linie) unter Belastung. Zystozelen, Enterozelen, Peritoneozelen, Rektozelen, uterovaginaler und anorektaler Deszensus werden quantifiziert und graduiert sowie assoziierte Pathologien (hypermobile Urethra, Intussuszeption, dyssynergische Defäkation) evaluiert. Die strukturierte Befunddokumentation ist ratsam.
CONCLUSIONS: Die umfassende qualitative und quantitative Analyse der Befunde in der dynamischen Beckenboden-MRT kann gegenüber anderen Bildgebungsmodalitäten therapierelevante Zusatzinformationen liefern und somit die (interdisziplinäre) Behandlung der Beckenbodendysfunktion verbessern.