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Consensus Definitions and Interpretation Templates for Magnetic Resonance Imaging of Defecatory Pelvic Floor Disorders

2021; Lippincott Williams & Wilkins; Volume: 64; Issue: 10 Linguagem: Inglês

10.1097/dcr.0000000000002155

1530-0358

Brooke Gurland, Gaurav Khatri, Roopa Ram, Tracy L. Hull, Ervin Kocjancic, Lieschen H. Quiroz, Rania Farouk El Sayed, Kedar Jambhekar, Victoria Chernyak, Raj Mohan Paspulati, Vipul Sheth, Ari Steiner, Amita Kamath, S. Abbas Shobeiri, Milena M. Weinstein, Liliana Bordeianou,

Anorectal Disease Treatments and Outcomes

The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, radiologists, physiotherapists, and other advanced care practitioners. Specialists from these fields are all dedicated to the diagnosis and management of patients with pelvic floor conditions, but they approach, evaluate, and treat such patients with their own unique perspectives given the differences in their respective training. The PFDC was formed to bridge gaps and enable collaboration between these specialties. The goal of the PFDC is to develop and evaluate educational programs, create clinical guidelines and algorithms, and promote high quality of care in this unique patient population. The recommendations included in this document represent the work of the PFDC Working Group on Magnetic Resonance Imaging of Pelvic Floor Disorders (members listed alphabetically in Table 1). The objective was to generate inclusive, rather than prescriptive, guidance for all practitioners, irrespective of discipline, involved in the evaluation and treatment of patients with pelvic floor disorders. TABLE 1. - Members of the working group Name and degree Affiliation City, state, country Jennifer Ayscue, M.D. Division of Colorectal Surgery, MedStar Washington Hospital Center North Washington, DC, USA Pedro Basilio, M.D. Department of Colorectal Surgery, Clinica de Saúde Intestinal Rio de Janeiro, Brazil Victoria Chernyak, M.D. Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center The Bronx, NY, USA Rania Farouk El Sayed, M.D. Cairo University Pelvic Floor Centre of Excellency and Research Lab, Department of Radiology, Faculty of Medicine, Cairo University Hospitals. Cairo, Egypt Brooke Gurland, M.D. Division of Colorectal Surgery. Stanford University Palo Alto, CA, USA Cynthia Hall, M.D. Department of Obstetrics and Gynecology UMass Memorial Medical Center Worcester, MA, USA Karin Herrmann, M.D. Department of Radiology, University Hospitals of Cleveland Cleveland, OH, USA Kedar Jambhekar, M.D. Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA Andreas M. Kaiser, M.D. Division of Colorectal Surgery, City of Hope National Cancer Center Duarte, CA, USA Amita Kamath, M.D. Department of Radiology, Icahn School of Medicine at Mount Sinai New York, NY, USA Gaurav Khatri, M.D. Department of Radiology, University of Texas Southwestern Medical Center Dallas, TX, USA Erin Kocjancic, M.D. Department of Urology College of Medicine University of Illinois Chicago, IL, USA Khashayar Rafatzand, M.D. Department of Radiology, UMass Memorial Medical Center Worcester, MA, USA Luz Maria Rodriguez, M.D. Division of Colorectal Surgery National Cancer Institute Rockville, MD, USA Kavita Mishra, M.D. Department of Obstetrics and Gynecology, Stanford University Palo Alto, CA, USA Leila Neshatian, M.D. Division of Gastroenterology, Stanford University Palo Alto, CA, USA Erin O’Neill, M.D. Department of Radiology, MedStar Washington Hospital Center North Washington, DC, USA Albert Parlade, M.D. Department of Radiology, Cleveland Clinic Weston, FL, USA Raj Mohan Paspulati, M.D. Department of Radiology, University Hospitals Cleveland Medical Center Cleveland, OH USA Roopa Ram, M.D. Department of Radiology, University of Arkansas for Medical Sciences Little Rock, AR, USA Vipul Sheth, M.D. Department of Radiology, Stanford University Palo Alto, CA, USA Ari Steiner, M.D. Department of Radiology, Mount Sinai South Nassau Hospital Oceanside, NY, USA Raveen Syan, M.D. Department of Urology, University of Miami Miller School of Medicine Miami, FL, USA Amber Traugott, M.D. Division of Colorectal Surgery, The Ohio State University Wexner Medical Center Columbus, OH, USA STATEMENT OF THE PROBLEM Magnetic resonance defecography (MRD) has emerged and continues to evolve as a powerful tool for dynamic evaluation of pelvic floor function. Magnetic resonance defecography provides multicompartment visualization and is able to evaluate the complex and dynamic interplay of the 3 pelvic floor compartments.1 In addition to providing global assessment of pelvic floor function, MRD can provide exquisite assessment of the pelvic floor anatomy because of its high-contrast resolution. Known limitations of MRD include the varied techniques used in performing this examination as well as the differences in nomenclature and reporting of MRD findings across different institutions and subspecialties. Furthermore, various experts involved in the care of patients with pelvic floor dysfunction sometimes use different definitions for the same condition and various thresholds for grading severity, consequently hindering consistent and effective communication between clinicians in the same institution and across institutions. To help standardize MRD technique, expert radiologists from the Pelvic Floor Dysfunction Disease Focused Panel of the Society of Abdominal Radiology (SAR) have recently published recommendations for MRD protocol and technique.2 However, these recently published recommendations from the SAR as well as other previous publications on dynamic MRD of the pelvic floor have lacked substantial multidisciplinary input from clinicians in other specialties.3,4 Consequently, there is a lack of shared understanding and “cross-talk” between various specialties involved in the care of patients with pelvic floor dysfunction, resulting in high variability in how different physicians and specialties interpret and utilize findings seen on MRD. This is of particular concern in this field of pelvic floor disorders, where patients often have recurrent or multifactorial symptomatology and seek care from multiple different specialists serially. Furthermore, multiple health care providers may be managing different aspects of pelvic floor dysfunction in the same patient in parallel. This can frequently create misunderstandings and confusion for both health care providers and patients. Thus, this effort was undertaken with the explicit goal of inviting and including representatives from all relevant clinical specialties for whom MRD holds clinical significance. The goal of this effort was to create a universal set of recommendations and language for MRD technique, interpretation, and reporting that can be utilized and carry the same significance across disciplines. Notably, pelvic floor disorders can manifest in both male and female patients. These recommendations do not make a distinction based on patient sex; however, certain recommendations may only be applicable to female pelvic floor anatomy, and normal criteria for pelvic floor imaging in male patients are less well established. METHODOLOGY This document was created at the initiative of the Pelvic Floor Disorders Consortium (PFDC) Working Group on MRI. The PFDC is composed of a volunteer cohort of clinicians with demonstrated expertise in the care and treatment of pelvic floor conditions. The working group was created by enlisting Pelvic Floor Consortium volunteers. Invitation criteria included leadership in the field of pelvic floor disorders with academic scholarship and a history of interdisciplinary collaboration. Members of the working group participated in preliminary group phone calls and researched assigned topics (Table 1). A radiologist was paired with a clinical specialist for each of the working group topics. An organized search of MEDLINE, PubMed, EMBASE, and the Cochrane Database of Collected Reviews was performed on July 1, 2018, and repeated on September 1, 2018. Retrieved publications were limited to the English language but no limits on year of publication were applied. The search terms included: “Dynamic MRI,” “Dynamic pelvic floor MR,” “MR defecography,” “Pelvic floor MR,” “Positioning for MR defecography,” “levator descent,” “pelvic organ prolapse,” “rectocele,” “rectal emptying,” “cystocele,” “rectal intussusception,” “Cul-de-sac hernias pelvic floor,” “uterine prolapse,” “Vaginal prolapse,” “urethral hypermobility,” “pubococcygeal line,” “pelvic floor dyssynergia,” and “anorectal angle.” Each working group pair identified the updated literature on the assigned relevant topic or point of controversy regarding MRD technique and/or reporting and performed a careful review of the pertinent literature using a standardized literature review format. A collective summary document of the researched topics was generated and used as a reference to steer discussion at the PFDC meeting. The working group presented their preliminary research to the consortium at large for further discussion. Pelvic Floor Consortium Expert Meeting The Pelvic Floor Consortium Expert Meeting convened on June 2, 2019, in Cleveland, Ohio. It was hosted and funded by the American Society of Colon and Rectal Surgeons (ASCRS) and included 126 in-person (or online) volunteer participants from North America, Europe, and Asia. These experts belonged to several subspecialties (colorectal surgery, gastroenterology, urogynecology, urology, physiotherapy, and radiology), and professional societies involved in the diagnosing and treating of pelvic floor disorders. The event was also audited by formal representatives from the ASCRS, the SAR, the International Continence Society, the American Urogynecologic Society, the International Urogynecology Association, and the Society Gynecologic Surgeons who then reported back to their leadership on the event. The participants at the expert consensus meeting analyzed all the proposed radiological definitions measuring each of the conditions reviewed in this statement, ultimately recommending a synoptic reporting template that included the recommended steps for a thorough and clinically relevant examination, as well as the clinically relevant radiological definitions for common evacuatory pelvic floor disorders seen on defecography. They labeled this final template as the “Magnetic Resonance Imaging Defecography Interpretation Template for the Initial Measurement of Patient Reported Pelvic Floor Complaints” or “MRI-IMPACT” (Table 2). For a recommendation to be included in the MRI-IMPACT template, an expert consensus was required. Consensus was defined as at least 70% agreement or more from the voting participants. When consensus was not reached, the workgroups performed additional research and literature reviews to clarify any questions raised during the meeting. A subsequent committee meeting was held to conduct final voting on the recommendations and definitions listed in the MRI-IMPACT document, while keeping the directives of the expert consensus panel discussions in mind. TABLE 2. - MRI-IMPACT template EXAMINATION: MRI defecography (pelvis) without intravenous contrast HISTORY: [ ] years old [female/male] with [ ] TECHNIQUE: [ ] mL of [gel/other contrast] was instilled into the rectum. Multiplanar MRI of the pelvis was performed utilizing [enter specific protocol]. All images were obtained with patient in [supine/upright/other] position following careful patient education. Intravenous contrast: None COMPARISON: [Prior study used for comparison] FINDINGS Anatomic Evaluation: [Anatomic findings including pertinent surgical changes (hysterectomy), urethral slings, vaginal mesh, urethral bulking agent. Discuss appearance of levator ani muscles, anal sphincter complex, and anal canal anatomy] Functional Evaluation Defecatory effort: [good/moderate/poor]. [None/one-third/two-thirds/nearly all] of the instilled rectal contrast was evacuated by the end of the examination. Anterior Compartment Bladder base location relative to the PCL: Rest: [ ] cm [above/below] PCL. Defecation/maximal Valsalva: [ ] cm [above/below] PCL. Findings are [consistent with/not consistent with] significant cystocele. Urethral hypermobility: [present/absent] Middle Compartment (female patients ) [Vaginal apex/cervix/uterus] location relative to PCL: Rest: [ ] cm [above/below]. Defecation/maximal Valsalva: [ ] cm [above/below]. Findings are [consistent with/not consistent with] significant vaginal/cervix/uterine prolapse. Levator hiatus and perineal/anorectal descent Levator hiatus (H-line): Rest: [ ] cm (normal ≤5 cm). Defection/maximal Valsalva: [ ] cm. M-line: Rest: [ ] cm [above/below] the PCL (normal ≤2 cm below). Defecation/maximal Valsalva: [ ] cm [above/below] the PCL. Above findings are consistent with [normal/widened] levator hiatus and [normal/low-lying] anorectal junction at rest with [no excessive widening/ excessive widening] and [no excessive descent/excessive descent] of the anorectal junction/perineum during defecation/maximal Valsalva. Posterior Compartment Periotoneocele/enterocele/sigmoidocele [present/absent]. Contents of cul-de-sac hernia sac: [small bowel/sigmoid colon/peritoneal fat only/other (specify)/NA] Distance below PCL [ ] cm Relationship to vaginal apex: [at top of vaginal apex, to middle of vagina, to pelvic floor] Protrusion of structures into vagina noted [yes/no]; protrusion into rectum noted [yes/no] Cul-de-sac hernia appears to [obstruct/not obstruct] complete rectal emptying Rectocele [present/absent]. Rectocele size: [ ] cm AP. Contrast entrapment within rectocele is: [present/absent/NA]. Rectal Intussusception: [present/absent] Location: [intrarectal/intra-anal/ extra-anal/NA]. Anorectal angle measurements: Rest: [ ] degrees Kegel: [ ] degrees Defecation/maximal Valsalva: [ ] degrees The anorectal angle [widens normally during defecation/stays the same during defecation /paradoxically narrows during attempted defecation]. The anus is [open/closed] at rest and [open/closed] at the point of maximum attempt to defecate. Other: [incidental findings as appropriate]. IMPRESSION 1. [Anatomic findings] 2. [Anterior compartment findings] 3. [Middle compartment findings] 4. [Levator hiatus and anorectal junction/perineal descent findings] 5. [Posterior compartment findings] AP = anterior-posterior; NA = not available; PCL = pubococcygeal line. Final Review Once the document was finalized, the proposed recommendations were presented for review by the ASCRS Pelvic Floor Disorders Steering Committee. This Steering Committee is directed to develop clinical practice recommendations on colorectal pelvic floor disorders based on best available evidence. The ASCRS Steering Committee edited the document and sent it to the ASCRS Executive Committee for final approval for publication. Similar reviews and endorsements were also given by the American Urogynecologic Society Publications Committee, the SAR Board of Directors and SAR Disease Focused Panel on Pelvic Floor Dysfunction, the International Continence Society Board of Directors, the International Urogynecology Association Board of Directors, and the Executive Board of the Society Gynecologic Surgeons. RECOMMENDATIONS General Considerations 1. MRD can be performed in either the upright (sitting) or supine position, and the position should be documented in the report to provide context for the imaging findings (Degree of consensus: 81%). Magnetic resonance defecography can be performed in upright or supine positions. The upright, or sitting, position is more physiologic and maximizes the impact of gravity to stimulate defecation. Defecation in the supine position can be difficult or even impossible for individuals who depend on gravity or various maneuvers such as digital splinting to effectively empty their bowels. However, most institutions lack open magnets to perform upright imaging, and the widely available closed magnets have excellent performance for MRD in the supine position. Literature comparing supine MRD to upright studies have produced variable results. A study comparing supine to upright MRD in the same patient population demonstrated lower positions of the bladder and vagina during upright MRD, but no significant difference in position of the anorectal junction.5 A study by Gufler et al6 demonstrated that supine MRD and upright colpocystography were not significantly different in terms of depiction of anterior and middle compartment prolapse. However, Kelvin et al7 showed that supine MRD underestimated cystoceles and enteroceles compared to upright fluoroscopic defecography. More recently, a study assessing anterior compartment prolapse showed more severe anterior prolapse and urethral hypermobility on supine MRD than on upright voiding cystourethrogram.8 For posterior compartment pathology (perineocele, rectocele, rectal prolapse, and anismus), Poncelet et al9 retrospectively compared upright fluoroscopic defecography to supine MRD in 50 women and revealed similar diagnostic sensitivities. van Iersel et al10 demonstrated that supine MRD was less sensitive than fluoroscopic defecography for diagnosing rectocele and enterocele but was superior in detection for intussusception. Foti et al11 demonstrated no significant differences between fluoroscopic defecography and supine MRD for evaluating outlet obstructive syndrome. Given the variable results from different studies, consortium members agreed that it is acceptable to perform MRD in the supine position when upright MRD is not available. Importantly, consortium experts stressed that it is very important that this imaging be performed following proper patient education on the purpose of the examination. The purpose of this education is to promote patient participation during acquisition of the defecation sequences; the importance of adequate patient effort is further discussed below.2,12–15 2. MRD quality is highly dependent on patient cooperation and effort. Patients should be adequately educated on the purpose and the steps of the MRD examination to ensure their cooperation with the examination (Degree of consensus: 98%). Patient participation is essential to obtain a successful and meaningful MRD examination. The consortium experts agreed that educating patients before the examination regarding what to expect and the sequence of events during the study results in a more meaningful examination. Patients are instructed to rest, then perform full defecation of gel on command with maximum effort to empty. Referring physicians can initiate this process of patient preparation by explaining the examination and its value for patient management to the patients either in person or on the phone before, or at the time of, ordering the examination. Referring physicians should emphasize the value of optimal patient defecatory effort during the study to achieve the most diagnostic results. Written educational material or trusted online resources were recommended to educate patients about the examination before their arrival at the radiology department. Knowledge of what to expect during the examination can help alleviate patient anxiety and minimize embarrassment during this unique examination. The patients should be given an opportunity to discuss any questions or concerns on arrival at the radiology department. Furthermore, the consortium experts emphasized that it is important for radiologists or technologists to coach the patients before starting the examination so they can follow instructions appropriately, resulting in the best quality examination. Technical terms such as “Kegel,” “Valsalva,” and “defecation” should be explained in layman’s language before patients are positioned in the MRI machine and before the rectal gel is inserted.2 The Kegel maneuver may be explained as maximal pelvic floor squeeze as if trying to prevent the passage of feces or urine; the Valsalva maneuver may be explained as bearing down on the pelvic floor maximally without evacuating any rectal contents; and defecation may be explained as bearing down maximally with complete evacuation of rectal contents. The patient should be instructed to sustain each maneuver for the duration of image acquisition as instructed by the radiology personnel performing the examination. Such proactive coaching is important to alleviate any confusion on the part of the patient during image acquisition. Contrast Considerations 1. Rectal contrast and defecation are essential for an appropriate MRD examination in both female and male patients (Degree of consensus: 100%). Based on the evidence in the literature and the experience of the experts, the consortium recommended that MRD should be performed with rectal distention using rectal contrast, and with acquisition of images during defecation. Rectal distention and defecation are critical elements of an MRD examination and differentiate it from simple dynamic pelvic floor MRI performed with the Valsalva maneuver. Multiple studies have shown larger and/or more frequent prolapse on MRD examinations with rectal distention and on defecation images compared to Valsalva images (Fig. 1).12–16 Rectal distention is an essential element of the technique to obtain images during defecation. Although various institutions have described protocols with different agents for rectal distention, most centers use ultrasound gel or lubricating jelly inserted in the rectum by using hand injection with a catheter tip syringe. This is easy to administer and is typically well tolerated by patients, although, in theory, the gel consistency may preclude adequate assessment of stool retention within rectoceles and, in other cases, may not induce the urge to defecate as would a more solid consistency of contrast. To our knowledge, there is no convincing evidence in the literature supporting the use of one consistency of rectal contrast over another for MRD. The volume of contrast used also varies widely between institutions, ranging from 60 mL to over 250 mL. Although there is a paucity of literature assessing the most appropriate volume of contrast in the rectum, a small study found no significant difference in the success of defecatory effort when comparing rectal distention with 120 mL compared to 180 mL and advocated use of the lower volume to minimize patient discomfort and risk of masking prolapse in other compartments due to rectal overdistention.17 Although the consortium experts did not specify the exact volume of rectal contrast to be used, practices should strive to use an appropriate volume that successfully induces defecatory urge without overdistending the rectum. One strategy may be to start with 60 or 120 mL of rectal contrast and increase the volume if the patient does not report fullness or an adequate urge to defecate. The volume of rectal contrast used should be stated in the report.FIGURE 1.: A 59-year-old woman with a history of rectal bulge and sensation of incomplete defecation. Sagittal steady-state images at rest (A), Valsalva (B), and defecation (B) demonstrate the bladder (B), vaginal apex (asterisk), and anorectal junction (dashed arrow) at or above the pubococcygeal line (PCL) (dashed line) at rest in A. During Valsalva in B, the bladder (B) extends below the PCL and there is a small cystocele (solid arrow), the vaginal apex is lower than at rest (asterisk), but remains above the PCL, and there is descent of the anorectal junction (dashed arrow). During defecation in C, there is significantly larger descent of the bladder below the PCL and enlargement of the cystocele (solid arrow), the vaginal apex now prolapses below the PCL (asterisk), and there is significant descent of the anorectal junction below the PCL (dashed arrow). There are also anterior and posterior rectoceles (left and right curved arrows). B = bladder; R = rectum; V = vagina. 2. Magnetic resonance defecography does not require routine use of vaginal contrast for adequate imaging of pathology (Degree of consensus: 88%). Some institutions use vaginal contrast on MRD in female patients to assist in detection of vaginal vault prolapse, and authors have reported using volumes ranging from 5 to 60 mL,15–18 but there is no convincing evidence in the literature to support routine use of vaginal contrast during MRD. Given its high spatial and contrast resolution, MRI allows direct visualization of soft tissue structures in the pelvis such as the anterior and posterior vaginal walls and vaginal apex (Figs. 2 and 3), precluding the need for routine use of vaginal contrast19 and avoiding the added burden on patient privacy and discomfort.2,3 Furthermore, if the vaginal contrast is not expelled during the examination, it could conceivably mask vaginal prolapse (descent of vaginal apex below the pubococcygeal line (PCL)) or prolapse in other compartments. Thus, there was consensus among the experts against the routine use of vaginal contrast for MRD.FIGURE 2.: A 68-year-old woman with a prior bladder suspension presents with the inability to complete defecation. Sagittal (A) and axial (B) T2-weighted images at rest demonstrate clear delineation of the anterior (white arrows) and posterior vaginal wall (black arrows) without intravaginal contrast. Sagittal steady-state images during early defecation (C) demonstrates a rectocele (solid black line in C). A vertical line is drawn from the anorectal junction to extrapolate the location of the anterior rectal wall at rest (dotted line in C). Rectocele is measured in anterior-posterior dimension using a line drawn from this location to the anteriorly displaced wall of the rectum (solid line in C). During late defecation (D), partial-thickness intrarectal intussusception (dashed white arrow in D) and sigmoidocele (solid white arrow in D) are seen. These findings were not present on the early defecation image. There is also increased descent of the bladder neck on the late defecation image (arrowhead in D). B = bladder; R = rectum; V = vagina.FIGURE 3.: A 64-year-old woman with a history of bladder and uterine prolapse. Axial (A) and sagittal (B) T2-weighted images of the pelvis at rest demonstrate uterocervical prolapse. The vaginal walls are well delineated circumferentially (long arrows) surrounding a caudally prolapsed cervix (asterisk). Also clearly visible is the symmetric thinning and ballooning of the levator ani muscles on the axial image (short arrows in A). Sagittal steady-state image from the same patient during end defecation demonstrates a large cystocele (solid white arrow in C), more significant uterine prolapse (asterisk), and rectal intussusception (dashed white arrow in C). B = bladder; R = rectum.Technique and Reporting/Grading of Relevant Pathology 1. A) Findings on MRD are highly dependent on patient effort during defecation, which should be reported as “good,” “moderate,” or “poor” to provide clinical context (Degree of consensus: 100%). B) Furthermore, patients should be coached to attempt defecation until complete rectal emptying is achieved or at least 3 times during the examination (Degree of consensus: 88%). C) Following defecation, the degree of evacuation should be assessed subjectively and reported as a function of initial rectal volume in thirds. The presence and location of contrast retention during maximal defecatory effort should be described (Degree of consensus: 80%). It is important to note that, based on their clinical experience and evidence in the literature, experts emphasized that MRD images should be acquired during full defecation rather than only a maximal Valsalva maneuver..12,13 They observed that the artificial lack of rectal emptying during a Valsalva maneuver may limit the detection of prolapse and may result in an underestimation of pelvic floor pathology on MRD.20 Thus, experts recommended not requiring a Valsalva phase of image acquisition during MRD, but rather proceeding directly to a defecation phase, where patients are encouraged to achieve complete or near-complete rectal emptying. Because rectal emptying can be difficult to achieve on command, experts recommended acquiring images during a minimum of 3 evacuation attempts, in particular, in cases when the rectum fails to fully empty during the initial attempts.21 In such cases, the later defecation images often demonstrate a larger degree of prolapse or new defects that may have been occult on earlier attempts (Figs. 2 and 4). Regardless of order, the set of images demonstrating the maximal degree of effort or largest degree of dysfunction should be used for measurement. Contrast reinstallation is not needed during these repeat defecation acquisitions. Patients who do not evacuate during the examination may be asked to attempt to defecate in a restroom (by splinting the perineum or by digital manipulation if needed) to empty the rectum. This should be followed by acquiring an additional set of MR images during maximal Valsalva (postdefecation Valsalva maneuver) to demonstrate any prolapse that may have been masked by a full or only partially empty rectum on the earlier attempted defecation images. These images should be labeled appropriately for subsequent review.FIGURE 4.: A 52-year-old woman with suspected pelvic organ prolapse after hysterectomy, constipation, and a limited clinical examination. Sagittal steady-state images during successive defecation attempts. First defecation attempt (A) shows rectocele (solid white arrow in A). Second defecation attempt shows less descent and rectocele due to poor effort (solid white arrow in B). Final defecation (C) shows large enterocele (dashed arrow in C) with mass effect on the rectum (solid white arrow). Dashed line measures the distance of enterocele sac descent from the pubococcygeal line; dotted line measures the extent of the enterocele sac along the posterior vaginal wall from va