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Accuracy of Four Imaging Techniques for Diagnosis of Posterior Pelvic Floor Disorders

van Gruting, Isabelle M. A. MD; Stankiewicz, Aleksandra MD, PhD; Kluivers, Kirsten MD, PhD; De Bin, Riccardo PhD; Blake, Helena MB, FRCR; Sultan, Abdul H. MD, FRCOG; Thakar, Ranee MD, FRCOG

doi: 10.1097/AOG.0000000000002245
Contents: Original Research

OBJECTIVE: To establish the diagnostic test accuracy of evacuation proctography, magnetic resonance imaging (MRI), transperineal ultrasonography, and endovaginal ultrasonography for detecting posterior pelvic floor disorders (rectocele, enterocele, intussusception, and anismus) in women with obstructed defecation syndrome and secondarily to identify the most patient-friendly imaging technique.

METHODS: In this prospective cohort study, 131 women with symptoms of obstructed defecation syndrome underwent evacuation proctogram, MRI, and transperineal and endovaginal ultrasonography. Images were analyzed by two blinded observers. In the absence of a reference standard, latent class analysis was used to assess diagnostic test accuracy of multiple tests with area under the curve (AUC) as the primary outcome measure. Secondary outcome measures were interobserver agreement calculated as Cohen's κ and patient acceptability using a visual analog scale.

RESULTS: No significant differences in diagnostic accuracy were found among the imaging techniques for all the target conditions. Estimates of diagnostic test accuracy were highest for rectocele using MRI (AUC 0.79) or transperineal ultrasonography (AUC 0.85), for enterocele using transperineal (AUC 0.73) or endovaginal ultrasonography (AUC 0.87), for intussusception using evacuation proctography (AUC 0.76) or endovaginal ultrasonography (AUC 0.77), and for anismus using endovaginal (AUC 0.95) or transperineal ultrasonography (AUC 0.78). Interobserver agreement for the diagnosis of rectocele (κ 0.53–0.72), enterocele (κ 0.54–0.94) and anismus (κ 0.43–0.81) was moderate to excellent, but poor to fair for intussusception (κ −0.03 to 0.37) with all techniques. Patient acceptability was better for transperineal and endovaginal ultrasonography as compared with MRI and evacuation proctography (P<.001).

CONCLUSION: Evacuation proctography, MRI, and transperineal and endovaginal ultrasonography were shown to have similar diagnostic test accuracy. Evacuation proctography is not the best available imaging technique. There is no one optimal test for the diagnosis of all posterior pelvic floor disorders. Because transperineal and endovaginal ultrasonography have good test accuracy and patient acceptability, we suggest these could be used for initial assessment of obstructed defecation syndrome.


There is no one optimal imaging technique for diagnosis of all posterior pelvic floor disorders in women with obstructed defecation syndrome.

Departments of Obstetrics and Gynaecology and Radiology, Croydon University Hospital, Croydon, United Kingdom; and the Departments of Obstetrics and Gynaecology and Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands.

Corresponding author: Ranee Thakar, MD, FRCOG, Croydon University Hospital, 530 London Road, Thornton Heath, CR7 7 YE, Surrey, UK; email:

Isabelle M. A. van Gruting was funded by the Mayday Childbirth Charity Fund.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented at the European Urogynaecology Association Annual Meeting, November 3–5, 2016, Amsterdam, the Netherlands.

Each author has indicated that he or she has met the journal’s requirements for authorship.

© 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.