Colorectal Cancer Screening

Colorectal Cancer Screening. DCBE DCBE also requires a preprocedural bowel cleansing preparation. The study is performed by administration of a liquid barium-based contrast agent and air-insufflation of the colon via a tube inserted into the rectum. Images are acquired with the patient in different obliquities and at different table angulations ranging from supine to standing. Performance of DCBE is dependent on optimal patient positioning because patient anatomy varies. The Colorectal Cancer Screening perforation rate during DCBE is approximately 1 in 25,000 [56] as compared to 1 in 22,000 for CTC and 1 in 1,000 for diagnostic colonoscopy [38,39]. Additional data on the effectiveness of the DCBE for detecting colorectal cancer comes from studies in which the imaging history of patients with colorectal cancer was reviewed. In many of these studies, the risk level of patients undergoing DCBE was not reported. Based on this methodology, the sensitivity of DCBE ranges from 75% to 95% [64-66]. This correlates with a large, population-based study that found the overall rate of new or missed cancers following a DCBE was 22% [67]. SCBE Single-contrast barium enema (SCBE) studies are performed by administration of liquid barium via a rectal tube. Unlike a DCBE, the colon is not insufflated with air. SCBE studies are generally performed when patients are unable to tolerate a DCBE (eg, patients unable to stand upright) and a CTC cannot be performed. A minority of studies have suggested that a SCBE has the potential to be as sensitive as a DCBE for detecting cancer and large polyps. The reported sensitivity for cancer ranges from 82% to 95% [65,66] and is approximately 95% for large polyps [69]. In a retrospective evaluation of individuals diagnosed with colorectal cancer who had undergone a prior DCBE or SCBE, the cancer miss rate was 4.8% for SCBE and 4.7% for DCBE [65].


Colorectal Cancer Screening

Colorectal Cancer Screening. However, because of the paucity of studies and limitations of the study designs, questions have been raised about the reproducibility of the results, particularly for large polyps. With current techniques, MR colonography does not perform as well as CTC for detection of polyps, especially for small lesions. Fewer published studies are available evaluating MR colonography as compared to CTC, and sample sizes are generally small for MR colonography studies, which remains primarily an investigational technique. In a systematic review of 13 prospective studies evaluating MR colonography performance in 1,285 Colorectal Cancer Screening Variant 2: Colorectal cancer screening. Moderate-risk individual. First-degree family history of cancer or adenoma. Initial screening, then follow-up every 5 years after initial negative screen. CTC Less evidence is available assessing the performance of CTC in moderate-risk as compared to average-risk individuals. In a study evaluating 156 asymptomatic individuals with a family history of colorectal cancer (defined as a first-degree relative [parent, sibling, or child] diagnosed with colorectal cancer before 60 years of age, or 2 first-degree relatives diagnosed with colorectal cancer at any age) and 8,857 subjects without family history of colorectal cancer, the referral rate for colonoscopy was higher in the family history cohort (16.0% versus 10.5%; P=0.035), but the frequencies of proven cancer (0.0% versus 0.4%), advanced adenoma (4.5% versus 3.2%), and nonadvanced adenoma (5.1% versus 2.6%) were not significantly increased [78]. The results of this study suggest that CTC is a viable screening option for individuals at moderate risk due to family history. DCBE Limited evidence is available regarding the performance of DCBE in individuals with a family history of colorectal cancer.


Colorectal Cancer Screening

Colorectal Cancer Screening. An older investigation of screening with colonoscopy or sigmoidoscopy and DCBE compared to no screening found a reduction in colorectal cancer incidence with screening in families with hereditary nonpolyposis colorectal cancer [79]. SCBE SCBE generally does not perform as well as DCBE for detection of polyps and cancers and should be used if CTC or DCBE cannot be performed. Limited evidence is available regarding the performance of SCBE in individuals with a family history of colorectal cancer. Colorectal Cancer Screening In studies comparing DCBE to endoscopy, when used to evaluate individuals with a positive FOBT, most reports indicate a sensitivity of 75% to 80% [85,86]. In a study comparing DCBE to endoscopy in 71 patients with rectal bleeding, the sensitivity of DCBE for detecting adenomas >6 mm was 58% [87]. SCBE SCBE generally does not perform as well as DCBE for detection of polyps and cancers and should be used if CTC or DCBE cannot be performed. In a retrospective evaluation of 165 patients who underwent SCBE, the sensitivity for colorectal cancer was 81.8% [66]. The majority of these patients were symptomatic (eg, bleeding, anemia, altered bowel habit) at time of imaging [66]. In a FOBT trial, SCBE was used as a diagnostic follow-up and the sensitivity for cancer was 80% [88]. Variant 4: Colorectal cancer screening. High-risk individual. Hereditary nonpolyposis colorectal cancer; ulcerative colitis or Crohn colitis. The risk of cancer in individuals with ulcerative colitis increases after the disease has been present 8 to 10 years, and it correlates with the extent of the disease. The cumulative probability of colorectal cancer in an ulcerative colitis patient is 2% by 10 years, 8% by 20 years, and 18% by 30 years [91]. The risk for individuals with Crohn colitis may be comparable.


Colorectal Cancer Screening

Colorectal Cancer Screening. Unlike the other forms of colorectal cancer screening, the screening of ulcerative colitis patients focuses on detecting dysplasia (which may be flat and identified only by random biopsies, or it may be macroscopically visible) and a subsequent prophylactic colectomy. There is no evidence of a reduction in mortality resulting from colorectal cancer screening in these patients, although annual colonoscopy screening has demonstrated a shift to early-stage detection. For patients at high risk because of known ulcerative colitis or Crohn colitis, a colonoscopy is preferred over CTC, MR imaging, or barium examinations because of its ability to obtain biopsies to look for dysplasia. Individuals with HNPCC, also known as Lynch syndrome, are at increased risk for colorectal cancer. Colorectal cancers tend to occur at a younger age and with a shorter dwell time in individuals with HNPCC [92]. Colorectal cancer screening recommendations for individuals with HNPCC or at risk (first-degree relatives) are colonoscopy every 1 to 2 years beginning at 20 to 25 years of age or earlier if familial diagnosis of colorectal cancer before age 25 years [92]. CTC Colonoscopy is preferred over CTC because of its ability to obtain biopsies to look for dysplasia. DCBE Colonoscopy is preferred over barium examinations because of its ability to obtain biopsies to look for dysplasia. Colorectal Cancer Screening MR Colonography Colonoscopy is preferred over MR imaging because of its ability to obtain biopsies to look for dysplasia. SCBE Colonoscopy is preferred over barium examinations because of its ability to obtain biopsies to look for dysplasia. DCBE Limited data have been published on the accuracy of DCBE following incomplete colonoscopy. In a study of 233 patients who underwent DCBE following incomplete colonoscopy, polyps were reported in 2.1% of patients (5 patients; 5 of 6 polyps >5 mm) [101].


Colorectal Cancer Screening

Colorectal Cancer Screening. However, 2 patients with 4- and 10-mm polyps reported on DCBE underwent repeat colonoscopy, and no polyps were found. The remaining 3 patients with polyps reported on DCBE refused repeat colonoscopy. Thirteen patients whose DCBE studies were reported as of suboptimal quality underwent repeat colonoscopy, and 5 patients were found to have polyps (one 1-cm tubular adenoma, 4 <5-mm hyperplastic polyps). In a study of 103 patients who underwent DCBE performed immediately after incomplete colonoscopy, the entire colon was visualized in 94% of subjects [102]. Five malignant neoplasms (size not reported) were identified at DCBE [102]. SCBE Very limited data are available regarding the accuracy of SCBE performed after incomplete colonoscopy. In a study of 118 patients who underwent barium enema following incomplete colonoscopy (103 double contrast, 15 single contrast), 2 polyps were found (4 and 5 mm) and removed at subsequent repeat colonoscopy [103]. Repeat colonoscopic findings were not available for the vast majority of study subjects [103]. Summary of Recommendations For average-risk individuals, CT colonography is usually appropriate for colorectal cancer screening. For moderate-risk individuals (eg, first-degree family history of cancer or adenoma), CT colonography is usually appropriate for colorectal cancer screening. For moderate-risk individuals after positive FOBT or positive fecal immunochemical test, CT colonography is usually appropriate for colorectal cancer detection. For high-risk individuals (eg, hereditary nonpolyposis colorectal cancer, ulcerative colitis, or Crohn colitis), colonoscopy is preferred over imaging tests because of its ability to obtain biopsies to look for dysplasia. For colorectal cancer screening after incomplete colonoscopy, CT colonography is usually appropriate for individuals at average, moderate, or high risk for colorectal cancer. Colorectal Cancer Screening


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs.  Introduction/Background Types of nondegenerative arthritides resulting in chronic extremity pain can be broadly divided into seropositive inflammatory arthritis, seronegative inflammatory arthritis (spondyloarthritis), and crystalline arthritis. Although erosive osteoarthritis is often classified as a subset of osteoarthritis [1], the severity of clinical symptoms often put it in the realm of inflammatory arthritis in terms of differential diagnosis. Although it is much less common than osteoarthritis, millions of Americans suffer from chronic extremity pain from inflammatory and crystalline arthropathies. The prevalence of rheumatoid arthritis (RA), the most common inflammatory arthritis, has been reported to be between 0.5% and 1% [2], and the prevalence of gout, the most common crystalline arthritis, is as high as 3.9% of adults in the United States [3]. Imaging plays an important role in the diagnosis and management of inflammatory and crystalline arthritis. It is important to consider global distribution of skeletal involvement, and correlating findings on multiple studies/modalities may be necessary. Furthermore, it is critical that imaging results are interpreted in the context of clinical and serologic results to add specificity because there is significant overlap of imaging findings amongst the various types of arthritis. Imaging can be used to identify osseous and/or soft tissues abnormalities that are seen with inflammatory and crystalline arthritis. In addition to joint space narrowing, the osseous abnormalities of the extremities that are assessed include erosions, bone proliferation in the form of enthesitis and periostitis, and bone marrow edema. The location of the erosions with respect to the joint (ie, marginal, para-articular, central, and subenethesial) is helpful in differential diagnosis.


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. Bone proliferation, in the form of enthesitis, is a hallmark of spondyloarthropathies and may occur at any cortical bone, including both tendon and ligament attachments. Soft tissue abnormalities of the extremities that are assessed with imaging include soft tissue crystal deposition and synovial hypertrophy, which may be intraarticular or involve tendon sheaths and bursae. This document discusses 5 variants: 1) Chronic extremity joint pain. Suspect inflammatory (seropositive or seronegative arthritis), crystalline (gout or pseudogout), or erosive osteoarthritis. Initial imaging. 2) Chronic extremity joint pain. Suspect inflammatory arthritis (seropositive or seronegative arthritis). Radiographs normal or inconclusive. Next imaging study. 3) Chronic extremity joint pain. Suspect gout. Radiographs normal or inconclusive. Next imaging study. 4) Chronic extremity joint pain. Suspect calcium pyrophosphate (CPP) dihydrate disease (pseudogout). Radiographs normal or inconclusive. Next imaging study. 5) Chronic extremity joint pain. Suspect erosive osteoarthritis. Radiographs normal or inconclusive. Next imaging study. aCleveland Clinic, Cleveland, Ohio. bResearch Author, Cleveland Clinic Foundation, Cleveland, Ohio. cPanel Chair, Mayo Clinic Arizona, Phoenix, Arizona. dPanel Vice-Chair, University of Virginia Health System, Charlottesville, Virginia. eMayo Clinic, Scottsdale, Arizona, Rheumatologist. fUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. gMoffitt Cancer Center and University of South Florida Morsani College of Medicine, Tampa, Florida; MSK-RADS (Bone) Committee. hCleveland Clinic Foundation, Cleveland, Ohio, Primary care physician. iMayo Clinic, Rochester, Minnesota. jHospital for Special Surgery, New York, New York. kDuke University Medical Center, Durham, North Carolina.


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. lUniversity of Washington Medical Center, Seattle, Washington; Committee on Emergency Radiology-GSER. mMayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging. nUniversity of Missouri Health Care, Columbia, Missouri. oPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland. pSpecialty Chair, VA San Diego Healthcare System, San Diego, California. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: publications@acr.org Chronic Extremity Joint Pain Special Imaging Considerations Image-guided aspiration may be helpful in confirming and characterizing crystal deposition disease and excluding infection. Image-guided aspiration may be challenging; however, depending on the amount of fluid present [6,7]. OR Discussion of Procedures by Variant Variant 1: Chronic extremity joint pain. Suspect inflammatory (seropositive or seronegative arthritis), crystalline (gout or pseudogout), or erosive osteoarthritis. Initial imaging. The area of interest for this variant include: the ankle, elbow, foot, hand, hip, knee, shoulder, and wrist. Bone Scan Whole Body There is no relevant literature supporting the use of bone scan whole body as the initial imaging modality in this clinical scenario. CT Area of Interest With IV Contrast There is no relevant literature supporting the use of CT area of interest with intravenous (IV) contrast as the initial imaging modality in this clinical scenario.


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. CT Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of CT area of interest without and with IV contrast as the initial imaging modality in this clinical scenario. CT Area of Interest Without IV Contrast There is no relevant literature supporting the use of CT area of interest without IV contrast as the initial imaging modality in this clinical scenario. FDG-PET/CT Whole Body There is no relevant literature supporting the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT whole body as the initial imaging modality in this clinical scenario. MRI Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of MRI area of interest without and with IV contrast as the initial imaging modality in this clinical scenario. MRI Area of Interest Without IV Contrast There is no relevant literature supporting the use of MRI area of interest without IV contrast as the initial imaging modality in this clinical scenario. Radiography Area of Interest Radiographs are beneficial as the initial imaging study for chronic extremity joint pain where inflammatory arthritis, crystalline arthritis, or erosive osteoarthritis is suspected. Radiography has a low sensitivity compared with other modalities including CT, MRI, US, and tomosynthesis [8-12] for the detection of erosions, and multiple radiographic views of a joint are often needed to improve erosion identification. Nevertheless, the location and distribution of osseous erosions and/or productive change are often adequate for diagnosis. Other causes of pain such as osteoarthritis, infection, and trauma may also be apparent. Thus, radiographs potentially avoid the need for further workup and delays in treatment. Even in the case of RA, in which early treatment is associated with improved Chronic Extremity Joint Pain


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. outcomes, the 2013 European League Against Rheumatism (EULAR) guidelines on imaging of the joints in RA recommends radiographs of the hand and feet as the initial imaging technique [13]. Assessment for synovitis and tenosynovitis is limited on radiography, although soft tissue swelling can be seen in the affected regions. Soft tissue and intraarticular crystal deposition as seen with gout or CPP deposition (CPPD); however, are readily apparent on radiographs in the form of tophi and chondrocalcinosis, respectively. US Area of Interest There is no relevant literature supporting the use of ultrasound (US) area of interest as the initial imaging modality in this clinical scenario. Variant 2: Chronic extremity joint pain. Suspect inflammatory arthritis (seropositive or seronegative arthritis). Radiographs normal or inconclusive. Next imaging study. Seropositive (rheumatoid) arthritis and seronegative spondyloarthritides including psoriatic arthritis, ankylosing spondylitis, reactive arthritis, and arthritis associated with inflammatory bowel disease share many clinical, pathologic, and imaging similarities. Thus, a uniform approach in the imaging workup of these entities is reasonable. Features of osseous erosions and soft tissue findings of synovitis and tenosynovitis may be seen in both seropositive and seronegative inflammatory arthritis, whereas enthesitis and dactylitis are typically seen only with the spondyloarthritis. The area of interest for this variant include: the ankle, elbow, foot, hand, hip, knee, shoulder, and wrist. Bone Scan Whole Body Tc-99m scintigraphy has been shown to be sensitive but not specific in the diagnosis of inflammatory arthritis, but it can detect inflammation and predict cortical erosions [9,14].


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. There is insufficient evidence to support routine use of bone scans for evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest When adding single-photon emission CT (SPECT), RA could be differentiated from osteoarthritis given the added information from tomographic images [14]. There is insufficient evidence to support routine use of bone scans with SPECT or SPECT/CT for evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. CT Area of Interest With IV Contrast There is insufficient evidence to support the routine use of CT area of interest with IV contrast for the evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. Although CT can show bony erosions and productive changes with high diagnostic confidence, the ability of CT to identify and characterize associated inflammatory soft tissue findings and bone marrow edema is limited. Newer techniques of iodine-dual-energy CT (DECT) mapping and high-resolution peripheral quantitative CT have shown promise in detection and quantification of periarticular/tenosynovial inflammation and bony changes respectively [15]. Further validation is needed; however, and these techniques are not widely used in clinical practice. CT Area of Interest Without and With IV Contrast There is insufficient evidence to support routine use of CT area of interest without and with IV for the evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. As mentioned before, although CT can show bony erosions and productive changes with high diagnostic confidence, the ability of CT to identify and characterize associated inflammatory soft tissue findings and bone marrow edema is limited.


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. Newer techniques of iodine-DECT mapping and high-resolution peripheral quantitative CT have shown promise in detection and quantification of periarticular/tenosynovial inflammation and bony changes, respectively [15]. Further validation is needed; however, and these techniques are not widely used in clinical practice. CT Area of Interest Without IV Contrast There is insufficient evidence to support the routine use of CT area of interest without IV contrast for the evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. As mentioned before, although CT can show bony erosions and productive changes with high diagnostic confidence, the ability of CT to identify and characterize associated inflammatory soft tissue findings and bone marrow edema is limited. Chronic Extremity Joint Pain FDG-PET/CT Whole Body FDG-PET uptake can be seen at sites of inflammation but is limited by being nonspecific [14,16]. Novel PET tracers targeting specific immunological targets in RA have been described but only tested preclinically or in small patient cohorts [17]. Further research is needed to validate these early results and determine their clinical role, if any. The literature suggests that PET/CT studies are not routinely obtained for evaluation of seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. Image-Guided Aspiration Area of Interest Image-guided aspiration is generally not useful in the seropositive or seronegative inflammatory arthritis in the extremities following initial radiographs. Image-guided aspiration may be helpful in excluding crystal deposition disease and infection.


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. MRI Area of Interest Without and With IV Contrast Regarding the diagnosis of RA, the 2013 EULAR task force recommendations on use of imaging of the joints in RA state that when there is diagnostic doubt following radiographs, either US or MRI can be used to improve certainty of diagnosis of RA above clinical criteria as well as to detect early joint damage before it is radiographically visible [13]. Both MRI and US outperform clinical evaluation in the detection of inflammation and structural damage and provide prognostic information concerning radiographic progression [18-20]. The evidence is inconclusive as to whether MRI or US should be considered the preferred method for evaluation of RA [18]. However, MRI with IV gadolinium contrast has been shown to be more sensitive compared with US in the early stages of RA [21] and aids in detection of synovitis and tenosynovitis [22,23]. Therefore, when safe to do so, MRI of the area of interest should ideally be performed without and with IV contrast. MRI area of interest without IV contrast can show cortical erosions, bone edema, synovial hypertrophy, and soft tissue abnormalities such as tenosynovitis and dactylitis. The use of IV gadolinium is less important in the detection of osseous erosions and bone edema but enhances detection of synovitis and tenosynovitis [22,23]. Cortical irregularity from inflammatory enthesitis and periostitis and increased fluid signal in the subjacent bone marrow may be seen on MRI without IV contrast [24]. Entheseal involvement in a characteristic distribution can suggest the diagnosis of seronegative spondyloarthropathy [25].


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. MRI-detected erosions as defined by the Rheumatoid Arthritis MRI Scoring System (RAMRIS) criteria [26] can be observed in the metacarpophalangeal and metatarsophalangeal joints of symptom-free individuals in the general population and in different types of rheumatologic diseases and are thus nonspecific [27]. Although synovial hypertrophy can be appreciated on unenhanced sequences, the use of IV gadolinium aids in the evaluation of synovitis because it helps differentiate joint effusion from synovium, which may demonstrate similar signal characteristics on unenhanced sequences [23,28]. MRI Area of Interest Without IV Contrast Regarding the diagnosis of RA, the 2013 EULAR task force recommendations on the use of imaging of the joints in RA state that when there is diagnostic doubt following radiographs, either US or MRI can be used to improve certainty of diagnosis of RA above clinical criteria as well as to detect early joint damage before it is radiographically visible [13]. Both MRI and US outperform clinical evaluation in the detection of inflammation and structural damage and provide prognostic information concerning radiographic progression [18-20]. The evidence is inconclusive as to whether MRI or US should be considered the preferred method for evaluation of RA [18]. MRI area of interest without IV contrast can show cortical erosions, bone edema, synovial hypertrophy, and soft tissue abnormalities such as tenosynovitis and dactylitis. Cortical irregularity from inflammatory enthesitis and periostitis and increased fluid signal in the subjacent bone marrow may be seen on MRI without IV contrast [27]. Entheseal the diagnosis of seronegative spondyloarthropathy [26].


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. MRI-detected erosions as defined by the RAMRIS criteria [24] can be observed in the metacarpophalangeal and metatarsophalangeal joints of symptom-free individuals in the general population and in different types of rheumatologic diseases and are thus nonspecific [25]. US Area of Interest As mentioned before, the 2013 EULAR task force recommendations on use of imaging of the joints in RA state that when there is diagnostic doubt following radiographs, US, or MRI can be used to improve the certainty of diagnosis of RA above clinical criteria as well as to detect early joint damage before it is radiographically visible [13]. Although MRI with IV contrast has been shown to be more sensitive compared with US and has higher diagnostic performance [21], both outperform clinical evaluation and provide prognostic information concerning Chronic Extremity Joint Pain radiographic progression [10-12]. The evidence is inconclusive as to whether MRI or US should be considered the preferred method for evaluation of RA [18]. US has been used to evaluate for osseous abnormalities in the setting of chronic inflammatory arthritis. Compared with radiography, US has been shown to demonstrate a 6.5-fold increase in the number of detected erosions of the metacarpophalangeal joints [12], but it is less accurate when compared with CT [11]. The false-positive rate for US in detection of metacarpophalangeal joint erosions has been reported as high as 29% [29]. Regardless, large erosions identified with US at the second and third metacarpophalangeal joints, the distal ulna, and the fifth metatarsophalangeal joint are highly specific for and predictive of RA [30]. US may also show imaging findings associated with enthesitis [25], with findings of enthesitis on power Doppler imaging having an accuracy of 85.6% in distinguishing peripheral spondyloarthritis versus nonspondyloarthropathy [31].


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. Studies have also found US to be helpful in differentiating RA and psoriatic arthritis [32,33]; for example, enthesitis is a finding often seen in spondyloarthritis but not seen in RA. Increased distance between the nail and distal phalanx in patients with psoriatic arthritis and cutaneous psoriasis is reported to have an 80% sensitivity and a 71% specificity [34]. US is also useful in the evaluation for synovitis and tenosynovitis, aided by the detection of hyperemia via color or Doppler signal [23]. Power Doppler US is more accurate for the diagnosis of synovitis and has a higher correlation with disease activity compared with grayscale US [35,36]. Synovitis on power Doppler US and grayscale US are both associated with the development of radiographic erosions in patients with RA compared with grayscale US [37,38]. Newer techniques for detecting microvascularization associated with joint inflammation like multimodal photoacoustic/US and ultra-microangiography have shown promise as indicators of disease activity [39,40]. US also provides prognostic information (such as detecting synovitis) that is linked to disease progression [13], although mild synovial hypertrophy as an isolated finding is not specific and has limited relevance [41]. In the evaluation of the finger joints with US, dorsal evaluation is recommended over palmar [42]. Abbreviated US scanning protocols of the hands, wrists, and feet to improve efficiency have been described [43-46]. Variant 3: Chronic extremity joint pain. Suspect gout. Radiographs normal or inconclusive. Next imaging study. The area of interest for this variant include: the ankle, elbow, foot, hand, hip, knee, shoulder, and wrist. Bone Scan Whole Body There is no relevant literature supporting the use of bone scan whole body for the evaluation of gout in the extremities following initial radiographs.


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. CT Area of Interest With IV Contrast There is no relevant literature supporting the use of CT area of interest with IV contrast for the evaluation of gout in the extremities following initial radiographs. CT Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of CT area of interest without and with IV for the evaluation of gout in the extremities following initial radiographs. CT Area of Interest Without IV Contrast DECT allows visualization of monosodium urate deposition with a sensitivity ranging from 81% to 88% and a specificity ranging from 90% to 93% [47-49]. However, DECT is less accurate in early stages of gout, with a sensitivity in initial stages of gout flare (<6 weeks) ranging between 36% and 80% [15,47]. Sensitivity is also low for deeper structures such as the shoulder and hip [16]. DECT outperforms clinical assessment in the diagnosis of gout [50] and has been shown to be more sensitive for the diagnosis of gout compared to US in studies of patients in mixed stages of disease [51-53]. DECT has been shown to be helpful in assessment of tophus resolution in response to treatment [54]. Although conventional CT area of interest without IV contrast can show characteristic osseous erosions and soft tissue tophi [38], the 2018 EULAR recommendations state that conventional CT without IV contrast has limited utility for diagnosis of gout compared with US and DECT [55]. However, for the purposes of this document, DECT is considered a technique categorized under this procedure subheading. FDG-PET/CT Whole Body There is no relevant literature supporting the use of FDG-PET/CT whole body for the evaluation of gout in the extremities following initial radiographs. Chronic Extremity Joint Pain Image-Guided Aspiration Area of Interest Image-guided aspiration may be helpful in confirming and characterizing crystal deposition disease and excluding infection.


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. The identification of urate crystals in the aspirate is diagnostic of gout. If urate crystals are not seen in the aspirate; however, this does not necessarily exclude gout. Up to 16% patients diagnosed with acute gout can have negative aspirates [56]. MRI Area of Interest Without and With IV Contrast MRI can show the presence of tophi, crystal induced synovitis, and joint damage [57]; however, the 2018 EULAR recommendations state that MRI has limited utility for diagnosis of gout compared with US and DECT. MRI with or without IV contrast is not supported for routine evaluation of gout in the extremities following initial radiographs [55]. MRI Area of Interest Without IV Contrast MRI can show the presence of tophi, crystal induced synovitis, and joint damage [57]; however, the 2018 EULAR recommendations state that MRI has limited utility for diagnosis of gout compared with US and DECT. MRI without IV contrast is not supported for routine evaluation of gout in the extremities following initial radiographs [55]. US Area of Interest The 2018 EULAR recommendations favor US over other modalities [55]. The Outcome Measures in Rheumatology definitions of US elementary lesions in gout include double contour sign, tophus, aggregates, and erosions [58]. Identification of the double contour sign and soft tissue tophi are highly sensitive, specific, and accurate for the diagnosis of gout [59,60], with double contour sign having excellent reliability [61]. US has been shown to outperform clinical assessment in the diagnosis of gout [50] and outperforms radiography in the detection of erosions, although limitations exist if an erosion involves an area of bone that is inaccessible to US evaluation [62]. There is evidence that US may have higher sensitivity for detection of gout compared with DECT in early gout (duration <1 year) [63].


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. US has also been shown to be helpful in assessment of tophus resolution in response to treatment [64,65]. Variant 4: Chronic extremity joint pain. Suspect calcium pyrophosphate deposition disease (pseudogout). Radiographs normal or inconclusive. Next imaging study. The EULAR defines CPPD as a general term encompassing variable phenotypes, including asymptomatic involvement, acute CPP crystal arthritis, osteoarthritis with CPPD, and chronic CPP crystal inflammatory arthritis [66]. CPPD is thought to have high prevalence in the elderly [67] but is underdiagnosed. CPPD joint involvement as defined by EULAR is when CPP is detected in the synovial fluid from affected joints [66]. Diagnosis is often challenging; however, because the reference standard of synovial fluid analysis has been shown to have a high specificity (100%) but a lower sensitivity (75%) [68]. Chondrocalcinosis is defined as cartilage calcification detected by imaging or histological examination and is most commonly due to CPPD. However, the relationship between chondrocalcinosis and commonly coexisting conditions like osteoarthritis and hemochromatosis is poorly understood. The area of interest for this variant include: the ankle, elbow, foot, hand, hip, knee, shoulder, and wrist. Bone Scan Whole Body There is no relevant literature supporting the use of bone scan whole body for the evaluation of CPPD in the extremities following initial radiographs. CT Area of Interest With IV Contrast There is no relevant literature supporting the use of CT area of interest with IV contrast for the evaluation of CPPD in the extremities following initial radiographs. CT Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of CT area of interest without and with IV for the evaluation of CPPD in the extremities following initial radiographs.


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. CT Area of Interest Without IV Contrast CT without IV contrast can identify chondrocalcinosis and mineralization of tendons, ligaments, and joint capsules as well as show that osseous changes related to CPPD, such as arthropathy characteristically involving the radiocarpal, metacarpophalangeal, atlantoaxial, and patellofemoral joints, are also well demonstrated by CT [69]. Chronic Extremity Joint Pain Both conventional CT without IV contrast and DECT have similarly high sensitivity for the detection of chondrocalcinosis [69-71]. DECT combines the information offered by conventional CT and adds information about the molecular compositions of the tissues. Therefore, the potential advantage of DECT over conventional CT is not an increased sensitivity but the ability to characterize (for example in distinguishing gout and pseudogout) and quantify crystal deposition. For the purposes of this document, DECT is considered a technique categorized under this procedure subheading. FDG-PET/CT Whole Body There is no relevant literature supporting the use of FDG-PET/CT whole body for the evaluation of CPPD in the extremities following initial radiographs. Image-Guided Aspiration Area of Interest Image-guided aspiration may be helpful in confirming and characterizing crystal deposition disease and excluding infection [68]. Diagnosis is often challenging; however, because the reference standard of synovial fluid analysis has been shown to have a high specificity (100%) but a lower sensitivity (75%) [68]. MRI Area of Interest Without and With IV Contrast Chondrocalcinosis may be seen as foci of low signal on MRI, and detection may be improved on gradient echo and ultra-short time to echo sequences [72]. Future research is needed to determine the role of MRI in the evaluation of CPPD in the extremities. There is insufficient evidence to support routine use of MRI with or without IV contrast in the diagnosis of CPPD.


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. MRI Area of Interest Without IV Contrast Chondrocalcinosis may be seen as foci of low signal on MRI, and detection may be improved on gradient echo and ultra-short time to echo sequences [72]. Future research is needed to determine the role of MRI in the evaluation of CPPD in the extremities. There is insufficient evidence to support routine use of MRI without IV contrast in the diagnosis of CPPD. US Area of Interest CPPD can be seen as echogenic foci in in hyaline cartilage, tendons, and the menisci. US has been shown to outperform radiography in detection of chondrocalcinosis [73,74]. Filippou et al [75] found that US had an overall diagnostic accuracy of 75%, with a sensitivity of 91% and a specificity of 59% with histology as the reference standard. The positive predicative value and negative predicative value were 88% and 76%, respectively. When considering combination of medial meniscus and medial condyle hyaline cartilage in combination, US has a sensitivity and specificity of 88% and 76%, respectively. Variant 5: Chronic extremity joint pain. Suspect erosive osteoarthritis. Radiographs normal or inconclusive. Next imaging study. Bone Scan Whole Body There is no relevant literature supporting the use of bone scan whole body for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. CT Area of Interest With IV Contrast There is no relevant literature supporting the use of CT area of interest with IV contrast for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. CT Area of Interest Without and With IV Contrast There is no relevant literature supporting the use of CT area of interest without and with IV contrast for the evaluation of erosive osteoarthritis in the extremities following initial radiographs.


Chronic Extremity Joint Pain Suspected Inflammatory Arthritis Crystalline Arthritis or Erosive Osteoarthritis PCAs. CT Area of Interest Without IV Contrast Although CT is well-suited for demonstration of osseous erosions, there is no relevant literature supporting the use of CT area of interest without IV contrast for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. FDG-PET/CT Whole Body There is no relevant literature supporting the use of FDG-PET/CT whole body for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. Chronic Extremity Joint Pain Image-Guided Aspiration Area of Interest There is no relevant literature supporting the use of image-guided aspiration for the evaluation of erosive osteoarthritis in the extremities following initial radiographs. MRI Area of Interest Without and With IV Contrast MRI can show the features of erosive osteoarthritis, although the findings may be nonspecific, potentially mimicking other types of joint inflammation. The addition of IV contrast may aid in the differentiation of synovitis from joint effusion [23]. MRI Area of Interest Without IV Contrast MRI can show the features of erosive osteoarthritis, although the findings may be nonspecific, potentially mimicking other types of joint inflammation. US Area of Interest US may demonstrate synovial hypertrophy, marginal osteophytes, and central erosions [76] but is not routinely used in clinical practice for the evaluation of erosive osteoarthritis. Both US and contrast-enhanced MRI have been shown to perform equally in the demonstration of synovitis of the fingers associated with erosive osteoarthritis [76]. However, synovitis on US is nonspecific and may be seen with erosive osteoarthritis and inflammatory arthritis. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females.  Support to the pelvic floor is provided by a combination of muscular and connective tissue structures. Direct or denervation injury to the pelvic floor musculature is postulated to increase stress on the fascia and lead to weakening of the pelvic floor. Risk factors for pelvic floor dysfunction include advanced age, menopause, vaginal multiparity, obesity, chronic straining, and conditions that result in chronic increase in intra-abdominal pressures [10]. Special Imaging Considerations Use of Contrast Material Pelvic floor imaging may require the instillation of contrast media in the bladder, vagina, rectum, and small bowel, depending on the specific examination to be performed. Fluoroscopy of the pelvic floor may be performed with Reprint requests to: publications@acr.org Pelvic Floor Dysfunction in Females oral, rectal, bladder, and vaginal contrast (cystocolpoproctography [CCP]), or only with rectal contrast (defecography or proctography), or any combination thereof. For these guidelines, fluoroscopic CCP will be the default fluoroscopic defecation examination of the pelvis unless noted. Voiding cystourethrogram (VCUG) has been used for evaluation of the anterior compartment and necessitates instillation of radiopaque contrast in the urinary bladder [14]. MRI of the pelvic floor allows for direct visualization of the intrapelvic contents, precluding need for contrast within the bladder, vagina, and small bowel; however, use of contrast in the rectum for MR defecography facilitates defecation and improves detection of prolapse compared with dynamic pelvic floor MRI without rectal contrast [15]. Various types and volumes of contrast media have been reported and may depend on the preference of the institution, although US gel or sterile lubricating jelly are the most commonly used rectal contrast agents for MR defecography. MR defecography is performed without IV contrast.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Dynamic US of the pelvic floor enables direct visualization of the pelvic floor organs and is most commonly performed without installation of contrast. MRI with Endorectal/Endoanal Coil The use of endorectal coil may help better visualize the supporting ligaments in the pelvis, and assessment of baseline external anal sphincter thickness on endoanal MRI in patients with fecal incontinence can help predict outcomes after sphincter repair [16]; however, endoanal MRI is relatively invasive and may decrease patient acceptance and compliance. The coil can cause distortion of the pelvic tissues in patients who have a small pelvis. During functional assessment, the coil in the rectum may temporarily prevent prolapse [17]. For these reasons, endoanal MRI is not routinely performed at most centers, and the high-resolution images achievable with external phased-array coils are utilized. Echodefecography Echodefecography, a US technique performed with an endorectal probe and gel in the rectum, has been described for evaluation of posterior compartment dysfunction [18,19]. Echodefecography is not routinely available at most centers and thus is not discussed as a separate procedure in these guidelines. OR Discussion of Procedures by Variant Variant 1: Vaginal protrusion or bulge, or clinically suspected pelvic organ prolapse. Initial imaging. POP is the excessive descent of organs through the pelvic floor hiatus and typically involves protrusion of anterior or posterior vaginal walls and/or descent of the vaginal apex [20]. Patients usually present with pelvic pressure or bulge and often have other associated pelvic floor dysfunction. POP may involve various compartments of the pelvic floor, including the anterior (cystocele and/or urethrocele), apical (uterine/cervical and/or vaginal prolapse), and posterior (rectocele). In addition, pelvic contents at the posterior cul-de-sac may herniate into the rectovaginal space.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. The cul-de-sac hernia may contain peritoneal fat (peritoneocele), small bowel (enterocele), or sigmoid colon (sigmoidocele). Infolding of the rectal wall into its lumen, rectal intussusception, can be partial thickness (involving only the mucosa) or full-wall thickness and may involve either only the anterior wall or both the anterior and posterior wall. Based on location, it may be classified as internal rectal prolapse (intrarectal, intra-anal), or external (extra-anal) intussusception (beyond the anal verge, also called complete rectal prolapse). The appearance of these findings is well described in the imaging literature [21,22]. Initial evaluation of patients with POP symptoms is clinical and begins with the physical examination. Imaging may be obtained when clinical evaluation is difficult or considered inadequate by the physician, or if patients present with persistent or recurrent prolapse symptoms after attempted surgical or nonsurgical treatments. Goals of imaging in this setting may include confirm clinically suspected Pelvic Floor Dysfunction in Females prolapse, assess severity of prolapse, evaluate for associated structural defects or functional abnormalities, differentiate between cul-de-sac hernias and anterior rectoceles (both of which can present clinically with posterior vaginal bulge), determine contents of cul-de-sac hernias, and evaluate for occult pelvic floor disorders in compartments other than those apparent on physical examination. CT Pelvis Although CT may be able to depict large levator muscle defects, to our knowledge there is no relevant literature regarding the use of CT, either with or without IV contrast, for assessment of a protruding or bulging vaginal mass or clinically suspected POP. Fluoroscopy Cystocolpoproctography Dynamic CCP is one of the imaging tests of choice for evaluation of a protruding or bulging vaginal mass or clinically suspected POP and may be an initial imaging test in the setting of posterior compartment prolapse.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Dynamic CCP involves fluoroscopic imaging during defecation with the patient sitting in physiologic upright position on a fluoroscopic commode. Images are obtained during rest, Kegel (contraction of the pelvic floor muscles), strain, and defecation. CCP demonstrates good agreement with surgical findings for detection of full-thickness rectal prolapse, posterior colpocele, rectocele, and peritoneocele and demonstrates excellent correlation for internal rectal prolapse (intrarectal and intra-anal). Sensitivities of CCP for detection of internal rectal prolapse and peritoneocele are 88% and 83%, respectively. [23]. There are few studies comparing CCP to surgical findings for assessment of anterior and middle compartment prolapse. The degree of concordance between CCP and physical examination varies based on the site of prolapse. Relative to physical examination, sensitivity of CCP for detection of cystoceles, rectoceles, and enteroceles is 96%, 94%, and 35%, respectively. Conversely, physical examination detects 83% of cystoceles, 77% of rectoceles, and 51% of enteroceles seen on CCP [11]. Thus, CCP may detect prolapse that is clinically occult. In general, the biggest advantage of CCP is that it allows for functional evaluation in the physiologic upright seated positioning. CCP also allows for assessment of barium contrast retention within rectoceles, which favors clinically relevant rather than incidental findings when present. Known limitations of fluoroscopic CCP include the lack of soft-tissue contrast resolution and the inability to directly visualize pelvic floor anatomy, particularly the pelvic floor muscles and fascia or postsurgical changes in the pelvic floor. As previously mentioned, dynamic CCP also requires installation of contrast in the bladder and vagina as well as administration of oral contrast prior to the examination in order to adequately assess all pelvic floor compartments.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Fluoroscopy Voiding Cystourethrography VCUG is a fluoroscopic technique that focuses on the bladder and urethra in the anterior compartment. Contrast is instilled into the bladder via a Foley catheter. Images are then taken in the upright position at rest and strain and during voiding. Cystocele is defined on VCUG as extension of the opacified urinary bladder below the level of the pubic symphysis and the urethral angle can be measured relative to the vertical axis of the patient [14]. VCUG can be used as an objective measure of change in cystocele height and urethral angle after surgical repair [14]. Wu et al [24] demonstrated a correlation between the shape of a cystocele seen on VCUG and outcomes after cystocele repair with anterior vaginal wall suspension procedure. A significant limitation of VCUG for assessment of POP is its focused evaluation that is limited to the anterior compartment (cystocele and urethral hypermobility). VCUG does not provide information regarding global function of the pelvic floor. Furthermore, a recent study showed lower prevalence and degree of cystoceles and urethral hypermobility on upright VCUG compared to supine MR defecography [25]. Because of its narrow focus on anterior compartment structures, utility of VCUG is limited to patients with suspected concomitant urinary dysfunction. Thus, it is rarely used for initial evaluation of patients with POP. To our knowledge, there is no relevant literature to support the use of VCUG for functional assessment of a protruding or bulging posterior vaginal mass or for clinically suspected POP in the middle or posterior compartment. MR Defecography MR defecography is one of the initial imaging tests of choice for evaluation of a vaginal protrusion or bulge, or clinically suspected POP. It allows for comprehensive anatomic and functional evaluation of the entire pelvic floor.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. MR defecography is a specialized type of dynamic MRI of the pelvic floor that is typically performed with rectal contrast but without IV contrast and includes MRI acquisition during active defecation of rectal contrast. Multiple Pelvic Floor Dysfunction in Females studies have demonstrated the added benefit of MRI with rectal contrast and the defecation phase for assessment of POP compared with dynamic straining MRI without rectal contrast or defecation [15,26-29]. Although MR defecography can be performed in upright or supine positions, most centers lack an open magnet to allow imaging in the upright position. Studies comparing MR defecography in supine position to that in upright position have shown variable results depending on site of prolapse. Some authors have reported that MR defecography in supine positioning may underestimate detection and size of rectal intussusception and rectocele [30,31], whereas other authors [32] demonstrated no significant difference in prevalence of cystocele or anorectal descent during defecation when comparing the two positions. Regardless of positioning, patients should be asked to perform repeated strain/defecation maneuvers to maximize the size of organ prolapse seen on MRI [33]. MR defecography has moderate correlation with surgical findings for diagnosis of full thickness rectal prolapse, internal rectal prolapse, posterior colopocele, rectocele, and peritoneocele; however, agreement between imaging and surgical findings is lower for MR defecography than CCP for full-thickness rectal prolapse, internal rectal prolapse, and peritoneocele. MR defecography sensitivity for internal rectal prolapse and peritoneocele was not significantly lower than that of CCP in one study [23]. MR defecography agreement with physical examination is best for prolapse in the anterior compartment (85%) compared with middle compartment (63%) and posterior compartment (79%).


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. MR defecography detects 45% of enteroceles seen on physical examination; however, physical examination only demonstrates 30% of enteroceles seen on MR defecography and misdiagnoses of 10% for enteroceles as rectoceles. Thus MR defecography is beneficial in detecting or differentiating cases of enteroceles in apical or posterior compartment prolapse [34]. Additional utility of MR defecography lies in its ability to demonstrate associated pelvic floor abnormalities in multiple compartments in addition to the expected clinical diagnoses [35,36]. Finally, the static high-resolution T2-weighted images performed as part of a routine MR defecography may be used for anatomic evaluation. The inherent high soft-tissue contrast resolution of MRI allows for assessment of the pelvic organs including the bladder and urethra as well as the urethral ligaments [37]. Routine T2-weighted images acquired at rest have utility in detecting and quantifying levator muscle defects in patients with prolapse [38] with high interobserver reliability [39]. Muscle defects seen on MRI correlate with symptoms of POP or histories of prior vaginal reconstructive surgery or episiotomy [40]. Muscle thickness is measured reliably on MRI with external phased array coils [41]. Secondary findings of vaginal support defects such as displaced lateral and apical vaginal wall are also seen on MRI [42,43]. MRI Pelvis Dynamic Maneuvers without Defecation Pelvic floor MRI with dynamic maneuvers (dynamic pelvic floor MRI) is similar to MR defecography; however, rectal gel or IV contrast are not generally administered, and the cine images are obtained during maximal straining or Valsalva rather than during defecation. MRI allows for comprehensive anatomic and functional evaluation of the entire pelvic floor. The inherent high soft-tissue contrast resolution of MRI allows for direct visualization of the pelvic organs and pelvic floor muscles and fascia [37-39].


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Muscle defects seen on MRI correlate with symptoms of POP or histories of prior vaginal reconstructive surgery or episiotomy [40]. Secondary findings of vaginal support defects such as displaced lateral and apical vaginal wall are also seen on MRI [42,43]. Imaging during dynamic maneuvers provides functional assessment of the pelvic floor. Dynamic pelvic floor MRI can detect POP in multiple compartments and may be most beneficial for diagnosis of enteroceles [44]. Although interobserver agreement for anterior and middle compartment prolapse is good to excellent [45,46], studies have shown variability in terms of correlation of findings on dynamic pelvic floor MRI with that on physical examination [45]. Furthermore, the detection rate of POP has been reported to be lower on MRI scans without rectal contrast than with rectal contrast [15]. Multiple studies have shown that dynamic pelvic floor MRI with straining rather than defecation demonstrates lower prevalence of prolapse in multiple compartments [12,15,26-29]. Thus, although it may be used for assessment of POP, dynamic pelvic floor MRI during straining (without defecation) is inferior to MR defecography for evaluation of a protruding or bulging vaginal mass or clinically suspected POP and is not considered the initial imaging examination of choice. MRI Pelvis To our knowledge, there is no relevant literature regarding the use of MRI pelvis without defecation or straining for functional assessment of a protruding or bulging vaginal mass or clinically suspected POP. MRI pelvis either without or with IV contrast may be used for anatomic evaluation. The inherent high soft-tissue contrast resolution of MRI allows for assessment of the pelvic organs, including the bladder and urethra, as well as Pelvic Floor Dysfunction in Females the urethral ligaments [37].


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Routine T2-weighted images acquired at rest have utility in detecting and quantifying levator muscle defects in patients with prolapse with high interobserver reliability [38,39]. Muscle defects seen on MRI correlate with symptoms of POP or histories of prior vaginal reconstructive surgery or episiotomy [40]. Muscle thickness is measured reliably on MRI with external phased-array coils [41]. Secondary findings of vaginal support defects such as displaced lateral and apical vaginal wall are also seen on MRI [42,43]. US Pelvis Transabdominal To our knowledge, there is no relevant literature regarding the use of transabdominal US (TAUS) for assessment of a protruding or bulging vaginal mass or clinically suspected POP. US Pelvis Transperineal Transperineal US (TPUS) or translabial US can be used for anatomic and functional evaluation of the pelvic floor, including evaluation of a protruding or bulging vaginal mass or clinically suspected POP. Images are obtained via cine loops in multiple planes during rest, strain, and Kegel maneuvers, with both 2-D and 3-D imaging for anatomic and functional pelvic floor assessment. Patients may be positioned semi-upright or in the dorsal lithotomy position. With regards to anatomic evaluation, TPUS can detect levator muscle avulsion, a predictor of prolapse recurrence after surgical repair [47]. Patients with signs of POP tend to demonstrate a larger pelvic floor hiatal area [48]. Translabial US shows moderate-to-good agreement with MRI for detection of levator ani defects and moderate-to- very-good agreement with MRI for measurement of hiatal biometry [49]. With regards to functional evaluation, dynamic TPUS performed during maximal strain or Valsalva demonstrates bladder and cervical prolapse and can demonstrate rectocele, enterocele/sigmoidocele, and rectal intussusception in the posterior compartment [50]. Detailed evaluation of urethral dysfunction including descent, kinking, and funneling can be obtained during the evaluation.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. A large cystocele may impair evaluation of urethral hypermobility, and TPUS can ensure empty bladder and/or manual replacement of a cystocele at the point of care. Studies comparing US to CCP have shown variable degrees of agreement for different measures of POP, including anorectal angle measurement, cystocele, rectocele, enterocele, descending perineum syndrome, and rectal prolapse [51-53], without emergence of a clear reference standard. For optimal multicompartment evaluation, CCP is performed with filling of the bladder, rectum, large and small bowel, whereas TPUS is generally performed without intraluminal contrast, although US gel can be instilled intravaginally or rectal as indicated. Appropriately performed TPUS with dynamic maneuvers can identify cul-de-sac herniation, although the exact contents may be more challenging to define than on MRI or CCP. Studies have shown significant correlation between TPUS and physical examination, for measures of prolapse, particularly in the anterior compartment [54,55], although US only predicted 59.6%, 61.5%, and 32.6% of prolapse cases in the anterior, posterior, and middle compartments, respectively, in one of these studies [55]. Another study demonstrated that TPUS failed to demonstrate abnormality in up to one-third of clinical cases of rectoceles [56]. In general, the main advantage of TPUS is that it is a noninvasive and less expensive technique with dynamic real- time functional assessment of the multiple compartments. US Pelvis Transrectal To our knowledge, there is no relevant literature to support the use of transrectal US (TRUS) alone for functional assessment of a protruding or bulging anterior vaginal mass or clinically suspected POP, particularly in the anterior or middle compartments. TRUS can be used for anatomic assessment of anal sphincter tears or defects, which can be associated with pelvic floor weakness.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. US Pelvis Transvaginal To our knowledge, there is no relevant literature regarding the use of transvaginal US (TVUS) alone for functional assessment of a protruding or bulging anterior vaginal mass or clinically suspected POP. 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. Urinary dysfunction may present as UI, which is the involuntary leakage of urine, classified as stress, urge, overflow, or mixed type of incontinence [57,58]. Initial evaluation of patients with urinary dysfunction may include physical examination, urinalysis, urinary stress testing, voiding diary, and urodynamic testing with cystourethrography. [58]. Imaging may be requested to assess postvoid bladder volume or evaluate for associated abnormalities in atypical or complex cases to confirm or further Pelvic Floor Dysfunction in Females characterize clinical findings. For instance, imaging can confirm presence of urethral diverticula or other anatomic abnormalities, which may be suspected, based on physical examination, or demonstrate bladder-neck/urethral hypermobility in patients with stress UI (SUI) [59]. In such cases, management of SUI may be aimed at correcting the urethral hypermobility. Imaging can depict bladder wall thickness, which may be increased in the setting of detrusor muscle instability [50]. Imaging may also be indicated in patients who present with persistent or recurrent urinary dysfunction after attempted surgical or nonsurgical treatments. Urinary dysfunction may also include incomplete or difficulty voiding, which can be caused by anatomic or functional abnormalities, for example, urethral or bladder masses; cystocele without urethral rotation, resulting in urethral kinking; neurogenic bladder; or as a complication of urethral sling or bulking agent procedures.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Imaging may be obtained as an adjunct to clinical evaluation when needed to depict these abnormalities. Although multiple imaging examinations may be needed depending of specific patient scenarios, this variant focuses on the initial imaging test that should be obtained when deemed necessary in patients with urinary dysfunction. CT Pelvis To our knowledge, there is no relevant literature regarding the use of CT, either with or without IV contrast for functional assessment of urinary dysfunction. CT can depict anatomic abnormalities such as bladder masses, bladder wall thickening, large urethral diverticula, or urethral masses that may be associated with urinary dysfunction. CT may demonstrate signs of urinary tract infection. CT with IV contrast is generally preferred over CT without IV contrast for anatomic evaluation unless evaluating for small urinary calculi. Fluoroscopy Cystocolpoproctography Dynamic CCP involves fluoroscopic imaging during defecation with the patient sitting upright on a fluoroscopic commode. Images are obtained during rest, Kegel (contraction of the pelvic floor muscles), strain, and defecation. A dedicated cystographic phase with bladder opacification can be performed either prior to instillation of rectal contrast or after complete rectal emptying, in order to avoid underestimation of bladder prolapse due to mass effect from a distended rectum [22]. Although cystocele and bladder-neck mobility may be directly visualized when intravesical contrast is used or may be inferred from posterior displacement of vaginal contrast, the urethra is not typically visible on this examination [22]. When contrast is administered in the bladder, stress incontinence may be visualized during straining or defecation; however, to our knowledge, there is no relevant literature regarding the utility of fluoroscopic CCP specifically for assessment of urinary dysfunction.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Although dynamic CCP can depict urinary abnormalities on the cystographic phase, it is a relatively invasive and time intensive examination and is generally not considered the initial imaging test of choice for patients with urinary dysfunction. Fluoroscopy Voiding Cystourethrography VCUG is a fluoroscopic technique that focuses on the bladder and urethra in the anterior compartment. Contrast is instilled into the bladder via a Foley catheter. Images are then taken in the upright position at rest and strain and during voiding. Cystocele is defined on VCUG as extension of the opacified urinary bladder below the level of the pubic symphysis, and the urethral angle can be measured relative to the vertical axis of the patient [14]. Change in position or angle of the urethra during straining can assess urethral hypermobility; however, a study by Walsh et al [60] in patients with SUI and POP demonstrated variable correlation in this regard between VCUG and the Q-tip test. A recent study demonstrated lower prevalence and degree of urethral hypermobility and cystoceles on VCUG compared with supine MR defecography [25]. VCUG may demonstrate opacification of urethral diverticula during the voiding phase, which can be associated with UI. In patients with suspected voiding dysfunction, VCUG may demonstrate funneling or involuntary leakage of urine during the straining phase, as well as indirect and direct findings of voiding dysfunction such as a trabeculated bladder, large postvoid bladder residual, inability to void during the examination, and urethral narrowing with or without upstream dilatation during the voiding phase. In the setting of severe voiding dysfunction, the urethra may not opacify, thus limiting evaluation.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Because VCUG is performed in the physiologic upright position and involves focused imaging of the bladder and urethra during active voiding, it may be used as the initial imaging test for evaluation of patients with urinary dysfunction when deemed necessary after appropriate clinical evaluation. The general limitation of this minimally invasive study is that it is limited to anterior compartment structures. MR Defecography MR defecography has utility in global functional and anatomic assessment of the pelvic floor, including depiction of cystoceles, location of urethrovesical junction at rest and defecation, assessment of urethral angle, urethral Pelvic Floor Dysfunction in Females hypermobility and/or kinking [50,61]. To our knowledge, there is no relevant literature regarding the utility of MR defecography specifically in patients with UI or voiding dysfunction. The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs, including the bladder and urethra, as well as urethral ligaments [37], and postoperative changes if present. MRI of the pelvis can demonstrate differences in pelvic floor musculature and bladder-neck morphology and urethrovesical angle when comparing patients with SUI, mixed UI, and continence [62]. MRI can also depict morphological alterations in the urethra, urethral ligaments, and vaginal fascia in patients with SUI [63-65]. Although MR defecography provides evaluation of all pelvic floor compartments and is not considered the initial imaging test of choice, it may be utilized for assessment of patients with urinary dysfunction in the appropriate clinical setting.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. MRI Pelvis Dynamic Maneuvers without Defecation To our knowledge, there is no relevant literature regarding the utility of MRI pelvis with dynamic maneuvers (dynamic pelvic floor MRI) specifically in patients with UI or voiding dysfunction; however, dynamic pelvic floor MRI allows for global functional and anatomic assessment of the pelvic floor, including depiction of cystoceles, location of urethrovesical junction, assessment of urethral angle, urethral hypermobility and/or kinking [50,61]. Dynamic pelvic floor MRI with straining rather than defecation demonstrates lower prevalence of prolapse in multiple compartments [12,15,26-29]. This may lower detection rates of cystoceles in patients with UI, although the clinical impact of this lower detection rate has not been reported in the literature to our knowledge. Furthermore, the inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs, including the bladder and urethra, as well as urethral ligaments [37], and postoperative changes if present. MRI of the pelvis can demonstrate differences in pelvic floor musculature and bladder-neck morphology and urethrovesical angle when comparing patients with SUI, mixed UI, and continence [62]. MRI can also depict morphological alterations in the urethra, urethral ligaments, and vaginal fascia in patients with SUI [63-65]. Although not considered the initial imaging test of choice, MR pelvis dynamic maneuvers without defecation may be utilized for assessment of patients with urinary dysfunction in the appropriate clinical setting. MRI Pelvis To our knowledge, there is no relevant literature regarding the use of MRI pelvis without defecation or straining for functional evaluation of urinary dysfunction; however, pelvic floor MRI allows for anatomic assessment of the pelvic floor, including location of urethrovesical junction, and assessment of urethral angle at rest [61].


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs, including the bladder and urethra, as well as urethral ligaments [37], and postoperative changes if present. MRI of the pelvis can demonstrate differences in pelvic floor musculature and bladder-neck morphology and urethrovesical angle when comparing patients with SUI, mixed UI, and continence [62]. MRI can also depict morphological alterations in the urethra, urethral ligaments, and vaginal fascia in patients with SUI [63-65]. Routine MRI of the pelvis with IV contrast may be preferred over MR defecography or MRI pelvis dynamic maneuvers without defecation for evaluation of pelvic floor anatomy and postoperative changes only, however, is not generally used for assessment of urinary dysfunction. US Pelvis Transabdominal To our knowledge there is no relevant literature regarding the use of TAUS for functional evaluation of the urethra or bladder neck in patients with urinary dysfunction. TAUS has utility for measurement of postvoid residual bladder volume and anatomic assessment of the bladder during evaluation of patients with urinary dysfunction. US Pelvis Transperineal TPUS can be used for anatomic and functional evaluation of the pelvic floor. Images are obtained via cine loops in multiple planes during rest, strain, and Kegel maneuvers with both 2-D and 3-D imaging for anatomic and functional pelvic floor assessment. Patients may be positioned semi-upright or in the dorsal lithotomy position. Postvoid residual bladder volume can be measured, and bladder wall thickening or trabeculation can be seen. TPUS can evaluate the morphology and volume of the circular urethral rhabdosphincter muscle; muscle volume has been associated with urethral closure pressures and SUI [66]. TPUS can also assess for anatomic abnormalities that can cause a bulge in the anterior vaginal wall, such as a urethral diverticulum, vaginal wall cyst, or mass [67].


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. TPUS can assess for urethral and bladder-neck mobility and urethral funneling in real time during maximal strain or Valsalva [54,59,68]; however, in contrast to VCUG, TPUS does not assess the bladder or urethra during active voiding. In addition to bladder-neck mobility and postvoid residual, TPUS may have utility in predicting response to treatment in patients with SUI with urethral sling placement based on preoperative measurement of pubourethral Pelvic Floor Dysfunction in Females distance and angle [69]. Although not the initial imaging test of choice, it may be used for assessment of urinary dysfunction in the appropriate clinical setting. US Pelvis Transrectal A few studies have reported the use of TRUS for assessment of the bladder neck and urethra in patients with SUI; however, these studies are dated [70-73]. To our knowledge, there is no relevant literature comparing TRUS to TPUS or TVUS for evaluation of patients with urinary dysfunction and no recent literature to support its use for evaluation of female patients with urinary dysfunction. US Pelvis Transvaginal To our knowledge, there is no relevant literature regarding the use of TVUS for functional evaluation of patients with urinary dysfunction; however, TVUS can be used to assess for anatomic abnormalities (other than a cystocele) causing a bulge in the anterior vaginal wall, such as a urethral diverticulum, vaginal wall cyst, or mass [67]. It can also be used to assess postvoid residual bladder volume and bladder wall thickness. Bladder wall thickness on TVUS has been shown to correlate with results of urodynamic testing in patients with voiding dysfunction [74]. TVUS can evaluate the morphology and volume of the circular urethral rhabdosphincter muscle; muscle volume has been associated with urethral closure pressures and SUI [66].


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Patients with SUI demonstrate thinner urethral rhabdosphincter muscles than continent patients [75], and urethral sphincter volume on preoperatively TVUS can predict surgical outcomes [76]. 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. Defecatory dysfunction may result from either structural or functional etiologies. Obstructed defecation is suspected in patients who have difficulty defecating and may require excessive straining or manual pressure for evacuation. Mechanical or structural etiologies include rectocele, enterocele, sigmoidocele, rectal intussusception, or rectal prolapse, whereas anatomically normal patients may have disordered defecation due to functional dyssynergia. Patients are assessed clinically with a digital rectal examination, anal manometry, and balloon expulsion test [77]. Imaging may be obtained for further evaluation, particularly in patients with discordant findings on manometry and the balloon expulsion test [78-80]. Imaging may also be obtained to either confirm clinically suspected or exclude occult structural or functional abnormalities such as rectal prolapse, excessive perineal descent, rectal intussusception, or pelvic floor dyssynergia, and to differentiate rectocele from cul-de-sac hernia in the posterior compartment. Finally, patients with fecal incontinence may present with anal sphincter abnormalities, and preoperative imaging may be obtained for surgical planning. Imaging may also be indicated in patients who present with persistent or recurrent defecatory dysfunction after attempted surgical or nonsurgical treatments. CT Pelvis To our knowledge, there is no relevant literature regarding the use of CT for functional assessment of defecatory dysfunction.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. CT may depict masses or other anatomic conditions in the pelvic floor at rest that may result in obstructed defecation or fecal incontinence; however, CT is not a test of choice for evaluation of anal sphincter defects. Fluoroscopy Cystocolpoproctography Fluoroscopic CCP is one of the initial imaging tests of choice for evaluation of defecatory dysfunction and augments the clinical examination by revealing clinically occult sigmoidoceles, enteroceles, and rectoanal intussusceptions, which can be present in isolation or in combination with other abnormalities [81,82]. The detection of these diagnoses on defecography has been shown to alter or clarify the initial clinical assessment in a significant percentage of patients with constipation [83]. Approximately one-third of patients with bulging of the posterior vaginal wall have been shown to have enteroceles or sigmoidoceles [11]. Opacification of small bowel with oral contrast allows for easier detection of enteroceles. A significant proportion of enteroceles may be seen only upon complete rectal emptying or on postdefecation strain images [11], because rectal or bladder distention with contrast may prevent the peritoneal sac from herniating into the rectovaginal space [22]. CCP can also be used to assess for presence and size of rectocele and to evaluate for contrast material retention within rectoceles. CCP may be obtained in patients with suspected dyssynergic defecation. Unlike manometry and the balloon expulsion test, defecography directly images the process of rectal evacuation and may identify associated structural abnormalities in the pelvic floor. Failed or prolonged evacuation of contrast on CCP is sensitive and specific for Pelvic Floor Dysfunction in Females diagnosing dyssynergia [84]. However, a meta-analysis demonstrated lower prevalence of findings of dyssynergic defecation on CCP compared with the balloon expulsion test and anal manometry [80].


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. CCP demonstrates good agreement with surgical findings for detection of full-thickness rectal prolapse, posterior colopocele, rectocele, and peritoneocele, and excellent correlation for detection of internal rectal prolapse (intrarectal and intra-anal). Relative to surgical findings, sensitivities of CCP for detection of internal rectal prolapse and peritoneocele are 88% and 83%, respectively [23], whereas comparisons to physical examination demonstrate sensitivity of CCP for detection of rectoceles and enteroceles to be 94% and 35%, respectively. Nonetheless, physical examination only detected 7% of rectoceles and 51% of enteroceles seen in CCP in that study [11]. Thus, CCP may detect rectoceles or enteroceles that are clinically occult. In patients with fecal incontinence, anorectal angle measured on CCP has been shown to correlate with severity of fecal incontinence [85]. Fluoroscopy Voiding Cystourethrography To our knowledge, there is no relevant literature to support the use of VCUG in assessment of patients with defecatory dysfunction. MR Defecography MR defecography with rectal contrast is one of the initial imaging tests of choice for evaluation of patients with defecatory dysfunction. The inherent high soft-tissue contrast resolution of MRI allows for direct visualization of pelvic organs, pelvic floor muscles and fascia, and associated anatomic abnormalities or masses that may cause rectal obstruction or incontinence. MR defecography can confirm suspected structural and functional abnormalities in patients with defecatory dysfunction such as rectal intussusception or prolapse, rectocele, and pelvic floor dyssynergia. Findings of pelvic floor dyssynergia on MR defecography include impaired evacuation, abnormal anorectal angle change, and paradoxical sphincter contraction [86].


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. MR defecography can also add clinical benefit in patients with rectal disorders by revealing additional clinically occult abnormalities such as enteroceles that alter patient management [35,87,88]. A study by Rentsch et al [36] demonstrated that, in patients with posterior compartment symptoms and defecatory dysfunction, MR defecography demonstrated multifocal defects in a significant number of patients and revealed defects in addition to clinical diagnoses in 34% of cases. Use of rectal contrast and imaging during defecation are particularly important when performing MR defecography for assessment of defecatory dysfunction [89]. Multiple studies have demonstrated the added benefit of MRI with rectal contrast and the defecation phase for assessment of POP compared with dynamic straining MRI without rectal contrast or defecation [15,26-29]. Although upright MR defecography may be preferred over supine MR defecography for evaluation of defecatory dysfunction, most centers lack an open magnet to allow imaging in upright position. Studies comparing MR defecography in supine position to that in upright position have shown variable results, with some reporting that MR defecography in supine positioning may underestimate detection and size of rectal intussusception and rectocele [30,31], whereas others [32] demonstrate no significant difference in prevalence of anorectal descent during defecation when comparing the two positions. Regardless of positioning, patients should be asked to perform repeated strain/defecation maneuvers to maximize pelvic floor dysfunction seen on MRI [33]. MR defecography in patients with fecal incontinence reveals excessive perineal descent, rectoceles, and rectal intussusceptions, which can alter surgical management [90]. MR defecography has moderate to good correlation with surgical findings for diagnosis of full thickness rectal prolapse, internal rectal prolapse, posterior colopocele, rectocele, and peritoneocele [23].


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. [23][23]MR defecography agrees with physical examination in 79% of cases of clinically significant posterior compartment prolapse and, in one study, detected 45% of cases of enteroceles seen on physical examination; however, physical examination only demonstrated 30% of enteroceles seen on MR defecography and also misdiagnosed 10% of enteroceles seen as rectoceles. Thus, MR defecography is beneficial in detecting or characterizing enteroceles as cause of posterior vaginal bulge [34]. Cul-de-sac hernias such as enteroceles are best seen at the end of the defecation acquisition upon complete rectal emptying. This may require multiple defecation attempts and/or additional imaging with maximal Valsalva after complete rectal emptying. Additional utility of MR defecography lies in its ability to demonstrate often unsuspected pelvic floor abnormalities in other compartments. Pelvic Floor Dysfunction in Females MRI Pelvis Dynamic Maneuvers without Defecation Use of rectal contrast and imaging during defecation are particularly important when performing MRI for assessment of defecatory dysfunction [89]. Multiple studies have demonstrated the added benefit of MRI with rectal contrast and the defecation phase for assessment of POP compared with dynamic straining MRI without rectal contrast or defecation [15,26-29]. Thus, the utility of MRI pelvis with dynamic maneuvers (dynamic pelvic floor MRI) to demonstrate functional abnormalities or occult multicompartment defects in the setting of defecatory dysfunction is relatively limited when compared with MR defecography. The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation by direct visualization of the pelvic organs and pelvic floor muscles and fascia. Pelvic masses that may cause rectal obstruction would be well seen on MRI. Levator muscle defects may be well depicted in patients with fecal incontinence.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. MRI Pelvis To our knowledge, there is no relevant literature to support the use of MRI pelvis without defecation or straining for functional evaluation of patients with defecatory dysfunction who are medically able to participate in dynamic imaging exams. MRI pelvis either without or with IV contrast may be used for anatomic evaluation of the pelvic organs and pelvic floor. Pelvic masses that may cause rectal obstruction would be well seen on MRI. Levator muscle defects may be well depicted in patients with fecal incontinence. Muscle thickness is measured reliably on external phased array MRI [41]. US Pelvis Transabdominal To our knowledge, there is no relevant literature to support the use of TAUS for assessment of defecatory dysfunction. US Pelvis Transperineal TPUS images are obtained via cine loops in multiple planes during rest, strain, and Kegel maneuvers with both 2- D and 3-D imaging for anatomic and functional pelvic floor assessment. Patients may be positioned semi-upright or in the dorsal lithotomy position. In a study by Beer-Gabel et al [53], dynamic TPUS showed concordance with CCP for presence of enteroceles in patients with defecatory dysfunction; however, it was discordant with regard to the contents and size of the cul-de-sac hernia in 45% of cases. There was variable agreement for demonstration of rectoceles, descending perineum syndrome, and rectal prolapse [53]. A study by Steensma et al [52] showed that TPUS had moderate to good correlation with CCP for detection of enterocele and rectocele. Another study in patients with defecatory disorders demonstrated that, although translabial US had high positive predictive value for rectocele and rectal intussusception, negative predictive value was low and there was poor agreement with CCP [51]. TPUS may be obtained for anatomic evaluation of patients with high suspicion of levator muscle defects based on clinical evaluation.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. To our knowledge, there is no relevant literature comparing the utility of TPUS for defecatory dysfunction to physical examination. US Pelvis Transrectal TRUS is the primary imaging method for anatomic evaluation of the internal and external anal sphincters and adds to the clinical examination and manometry in patients with fecal incontinence [20,91-93]. It has high correlation with surgical and histologic findings [94]. Interobserver agreement is good when evaluating sphincter defects [95] and is better for internal versus external sphincter when measuring muscle thickness [41]. The thickness of the internal anal sphincter is also slightly greater on TVUS compared with TRUS as the anal canal is collapsed. Three- dimensional US provides multiplanar images allowing visualization of the levator ani muscle and measurement of sphincter tear lengths [96]. However, it is not an established method for assessing external anal sphincter atrophy [97,98]. TRUS may be obtained for anatomic evaluation of patients with high suspicion of anal sphincter defects based on clinical evaluation as a complementary test to fluoroscopic CCP or MR defecography, which are the imaging tests of choice for functional evaluation of patients with defecatory dysfunction. US Pelvis Transvaginal TVUS may be an alternative to endoanal US for anatomic evaluation of sphincter defects, albeit with some limitations and challenges [99]. To our knowledge, there is no relevant literature comparing the utility of TVUS to physical examination, fluoroscopic CCP, or MR defecography for assessment of defecatory dysfunction. Pelvic Floor Dysfunction in Females Variant 4: Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. This variant focuses on initial imaging evaluation of patients with subacute or chronic complications of pelvic floor repair, often with biological or synthetic graft materials, rather than acute perioperative complications, recurrent prolapse or other recurrent pelvic floor dysfunction. Imaging for evaluation of recurrent prolapse or other recurrent pelvic floor dysfunction follows the same appropriateness criteria as for primary pelvic floor dysfunction in Variants 1 thru 3 described above. Imaging can complement clinical evaluation in patients that present with subacute or chronic complications after pelvic floor surgery [100]. Evaluation may be complicated by multiple prior procedures with limited access to previous surgical details. The lifetime risk of undergoing a surgical procedure for POP or UI in the US is 11%, and the reoperation rate is as high as 29% [7]. Reconstructive surgical treatments for POP or UI include primary surgical repair of native tissues, repair with biologic or absorbable grafts, placement of synthetic implants such as urethral slings, vaginal mesh or bulking agents, and vaginal wall or bladder-neck suspension procedures. Potential subacute or chronic complications of POP repair with mesh material include contraction or shrinkage, mesh exposure through a mucosal surface, or mesh extrusion out of the body cavity [101-104]. Patients may thus present with pelvic or groin pain, infection, voiding dysfunction, or pain/dyspareunia due to improper positioning or migration of synthetic materials or from excessive scarring. Functional complications of pelvic floor surgery include devascularization and denervation leading to voiding dysfunction, persistent pain, and dyspareunia [105,106].


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. CT Pelvis Although CT may be used for the evaluation of patients that present with acute complications after surgical repair, to our knowledge, there is no relevant literature that supports use of CT for routine assessment or initial imaging of patients with subacute or chronic complications of pelvic floor repair. CT can demonstrate certain urethral bulking agents (when calcified), retropubic arms and bone anchors of urethral slings, and sacrocolpopexy mesh as it courses from the vaginal apex to the sacral promontory [100,107]; however, the poor inherent soft-tissue resolution of CT makes visualization of synthetic materials challenging compared with MRI. The synthetic materials along the anterior and posterior vaginal walls are also not depicted well on CT. Fluoroscopy Voiding Cystourethrography VCUG can be used as an objective measure of change in cystocele height and urethral angle after surgical repair [14]. Although VCUG can be used to assess for urinary dysfunction in the postoperative setting, it is not able to directly depict pelvic floor musculofascial structures. Patients that present with new voiding dysfunction or chronic urinary tract infections after surgery may be assessed with VCUG. In the setting of severe voiding dysfunction, the urethra may not opacify, thus limiting evaluation. In other cases, there may be narrowing of the voiding urethra, a secondary sign to suggest urethral obstruction due to implanted sling or other material. Indirect findings of voiding dysfunction, such as a trabeculated bladder, and large postvoid bladder residual may be seen. In most cases, other anatomic changes after surgery, including implanted surgical material, may not be directly visible on fluoroscopy. MRI Defecography MR defecography includes both an anatomic and functional evaluation of the pelvic floor. It is used to evaluate patients with suspected postsurgical complications if there is concomitant concern for persistent recurrent POP or other pelvic floor dysfunction.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs and structural changes after surgery [37,40,108]. In addition to changes in native anatomy, MRI is able to visualize implanted synthetic material including urethral bulking agents, midurethral slings, and different types of vaginal mesh and their complications, although scar tissue may appear similar to sling and mesh components and can confound evaluation [107]. Although there are no studies evaluating the utility of gadolinium IV contrast after surgical repair in the pelvic floor, certain complications such as collections or fistula may be better depicted with contrast as is the case in other parts of the body. MR defecography is generally performed without IV contrast may thus be limited compared with MRI pelvis with IV contrast for this indication. Pelvic Floor Dysfunction in Females Furthermore, functional evaluation with the defecography component of the examination would only be indicated if there is concern for recurrent prolapse, urinary incontinence, or defecatory dysfunction. MRI Pelvis Dynamic Maneuvers without Defecation MRI pelvis with dynamic maneuvers (dynamic pelvic floor MRI) includes both anatomic and functional evaluation of the pelvic floor and, similar to MR defecography, can be performed in postsurgical patients with subacute or chronic complications only if there is suspicion for persistent or recurrent prolapse or other pelvic floor dysfunction. The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs and structural changes after surgery [37,40,108]. In addition to changes in native anatomy, MRI is able to visualize implanted synthetic material including urethral bulking agents, midurethral slings, and different types of vaginal mesh and their complications, although scar tissue may appear similar to sling and mesh components and can confound evaluation [107].


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Although there are no studies evaluating the utility of gadolinium IV contrast after surgical repair in the pelvic floor, certain complications such as collections or fistula are better depicted after contrast, as is the case in other parts of the body. Dynamic pelvic floor MRI is generally performed without gadolinium IV contrast, which may be limited compared with MRI pelvis with IV contrast for this indication. Furthermore, functional evaluation with dynamic maneuvers would only be indicated if there is concern for recurrent prolapse, urinary incontinence, or defecatory dysfunction MRI Pelvis MRI of the pelvis with gadolinium IV contrast is often used as an initial test for patients with subacute or chronic complications after pelvic floor repair. The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs and structural changes after surgery [37,40,108]. In addition to changes in native anatomy, MRI depicts implanted synthetic material including urethral bulking agents, midurethral slings, and different types of vaginal mesh and their complications, although scar tissue may appear similar to sling and mesh components and can confound evaluation [107]. MRI can depict volume and configuration of urethral bulking agent; however, it may not be predictive of clinical outcome [109]. MRI allows for evaluation of urethral slings in the retropubic space better than US, whereas US allows for evaluation in the sub/peri-urethral space [110]. Components of routinely available polypropylene vaginal mesh can typically be seen on T2-weighted MRI. MRI can also assess the integrity of sacrocolpopexy mesh and associated complications such as presacral hematomas, bowel or bladder injury, peritoneal inclusion cyst formation, mesh infection, or discitis/osteomyelitis at the sacral promontory [100,111].