Table 9.

Evidence table for the evaluation of prolapse in women with symptoms of obstructed defecation and anal incontinence

Reference	Study design	Population	Method(s) of clinical assessment	Results						Discussion
Fluoroscopic defecography
Kelvin et al. [111]	Retrospective cohort study, USA	n=170 consecutive women with symptoms of pelvic floor dysfunction referred for dynamic cystoproctography	BW ±POP-Q	Only 74% POP-Q—POP-Q not used for analysis						Descriptive study showing that cystoceles and rectoceles are similarly diagnosed by both BW and DCP, but more enteroceles diagnosed by examination
				Findings on BW vs DCP
						BW	DCP	Both
				Rectocele		91%	76%	70%
				Enterocele		40%	28%	14%
			DCP	Cystocele		81%	94%	78%
Kaufman et al. [112]	Retrospective descriptive cohort study, USA	n=22 women with symptomatic prolapse went on to pelvic reconstructive surgery	Questionnaires	86% had previous pelvic surgery						Low concordance of findings between modalities
				41% patients had a change in surgical plan owing to imaging results
				POP-Q vs DCCP vs dMRI
						POP-Q	DCCP	dMRI
				Cystocele		68%	45%	41%
				Rectocele		86%	82%	50%
			Physical examination, POP-Q	Enterocele		36%	41%	36%
			DCCP	Sigmoidocele		0%	9%	0%
			Had defecography phase	Levator ani defect		0%	0%	18%		Levator ani defects only diagnosed by dMRI
			dMRI	Internal rectal prolapse		9%	45%	0%		Sigmoidocele only diagnosed by DCCP
			No defecography phase	Full-thickness rectal prolapse		9%	0%	0%		Lack of defecography phase during MRI likely contributes to findings
Lopez et al. [113]	Prospective cohort study, Sweden	n=25 women with POP on clinical examination planning to undergo surgery	Clinical examination (no POP-Q or BW)	No statistical analysis						Descriptive study suggesting CDP might contribute to characterization of prolapse, but limited by lack of use of either POP-Q or BW and small numbers
				Pre-operatively: cystocele on clinical examination vs CDP 28% vs 88%
			Questionnaires	Pre-operatively: rectocele on clinical examination vs CDP 96% vs 84%
			CDP	Enterocele on clinical examination vs CDP 8% vs 24%						CDP may be helpful in diagnosing enteroceles
Takano and Hamada [114]	Prospective cohort, Japan	n=66, which included 55 female patients, 11 male patients	Clinical examination (no POP-Q or BW)	No statistical analysis						Descriptive study limited by lack of statistical analysis, lack of POP-Q or BW, mixed sex population, and lack of defecography phase
				75% of patients with symptoms of vaginal prolapse showed descent of the vagina on DCR
			DCR: opacification of the ileum, bladder, vagina, rectum, and perineum	78% of patients with uterine descent had an enlarged angle between the vaginal axis and horizontal line at the superior border of the sacrum on DCR
			No defecography phase	*68% of patients with symptoms of descent of the rectum or obstructed defecation had descent of the rectum on DCR
		Symptoms of prolapse, defecatory dysfunction, incontinence NOS		*Female + male						Study does not demonstrate benefit of DCR
Roovers et al. [115]	Prospective cohort study, The Netherlands	n=82 women with symptomatic stage II or greater prolapse, planned for surgery	Physical examination, POP-Q	Abnormal defecography was defined as presence of an enterocele, rectal intussusception, or both						Applying the proposed scoring system may predict the probability that an enterocele or rectal intussusception is found; for scores >1 and <8, defecography may be more useful i.e., for patients with some predictive factors but not others, imaging may add to clinical assessment
				Abnormal= 32%
				Enterocele = 28%
				Rectal intussusception 11%
				Both = 7%
				History of pelvic surgery, size of the posterior vaginal wall prolapse, and the presence of constipation predicted abnormal defecography (i.e., enterocele, rectal intussusception)
				Used to create a formula to predict probability = 3+3 × history of pelvic surgery* + Ap (in cm) +3 × constipation*
			Questionnaires (standardized)	*Present = 1, absent = 0
			Fluoroscopic defecography with vaginal also opacified	Patients with probability less than 20% (score ≤1) or greater than 70% (score ≥8) of abnormal defecation do not get additional information from this study
Groenendijk et al. [116]	Prospective cohort study, The Netherlands	n=59, women with primary pelvic organ prolapse: 68 enrolled; 5 dropped out; 4 defecography incorrectly performed	Physical examination, POP-Q	No significant relationship was found between defecatory symptoms and presence of posterior vaginal wall prolapse on examination (p=0.33), rectocele (n=0.19), or enterocele (n=0.99) on defecography						Clinical examination may overestimate posterior vaginal wall prolapse and underestimate enterocele
			DDI
			Fluoroscopic defecography with vagina also opacified	Clinical examination diagnosis of a rectocele compared with defecography
				Sensitivity 1.0, 95% CI 0.82 to 1
				Specificity 0.23 95% CI −0.11 to 0.38
				Clinical examination diagnosis of enterocele compared with defecography
				Sensitivity 0.07, 95% CI 0.002 to 0.32
				Specificity 0.95, 95% CI 0.85 to 0.99						No correlation of bowel symptoms with posterior wall prolapse on examination or rectocele or enterocele on defecography
Kim et al. [117]	Prospective cohort, South Korea	n=109	Physical examination, POP-Q	Physical examination did not diagnose enterocele, sigmoidocele, or RI						Clinical examination misses enteroceles, sigmoidoceles, and rectal intussusception found by DCCP
				The surgical plan changed in 22% of cases
				Patients with a changed surgical plan had a higher prevalence of bowel symptoms (p=0.023
				Findings on examination vs DCCP
					Examination	DCCP		Total	p value
						Negative	Positive
				Cystocele total	Negative	20	10	30	<0.001
						0	79	79
					Positive	20	89	109
		113 enrolled		Rectocele total	Negative	27	32	59	<0.001
						0		50
					Positive	27	5,820	109
		4 dropped out		RI total	Negative	101	8	109
						0	0	0
					Positive	101	8	109
		Women with stage ≥II POP and urodynamic confirmed urinary incontinence	DCCP	Enterocele total	Negative	107	2	109
						0	0	0
					Positive	107	2	109
		Without HO pelvic reconstructive surgery	Bladder and vaginal = also opacified	Sigmoidocele total	Negative	105	4	109		This may influence surgical planning
						0	0	0
					Positive	105	4	109
Vanbeckevoort et al. [118]	Prospective cohort study, Belgium	n=35 women with clinical evidence of pelvic floor descent	Clinical examination (no POP-Q or BW)	All patients underwent both imaging studies						Cystocele, vaginal vault prolapse, rectocele, enterocele, and rectal descent most readily seen on CCD with voiding and defecation phase
				Compared with MRI, CCD II diagnoses additional defects:
				Cystocele = 14
				Vaginal vault prolapse = 20
				Enterocele = 4
			CCD with (CCDII) and without (CCDI) a voiding and defecation phase	Rectocele = 13
			Dynamic, single-shot MRI sequence without defecography phase	Rectal descent = 5
MR defecography
Hausammann et al. [ 119]	Prospective cohort study, Switzerland	n=37 women	BW	2/3 patients had moderate to large rectocele on MRD						Patients with a rectocele on examination may have other pelvic floor defects as well
				No significant association between size of rectocele on MRD and constipation or fecal incontinence
				67.5% of women with a rectocele had a concomitant intussusception
				Significantly more likely to have an enterocele (p=0.013)
			Symptom questionnaires (Cleveland clinic constipation score and Wexner faecal incontinence score)	Obstructed defecation symptoms did not differ between isolated rectocele and rectocele + intussusception
		Patients with rectocele and defecatory dysfunction	MRD (open)	Higher grade intussusception was associated with FI (p=0.048)
Aziz et al. [120]	Case series	n=7 patients with pelvic floor disorder symptoms and a history of cystectomy and hysterectomy referred for MRD	Physical examination	5 POP-Q stage II or III						MRD may be useful in post-cystectomy patients with vaginal bulge
				2 POP-Q stage 0
				MRD findings:
			POP-Q	4 patients = anterior enterocele (small bowel), moderate
			MRD	3 patients = anterior sigmoidocele, moderate						Study limited by very specific population
Pollock et al. [121]	Retrospective cohort study,	n=54 women	Physical examination	Symptoms						MRD not significantly correlated with BW
				96% bothersome POP
				Spearman correlation coefficient between MRD grading compared with examination
						Overall		Anterior wall
		170 patients with POP screened	POP-Q or BW	BW		rho −0.001; p=0.998		rho 0.197; p=0.154		Overall POP-Q stage and anterior wall correlated positively and significantly with MRD
		116 excluded because of incomplete examination or MRD information	MRD	POP-Q		rho 0.305; p=0.025		rho 0.436; p=0.001		MRD may provide different information than clinical examination, particularly BW staging
Lin et al. [122] (same group as Pollock et al. [121])	Retrospective cohort study, USA	n=178	Physical examination, BW	Patients with POP specifically not reported						MRD may provide additional information on the presence of an enterocele
				Physical examination compared with MRD for enterocele detection
				Sensitivity 0.300, specificity 0.926						Anterior wall had the best correlation between examination and MRD
				Spearman correlation coefficient between MRD grading and BW grading				Agreement between BW grade 3,4 and MRD moderate to severe		Findings impacted by how MRD grading is defined
				Anterior		rho=0.652, moderate positive		84.6%
		274 patients with POP or other pelvic floor disorder underwent MRD		Apical		rho=0.195, poor		63%
		96 excluded for male sex, incomplete examination or MRD, inability to defecate rectal gel	MRD	Posterior		rho=0.277, poor		78.7%
Arif-Tiwari et al. [123] (same group as Lin et al. [122] and Pollock et al. above [121])	Retrospective cohort study, USA	n=237	Dynamic MR with Valsalva only vs defecography phase	56% prior surgery for POP or UI Vaginal prolapse 22.8%						Suggests that dynamic MRI for patients with POP should include defecography phase
				67.4% prior hysterectomy
				0% prolapse detected by Valsalva only but not defecography phase
				Percentage POP detected by defecography phase but not Valsalva only:
				Cystocele 37.6%
				Rectocele 25.7%
		274 with symptoms of POP		p<0.0001
		37 patients excluded for male sex or inability to tolerate or defecate rectal gel	No physical examination data
Faucheron et al. [124]	Prospective cohort study, France	n=50 patients with posterior vaginal wall prolapse who ultimately had surgical repair	Physical examination	Peritoneocele						MRD and DCCP had good interobserver agreement for rectocele and posterior colpocele
				DCCP
				Sensitivity 0.833; specificity 1.000
			POP-Q	MRD
			DCCP	Sensitivity 0.633, specificity 1.000
			MRD	Detection of defects and interobserver agreement of findings at surgery and radiographic findings
			Findings at surgery		DCCP		MRD
			Studies undergone by all patients but not reported on:	Posterior colpocele	89%; kappa=0.69, good		91%; kappa=0.76, good
			Colonic transit time study	Rectocele	91%; kappa=0.69, good		93%; kappa=0.79, good
			Anal manometry	Peritoneocele	87%; kappa=0.72, good		76%; kappa=0.54, moderate
			Endoanal US	Full-thickness rectal prolapse	95%; kappa=0.80, good		91%; kappa=0.56, moderate
			Colonoscopy	Internal rectal prolapse	93%; kappa=0.85, excellent		87%; kappa=0.69, good			DCCP was better at detecting peritoneocele, full-thickness, and internal rectal prolapse, possibly because of more physiological positioning for DCP
Lienemann et al. [125]	Case–control study, Germany	n=66	Physical examination	Diagnosis of enterocele	Examination		MR-CCRG			MR-CCRG was better than DCP at diagnosing enteroceles
				Present	43		53
				Absent	12		2
				Diagnosis of enterocele	Examination		DCP
				Present	23		14
				Absent	11		20
				Diagnosis of enterocele	MR-CCRG		DCP
		55 patients with POP	DCP	Present	29		14
		11 controls without POP	MR-CCRG	Absent	5		20			MR-CCRG detected enteroceles missed on examination
Anal physiology testing
Groenendijk et al. [126]	Prospective cohort study, The Netherlands	n=59 women with primary POP stage ≥II	Symptom questionnaire (defecation distress inventory)	Patients with POP vs health controls reference values						AFT and AES add limited information to the routine evaluation of POP patients.
				Lower squeezing pressure
				Delayed first sensation, desire, capacity
				Prolonged PNTLT
				p<0.01
		68 enrolled	POP-Q	Patients with FI had significantly lower resting (p=0.036) and squeezing pressures (p=0.046) and increased risk of external sphincter defect
		4 dropped out	AFT: manometry, sensation, PNTLT	OR= 12.75; 95% CI 2.40–66.67
		5 had testing done incorrectly	AES	Manometry was not different between patients with and without constipation
				Anorectal sensation and sensitivity were not related to the stage of posterior wall prolapse						Patients with fecal incontinence may benefit from this testing
Zbar et al. [127]	Prospective cohort study, UK	n=73 women (14 isolated rectocele aka type 1, 26 rectocele and apical POP aka type 2, 33 controls)	BW	All patients with rectocele had this finding on examination and defecography						There are few consistent, differences in anal physiology between isolated rectoceles and those associated with other prolapse
				Reduced resting and squeeze pressure in type 2 rectoceles
				p<0.001
				Elevated resting pressure in type 1 rectocele
				p<0.001
				But squeeze pressure not significantly different
				Reduced inhibitory slope in RAIR measurements in both rectocele types compared with controls (type 1 p<0.001, type 2 p=0.002)
			Defecography	Maximum inhibitory pressure lower in type 1
			Anorectal manometry, vector manometry, parametric assessment of the rectoanal inhibitory reflex	n=0.006

BW Baden–Walker prolapse grading system, POP-Q Pelvic Organ Prolapse Quantification, DCP dynamic cystoproctography, DCCP dynamic cystocolpoproctography, dMRI dynamic magnetic resonance imaging, CDP cystodefecoperitoneography, NOS not otherwise specified, DCR dynamic contrast roentgenography, DDI defecation distress inventory, HO heterotopic ossification, CCD colpocystodefecography, MRD magnetic resonance defecography, FI fetal incontinence, MR-CCRG magnetic resonance colpocystorectography, PNTLT pudendal nerve terminal latency time, AFT anorectal function testing, AES anal endosonography, RAIR renoanal inhibitory index