Seminars in Colon and Rectal Surgery 27 (2016) 514

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Seminars in Colon and Rectal Surgery

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Pelvic oor anatomy and imaging

Giulio A. Santoro, MD, PhDa,n, Abdul H. Sultan, MB ChB, MD, FRCOGb
a
Head Pelvic Floor Unit, Department of Surgery, Regional Hospital, Piazzale Ospedale 1, Treviso 31100, Italy
b
Croydon University Hospital, Surrey, UK

a b s t r a c t

The pelvic oor is a complex, three-dimensional mechanical apparatus that consists of several components:
the pelvic organs and endopelvic fascia, the ligament and perineal membrane, the levator ani muscles and
supercial perineal muscles, and the pelvic nerves. The support for the pelvic organs comes from connections
to the bony pelvis and its attached muscles. Any damage to the structural and functional interactions of the
pelvic oor elements can potentially cause multicompartmental dysfunction. Surgical management of pelvic
oor disorders depends on a comprehensive understanding of the structural integrity and function of the
pelvic oor. As a result of technological progress, dedicated imaging modalities including static and dynamic
3D and 4D transvaginal, endoanal and transperineal ultrasound, dynamic Magnetic Resonance, and
evacuation proctography have been introduced. The integrated use of these techniques provides outstanding
visualization of the anatomy of the pelvic oor, allowing for accurate assessment of the major disorders
urinary and fecal incontinence, pelvic organ prolapse, and obstructed defecation syndrome.
& 2016 Elsevier Inc. All rights reserved.

Introduction only one compartment, 95% of these have abnormalities in all

The pelvic oor is a complex, three-dimensional (3D) mechan-
ical apparatus that has been articially divided into three different
regions (anterior, middle, and posterior compartments). In this
article, the term pelvic oor is used broadly to include all the
structures supporting the pelvic cavity rather than the restricted
use of this term to refer to the levator ani group of muscles.
The pelvic oor consists of several components lying between
the peritoneum and the vulvar skin. From above downwards, these
are the peritoneum, pelvic viscera and endopelvic fascia, levator
ani muscles, perineal membrane, and supercial genital muscles.
The support for all these structures comes from connections to the
bony pelvis and its attached muscles. The pelvic organs are often
thought of as being supported by the pelvic oor, but in reality
form part of it. The pelvic viscera play an important role in forming
the pelvic oor through their connections with structures, such as
the cardinal and uterosacral ligaments and are attached to the
levator ani muscles when they pass through the urogenital hiatus.
As a consequence, any dysfunction of the structural and functional
interactions of the pelvic oor elements can potentially cause a
multicompartmental disorder.1 Although patients may present
with symptoms (urinary incontinence, voiding dysfuntion, fecal
incontinence, obstructed defecation, and dyssynergy) that involve
n
Corresponding author.
E-mail address: giulioasantoro@yahoo.com (G.A. Santoro).
three compartments.2 Therefore, the specialist (urologist, gynecol-
ogist, gastroenterologist, colorectal surgeon, or physical therapist)
needs to appreciate that as pelvic oor disorders rarely occur in
isolation, evaluation and surgery can impact on the function of the
neighboring compartment.3,4
Diagnostic evaluation has a fundamental role to identify all
pelvic oor disorders and to provide comprehensive information
for a management that encompasses the consequences of therapy
on adjacent organs and avoid sequential surgery. The increasing
availability of ultrasound equipment in the clinical setting, and the
recent development of 3D and 4D ultrasound, have renewed
interest in using this modality to image pelvic oor anatomy as a
key to understanding dysfunction.5 The integrated approach, by
using a combination of different modalities (endovaginal ultra-
soundEVUS, endoanal ultrasoundEAUS, and transperineal
ultrasoundTPUS) provides a comprehensive evaluation of this
region.5 In this article, we will also present the advantages and
limitations of other imaging modalities such as evacuation proc-
tography and dynamic magnetic resonance imaging (MRI).
Pelvic oor anatomy
The pelvic organ support system includes the endopelvic fascia,
the perineal membrane, and the levator ani muscles that are
controlled by the central and peripheral nervous system. The
supports of the uterus and vagina are different in different regions.

http://dx.doi.org/10.1053/j.scrs.2015.12.003
1043-1489/& 2016 Elsevier Inc. All rights reserved.
6 G.A. Santoro, A.H. Sultan / Seminars in Colon and Rectal Surgery 27 (2016) 514
Fig. 1. Levels of vaginal support according to DeLancey. In level I (suspension) the
uterosacral and cardinal ligaments suspend the vagina from the lateral pelvic walls.
In level II (attachment) the vagina is attached to the arcus tendineus fasciae pelvis
and the superior fascia of levator ani by the pubocervical (PCF) and rectovaginal
fascia (RVF). In level III (distal support) the vagina is attached directly to the
perineal body (PB) and the perineal mambrane.
According to DeLancey,6 the cervix and the upper one-third of the
vagina (level I) have relatively long suspensory bers (uterosacral
and cardinal ligaments) that are vertically oriented in the standing
position, while the mid portion of the vagina (level II) has a more
direct attachment (pubocervical and rectovaginal fascia) laterally
to the pelvic wall. In the most caudal region (level III), the vagina is
attached directly to the structures that surround it (Fig. 1). At this
level, the levator ani muscles and the perineal membrane have
important supportive functions.
In the upper part of the genital tract, a connective tissue
complex attaches all the pelvic viscera to the pelvic sidewall. This
endopelvic fascia forms a continuous sheet-like mesentery,
extending from the uterine artery at its cephalic margin to the
point at which the vagina fuses with the levator ani muscles
below. The uterosacral and cardinal ligaments together support
the uterus and upper one-third of the vagina.6 At level II, the
pubocervical and rectovaginal fascia form more direct lateral
attachments of the mid portion of the vagina to the pelvic walls.
These lateral attachments stretch the vagina transversely between
the bladder and the rectum.6 In the distal vagina (level III), the
vaginal wall is directly attached to surrounding structures. Ante-
riorly, the vagina fuses with the urethra, posteriorly with the
perineal body, and laterally with the levator ani muscles.6 Damage
to level I support can result in uterine or vaginal prolapse of the
apical segment. Damage to the level II and III portions of vaginal
support results in anterior and posterior vaginal wall prolapse.3,4
The varying combinations of these defects are responsible for the
diversity of clinically encountered problems and will be discussed
in the following sections.
Apical segment
In level I, the cardinal and uterosacral ligaments attach the
cervix and the upper one-third of the vagina to the pelvic walls
(Fig. 2). The uterosacral ligaments are bands of tissue running
under the rectovaginal peritoneum composed of smooth muscle,
loose and dense connective tissue, blood vessels, nerves, and
lymphatics.6 They originate from the posterolateral aspect of the
cervix at the level of the internal cervical os and from the lateral
vaginal fornix. The cardinal ligament is a mass of retroperitoneal
areolar connective tissue in which blood vessels predominate; it
Fig. 2. Uterosacral ligaments (USL) extend both vertically and also posteriorly
toward the sacrum (S). Cardinal ligaments (CL) suspend the cervix (CX) from the
lateral pelvic walls.
also contains nerves and lymphatic channels. When placed under
tension, it assumes the appearance of a strong cable as the bers
align along the lines of tension. It originates from the pelvic
sidewall and inserts on the uterus, cervix, and upper one-third
of the vagina. Both the uterosacral and cardinal ligaments are
critical components of level I support and provide support for the
vaginal apex following hysterectomy6 (Fig. 2). The cardinal liga-
ments are oriented in a relatively vertical axis (in the standing
posture) while the uterosacral ligaments are more dorsal in their
orientation.
The suspensory ligaments hold the uterus in position over the
levator muscles that in turn reduce the tension on the ligaments
and protect them from excessive tension.7 After a certain amount
of descent, the level I supports become taut and arrest further
cervical descent. Damage to the upper suspensory bers allows
uterine or apical segment to prolapse.8
Anterior compartment
Anterior compartment support depends on the connections of
the vagina and periurethral tissues to the muscles and fascia of the
pelvic wall via the arcus tendineus fascia pelvis. On both sides of
the pelvis, the arcus tendineus fascia pelvis is a band of connective
tissue attached at one end to the pubic bone and at the other end
to the ischium, just above the spine.
The anterior wall fascial attachments to the arcus tendineus
fascia pelvis is also dened as paravaginal fascial attachments.
Anterior vaginal wall prolapse (cystocele) can occur either because
of lateral detachment of the anterior vaginal wall at the pelvic
sidewall or as a central failure of the vaginal wall itself9 (Fig. 3).
However, if the cardinal and uterosacral ligaments fail, the upper
vaginal wall prolapses downward while the lower vagina (levels II
and III) remains supported.
Perineal membrane (urogenital diaphragm)
The perineal membrane is a dense connective tissue that
surround the urethra and close the anterior part of the pelvic
outlet. It lies at the level of the hymen and attaches the urethra,
vagina, and perineal body to the ischiopubic rami.10 The compres-
sor urethrae and urethrovaginal sphincter muscles are associated
with the cranial surface of the perineal membrane.
Posterior compartment and anal sphincters
The posterior vagina is supported by connections between the
vagina, the bony pelvis, and the levator ani muscles. The lower
one-third of the vagina is fused with the perineal body (level III)
 G.A. Santoro, A.H. Sultan / Seminars in Colon and Rectal Surgery 27 (2016) 514
Fig. 3. Anterior vaginal wall prolapse may occur for the detachment of the
pubocervical fascia from the arcus tendineous fascia pelvis (lateral defect).
that connects the perineal membranes on either side. The mid-
posterior vagina (level II) is connected to the inside of the levator
ani muscles by sheets of endopelvic fascia. These connections
prevent vaginal descent during increases in abdominal pressure.
The bers of the perineal membrane connect through the perineal
body thereby providing a layer that resists downward descent of
the rectum.11 If this attachment becomes broken, then the resist-
ance to downward descent is lost.
The muscular structures that maintain fecal continence include
the internal anal sphincter (IAS), the external anal sphincter (EAS),
and the puborectalis (PR) muscle (Fig. 4). The anal canal is 24 cm
long. The spatial relationships between the internal and external
sphincters are such that the IAS extends above the EAS for a
distance of greater than 1 cm.12 The internal sphincter lay con-
sistently between the external sphincter and the anal mucosa. It is
a circular smooth muscle that is the continuation of the circular
layer of the muscularis propria of the rectum. This layer increases
in thickness below the anorectal junction to form the IAS. The IAS
has an important role in maintaining continence and is the main
contributor to anal rest pressure. The IAS is approximately 2-mm
thick. The intersphincteric space is the plane between the sphinc-
ters containing loose areolar tissue. The longitudinal layer (con-
joined longitudinal layer or longitudinal muscle) is a sheet of
broelastic and muscular tissue. This layer is the continuation of
the smooth muscle longitudinal layer of the rectum with contri-
bution from the levator ani striated muscle (puboanalis) and
broelastic components of the endopelvic fascia. Cranially it is
Fig. 4. The muscular structures of the anal canal include the internal anal sphincter,
the external anal sphincter, and the puborectalis muscle.
7
predominantly muscular and caudally broelastic. The broelastic
tissue forms a network throughout the sphincter and passes
through the subcutaneous EAS as bundles or bers to insert into
the perianal skin.12
The inferior outer aspect of the anal sphincter is formed by the
cylindrical EAS which is a striated muscle under voluntary con-
trol.12 The action of the EAS is voluntary closure and reex closure
of the anal canal and thereby contributes to the sphincter tone to
some extent. The EAS has a thickness of 4 mm and it is approx-
imately 2.7-cm high while it is shorter anteriorly in women,
approximately 1.5 cm.
Three different parts (deep, supercial, and subcutaneous) of
the EAS can be identied at certain levels, which to some extent
supports a multilayer anatomy.12 The deep part is intimately
related to the PR muscle. The supercial part overlies the IAS at
the middle level of the anal canal. Fibers of the anterior part of the
EAS decussate into the transverse perineal muscle and perineal
body. Posterior bers continues with the anococcygeal ligament.
The subcutaneous part extends approximately 1 cm beyond the
IAS and envelops the lower part of the intersphincteric space.
Lateral compartment and the levator ani muscles
Below and surrounding the pelvic organs is the levator ani
muscle. There are three major components of the levator ani
muscle13 (Fig. 5). The iliococcygeal portion forms a thin, relatively
at, horizontal shelf that spans the potential gap from one pelvic
sidewall to the other. The pubovisceral (also known as the
pubococcygeus) muscle attaches the pelvic organs to the pubic
bone while the PR muscle forms a sling behind the rectum. The
lesser known subdivisions of the levator are pubovaginal, puboa-
nal, and the puboperineal muscles.13 When these muscles and
their covering fascia are considered together, the combined struc-
tures are referred to as the pelvic diaphragm.
The opening between the levator ani muscles through which
the urethra, vagina, and rectum pass is the levator hiatus. The
portion of the levator hiatus ventral to the perineal body is
referred to as the urogenital hiatus, and it is through this that
prolapse of the vagina, uterus, urethra, and bladder occurs. The
urogenital hiatus is bounded anteriorly by the pubic bones,
laterally by levator ani muscles, and posteriorly by the perineal
body and external anal sphincter. The baseline tonic activity of the
levator ani muscle keeps the hiatus closed by compressing the
urethra, vagina, and rectum against the pubic bone, pulling the
pelvic oor and organs in a cephalic direction. This continuous
muscle action closes the lumen of the vagina and forms a relatively
Fig. 5. Schematic view of the levator ani with its three major components: the
iliococcygeous muscle, the pubococcygeous muscle, and the puborectalis muscle.
8 G.A. Santoro, A.H. Sultan / Seminars in Colon and Rectal Surgery 27 (2016) 514
horizontal shelf on which the pelvic organs are supported. Damage
to the levators resulting from nerve or connective tissue damage
will leave the urogenital hiatus open and result in prolapse.14,15
The interaction between the levator ani muscles and the
endopelvic fascia is one of the most important biomechanical
features of pelvic organ support. As long as the muscles maintain
their constant tone closing the pelvic oor, the ligaments of the
endopelvic fascia have very little tension on them even with
increase in abdominal pressure.6 If the muscles become damaged
so that the pelvic oor sags downward, the organs are pushed
through the levator hiatus. Once they have fallen below the level of
the hymenal ring, they are unsupported by the levator ani muscles
and the ligaments must carry the entire load. Although the
endopelvic fascia can sustain these loads for short periods of time,
if the pelvic muscles do not close the urogenital hiatus, the
connective tissue eventually fails, resulting in prolapse.16 The inter-
actions between the pelvic oor muscles and endopelvic fascia are
responsible for the pelvic organs support. It requires the dorsal
traction of the uterosacral ligaments, and to some extent the cardinal
ligaments, to hold the cervix back in the hollow of the sacrum. It also
requires the ventral pull of the pubovisceral portions of the levator
ani muscle to swing the levator plate more horizontally to close the
levator hiatus. It is, therefore, this interaction between the directions
of these two forces that is so critical in maintaining the normal
structural relationships that lessen the tension on ligaments and
muscles.16,17
Nerves
There are two main nerves that supply the pelvic oor relative
to pelvic organ prolapse. One is the pudendal nerve that supplies
the urethral and anal sphincters and perineal muscles, and the
other is the nerve to the levator ani that innervates the major
musculature that supports the pelvic oor. These are distinct
nerves with differing origins, courses, and insertions. The nerve
to the levator originates from S3 to S5 foramina, runs inside of the
pelvis on the cranial surface of the levator ani muscle, and
provides the innervation to all the subdivisions of the muscle.
The pudendal nerve originates from S2 to S4 foramina and runs
through Alcock's canal which is caudal to the levator ani muscles.
The pudendal nerve has three branches: the clitoral, perineal, and
Fig. 6. 2D-transperineal ultrasound: midsagittal view showing symphysis pubis (SP), the urethra (U), bladder (B), the vagina (V), the rectum (R), the anal canal (AC), and the
puborectalis muscle (PR). (A) Schematic drawing and (B) ultrasonographic view.
inferior hemorrhoidal, which innervate the clitoris, the perineal
musculature, and inner perineal skin and the EAS, respectively.
Motor nerves to the IAS are derived from (1) L5 presacral plexus
sympathetic bers, (2) S24 parasympathetic bers of the pelvic
splanchnic nerve.
Pelvic oor imaging
The knowledge of pelvic oor anatomy and function is essential
to effective imaging of pelvic oor defects. With advancing
technology, MRI and 3D ultrasound techniques have increased
our ability to detect pelvic oor defects and helped us gain insight
into pathophysiology of pelvic oor disorders. An integrated
approach with a combination of different modalities has been
described for a global and multicompartmental perspective of
pelvic oor dysfunction.5,18,19
Ultrasonographic techniques
Transperineal ultrasonography (TPUS)
TPUS is performed with the patient placed in the dorsal
lithotomy position, with hips exed and abducted, and a convex
transducer positioned on the perineum between the mons pubis
and the anal margin (perineal approach). Imaging is performed at
rest, during maximal Valsalva maneuver, and during pelvic oor
muscle contraction (PFMC). Conventional convex transducers
(with frequencies of 36 MHz and eld of view at least 701)
provide 2D imaging of the pelvic oor.20,21 In the midsagittal
plane, with an acquisition angle of 701 or more, all anatomical
structures (bladder, urethra, vaginal walls, anal canal, and rectum)
between the posterior surface of the symphysis pubis and the
posterior part of the levator ani are visualized. A midsagittal view
obtained will include the symphysis pubis, the urethra and
bladder, the vagina and uterus, the rectum, and the anal canal
(Fig. 6). Using 3D transabdominal probes developed for obstetric
imaging (RAB 8-4, GE Healthcare Ultrasound, Milwaukee, WI; AVV
531, Hitachi Medical Systems, Tokyo, Japan; V 8-4, Philips Ultra-
sound, Bothell, WA; 3D 47EK, Medison, Seoul, South Korea), 3D-
and 4D-TPUS may be performed.22 These transducers combine an
electronic curved array of 48 MHz with mechanical sector tech-
nology, allowing fast motorized sweeps through the eld of view.
 G.A. Santoro, A.H. Sultan / Seminars in Colon and Rectal Surgery 27 (2016) 514
Fig. 7. 2D-transperineal ultrasound. Bladder (B) base descent (cystocele) below the
referral line (horizontal line to the inferior margin of the symphysis pubisSP)
during maximal Valsalva maneuver (U: urethra).
An advantage of this technique, compared with 2D mode, is the
opportunity to obtain tomographic or multislice imaging in order
to assess the entire PR muscle and its attachment to the pubic rami
and to measure the diameter and area of the levator hiatus.
Pelvic organ descent is usually assessed with 2D-TPUS.2123
Anterior compartment prolapse, or cystocele, is common in
women and may cause symptoms such as pelvic heaviness, the
sensation of a lump, and voiding difculty. Cystocele frequently
coexists with other disorders involving the central and the
posterior compartments, such as uterine prolapse, rectocele, and
enterocele. Dynamic 2D-TPUS demonstrates downward displace-
ment of the urethra and the presence of cystocele in the mid-
sagittal plane during maximal Valsalva maneuver24,25 (Fig. 7).
Ultrasonography also allows evaluation of mesh implants for
anterior compartment prolapse.26 This is particularly useful con-
sidering that complications such as support failure, mesh erosion,
and chronic pain are not uncommon. Sonographic imaging can
determine the position, extent, and mobility of implants in the
anterior vaginal wall, dorsal to the trigone and posterior to the
bladder wall. Ultrasonography also allows evaluation of tapes used
Fig. 8. 2D-transperineal ultrasound. Axial view of a transobturator tape (TOT) for stress urinary incontinence. (A) Normal positioning of the sling at midurethra level and (B)
distal displacement of the sling causing recurrence of symptoms (B: bladder and U: urethra).
9
in anti-incontinence surgery, whose improper positioning or
dislodgement may be associated with failed surgery26 (Fig. 8).
Uterine prolapse is dened as downward displacement of the
uterus beyond the halfway point of the vagina. Vaginal vault
prolapse refers to descent of the vaginal apex in a patient who
has had a hysterectomy and is commonly associated with enter-
ocele or sigmoidocele. Continued descent of the apex of the vagina
may result in complete eversion of the vagina. These conditions
are usually obvious clinically, but dynamic 2D-TPUS can demon-
strate the effect of the descending uterus on the bladder neck,
urethra, or anorectum, explaining symptoms of voiding dysfunc-
tion or obstructed defecation.
Posterior compartment prolapse includes rectocele, rectal
intussusception, rectal prolapse, enterocele, and perineal descent.
Symptoms that can be related to these disorders include
obstructed defecation, such as incomplete evacuation, straining
at stool, and vaginal digitation. Dynamic TPUS is able to demon-
strate rectocele, enterocele, and rectal intussusception with images
comparable to those of defecography.2729 Rectocele is measured
as the maximal depth of the protrusion beyond the expected
margin of the normal anterior rectal wall. A herniation of a depth
of over 10 mm has been considered diagnostic (Fig. 9). Rectal
intussusception may be detected as an invagination of the rectal
wall into the rectal lumen during maximal Valsalva maneuver. The
intussusception may also be observed to enter the anal canal or
exteriorized beyond the anal canal. Enterocele is diagnosed ultra-
sonographically as a herniation of bowel loops into the vagina. It
can be graded as small, when the most distal part descends into
the upper third of the vagina; moderate, when it descends into the
middle third of the vagina; or large, when it descends into the
lower third of the vagina. Enterocele may also coexist with
rectocele.23
Pelvic oor dyssynergy, also known as anismus, spastic pelvic
oor syndrome, or paradoxical PR syndrome, is a phenomenon
characterized by a lack of normal relaxation of the PR muscle
during defecation. Dyssynergy is associated with symptoms of
obstructed defecation and incomplete emptying. Various TPUS
abnormalities have been described during Valsalva maneuver:
the anorectal angle becomes narrower, the levator hiatus is
shortened in the anteroposterior dimension, and the PR muscle
thickens as a result of contraction. This sonographic nding may
help to choose biofeedback therapy and to evaluate the results of
the treatment.
10 G.A. Santoro, A.H. Sultan / Seminars in Colon and Rectal Surgery 27 (2016) 514

Fig. 10. 3D-endovaginal ultrasound. The levator ani (LA) is visualized as a multi-
layer hyperechoic sling coursing laterally to the vagina and posteriorly to the anal
canal (AC) and attaching to the inferior pubic rami (IPR) anteriorly (OF: obturator
foramen; SP: symphysis pubis; T: transducer; and U: urethra).

whereas tears may occur in any part of the muscle. Avulsion is a

common consequence of overstretching of the levator ani during
Fig. 9. 2D-transperineal ultrasound: multicompartmental prolapse. Bladder base the second stage of labor and occurs in 1036% of women at the
descent (cystocele) below the referral line (horizontal line to the inferior margin of time of their rst delivery. The functional and anatomical con-
the symphysis pubis) during maximal Valsalva maneuver. Rectocele is visualized as sequences of levator ani avulsion are considerable, with a reduc-
the protrusion of the anterior rectal wall beyond the expected margin. tion in muscle strength of about one-third and marked alteration
of anatomy. The main effect of avulsion is due to enlargement of
Endovaginal ultrasonography (EVUS) the levator hiatus that may result in excessive loading and failure
EVUS is performed with a high multifrequency (916 MHz), of ligamentous and fascial structures, which may, over time, lead
3601 rotational mechanical probe (type 2052, B-K Medical, Herlev, to the development of prolapse.33
Denmark) or with a radial electronic probe (type AR 54 AW, 5
10 MHz, Hitachi Medical Systems).5 The 3D acquisition is free-
Endoanal ultrasonography (EAUS)
hand with the electronic transducer, whereas the mechanical
3D-EAUS is rmly established as one of the cornerstones of a
transducer has an internal automated motorized system that
colorectal diagnostic work-up, and it is performed with the same
allows an acquisition of 300 aligned transaxial 2D images over a
probes adopted for 3D-EVUS.34,35 During examination, the patient
distance of 60 mm in 60 s, without any movement of the probe
may be placed in a dorsal lithotomy, left lateral, or prone position.
within the tissue.30 The set of 2D images is reconstructed instanta-
However, irrespective of patient position, the transducer should
neously into a high-resolution 3D image for real-time manipula-
be rotated so that the anterior aspect of the anal canal is superior
tion and volume rendering. An advantage of 3D compared with 2D
mode is the opportunity to obtain sagittal, axial, coronal, and any
desired oblique sectional image. The 3D image may be rotated,
tilted, and sliced to allow the operator to vary innitely the
different section parameters, to visualize and measure distance,
area, angle, and volume in any plane. The 3D volume can also be
archived for ofine analysis on the ultrasonographic system or on a
PC with the help of dedicated software.
3D-EVUS provides a topographical overview of pelvic oor
anatomy. Four levels of assessment in the axial plane can be
dened.30 At the highest level (level I), the bladder base can be
seen anteriorly and the inferior third of the rectum posteriorly.
Level II corresponds to the bladder neck, the intramural region of
the urethra, and the anorectal junction. Level III corresponds to the
midurethra and the upper third of the anal canal. At this level, the
levator ani can be visualized as a multilayer hyperechoic sling
coursing laterally to the vagina and posteriorly to the anal canal
and attaching to the inferior pubic rami anteriorly. Levator hiatus
dimensions (anteroposterior and laterolateral diameters and area)
can be measured31 (Fig. 10). At the lowest level (level IV), the
supercial perineal muscles (bulbospongiosus, ischiocavernosus,
and supercial transverse perineal muscles), the perineal body, the
distal urethra, and the middle and inferior thirds of the anal canal
can be visualized.11
3D-EVUS may be utilized to document major levator trauma
Fig. 11. 3D-endovaginal ultrasound. The levator ani (LA) is disconnected (avulsion)
(Fig. 11).32 Levator avulsion is the disconnection of the muscle from from the left inferior pubic rami (IPR) (arrows) (A: anal canal; SP: symphysis pubis;
its insertion on the inferior pubic ramus and the pelvic sidewall, and U: urethra).
 G.A. Santoro, A.H. Sultan / Seminars in Colon and Rectal Surgery 27 (2016) 514
Fig. 12. 3D-endoanal ultrasound. The anal canal is divided into three levels of assessment in the axial plane, dened by the following landmarks: (A) upper level:
puborectalis muscle (PR); (B) middle level: internal (IAS) and external anal sphincter (EAS); (C) lower level: external anal sphincter.
(12 o'clock position) on the screen, the right lateral aspect is to the
left (9 o'clock), the left lateral aspect is to the right (3 o'clock), and the
posterior aspect is inferior (6 o'clock). The recording of data should
extend from the upper aspect of the PR muscle to the anal verge.
With EAUS, the anal canal is divided into three levels of assess-
ment in the axial plane35 (Fig. 12): (1) the upper level corresponds
to the hyperechoic sling of the PR muscle and the concentric
hypoechoic ring of the IAS. In males, the deep part of the EAS is
also identied at this level; (2) in the middle level, the complete
ring of the supercial EAS (concentric band of mixed echogenicity),
the conjoined longitudinal layer, the complete ring of the IAS, and
the transverse perinei muscles are visualized; and (3) the lower
level corresponds to the subcutaneous part of the EAS.
EAUS has been recommended by the International Consultation
on Incontinence as the gold standard investigation to identify anal
sphincter injury in fecal incontinence (FI).36 It can differentiate
between incontinent patients with intact anal sphincters and
those with sphincter lesions (defects, scarring, thinning, thicken-
ing, and atrophy).37,38 Tears are identied by interruption of the
circumferential brillar echo texture (Fig. 13). Scarring is charac-
terized by loss of normal architecture, with an area of amorphous
texture that usually has low reectivity. Ultrasonography also
allows evaluation of anti-incontinence surgery (sphincter repair,
graciloplasty, bulking agents injection).39
Echodefecography (EDF)
This is a 3D dynamic anorectal ultrasonographic modality
performed with the same 3601 rotating transducer used for EAUS
Fig. 13. 3D-endoanal ultrasound. Internal (IAS) and external anal sphincter (EAS)
lesions in the anterior quadrant of the middle level of the anal canal. The muscle is
replaced by a mixed echogenicity scar tissue (ST).
11
to evaluate posterior compartment prolapse.40 The patient is
examined in the left lateral position. Images are acquired by four
automatic scans: Scan 1 (at rest position without gel): the trans-
ducer is positioned at 5.06.0 cm from the anal margin. It is
performed to visualize the anatomic integrity of the anal sphincter
musculature and to evaluate the position of the PR and EAS at rest;
Scan 2 (at reststrainingat rest without gel): the transducer is
positioned at 6.0 cm from the anal verge. The patient is requested
to rest during the rst 15 s, strain maximally for 20 s, then relax
again, with the transducer following the movement. The purpose
of the scan is to evaluate the movement of the PR and EAS during
straining, identifying normal relaxation, nonrelaxation, or para-
doxical contraction (anismus); Scan 3: the transducer is positioned
proximally to the PR (anorectal junction). The scan starts with the
patient at rest (3.0 s), followed by maximum straining with the
transducer in xed position (the transducer does not follow the
descending muscles of the pelvic oor). When the PR becomes
visible distally, the scan is stopped. Perineal descent is quantied
by measuring the distance between the position of the proximal
border of the PR at rest and the point to which it has been
displaced by maximum straining (PR descent). Straining time is
directly proportional to the distance of perineal descent; Scan 4:
following injection of 120180 ml ultrasound gel into the rectal
ampulla, the transducer is positioned at 7.0 cm from the anal
verge. The scanning sequence is the same as in Scan 2 (at rest
15 s, strain maximally20 s, then relax again with the transducer
following the movement). The purpose of the scan is to visualize
and quantify all anatomical structures and functional changes
associated with voiding (rectocele, intussusception, grade II or III
sigmoidocele/enterocele). In normal patients, the posterior vaginal
wall displaces the lower rectum and upper anal canal inferiorly
and posteriorly but maintains a straight horizontal position during
defecatory effort. If rectocele is identied, it is classied as grade I
(o 6.0 mm), grade II (6.013.0 mm), or grade III ( 413.0 mm)
(Fig. 14). Intussusception is clearly identied by observing the
rectal wall layers protruding through the rectal lumen. Grade II or
III sigmoidocele/enterocele is recognized when the bowel is
positioned below the pubococcygeal line (on the projection of
the lower rectum and upper anal canal).41,42
Magnetic resonance imaging (MRI)
Static MRI
Static MRI provides detailed information on pelvic oor anat-
omy. Current state-of-the-art MR of the pelvic oor includes
imaging at a magnetic eld strength of 1.5 Tesla (T), using pelvic
or phased array coils and T2-weighted fast spin-echo (FSE)
12 G.A. Santoro, A.H. Sultan / Seminars in Colon and Rectal Surgery 27 (2016) 514

Fig. 15. Pelvic MRI with external phased array. The levator ani (LA) is damaged on
the right side (arrow), with a complete detachment from the inferior pubic rami
(AC: anal canal; SP: symphysis pubis; U: urethra; and V: vagina).
Fig. 14. 3D-echodefecography. Rectocele is identied for the displacement of the
anterior wall of the lower rectum (arrows) and the protrusion of the posterior the inferior border of the symphysis pubis to the last or second last
vaginal wall (EAS: external anal sphincter and PR: puborectalis muscle).
coccygeal joint.45 The anorectal junction (ARJ) is dened as the
cross point between a line along the posterior wall of the distal
sequences.43 The spatial resolution can be enhanced by using
part of the rectum and a line along the central axis of the anal
endoluminal (endorectal, endovaginal) coils. In combination with
canal. To determine pathologic pelvic oor descent, the measure-
T2-weighted FSE sequences, endoluminal coils provide improved
ments are made on the images, which show maximal organ
signal-to-noise ratio (SNR) and high-resolution images. Based on
descent, usually during maximal straining or during evacuation.
T2-weighted turbo spin-echo sequences, muscles are relatively
The anorectal angle (ARA) is dened as the angle between the
hypointense, ligaments and fascia hypointense, while fat and
posterior wall of the distal part of the rectum and the central axis
smooth muscle are hyperintense. The prominent pelvic oor
of the anal canal and can be measured at rest, squeezing, and
structures of the posterior compartment visualized at MRI are
straining. Dynamic MRI may be used to demonstrate posterior
(1) perineal body and supercial perineal muscles; (2) anal
compartment prolapse during maximal Valsalva maneuver:
sphincters: the IAS is easily recognized as a circular hyperintense
structure. It is approximately 2.9 mm thick on endoluminal MRI.
 Rectocele: measured as the depth of wall protrusion beyond the
The intersphincteric space is seen as a bright line on T2-weighted
expected margin of the normal anorectal wall. Based on sagittal
MRI. The EAS has a thickness of 4.1 mm on endoluminal imaging;
MR-sections through mid of pelvis, rectoceles are graded as
(3) PR muscle and levator ani; and (4) rectum and rectal support.
small (o 2 cm), moderate (from 2 to 4 cm), and large ( 44 cm)
Endoanal MRI has been demonstrated to be comparable to
(Fig. 17);
EAUS in the detection of anal sphincter defects in FI.44 External
 Rectal intussusception: the infolding of the rectal mucosa
phased array coil MRI can replace endoluminal MRI with com-
occurring during defecation. Depending on the location, an
parable results.44 Abnormalities of the levator ani are identied on
MRI as present or absent. Defect severity is further scored in each
muscle from 0 (no defect) to 3 (complete loss) (Fig. 15). A summed
score for the two sides (06) is assigned and grouped as minor (0
3) or major (46).

Dynamic MRI
With the development of fast multislice sequences, MR imaging
has gained increasing acceptance for dynamic imaging of pelvic
oor. Because the posterior compartment is traditionally in the
focus of interest, dynamic MR imaging of the pelvic oor is often
called MR defecography.45 Dynamic pelvic imaging may be
performed in an open-conguration MR system in the sitting
position, or in a closed-conguration MR-system in the supine
position. Both techniques are equally effective in identifying most
of the clinically relevant abnormalities of the pelvic oor. For
evaluation of the posterior compartment, the rectum should be
lled with a contrast agent (ultrasound gel or mashed potatoes,
gadolinium-based MR contrast agent) to study the actual act of
defecation.
The use of reference lines for image evaluation is helpful Fig. 16. Dynamic MRI of the pelvic oor. Multicompartmental prolapse. Bladder
(Fig. 16). The most used reference line is the pubococcygeal line (B) base, uterus (U), and rectum (R) descent below the pubococcygeal line (PCL)
(PCL), which is dened on midsagittal images as the line joining during maximal Valsalva maneuver.
 G.A. Santoro, A.H. Sultan / Seminars in Colon and Rectal Surgery 27 (2016) 514
Fig. 17. Evacuation proctography. Rectocele is visualized as a bulging of the anterior
rectal wall.
intrarectal intussusception, limited to the rectum, is distin-
guished from an intra-anal intussusception extending into the
anal canal. The location of the intussusception may be anterior,
posterior, or circumferential. The intussusception either
involves only the mucosa or the full thickness of the rectal
wall46;
 Enterocele: dened as a herniation of the peritoneal sac, which
contains omental fat (peritoneocele), small bowel (enterocele),
or sigmoid (sigmoidocele), into the rectovaginal or rectovesical
space below the PCL. The largest distance between the PCL and
the most inferior point of the enterocele is measured with a
perpendicular line. Depending on this distance, small ( o3 cm),
moderate (36 cm), and large ( 4 6 cm) enteroceles are
distinguished47;
 Dyssynergic defecation: different structural imaging ndings
can be seen on dynamic pelvic MRI, including prominent
impression of the PR sling, narrow anal canal, prolonged
evacuation, a lack of descent of the pelvic oor, and thus a
failure to increase the ARA.
Evacuation proctography
This modality evaluates in real time the morphology of rectum
and anal canal in correlation with pelvic bony components both
statically and dynamically by injection of a thick barium paste into
the rectum and its subsequent evacuation. Contrast administration
into the bladder and vagina provides a more comprehensive
assessment of the pelvic organs and has been labeled dynamic
cystoproctography. At rest, the anal canal is closed and rectum
assumes its normal upright conguration. The position of the
pelvic oor is inferred by reference to the PCL (inferior margin of
pubic symphysis to the sacrococcygeal junction).48 Perineal
descent is measured from this line to the ARJ and may be up to
1.8 cm at rest. Some pelvic oor descent during evacuation is
considered normal, and a descent of up to 3 cm from the rest
position to anal canal opening is acceptable. The ARA is dened as
the angle between the anal canal axis and the posterior rectal wall
and on average is around 901. The puborectalis length (PRL) can be
estimated by measuring the distance between the ARA and the
symphysis pubis. A normal emptying phase at the proctogram is
described by ve elements: (1) increase in the ARA by around 20
301, (2) obliteration of the PR impression and the PRL should
increase by around 34 cm, (3) wide opening of the anal canal
within a couple of seconds, (4) evacuation of rectal contents
13
proceeding promptly and to completion, and (5) lack of signicant
pelvic oor descent. After evacuation is complete, the anal canal
should close, the ARA recover, and the pelvic oor return to its
normal baseline position. Post toilet imaging may be required,
particularly in those suspected of retained barium within
rectoceles.
The major function of proctography is not merely to document
evacuatory abnormalities,49,50 but also to classify those abnormal-
ities into those potentially surgically relevant, those likely to
benet from behavioral biofeedback therapy alone, or indeed
those which are incidental:
 Pelvic oor descent: it is dened as the distance moved by the
ARJ or ARA at rest to the point of anal canal opening and is
considered abnormal if it exceeds 3 cm;
 Intussusception and prolapse: refers to infolding of the rectal
wall into the rectal lumen. It may be described as intrarectal,
intra-anal, or external to form a complete rectal prolapse;
 Rectocele: it is dened as any anterior rectal bulge. The depth of
a rectocele is measured from the anterior border of the anal
canal to the anterior border of the rectocele (Fig. 17). A distance
of o2 cm is classied as small, 24 cm as moderate, and
4 4 cm as large. Of more relevance, however, is barium trap-
ping at the end of evacuation;
 Enterocele: it is diagnosed when small bowel loops enter the
peritoneal space between the rectum and vagina. Diagnosis of
an enterocele on proctography is only really possible if oral
contrast has been administered before the examination. Her-
niation of the sigmoid into the rectogenital space (sigmoido-
cele) is signicantly less common than an enterocele; and
 Dyssynergic defecation: various proctographic abnormalities
have been described including prominent PR impression, a
narrow anal canal, and acute ARA. However, these observations
may be found in normal controls and are in themselves
unreliable distinguishing features.
Conclusion
Care of women with pelvic oor disorders begins with an
understanding of the unique musculofascial system that supports
the pelvic organs. The principles underlying reconstructive surgery
are either restoration of normal anatomy and thereby a presumed
return to normal function, or creation of compensatory anatomical
mechanisms. Combining different imaging modalities has the
potential to complement the advantages and to overcome the
limitations of each of these tools and to substantially improve the
clinical management of these conditions.51
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