Consensus Definitions and Interpretation Templates for Dynamic Ultrasound Imaging of Defecatory Pelvic Floor Disorders: Proceedings of the Consensus Meeting of the Pelvic Floor Disorders Consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdominal Radiology, the International Continence Society, the American Urogynecologic Society, the International Urogynecological Association, and the Society of Gynecologic Surgeons

See “editorial” on page 169. The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, radiologists, physiotherapists, and other advanced care practitioners. Specialists from these fields are all dedicated to diagnosing and managing patients with pelvic floor conditions but approach evaluation and treatment of such patients with their unique perspectives given differences in their training. The PFDC was formed to enable collaboration between these specialties in developing and evaluating educational programs, creating clinical guidelines and algorithms, and promoting high-quality care for this unique patient population. The recommendations included in this document represent the work of the PFDC Working Group on Ultrasound in Imaging of Defecatory Disorders of the Pelvic Floor (members listed alphabetically in Table 1). The objective was to generate inclusive, rather than prescriptive, guidance for all practitioners interested in considering pelvic floor ultrasound imaging in their assessment of defecatory pelvic floor disorders. TABLE 1. - Members of the workgroup on the use of dynamic ultrasound in the evaluation of defecatory pelvic floor disorders Name and degree Affiliation City, state, country Amy Halverson, M.D. Department of Surgery, Northwestern Memorial Hospital and Feinberg School of Medicine Chicago, IL, USA Jonia Alshiek, M.D.1 Urogynecology Unit, Hillel Yaffe Medical Center, Technion Medical School Technion Medical School, Hadera, Israel Hina Arif-Tiwari, M.D. Department of Medical Imaging, College of Medicine, University of Arizona. Phoenix, AZ, USA Liliana Bordeianou, M.D. Section of Colorectal Surgery, Massachusetts General Hospital Pelvic Floor Disorders Center, Harvard Medical School Boston, MA, USA Shuqing Ding, Ph.D. Department of Surgery, Northwestern Health Sciences University Bloomington, MN, USA Andrea Ferrara, M.D. Department Colorectal Surgery, Colon & Rectal Surgery Clinic of Orlando Orlando, FL, USA Linda Ferrari, M.D. Pelvic floor unit. St. Thomas’ Hospital London, UK Giuseppe Gagliardi, M.D. Department of Colorectal Surgery, University of Illinois Chicago, IL, USA Phyllis Glanc, M.D. Department of Medical Imaging, Sunnybrook Health Sciences Center Toronto, ON, Canada Gaurav Khatri, M.D. Department of Radiology, University of Texas Southwestern Medical Center Dallas, TX, USA S. Abbas Shobeiri, M.D. Department of Obstetrics and Gynecology, Inova Health System Fairfax, VA, USA Lieschen H. Quiroz Department of Obstetrics and Gynecology, The University of Oklahoma Health Sciences Center Oklahoma City, OK, USA Ari Steiner, M.D. Department of Radiology, South Nassau Community Hospital Oceanside, NY, USA David Sheyn, M.D. Department of OBGYN, University Hospitals Cleveland, OH, USA Joanne Favuzza, M.D. Department of Surgery, Boston Medical Center Boston, MA, USA Sergio Larach, M.D. Department of Surgery, Digestive and Liver Center of Florida Orlando, FL, USA Anders Mellgren, M.D. Department of Surgery, University of Illinois Chicago, IL, USA Yara Lima de Mendonca, M.D. Colorectal Surgery, Hospital Municipal Ronaldo Gazolla and University of Exeter Rio de Janeiro, Brazil, and Exeter, UK Miles Murphy, M.D. Division of Urogynecology, Department of OB–GYN, Abington—Jefferson Health Abington, PA, USA Sthela Murad-Regadas, M.D. Department of Surgery, School of Medicine of the Federal University of Ceará Fortaleza, Brazil Lucia Oliveira, M.D. Department of Anorectal Physiology, Policinica General do Rio de Janeiro Rio de Janeiro, Brazil Ghazaleh Rostaminia, M.D. Department of Obstetrics and Gynecology, Northshore Hospital Chicago, IL, USA Milena Weinstein, M.D. Department of Obstetrics and Gynecology, Massachusetts General Hospital Boston, MA, USA Steven Wexner, M.D. Department of Surgery, Cleveland Clinic Florida Weston, FL, USA STATEMENT OF THE PROBLEM Dynamic pelvic floor ultrasound (PFUS) has been shown to be an effective and relatively inexpensive method for evaluating pelvic organs, including the urethra, bladder, vagina, cervix and uterus, anal canal, rectum, and other pelvic floor structures, such as the levator ani muscles. PFUS can be performed using transperineal/introital, endovaginal, or endoanal/endorectal approaches. There is considerable evidence for the use of PFUS imaging to quantify pelvic floor disorders. Still, there is significant variation across disciplines regarding the degree of utilization of PFUS for such indications and the preferred choice of specific PFUS technique.1–4 Also, there is variability in the definitions of pathology described on PFUS between specialists, which results in more significant variability in how different physicians and specialties interpret and use findings seen on PFUS. These factors create challenges for health care providers in their efforts to counsel patients and effectively communicate and cooperate between specialities. Patients with pelvic floor disorders often have recurrent or multifactorial symptomatology, which may require care from multiple disciplines. Furthermore, many health care providers may be concurrently managing different aspects of pelvic floor dysfunction in the same patient in parallel. Lack of coordination and communication in imaging terminology can create misunderstandings and confusion for health care providers and patients. The American Institute of Ultrasound in Medicine and the International Urogynecologic Association generated a practice parameter guideline that made one of the first attempts at standardization of the language in the field of pelvic floor ultrasonography.5 However, the document had limited reference to defecatory pelvic floor disorders. Thus, this effort was undertaken with the explicit goal of inviting and including representatives from all relevant clinical specialties for whom PFUS holds clinical significance. This document aims to create a universal set of recommendations for a minimum common language for PFUS interpretation and reporting of defecatory pelvic floor disorders, with relevance across disciplines and all PFUS modalities. METHODOLOGY This document was developed by the Pelvic Floor Disorders Consortium (PFDC) Working Group on Ultrasound Imaging of Defecatory Disorders and created under the guidance of the American Society of Colon and Rectal Surgeons (ASCRS). The PFDC comprises clinicians with demonstrated expertise in the care and treatment of patients with pelvic floor conditions. The Working Group was created by enlisting PFDC volunteers. Invitation criteria included leadership in pelvic floor disorders with academic scholarship and a history of crossdisciplinary collaboration. Members of the working group participated in at least 2 group preliminary phone calls and researched an assigned topic. Each topic had at least 2 members assigned, always from different specialties. Each pair identified the literature on a relevant topic and performed a systematic review of the literature using a specified format. These systematic reviews involved an organized search of MEDLINE, PubMed, Embase, and the Cochrane Database of Collected Reviews performed up to April 1, 2019. Retrieved publications were limited to the English language, but no limits on the year of publication were applied. The search terms included “fecal incontinence,” “urinary incontinence,” “constipation,” “lower urinary tract symptoms in men and women,” and “pelvic floor disorders in men and women.” The search strategies used “dynamic ultrasound,” “pelvic organ prolapse,” “obstructed defecation,” “anal incontinence,” “pelvic pain,” “dyspareunia,” “obstetric injury,” “OASIS” (obstetric anal sphincter injuries), “anal sphincter injury,” “pelvic floor ultrasound,” “translabial ultrasound,” “transperineal ultrasound,” “endoanal ultrasound,” “endorectal ultrasound,” “transvaginal ultrasound,” “echodefecography,” “enterocele,” “internal intussusception,” “rectocele,” “sigmoidocele,” “perineal descent,” “levator ani tears,” “levator ani avulsion,” “levator injury,” “pelvic floor dysfunction,” and “rectal prolapse” as primary search terms. Directed searches of the embedded references from the primary articles were also sometimes performed. Criteria for inclusion of references included articles that described original descriptions of relevant ultrasound measurements or clinically relevant literature describing the use of ultrasound imaging in clinical practice. The workgroup presented its preliminary research to the consortium at large for further discussion. Pelvic Floor Consortium Expert Meeting The Pelvic Floor Consortium Expert Meeting convened on June 2, 2019, in Cleveland, Ohio. It included 126 in-person (or online) participants from the United States, Europe, Asia, England, and Canada. These experts belonged to several subspecialties (colorectal surgery, gastroenterology, urogynecology, urology, physiotherapy, and radiology). They included members of numerous professional societies involved in the diagnosis and treatment of pelvic floor disorders. The event was also audited by formal representatives from the ASCRS, the Society of Abdominal Radiology (SAR), the American Urogynecologic Society, the International Urogynecological Association (IUGA), and the Society of Gynecologic Surgeons. The meeting was funded by the ASCRS. The participants at the expert consortium meeting analyzed the proposed sonographic techniques and definitions for each of the conditions reviewed in this statement, ultimately offering consensus recommendations for the technique and interpretation of PFUS as well as a standardized and clinically relevant synoptic reporting template. The group labeled this final template as the “Ultrasound Interpretation Template for the Initial Measurement of Patient-Reported Defecatory Pelvic Floor Complaints,” or “Ultrasound-IMPACT” (see Supplement 1 at https://links.lww.com/DCR/C46). 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