Magnetic resonance imaging of pelvic floor dysfunction - joint recomendations of the ESUR & ESGAR pelvic working group
Rania Farouk El Sayed, Celine D. Alt, Francesca Maccioni, Matthias Meissnitzer, Gabriele Masselli, Lucia Manganaro, Valeria Vinci & Dominik Weishaupt On behalf of the ESUR and ESGAR Pelvic Floor Working Group
Pelvic floor dysfunction (PFD) comprises a group of disorders resulting from impaired support and coordination of pelvic organs, leading to symptoms such as pelvic organ prolapse, urinary incontinence, and obstructed defecation. These conditions are highly prevalent, particularly among multiparous and elderly women, and often require multidisciplinary assessment before treatment. Magnetic resonance imaging (MRI) has emerged as the most comprehensive non-invasive technique for evaluating pelvic floor anatomy and function in a single examination. However, prior to this publication, considerable variation existed in MRI protocols, interpretation criteria, and reporting styles, reducing reproducibility and clinical confidence.
The reviewed article by El Sayed et al. was designed to address this gap by providing standardized, evidence-based recommendations for MRI assessment of pelvic floor dysfunction. The primary objective of the study was to unify indications, patient preparation, imaging technique, measurements, grading systems, and reporting structure, thereby improving diagnostic accuracy and communication between radiologists and clinicians.
Methodologically, the study combined a systematic literature review (1993–2013) with an expert consensus process. The expert panel consisted of 13 experienced radiologists from 8 European and North African institutions, working within the European Society of Urogenital Radiology (ESUR) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR). A structured questionnaire of 89 items covering all aspects of MRI in pelvic floor dysfunction was used. Consensus was defined as ≥80% agreement, and was achieved in approximately 88% of items, indicating strong agreement among experts.
The results demonstrated that MRI is particularly valuable in complex or multi-compartment pelvic floor dysfunction, especially when clinical examination is inconclusive or when detailed preoperative mapping is required. The strongest indications for MRI included rectal outlet obstruction, rectocele, enterocele, anismus, and recurrent pelvic organ prolapse. MRI was emphasized as a problem-solving modality, rather than a first-line test for isolated, clinically obvious conditions.
Regarding patient preparation and technical requirements, the consensus recommended MRI acquisition using a field strength of at least 1.5 Tesla, with a phased-array surface coil. Patients should be examined in the supine position, with moderate bladder filling and rectal distension using ultrasound gel to enhance visualization of posterior compartment disorders. Patient training before scanning was highlighted as essential to ensure correct performance of squeezing, straining, and evacuation maneuvers.
The article strongly emphasized the importance of combined static and dynamic MRI. High-resolution T2-weighted images are recommended for detailed anatomic evaluation, while dynamic balanced sequences should be obtained during squeezing, straining, and evacuation. The evacuation phase was considered mandatory, as it often reveals clinically significant abnormalities not visible on rest or strain images alone. This aspect represents a key advantage of MRI over other imaging modalities.
One of the most influential contributions of the article is the standardization of measurements and reference lines. The pubococcygeal line (PCL) was established as the universal reference line for assessing pelvic organ descent across all compartments. Specific anatomical landmarks were defined for the anterior, middle, and posterior compartments, and measurements should be reported both at rest and during maximum strain, with emphasis on organ mobility rather than static position alone.
The article also introduced simple and reproducible grading systems to categorize the severity of pelvic floor abnormalities. The “rule of three” was recommended for grading anterior and middle compartment prolapse, while the “rule of two” was applied for rectoceles. Clinically relevant abnormalities typically begin at grade II, helping to avoid over-reporting of mild findings.
Another major strength of the paper was the recommendation for a structured MRI reporting template. Such structured reports improve clarity, completeness, and interdisciplinary communication, and they can be tailored according to the referring specialty, including gynecology, urology, or colorectal surgery. Importantly, the article highlighted that MRI findings frequently alter surgical planning and patient management, underlining their clinical importance.
Among the most outstanding aspects of this publication are its status as the first international consensus guideline dedicated specifically to MRI of pelvic floor dysfunction, its integration of evidence-based data with expert clinical experience, and its successful standardization of protocols that were previously highly variable. These contributions significantly enhance interobserver agreement and diagnostic confidence.
In conclusion, this article represents a landmark reference in pelvic floor imaging. By establishing uniform standards for MRI acquisition, interpretation, grading, and reporting, it has reinforced MRI as a comprehensive, reliable, and clinically impactful tool in the evaluation of pelvic floor dysfunction. The article was published in European Radiology in 2016 and remains a cornerstone guideline for radiologists and clinicians involved in pelvic floor disorders.