{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T03:39:27Z","timestamp":1780544367553,"version":"3.54.1"},"reference-count":54,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2025,1,16]],"date-time":"2025-01-16T00:00:00Z","timestamp":1736985600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Objectives: The aim of this study is to validate a uniform method for measuring perineal descent which can be used for different imaging methods, to establish cut-off values for this measurement, and to assess diagnostic test accuracy (DTA) of imaging techniques using these cut-off values. Secondly, the study aims to correlate perineal descent to symptoms, signs and imaging findings in women with obstructed defaecation syndrome (ODS) to assess its clinical relevance. Methods: Cross-sectional study of 131 women with symptoms of ODS. Symptoms and signs were assessed using validated methods. These women underwent evacuation proctography (EP), magnetic resonance imaging (MRI), transperineal ultrasound (TPUS) and endovaginal ultrasound (EVUS). Perineal descent was measured on EP and MRI as the position of anorectal junction (ARJ) with respect to the pubococcygeal line (PCL) at rest (i.e., static descent) and during evacuation (i.e., descent at Valsalva). Dynamic perineal descent was measured on all four imaging techniques as the difference between the position of the ARJ at rest and Valsalva. DTA of dynamic perineal descent was estimated using Latent Class Analysis in the absence of a reference standard. Results: Interobserver agreement of dynamic perineal descent measurements was good for MRI and EVUS (ICC 0.86 and 0.85) and moderate for EP and TPUS (ICC 0.61 and 0.59). The systematic differences in measurements between imaging techniques show the need for individual cut-off values. New established cut-off values for dynamic descent are for EP 20 mm, MRI 35 mm, TPUS 15 mm and EVUS 15 mm. Sensitivity was moderate for EP (0.78) and MRI (0.74), fair for TPUS (0.65) and poor for EVUS (0.58). Specificity was similar for all imaging techniques (0.73\u20130.77). Static perineal descent correlated with symptoms of pelvic organ prolapse (POP) (r = 0.19), prolapse of all three compartments (r = 0.19\u20130.36), presence of levator ani muscle avulsion (p = 0.01) and increased hiatal area (r = 0.51). Dynamic perineal descent correlated with excessive straining (r = 0.24) and use of laxatives (r = 0.24). Classic symptoms of ODS (incomplete evacuation and digitation) did not correlate with perineal descent measurements. Static and dynamic perineal descent were associated with presence of rectocele, enterocele, intussusception, and absence of anismus. Conclusions: Dynamic perineal descent is a reliable measurement that can be applied to different imaging techniques to allow standardisation. Static descent is more often present in women with POP and dynamic descent is more often present in women with constipation. Perineal descent does not correlate with typical symptoms of ODS. Specificity of TPUS and EVUS is comparable to EP and MRI, hence ultrasound could be used for the initial assessment of pelvic floor dysfunction.<\/jats:p>","DOI":"10.3390\/jcm14020548","type":"journal-article","created":{"date-parts":[[2025,1,16]],"date-time":"2025-01-16T06:46:10Z","timestamp":1737009970000},"page":"548","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Evaluation of Perineal Descent Measurements on Pelvic Floor Imaging"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9470-1291","authenticated-orcid":false,"given":"Isabelle M. A.","family":"van Gruting","sequence":"first","affiliation":[{"name":"Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon CR7 7YE, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4681-4304","authenticated-orcid":false,"given":"Kirsten","family":"Kluivers","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynaecology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aleksandra","family":"Stankiewicz","sequence":"additional","affiliation":[{"name":"Department of Radiology, Croydon University Hospital, Croydon CR7 7YE, UK"},{"name":"Department of Radiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent ST4 6QG, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6127-0747","authenticated-orcid":false,"given":"Joanna","family":"IntHout","sequence":"additional","affiliation":[{"name":"IQ Health Department, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5440-8605","authenticated-orcid":false,"given":"Kim W. M.","family":"van Delft","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynaecology, Jeroen Bosch Ziekenhuis, 5223 GW Den Bosch, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ranee","family":"Thakar","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon CR7 7YE, UK"},{"name":"Medical School, St. Georges University London, London SW17 0RE, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8979-2304","authenticated-orcid":false,"given":"Abdul H.","family":"Sultan","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon CR7 7YE, UK"},{"name":"Medical School, St. Georges University London, London SW17 0RE, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,1,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1007\/s00192-016-3140-3","article-title":"An International Urogynecological Association (IUGA)\/International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction","volume":"28","author":"Sultan","year":"2017","journal-title":"Int. Urogynecol. J."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1177\/003591576605900601","article-title":"The syndrome of the descending perineum","volume":"59","author":"Parks","year":"1966","journal-title":"Proc. R. Soc. Med. June"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"300","DOI":"10.1055\/s-2000-7385","article-title":"Dynamic anal endosonography may challenge defecography for assessing dynamic anorectal disorders: Results of a prospective pilot study","volume":"32","author":"Barthet","year":"2000","journal-title":"Endoscopy"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1016\/S0016-5085(83)80231-5","article-title":"Differences in anal sphincter function and clinical presentation in patients with pelvic floor descent","volume":"85","author":"Bartolo","year":"1983","journal-title":"Gastroenterology"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1007\/BF01648413","article-title":"The relationship between perineal descent and denervation of the puborectalis in continent patients","volume":"1","author":"Bartolo","year":"1986","journal-title":"Int. J. Colorectal. Dis."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1398","DOI":"10.1097\/DCR.0b013e31822e89bc","article-title":"Dynamic anal endosonography and MRI defecography in diagnosis of pelvic floor disorders: Comparison with conventional defecography","volume":"54","author":"Vitton","year":"2011","journal-title":"Dis. Colon Rectum"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e293","DOI":"10.1016\/j.crad.2012.11.013","article-title":"Static and dynamic evaluation of pelvic floor disorders with an open low-field tilting magnet","volume":"68","author":"Fiaschetti","year":"2013","journal-title":"Clin. Radiol."},{"key":"ref_8","first-page":"740","article-title":"A novel three-dimensional dynamic anorectal ultrasonography technique for the assessment of perineal descent, compared with defaecography","volume":"14","author":"Soares","year":"2011","journal-title":"Color. Dis."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"253","DOI":"10.1007\/BF01887846","article-title":"Defecography: II Contribution to the diagnosis of defecation disorders","volume":"9","author":"Mahieu","year":"1984","journal-title":"Gastrointest. Radiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1067\/mob.2001.116365","article-title":"Two-and 3-dimensional MRI comparison of levator ani structure, volume, and integrity in women with stress incontinence and prolapse","volume":"185","author":"Hoyte","year":"2001","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"721","DOI":"10.1007\/s00192-010-1099-z","article-title":"Perineal descent and patients\u2019 symptoms of anorectal dysfunction, pelvic organ prolapse, and urinary incontinence","volume":"21","author":"Broekhuis","year":"2010","journal-title":"Int. Urogynecol. J."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1007\/s11547-012-0840-8","article-title":"Pelvic floor imaging: Comparison between magnetic resonance imaging and conventional defecography in studying outlet obstruction syndrome","volume":"118","author":"Foti","year":"2013","journal-title":"Radiol. Medica"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1167","DOI":"10.1111\/j.1463-1318.2010.02427.x","article-title":"Clinical relevance of transperineal ultrasound compared with evacuation proctography for the evaluation of patients with obstructed defaecation","volume":"13","author":"Martellucci","year":"2011","journal-title":"Color. Dis."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"795","DOI":"10.1007\/s10151-017-1666-0","article-title":"Magnetic resonance defecography versus videodefecography in the study of obstructed defecation syndrome: Is videodefecography still the test of choice after 50 years?","volume":"21","year":"2017","journal-title":"Tech. Coloproctol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.ejro.2014.09.003","article-title":"Conventional videodefecography: Pathologic findings according to gender and age","volume":"1","author":"Andrade","year":"2014","journal-title":"Eur. J. Radiol. Open"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1097\/DCR.0000000000001829","article-title":"Consensus Definitions and Interpretation Templates for Fluoroscopic Imaging of Defecatory Pelvic Floor Disorders: Proceedings of the Consensus Meeting of the Pelvic Floor 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","volume":"64","author":"Paquette","year":"2021","journal-title":"Dis. Colon Rectum"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1007\/BF01660711","article-title":"Evaluation of perineal descent by defaecography","volume":"3","author":"Skomorowska","year":"1988","journal-title":"Int. J. Colorectal. Dis."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1007\/DCR.0b013e3181972447","article-title":"Perineal descent predicted by a pelvic bone factor: The pelvic incidence angle","volume":"52","author":"Boulay","year":"2009","journal-title":"Dis. Colon Rectum"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1007\/BF02048163","article-title":"Anterior rectocele: Assessment with radiographic defecography, dynamic magnetic resonance imaging, and physical examination","volume":"37","author":"Delemarre","year":"1994","journal-title":"Dis. Colon Rectum"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1737","DOI":"10.1136\/gut.30.12.1737","article-title":"Defecography in normal volunteers: Results and implications","volume":"30","author":"Shorvon","year":"1989","journal-title":"Gut"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"638","DOI":"10.1111\/j.1440-1746.2006.04333.x","article-title":"Constipation of anorectal outlet obstruction: Pathophysiology, evaluation and management","volume":"21","author":"Andromanakos","year":"2006","journal-title":"J. Gastroenterol. Hepatol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"420","DOI":"10.1053\/j.sult.2008.10.003","article-title":"Practical performance of defecography for the evaluation of constipation and incontinence","volume":"29","author":"Brennan","year":"2008","journal-title":"Semin. Ultrasound CT MR"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"661","DOI":"10.2214\/ajr.174.3.1740661","article-title":"Dynamic MR imaging of the pelvic floor in asymptomatic subjects","volume":"174","author":"Goh","year":"2000","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1002\/(SICI)1522-2586(199903)9:3<373::AID-JMRI2>3.0.CO;2-H","article-title":"Pelvic floor descent in females: Comparative study of colpocystodefecography and dynamic fast MR imaging","volume":"9","author":"Vanbeckevoort","year":"1999","journal-title":"J. Magn. Reson. Imaging"},{"key":"ref_25","first-page":"O46","article-title":"Comparison of dynamic magnetic resonance defaecography with rectal contrast and conventional defaecography for posterior pelvic floor compartment prolapse","volume":"19","author":"Verheijen","year":"2017","journal-title":"Color. Dis."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"762","DOI":"10.1007\/BF02050326","article-title":"Is the volume retained after defecation a valuable parameter at defecography?","volume":"35","author":"Ting","year":"1992","journal-title":"Dis. Colon Rectum"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1372","DOI":"10.1111\/j.1463-1318.2012.03018.x","article-title":"Perineal descent does not imply a more severe clinical disorder","volume":"14","author":"Gurland","year":"2012","journal-title":"Colorectal. Dis."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"927","DOI":"10.1007\/BF02052600","article-title":"Patient position during cinedefecography. Influence on perineal descent and other measurements","volume":"37","author":"Jorge","year":"1994","journal-title":"Dis. Colon Rectum"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"126","DOI":"10.1111\/j.1572-0241.1999.00782.x","article-title":"Descending perineum syndrome: Audit of clinical and laboratory features and outcome of pelvic floor retraining","volume":"94","author":"Harewood","year":"1999","journal-title":"Am. J. Gastroenterol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"999","DOI":"10.1002\/bjs.1800721222","article-title":"What is the best way of measuring perineal descent? A comparison of radiographic and clinical methods","volume":"72","author":"Oettle","year":"1985","journal-title":"Br. J. Surg."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1133","DOI":"10.1007\/BF02049817","article-title":"Defecography: Results of investigations in 2816 patients","volume":"37","author":"Mellgren","year":"1994","journal-title":"Dis. Colon Rectum"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"2067","DOI":"10.1007\/s00330-016-4471-7","article-title":"Magnetic resonance imaging of pelvic floor dysfunction-joint recommendation of the ESUR and ESGAR Pelvic Floor Working Group","volume":"27","author":"Alt","year":"2017","journal-title":"Eur. Radiol."},{"key":"ref_33","first-page":"CD011482","article-title":"Imaging modalities for the detection of posterior pelvic floor disorders in women with obstructed defaecation syndrome","volume":"9","author":"Stankiewicz","year":"2021","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1017","DOI":"10.1097\/AOG.0000000000002245","article-title":"Accuracy of four imaging techniques for diagnosis of posterior pelvic floor disorders","volume":"130","author":"Stankiewicz","year":"2017","journal-title":"Obs. Gynecol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1177\/1553350612446354","article-title":"Five-item score for obstructed defecation syndrome: Study of validation","volume":"20","author":"Renzi","year":"2013","journal-title":"Surg. Innov."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1136\/gut.44.1.77","article-title":"Prospective comparison of faecal incontinence grading systems","volume":"44","author":"Vaizey","year":"1999","journal-title":"Gut"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1111\/j.1471-0528.2008.01903.x","article-title":"Psychometric properties of the pelvic organ prolapse symptom score","volume":"116","author":"Hagen","year":"2009","journal-title":"BJOG"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1016\/S0002-9378(96)70243-0","article-title":"The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction","volume":"175","author":"Bump","year":"1996","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"571","DOI":"10.1007\/BF02234331","article-title":"A comparison between dynamic magnetic resonance imaging and videoproctography in patients with constipation","volume":"44","author":"Matsuoka","year":"2001","journal-title":"Dis. Colon Rectum"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1097\/01.AOG.0000250901.57095.ba","article-title":"Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse","volume":"109","author":"DeLancey","year":"2007","journal-title":"Obs. Gynecol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1016\/j.jcm.2016.02.012","article-title":"A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research","volume":"15","author":"Koo","year":"2016","journal-title":"J. Chiropr. Med."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1002\/uog.122","article-title":"Applying the right statistics: Analyses of measurement studies","volume":"22","author":"Bland","year":"2003","journal-title":"Ultrasound. Obs. Gynecol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"423","DOI":"10.1093\/aje\/kwt286","article-title":"Latent class models in diagnostic studies when there is no reference standard\u2014A systematic review","volume":"179","author":"Naaktgeboren","year":"2014","journal-title":"Am. J. Epidemiol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1","DOI":"10.18637\/jss.v061.i13","article-title":"BayesLCA: An R Package for Bayesian Latent Class Analysis","volume":"61","author":"White","year":"2014","journal-title":"J. Stat. Softw."},{"key":"ref_45","first-page":"7","article-title":"CODA: Convergence Diagnosis and Output Analysis for MCMC","volume":"6","author":"Plummer","year":"2006","journal-title":"R News"},{"key":"ref_46","unstructured":"R Core Team (2022). R: A Language and Environment for Statistical Computing, R Foundation for Statistical Computing. Available online: https:\/\/www.R-project.org\/."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1007\/s00192-008-0760-2","article-title":"Dynamic magnetic resonance imaging: Reliability of anatomical landmarks and reference lines used to assess pelvic organ prolapse","volume":"20","author":"Broekhuis","year":"2009","journal-title":"Int. Urogynecol. J. Pelvic. Floor Dysfunct."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"6594152","DOI":"10.1155\/2016\/6594152","article-title":"MR imaging in diagnosis of pelvic floor descent: Supine versus sitting position","volume":"2016","author":"Iacobellis","year":"2016","journal-title":"Gastroenterol. Res. Pract."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1121","DOI":"10.1007\/BF02236560","article-title":"Intraobserver and interobserver measurements of the anorectal angle and perineal descent in defecography","volume":"43","author":"Choi","year":"2000","journal-title":"Dis. Colon Rectum"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"395","DOI":"10.3393\/jksc.2010.26.6.395","article-title":"Clinical Significance of Perineal Descent in Pelvic Outlet Obstruction Diagnosed by using Defecography","volume":"26","author":"Baek","year":"2010","journal-title":"J. Korean Soc. Coloproctol."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1007\/BF00303277","article-title":"The effect of age on pelvic floor dynamics","volume":"5","author":"Pinho","year":"1990","journal-title":"Int. J. Colorectal. Dis."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"704","DOI":"10.1007\/BF02050355","article-title":"Physiologic and anatomic assessment of patients with rectocele","volume":"34","author":"Yoshioka","year":"1991","journal-title":"Dis. Colon Rectum"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1007\/BF01649677","article-title":"An analysis of rectal morphology in obstructed defaecation","volume":"3","author":"Bartolo","year":"1988","journal-title":"Int. J. Colorectal. Dis."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"195","DOI":"10.3393\/jksc.2012.28.4.195","article-title":"An analysis of factors associated with increased perineal descent in women","volume":"28","author":"Chang","year":"2012","journal-title":"J. Korean Soc. Coloproctol."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/2\/548\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,8]],"date-time":"2025-10-08T10:29:57Z","timestamp":1759919397000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/2\/548"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,1,16]]},"references-count":54,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2025,1]]}},"alternative-id":["jcm14020548"],"URL":"https:\/\/doi.org\/10.3390\/jcm14020548","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,1,16]]}}}