Integrated total pelvic floor ultrasound (TPFUS) may provide an alternative to defaecation proctography (DP) in decision-making and treatment planning for patients with pelvic floor defaecatory dysfunction (PFDD).  This study evaluates the use of TPUS as a screening tool, and its likelihood to predict long-term treatment outcomes.

Two blinded clinicians reviewed 100 women who had historically presented to a tertiary referral colorectal unit with PFDD from October 2014 to April 2015. The clinical history of the patients together with TPFUS or DP results were used to decide on main impression, treatment plan, likelihood of surgery and certainty of plan. These were compared to the actual treatment received six months later and again after a median follow-up of 68 months (range 48-84).

82 patients were treated with biofeedback only and 18 also underwent surgery (7 ventral mesh rectopexy, 8 transvaginal rectocoele repair, 1 extended sphincter repair and rectocoele repair, 1 sacral nerve stimulation and 1 injection of sphincter bulking agent).  
The accuracy of the decision made with DP or TPFUS  when compared to the actual treatment received is outlined in Table 1. A positive decision was the decision for surgery. After review with DP, all women requiring surgery were correctly identified (no false negative). After review with TPFUS alone, there were four women who were deemed suitable for biofeedback but underwent surgery. The decision for three of these four women was ’biofeedback with a proctogram should biofeedback fail’ and therefore would have been treated appropriately. One of the four was deemed suitable for biofeedback alone after review of TPFUS, but was actually treated with an extended sphincter repair and rectocoele repair. 
On long term follow-up, all 18 patients who underwent surgery did not develop complications. The majority (76/82) of the patients who had biofeedback therapy were eventually discharged from the clinic after significant improvement in symptoms. Two patients were referred again for pelvic floor strengthening exercises, toilet positioning, and lifestyle modifications. Four patients deemed suitable for biofeedback, eventually needed surgery (insertion of gatekeeper implant, Delorme’s procedure, transvaginal rectocoele repair, and formation of loop ileostomy).

When compared with the actual treatment received, TPFUS alone would have ensured the same treatment in 99 out of 100 patients (one deemed suitable for conservative treatment, but actual treatment was surgical). The number of false positives (deemed suitable for surgery where actual treatment was conservative) was lower with TPFUS compared to DP. Both imaging modalities are useful for predicting which patients require surgery, but neither is useful for deciding the type of surgery. These factors support the use of TPFUS as a screening tool for the initial decision-making in symptomatic women with pelvic floor defaecatory dysfunction. However, there are still some discrepancies between the overall impression made using the two assessment tools, and clinician confidence is lower with ultrasound.  This is expected as DP is more familiar. Further studies, training and expertise are required before colorectal pelvic floor surgeons can place more confidence in TPFUS.

To our knowledge, this is the first study to look at the long-term clinical value of TPFUS in decision-making and treatment planning for patients with PFDD. TPFUS is a reliable assessment tool, has a lower false positive rate for surgical treatment than DP, can highlight those patients who may go straight to biofeedback ,and is just as effective at predicting likelihood of surgery as DP. Neither imaging modality has proven superior for surgical planning, but as our understanding of pelvic floor pathology improves, and the anatomical findings which predict optimal surgical outcomes are identified, we hope to re-evaluate the use of TPUS for surgical planning.

Continence 2S2 (2022) 100300
DOI: 10.1016/j.cont.2022.100300