American College of Radiology
ACR Appropriateness Criteria®

Pelvic Floor Dysfunction

Variant 1: Protruding/bulging vaginal mass, chronic Pelvic Floor Dysfunction pelvic pressure/discomfort, clinically suspected pelvic organ prolapse.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
X-ray fluoroscopic cystocolpoproctography Usually appropriate ☢☢☢ 1-10 mSv 9 n/a 0 0 0 0 0 0 0 0 0
MR defecography with rectal contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
US pelvis transperineal Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis dynamic with rectal contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
X-ray fluoroscopic defecography May be appropriate ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
US pelvis transvaginal Usually not appropriate O 0 mSv O 0 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
US pelvis transabdominal Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
US pelvis transrectal Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis endorectal coil Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT pelvis with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Urinary dysfunction. Involuntary leakage of urine, frequent urination, urgency. Straining to void, incomplete voiding, splinting, or digital maneuvers to void.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US pelvis transperineal Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis dynamic with rectal contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
X-ray fluoroscopic cystocolpoproctography Usually appropriate ☢☢☢ 1-10 mSv 7 n/a 0 0 0 0 0 0 0 0 0
MR defecography with rectal contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
US pelvis transabdominal May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis endorectal coil Usually not appropriate O 0 mSv O 0 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
US pelvis transvaginal Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
X-ray fluoroscopic defecography Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
US pelvis transrectal Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT pelvis with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Anal incontinence. Involuntary leakage of stool/liquid/gas.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US pelvis transrectal (anal sphincter) Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis (anal sphincter) Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
X-ray fluoroscopic defecography May be appropriate ☢☢☢ 1-10 mSv 6 n/a 0 0 0 0 0 0 0 0 0
X-ray fluoroscopic cystocolpoproctography May be appropriate ☢☢☢ 1-10 mSv 6 n/a 0 0 0 0 0 0 0 0 0
MR defecography with rectal contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis dynamic with rectal contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
US pelvis transvaginal May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
US pelvis transperineal May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
US pelvis transabdominal Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT pelvis with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Defecatory dysfunction. Straining during defecation, difficulty initiating defecation, incomplete evacuation, or splinting or digital maneuvers to defecate.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
X-ray fluoroscopic defecography Usually appropriate ☢☢☢ 1-10 mSv 9 n/a 0 0 0 0 0 0 0 0 0
MR defecography with rectal contrast Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
X-ray fluoroscopic cystocolpoproctography Usually appropriate ☢☢☢ 1-10 mSv 7 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis dynamic with rectal contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
US pelvis transperineal May be appropriate O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis endorectal coil Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
US pelvis transvaginal Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US pelvis transabdominal Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US pelvis transrectal Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT pelvis with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Clinically suspected postoperative complication following pelvic floor repair.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT pelvis with IV contrast Usually appropriate ☢☢☢ 1-10 mSv 8 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without and with IV contrast May be appropriate ☢☢☢☢ 10-30 mSv 6 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
US pelvis transvaginal May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without IV contrast May be appropriate ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
US pelvis transabdominal May be appropriate O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
US pelvis transperineal Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
X-ray fluoroscopic defecography Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
X-ray fluoroscopic cystocolpoproctography Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
MR defecography with rectal contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis dynamic with rectal contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
US pelvis transrectal Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis endorectal coil Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Clinically suspected recurrent prolapse and pelvic floor dysfunction following pelvic floor repair.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US pelvis transperineal Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0
MR defecography with rectal contrast Usually appropriate O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
X-ray fluoroscopic cystocolpoproctography Usually appropriate ☢☢☢ 1-10 mSv 7 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis dynamic with rectal contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
US pelvis transvaginal May be appropriate O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis endorectal coil May be appropriate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
US pelvis transrectal May be appropriate O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
US pelvis transabdominal Usually not appropriate O 0 mSv O 0 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
X-ray fluoroscopic defecography Usually not appropriate ☢☢☢ 1-10 mSv 2 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT pelvis without and with IV contrast Usually not appropriate ☢☢☢☢ 10-30 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CT pelvis with IV contrast Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.