Back to Menu
🚽

Defecography Report Assistant

Fill the fields, or load an existing draft to adjust; the Findings and Impression build below for copy/paste. Grades auto-derive from the measurements but can be overridden. How-to-measure notes sit under each heading.
Load an existing draft report

Paste a Findings block (with or without the Impression) that this tool produced. It is read back into the fields below, so you can change a measurement or grade and copy the rebuilt report. Text you added by hand that the tool does not produce is listed after parsing and will not be carried into the rebuilt report.

Set-up for every measurement. Work on the mid-sagittal dynamic images. Draw the pubococcygeal line (PCL) from the inferior edge of the pubic symphysis to the last coccygeal joint, not the coccygeal tip. Measure at three points in the exam: rest, Kegel (squeeze), and maximal defecation (the frame of greatest strain or lowest position). Distances to the PCL are taken perpendicular to it; enter the number and pick above or below.

Methods paraphrased from Revels et al., RadioGraphics 2022, and the Pelvic Floor Disorders Consortium consensus (Gurland et al., AJR 2021).

Posterior compartment

Anorectal angle (degrees)
Angle between a line along the posterior wall of the distal rectum and a line along the long axis of the anal canal. Use the same two landmarks on all three phases so the change is comparable. Expected pattern: the angle narrows with Kegel and widens with defecation, by roughly 15-20 degrees each way. Narrowing or no change on defecation points to dyssynergia.
° ° °
Findings: resting angle, expected narrowing during Kegel, and during defecation.
Anorectal junction vs PCL (normal <2 cm below)

Mark the anorectal junction at the posterior rectal wall where it meets the axis of the anal canal (the same point that ends the H-line). Drop a line from it perpendicular to the PCL and measure that length in cm, at rest and again at maximal defecation. At rest the junction normally sits no more than 2 cm below the PCL.

Perineal descent is how far the junction drops from its resting position to its lowest point on straining, so enter both the rest and defecation values. The PFDC calls descent present when that drop is more than 2 cm and asks for the drop in cm rather than a grade. The finding below is derived from your two numbers, and the Findings text states the drop.

cm
cm
cm
Findings: anorectal junction at rest, with descent during defecation.
Other posterior findings
Peritoneocele, enterocele, sigmoidocele. Name the sac by its contents: peritoneal fat only is a peritoneocele, small bowel an enterocele, sigmoid a sigmoidocele. Look on the last frames of defecation, when the rectum is empty. Give the lowest point in cm below the PCL, where it sits relative to the vagina (top, middle, or pelvic floor level), and whether it compresses the rectum and impairs emptying. For example: Small-bowel enterocele reaching 3.0 cm below the PCL, to the mid vagina.

Rectocele depth. Use the frame of maximal straining or evacuation. Draw a reference line that continues the expected course of the anterior rectal wall upward from the anterior edge of the anal canal, that is, where the wall would lie if there were no bulge. Then measure the greatest distance from that line to the most displaced point of the anterior rectal wall, perpendicular to the line. Enter that single depth in cm.

Measure to the rectal wall, not to the contrast or stool column and not to the vaginal wall. A bulge under about 2 cm is common in asymptomatic women, so report the number rather than a size word, and say separately whether the rectocele empties or traps contrast and whether the posterior vaginal wall bulges with it. The Impression grade below is derived from this number (under 2 cm grade I, 2 to under 4 cm grade II, 4 cm and over grade III).

depth reference line anal canal rectum ← anterior posterior →
Schematic, mid-sagittal, maximal straining. Depth is the widest gap between the dashed line and the displaced anterior wall.
cm (blank = none)
Classify by how far the leading edge (apex) travels during defecation: intrarectal (stays within the rectum), intra-anal (reaches the anal canal), or extra-anal (external prolapse). Note whether it is full thickness and whether it impairs emptying. It is present in a large share of asymptomatic volunteers, so it needs clinical correlation. The three location choices below are the PFDC minimum classification.

Middle compartment

Use the lowest point of the vaginal apex or cervix (the vaginal cuff after hysterectomy). Measure perpendicular to the PCL at rest and at maximal defecation, then choose above or below. Pick the landmark label that matches the anatomy so the report names the right structure.
location relative to PCL
cm
cm

Anterior compartment

Bladder — most caudal extent vs PCL
Take the lowest point of the bladder base and measure its perpendicular distance to the PCL at rest and at maximal defecation. The cystocele grade below is derived from the defecation distance below the PCL. Urethral hypermobility is a present or absent call, made by comparing the position of the urethra and bladder neck between rest and straining; the consensus gives no numeric cutoff.
cm
cm

Post-defecation Valsalva

An extra strain sequence acquired after evacuation. Look again for a rectocele or cul-de-sac hernia that stool or contrast may have hidden; hernias are seen best with an empty rectum. Choose Performed only if this sequence was actually acquired.

Impression

auto-derived; override as needed
1. Dyssynergic defecation:
2. Anorectal descent: anorectal descent.
3. Rectocele: rectocele.
4. Cystocele: cystocele.

Findings

Impression

PFDC synoptic reporting recommendations

Pelvic Floor Disorders Consortium (ASCRS, SAR, ICS, AUGS, IUGA, SGS) standardized synoptic templates — Fluoro-IMPACT (fluoroscopic) and MRI-IMPACT (MR defecography). Key consensus points:

Anorectal angle

  • Report both the direction (widening vs. narrowing) and the degree of change from the resting baseline to defecation and Kegel (80% consensus) — both are clinically meaningful. Paradoxical narrowing during defecation is the hallmark of pelvic floor dyssynergia.

Evacuation effort & rectal emptying

  • Effort: good / moderate / poor.
  • Degree of emptying relative to initial contrast: 1/3, 2/3, or complete evacuation.
  • Location of any retained contrast (e.g., within a rectocele vs. proximal rectum above an intussusception) — helps differentiate causes of impaired evacuation.

Perineal descent

  • Present/absent (anorectal junction dropping >2 cm from rest to maximal defecation); quantify in cm. On MRD, use the H-line (hiatal AP dimension) and M-line (PCL to anorectal junction). Avoid mild/moderate/severe grading.

Rectocele

  • Quantify in cm (anterior rectal wall displacement, rest → maximal evacuation). Note whether it empties or retains contrast, and whether digital manipulation/splinting was used (suggests biofeedback alone may not improve symptoms). Report concomitant posterior vaginal wall displacement. Avoid small/medium/large grading.

Internal intussusception / prolapse

  • Present/absent; classify at minimum as intrarectal, intra-anal, or external (extra-anal). Oxford grading debated but not mandated. Present in 20–50% of asymptomatic volunteers — clinical correlation essential.

Multi-compartment prolapse

  • Use the PCL as the reference. Anterior: cystocele. Middle: vaginal apex prolapse. Cul-de-sac hernias: type (entero / sigmoido / peritoneocele), relationship to the vaginal apex, and extension below PCL in cm — describe rather than grade. Posterior: rectocele, intussusception, and emptying.

Source: PFDC consensus synoptic reporting (Fluoro-IMPACT / MRI-IMPACT). Note: perineal descent in this tool follows the PFDC (present when the anorectal junction drops more than 2 cm from rest, stated in cm, no grade). The optional Grade I/II/III scheme for rectocele and cystocele is the older convention — the PFDC favors quantitative cm measurements plus descriptive reporting over size grading.

Rectocele grade I (0–2 cm) may be normal in women and is always abnormal in men. Rectocele and cystocele grades do not translate directly to the clinical stage of pelvic floor dysfunction.

Dartmouth Geisel School of Medicine, Department of RadiologyDartmouth Health
© 2026 Matthew Maeder, MD. Original design and implementation, licensed under CC BY-NC 4.0 — share and adapt with attribution; no commercial use.
Educational tool — not a substitute for clinical judgment. No patient-identifiable information.