Most patients with faecal incontinence require only a full history (information about other predisposing causes) and examination (assessment for faecal impaction and evaluation of sphincter function and structure). When necessary, anorectal physiological studies, endoanal ultrasound and magnetic resonance imaging allow accurate characterization of sphincter function and structure.

Integrated total pelvic floor ultrasound provides a useful screening tool for women with defaecatory dysfunction such that defaecatory imaging can avoided in some.

Total pelvic floor ultrasound is used for the dynamic assessment of pelvic floor dysfunction and allows multicompartmental anatomical and functional assessment. Pelvic floor dysfunction includes defaecatory, urinary and sexual dysfunction, pelvic organ prolapse and pain. It is common, increasingly recognized and associated with increasing age and multiparity. Other options for assessment include defaecation proctography and defaecation MRI. Total pelvic floor ultrasound is a cheap, safe, imaging tool, which may be performed as a first-line investigation in outpatients. It allows dynamic assessment of the entire pelvic floor, essential for treatment planning for females who often have multiple diagnoses where treatment should address all aspects of dysfunction to yield optimal results. Transvaginal scanning using a rotating single crystal probe provides sagittal views of bladder neck support anteriorly. Posterior transvaginal ultrasound may reveal rectocoele, enterocoele or intussusception whilst bearing down. The vaginal probe is also used to acquire a 360°cross-sectional image to allow anatomical visualization of the pelvic floor and provides information regarding levator plate integrity and pelvic organ alignment. Dynamic transperineal ultrasound using a conventional curved array probe provides a global view of the anterior, middle and posterior compartments and may show cystocoele, enterocoele, sigmoidocoele or rectocoele. This pictorial review provides an atlas of normal and pathological images required for global pelvic floor assessment in females presenting with defaecatory dysfunction. Total pelvic floor ultrasound may be used with complementary endoanal ultrasound to assess the sphincter complex, but this is beyond the scope of this review.

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Aim To compare features on imaging (integrated total pelvic floor ultrasound (transperineal, transvaginal) and defaecation proctography) with bowel, bladder and vaginal symptoms in pelvic floor defaecatory dysfunction. Method A prospective observational case series of 216 symptomatic women who underwent symptom severity scoring (bowel, bladder and vaginal), integrated total pelvic floor ultrasound and defaecation proctography. Anatomical (rectocele, intussusception, enterocele, cystocele) and functional (co‐ordination, evacuation) features were examined. Results Irrespective of imaging modality, patients with a rectocele had higher International Consultation on Incontinence Modular Questionnaire – Vaginal Symptoms (ICIQ‐VS) scores than patients without. On integrated total pelvic floor ultrasound, ICIQ‐VS quality of life scores were higher in those with a rectocele. There was a higher International Consultation on Incontinence Modular Questionnaire – Bowel Symptoms (ICIQ‐BS) bowel pattern score in those with a rectocele, and a lower ICIQ‐BS bowel pattern and sexual impact score in those with intussusception. Poor co‐ordination was associated with increased ICIQ‐BS bowel control scores and obstructed defaecation symptom scores. On defaecation proctography, ICIQ‐VS symptom scores were lower in patients with poor co‐ordination. Conclusion Patients with a rectocele on either imaging modality may have qualitative vaginal symptoms on assessment. In patients with bowel symptoms but no vaginal symptoms, it is not possible to predict which anatomical abnormalities will be present on imaging.