ESR Essentials: pelvic floor imaging—practice recommendations by the European Society of Urogenital Radiology

Pelvic floor dysfunction is a common and underdiagnosed condition affecting urinary, gastrointestinal, and sexual function. Imaging plays a pivotal role in diagnosis and treatment planning, yet approaches to technique, interpretation, and reporting remain inconsistent. This article, authored by members of the ESUR Pelvic Floor Working Group, provides practical recommendations for the use of fluoroscopic defecography, MR defecography, and pelvic floor ultrasound, including standardized protocols, key measurements, and a structured, compartment-based interpretation strategy. We detail the imaging features of anterior, middle, and posterior compartment disorders and highlight common pitfalls. Implementing these recommendations by adopting the suggested protocols and reporting approach in routine practice will help ensure consistent, clinically relevant pelvic floor assessments. KEY POINTS: Pelvic floor dysfunction frequently involves multiple compartments, and MRI provides a detailed structural and functional assessment of all pelvic compartments. Fluoroscopic defecography remains the mainstay for the evaluation of defecatory disorders. Pelvic floor ultrasound is increasingly valuable for triaging pelvic floor dysfunction and for detailed assessment of pelvic floor anatomy and anal sphincter integrity.