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BACKGROUND Anorectal manometry is the most commonly performed test of anorectal function. The cough-anorectal response is frequently assessed as part of a routine manometric investigation but has not previously been the subject of detailed analysis. This study systematically examined anorectal pressure responses to cough in health and evaluated the impact of parity and symptoms of fecal incontinence (FI) on measurements. METHODS High-resolution anorectal manometry (HR-ARM) traces from nulliparous (n = 25) and parous (n = 25) healthy volunteers (HV: aged 41, range 18-64), and 57 parous patients with FI (age 47, range 28-72) were retrospectively reviewed. Cough-anorectal pressure responses were analyzed between groups by qualitative and quantitative approaches. KEY RESULTS In health, traditional anal pressure measurements ("rest" and "squeeze") were similar between nulliparous and parous women. In contrast, incremental anal-rectal pressure difference during cough significantly differed: nulliparous 42 mm Hg (95% CI: 21-64) vs. parous 6 mm Hg (-14-25), P

Purpose Fecal continence is maintained by voluntary and involuntary contraction of the anal sphincter, and voluntary contractions of puborectal muscle. We investigated whether the puborectal muscle can control fecal continence not only by voluntary contractions but also by involuntary contractions. Methods We performed anorectal function tests in 23 healthy subjects. The anorectal pressure test was used to investigate voluntary contractions of the puborectal muscle. The balloon retention test was used to assess if the puborectal muscle can contract involuntarily. Results During the balloon retention test, we observed an involuntary contraction of the puborectal muscle, which gradually increased during progressive filling of the rectum. The maximal involuntary contraction of the puborectal muscle was significantly stronger and longer than its maximal voluntary contraction (150 versus 70 mmHg, P

WOS: 000401428700032, PubMed: 27083462, Transanal endorectal pull-through (TEPT) is the latest advancement in the treatment of Hirschsprung's disease (HD). The aim of this study was to evaluate the safety and efficacy of TEPT as a definitive treatment for patients with HD. A retrospective study of 50 patients who underwent TEPT at Uludag University, Bursa, Turkey, between June 2001 and April 2012 was conducted. These patients were evaluated with regard to their age, sex, preoperative findings, and length of the aganglionic segment, intraoperative and postoperative complications, and results of the follow-up. Forty-three patients were boys and seven were girls. The median age was 3 months (range 0-96 months). The most common symptoms were abdominal distention and vomiting. HD was diagnosed in 38 patients using barium enema and anorectal manometry, in 11 patients using rectal biopsy, and in 1 patient using laparotomy with biopsy. The mean time from the beginning of enteral feeding was 2.2 +/- 1.1 days. The mean follow-up period was 26.7 +/- 20.8 months. The postoperative complications included transient perianal excoriation in 12 patients, enterocolitis in 10, anastomotic stricture in 3, soiling in 3, recurrent constipation in 2, prolapse of the pulled through colon in 1, anastomotic leak in 1, and rectovestibular fistula in 1 patient. TEPT is a feasible and safe procedure in children with rectosigmoid HD.

Methane (CH4)-producing intestinal bacteria might be related to constipation. This study was carried out to evaluate the association between breath CH4, colonic transit, and anorectal pressure in constipated patients.A database of consecutive 62 constipated patients fulfilling the Rome III with the lactulose CH4 breath test (LMBT), a colon marker study, and anorectal manometry was studied. The profile of LMBT in patients was compared with 49 healthy controls. The positivity to LMBT (LMBT+) was defined as CH4 of at least 10 ppm in baseline or above baseline within 90 min. There were two types of constipation: normal and delayed transit.There were significant differences in the breath CH4 between patients with delayed transit and (a) normal transit from 0 to 135 min or (b) healthy controls from 0 to 180 min. The LMBT+ was higher in delayed transit patients than in healthy controls (58.8 vs.12.2%) or in normal transit patients (vs. 13.3%), respectively (P0.01). The delayed transit was the only independent factor for LMBT+ [odds ratio (95% confidence interval), 27.8 (3.32-250.00), P0.01]. The left and total colonic transit time were significantly increased in LMBT-positive than in LMBT-negative patients. Significant correlations were found between total CH4 and the time of left or total colonic transit. However, no difference was found in the parameters of manometry by LMBT status.A positive breath CH4 was associated with delayed colonic transit and left colon, and it could be a new therapeutic target for the management of constipated patients with delayed colonic transit.

Introduction: The gastrointestinal system is frequently affected in patients with diabetes mellitus (DM). Some of these alterations are due to oxidative stress and the production of free radicals. The present study was designed to evaluate whether treatment with superoxide dismutase (SOD) exerts protection on established bowel alterations in experimental diabetes mellitus induced by streptozotocin. We measured the lipid peroxidation, the superoxide dismutase activity and the DNA damage. Materials and Methods: We used the anorectal pressure to evaluate the nitrosative stress and used an inflammatory score to measure the macroscopic and microscopic bowel alterations. Results: The oxidative stress and the DNA damage was elevated in DM group and reduced with the SOD administration. The use of SOD also ameliorates the inflammatory bowel alterations and the anorectal pressure. Conclusion: SOD administration showed beneficial effects in all parameters of large bowel alterations in DM rats.

Objective: To investigate the value of anorectal manometry, combined with measuring pelvic floor muscle tension, to assess the anorectal dynamics of patients with pelvic floor organ prolapse accompanied by outlet obstruction. Methods: 30 patients with pelvic floor organ prolapse and 30 healthy volunteers were included in the observation group. The relationships between anorectal pressure and pelvic floor muscle tension, the patients’ subjective and objective symptoms, and posterior vaginal wall prolapse were analyzed in both groups. Results: No significant difference was observed in the anorectal pressure between the observation group during straining to defecate and the control group (p = 0.098). Statistically significant differences were found in the initial rectal sensory volume, the maximum tolerated volume, and the initial desire to defecate sensory volume between the two groups (p = 0.020, 0.001 and 0.035, respectively). A decrease in pelvic floor muscle tension was measured in the observation group (p = 0.037). Compared with the control group, the observation group exhibited decreased internal and external anal sphincter resting pressures, elevated rectal perception threshold, and reduced pelvic floor muscle tone. Conclusions: Anorectal manometry, combined with measuring pelvic floor muscle tension, can provide important references for diagnosing and assessing pelvic floor organ prolapse accompanied by outlet obstruction.

Objectives and background: Hysterectomy is the most commonly performed major gynecological operation for both benign and malign gynecologic conditions. After hysterectomy, although some investigators have declared an increased incidence of urinary and anorectal dysfunction, some others could not show any connection. Methods: The voluntary patients were divided in two groups: abdominal hysterectomy (Group 1) and vaginal hysterectomy (Group 2). Anal manometry and all the other examinations of the patients were performed at the Department of General Surgery Endoscopy Unit of Ankara University, Faculty of Medicine. Results: When the quality of life of the patients was assessed before the operation and on the 12th post-operative month via the SF-36 form; it can be seen that body pain parameters of the patients in Group 1 had significantly improved and there is no statistical difference in other parameters. When the effect of hysterectomy on the quality of life of the patients was evaluated by the “Cleveland Clinic Global Quality of Life” form, the statistically significant improvement in the quality of life of the patients in Group 2 was observed. Conclusion: If the type of operation (vaginal or abdominal) is performed due to benign causes, it does not affect the urinary and anorectal functions of the patients. Depending on the decrease of complaints of the patients, it has a positive effect on the quality of life. Keywords: Hysterecetomy, anorectal functions, life quality.

Clinical gastrointestinal manometry studies are currently performed with multilumen water-perfused polyvinyl or strain gauge sensor solid-state catheters. A disposable catheter incorporating air-filled balloons has been developed with performance characteristics suitable for esophageal and anorectal manometry studies. Our aim was to compare esophageal and anorectal pressure measurements using this newly developed catheter with measurements obtained using standard solid-state or water-perfused catheters. Measurements of resting LES pressure, esophageal contraction amplitudes, and anorectal rest and squeeze pressures were obtained in 10 healthy volunteers using a solid-state esophageal catheter, a water-perfused anorectal catheter, and air-filled balloon esophageal and anorectal catheters. Correlation coefficient analysis demonstrated that LES pressures, esophageal contraction amplitudes, and anorectal resting and squeeze pressures were not significantly among between the different catheters. We conclude that recently developed air-filled balloon esophageal and anorectal manometry catheters provide very similar measurements of LES, esophageal body, and anorectal sphincter pressures compared to presently used manometry catheters.

Introduced approximately 10 years ago, high-resolution manometry catheters have fostered interest in anorectal manometry. This review, which accompanies two articles in this issue of Neurogastroenterology and Motility, reviews the methods, clinical indications, utility, and pitfalls of anorectal manometry and revisits the American Gastroenterological Association (AGA) Medical Position Statement on Anorectal Testing Techniques, which was last published in 1999. High-resolution manometry provides a refined assessment of the anorectal pressure profile, obviates the need for station pull-through maneuvers, and minimizes movement artifacts. In selected cases, this refined assessment may be useful for identifying structural abnormalities or anal weakness. However, many manometry patterns that were previously regarded as abnormal are also observed in a majority of healthy patients, which substantially limits the utility of manometry for identifying defecatory disorders. It is our impression that most conclusions of the AGA medical position statement from 1999 remain valid today. High-resolution techniques have not substantially affected the number of publications on or management of anorectal disorders. The ongoing efforts of an international working group to standardize techniques for anorectal manometry are welcome. Although high-resolution manometry is more than an expensive hobby, improvements in catheter design and further research to rigorously define and evaluate these techniques are necessary to determine if they are worth every penny.

OBJECTIVES The aim of this study is to evaluate the three-dimensional anorectal pressure topography of normal healthy adults and patients with paradoxical puborectalis syndrome (PPS) using a novel three-dimensional high-resolution manometry (3D-HRM) of the anorectum. METHODS The 3D-HRM probe has a 6.4 cm long sensing segment that is composed of 256 independent pressure transducers around its circumference. It generates a 3D pressure topographic profile of the anorectum. We evaluated 41 women and 38 men with PPS (median age 52 years), and compared them with 37 women and 34 men who were healthy (median age 51 years). The three-dimensional anorectal pressure topography was evaluated at rest, and during squeeze, stimulated defecation, and balloon inflation. RESULTS Maximum resting pressure, mean resting pressure, high pressure zone length, and residual anal pressure were significantly higher in patients with PPS compared with healthy adults (P

Background The aim of this study was to compare the results of conventional open haemorrhoidectomy as currently practised in Italy (group 1) with stapled haemorrhoidectomy using a 33-mm circular stapling device (group 2). Methods One hundred patients with symptomatic third- and fourth-degree haemorrhoids were enrolled by five hospitals. Patients were allocated to the two groups according to a centralized randomization scheme featuring five permutated blocks of 20. Preoperative clinical examination and anorectal manometry demonstrated no features of anal incontinence. Patients had a clinical and manometric re-evaluation after operation and were asked to complete a clinical diary. After a median of 16 (range 8–19) months patients were administered a standardized questionnaire by telephone. Results Postoperative bleeding requiring haemostatic procedures occurred in three patients in each group. Patients in group 1 complained of moderate pain for a median of 5·3 (range 0–19) days compared with 3·1 (range 0–10) days in group 2 (P = 0·01), while severe pain was present for 2·3 (range 0–24) days in group 1 but only for 1 (range 0–14) day in group 2 (P = 0·03). The median hospital stay was 2 days in group 1 compared with 1 day in group 2 (P = 0·01). In the early days after operation, patients in group 2 had greater difficulty in maintaining normal continence to liquid stools (P = 0·01), but after 30 days the continence score was better in group 2 (P = 0·04). Conclusion Stapled haemorrhoidectomy is as effective as conventional haemorrhoidectomy. Reduced postoperative pain, shorter hospital stay and a trend toward earlier return to work suggest short-term advantages for the stapled technique.

We aimed to investigate the value of scintigraphically determined evacuation fraction (EVF) as an objective follow-up criterion in medically treated children with chronic constipation, and to evaluate the relation between patients' symptoms and rectal emptying rate. Thirty children (m: 22, f: 8, mean age: 8.9 +/- 0.9 year) suffering from chronic constipation were assessed by scintigraphic evacuation study. All patients underwent anal manometric and scintigraphic examinations before their therapy was started. During 3 months, they received conventional laxative treatment for constipation, and scintigraphic studies were repeated in 20 of 30 patients. Scintigraphic examinations consisted of instillation of artificial stool into the rectum up to the volume impending rectal evacuation, and acquisition of pre- and post-evacuation images. EVF values were then calculated from the images using a fixed region of interest. All of the patients had high resting anal canal pressure (75 +/- 12 mmHg) and had positive rectoanal inhibitory reflex. In 14/20 patients (70%) who benefited from therapy, mean EVF changed from 43.6% to 62.2% (p < 0.001), while decreasing in 6120 who did not benefit. The volume arousing rectal evacuation was significantly lower at the second scintigraphic study (261 +/- 98 ml) than the first study (354 +/- 138 ml) (p < 0.05). As a conclusion: 1) EVF was low in chronically constipated children, 2) it was improved after conventional laxative treatment and, 3) radionuclide EVF determination may be a useful method for follow-up.

The purpose of this study is to evaluate normal values and pressure morphology of three-dimensional high-resolution anorectal manometry (3D-HRM) in asymptomatic volunteers and to determine the relationship between objective measurable values, gender, and age. Anorectal pressures and rectal sensation were evaluated in 110 asymptomatic volunteers (46 females and 64 males) ranging in age from 18 to 80 years (median age, 52 years) in left lateral position by three-dimensional high-resolution manometry. Maximum squeeze pressure, residual anal pressure, and intrarectal pressure were significantly higher in males compared to females (p

Background/Purpose There has not been any study comparing laparoscopic abdominoperineal rectoplasty (ARP) with open ARP. This study investigated the true benefits of the laparoscopic approach in infants with high anorectal malformation. Patients and methods A retrospective analysis was performed in 28 infants with high anorectal malformation treated between 1990 and 2007. Fifteen were treated by open ARP, and 13 were treated by laparoscopic ARP. Surgical durations, amount of bleeding, complications, anorectal pressure measurements, barium enema study, and clinical assessment were compared between the 2 groups. Results The amount of intraoperative bleeding was significantly less in laparoscopic ARP (12 ± 11 g) than in open ARP (65 ± 44 g) ( P = .003). Anal resting pressure was 34 ± 9 cm H 2 O after laparoscopic ARP and 31 ± 14 cm H 2 O after open ARP. Anorectal reflex was positive in 1 (7%) of 15 after open ARP and 3 (23%) of 13 after laparoscopic ARP. There was no significant difference in barium enema study and clinical assessment between the 2 groups. With regard to postoperative complications, mucosal prolapse occurred in 10 (67%) of 15 after open ARP and in none of 13 after laparoscopic ARP ( P = .003). Conclusion Benefits of the laparoscopic approach were reduced intraoperative bleeding and a lower incidence of postoperative anal mucosal prolapse. These results indicate that minimal dissection of the mesorectum in laparoscopic ARP may provide those better outcomes.

Although bidets are widely used in Korea, its effects on anorectal pressures have not been studied in detail in terms of the water settings used. Twenty healthy volunteers were placed on a toilet equipped with a bidet, and anorectal pressures were measured with a manometry catheter inserted into the rectum and anal canal before and after using the bidet at different water forces (40, 80, 160, 200 mN), temperatures (24°C vs 38°C), and water jet widths (narrow vs wide). The pressure at anal high pressure zone decreased from 96.1 ± 22.5 to 81.9 ± 23.3 mmHg at water jet pressure of 40 mN and 38°C wide water jet (P < 0.001), from 94.3 ± 22.4 to 80.0 ± 24.1 mmHg at water jet pressure of 80 mN and 38°C narrow water jet (P < 0.001), and from 92.3 ± 22.4 to 79.6 ± 24.7 mmHg at a water jet pressure of 80 mN and 38°C wide water jet (P < 0.001). At other settings, no significant changes were observed. Our results indicate that, in addition to cleansing effect, bidet could be used to reduce anal resting pressure in the same manner as the traditional warm sitz bath under the conditions of low or medium water jet pressure, a warm water temperature, and a wide type water jet.

Background The aim of the study was to evaluate the efficacy of botulinum toxin injection in the treatment of recurrent anal fissure following lateral internal sphincterotomy. Methods Eighty patients were treated with botulinum toxin (30 units Botox® or 90 units Dysport®), injected into two sites of the internal sphincter. Clinical and manometric results were recorded before and after treatment. If symptoms persisted at 2 months, the examiners could decide to re-treat the patient. The same preparation of serotype A of botulinum neurotoxin was used for reinjection. Results One month after injection there was complete healing in 54 patients (68 per cent). Eight patients (10 per cent) reported mild incontinence of flatus that had disappeared spontaneously within 2 months. At 2 months, 59 patients (74 per cent) had a healing scar. After reinjection, 11 of 21 re-treated patients reported mild incontinence to flatus that lasted for a few weeks and resolved spontaneously. Anorectal manometry at 1 month demonstrated a significant reduction in both resting anal pressure and maximum voluntary squeeze pressure (P < 0·001). There were no relapses during a mean value of 57·9 months of follow-up. Conclusion Botulinum toxin is efficacious in patients with recurrent anal fissure following lateral internal sphincterotomy.

Uchikawa K, Takahashi H, Deguchi G, Liu M: A washing toilet seat with a CCD camera monitor to stimulate bowel movement in patients with spinal cord injury. Am J Phys Med Rehabil 2007;86:200–204. The objective was to study the effectiveness of a modified washing toilet seat equipped with a CCD camera monitor and an electronic bidet to facilitate precise hitting of the anal area with water streams to stimulate bowel movement in patients with spinal cord injury (SCI). There were 20 subjects, all of whom had traumatic SCI, were at least 5 mos post acute injury, and could change their position on the toilet seat while watching the monitor. Stimulation of bowel movement with the modified toilet seat was provided for a maximum of 30 mins. Success or failure to induce bowel movement was evaluated as related to injury level, ASIA impairment scale, and ability to voluntarily increase anorectal pressure, measured with a manometory. Bowel movement was successfully induced in 15 of the 20 patients (75%). Success was not related significantly to injury level, ASIA impairment scale, or ability to voluntarily squeeze. Compared with their usual manner of bowel management, for which they spent more than 30 mins, time needed for successful bowel movement was shortened in 11 of 13 patients. No complications were observed. This preliminary study suggests that our newly modified washing toilet seat with a monitoring system could be a useful alternative for bowel management in patients with SCI.

The objective of this paper is to evaluate age and associated factors affecting anorectal pressure profilometry in anal-continent women with lower urinary tract symptoms. One hundred and ten anal-continent women (mean age, 47.7±12.8 years; range, 23–87 years) with lower urinary tract symptoms voluntarily participated in this study after undergoing a complete urogynecological evaluation including a multichannel urodynamic study. Anorectal pressure was evaluated by using a radial four-channel manometry with a water-filled catheter, which was placed 10 cm into the anorectum above the anal verge. We divided the anorectal pressure profile into five segments and four axes to clarify the axis-specific defect or site-specific damage in the sphincter profile. The aging process had a negative effect on the peak resting pressure from the 41 to 100th percentile of the anorectal pressure profile at 12 o’clock, 3 o’clock, and 6 o’clock (P

The development of a silicone fixation device to perform ambulant anorectal manometry is described. This device provides adequate fixation of recording instruments and facilitates prolonged anorectal pressure recording at home, even in patients with a high frequency of defecation.

To study whether anorectal pressure gradients discriminated better than standard anal manometry between patients with fecal incontinence and subjects with normal anal function, anorectal pressure gradients were measured during rectal compliance measurements in 36 patients with fecal incontinence and in 22 control subjects. Anal and rectal pressures were measured simultaneously during the rectal compliance measurements. With standard anal manometry, 75% of patients with fecal incontinence had maximal resting pressure within the normal range, and 39% had maximum squeeze pressure within the normal range. Anorectal pressure gradients did not discriminate better between fecal incontinence and normal anal function, since, depending on the parameters used, 61%-100% of the incontinent patients had anorectal pressure gradients within the normal range. Patients with fecal incontinence had lower rectal volumes than controls at constant defecation urge (median 138 ml and 181 ml, P < 0.05) and at maximal tolerable volume (median 185 ml and 217 ml, P < 0.05). We conclude that measurements of anorectal pressure gradients offer no advantage over standard anal manometry when comparing patients with fecal incontinence to controls. Patients with fecal incontinence have a lower rectal volume tolerability than control subjects with normal anal function.

PURPOSE: The purpose of this study is to establish a simple technique to evaluate anorectal motility and the dynamics of defecation. METHODS: Pressure fluctuations in the rectum and anal canal during 500 ml of saline infusion in the rectum and then a saline evacuation curve were recorded using manometer and uroflowmeter. RESULTS: This study consisted of 37 patients with a mean age of 49.6 years. All patients without problems with defecation showed periodic relaxation of the anal canal, which was synchronized with rectal contractions during saline infusion. The saline evacuation curves of these patients were characterized by short evacuation time and high-peak flow. Of the 13 patients with constipation, 9 showed no rectoanal synchronization and had segmental evacuation curves. The patients with incontinence tended to have poor ability for holding saline in the rectum, resulting in low-peaked evacuation curves. CONCLUSIONS: This simple and noninvasive technique for recording anorectal pressure fluctuations and dynamics of saline evacuation from the rectum enables quantitative and qualitative evaluation of the ability to defecate.

Background: Methane (CH4) producing small intestinal bacterial overgrowth (SIBO) is related with constipation, however its relationship with colonic motility is unclear. The aims were to evaluate breath CH4 associated with colonic transit and anorectal pressure in constipated patients. Methods: The study with prospectively collected database involved 51 constipated patients who underwent lactulose CH4 breath test (LMBT), colon marker study, and anorectal manometry. The profile of LMBT in patients were compared to 49 healthy controls. The positivity to LMBT was CH4≥10 ppm in baseline or above baseline within 90 min. The types of constipationwere defined as normal transit and delayed transit constipation according to retention of ≥20% colonic markers. Results: The mean age of the patient was 57.3 years (range: 41 ~ 80 years) and 13 patients (23.8%) were men. There were significant differences in the breath CH4 at the time points of 0, 15, 30, 45, 60, 75, 90, 105, 120, and 135 minute intervals between the delayed transit patients and 1) normal transit patients, or 2) healthy controls, respectively (Fig 1). The positivity to LMBT were higher in delayed transit patients (53.3%, 8/15), than in healthy controls (13.9%, 5/36) or in normal transit patients (53.3%, 8/15), respectively (P < 0.01). The delayed transit was the only independent factor for the positivity to LMBT (OR (95% CI), 142.86 (3.44 9090.9), P < 0.01). The left and total colonic transit time were significantly increased in LMBT-positive patients than in -negative patients (16.4±13.4 vs. 32.5±16.9, P < 0.01, and 48.1±40.2 vs. 82.4±36.7, P < 0.01). The significant correlation was shown between total breath CH4 and time of left colonic transit (γ = 0.39, P < 0.01) (Fig 2), or total colonic transit (γ = 0.33, P = 0.02). However, no significant difference was observed in parameters of anorectal manometry according to LMBT status. Conclusions: SIBO was associated with delayed colonic transit, especially with left colonic transit time, accordingly, which might create a vicious cycle. Further investigation is needed to break the link by therapeutic modality such as antibiotics to target the CH4 producing intestinal bacteria.

Anorectal pressures in patients with fecal incontinence have been investigated. With anal manometry, 34 percent of patients with fecal incontinence had maximal resting pressure and 39 percent had maximal squeeze pressure within the normal range. When a pressure gradient was calculated as the pressure difference between maximal resting pressure and rectal pressuring during filling of a rectal balloon, patients with fecal incontinence could be better distinguished from controls: 20 percent of patients with fecal incontinence had values within the normal range when the rectal pressure at the earliest defecation urge was used (P less than 0.05), and 12 percent had values within the normal range when the rectal pressure at maximal tolerable volume was used (P less than 0.01). Anorectal pressure gradient measurements seem to distinguish patients with fecal incontinence from controls better than maximal resting pressure or maximal squeeze pressure alone.

The diagnosis of neuronal intestinal dysplasia (NID) is currently established by histochemical procedures. From October 1, 1981, until July 31,1990, we submitted a total number of 737 patients under 15 years of age with several distinct colonic and anorectal disorders, to clinical, radiological, electromanometrical, histochemical and histological evaluation. 573 had a clinical diagnosis of chronic constipation, and in 38 of these NID could be demonstrated by histochemical examination. Motivated by our own findings with the anorectal electromanometry in these patients we performed a double-blind prospective study to find out if there are any particular and pathognomonic manometric parameters of NID in childhood. 80 % of our patients with NID diagnosed prospectively since April 1st, 1986, had a relaxation of the internal anal sphincter which was not proportional to the volume of rectal distention. Anorectal hyperexcitability was also present in these patients, whereas a statistically highly significant (p

To characterize spontaneous anorectal pressure activity and a possible relation between the activity in the rectum and the anal canal, 11 healthy female volunteers were investigated. Resting activities were obtained during 1-h recordings with a multi-channel perfused catheter measuring the pressure 1, 2, 3, 7, and 8 cm from the anal verge. In five subjects sequences of rhythmic rectal pressure waves with amplitudes exceeding the maximal anal resting pressure coincided with a similar internal anal sphincter activity, preventing rectal pressure from exceeding the anal pressure at any point. The mean frequency was 5 x min-1 (range, 3-6 x min-1). This may well be a reflex mechanism by which the internal anal sphincter prevents incontinence in the resting state. Low-frequency pressure waves, not previously described, were detected in four women. These pressure waves were attributed to the internal anal sphincter and were named ultra-slow waves type II. The mean frequency and amplitude were 0.16 x min-1 (range, 0.15-0.17 x min-1) and 24 cm H2O (range, 11-41 cm H2O), respectively. The function of these pressure waves is unknown.

2,043 anorectal pressure measurements were performed at our hospital during the past 8 years. A majority of the studies, 1,595 measurements (78.1%), involved the differential diagnosis of chronic constipation. The validity of the electromanometry was analyzed on the basis of 332 patients with chronic constipation who were examined during the past 2 years. The electromanometric diagnostic failure rate was 17.6% in newborns up to 4 weeks of age, whereby false negative results predominated, at 11.7%. The diagnostic failure rate subsequently diminished rapidly, and was only 3.4% in the 1-6 month age group 0.6% in children over the age of 5. The overall figure was 1.5%. Among 91 patients with Hirschsprung's disease, a false electromanometric diagnosis was made in 18.5% of cases in the 0-31-day age group. Here too, the diagnostic failure rate decreased with increasing age of the children, to up to 9.5% (1-6 months) and 5.5% (over 5). The overall diagnostic failure rate was 8.7%. When compared with other methods of diagnosing Hirschsprung's disease, however, X-ray studies proved to be no better, with 25.9% false diagnoses in the 1-31-day-olds and an overall failure rate of 16.3%. The histologic diagnosis of Hirschsprung's disease fared the worst: faulty ganglion cell evaluations were made in 29.6% of cases in the 0-31-day age group. The overall diagnostic failure rate here was 16.3%. Acetylcholinesterase staining provided the most favorable results, with 13.3% false diagnoses in 0-4-week-olds and an overall diagnostic failure rate of 10.4%.

In 15 patients suffering from idiopathic faecal incontinence and in 15 matched controls, manometric studies of anorectal pressure and studies of the rectoanal reflex and rectal sensitivity were carried out. Patients with idiopathic faecal incontinence had normal resting pressure but reduced squeeze and stress pressures; the anal sphincter relaxed before a sensation of rectal distension occurred. The conclusion is that both reduced voluntary muscle contraction and impairment of rectal sensation are conducive to soiling in idiopathic faecal incontinence.

Functional results after surgical correction of anorectal malformations were assessed on a clinical basis following Kelly score and by manometric study. Forty-six patients, aged 2--17, were personally interviewed and 25 of these 46 had manometric studies to evaluate postoperative continence. The manometric study was also performed on 35 normal children as a control group. Continent patients characteristically had marked high pressure zones as did the normal subjects. On the other hand, in the patients with fair or poor results, the anorectal pressure profile had no marked high pressure zone in the anal canal. The presence of normal anal pressure at rest as well as adequate ano-rectal pressure difference was found to correlate well with continence. In patients with perineoplasty, the ano-rectal reflex correlated well with continence but not in patients treated by abdominoperineal rectoplasty.

At the Surgical Clinic of the University of Munich, 129 patients underwent sphincter-saving high (distal tumour margin 11–16 cm above the anal verge) and low (distal tumour margin 6–10 cm) anterior resections because of rectal cancer in a period from 1973 to 1981. At the last follow-up, anorectal pressure studies were performed in 41 of these patients. Further investigations were made by questioning for symptoms of continence and incontinence respectively, and so naturally include besides the objective facts a certain amount of subjective judgement on the part of the patients.

This study was carried out on 30 patients with symptomatic internal hemorrhoids and 20 normal controls. The anal sphincter pressure was studied before and after surgery. A significantly high anal pressure was found in all patients with symptomatic internal hemorrhoids, when compared with normal controls, and there was no relation between this increase and the degree of hemorrhoids. One week following surgery, this high pressure was reduced significantly and was not affected by the type of operation. Thus, this increase in resting anal pressure is due to an overactivity of the internal hemorrhoids, which is secondary to the presence of the hemorrhoidal mass.

Functional results after surgical correction of anorectal malformations were assessed on a clinical basis using the Kelly score and by manometric study. In all, 65 patients, aged 5–28 years, were interviewed personally, and 51 of these 65 had manometric studies to evaluate postoperative continence. The manometric study was also performed on 45 normal children as control group. Continent patients characteristically had a marked high-pressure zone, as did the normal subjects. On the other hand, in the patients with fair or poor results, the anorectal pressure profile had no marked high-pressure zone in the anal canal. The presence of normal anal pressure at rest as well as adequate anorectal pressure difference was found to correlate well with continence. In the patients with perineoplasty, the anorectal reflex correlated well with continence, but not in patients treated by abdominoperineal rectoplasty.

Anorectal manometry was performed in 27 patients 2 to 16 years after surgical correction of anorectal malformations and again 3 years after the initial examination. Further clinical improvement from faecal incontinence to normal bowel habits was observed in 3 of 11 patients with high anomaly. All of these 3 patients received special physiotherapeutic training from 3 months to 1 year during the two examinations. At the second examination these 3 patients had an anorectal pressure difference of more than 10 cmH2O, which is almost normal, and one of the 3 patients had developed an anorectal reflex. These results suggest that the functioning puborectalis muscle, which had been left intact during surgery, might be reinforced by physiotherapeutic training.

To clarify the cause of constipation which follows surgery for the supralevator type of disorder associated with the imperforate anus, rectal compliance, percentage maximum static anorectal pressure, and reflex profile were measured by anorectal manometry in 108 normal controls and 42 patients. Patients with constipation had a low percentage anorectal pressure (50%), high rectal compliance, associated with megarectum, and defecation of the staining type with constipation due to a reaction in anorectal motility.

✓ Intraoperative monitoring of anorectal pressure was used in a case of sacral lipomeningocele accompanied by congenital dermal sinus to protect the physiological function of the anorectal sphincters. This monitoring system consists of a manometric anorectal balloon and neural electrical stimulation. The system was able to differentiate functioning neural structures from surrounding tissues during the operation.