Anorectal Inhibitory Reflex Research Articles

OP‐9 MODULATION OF THE RECTOANAL INHIBITORY REFLEX IN PATIENTS WITH MYELOMENINGOCELE WITH AND WITHOUT BLADDER AUGMENTATION

Introduction:Some patients with myelomeningocele need bladder augmentation (augmentation cystoplasty). The aim of this study was to evaluate the relationship between the bladder augmentation and the rectoanal inhibitory reflex (RAIR) modulation in patients with myelomeningocele. The modulation of the anorectal inhibitory reflex in accord the use of oxybutynin chloride was also evaluated.Methods:It is a cross‐sectional and comparative study. We studied a convenience sample consisting of 24 children and adolescents with myelomeningocele aged between 4 and 18 years. Ten of these 24 patients had surgery to expand the bladder. Anorectal manometry of perfusion were performed with 8‐channel radial catheter (Dynamed®) in latex free protocol. The evaluation of the (RAIR) modulation was determined by inflating the balloon with 20 mL of air in rectal. The RAIR modulation was determined by duration (seconds) and amplitude (% relaxation) of RAIR.Results:RAIR was present in all the patients. The duration of the RAIR (seconds) with 20 mL and 40 mL was similar in the both groups, with or without bladder augmentation (27.11 ± 11.95; 27.37 ± 9.29; p = 0.953 and 30.32 ± 7.30; 32.08 ± 10.13, p = 0.653). The RAIR amplitude with 20 mL and 40 mL was higher in the patients with bladder augmentation than in patients without bladder augmentation (63.87 ± 24.58; 82.31 ± 15.94, p = 0.036 and 68.06 ± 14.80;88.93 ± 16.31, p = 0.004). The patients who used oxybutynin chloride presented higher amplitude (% relaxation) in relation those did not used this drug, with 20 mL (80.91 ± 15.37 and 65.21 ± 25.73; p = 0.074) and 40 mL (85.78 ± 15.96 and 73.05 ± 19.29; p = 0.084), however, the statistic evaluation did not reach significance.Conclusions:The RAIR modulation is different between patients with and without bladder augmentation. The use of oxybutynin chloride also appears to interfere in the RAIR, increasing its amplitude.

Detubularised isolated ureterosigmoidostomy (Atta pouch): Manometric and radiological studies in a sample of patients

ObjectivesTo assess whether the detubularised isolated ureterosigmoidostomy (DIUS) technique is safe for urinary diversion after radical cystectomy. Patients and methodsThe study included 10 patients (mean age 61.8years) with invasive bladder tumour, operated at the Alexandria University, Egypt. The diversion in all patients was through a DIUS, with ureteric reimplantation by an antirefluxing procedure, using an embedded-nipple technique. The patients were evaluated before and after surgery using radiological and manometric studies, and the results analysed statistically using Student’s t-test. ResultsNine of the 10 patients could differentiate between urinary and stool sensation, and evacuate them separately. The mean (range) daytime frequency was 4.1 (3–5) and the mean night-time frequency was 0.5 (0–1). Before and after surgery, the respective mean resting anal pressure was 71 and 74cmH2O (P=0.004), the volume at first desire to defecate was 54 and 72mL (P=0.004) and the maximum tolerable volume was 140 and 160mL (P<0.001). The anorectal inhibitory reflex was lost in all patients after surgery. The mean (SD, range) basal pouch pressure was 5 (3.33, 0–10) cmH2O, and the end pressure was 13.2 (4.42, 9–20) cmH2O. ConclusionAlthough the Mainz II pouch has a documented efficacy for urinary diversion after radical cystectomy, the modifications we applied to the DIUS improved that method of diversion, by separating urine and stool evacuation, maintaining continence, and with a low frequency and better protection of the upper urinary tracts, resulting in an improvement in the patients’ quality of life.

1165 COMPARISON OF MANOMETRIC AND RADIOLOGIC FINDINGS IN SIGMA VS. DETUBULARIZED ISOLATED URETEROSIGMOIDOSTOMY (ATTA POUCH)

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion1 Apr 20121165 COMPARISON OF MANOMETRIC AND RADIOLOGIC FINDINGS IN SIGMA VS. DETUBULARIZED ISOLATED URETEROSIGMOIDOSTOMY (ATTA POUCH) Tamer Abou Youssif, Grgs Fawzy, Wael Sameh, and Mohammed Atta Tamer Abou YoussifTamer Abou Youssif Alexandria, Egypt More articles by this author , Grgs FawzyGrgs Fawzy Alexandria, Egypt More articles by this author , Wael SamehWael Sameh Alexandria, Egypt More articles by this author , and Mohammed AttaMohammed Atta Alexandria, Egypt More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1389AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Detubularized Isolated Ureterosigmoidostomy (DIUS) involves detubularization of the rectum and sigmoid colon and refashioning into an isolated pouch with fixation of the new non-dismembered left colon stoma into posterior rectal wall facing the anal canal (Atta MA, J Urol, 1996). Improvement bowel evacuation pattern, and absence of urgency and nocturnal wetting was shown in a previous study. The present study provides rectodynamic as well as radiologic evidences for improved function following DIUS. METHODS This study was conducted on 20 patients divided into two groups: group(A) including ten patients scheduled for radical cystectomy and urinary diversion by DIUS, and group (B) including ten patients who had previously underwent radical cystectomy and urinary diversion by sigma rectum pouch (Mainz II). The rectal and anal pressures as well as the anorectal inhibitory reflex were measured preoperatively and repeated 6 months in both groups. Ascending pouchography was done postoperatively with incremental increase of the infused volume till 500 ml, and post-evacuation film was taken to confirm complete colon evacuation. Comparison of both groups was done using Student t-test. RESULTS In group A there was a statistical significant difference between preoperative and postoperative mean resting anal pressure, which was 71 ± 4.007 (66-80) cmH2O and 73.9 ± 4.42 (69-83) cmH2O respectively. There was no significant difference between post-operative mean resting anal pressure in group A and B. In group A the mean basal pouch pressure was 5 ± 3.33 (0-10) cmH2O, mean end pressure was 13.2 ± 4.42 (9-20) cmH2O and contraction waves were found in one patient with pressure up to 40 cmH2O. In group B the mean basal pouch pressure was 7 ± 2.58 (5-10) cmH2O, mean end pressure was 17.7 ± 6.11 (10-30) cmH2O and contraction waves were found in three patients with pressure up to 40 cmH2O The anorectal inhibitory reflex was lost in all patients of group A after surgery. All patients of group B showed preserved anorectal reflex. Pouchogram with a maximum infused volume of 500 ml showed no reflux to the colon or the ureters in group A, with full emptying on post evacuation films. In group B eight patients had reflux up to the transverse colon starting at 350 ml and became more evident at 500 ml in all patients, with failed emptying post evacuation films. CONCLUSIONS Detubularization of the rectum and sigmoid results in a capacious low pressure pouch with absent anorectal inhibitory reflex, consequently decreasing the frequency of evacuation without any urgency. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e472 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tamer Abou Youssif Alexandria, Egypt More articles by this author Grgs Fawzy Alexandria, Egypt More articles by this author Wael Sameh Alexandria, Egypt More articles by this author Mohammed Atta Alexandria, Egypt More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Megarectum after surgery for anorectal malformations

Purpose Megarectum complicating surgery for anorectal malformation (ARM) has implications for long-term continence. Factors influencing continence and defecation include intact rectal reservoir, innervation/proprioception of the anorectal muscle complex, functioning anorectal inhibitory reflex (AIR), and intact perception at the anal margin. We studied outcomes after surgery for ARM with emphasis on megarectum; particularly as to whether altered rectal proprioception from anatomic sacrococcygeal anomalies affect incidence. We also assessed whether an abnormal AIR could trigger passive rectal dilatation without mechanical obstruction. Methods Eighty six infants (53 male) with ARM over 20 years were included. Demographics, surgical history, pathology, defecation patterns, imaging, manometry, and morbidity were analyzed. Incidence of sacrococcygeal malformations in children with and without megarectum was compared using Fisher exact test. Manometry results were evaluated for integrity of AIR and correlated to megarectum occurrence. Results There were 23 high/intermediate and 63 low ARMs. Fourteen (16%) developed a megarectum: 6 of 23 in high and 8 of 63 in low anomalies ( P = .33). Twelve patients underwent megarectum resection at a median of 2.6 years (7 months to 10 years); 2 received bowel management protocols. Fifty-seven percent (8/14) of children with and 7% (5/72) without megarectum had sacrovertebral anomalies ( P = .0001). Patients with preoperative manometry (n = 5) demonstrated an intact AIR. Colonic manometry demonstrated hyperactive colons (n = 2). Constipation was the predominant preoperative symptom; 3 patients suffered from incontinence after resection. All the specimens showed normal innervation and thickened muscularis on pathology. Conclusions Sacral anomalies, which are more prevalent in children who developed megarectum, may result in abnormal rectal proprioception contributing to this pathology. Innervation anomalies may coexist, although preoperative manometries showed normal AIRs. Rectal dysmotility may lead to stool retention with subsequent dilatation, and patients who underwent colonic manometry had diffuse colonic hypermotility. Further physiologic and cellular studies are needed to elucidate the causes of this significant complication after surgical ARM repair in the absence of obstruction.

Multiple Rectal Polyps in a Young Woman with Constipation

A 27-year-old Asian-American woman presented for evaluation of long-standing constipation. Her first severe episode of constipation occurred at age 7 and resolved with colonic lavage. Colonoscopy at that time was normal. She then experienced complete resolution of her symptoms from ages 7 to 17, when she started again experiencing defecatory difficulties with infrequent and hard stools, difficulties with evacuation, and a sensation of incomplete rectal emptying. On presentation in July 2009, she was dependent on two Senna pills per day; without them, she would not have a bowel movement for up to 1 week. She also reported episodes of rectal bleeding or blood in toilet paper, and abdominal bloating and pain that were relieved with bowel evacuation, as well as continuous and severe straining at evacuation with a feeling of incomplete evacuation. She did not, however, use finger manipulations to facilitate defecation. Her past medical and surgical history was negative and she was using no other medications except for oral contraceptives and multivitamins. She was single, worked as a program manager, lived with her boyfriend, and exercised 3–4 times/week. She did not smoke cigarettes, and drank wine socially. She was vaccinated against human papillomavirus (HPV). Family history was significant for her mother having lung cancer and her father with diabetes mellitus; she had one healthy sister. Upon further review of systems, she reported 8 lbs of weight gain, general fatigue, headaches, and mild anxiety. Her physical examination was normal except for small external hemorrhoids. Complete blood count, comprehensive chemistry panel, and thyroid function tests were all normal. On initial assessment of her constipation, a lactulose breath test was negative. A colon transit study using Sitzmarks was normal. An anorectal motility and compliance study showed a normal anal sphincter length of 5 cm, a normal internal anal sphincter pressure of 72 mmHg, and a slightly decreased external anal sphincter pressure of 91 mmHg. Rectal sensation was impaired since she barely sensed a rectal balloon filled with 50 cc of water. The anorectal inhibitory reflex was present and elicited with 30 cc of balloon distention, thereby excluding Hirschsprung’s disease. Rectal compliance was normal, but she was unable to expel an empty rectal balloon, which was suggestive of pelvic floor dysfunction. Colonoscopy revealed multiple inflammatory polyps in the rectal vault extending circumferentially to the anorectal junction. Biopsies of the polyps were performed and were associated with significant oozing that required control with application of hemostatic clips (Fig. 1). Pathologic examination of the polyp biopsies revealed six separate fragments of rectal mucosa. Five of these fragments showed polypoid hyperplastic mucosa with areas of ulceration, consistent with rectal prolapse. One of these fragments showed an area of moderate squamous epithelial dysplasia (AIN 2). No evidence of an invasive lesion was identified (Fig. 2). Despite her previous vaccination history, HPV immunohistochemistry was positive. She was then treated with polyethylene glycol twice daily for the next 3 months with some improvement of her G. Triadafilopoulos (&) Division of Gastroenterology and Hepatology, Stanford University Medical Center, Alway Building, Room M 211, 300 Pasteur Drive, MC: 5187, Stanford, CA 94305-5187, USA e-mail: vagt@stanford.edu

Botulinium toxin, as bridge to transanal pullthrough in neonate with Hirschsprungs disease

Aims and Objectives:The aim of this study is to find easier way of home care while obviating the colostomy before single stage pull through operation.Materials and Methods:From August 2005 to December 2006, eight cases of neonatal Hirschsprung disease were treated. Mean age 4.5 (2-6) day/old with absent anorectal inhibitory reflex, rectosigmiod disease in Barium enema, positive Acetylcholine esterase (Ache) staining, good response to rectal washout. They underwent botulinium toxin injection (5 unit /kg/quadrant) in four quadrant intrasphincteric. They were followed until pull through operation in 8-10 weeks post injection.Results:Four of 8 (50%) cases only needed rectal washout for three to five days post injection until pull through operation, two had decrease in number of rectal washouts /day and the remaining two underwent colostomy five days post injection because of no response.Conclusion:Botulinium toxin injection can help in palliative care in patients with Hirschsprung disease who are waiting for colostomy or definitive pullthrough. It gives an option of eaiser home care for these patients.

Impaired anal sphincter function in professional cyclists

The purpose of our study was to assess anal function in professional mountain bikers, as an increasing number of cycling enthusiasts report functional and morphological problems in the anal region. We tried to find out if constant saddle vibration suffered by professional cyclists could lead to defecation disorders. 19 professional male mountain bikers took part in this study. The findings were compared with those of a control group (CG) of healthy volunteers who rode bikes less frequently. Both groups underwent rectal examination and anorectal manometry. Rectal sensation, rectal compliance and the anorectal inhibitory reflex were also assessed. Information on anal pain, blood on the toilet tissue, history of hemorrhoids, anal fissure, abscess formation and problems with defecation was collected by questionnaire and local examination was carried out. Sphincter resting pressures (89 +/- 27 mmHg vs CG: 69 +/- 16 mmHg), squeeze pressures (137 +/- 36 mmHg vs CG: 96 +/- 19 mmHg) and sphincter volumes (resting vector volume: 513 +/- 277 cc vs CG 273 +/- 170 cc, squeeze vector volume: 1389 +/- 867 cc vs CG: 490 +/- 219 cc) were significantly higher in the professional mountain bikers. Values reflecting rectal sensation (sensory threshold: 51 +/- 32 ml vs CG: 46 +/- 12 ml) were not significantly different between the groups. Proctological problems are very common in professional mountain bikers. Permanent microtrauma through constant saddle vibration may lead to chronic inflammation and anal fissure resulting in anal pain and therefore high sphincter pressure. Muscle hypertrophy as a consequence may lead to defecation disorders.

Characterization of anorectal pressure and the anorectal inhibitory reflex in healthy preterm and term infants

Objectives: To evaluate anorectal motor function in healthy premature and term infants with the use of micromanometric techniques. Study design: Anorectal manometry was performed in 22 healthy neonates (9 female) with a mean postmenstrual age of 32 weeks (range, 30 to 38 weeks) with a micromanometric anorectal assembly (od 2.0 mm). The assembly incorporated a 2-cm-long sleeve sensor for measurement of resting anal sphincter pressures and relaxation, and 4 sideholes recorded anal and rectal pressures. Rectal distension was performed with a latex balloon or direct air insufflation to elicit the anorectal inhibitory reflex (AR). Results: The mean anal sphincter pressure, rectal pressure, and rhythmic wave frequency were 40 mm Hg (range, 7 to 65 mm Hg), 11 mm Hg (range, 1 to 27 mm Hg), and 10/min (range, 8 to 14/min), respectively. A normal AR could be elicited in 21 of the 22 infants studied. Conclusion: An anorectal micromanometric sleeve catheter is suitable for use in evaluating anorectal pressures in preterm and term neonates. Insufflation of air without the use of a balloon to elicit the AR is reliable and suitable for use in infants <34 weeks. Premature infants older than 30 weeks’ postmenstrual age have normal anorectal pressures and a normal AR. (J Pediatr 2001;139:233-7)

Functional outcome of stapled ileal pouch-anal canal anastomosis versus handsewn pouch-anal anastomosis.

This study was conducted to determine whether stapled ileal pouch-anal canal anastomosis (IACA) preserving the anal transitional zone (ATZ) or hand-sewn ileal pouch-anal anastomosis with mucosectomy (IPAA) is more beneficial in achieving disease eradication and better postoperative function. IACA was performed in 10 patients with ulcerative colitis (UC) and 10 patients with familial adenomatous polyposis (FAP), 15 of whom were examined proctoscopically. IPAA was performed in 4 patients with UC and 8 patients with FAP. The mean maximum resting pressure (MRP) was 55 mmHg in the IACA group and 34 mmHg in the IPAA group (P < 0.01). The anorectal inhibitory reflex was positive in 18 patients (90%) from the IACA group and 5 (42%) from the IPAA group (P < 0.05). The pre- and postoperative MRPs were 61 mmHg and 55 mmHg, respectively, in the IACA group vs 63 mmHg and 34 mmHg, respectively, in the IPAA group (P < 0.01). Whereas 16 (80%) of the 20 IACA patients could discriminate feces from gas, only 4 (33%) of the 12 IPAA patients could (P < 0.05). The mean observation period was 2.3 years, the mean length of the columnar cuff was 2.8 cm, and no case of dysplasia or adenoma was seen. Postoperative function is more favorable following IACA than following IPAA, both physiologically and symptomatically. However, long-term surveillance of the residual mucosa is necessary before making a final recommendation.

The effect of hysterectomy on ano-rectal physiology.

Hysterectomy is associated with severe constipation in a subgroup of patients, and an adverse effect on colonic motility has been described in the literature. The onset of irritable bowel syndrome and urinary bladder dysfunction has also been reported after hysterectomy. In this prospective study, we investigated the effect of simple hysterectomy on ano-rectal physiology and bowel function. Thirty consecutive patients were assessed before and 16 weeks after operation. An abdominal hysterectomy was performed in 16 patients, and a vaginal procedure was performed in 14. The parameters measured included the mean resting, and maximal forced voluntary contraction anal pressures, the recto-anal inhibitory reflex, and rectal sensation to distension. In 8 patients, the terminal motor latency of the pudendal nerve was assessed bilaterally. Pre-operatively, 8 patients were constipated. This improved following hysterectomy in 4, worsened in 2, and was unchanged in 2. Symptomatology did not correlate with changes in manometry. Although, the mean resting pressure was reduced after hysterectomy (57 mmHg-53 mmHg, P = 0.0541), the maximal forced voluntary contraction pressure was significantly decreased (115 mmHg-105 mmHg, P = 0.029). This effect was more pronounced in those with five or more previous vaginal deliveries (P = 0.0244, n = 9). There was no significant change in the number of patients with an intact ano-rectal inhibitory reflex after hysterectomy. There was no change in rectal sensation to distension, and the right and left pudendal nerve terminal motor latencies were unaltered at follow-up. Our results demonstrate that hysterectomy causes a decrease in the maximal forced voluntary contraction and pressure, and this appears to be due to a large decrease in a small group of patients with previous multiple vaginal deliveries.

Treatment of benign anal disease with topical nitroglycerin

Fissure-in-ano and acutely thrombosed external hemorrhoids are common, benign anal conditions, usually characterized by severe anal pain. Internal anal sphincter hypertonia appears to play a role in the etiology of this pain. Nitric oxide has recently been identified as the "novel biologic messenger" that mediates the anorectal inhibitory reflex in humans. This report documents a therapeutic role for nitroglycerin, a nitric oxide donor, in the treatment of acutely thrombosed external hemorrhoids and anal fissure. Five patients with thrombosed external hemorrhoids and fifteen patients with anal fissure or ulcer were identified. A treatment regimen that included 0.5 percent nitroglycerin ointment applied topically to the anus was instituted. After one week of therapy, all patients were re-examined and questioned regarding pain relief and side effects of treatment. Fissure patients were followed for eight weeks or until healing occurred. All patients reported dramatic relief of anal pain following application of nitroglycerin. Pain relief lasted from two to six hours. Complete healing of fissures occurred within two weeks in ten patients and within one month in two patients. One patient, whose fissure had not healed completely within two weeks requested surgical sphincterotomy. Two patients remained with persistent anal ulcers despite two months of therapy. Both, however, were pain-free. Side effects were limited to transient headache in 7 of 20 patients. Topically applied nitroglycerin ointment appears to have a therapeutic role in the treatment of thrombosed external hemorrhoids and anal fissure.

The position of the patient does not adversely influence the results of the most clinically important measurements of anorectal function.

Anorectal physiological measurements were carried out in three groups of patients: Controls (n = 11), slow transit constipation (n = 21) and neuropathic faecal incontinence (n = 14) to examine whether the position of the patient influenced the result of tests of anorectal function. Measurements were made in both the conventional left lateral and the seated position. No significant differences were observed in the pressures within the anal canal at 2 cm from the anal verge, the usual site of maximum resting and maximum squeeze pressures, although, at 4 cm pressures were significantly different in the two positions. With all other tests including rectal compliance, anorectal inhibitory reflex and rectal sensation there was no significant difference due to position in any of the three clinical groups. We conclude that the left lateral position is generally satisfactory for measurement of the most clinically important aspects of anorectal function.

Adult Hirschsprung's disease

Two cases of adult Hirschsprung's disease are reported along with a review of 47 cases reported in the literature. Chronic constipation is present in almost all cases. The barium enema examination may suggest the diagnosis if an area of smooth narrowing with proximal dilatation is seen (83%), but biopsy proof of absence of ganglion cells is necessary. Fourteen per cent of patients had a dilated colon without a narrowed segment. Anal manometry is helpful if it demonstrates absence of normal anorectal inhibitory reflex. Total colonic aganglionosis in the adult has been reported, but is exceptionally unusual. The diagnosis of adult Hirschsprung's disease should be suspected in patients with a history of chronic constipation and appropriate radiographic findings.

Physiologic and anatomic assessment of patients with rectocele

Clinical, physiologic, and anatomic assessments were carried out in 22 female patients with symptomatic rectocele (Group A), 15 patients with asymptomatic rectocele (Group B), and 14 subjects having no rectocele (Group C). Resting and pressure, rectal pressure, rectal compliance, anorectal inhibitory reflex, and rectal sensation did not differ among the groups. Proctography revealed that the lengths of the rectocele during attempted defecation in groups A (1.6 [1.0-3.5] cm) (median and range) and B (1.6 [1.0-3.0] cm) were significantly greater than that in Group C (0.4 [0.1-0.9] cm) (P less than 0.001 in both groups). Median pelvic floor descent at rest in Groups A (4.3 [1.6-7.5] cm) (median and range) and B (4.3 [1.3-6.9] cm) were significantly greater than that in Group C (2.5 [1.2-5.0] cm) (P less than 0.001 and P less than 0.02, respectively). These results indicate that rectocele is not associated with any physiologic change apart from a significant increase of pelvic floor descent.

Reliability of anal pressure measurements

This study investigates whether measurements of anal sphincter pressure and length are reproducible and whether visual analyses of manometric tracings are reliable. Manometric studies were performed on three different days in 10 male and 10 female healthy subjects with the use of a pneumohydraulic capillary perfusion system. There was complete agreement between both observers in the analysis of anal resting and squeeze pressure as well as sphincter length. The pressure profiles from different days correlated significantly (P less than 0.01) with each other regardless of whether the studies were performed in the prepared or unprepared bowel. However, anal sphincter length and the quality of the anorectal inhibitory reflex varied greatly on different days. Male and female subjects showed major differences in the capacity of the anal sphincter to contract voluntarily (P less than 0.01), but resting tone and sphincter length were comparable in the two groups. It is concluded that pressure determinations in the anal canal are reliable and reproducible, but that alterations in the quality of the anorectal reflex need to be confirmed by repeated measurements before pathology is diagnosed.

Ano-rectal manometry as an evaluating test for impaired ano-rectal function in diabetes mellitus.

Diarrhea and/or rectal incontinence may represent a sign of autonomic neuropathy in diabetes. The present investigation was performed to study ano-rectal function and reactivity to appropriate stimuli in 20 diabetic patients with or without autonomic neuropathy (14 insulin-dependent diabetics; 6 non-insulin-dependent diabetics; mean age 39.2 years; mean duration of diabetes 12.6). Twenty-five healthy subjects (mean age 43.5 years) were studied as controls. All subjects underwent ano-rectal manometry by means of special open-ended-tip catheters connected with a 6-channel polygraph. A rectal latex balloon was inflated with 30 or 60 ml air to induce a stimulus which, under normal conditions, is apt to relax the internal sphincter and to contract the external one (ano-rectal inhibitory reflex). Eleven diabetics had symptoms and signs of autonomic neuropathy: 8 of these (73%) showed marked abnormalities of ano-rectal function (i.e. no response even to maximum stimulus or contraction of both sphincters). All non-neuropathic patients showed a normal pattern of ano-rectal manometry. A relationship between abnormal response to rectal stimulation and the presence of autonomic neuropathy involving the pelvic parasympathetic section or regional intramural plexuses may be suspected and demonstrated in diabetic neuropathic patients.

Anorectal physiology after anterior resection and pull-through operation.

Sensory and motor investigations have been performed in normal subjects, in patients who had undergone low anterior resection of the rectum and in patients following Bacon-type pull-through operation. The electromechanical relationship has been clearly defined in the anal sphincter activity. The motor findings, the threshold for sensation and its quality in the patients following low anterior resection were similar to those of the controls. Following pull-through operation the anorectal inhibitory reflex is frequently replaced by a contraction of the sphincteric zone. But, sometimes, this reflex is preserved as well as a fine discriminatory sensation. These data suggest that at least some of the mechanisms of anal sphincter continence have been preserved even after complete excision of the rectum.

Ano-rectal motility in sick children.

Motility of anus and rectum has been studied in 36 normal, and 67 pathological subjects. Normal mechanical characteristics in resting state and after stimulations are shown to be necessary for normal continence. Normal values are determined in normal subjects. In spina bifida, higher rectal activity is described, and normal anal resting and relaxing pressures are shown in continent subjects. In Hirschsprung's disease, defect of ano-rectal inhibitory reflex is confirmed, and normal anal pressures are found. In operated anorectal malformations, incontinence always corresponds with defect of recto-anal inhibitory reflex, lower length of anal resistance, or no functional striated sphincteric muscles.