Anorectal Manometry Testing Research Articles

Management After Obstetric Anal Sphincter Injury: Anorectal Manometry and Symptoms Predict Long-Term Fecal Incontinence.

Obstetric anal sphincter injury (OASI) is associated with serious morbidity and reduced quality of life. The role of anorectal manometry (ARM) to guide treatment is unclear. We aimed to define the role of ARM and symptom assessment after OASI in predicting anal incontinence at long-term follow-up. Prospective evaluation of 205 consecutive post-OASI women who underwent baseline ARM and symptom assessment in a tertiary setting was undertaken. Ninety-nine women were available for long-term follow-up (median 6.6 years). Associations between post-OASI ARM testing and short-term and long-term anal incontinence were examined in addition to clinical and obstetric factors. Fourth degree tears and lower anal resting and squeeze pressures were associated with short-term anal incontinence. Women with anal incontinence at baseline and women with lower anal resting pressure were more likely to suffer from long-term fecal incontinence (FI). A best-fit cutoff value of 59 mm Hg for baseline anal resting pressure predicted long-term FI, and none of the short-term asymptomatic women with an anal resting pressure of >59 mm Hg reported FI at long-term follow-up. Symptoms of anal incontinence and ARM in patients after OASI are both useful to predict subsequent long-term FI with a best-fit cutoff of 59 mm Hg for anal resting pressure. This provides rationale for routine ARM and accurate symptom assessment in all patients after OASI, to identify high-risk groups to follow and treat, and it may assist decision making regarding mode of subsequent obstetric deliveries.

Anorectal physiology and colonic motility in children with a history of tethered cord syndrome.

The understanding of the impact of tethered cord syndrome (TCS) on the physiology of the colorectal area is limited. Our aim was to describe anorectal and colonic motility in children with TCS and compare the findings to those of children with functional constipation (FC). We conducted a retrospective review of children with TCS who had an anorectal manometry (ARM) performed at our institution from January 2011 to September 2023. We recorded demographics, medical and surgical history, clinical symptoms, and treatment at time of ARM, ARM findings (resting pressure, push maneuver, rectal sensation, rectoanal inhibitory reflex [RAIR], and RAIR duration), and the final interpretation of colonic manometry (CM) if performed. We identified age and sex-matched control groups of children with FC. We included 24 children with TCS (50% female) who had ARM testing (median age at ARM 6.0 years, interquartile range 4.0-11.8 years). All children had constipation at time of ARM. Nineteen children had detethering surgery before ARM was performed. No significant differences in ARM parameters were found between children who had detethering surgery before ARM and children with FC. Among the 24 children, 14 also had a CM performed (13/14 after detethering surgery). No significant differences in colonic motility were found between children with a history of TCS and children with FC. Anorectal physiology and colonic motility are similar between children with a history of TCS and children with FC, suggesting that the underlying pathophysiology of defecatory disorders in children with and without history of TCS is similar.

Anorectal Manometry in Pediatric Colorectal Surgical Care.

Pediatric colorectal specialists care for patients with a variety of defecation disorders. Anorectal (AR) manometry testing is a valuable tool in the diagnosis and management of these children. This paper provides a summary of AR manometry techniques and applications as well as a review of AR manometry findings in pediatric patients with severe defecation disorders referred to a pediatric colorectal center. This is the first study describing multi-year experience using a portable AR manometry device in pediatric patients. An electronic medical record review was performed (1/2018 to 12/2023) of pediatric patients with defecation disorders who had AR manometry testing. Demographics, diagnostic findings, and outcomes are described. A total of 297 unique patients (56.9% male, n = 169) had AR manometry testing. Of these, 72% (n = 188) had dyssynergic defecation patterns, of which 67.6% (n = 127) had fecal soiling prior to treatment. Pelvic rehabilitation (PR) was administered to 35.4% (n = 105) of all patients. A total of 79.5% (n = 58) of the 73 patients that had fecal soiling at initial presentation and completed PR with physical therapy and a bowel management program were continent after therapy. AR manometry was well tolerated, with no major complications. AR manometry is a simple test that can help guide the management of pediatric colorectal surgical patients with defecation disorders. As a secondary finding, PR is a useful treatment for patients with dyssynergic stooling.

S558 Association of Chronic Opioid Use With Dyssynergic Defecation: Dose and Exposure Effects

Introduction: While opioids can be effective management for analgesia, GI side effects can limit tolerability. Chronic opioid use (OU) is associated with opioid-induced constipation (OIC) through slowing of GI transit. Studies have noted possible associations between OU and dyssynergic defecation (DD). The aim of this study was to identify chronic OU amongst patients who underwent anorectal manometry (ARM) testing to determine dose or exposure related effects on anorectal function. Methods: We conducted a retrospective study of patients who had ARM from January 2015 to October 2021. OU was determined by pre-procedure questionnaire and medical record review. OU was considered at least one month of use at time of ARM and was standardized based on morphine milliequivalents (MMEs). Results: Demographics are summarized in Table. Of 773 patients undergoing ARM, 12.7% had chronic OU. OU was associated with having DD; Type 1 DD being most common (p< 0.001). Chronic OU patients were older than patients without OU (p< 0.001). ARM in chronic OU patients was performed more often for constipation, constipation and fecal incontinence, and constipation and diarrhea when compared to patients without OU (p=0.04). Chronic OU patients were more likely to have abnormal balloon expulsion time (BET) defined as > 60 seconds (p< 0.001). Within OU, patients were divided into low and high dose of opiates for likelihood of DD findings on ARM (Figure). The lowest group dosing that reached significance defined low OU as 0-10 MME and high OU as ≥10 MME (p=0.005). Of the 34 low dose patients, 67.6% had DD; of the 64 high dose patients, 95.3% had DD (p=0.004). High dose OU was associated with fewer normal ARM tests and more Type I-III DD (p=0.005). Of the chronic OU, high dose patients were more likely to have abnormal defecation index (DI) defined as < 1.4 compared to low dose patients (p=0.006). Conclusion: Our data suggests a correlation between OU and ARM indications as well as OU and DD. We also found that 10 MME was the opioid dose threshold above which there is a greater association with anorectal dysfunction. Chronic OU patients suffered from constipation, were older, and had greater abnormal BET than those without OU, suggesting exposure-dependent association with OU. DI was abnormal at high dose OU compared to low dose OU, suggesting dose-dependent association with OU. Our study suggests that OIC can be associated with DD in addition to the known delayed colonic transit.Figure 1.: Presence of Dyssynergic Defecation in Low Dose Opioid Use and High Dose Opioid Use Groups (Blue: Normal ARM, Orange: Dyssynergic Defecation on ARM) [p=0.004] Table 1. - Distributions and Variables for Non-Opioid Users and Opioid Users in Patients undergoing Anorectal Manometry Non-Opioid(n=675) All Opioid(n=98) p-Value Low Dose (0-10 MME) Opioid(n= 34) High Dose ( > 10 MME) Opioid(n=64) p-Value Gender Male 142 (20%) 24 (24%) 0.43 7 (20.6%) 17 (26.6%) 0.62 Female 533 (80%) 74 (66%) 27 (79.4%) 47 (73.4%) Age (mean) y 48.7 + 16.0 56.0 + 16.9 < 0.001 55.9 + 17.0 56.0 + 17.0 0.98 ARM Indication Constipation 511 (75.6%) 78 (79.6%) 0.04 24 (70.6%) 54 (84.4%) 0.14 Fecal Incontinence 120 (17.8%) 13 (13.3%) 8 (23.6%) 5 (7.8%) Constipation and Fecal incontinence 23 (3.5%) 5 (5.1%) 1 (2.9%) 4 (6.2%) Fecal Urgency 8 (1.2%) 0 - - Incomplete Defecation 2 (0.3%) 0 - - Diarrhea 10 (1.5%) 0 - - Constipation and Diarrhea 1 (0.1%) 2 (2%) 1 (2.9%) 1 (1.6%) ARM Result Normal 281 (41.6%) 14 (14.3%) < 0.001 11 (32.4%) 3 (4.7%) 0.005 Type I DD 174 (25.8%) 43 (34.9%) 10 (29.4%) 33 (51.6%) Type II DD 33 (4.9%) 9 (9.2%) 2 (5.9%) 7 (10.9%) Type III DD 116 (17.2%) 18 (18.4%) 6 (17.6%) 12 (18.8%) Type IV DD 71 (10.5%) 14 (14.3%) 5 (14.7%) 9 (14.1%) Defecation Index Abnormal (< 1.4) 502 (74.3%) 80 (81.6%) 0.13 21 (61.8%) 59 (92.2%) 0.006 Normal ( >1.4) 174 (25.7%) 18 (18.4%) 13 (38.2%) 5 (7.8%) Balloon Expulsion Time Abnormal ( >60sec) 238 (35.3%) 64 (65.3%) < 0.001 21 (61.8%) 43 (67.2%) 0.65 Normal (< 60 sec) 436 (64.7%) 34 (34.7%) 13 (38.2%) 21 (32.8%) Sensory Threshold Low 155 (22.9%) 26 (26.5%) 0.50 11 (32.4%) 15 (23.4%) 0.33 Normal 339 (50.1%) 43 (43.9%) 16 (47.1%) 27 (42.2%) High 182 (26.9%) 29 (29.6%) 7 (20.6%) 22 (34.4%) Mean sphincter pressure (resting) mmHg 64.60 + 23.6 63.50 + 25.3 0.66 58.6 + 25.3 66.1 + 25.2 0.16 Max sphincter pressure (squeeze) mmHg 157.5 + 68.0 147.0 + 62.9 0.15 138.6 + 64.9 151.5 + 61.8 0.33

Anorectal Manometry Profile among Patients with Chronic Constipation and Faecal Incontinence in Western India: A Retrospective Study

Introduction: About 50% of patients referred to tertiary care centre for constipation in the western countries have faecal evacuation disorder. A diagnosis of faecal evacuation disorder requires specialised investigations such as anorectal manometry. Anorectal manometry is a method to measure pressure exerted by the muscles in anus and rectum. Aim: To evaluate the characteristics of anorectal pressure in a cohort of western Indian patients with chronic constipation and faecal incontinence. Also, to evaluate the types of faecal evacuation disorders in patients with chronic constipation. Materials and Methods: The present retrospective study was conducted from January 2020 to May 2022 at Department of Gastroenterology, National Institute of Medical College and Research, Jaipur, Rajasthan. Total of 115 patients presented with chronic constipation and faecal incontinence, were included in the study. Sigmoidoscopy or full-length colonoscopy, Balloon Expulsion Test (BET) and anorectal manometry test were done in all the patients. Mean resting and squeeze pressure were measured by anorectal manometry. Continuous variables were summarised using means and standard deviations for normally distributed data. Statistical analysis was performed using Statistical Package for Social Sciences software (SPSS) version 20.0 (IBM Corp, Armonk, NY, USA). Results: Among 115, 62 were (53.9%) males and 53 (46.1%) females with mean age 51.9±16.2 years. In High Resolution Anorectal Manometry (HRAM), the mean resting anal pressure was 67.2±34.24 mmHg (range 14-183 mmHg) and mean squeeze pressure was 113.4±60.9 mmHg (range 30-290 mmHg). In present study type I dyssynergic defecations was most common with 20 (17.4%) patients. Conclusion: The present study showed that almost half of the patients had defecation disorders and type I dyssynergic defecations was most common, followed by type IV

Rectal Evacuation Disorders are Associated With Poor Bowel Preparation in Patients With Chronic Constipation: Results From Two Centers.

We evaluated factors that can predict the adequacy of bowel preparation in patients with chronic constipation undergoing colonoscopy. We identified patients with chronic constipation who underwent anorectal manometry and at least 1 colonoscopy at 2 tertiary referral centers from 2003 to 2019. We also identified a subgroup of patients who underwent colonic transit testing through radiopaque marker testing. We determined demographic, medical, and constipation-related factors associated with poor bowel preparation and their effect on standardized quality metrics using univariate and multivariate analyses. We identified 274 patients with chronic constipation who underwent anorectal manometry testing. Both outlet dysfunction (prolonged balloon expulsion) and slow-transit constipation were associated with suboptimal bowel preparation. Outlet dysfunction was also associated with decreased cecal intubation rates, adenoma detection rates, and sessile serrated polyp detection rates. In multivariable analyses controlling for demographics and known factors associated with poor bowel preparation, outlet dysfunction was associated with an almost 3-fold odds of suboptimal bowel preparation [odds ratio (OR): 2.9; 95% confidence interval (CI): 1.6-5.1] and a 3-fold reduction in cecal intubation rates (OR: 0.3; 95% CI: 0.1-0.8). Among those with radiopaque marker colonic transit testing available, slow-transit constipation was associated with a >2-fold odds of suboptimal bowel preparation (OR: 2.2; 95% CI: 1.1-4.4). Among a cohort of patients with chronic constipation undergoing colonoscopy, outlet dysfunction was associated with suboptimal bowel preparation and other quality metrics. Constipated patients with a rectal evacuation disorder may represent a subgroup of patients that could benefit from individualized strategies for better bowel preparation.

The not-so-rare absent RAIR: Internal anal sphincter achalasia in a review of 1072 children with constipation undergoing high-resolution anorectal manometry.

BackgroundOur objective is to describe the prevalence of patients with internal anal sphincter achalasia (IASA) without Hirschsprung disease (HD) among children undergoing anorectal manometry (ARM) and their clinical characteristics.MethodsWe performed a retrospective review of high‐resolution ARM studies performed at our institution and identified patients with an absent rectoanal inhibitory reflex (RAIR). Clinical presentation, medical history, treatment outcomes, and results of ARM and other diagnostic tests were collected. We compared data between IASA patients, HD patients, and a matched control group of patients with functional constipation (FC).Key resultsWe reviewed 1,072 ARMs and identified 109 patients with an absent RAIR, of whom 28 were diagnosed with IASA. Compared to patients with FC, patients with IASA had an earlier onset of symptoms and were more likely to have abnormal contrast enema studies. Compared to patients with HD, patients with IASA were more likely to have had a normal timing of meconium passage, a later onset of symptoms, and were diagnosed at an older age. At the latest follow‐up, the majority of patients diagnosed with IASA (54%) were only using oral laxatives. Over half of patients with IASA had been treated with anal sphincter botulinum toxin injection, and 55% reported a positive response.Conclusions and InferencesPatients diagnosed with IASA may represent a more severe patient population compared to patients with FC, but have a later onset of symptoms compared to patients with HD. They may require different treatments for their constipation and deserve further study.

Gastrointestinal Amyloidosis in Children with Familial Mediterranean Fever Disease and Anorectal Manometry Results

Objectives: The aim of this study was to evaluate the effect of amyloid deposition in colon mucosa on the results of anorectal manometry test and the use of ROME III questionnaire in patients with Familial Mediterranean Fever (FMF). Methods: The files of patients diagnosed with FMF were scanned to evaluate the patients at risk for amyloid deposition. Predisposing factors were identified. The patients were sampled using anorectal manometry test, Rome III questionnaire and the rectal mucosa suction biopsy and the test results were compared. Results: 17 (63%) of the patients were female and 10 (37%) were male. The mean age was 12.15 ± 2.40 years. The number of patients with amyloid deposition in the rectal mucosa sample was 2 (7.4%). Both of these patients had regularly used colchicine. Amyloid deposition was found to be high in patients with M694V homozygous mutation (P = 0.05). According to the Rome III questionnaire, findings suggestive of irritable bowel syndrome were found in 5 patients and abdominal migraine was found in 3 patients. However, no statistical difference was found when the results of the Rome III questionnaire were compared with the results obtained from the anorectal manometry test (P &gt; 0.05). Conclusions: Amyloidosis can be seen due to various environmental factors, regardless of age, even when colchicine is regularly used. Anorectal manometry is an easy to perform test, helping diagnosis in this patient group. Although it has been shown that in patients with predisposing factors for amyloid deposition RAIR can be detected at lower pressures in anorectal manometry, the clinical significance of this finding is unclear. Since the Rome III questionnaire showed findings consistent with functional abdominal pain disease in one third of the patients, independent of the presence of FMF, it was found that the application of this questionnaire in patients with FMF could be misleading.

Consistency between symptoms and colorectoanal function tests in elderly patients with functional constipation

Objective To analyze the consistency between constipated symptoms and the parameters of gastrointestinal transit time (GITT), anorectal manometry (ARM) in elderly patients with functional constipation. Methods Total 111 patients (54 males and 57 females) with an average age of (70.2±6.5) years, who met Rome Ⅲ criteria of functional constipation were enrolled from June 2010 to October 2012. After enrollment, patients took two-week diary, recording the spontaneous bowel movements per week, stool type of Bristol Stool Form, the frequency and severity of defecation straining, sensation of anorectal obstruction, manual maneuvers and sensation of incomplete evacuation. The GITT and ARM tests were performed, and the consistency between symptoms and test results were analyzed. Results Patients with symptoms of slow transit, defecation disorder and mixed symptoms were 19.8% (22/111), 16.2% (18/111) and 59.5% (66/111) respectively; and 4.5% (5/111) patients had scattered symptoms. Based on results of GITT, slow transit subtype, defecation disorder subtype and mixed subtype were 54.1% (59/109), 1.8% (2/109) and 29.4% (32/109) respectively; and 14.7% (16/109) patients were with normal transit time. ARM results showed that 38.0% (41/109) of patients had dyssynergic defecation. The percentage of slow transit in GITT test showed no significant difference between patients with slow transit symptoms and mixed symptoms[50.0% (11/22) vs. 57.9% (33/57) , χ2=0.401, P=0.527]. The consistency of predominant symptom with GITT subtype was low (к=-0.013). The percentage of dyssynergic defecation detected with ARM showed no significant difference between patients with defecation disorder-predominant symptom and with mixed symptom [23.1% (6/24) vs. 38.2% (21/55) , χ2=1.813, P=0.178]. The consistency of defecation disorder-predominant symptom with dyssynergic defecation in ARM was low (к=-0.019). Conclusion The mixed subtype symptoms are the most common presentations of elderly patients with functional constipation, and the consistency of predominant constipated symptoms with GITT, ARM test results is poor. Key words: Aged; Constipation; Gastrointestinal transit; Anorectal manometry

How to Perform and Interpret a High-resolution Anorectal Manometry Test

High-resolution anorectal manometry (HR-ARM) and high-definition anorectal manometry (HD-ARM) catheters have closely spaced water-perfused or solid state circumferentially-oriented pressure sensors that provide much better spatiotemporal pressurization than non-high resolution catheters. This is a comprehensive review of HR-ARM and HD-ARM anorectal manometry catheter systems, the methods for conducting, analyzing, and interpreting HR-ARM and HD-ARM, and a comparison of HR-ARM with non-high resolution anorectal manometry. Compared to non-high resolution techniques, HR-ARM and HD-ARM studies take less time and are easier to interpret. However, HR-ARM and HD-ARM catheters are more expensive and fragile and have a shorter lifespan. Further studies are needed to refine our understanding of normal values and to rigorously evaluate the incremental clinical utility of HR-ARM or HD-ARM compared to non-high resolution manometry.

Resting anal pressure, not outlet obstruction or transit, predicts healthcare utilization in chronic constipation: a retrospective cohort analysis.

Chronic constipation is common and exerts a considerable burden on health-related quality of life and healthcare resource utilization. Anorectal manometry (ARM) and colonic transit testing have allowed classification of subtypes of constipation, raising promise of targeted treatments. There has been limited study of the correlation between physiological parameters and healthcare utilization. All patients undergoing ARM and colonic transit testing for chronic constipation at two tertiary care centers from 2000 to 2014 were included in this retrospective study. Our primary outcomes included number of constipation-related and gastroenterology visits per year. Multivariate linear regression adjusting for confounders defined independent effect of measures of colonic and anorectal function on healthcare utilization. Our study included 612 patients with chronic constipation. More than 50% (n=333) of patients had outlet obstruction by means of balloon expulsion testing and 43.5% (n=266) had slow colonic transit. On unadjusted analysis, outlet obstruction (1.98 vs 1.68), slow transit (2.40 vs 2.07) and high resting anal pressure (2.16 vs 1.76) were all associated with greater constipation-related visits/year compared to patients without each of those parameters (p<0.05 for all). Outlet obstruction and high resting anal pressure were also associated with greater number of gastroenterology visits/year. After multivariate adjustment, high resting anal pressure was the only independent predictor of increased constipation-related visits/year (p=0.02) and gastroenterology visits/year (p=0.04). Among patients with chronic constipation, high resting anal pressure, rather than outlet obstruction or slow transit, predicts healthcare resource utilization.

Clinical application of anterior perineal plane for ultra-low anterior resection of the rectum

To summarize clinical experience in the treatment of low rectal cancer with anterior perineal plane for ultra-low anterior resection of the rectum(APPEAR). Clinical and follow-up data of 26 patients with low rectal cancer undergoing the APPEAR operation in Department of General Surgery at Peking Union Medical College from September 2009 to August 2011 were retrospectively analyzed. The 26 cases consisted of 19 male and 7 female patients with an average age of (63.4 ± 9.5) years. The average tumor distance from the anal verge was (4.6 ± 0.7) cm according to preoperative examinations. Fourteen patients received neoadjuvant radiochemotherapy before the operation. All the 26 patients had successful sphincter-preserving operations. The average operative time was (170 ± 21) min and the average intra-operative blood loss (140 ± 69) ml. Complications included one case of intraoperative injury to the rectal wall and 4 cases of postoperative perineal wound infection. Postoperative pathological examination showed well to moderately differentiated adenocarcinomas(n=10), moderately differentiated adenocarcinomas with partial mucinous adenocarcinomas (n=7), poorly differentiated adenocarcinoma(n=1), villous adenoma with high-grade intraepithelial neoplasia (n=1), and rectal villous adenoma(n=1). In 6 cases no residual tumor cells were detected in the surgical specimens. All the patients were followed-up for an average period of(11.4 ± 5.6) months. No impaired urinary function or tumor recurrence was observed during the follow-up. Eighteen patients had the transverse colon stoma closure six months after the operation. The average Wexner continence score was 5.5 after colostomy reversal surgery. The anorectal manometry tests showed that maximum squeeze pressure of the anal sphincter was(224.0 ± 59.3) mm Hg. The maximum resting pressure was (42.5 ± 11.8) mm Hg, and the maximum tolerable volume of the rectum was (120.0 ± 27.4) ml. Anorectal reflexes were present in all these patients. The APPEAR technique can be applied in the sphincter-preserving operations for low rectal cancer patients with satisfactory anal function.

How to Interpret Conventional Anorectal Manometry

Anorectal manometry is the most well established and widely available tool for investigating anorectal function. Anal sphincter tone can be quantified by anorectal manometry. The anorectal sensory response, anorectal reflexes, rectal compliance, and defecatory function are also assessed by anorectal manometry. This report will focus on defining parameters for measurement and interpretation of anorectal manometry tests.

W1339 Use of Colonic and Anorectal Manometry Testing to Evaluate Patients with Constipation Refractory to Medical Therapy

W1339 Use of Colonic and Anorectal Manometry Testing to Evaluate Patients with Constipation Refractory to Medical Therapy

Letters to the Editors

Sirs, The review by Steele and Madoff1 on chronic anal fissure (CAF) concludes that no single treatment is the best option for all patients. Responding to the presumed mechanisms of fissure formation internal anal sphincter (IAS) hypertonia and inadequate blood flow to the anoderm several treatment options have been developed to restore normal sphincter tone and allow fissure healing. These options include either pharmacological or invasive treatments. The main advantages of invasive treatment are rapid pain relief, high success rate, low relapses rate, technical simplicity and minimum morbidity. The internal lateral sphincterotomy is considered at present the gold standard therapy in CAF to obtain the highest healing rates. Manual anal dilatation (MAD) should not be used because there is a high risk of incontinence. However controlled endoscopic anal dilatation (CEAD) has been standardized and obtains high healing rates, adequate reduction in mean resting anal pressure and low rates of recurrence and incontinence, similar to those found in surgery.2–7 We have been able to reduce the rate of complications secondary either to lateral sphincterotomy or CEAD as treatment for anal fissure4–6, probably because of evaluation by anal manometry before endoscopic dilation IAS hypertonia is not present in all CAF patients.8, 9 A normal or diminished IAS pressure in presence of CAF must raise the suspicion of an atypical anal fissure10 and the existence of an underlying condition such as Crohn's disease, ulcerative colitis, cancer, leukaemia, syphilis, tuberculosis or HIV. In this group of patients invasive treatment of CAF is not appropriate. In our opinion, before any invasive treatment (surgery or CEAD) for CAF, an anorectal manometry test should play a decisive role in the selection of the therapeutic options. Determining mean anal resting pressure may be of value in order to avoid postsurgery continence problems, especially in older patients, women with vaginal deliveries, previous sphincter injuries or perineal lacerations, inflammatory bowel disease and chronic diarrhoea.

The use of a balloon catheter to improve evaluation in anorectal manometry

The squeeze pressure in the anal canal reflects the contribution of the external anal sphincter and is normally assessed manometrically by asking patients to contract their anal muscles. However, this is an artificial situation as normally the external sphincter contracts to retain rectal content. Some patients with normal anal sphincter anatomy and innervation record low squeeze pressures suggesting that the concept of voluntary squeeze is foreign. The aim of this study was to examine whether squeezing to retain a balloon mimics the physiology of defaecation more accurately. Patients undergoing routine anorectal manometry testing had in addition the inflation of a balloon catheter to the volume of the first and sustained sensation to simulate a faecal bolus within the rectum. The patient was asked to retain it when the balloon was subjected to gentle traction, thus contracting their anal sphincter to prevent passage of the balloon. Squeeze pressure was measured in response to voluntary contraction, the pressure generated to retain the balloon, then voluntary contraction again. Eighteen women and 2 men were tested. The median maximal squeeze pressures with the routine assessment was 131.0 cmH2O. This increased to 210.0 cmH2O when the patients attempted to retain the balloon and fell to 165.4 cmH2O when patients were reassessed with voluntary squeeze postintervention. 15 of the patients improved their squeeze pressures with traction on the balloon. External anal sphincter contraction is difficult for some patients to perform on request. With traction on a balloon catheter anal squeeze pressures improved in most patients. This indicates that many patients perform maximal anal squeeze pressures better once that muscle group has been tested in a more normal physiological function. This simple technique could improve the accuracy of anorectal manometry results and evaluation in a larger population of symptomatic patients is warranted.