Conventional Anorectal Manometry Research Articles

Evaluation of conventional anorectal manometry and biofeedback therapy in adolescents with functional constipation.

The aim was to evaluate the outcomes of conventional anorectal manometry (ARMM) testing and biofeedback therapy in adolescents with functional constipation. A retrospective analysis of ARMM findings in patients aged 10-18 years with intractable constipation over a 4-year period was conducted. Of the 41 patients (mean age, 13.5±2.44 years) included, 20 (48.7%) were male. Rectoanal inhibitory reflex (RAIR) was positive in all patients. Group 1 had 31 patients with dyssynergic defecation (DD) and Group 2 had 10 patients without DD. Anal canal resting pressure, squeeze test pressure, rectal defecation pressure, and first and urge sensation volumes were similar between the groups. Maximum tolerated volume and the relaxation percentage of RAIR were higher in Group 1 than in Group 2 (p<0.05). Among 31 patients referred for biofeedback therapy, 8 (25.6%) completed the program with complete resolution of their symptoms. The mean follow-up period for these patients was 21±14.7 months. DD is relatively common in patients with psychosocial adjustment disorders, and it can be diagnosed via ARMM. Despite the low rate of adherence to the therapy in the presented series, biofeedback therapy was highly effective in resolving the symptoms including soiling.

Effects of Aging and Gender on the Anorectal Function of Healthy Subjects Assessed with Conventional Anorectal Manometry.

Anorectal functions are influenced by gender and age. This study sought to define the normal anorectal pressure values measured with conventional anorectal manometry (ARM) and to evaluate the effects of age and gender on anorectal function in asymptomatic subjects. Conventional ARM was used to measure the anorectal pressures of 164 asymptomatic healthy subjects, including 86 males and 76 females. The resting anal pressures of males and females aged >60 years were significantly lower than those ≤60 years (males, 44.09±14.22 vs. 57.45±17.69, p<0.001; females, 44.09±14.22 vs. 57.45±17.69, p<0.001). The anal high-pressure zone was significantly lower in older males than in younger males (2.42±0.93 vs. 2.82±0.739, p=0.048). In both age groups (<60 and ≥60 years), the anal squeezing pressures of males were significantly higher than those of females (<60 years old, 168.40±75.94 vs. 119.15±57.53, p=0.001; ≥60 years, 149.61±64.68 vs. 101.3±54.92, p=0.006). The normal anorectal pressure values measured with ARM in males and females were different. Older males and females had lower anal resting pressures than those of the younger subjects, but squeezing pressure was not affected by age.

Anorectal Function with High-Resolution Anorectal Manometry in Active Ulcerative Colitis and after Remission: A Pilot Study.

Ulcerative colitis may impair anorectal function, causing disabling symptoms such as incontinence and/or increase in the stool frequency, urgency and tenesmus. Data on anorectal function in these patients evaluated by conventional anorectal manometry are conflicting. The aim of this prospective study was to assess by means of high resolution anorectal manometry the anorectal function in patients with mild-to-moderate ulcerative colitis at presentation and after remission. Anorectal function of ulcerative colitis patients was compared to that observed in healthy volunteers. 20 patients with mild to moderate left-sided ulcerative colitis or proctitis and 20 healthy volunteers were prospectively enrolled. All ulcerative colitis patients underwent high resolution anorectal manometry before treatment and after clinical remission. Ulcerative colitis patients showed similar values for anal sphincter function as healthy volunteers, whereas rectal threshold volume for the first sensation, desire to defecate, urgency to defecate and maximum discomfort were significantly lower than in healthy volunteers (p<0.05). Rectal compliance was significantly lower in ulcerative colitis than in healthy volunteers (p<0.05). After remission, rectal threshold volumes, as well as rectal compliance, significantly increased. An inverse linear correlation was found between regression of urgency and stool frequency and rectal compliance (r=0.811; p<0.05). Ulcerative colitis patients show altered rectal function, with increased rectal sensitivity and lower compliance, compared to controls. This altered function is restored after successful treatment of the underlying inflammatory process. Finally high resolution anorectal manometry provides useful information on anorectal functionality and, in our opinion, should be preferred over conventional manometry.

MOTILITY OF THE UNPREPARED INTESTINAL TRACT IN HEALTHY HUMANS AND PATIENTS WITH SLOW TRANSIT CONSTIPATION REVEALED BY USING MICRO-ELECTRONIC CAPSULE

Slow transit constipation (STC) is usually accompanied by intestinal motility abnormalities. Although conventional anorectal manometry could record the pressure in the colon, most patients need preparation of intestinal tract. The intervention of catheter for monitoring the intestinal pressure also affects the clinical measurement. The pressure data collected by the conventional anorectal manometry cannot fully characterize the dynamic characteristics of the intestine. Thus, we aimed to obtain colonic pressure data under normal physiological conditions. Utilizing these data, we analyze the difference of colonic motility parameters between healthy control and patients with STC. A micro-electronic capsule made by ourselves was used to gather the subjects’ intestinal pressure in their daily life. Several intestinal motility parameters were calculated from the pressure profile. The average energy of colonic pressure data in the STC group is higher than the healthy control group (HC: 259.95 vs. STC: 821.28). But the STC group has a lower average complexity of colonic motility (HC: 0.80 vs. STC: 0.64). About 81.25% of the colonic data from patients with STC could be identified by using slow transit constipation (SVM) classifier. Compared with health control, most colonic parameters of patients with STC are higher under the normal physiological conditions, but the complexity of colonic motility is lower in the STC group. The correct rate of colonic pressure recognition in the STC group is more than 80% by using SVM classifier.

Young Investigator: Use of High Resolution Anorectal Manometry in UC Patients in Remission With Persistent Anorectal Symptoms

BACKGROUND: A group of patients with UC continue to present symptomatology despite being in remission. Previous studies with conventional anorectal manometry in patients with active UC or remission, decreased rectal compliance was reported, and sphincter pressures within normal parameters. Because of inflammation-induced fibrosis in activity periods, decreased rectal compliance has been proposed as the cause of persistent symptomatology, in remission. Our aim was evaluated UC patients in remission with persistent anorectal symptoms with HRAM. METHODS: Patients in remission in the Montreal and Mayo activity score for colonoscopy, from July 1, 2015 to June 31, 2016. Inclusion criteria:> 18 years, anorectal symptoms, signing of consent for HRAM. Exclusion criteria: alterations in proctological examination, loss of remission, anorectal surgery. A Manoscan 360 Sierra Scientific device with solid-state catheter, Manoview 2.1 software, was used. The mean volume for the first sensation, sensation and urgency of defecation, mean basal pressure of the sphincter and maximum contraction were reported. We analyzed the association between symptoms and HRAM results with the t test, and the association between symptoms and the extent of disease and evolution with X2. P=<0.5 to two tails was taken as significant. Analyzed with SPSS v22. RESULTS: The inclusion criteria were 17 patients with anorectal symptoms, 9 accepted HRAM. The median age: 59 years, with 14 years of evolution, 66.7% female gender. Patients who accepted HRAM, according to Montreal: E3 44.4%, E1 33.3% and E2 22.2%; 66.7% were Mayo 1 and Mayo 0, 33.3%. 55.6% had tenesmus, fecal incontinence 22.2%, proctalgia 22.2% and constipation 22.2%. Two patients had constipation and tenesmus, one proctalgia and tenesmus. The median anal resting and squeeze of female patients: anal resting 71.25 mmHg (42.5-75.9), squeeze 132 mmHg (86.7-267.5). In male patients: anal resting 84.6 (82.6-92.3) and squeeze 251.4 mmHg (208.9-273.2). Volume for first sensation in female: 40 mL (30-50) and urge to defecate 150 mL (120-160). Volume in male: first sensation 50 mL (20-60) and urge to defecate 140 mL (140-150). Two presented paradoxical contraction. We found correlation of proctalgia with first sensation with P=0.210 and urge to defecate P=0.015. There was no relationship of symptoms with years of evolution or extension of UC. CONCLUSION(S): The persistence of anorectal symptoms in patients with UC in remission is high. In our study, the most frequent symptom is tenesmus (55.6%). Patients had hyposensitivity and decreased rectal capacity. The anorectal symptoms are not related to years of evolution and extent of disease. There is correlation between proctalgia and changes in rectal capacity reported in HRAM.

Diagnostic Role of Anal Sphincter Relaxation Integral in High-Resolution Anorectal Manometry for Hirschsprung Disease in Infants

To investigate the possible diagnostic role of anal sphincter relaxation integral (ASRI) in high-resolution anorectal manometry (HRAM) for Hirschsprung disease. We performed conventional anorectal manometry (ARM) in 24 infants (8 with Hirschsprung disease and 16 without Hirschsprung disease) and HRAM in another 21 infants (9 with Hirschsprung disease and 12 without Hirschsprung disease) before and after October 2014. All infants underwent rectal suction biopsy for confirmation of Hirschsprung disease. We quantified rectoanal inhibitory reflex (RAIR) adequacy by calculating the ASRI in HRAM study at pressure cutoffs of less than 10, 15, and 20 mm Hg (ASRI10, ASRI15, and ASRI20, respectively) and investigated the diagnostic utility. Patients with Hirschsprung disease who underwent HRAM had significantly lower ASRI10, ASRI15, and ASRI20 values than did infants without Hirschsprung disease (P = .0002, .0002, and .0003, respectively), indicating significant difference in internal anal sphincter relaxation during RAIR test between these 2 groups. ASRI10 exhibited a greater diagnostic accuracy, area under the curve, sensitivity, and specificity than did ASRI15 and ASRI20 for Hirschsprung disease. Moreover, the diagnostic accuracy of HRAM for Hirschsprung disease based on ASRI10 <7 mm Hg.s.cm was significantly greater than that of conventional ARM (P = .02). ASRI10 may be indicative of the adequacy of RAIR by HRAM in infants, thus assisting the diagnosis of Hirschsprung disease. The diagnostic accuracy of HRAM (based on the ASRI10 value) is greater than that of conventional ARM for Hirschsprung disease. ASRI10 may be used in an automatic HRAM analysis system for the diagnosis of anorectal motility disorders.

Methods of anorectal manometry vary widely in clinical practice: Results from an international survey.

Ano-rectal manometry (ARM) is the most commonly performed investigation for assessment of anorectal dysfunction. Its use is supported by expert consensus documents and international guidelines. Variation in technology, data acquisition, and analysis affect results and clinical interpretation. This study examined variation in ARM between institutions to establish the status of current practice. A 50-item web-based questionnaire assessing analysis and interpretation of ARM was distributed by the International Anorectal Physiology Working Group via societies representing practitioners that perform ARM. Study methodology and performance characteristics between institutions were compared. One hundred and seven complete responses were included from 30 countries. Seventy-nine (74%) institutions performed at least two studies per week. Forty-nine centers (47%) applied conventional ARM (≤8 pressure sensors) and 57 (53%) high-resolution ARM (HR-ARM). Specialist centers were most likely to use HR-ARM compared to regional hospitals and office-based practice (63% vs 37%). Most conventional ARM systems used water-perfused technology (34/49); solid-state hardware was more frequently used in centers performing HR-ARM (44/57). All centers evaluated rest and squeeze. There was marked variation in the methods used to report results of maneuvers. No two centers had identical protocols for patient preparation, setup, study, and data interpretation, and no center fully complied with published guidelines. There is significant discrepancy in methods for data acquisition, analysis, and interpretation of ARM. This is likely to impact clinical interpretation, transfer of data between institutions, and research collaboration. There is a need for expert international co-operation to standardize ARM.

Downregulation of neuronal vasoactive intestinal polypeptide in Parkinson's disease and chronic constipation.

Chronic constipation (CC) is a common and severe gastrointestinal complaint in Parkinson's disease (PD), but its pathogenesis remains poorly understood. This study evaluated functionally distinct submucosal neurons in relation to colonic motility and anorectal function in PD patients with constipation (PD/CC) vs both CC and controls. Twenty-nine PD/CC and 10 Rome III-defined CC patients were enrolled. Twenty asymptomatic age-sex matched subjects served as controls. Colonic transit time measurement and conventional anorectal manometry were evaluated in PD/CC and CC patients. Colonoscopy was performed in all three groups. Colonic submucosal whole mounts from PD/CC, CC, and controls were processed for immunohistochemistry with antibodies for vasoactive intestinal polypeptide (VIP) and peripheral choline acetyltransferase, markers for functionally distinct submucosal neurons. The mRNA expression of VIP and its receptors were also assessed. Four subgroups of PD/CC patients were identified: delayed colonic transit plus altered anorectal manometry (65%); delayed colonic transit (13%); altered manometric pattern (13%); and no transit and manometric impairment (9%). There were no differences in the number of neurons/ganglion between PD/CC vs CC or vs controls. A reduced number of submucosal neurons containing VIP immunoreactivity was found in PD/CC vs controls (P<.05). VIP, VIPR1, and VIPR2 mRNA expression was significantly reduced in PD/CC vs CC and controls (P<.05). Colonic motor and rectal sensory functions are impaired in most PD/CC patients. These abnormalities are associated with a decreased VIP expression in submucosal neurons. Both sensory-motor abnormalities and neurally mediated motor and secretory mechanisms are likely to contribute to PD/CC pathophysiology.

Assessment of Obstructive Defecation by High-Resolution Anorectal Manometry Compared With Magnetic Resonance Defecography

Patients with obstructive defecation have abnormalities of anorectal function and/or structure. Conventional anorectal manometry (ARM) can identify abnormal function and behavior (dyssynergia); however, agreement between manometry and defecography is only fair. High-resolution (HR)-ARM may improve diagnostic agreement by differentiating pressure effects caused by dyssynergia and obstruction. We compared HR-ARM findings with magnetic resonance (MR) defecography in the clinical assessment of patients with symptoms of obstructive defecation defined by Rome III criteria. HR-ARM (Manoscan AR 360; Given Imaging, Yoqeam, Israel) assessed anal sphincter function and pressure during simulated defecation. Abnormal manometric findings were classified according to the Rao system and compared with MR defecography as the reference standard. A total of 188 consecutive patients (155 women; age, 19-93 y) with obstructive defecation underwent a full investigation. Compared with patients with dyssynergia on MR imaging (n = 66), patients with structural pathology (n = 87) had lower resting (P < .003) and squeeze pressures (P < .011), but a higher rectoanal pressure gradient (P < .0001) on HR-ARM. High intrarectal pressure with a steep, positive pressure gradient consistent with outlet obstruction on HR-ARM was present in 24 patients with intra-anal intussusception on MR imaging. This pattern was not observed in other patients. Interobserver agreement was substantial for HR-ARM diagnoses (κ = 0.67; 95% confidence interval, 0.559-0.779). Diagnostic accuracy for dyssynergia was 82% compared with MR imaging (sensitivity, 77% [51 of 66]; specificity, 85% [104 of 122]). The diagnostic agreement between anorectal HR-ARM and MR defecography is high and pressure measurements accurately identify recto-anal dyssynergia and intra-anal outlet obstruction by structural pathology as causes of obstructive defecation.

Rectocele—does the size matter?

Large rectoceles (>2 cm) are believed to be associated with difficulty in evacuation, constipation, rectal pain, and rectal bleeding. The aim of our study was to determine whether rectocele size is related to patient's symptoms or defecatory parameters. We conducted a retrospective study on data collected on patients referred to our clinic for the evaluation of evacuation disorders. All patients were questioned for constipation, fecal incontinence, and irritable bowel syndrome and were assessed with dynamic perineal ultrasonography and conventional anorectal manometry. Four hundred eighty-seven women were included in our study. Rectocele was diagnosed in 106 (22%) women, and rectocele diameter >2 cm in 93 (87%) women. Rectocele size was not significantly related to demographic data, parity, or patient's symptoms. The severity of the symptoms was not correlated to the size or to the position of the rectocele. The diagnosis of irritable bowel syndrome was neither related to the size of the rectocele. Rectocele location, occurrence of enterocele, and intussusception were not related to the size of the rectocele. Full evacuation of rectoceles was more common in small rectoceles (79% vs. 24%, p = 0.0001), and no evacuation was more common in large rectoceles (37% vs. 0, p = 0.01). Rectal hyposensitivity and anismus were not related to the size of the rectocele. In conclusion, only the evacuation of rectoceles was correlated to the size of the rectoceles, but had no clinical significance. Other clinical, anatomical factors were also not associated to the size of the rectoceles. Rectoceles' size alone may not be an indication for surgery.

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.

T1352 Comparison of High Resolution Anorectal Manometry With Conventional Anorectal Manometry in the Diagnosis of Defecatory Disorder Caused by Pelvic Floor Dysfunction

T1352 Comparison of High Resolution Anorectal Manometry With Conventional Anorectal Manometry in the Diagnosis of Defecatory Disorder Caused by Pelvic Floor Dysfunction

Is Abnormality in the Conventional Anorectal Manometry Really Abnormal?

A 54-year-old woman, with chronic abdominal discomfort and difficulty in defecation, was admitted to the hospital. There were no abnormal findings on abdominal X-ray and colonic transit time remained within the normal values. The result by colonoscopic examination was normal. Bulk-forming laxatives were prescribed for a month, but symptomatic improvement was not found at all. Then, a defecography and the high resolution anorectal manometry (HR-ARM) of ManoScan TM system (Sierra Scientific Instruments, Los Angeles, CA, USA) were performed to differentiate functional anorectal disorders. Defecogram did not show significant findings. HR-ARM finding in left lateral decubitus position revealed the inappropriate increase of rectal pressure and no decrease in anal sphincter pressure (Fig. 1A). These findings were consistent with pelvic floor dyssynergia. However, when HR-ARM was performed with the patient in the sitting position, the increase of rectal pressure could be found in coordination with relaxation of the anal sphincter pressure (Fig. 1B). These results were consistent with the previous report obtained in the lying position; one-third showed dyssynergia and one-half could not expel artificial stool. However, when sitting with distended rectum, most patients showed a normal defecation pattern and ability to expel stool.1 Figure 1 Colored pressure topography plots of anorectal pressure during simulated defecation in left lateral decubitus position (A) and sitting position (B). High resolution anorectal manometry (HR-ARM) finding in left lateral decubitus position revealed inappropriate ... During the conventional water perfusion manometry, patients are expected to be in their lateral decubitus position, which interferes with an optimal abdominal contraction and anal relaxation during simulated defecation. However, in case of HR-ARM, patients can take sitting position in commode, which is more physiological since patients can feel more comfortable and they can generate enough movement of rectum for defecation and adequate anal relaxation.2 In conclusion, defecation is best evaluated in the sitting position of patient by using HR-ARM.

Rectoanal inhibition and rectocele: physiology versus categorization.

Some authors divide rectoceles into those with chronic evacuatory difficulty and normal genital position (type 1) and those with associated pelvic organ prolapse (type 2). This study assessed whether there are physiological differences between these two clinical rectocele types. Female patients were assessed by conventional anorectal manometry, vector manometry, parametric assessment of the rectoanal inhibitory reflex (RAIR), and defecography. Subjects included 33 volunteer controls without anorectal disease, 14 patients with type I rectocele, and 26 patients with type II rectocele. Significant differences were noted for resting pressure measurements (maximal resting anal pressure and vector volume) between rectocele types and between type I patients and controls. Significant differences were noted for squeeze parameters (maximal squeeze pressure and vector volume) only between rectocele types. There were minimal differences in parameters of the RAIR, with a reduced slope of inhibition in the proximal sphincter for both rectocele groups and a reduced maximal inhibitory pressure in the intermediate and distal sphincter of type 1 rectocele patients. There were no differences in transient excitation of the pressure wave during the RAIR reflex to account for pressure variations with no measured differences in rectocele depth (type 1, 2.87 +/- 0.7 cm; type 2, 2.84 +/- 1.4 cm) There are few physiological differences between the different clinical categories of rectocele patients based on the presence or absence of associated genital prolapse.

Anorectal functions in patients with spinal cord injury.

We wished to establish anorectal functions in patients with spinal cord lesions, related to the level of lesion and its completeness. We also wished to determine the value of neurophysiological tests for completeness of transsections in comparison with manometry and visceral sensory testing. In 32 patients (31.5 +/- 14.1 years, 25 males) with spinal trauma, completeness of transsection was assessed clinically. In 16 of these patients (30 +/- 15.6 years, nine males), a neurological work-up included recording of somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) from the pudendal nerve within the first week after trauma. Also, anal sphincter EMG and pudendal nerve terminal motor latency (PNTML) were assessed. All patients also underwent conventional anorectal manometry and visceral sensory testing. Of all 32 patients, 15 were judged as 'complete' based on their clinical signs. Of those 16 tested neurologically, seven were labelled 'complete' since no MEP or SEP were detectable; one had pudendal SEP and MEP present, while SEP were present but delayed (47.0 +/- 8.8 msec) in the remaining patients. In four of these patients, also MEP were recorded (27.9 +/- 5.2 msec) and normal. PNTML was present in 12/16 patients independent of the completeness of lesion, and was rated normal in nine and delayed in three patients. EMG was normal in five, and pathological in 11 cases. In 5/15 cases of those judged as 'complete' (in 3/7 evaluated neurologically), visceral sensory testing revealed a minimal threshold for rectal perception of distension of 44 mL (range: 10-130), which sometimes was also perceived as urge to defecate. In a further case, manometry showed major voluntary action of the anal sphincter. These patients had lesions at all levels of the spinal column, ranging from cervical (C4,C6,C7) via thoratical (2 x T7,T8,T12) to lumbar segments. Anorectal function testing, and specifically visceral sensory testing may be superior to neurological assessment of 'completeness' of spinal cord lesions. It may be that visceral afferent pathways others than spinothalamic tract are involved in rectal perception that are less accessible to conventional neurophysiological diagnostic work-up.

Clinical value of anorectal manometry index in neurogenic fecal incontinence.

The present communication is an endeavor to assess the value of a simple motility index to separate patients with neurogenic or idiopathic fecal incontinence from those patients with the secondary form of the disease. Study population consisted of 23 patients with idiopathic fecal incontinence and 13 patients with fecal incontinence secondary to surgical or obstetric trauma. They all had a standard anorectal manometric study after a 12-hour fast. A motility index was then prepared taking into consideration the peak sphincter pressure values, contractility endurance, and rectal sensory threshold. Despite differences in the mean peak squeeze pressure and sensory threshold between the two groups, there were significant overlaps for all parameters of standard anorectal manometry in both groups. However, patients with idiopathic incontinence had an index of smaller than 28, and the group with the secondary form of incontinence had indexes higher than 30. 1) None of the four parameters of a conventional anorectal manometry can accurately separate patients with neurogenic incontinence from those with secondary forms of the disorder. 2) The anorectal motility index presented here can accurately separate the two groups. 3) This index is superior to the standard anorectal manometry in evaluating patients with fecal incontinence.

FECOFLOWMETRY AND ANORECTAL MANOMETRY IN POSTOPERATIVE PATIENTS AFTER THE REPAIR OF ANORECTAL MALFORMATION

Defecation is the sum of the functions of all mechanisms of anorectal evacuation. With only anorectal manometry, little correlation was found between investigative results and symptoms. The aim is to characterize a flow pattem for functional diagnosis in postoperative patients of anorectal malformation(ARM). Material and Methods: This study comprised 16 patients in the long term after repair of ARM. The mean age of the patients was 9.8years. Type of ARM is as following;high type:8cases, intermediate type:4cases, low type:4cases. The subjects were instructed to evacuate their bowels by enema prior to examination. In the conventional anorectal manometry, rectal pressure(RP), anal canal pressure(AP), anal squeezing pressure(ASP) was calculated. In the fecoflowmetry, redesigned uroflowmeter was used. After an enema of 20ml/kg body weight of normal saline solution(37°C) as imitation of stool was given under rectal pressure monitoring, the patients defecated on the fecoflowmeter(FFM). We discussed on maximum defecation flow(Fmax), defecation pattem, and manometric findings. Results: 1. There were 3 defecational pattems; Block pattem(B type),Segmental pattem(S type),and Flat pattem(F type). 2. Clinically good cases showed B type or S type(Defecation time<1.5min). 3. Clinically fair or poor cases with incontinence or soiling showed F type or S type with Fmax<40ml/sec. 4. Patients with Fmax>40ml/sec were clinically good even in case of AP<15mmHg. Conclusion: FFM provides quantitative and qualitative data conceming the defecation act in postoperative ARM patients.