Functional anorectal disorders such as faecal incontinence (FI), functional anorectal pain, and functional defecation disorders (FDD) are highly prevalent and represent a high socioeconomic burden. Several tests of anorectal function exist in this setting; however, high-resolution anorectal manometry (HR-ARM) is a new tool that depicts pressure all along the anal canal and can assess rectoanal coordination. HR-ARM is used in the diagnosis of FI and especially FDD although data in health is still sparse, and pressure phenomena seen during simulated defecation, such as dyssynergia, are highly prevalent in health.

Functional anorectal disorders comprise faecal incontinence (FI), functional anorectal pain, and functional defecation disorders (FDD), including dyssynergic defecation (DD) and inadequate propulsion according to the new Rome IV criteria [1]. Functional anorectal pain is subdivided into levator ani syndrome, unspecified anorectal pain, and proctalgia fugax. The definitions of these conditions are based on symptoms and, in the case of FI and FDD, in part on physiological testing. FDD are diagnosed when more than two symptoms of chronic constipation or irritable bowel syndrome (IBS) and more than two parameters of impaired evacuation, i.e. dyssynergic manometry patterns, impaired evacuation on imaging, or failed balloon expulsion test (BET), are present. Functional anorectal disorders are highly prevalent and have a significant impact on quality of life. Symptoms are often not mentioned by patients due to perceived social stigma [2,3,4,5]. Doctors often do not screen for anorectal dysfunction, which remains a significant economic and medical challenge [6,7,8,9].

Various tests are available to investigate anorectal function; for FI and FDD, however, anorectal manometry (ARM) is the most commonly performed, accepted, and best established investigation [10,11,12]. ARM assesses the pressure in the anal canal at rest and during voluntary effort (squeeze) as well as attempted evacuation (simulated defecation). Pressures in the anal canal and rectum are either presented as line traces (conventional manometry) or as colour-contour plots (high-resolution manometry (HRM)). Both water-perfused and solid-state catheters are used in clinical practice.

Rectal sensation can be assessed by rectal barostat studies or by syringe-driven balloon distension with the balloon either mounted on the manometry catheter or attached to a Foley catheter. The ability to evacuate is tested by BET, where patients are asked to expel a water-filled balloon attached to a Foley catheter sitting on a commode in privacy.

Conventional and magnetic resonance defaecography (MRD) allow identification of structural rectal abnormalities such as rectocele or enterocele with intussception. Furthermore, they can assess pelvic floor descent and rectal emptying of applied contrasts. MRD has the advantage of not exposing the patient to radiation and of giving detailed, dynamic information on the surrounding pelvic floor anatomy.

However, none of the diagnostic tests currently available provide a complete and comprehensive assessment of the complexity of anorectal function. Guidelines recommend a series of tests for the diagnosis of anorectal disorders such as FI and FDD after thorough clinical assessment [13,14].

Management of FI and FDD includes diet modification, medication, and pelvic floor physiotherapy. Biofeedback is effective in FI and FDD.

This review will explore the role of high-resolution anorectal manometry (HR-ARM) for the diagnosis of functional anorectal disorders with a special focus on FI and FDD.

The introduction of HRM utilizing a higher number of closely spaced, circumferential pressure sensors with data presented as colour-contour plots has revolutionized the field of gastrointestinal motility [11]. In contrast, conventional manometry measures pressure only at certain points within the anal canal and presents pressures as trace lines. Even though ARM remains the most frequently performed test of anorectal sphincter function and recto-anal coordination, application and uptake of the high-resolution technology in the anorectum has been slow in comparison to oesophageal manometry, where a validated classification system of motility disorders based on the high-resolution technology has been established [15]. Current guidelines for ARM mainly focus on conventional manometry and are based on expert consensus [16,17,18].

For HR-ARM, several technologies and catheters with different sensor designs by various manufacturers exist. In two-dimensional HR-ARM, pressure is recorded by flexible catheters with circumferential or unidirectional sensors at different levels of the anorectum. Data are usually presented as an average of measured pressures. Three-dimensional HR-ARM (3D-ARM), also referred to as high-definition ARM in the literature, utilizes a rigid probe with data measured with 256 circumferential pressure sensors. Recorded pressures can be presented either two- or three-dimensionally.

All HR-ARM catheters have sensors at their tip for assessment of rectal pressure. However, the design of rectal sensors is different from those placed in the anal canal in most catheters. Furthermore, the rectal sensors are generally covered by a non-latex balloon, which impacts on the validity of measurement of rectal pressures [19].

FI afflicts all age groups and sexes. Its prevalence is highest amongst middle-aged and elderly women and nursing home residents [20,21].

FI is characterized by the symptoms urgency, faecal leakage, and involuntary loss of stool or flatus. ARM can provide information on the function of the internal anal sphincter (anal resting pressure) and the external anal sphincter (pressure during voluntary squeeze effort). When it comes to the assessment of sphincter pressures by ARM, differences between healthy volunteers and FI patients exist. Several studies were able to demonstrate an association between a low anal resting pressure and symptoms of passive FI; however, sensitivity for this finding is low [22,23,24,25,26,27]. Low pressure during voluntary contraction has been demonstrated to be associated with urge FI [23,28].

3D-ARM has the additional feature of visualizing the physiological asymmetry of the anal canal with higher pressures in the posterior proximal and anterior distal parts of the sphincter complex. Furthermore, 3D-ARM can correlate pressure defects with pathology seen on endoanal ultrasound, e.g. in women with postpartum tears. However, normative data in health and disease, as well as validation of the functional impact of pressure defects seen on 3D ARM are still lacking. Therefore, pressure defects seen on 3D-ARM should be verified by further imaging such as endoanal ultrasound [29,30].

The Functional Lumen Imaging Probe (Endoflip) is a new tool to assess distensibility in the gastrointestinal tract via impedance planimetry. It is currently mainly applied in the oesophagus for guiding treatment in achalasia (Heller myotomy) as well as before and after semifundoplication [31,32,33].

The use of Endoflip in the anal canal shows higher distensibility in patients with FI when compared to healthy volunteers, regardless of the pathophysiology of FI (sphincter injury vs. fibrosis). When compared to 3D-ARM, Endoflip has shown a large diagnostic overlap of results in a substantial proportion of investigated patients with FI. Similar to HR-ARM, where a subset of patients with symptoms of FI shows normal sphincter pressures at rest and during voluntary effort, Endoflip has detected normal mechanical properties of the anal canal in some FI patients [34,35]. This finding highlights that continence function is determined not only by absolute sphincter pressures and possibly by distensibility but also by rectal sensation, volume, and compliance [36]. At present, application of the Endoflip technology in the anorectum is limited to research, and it remains to be investigated if results show additional information when compared to HR-ARM.

FDD are part of the spectrum of chronic constipation with outlet obstruction: Symptoms include excessive straining, feeling of incomplete evacuation, and digital facilitation of defecation. The prevalence of FDD ranges between 20 and 80% in patients with chronic constipation in the literature [37,38,39]. As a symptom-based diagnosis cannot rule out other causes of chronic constipation from FDD, physiological testing is required for diagnosis.

The Rome IV criteria for FDD require fulfilment of diagnostic criteria of functional constipation and/or IBS with constipation for at least 3 months. The inclusion of IBS with constipation is based on emerging evidence for an association between IBS and pelvic floor dysfunction [40]. A combination of anorectal tests, such as manometry, balloon expulsion, imaging via conventional defaecography or MRD or surface electromyography, are generally recommended to detect anorectal dysfunction during attempted defecation.

High anal pressures can be detected by ARM in constipation and also in the presence of anal fissure, and exact cut-offs for anal hypertonia are lacking [41,42,43,44].

While pressures measured by AMR in constipation are not sensitive and specific, ‘defaecatory forces' and deficient recto-anal coordination, particularly inadequate defaecatory propulsion (impaired rectal force during simulated defecation) and dyssynergic defecation (paradoxical anal sphincter contraction during simulated defecation), can be described by manometry in FDD. DD can be further subclassified using the Rao classification (fig. 1).

Fig. 1

Manometry patterns for dyssynergic defecation according to Rao. A Rao type I: Paradox anal sphincter contraction with a significant increase (>40 mm Hg) in rectal pressure during simulated defecation. B Rao type II: Paradox contraction with no increase (<40 mm Hg) in abdominal pressure during attempted defecation. C Rao type III: No paradox contraction but also no sphincter relaxation is seen. There is an increase (>40 mm Hg) in rectal pressure during simulated defecation manoeuvre; however, it is less than anal sphincter pressure and not sufficient to drive defecation. D Rao type IV: No contraction or relaxation of the anal sphincter and no significant increase in rectal pressure during simulated defecation. If this is seen with a lack of sphincter contraction during voluntary squeeze, pelvic floor akinesia is present [47,52]

Fig. 1

Manometry patterns for dyssynergic defecation according to Rao. A Rao type I: Paradox anal sphincter contraction with a significant increase (>40 mm Hg) in rectal pressure during simulated defecation. B Rao type II: Paradox contraction with no increase (<40 mm Hg) in abdominal pressure during attempted defecation. C Rao type III: No paradox contraction but also no sphincter relaxation is seen. There is an increase (>40 mm Hg) in rectal pressure during simulated defecation manoeuvre; however, it is less than anal sphincter pressure and not sufficient to drive defecation. D Rao type IV: No contraction or relaxation of the anal sphincter and no significant increase in rectal pressure during simulated defecation. If this is seen with a lack of sphincter contraction during voluntary squeeze, pelvic floor akinesia is present [47,52]

Close modal

Data regarding the performance of HR-ARM in detecting different types of DD are conflicting: In conventional manometry, a normal simulated defecation manoeuvre is generally marked by an increase in rectal pressure and a decrease in anal pressure, which is described as anal relaxation in the literature [45]. Paradoxical contraction (i.e. sphincter contraction during simulated defecation), as seen in FDD, is characterized by an insufficient increase in rectal pressure and/or an increase in anal pressure (fig. 2). It has been shown that, due to the larger spacing of sensors in conventional manometry, the actual movement of the catheter during simulated defecation is not being taken into account. When simulated defecation manoeuvres were compared in the conventional and high-resolution mode, a significant proportion showed catheter movement on conventional manometry, which would have led to a finding of false-positive anal relaxation on conventional tracings. Therefore, HR-ARM should actually facilitate data acquisition and interpretation during the simulated defecation manoeuvre [46].

Fig. 2

Simulated defecation manoeuvres on a conventional anorectal manometry and b high-resolution anorectal manometry (HR-ARM). HR-ARM shows that relaxation in the anal canal is actually caused by catheter movement out of the anal canal.

Fig. 2

Simulated defecation manoeuvres on a conventional anorectal manometry and b high-resolution anorectal manometry (HR-ARM). HR-ARM shows that relaxation in the anal canal is actually caused by catheter movement out of the anal canal.

Close modal

Additionally, in comparison to MRD, a high diagnostic accuracy to detect dyssynergia has been reported in some studies [47]. However, other studies have described a high frequency of DD patterns also in healthy persons [48,49]. This is limiting the clinical utility of ARM for the diagnosis of DD until further quantitative metrics are developed and validated, and could lead to a high rate of false-positive results in the diagnosis of FDD based on ARM [47,50,51,52].

A new manometric pattern termed pelvic floor akinesia, i.e. lack of pelvic floor movement on simulated defecation and voluntary effort, is emerging, with high sensitivity and specificity for poor evacuatory function [52].

Whether the overall low diagnostic accuracy of ARM in this setting can be attributed to the awkward nature of the investigation and non-physiological left lateral test position has still not been sufficiently investigated. Unpublished data show that patients prefer investigation in the sitting position instead of the left lateral position, in which most tests of anorectal function are performed [53]. When measured in the sitting position, resting pressure is lower and fewer healthy volunteers and patients show a pattern of DD, possibly due to more physiological defecation mechanics with higher abdominal pressures [53,54].

It can be further argued that the simulated defecation manoeuvre is performed with an empty rectum, driving the catheter into the wall of the anal canal during attempted defecation and causing a picture of contraction rather than of relaxation. Further studies investigating anorectal pressures with HR-ARM with a filled rectum in the sitting position are warranted.

For the diagnosis of structural reasons for constipation, such as rectocele or enterocele with intussusception, HR-ARM and 3D-ARM allow the identification of pressure phenomena not previously identified by conventional ARM (fig. 3). 3D-HRM can give an impression of the amount of pelvic floor descent [55]. Furthermore, recent studies have demonstrated that HR-ARM and 3D-ARM have a high positive predictive value for the presence of an intra-anal intussusception diagnosed by defaecography and MRD [47,56] (fig. 3). In patients with evacuatory dysfunction, these manometric patterns can be a useful tool to detect structural pelvic floor abnormalities and help to direct further investigations, such as defaecography, and guide treatment.

Fig. 3

Structural outlet obstruction observed on high-resolution anorectal manometry and magnetic resonance imaging. Note a localized, high-pressure band at the level of the anal sphincter during simulated defecation, clearly different from voluntary contraction (squeeze). Magnetic resonance defaecography shows a rectocele with intra-anal intussusception [47].

Fig. 3

Structural outlet obstruction observed on high-resolution anorectal manometry and magnetic resonance imaging. Note a localized, high-pressure band at the level of the anal sphincter during simulated defecation, clearly different from voluntary contraction (squeeze). Magnetic resonance defaecography shows a rectocele with intra-anal intussusception [47].

Close modal

The prevalence of functional anorectal pain is estimated to range between 8 and 18%, with both sexes being equally affected across almost all age groups in the community [57].

The levator ani syndrome is generally defined as a chronic or recurrent dull ache high in the rectum over a time frame of 3 months. Symptoms usually last 30 min or longer and digital rectal examination reveals tenderness during traction on the puborectalis. Unspecified functional anorectal pain is defined by the same criteria as the levator ani syndrome with the exception that there is no local pain during digital rectal examination on traction of the puborectalis [1,58]. In contrast to the levator ani syndrome, proctalgia fugax is defined as recurrent but inconsistent episodes of gnawing, aching, or cramping rectal pain not associated with defecation over 3 months. Episodes can last from seconds to a maximum of 30 min, interrupt activities, and wake patients from their sleep [1].

For the diagnosis of all forms of functional anorectal pain, other causes including inflammatory bowel disease, fissures, thrombosed haemorrhoids, and prostatitis must be ruled out in the first step. Important overlaps exist between the levator ani syndrome, unspecified functional anorectal pain, and proctalgia fugax [1].

Diagnosis is mainly clinical, and evidence for the diagnostic utility of manometry is scarce. With regard to levator ani syndrome, several reports using conventional manometry indicate higher anal sphincter pressures as well as typical manometric patterns of DD. Improvement of symptoms with biofeedback therapy supports the validity of these observations [58,59,60]. Currently, no data exist on the role of HR-ARM in the assessment of functional anorectal pain, and it remains to be investigated if results seen on conventional manometry are transferable to HR-ARM.

Interpretation of the findings of ARM is still challenging due to the wide variability of manometric measurements in health and disease. Recent studies have shown that in spite of its wide application, striking variability in practices between institutions exists when it comes to protocol, equipment, and metrics applied for analysis [61].

Furthermore, existing normative data sets need to be extended to take into account age, sex, parity, and gender [26,48,49,62,63,64,65,66,67,68,69,70,71,72,73,74,75]. Lack of standardization for interaction of the investigator with the patient and feedback during the investigation also increase variance of reported normal values and possibly the rate of DD seen with ARM [65,68].

Catheter configuration (water-perfused vs. solid-state design) and diameter, sensor configuration of HR-ARM solid-state catheters (unidirectional vs. multidimensional), and sensor density (3D-ARM vs. HR-ARM) also impact on measurements. Strikingly, usage of a high-resolution solid-state catheter with 23 microtransducers, comprising four radially arranged sensors, yielded lower values (20 mm Hg) for resting pressure and maximum squeeze pressure than another solid-state catheter with 10 pressure sensors with 36 circumferentially oriented, pressure-sensing elements [70]. When looking at another normative data set based on data acquired by a catheter with 12 microtransducers, measuring circumferential pressure by means of unidirectional pressure sensors embedded in silicone gel, these values are significantly higher than those reported by the two other catheters [65]. Even though experimental variability and epidemiological differences in investigated volunteers might partially explain these differences, it is evident that application of catheter-specific normal values is crucial due to differing sensor design and sensor density to assess anorectal dysfunction correctly.

Furthermore, the presence or absence of a stimulus for defecation may have a significant impact on absolute values reported [76,77,78,79,80,81].

ARM is a safe and widely available test accepted by patients and doctors. HR-ARM and 3D-ARM are promising new tools in the diagnosis of functional anorectal disorders. HR-ARM can - in combination with further tests of rectal sensitivity and evacuation - provide important information on pathophysiology and guide further treatment. Its ability to visualize subtle pressure changes in the rectum and anal canal during voluntary squeeze effort and simulated defecation provides a clearer depiction of anorectal pressure phenomena. However, actual evidence on usability, consistency, and clinical utility is still lacking, and the impact of this new technology on clinical diagnosis and therapy of FI and FDD needs to be further investigated.

Both authors report no conflicts of interests.

Rao SS, Bharucha AE, Chiarioni G, Felt-Bersma R, Knowles C, Malcolm A, Wald A: Functional anorectal disorders. Gastroenterology 2016;150:1430-1442.e4.
Bharucha AE, Dunivan G, Goode PS, Lukacz ES, Markland AD, Matthews CA, Mott L, Rogers RG, Zinsmeister AR, Whitehead WE, Rao SS, Hamilton FA: Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol 2015;110:127-136.
Norton NJ: The perspective of the patient. Gastroenterology 2004;126:S175-179.
Leigh RJ, Turnberg LA: Faecal incontinence: the unvoiced symptom. Lancet 1982;1:1349-1351.
Johanson JF, Lafferty J: Epidemiology of fecal incontinence: the silent affliction. Am J Gastroenterol 1996;91:33-36.
Boreham MK, Richter HE, Kenton KS, Nager CW, Gregory WT, Aronson MP, Vogt VY, McIntire DD, Schaffer JI: Anal incontinence in women presenting for gynecologic care: prevalence, risk factors, and impact upon quality of life. Am J Obstet Gynecol 2005;192:1637-1642.
Whitehead WE, Borrud L, Goode PS, Meikle S, Mueller ER, Tuteja A, Weidner A, Weinstein M, Ye W; Pelvic Floor Disorders Network: Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology 2009;137:512-517, 517.e1-2.
Bharucha AE, Pemberton JH, Locke GR 3rd: American Gastroenterological Association technical review on constipation. Gastroenterology 2013;144:218-238.
Mearin F: Impact of chronic constipation on quality of life: much more important than it seems (Article in Spanish). Gastroenterol Hepatol 2013;36:467-472.
Phillips SF, Edwards DA: Some aspects of anal continence and defaecation. Gut 1965;6:396-406.
Fox MR, Bredenoord AJ: Oesophageal high-resolution manometry: moving from research into clinical practice. Gut 2008;57:405-423.
Schuster MM, Hendrix TR, Mendeloff AI: The internal anal sphincter response: manometric studies on its normal physiology, neural pathways, and alteration in bowel disorders. J Clin Invest 1963;42:196-207.
Rao SS: Advances in diagnostic assessment of fecal incontinence and dyssynergic defecation. Clin Gastroenterol Hepatol 2010;8:910-919.
Dinning PG, Carrington EV, Scott SM: Colonic and anorectal motility testing in the high-resolution era. Curr Opin Gastroenterol 2016;32:44-48.
Basilisco G, Bharucha AE: High-resolution anorectal manometry: an expensive hobby or worth every penny? Neurogastroenterol Motil 2017;29:DOI: 10.1111/nmo.13125.
Pehl C, Enck P, Franke A, et al: Anorectal manometry (Article in German). Z Gastroenterol 2007;45:397-417.
Rao SS, Azpiroz F, Diamant N, Enck P, Tougas G, Wald A: Minimum standards of anorectal manometry. Neurogastroenterol Motil 2002;14:553-559.
Azpiroz F, Enck P, Whitehead WE: Anorectal functional testing: review of collective experience. Am J Gastroenterol 2002;97:232-240.
Lee TH, Bharucha AE: How to perform and interpret a high-resolution anorectal manometry test. J Neurogastroenterol Motil 2016;22:46-59.
Nelson R, Furner S, Jesudason V: Fecal incontinence in Wisconsin nursing homes: prevalence and associations. Dis Colon Rectum 1998;41:1226-1229.
Perry S, Shaw C, McGrother C, Matthews RJ, Assassa RP, Dallosso H, Williams K, Brittain KR, Azam U, Clarke M, Jagger C, Mayne C, Castleden CM: Prevalence of faecal incontinence in adults aged 40 years or more living in the community. Gut 2002;50:480-484.
Lestar B, Penninckx F, Kerremans R: The composition of anal basal pressure. An in vivo and in vitro study in man. Int J Colorectal Dis 1989;4:118-122.
Engel AF, Kamm MA, Bartram CI, Nicholls RJ: Relationship of symptoms in faecal incontinence to specific sphincter abnormalities. Int J Colorectal Dis 1995;10:152-155.
Vaizey CJ, Kamm MA, Bartram CI: Primary degeneration of the internal anal sphincter as a cause of passive faecal incontinence. Lancet 1997;349:612-615.
Felt-Bersma RJ, Klinkenberg-Knol EC, Meuwissen SG: Anorectal function investigations in incontinent and continent patients. Differences and discriminatory value. Dis Colon Rectum 1990;33:479-485.
Bharucha AE, Fletcher JG, Harper CM, Hough D, Daube JR, Stevens C, Seide B, Riederer SJ, Zinsmeister AR: Relationship between symptoms and disordered continence mechanisms in women with idiopathic faecal incontinence. Gut 2005;54:546-555.
Prichard D, Harvey DM, Fletcher JG, Zinsmeister AR, Bharucha AE: Relationship among anal sphincter injury, patulous anal canal, and anal pressures in patients with anorectal disorders. Clin Gastroenterol Hepatol 2015;13:1793-1800.e1.
Telford K, Ali A, Lymer K, Hosker G, Kiff E, Hill J: Fatigability of the external anal sphincter in anal incontinence. Dis Colon Rectum 2004;47:746-752.
Rezaie A, Iriana S, Pimentel M, Murrell Z, Fleshner P, Zaghiyan K: Can 3D high resolution anorectal manometry detect anal sphincter defects in patients with faecal incontinence? Colorectal Dis 2017;19:468-475.
Vitton V, Ben Hadj Amor W, Baumstarck K, Behr M, Bouvier M, Grimaud JC: Comparison of three-dimensional high-resolution manometry and endoanal ultrasound in the diagnosis of anal sphincter defects. Colorectal Dis 2013;15:e607-611.
Ahuja NK, Agnihotri A, Lynch KL, Hoo-Fatt D, Onyimba F, McKnight M, Okeke FC, Garcia P, Dhalla S, Stein E, Pasricha PJ, Clarke JO: Esophageal distensibility measurement: impact on clinical management and procedure length. Dis Esophagus 2017;30:1-8.
Carlson DA, Kahrilas PJ, Ritter K, Lin Z, Pandolfino JE: Mechanisms of repetitive retrograde contractions in response to sustained esophageal distension: a study evaluating patients with postfundoplication dysphagia. Am J Physiol Gastrointest Liver Physiol 2018;314: G334-G340.
Hirano I, Pandolfino JE, Boeckxstaens GE: Functional Lumen Imaging Probe for the management of esophageal disorders: expert review from the Clinical Practice Updates Committee of the AGA Institute. Clin Gastroenterol Hepatol 2017;15:325-334.
Gourcerol G, Granier S, Bridoux V, Menard J, Ducrotté P, Leroi A: Do endoflip assessments of anal sphincter distensibility provide more information on patients with fecal incontinence than high‐resolution anal manometry? Neurogastroenterol Motil 2016;28:399-409.
Leroi AM, Melchior C, Charpentier C, Bridoux V, Savoye-Collet C, Houivet E, Ducrotte P, Gourcerol G: The diagnostic value of the functional lumen imaging probe versus high-resolution anorectal manometry in patients with fecal incontinence. Neurogastroenterol Motil 2018;DOI: 10.1111/nmo.13291.
Scott SM, Gladman MA: Manometric, sensorimotor, and neurophysiologic evaluation of anorectal function. Gastroenterol Clin North Am 2008;37:511-538, vii.
Nullens S, Nelsen T, Camilleri M, Burton D, Eckert D, Iturrino J, Vazquez-Roque M, Zinsmeister AR: Regional colon transit in patients with dys-synergic defaecation or slow transit in patients with constipation. Gut 2012;61:1132-1139.
Duthie GS, Bartolo DCC: Anismus: the cause of constipation? Results of investigation and treatment. World J Surg 1992;16:831-835.
Wald A, Caruana BJ, Freimanis MG, Bauman DH, Hinds JP: Contributions of evacuation proctography and anorectal manometry to evaluation of adults with constipation and defecatory difficulty. Dig Dis Sci 1990;35:481-487.
Prott G, Shim L, Hansen R, Kellow J, Malcolm A: Relationships between pelvic floor symptoms and function in irritable bowel syndrome. Neurogastroenterol Motil 2010;22:764-769.
Farouk R, Duthie GS, MacGregor AB, Bartolo DC: Sustained internal sphincter hypertonia in patients with chronic anal fissure. Dis Colon Rectum 1994;37:424-429.
Xynos E, Tzortzinis A, Chrysos E, Tzovaras G, Vassilakis J: Anal manometry in patients with fissure-in-ano before and after internal sphincterotomy. Int J Colorectal Dis 1993;8:125-128.
Jones OM, Ramalingam T, Lindsey I, Cunningham C, George BD, Mortensen NJM: Digital rectal examination of sphincter pressures in chronic anal fissure is unreliable. Dis Colon Rectum 2005;48:349-352.
Staller K, Barshop K, Kuo B, Ananthakrishnan AN: Resting anal pressure, not outlet obstruction or transit, predicts healthcare utilization in chronic constipation: a retrospective cohort analysis. Neurogastroenterol Motil 2015;27:1378-1388.
Rao SS: Pathophysiology of adult fecal incontinence. Gastroenterology 2004;126:S14-22.
Sauter M, Heinrich H, Fox M, Misselwitz B, Halama M, Schwizer W, Fried M, Fruehauf H: Toward more accurate measurements of anorectal motor and sensory function in routine clinical practice: validation of high-resolution anorectal manometry and Rapid Barostat Bag measurements of rectal function. Neurogastroenterol Motil 2014;26:685-695.
Heinrich H, Sauter M, Fox M, Weishaupt D, Halama M, Misselwitz B, Buetikofer S, Reiner C, Fried M, Schwizer W, Fruehauf H: Assessment of obstructive defecation by high-resolution anorectal manometry compared with magnetic resonance defecography. Clin Gastroenterol Hepatol 2015;13:1310-1317.e1.
Ratuapli SK, Bharucha AE, Noelting J, Harvey DM, Zinsmeister AR: Phenotypic identification and classification of functional defecatory disorders using high-resolution anorectal manometry. Gastroenterology 2013;144:314-322.e2.
Grossi U, Carrington EV, Bharucha AE, Horrocks EJ, Scott SM, Knowles CH: Diagnostic accuracy study of anorectal manometry for diagnosis of dyssynergic defecation. Gut 2016;65:447-455.
Rao SS, Welcher KD, Leistikow JS: Obstructive defecation: a failure of rectoanal coordination. Am J Gastroenterol 1998;93:1042-1050.
Bharucha AE, Fletcher JG, Seide B, Riederer SJ, Zinsmeister AR: Phenotypic variation in functional disorders of defecation. Gastroenterology 2005;128:1199-1210.
Carrington EV, Grossi U, Knowles C, Scott SM: 43 - ‘Pelvic Floor Akinesia' - a highly specific manometric finding in patients with defecatory dysfunction. Gastroenterology 2017;152:S16.
Heinrich H, Reiner C, Parker H, Misselwitz B, Hollenstein M, Carrington EV, Pohl D, Schwizer W, Fried M, Fox M: 834 Seated evaluation of anorectal function by high resolution manometry: a randomized comparison of measurements in the seated and left lateral positions. Gastroenterology 2016;150(suppl 1):S176.
Rao SSC, Kavlock R, Rao S: Influence of body position and stool characteristics on defecation in humans. Am J Gastroenterol 2006;101:2790-2796.
Benezech A, Bouvier M, Grimaud JC, Baumstarck K, Vitton V: Three-dimensional high-resolution anorectal manometry and diagnosis of excessive perineal descent: a comparative pilot study with defaecography. Colorectal Dis 2014;16:O170-175.
Benezech A, Cappiello M, Baumstarck K, Grimaud JC, Bouvier M, Vitton V: Rectal intussusception: can high resolution three‐dimensional ano‐rectal manometry compete with conventional defecography? Neurogastroenterol Motil 2017;29:DOI: 10.1111/nmo.12978.
de Parades V, Etienney I, Bauer P, Taouk M, Atienza P: Proctalgia fugax: demographic and clinical characteristics. What every doctor should know from a prospective study of 54 patients. Dis Colon Rectum 2007;50:893-898.
Grimaud J-C, Bouvier M, Naudy B, Guien C, Salducci J: Manometric and radiologic investigations and biofeedback treatment of chronic idiopathic anal pain. Dis Colon Rectum 1991;34:690-695.
Chiarioni G, Nardo A, Vantini I, Romito A, Whitehead WE: Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome. Gastroenterology 2010;138:1321-1329.
Eckardt VF, Dodt O, Kanzler G, Bernhard G: Anorectal function and morphology in patients with sporadic proctalgia fugax. Dis Colon Rectum 1996;39:755-762.
Carrington EV, Heinrich H, Knowles CH, Rao SS, Fox M, Scott SM; The International Anorectal Physiology Working Party Group: Methods of anorectal manometry vary widely in clinical practice: results from an international survey. Neurogastroenterol Motil 2017;29:DOI: 10.1111/nmo.13016.
Sun WM, Donnelly TC, Read NW: Utility of a combined test of anorectal manometry, electromyography, and sensation in determining the mechanism of ‘idiopathic' faecal incontinence. Gut 1992;33:807-813.
Maeda Y, Vaizey CJ, Hollington P, Stern J, Kamm MA: Physiological, psychological and behavioural characteristics of men and women with faecal incontinence. Colorectal Dis 2009;11:927-932.
Zbar AP, Kmiot WA, Aslam M, Williams A, Hider A, Audisio RA, Chiappa A, deSouza N: Use of vector volume manometry and endoanal magnetic resonance imaging in the adult female for assessment of anal sphincter dysfunction. Dis Colon Rectum 1999;42:1411-1418.
Carrington EV, Brokjaer A, Craven H, Zarate N, Horrocks EJ, Palit S, Jackson W, Duthie GS, Knowles CH, Lunniss PJ, Scott SM: Traditional measures of normal anal sphincter function using high-resolution anorectal manometry (HRAM) in 115 healthy volunteers. Neurogastroenterol Motil 2014;26:625-635.
Gruppo Lombardo per lo Studio della Motilità Intestinale: Anorectal manometry with water-perfused catheter in healthy adults with no functional bowel disorders. Colorectal Dis 2010;12:220-225.
Banasiuk M, Banaszkiewicz A, Dziekiewicz M, Zaleski A, Albrecht P: Values from three-dimensional high-resolution anorectal manometry analysis of children without lower gastrointestinal symptoms. Clin Gastroenterol Hepatol 2016;14:993-1000.e1003.
Gundling F, Seidl H, Scalercio N, Schmidt T, Schepp W, Pehl C: Influence of gender and age on anorectal function: normal values from anorectal manometry in a large Caucasian population. Digestion 2010;81:207-213.
Kumar S, Ramadan S, Gupta V, Helmy S, Atta I, Alkholy A: Manometric tests of anorectal function in 90 healthy children: a clinical study from Kuwait. J Pediatr Surg 2009;44:1786-1790.
Lee HJ, Jung KW, Han S, Kim JW, Park SK, Yoon IJ, Koo HS, Seo SY, Yang DH, Kim KJ, Ye BD, Byeon JS, Yang SK, Kim JH, Myung SJ: Normal values for high-resolution anorectal manometry/topography in a healthy Korean population and the effects of gender and body mass index. Neurogastroenterol Motil 2014;26:529-537.
Li Y, Yang X, Xu C, Zhang Y, Zhang X: Normal values and pressure morphology for three-dimensional high-resolution anorectal manometry of asymptomatic adults: a study in 110 subjects. Int J Colorectal Dis 2013;28:1161-1168.
Mion F, Garros A, Brochard C, Vitton V, Ropert A, Bouvier M, Damon H, Siproudhis L, Roman S: 3D high-definition anorectal manometry: values obtained in asymptomatic volunteers, fecal incontinence and chronic constipation. Results of a prospective multicenter study (NOMAD). Neurogastroenterol Motil 2017;29:DOI: 10.1111/nmo.13049.
Noelting J, Ratuapli SK, Bharucha AE, Harvey DM, Ravi K, Zinsmeister AR: Normal values for high-resolution anorectal manometry in healthy women: effects of age and significance of rectoanal gradient. Am J Gastroenterol 2012;107:1530-1536.
Pilipenko VI, Tepliuk DA, Shakhovskaia AK, Isakov VA: Normal values for high-resolution anorectal manometry in a healthy women: effects of age and maternity (Article in Russian). Eksp Klin Gastroenterol 2014:55-58.
Rasijeff AMP, Withers M, Burke JM, Jackson W, Scott SM: High-resolution anorectal manometry: a comparison of solid-state and water-perfused catheters. Neurogastroenterol Motil 2017;29:DOI: 10.1111/nmo.13124.
Jones MP, Post J, Crowell MD: High-resolution manometry in the evaluation of anorectal disorders: a simultaneous comparison with water-perfused manometry. Am J Gastroenterol 2007;102:850-855.
Fang JC, Hilden K, Tuteja AK, Peterson KA: Comparison of air-coupled balloon esophageal and anorectal manometry catheters with solid-state esophageal manometry and water-perfused anorectal manometry catheters. Dig Dis Sci 2004;49:1657-1663.
Simpson RR, Kennedy ML, Nguyen MH, Dinning PG, Lubowski DZ: Anal manometry: a comparison of techniques. Dis Colon Rectum 2006;49:1033-1038.
Vitton V, Ben Hadj Amor W, Baumstarck K, Grimaud JC, Bouvier M: Water-perfused manometry vs. three-dimensional high-resolution manometry: a comparative study on a large patient population with anorectal disorders. Colorectal Dis 2013;15:e726-731.
Kang HR, Lee JE, Lee JS, Lee TH, Hong SJ, Kim JO, Jeon SR, Kim HG: Comparison of high-resolution anorectal manometry with water-perfused anorectal manometry. J Neurogastroenterol Motil 2015;21:126-132.
Thekkinkattil DK, Lim MK, Nicholls MJ, Sagar PM, Finan PJ, Burke DA: Contribution of posture to anorectal manometric measurements: are the measurements in left-lateral position physiologic? Dis Colon Rectum 2007;50:2112-2119.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.