Chapter 4 112 are used for different purposes in clinical practice. The question that remains is how relevant small differences are in clinical practice. The results of the six different function tests used to diagnose pelvic floor dyssynergia, namely DRE by both the surgeon and the pelvic floor physical therapist, 3D-HRAM, s-EMG, BET and transperineal ultrasound (with echo lucent gel) were to some extent comparable. Although most comparisons were statistically significant, the correlation remained low. Discrepancies with TPUS could be explained by the non-anatomical supine position of the test and the fact that the patient is not in private environment. Three patients who evacuated the gel – although not completely – but were not able to expel the balloon within 1 minute, were referred for PFPT because of fecal incontinence. It is very likely that these patients lost the gel by leaking, not because of the push effort. This makes these tests not suitable to compare. Furthermore, the tests are performed in different postures; the balloon expulsion is performed in a private setting, in sitting position, whereas the other tests are performed by an examiner with the patient lying in the left lateral position. 3D-HRAM measures the anorectal pressures, s-EMG measures electrical activity and TPUS is visually assessed by the doctor were evacuating echo lucent gel might support their findings. Some discrepancies cannot be explained except the snapshot nature of the tests. It is known that the diagnostic accuracy of ARM is limited for discriminating between healthy people and patients with functional constipation.42 Unfortunately, previous studies with TPUS assessed its accuracy for detecting rectocele, intussusception or enterocele, or used a total pelvic floor ultrasound without echo lucent gel. No previous studies reported its accuracy to diagnose dyssynergia. However, based on our experience the TPUS is a low cost and easy tool for surgeons to perform. Surgeons are able to perform their own test in the outpatient clinic and, moreover, it has comparable results with the classical defecography 43 which makes it worth considering it a relevant anorectal function test. The BET is a frequently used test for assessing defecatory dysfunction since it is a simple and low-cost procedure. Different protocols are used to perform the procedure; air filled or water-filled balloon, lying or seated position. Time values that are considered abnormal range from 1 till 5 minutes.28-30,44,45 In our study, a balloon expulsion time of more than 1 minute was considered prolonged. This was categorized as dyssynergia by the 3D-HRAM in 32% of the cases. In contrast to older studies more recent studies demonstrated poor agreement between BET and ARM.46,47 According to the ROME IV criteria, dyssynergic defecation is established by two out of three tests: 1) ARM
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