4 Comparing anorectal function tests 113 or s-EMG; 2) balloon expulsion test or 3) defecography. Remarkable is that the ARM or the s-EMG should be abnormal and that DRE and the transperineal ultrasound are not mentioned in this work-up.7 This might be confusing and suggests that none of the tests can be considered as golden standard. Furthermore, anorectal function tests provide additional workload and costs whereas DRE is widely available and dyssynergia is a widespread phenomenon. The ROME IV criteria are merely used to standardize patients in an attempt to objectivize dyssynergia. Also, Bordeianou et al. had their doubts about which test to assign highest value, the s-EMG, BET or ARM, prior to referral to the pelvic floor physical therapist with dyssynergia.48 Undoubtedly this study has several limitations which should be acknowledged. First, the surgeons and the pelvic floor physical therapist were unblinded to the patients’ medical history when performing the DRE which likely has influenced the results by information bias. Secondly, although all surgeons and the pelvic floor physical therapist were given instructions before the study started on how to perform a complete structured DRE and systematically describe the physical examination in the electronic health record, variety in performing and assessing DRE is insurmountable. The single observer for all 3D-HRAM results might be a lowness or a strength in this study. A considerable limitation of this study is that we were not able to use controlled normal s-EMG values since they have not yet been published. Furthermore, the results of the study would have had more relevance if there was a gold standard or known sensitivity of the tests. This issue is also reflected in the ROME IV criteria for dyssynergic defecation as mentioned above. Unfortunately, not all patients underwent all tests due to logistic problems in the outpatient clinic concerning the tests in the context of the study. Consequently, some patients did not undergo the BET or the TPUS. Lastly, there might have been interpretation bias by assessing straining movement of the pelvic floor. It is not known how ‘indifferent’ movement of the pelvic floor is defined among the examiners; does this mean ‘no movement’ or also ‘relaxation but not enough’? This probably resulted in different outcomes. This study showed that squeeze pressures were more often similarly categorized than resting pressures in anorectal function tests. It further shows that the surgeons’ DRE and the pelvic floor physical therapist’s DRE more often similar assessed in comparison to anorectal functions tests as 3D-HRAM, s-EMG or TPUS. Still, the correlation between all tests is quite disappointing and this raises questions regarding when to perform these tests in addition to DRE. Or does this mean that we can suffice with an expert’s DRE when referring to the pelvic floor physical therapist for
RkJQdWJsaXNoZXIy MTk4NDMw