1 General introduction 25 Anorectal manometry Anorectal high-resolution manometry (HRM) and three-dimensional high-definition manometry (3D-HRAM) are the ‘gold standard’ in investigating anorectal disorders.62 The International anorectal physiology working group (IAPWG) recommends anorectal manometry in the assessment of symptoms of functional anal pain for identification of anal sphincter hypertonicity and abnormalities of rectoanal coordination and parameters of evacuation.63 Manometry provides a comprehensive assessment of pressure activity in the rectum and sphincter complex with an assessment of rectal sensation, reflexes and rectal compliance.21 It can be used as a component of clinical evaluation for patients in whom advanced management strategies are regarded especially in disordered evacuation.64 In patients with CAF, anal manometry has demonstrated high anal basal pressures.65,66 Dyssynergia is defined by the absence of pressure reduction or an increase in the residual anal pressure during straining.67 Rao et al.68 classified 4 patterns: rectal pressure > 40 mmHg and paradoxical anal contraction (type I); rectal pressure < 40 mmHg and paradoxical anal contraction (type II); rectal pressure > 40 mmHg and incomplete anal relaxation (type III); and rectal pressure < 40 mmHg and incomplete anal relaxation (type IV). In a study of Jain,66 dyssynergic defecation was investigated with ARM and was more common in patients with CAF. 3D-HRAM resting pressure, squeezing, and straining Defecation not only involves correct anorectal synchronisation but also a correct thoraco-abdominoperineal dynamic and vertebral position.69 Alterations of pelvic statics may be a cause for dyssynergia. Lumbar hyperlordosis causes a horizontally position of
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