Chapter 4 96 Introduction Anorectal function disorders like fecal incontinence and chronic constipation are very common. Generally, a conservative approach with lifestyle advice, fibers, laxative and pelvic floor physical therapy will improve complaints in many patients. When unsuccessful, or the underlying cause seems unclear, these patients are referred to a specialist for further evaluation of anorectal function and possible therapy.1 Besides digital rectal examination (DRE), a variety of tests are available to evaluate anorectal function. One may then objectively assess e.g., low, or high tone of the anal sphincter, paradoxical contraction, or inadequate relaxation of the pelvic floor. Available tests are for example, anorectal manometry (ARM), 3-dimensional highresolution anorectal manometry (3D-HRAM), balloon expulsion test (BET), surface electromyography with or without an intra anal probe (s-EMG), transperianal ultrasound defecography and the classical defecography. Although some studies suggest that DRE alone is a useful tool to identify anorectal disorders,2,3 others propose that anorectal function tests objectively evaluate anorectal function and might provide a predictive value for treatment results and influence management.4-9 Which anorectal function test is the most accurate, is under debate. The s-EMG with intra-vaginal or -anal electrode probes is commonly utilized by the pelvic floor physical therapist to confirm DRE and evaluate therapy.5,10 ARM is often considered the gold standard to measure anal pressures, however lack of reproducibility mentioned in several studies makes the test questionable.11-16 Few studies compared ARM with anal s-EMG and showed limited concordance.17-19 A more recent study compared ARM with DRE to determine dyssynergia and concluded that there was a moderate agreement.20 According to the ROME IV criteria dyssynergia is established by two out of three anorectal function tests: first; abnormal anorectal evacuation pattern measured with ARM or s-EMG, second; abnormal BET, and third; impaired rectal evacuation diagnosed on imaging studies (e.g., defecography).7 Furthermore, examinations as DRE and transperineal ultrasound are not mentioned in this context and a clear gold standard for one of these tests is not suggested. One could wonder whether a restricted use of these additional tests is justified. Could we rely on DRE and use additional tests only in complex patients? Another reason to perform anorectal function tests is an attempt to objectively measure the anal pressures. Since there is no gold standard, a reappraisal for DRE by experienced investigators seems worthwhile investigating.
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