Chapter 4 98 were asked to empty their bladder before the assessment. After careful insertion of the index finger, the sphincter tone was assessed at rest and scored as low, normal- or high (Table 1). Squeeze tone was evaluated as the increment in pressure and scored similar. Then the patient was asked to squeeze for 30 seconds. The squeeze pressure was scored as low, normal, or high. Subsequently, the examiner placed his/her left hand on the patient’s abdomen and the patient was asked to push and bear down. Push effort was scored as relaxation, indifferent or paradoxical contraction. Surface electromyography (s-EMG) Pelvic floor muscle tone and function were measured with s-EMG (μV) 10 with an intraanal probe (MAPLe® Novuqare Pelvic Health B.V. CE 0344, Rosmalen, the Netherlands). This is a probe with a matrix of 24 electrodes enabling measuring EMG signals from the different sides and layers of the pelvic floor muscles. The EMG probe is placed intraanal, with the reference electrode placed on the spina iliaca anterior superior. Patients were asked to perform four consecutive tasks: 1) one minute rest where patients were instructed to feel the pelvic floor in rest 2) three maximum voluntary contractions where patients were instructed to perform a controlled contraction and relaxation of the pelvic floor muscles 3) one endurance contraction where patients were instructed to contract the pelvic floor muscles at such a level that they could hold for 30 seconds and 4) one push effort where the patient was asked to bear down. The examiner was holding the probe to keep it in place. From these s-EMG measurements, mean s-EMG amplitudes per electrode were calculated. A sustained increase in surface s-EMG activity (>50% increase from baseline) on attempted bearing down was defined as dyssynergia. The EMG values are presented as absolute values (μV). Normal values have not been published yet. For this reason, the pelvic floor physical therapist estimated the normal values for men and women on clinical experience and a recent study where EMG values were measured during PFPT in patients with a chronic anal fissure21 (Table 1). Results of the one year follow-up will be published shortly. 3D high resolution anal manometry (3D-HRAM) The 3D-HRAM was performed by a nurse continence specialist and, the methods are previously described.22 The anorectal probe has 256 pressure sensors on 16 lines, each line having 16 circumferential sensors. The probe, which is covered by a disposable sheath, has a diameter of 10.75 mm, a length of 64 mm and an internal lumen to inflate the balloon (3.3 cm long with a capacity of 400cc). Patients underwent the test in the
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