Fecal evacuation disorders in anal fissure, hemorrhoids, and solitary rectal ulcer syndrome

  • Mayank JainEmail author
  • Rajiv Baijal
  • M. Srinivas
  • Jayanthi Venkataraman


The causative factors for hemorrhoids, anal fissure, and solitary rectal ulcer syndrome (SRUS) are poorly understood. The study was done to identify the prevalence of fecal evacuation disorders in patients with anal fissure, hemorrhoids, and SRUS using anorectal manometry (ARM). Retrospective analysis of ARM data from three centers across India was done. Baseline demographic details and symptoms pertaining to bowel movements were noted. Limited colonoscopy details pertaining to hemorrhoids, fissure-in-ano, and SRUS were noted. The patients were divided into two groups—group I (those with fissure, hemorrhoids, or solitary rectal ulcer) and group II (normal study). ARM parameters of resting anal pressure, squeeze pressure, dyssynergic defecation, and abnormal balloon expulsion were compared between the two groups. Sub-analysis was done for ARM metric differences between those with hemorrhoids, chronic fissure, and SRUS. Appropriate statistical tests were used. A p-value of < 0.05 was considered significant. There were more men in group I (87%; p-value 0.01) with a higher resting anal pressure (80 vs. 69 mmHg, p-value 0.03). Functional evacuation disorders (p < 0.0001), dyssynergic defecation (77.2% vs. 46.8%, p < 0.0001) and abnormal balloon expulsion (66.7% vs. 20.3%, p < 0.0001) were significantly higher in group I. These were significantly more common in patients with anal fissure and SRUS compared to those with hemorrhoids (p-value 0.028). Functional evacuation disorders are frequently noted in patients with hemorrhoids, anal fissure, and SRUS.


Fissure Hemorrhoids Manometry Rectum 


Compliance with ethical standards

Conflict of interest

MJ, RB, MS, and JV declare that they have no conflict of interest.

Ethics statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.


The authors are solely responsible for the data and the content of the paper. In no way, the Honorary Editor-in-Chief, Editorial Board Members, or the printer/publishers are responsible for the results/findings and content of this article.


  1. 1.
    Jain M, Baijal R. Dyssynergic defecation: demographics, symptoms, colonoscopic findings in north Indian patients. Indian J Gastroenterol. 2017;36:435–43.CrossRefGoogle Scholar
  2. 2.
    Jain M, Baijal R, Srinivas M, Venkataraman J. Clinical predictors and gender-wise variations in dyssynergic defecation disorders. Indian J Gastroenterol. 2018;37:255–60.CrossRefGoogle Scholar
  3. 3.
    Mearin F, Lacy BE, Chang L, et al. Bowel disorders. Gastroenterology. 2016;150:1393–407.Google Scholar
  4. 4.
    Gearhart SL. Diverticular disease and common anorectal disorders. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Larry Jameson J, Loscalzo J. Eds. Harrison’s Textbook of Internal Medicine. 18th ed. New York: McGraw Hill. 2012.Google Scholar
  5. 5.
    Tjandra JJ, Fazio VW, Church JM, Lavery IC, Oakley JR, Milsom JW. Clinical conundrum of solitary rectal ulcer. Dis Colon Rectum. 1992;35:227–34.CrossRefGoogle Scholar
  6. 6.
    Suresh N, Ganesh R, Sathiyasekaran M. Solitary rectal ulcer syndrome: a case series. Indian Pediatr. 2010;47:1059–61.CrossRefGoogle Scholar
  7. 7.
    Abid S, Khawaja A, Bhimani SA, Ahmad Z, Hamid S, Jafri W. The clinical, endoscopic and histological spectrum of the solitary rectal ulcer syndrome: a single-center experience of 116 cases. BMC Gastroenterol. 2012;12:72.CrossRefGoogle Scholar
  8. 8.
    Rao SS, Hatfield R, Soffer E, Rao S, Beaty J, Conklin JL. Manometric tests of anorectal function in healthy adults. Am J Gastroenterol. 1999;94:773–83.CrossRefGoogle Scholar
  9. 9.
    Rao SS. Dyssynergic defecation and biofeedback therapy. Gastroenterol Clin N Am. 2008;37:569–86.CrossRefGoogle Scholar
  10. 10.
    Ghoshal UC, Abraham P, Bhatt C, et al. Epidemiological and clinical profile of irritable bowel syndrome in India: report of the Indian Society of Gastroenterology Task Force. Indian J Gastroenterol. 2008;27:22–8.PubMedGoogle Scholar
  11. 11.
    Simsek A, Yagci G, Gorgulu S, Zeybek N, Kaymakcioglu N, Sen D. Diagnostic features and treatment modalities in solitary rectal ulcer syndrome. Acta Chir Belg. 2004;104:92–6.CrossRefGoogle Scholar
  12. 12.
    Sharma A, Misra A, Ghoshal UC. Fecal evacuation disorder among patients with solitary rectal ulcer syndrome: a case control study. J Neurogastroenterol Motil. 2014;20:531–8.CrossRefGoogle Scholar
  13. 13.
    Rao SS, Ozturk R, De Ocampo S, Stessman M. Pathophysiology and role of biofeedback therapy in solitary rectal ulcer syndrome. Am J Gastroenterol. 2006;101:613–8.CrossRefGoogle Scholar
  14. 14.
    Behera MK, Dixit VK, Shukla SK, et al. Solitary rectal ulcer syndrome: clinical, endoscopic, histological and anorectal manometry findings in north Indian patients. Trop Gastroenterol. 2015;36:244–50.CrossRefGoogle Scholar
  15. 15.
    Sun WM, Read NW, Shorthouse AJ. Hypertensive anal cushions as a cause of the high anal canal pressures in patients with haemorrhoids. Br J Surg. 1990;77:458–62.CrossRefGoogle Scholar
  16. 16.
    Girardi S, Piccinelli D, Lolli P, et al. Anorectal manometry in hemorrhoidal disease. Ann Ital Chir. 1995;66:757–60.PubMedGoogle Scholar
  17. 17.
    Lin JK. Anal manometric studies in hemorrhoids and anal fissures. Dis Colon Rectum. 1989;32:839–42.CrossRefGoogle Scholar
  18. 18.
    Schouten WR, Briel JW, Auwerda JJ. Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures. Dis Colon Rectum. 1994;37:664–9.CrossRefGoogle Scholar
  19. 19.
    Farouk R, Duthie GS, MacGregor AB, Bartolo DC. Sustained internal sphincter hypertonia in patients with chronic anal fissure. Dis Colon Rectum. 1994;37:424–9.CrossRefGoogle Scholar
  20. 20.
    Forootan M, Shekarchizadeh M, Farmanara H, Esfahani ARS, Esfahani MS. Biofeedback efficacy to improve clinical symptoms and endoscopic signs of solitary rectal ulcer syndrome. Eur J Transl Myol. 2018;28:7327.CrossRefGoogle Scholar

Copyright information

© Indian Society of Gastroenterology 2019

Authors and Affiliations

  1. 1.Department of GastroenterologyGleneagles Global Health CityChennaiIndia
  2. 2.Choithram Hospital and Research CentreIndoreIndia
  3. 3.Pushpavati Singhania Hospital and Research CentreNew DelhiIndia

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