Diseases of the Colon & Rectum

, Volume 41, Issue 2, pp 200–208 | Cite as

Parameters of the rectoanal inhibitory reflex in patients with idiopathic fecal incontinence and chronic constipation

  • Andrew P. Zbar
  • Mohammed Aslam
  • Darren M. Gold
  • Christopher Gatzen
  • Amy Gosling
  • Witold A. Kmiot
Original Contributions


PURPOSE: The rectoanal inhibitory reflex is a response of the internal anal sphincter to rectal distention, reflecting the functional nature of the anal sampling mechanism of rectal discrimination. The aim of this study was to assess the parameters of the rectoanal inhibitory reflex in healthy volunteers and incontinent and symptomatically constipated patients. METHODS: The rectoanal inhibitory reflex was recorded in 42 patients using reproducible threshold volumes. Excitatory and inhibitory latencies, maximum excitatory and inhibitory pressures, amplitude, and slope of inhibition, slope and time of pressure recovery, and area under the inhibitory curve were estimated. Pudendal nerve terminal motor latency and endoanal magnetic resonance imaging were performed in all incontinent patients. RESULTS: Significant linear trends were found for most parameters at each sphincter level when analyzed. Recovery time and area under the inhibitory curve differed between the sphincter levels and patient groups, with the most rapid recovery occurring in the distal sphincter of incontinent patients (P<0.001). These pressure findings were not accounted for by differences in excitation between patient groups. CONCLUSION: A coordinated response by the internal anal sphincter to rectal distention with recovery of anal pressure from the distal to the proximal sphincter is suggested. Continence may rely on the character of internal anal sphincter inhibition, and recovery and preoperative assessment of rectoanal inhibitory reflex parameters may be important for predicting functional result following low anastomosis.

Key words

Anal physiology Rectoanal inhibitory reflex Fecal incontinence Rectoanal excitatory reflex 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Gowers WR. The automatic action of the sphincter ani. Proc R Soc Lond [Biol] 1877;26:77–84.Google Scholar
  2. 2.
    Denny-Brown D, Robertson EG. An investigation of the nervous control of defecation. Brain 1935;58:256–310.Google Scholar
  3. 3.
    Duthie HL, Bennett RC. The relation of sensation in the anal canal to the functional anal sphincter: a possible factor in anal continence. Gut 1963;4:179–82.Google Scholar
  4. 4.
    Lubowski DZ, Nicholls RJ, Swash M, Jordan MJ. Neural control of internal anal sphincter function. Br J Surg 1987;74:688–90.Google Scholar
  5. 5.
    Meunier P, Marechal JM, Mollard P. Accuracy of the manometric diagnosis of Hirschsprung's disease. J Pediatr Surg 1978;13:411–4.Google Scholar
  6. 6.
    Howard ER, Nixon HH. Internal anal sphincter: observation on development and mechanism of inhibitory response in premature infants and children with Hirschsprung's disease. Arch Dis Child 1968;43:569–78.Google Scholar
  7. 7.
    O'Riordain MG, Molloy RG, Gillen P, Horgan A, Kirwan WO. Rectoanal inhibitory reflex following low stapled anterior resection of the rectum. Dis Colon Rectum 1992;35:874–8.Google Scholar
  8. 8.
    Lewis WG, Williamson ME, Miller AS, Sagar PM, Holdsworth PJ, Johnston D. Preservation of complete anal sphincteric proprioception in restorative proctocolectomy: the inhibitory reflex and fine control of continence need not be impaired. Gut 1995;36:902–6.Google Scholar
  9. 9.
    deSouza NM, Puni R, Zbar AP, Gilderdale DJ, Coutts GA, Krausz T. MR Imaging of the anal sphincter in multiparous women using an endoanal coil: correlation within vitro anatomy and appearances in fecal incontinence. AJR Am J Roentgenol 1996;167:1465–71.Google Scholar
  10. 10.
    Favetta U, Amato A, Interisano A, Pescatori M. Clinical, manometric and sonographic assessment of the anal sphincters: a comparative prospective study. Int J Colorectal Dis 1996;11:163–6.Google Scholar
  11. 11.
    Goes RN, Simons AJ, Masri L, Beart RW Jr. Gradient of pressure and time between the proximal anal canal and high pressure zone during internal anal sphincter relaxation: its role in the fecal continence mechanism. Dis Colon Rectum 1995;38:1043–6.Google Scholar
  12. 12.
    Swash M, Snooks SJ. Motor nerve conduction studies of the pelvic floor innervation. In: Henry MM, Swash M. Coloproctology and the pelvic floor. 2nd ed. London: Butterworth Heinemann, 1992:196–207.Google Scholar
  13. 13.
    Cuzick J. A Wilcoxon type test for trend. Stat Med 1985;4:87–90.Google Scholar
  14. 14.
    Shouler P, Keighley MR. Changes in colorectal function in severe idiopathic constipation. Gastroenterology 1986;90:40–7.Google Scholar
  15. 15.
    Merkel IS, Locher J, Burgio K, Towers A, Wald A. Physiologic and psychologic characteristics of an elderly population with chronic constipation. Am J Gastroenterol 1993;88:1854–9.Google Scholar
  16. 16.
    Cheong DM, Vaccaro CA, Salanga VD, Wexner SD, Phillips RA, Hanson MR. Electrodiagnostic evaluation of fecal incontinence. Muscle Nerve 1995;18:612–9.Google Scholar
  17. 17.
    Sangwan YP, Coller JA, Schoetz DJ Jr, Murray JJ, Roberts PL. Latency measurement of rectoanal reflexes. Dis Colon Rectum 1995;38:1281–5.Google Scholar
  18. 18.
    Sangwan YP, Coller JA, Barrett RC, Murray JJ, Roberts PL, Schoetz DJ Jr. Distal rectoanal excitatory reflex: a reliable index of pudendal neuropathy? Dis Colon Rectum 1995;38:916–20.Google Scholar
  19. 19.
    Bannister JJ, Abouzersky L, Read NW. Effect of ageing on anorectal function. Gut 1987;28:353–7.Google Scholar
  20. 20.
    Akervall S, Nordgren S, Furth S, Oresland T, Pettersson K, Hulten L. The effect of age, gender and parity on rectoanal function in adults. Scand J Gastroenterol 1990;25:1247–56.Google Scholar
  21. 21.
    Gang Y. What is the desirable stimulus to induce the rectoanal inhibitory reflex? Dis Colon Rectum 1995;38:60–3.Google Scholar
  22. 22.
    Whitehead WE, Orr WC, Engel BT, Schuster MM. External anal sphincter response to rectal distension: learned response or reflex? Psychophysiology 1981;19:57–62.Google Scholar
  23. 23.
    Williamson JL, Nelson RL, Orsay C, Pearl RK, Abcarian H. A comparison of simultaneous longitudinal and radial recordings of anal canal pressures. Dis Colon Rectum 1990;33:201–6.Google Scholar
  24. 24.
    Oh C, Kark AE. Anatomy of the external anal sphincter. Br J Surg 1972;59:717–23.Google Scholar
  25. 25.
    Taylor BM, Beart RW, Phillips SF. Longitudinal and radial variations of pressure in the human anal sphincter. Gastroenterology 1984;86:693–7.Google Scholar
  26. 26.
    Johnston D, Holdsworth PJ, Nasmyth DG,et al. Preservation of the entire anal canal in conservative proctocolectomy for ulcerative colitis: a pilot study comparing end-to-end ileo-anal anastomosis without mucosal resection with mucosal proctectomy and endo-anal anstomosis. Br J Surg 1987;74:430–4.Google Scholar
  27. 27.
    Tuckson W, Lavery I, Fazio VW, Oakley J, Church J, Milsom J. Manometric and functional comparison of ileal pouch anal anastomosis with and without anal manipulation. Am J Surg 1991;161:90–6.Google Scholar
  28. 28.
    Johansen OB, Wexner SD, Daniel N, Nogueras JJ, Jagelman DG. Perineal rectosigmoidectomy in the elderly. Dis Colon Rectum 1993;36:767–72.Google Scholar
  29. 29.
    Bouchoucha M, Denis P, Arhan P, Faverdin C, Devroede G, Pellerin D. Morphology and rheology of the rectum in patients with chronic idiopathic constipation. Dis Colon Rectum 1989;32:788–92.Google Scholar

Copyright information

© the American Society of Colon and Rectal Surgeons 1998

Authors and Affiliations

  • Andrew P. Zbar
    • 1
  • Mohammed Aslam
    • 1
  • Darren M. Gold
    • 1
  • Christopher Gatzen
    • 1
  • Amy Gosling
    • 2
  • Witold A. Kmiot
    • 1
  1. 1.From the Academic Department of Colorectal SurgeryHammersmith HospitalUK
  2. 2.Department of Medical Statistics and EvaluationRoyal Postgraduate Medical SchoolLondonUnited Kingdom

Personalised recommendations