Technique, Interpretation and Clinical Application of Anorectal Manometry and Balloon Expulsion Test

  • Kee Wook Jung
  • Seung-Jae MyungEmail author


Anorectal manometry and rectal balloon expulsion tests are necessary for the diagnosis of functional defecatory disorders. They can provide comprehensive information about anal sphincter function, rectal sensation, rectal compliance, anorectal coordination during evacuation, and anorectal reflexes. Moreover, they provide new information that may not be detected clinically and can influence the outcome of patients with defecation disorders. Selective tests should be performed based on the potential indication to evaluate each condition. High-resolution manometry based on spatiotemporal plot was developed recently, and it can display the anorectal change during testing with a great resolution, replacing the conventional manometry system.


Anorectal manometry Balloon expulsion Constipation Incontinence Sphincter function Defacation disorders 


  1. 1.
    Karulf RE, Coller JA, Bartolo DC, Bowden DO, Roberts PL, Murray JJ, et al. Anorectal physiology testing. A survey of availability and use. Dis Colon Rectum. 1991;34:464–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Bharucha AE, Wald A, Enck P, Rao S. Functional anorectal disorders. Gastroenterology. 2006;130:1510–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Barnett JL, Hasler WL, Camilleri M. American Gastroenterological Association medical position statement on anorectal testing techniques. Gastroenterology. 1999;116:732–60.CrossRefPubMedGoogle Scholar
  4. 4.
    American Gastroenterological Association, Bharucha AE, Dorn SD, Lembo A, Pressman A. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013;144:211–7.Google Scholar
  5. 5.
    Rao SS, Patel RS. How useful are manometric tests of anorectal function in the management of defecation disorders? Am J Gastroenterol. 1997;92:469–75.PubMedGoogle Scholar
  6. 6.
    Rao SS, Azpiroz F, Diamant N, Enck P, Tougas G, Wald A. Minimum standards of anorectal manometry. Neurogastroenterol Motil. 2002;14:553–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Sun WM, Rao SS. Manometric assessment of anorectal function. Gastroenterol Clin North Am. 2001;30:15–32.CrossRefPubMedGoogle Scholar
  8. 8.
    Scott SM, Gladman MA. Manometric, sensorimotor, and neurophysiologic evaluation of anorectal function. Gastroenterol Clin North Am. 2008;37:511–38. vii.CrossRefPubMedGoogle Scholar
  9. 9.
    Schuster MM, Hookman P, Hendrix TR, Mendeloff AI. Simultaneous manometric recording of internal and external anal sphincteric reflexes. Bull Johns Hopkins Hosp. 1965;116:79–88.PubMedGoogle Scholar
  10. 10.
    Meunier PD, Gallavardin D. Anorectal manometry: the state of the art. Dig Dis. 1993;11:252–64.CrossRefPubMedGoogle Scholar
  11. 11.
    Jones MP, Post J, Crowell MD. High-resolution manometry in the evaluation of anorectal disorders: a simultaneous comparison with water-perfused manometry. Am J Gastroenterol. 2007;102:850–5.CrossRefPubMedGoogle Scholar
  12. 12.
    Tantiphlachiva K, Rao SSC. Anorectal manometry. In: Parkman HP, McCallum RW, Rao SSC, editors. GI motility testing. Thorofare, NJ: Slack Incorporated; 2011. p. 163–78.Google Scholar
  13. 13.
    Cheeney G, Remes-Troche JM, Attaluri A, Rao SS. Investigation of anal motor characteristics of the sensorimotor response (SMR) using 3-D anorectal pressure topography. Am J Physiol Gastrointest Liver Physiol. 2011;300:G236–40.CrossRefPubMedGoogle Scholar
  14. 14.
    Tantiphlachiva K, Rao P, Attaluri A, Rao SS. Digital rectal examination is a useful tool for identifying patients with dyssynergia. Clin Gastroenterol Hepatol. 2010;8:955–60.CrossRefPubMedGoogle Scholar
  15. 15.
    Wong RK, Drossman DA, Bharucha AE, Rao SS, Wald A, Morris CB, et al. The digital rectal examination: a multicenter survey of physicians’ and students’ perceptions and practice patterns. Am J Gastroenterol. 2012;107:1157–63.CrossRefPubMedGoogle Scholar
  16. 16.
    Soh JS, Lee HJ, Jung KW, Yoon IJ, Koo HS, Seo SY, et al. The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence. Am J Gastroenterol. 2015;110:1197–204.Google Scholar
  17. 17.
    Prott G, Hansen R, Badcock C, Kellow J, Malcolm A. What is the optimum methodology for the clinical measurement of resting anal sphincter pressure? Neurogastroenterol Motil. 2005;17:595–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Bharucha AE, Pemberton JH, Locke 3rd GR. American Gastroenterological Association technical review on constipation. Gastroenterology. 2013;144:218–38.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Fleshman JW. Anorectal motor physiology and pathophysiology. Surg Clin North Am. 1993;73:1245–65.CrossRefPubMedGoogle Scholar
  20. 20.
    Cali RL, Blatchford GJ, Perry RE, Pitsch RM, Thorson AG, Christensen MA. Normal variation in anorectal manometry. Dis Colon Rectum. 1992;35:1161–4.CrossRefPubMedGoogle Scholar
  21. 21.
    Engel AF, Kamm MA, Bartram CI, Nicholls RJ. Relationship of symptoms in faecal incontinence to specific sphincter abnormalities. Int J Colorectal Dis. 1995;10:152–5.CrossRefPubMedGoogle Scholar
  22. 22.
    Bharucha AE, Fletcher JG, Harper CM, Hough D, Daube JR, Stevens C, et al. Relationship between symptoms and disordered continence mechanisms in women with idiopathic faecal incontinence. Gut. 2005;54:546–55.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Lee HJ, Jung KW, Han S, Kim JW, Park SK, Yoon IJ, et al. Normal values for high-resolution anorectal manometry/topography in a healthy Korean population and the effects of gender and body mass index. Neurogastroenterol Motil. 2014;26:529–37.Google Scholar
  24. 24.
    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.CrossRefPubMedGoogle Scholar
  25. 25.
    Azpiroz F, Enck P, Whitehead WE. Anorectal functional testing: review of collective experience. Am J Gastroenterol. 2002;97:232–40.PubMedGoogle Scholar
  26. 26.
    Bannister JJ, Abouzekry L, Read NW. Effect of aging on anorectal function. Gut. 1987;28:353–7.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Chiarioni G, Scattolini C, Bonfante F, Vantini I. Liquid stool incontinence with severe urgency: anorectal function and effective biofeedback treatment. Gut. 1993;34:1576–80.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Telford KJ, Ali AS, Lymer K, Hosker GL, Kiff ES, Hill J. Fatigability of the external anal sphincter in anal incontinence. Dis Colon Rectum. 2004;47:746–52. discussion 752.CrossRefPubMedGoogle Scholar
  29. 29.
    Felt-Bersma RJ, Klinkenberg-Knol EC, Meuwissen SG. Anorectal function investigations in incontinent and continent patients. Differences and discriminatory value. Dis Colon Rectum. 1990;33:479–85. discussion 485–76.CrossRefPubMedGoogle Scholar
  30. 30.
    Sun WM, Donnelly TC, Read NW. Utility of a combined test of anorectal manometry, electromyography, and sensation in determining the mechanism of ‘idiopathic’ faecal incontinence. Gut. 1992;33:807–13.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Siproudhis L, Bellissant E, Pagenault M, Mendler MH, Allain H, Bretagne JF, et al. Fecal incontinence with normal anal canal pressures: where is the pitfall? Am J Gastroenterol. 1999;94:1556–63.CrossRefPubMedGoogle Scholar
  32. 32.
    Jung KW, Joo S, Yang D-H, Yoon IJ, Seo SY, Kim S-O et al. A novel high-resolution anorectal manometry parameter based on a three-dimensional integrated pressurized volume of a spatiotemporal plot, for predicting balloon expulsion in asymptomatic normal individuals. Neurogastroenterol Motil. 2014;26:937–49.Google Scholar
  33. 33.
    Rao SS. Dyssynergic defecation and biofeedback therapy. Gastroenterol Clin North Am. 2008;37:569–86. viii.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Rao SS. Constipation: evaluation and treatment. Gastroenterol Clin North Am. 2003;32:659–83.CrossRefPubMedGoogle Scholar
  35. 35.
    Rao SS, Mudipalli RS, Stessman M, Zimmerman B. Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (Anismus). Neurogastroenterol Motil. 2004;16:589–96.CrossRefPubMedGoogle Scholar
  36. 36.
    Duthie GS, Bartolo DC. Anismus: the cause of constipation? Results of investigation and treatment. World J Surg. 1992;16:831–5.CrossRefPubMedGoogle Scholar
  37. 37.
    De Ocampo S, Remes-Troche JM, Miller MJ, Rao SS. Rectoanal sensorimotor response in humans during rectal distension. Dis Colon Rectum. 2007;50:1639–46.CrossRefPubMedGoogle Scholar
  38. 38.
    Rao SS, Kavlock R, Rao S. Influence of body position and stool characteristics on defecation in humans. Am J Gastroenterol. 2006;101:2790–6.CrossRefPubMedGoogle Scholar
  39. 39.
    Gladman MA, Lunniss PJ, Scott SM, Swash M. Rectal hyposensitivity. Am J Gastroenterol. 2006;101:1140–51.CrossRefPubMedGoogle Scholar
  40. 40.
    Remes-Troche JM, De-Ocampo S, Valestin J, Rao SS. Rectoanal reflexes and sensorimotor response in rectal hyposensitivity. Dis Colon Rectum. 2010;53:1047–54.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    van der Schaar PJ, Lamers CB, Masclee AA. The role of the barostat in human research and clinical practice. Scand J Gastroenterol. 1999;230:52–63.Google Scholar
  42. 42.
    Minguez M, Herreros B, Sanchiz V, Hernandez V, Almela P, Añon R, et al. Predictive value of the balloon expulsion test for excluding the diagnosis of pelvic floor dyssynergia in constipation. Gastroenterology. 2004;126:57–62.CrossRefPubMedGoogle Scholar
  43. 43.
    Cho YB, Lee WY, Yun HR, Lee WS, Yun SH, Chun HK. Colonic perforation caused by anorectal manometry. Int J Colorectal Dis. 2008;23:219–20.CrossRefPubMedGoogle Scholar
  44. 44.
    Park JS, Kang SB, Kim DW, Kim NY, Lee KH, Kim YH. Iatrogenic colorectal perforation induced by anorectal manometry: report of two cases after restorative proctectomy for distal rectal cancer. World J Gastroenterol. 2007;13:6112–4.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Senel E, Demirbag S, Tiryaki T, Erdogan D, Cetinkursun S, Cakmak O. Postoperative anorectal manometric evaluation of patients with anorectal malformation. Pediatr Int. 2007;49:210–4.CrossRefPubMedGoogle Scholar
  46. 46.
    Ganio E, Masin A, Ratto C, Altomare DF, Ripetti V, Clerico G, et al. Short-term sacral nerve stimulation for functional anorectal and urinary disturbances: results in 40 patients: evaluation of a new option for anorectal functional disorders. Dis Colon Rectum. 2001;44:1261–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer India 2016

Authors and Affiliations

  1. 1.Department of GastroenterologyUniversity of Ulsan College of Medicine, Asan Medical CenterSongpa-gu, SeoulSouth Korea

Personalised recommendations