Anorectal Manometry

WHAT IS ANORECTAL MANOMETRY?
The process of measuring the strength of the anal muscles is called "anorectal manometry" examination. With this procedure, the strength of the muscles controlling the anus at rest and during voluntary squeezing (internal and external sphincter functions), the length of the muscles (sphincter length), the compliance between the anus and the large intestine (recto-anal inhibitory reflex) and the expansion capacity of the rectum (compliance) are measured.
Anorectal manometry; It is applied in cases of gas incontinence, poop incontinence, chronic constipation, and problems with holding gas and poop after previous anorectal area operations.
How is the procedure performed?
Anorectal manometry can be performed using capillary perfusion technique, microballoon probe technique, microtransducer technique, double balloon techniques. Capillary perfusion technique is the most commonly used technique.

Before the procedure, the rectum is emptied by enema. Since patients do not feel pain during anorectal manometry, no sedation is applied. This procedure can also be performed under sedative medication in young and agitated patients.
The patient lies on his left side, pulling his hips and knees towards his abdomen. A plastic tube (catheter) with a balloon at the end, 4 mm in diameter, with 8 channels, connected to the computer by a pressure measuring device, through which clean water passes at a constant rate, is inserted into the last part of the intestine from the anus and placed 10 cm above the anus. The pressure inside the intestinal cavity and the anus is measured and recorded while listening and squeezing the anus with as much force as possible. While the catheter is slowly withdrawn, measurements are repeated at half-centimeter intervals.

The patient is then asked to cough and squeeze his anus for 30 seconds as if holding his stool, while the pressure inside the anus is measured and recorded. After this procedure, the patient is asked to push the balloon out like defecation. To evaluate the sensitivity and reflexes of the anus and the last part of the intestine, the balloon at the tip of the catheter is inflated with 10 - 200 ml of air and the presence of the feeling of defecation is questioned, while the pressure in the anus is measured. The obtained values are compared with the values determined in a healthy person.
After the procedure, which takes approximately 20 minutes, patients return to their daily lives. Rarely, on the day of the procedure, there may be a slight burning and irritation in the anus, and a small amount of bleeding may occur.
RECTOANAL INHIBITOR REFLEX (RAIR);
It is the response to a decrease in the resting pressure of the anal canal by sudden inflation of the rectal balloon.
Normally, the resting pressure is expected to decrease by more than 25%.
Down rectal excision, RAIR disappears in Hirschsprung disease, scleroderma, sometimes rectal prolapse and neurogenic anal incontinence.

ISTANBUL MEDENİYET UNIVERSITY GÖZTEPE TRAINING AND RESEARCH HOSPITAL PEDIATRIC SURGERY CLINIC ANORECTAL MANOMETER UNIT:
BIOFEEDBACK TREATMENT:

Biofeedback is a behavioral treatment method that involves retraining the bowel. It is most commonly applied to patients suffering from gas and fecal incontinence and chronic constipation. The main purposes of this treatment are to relax the pelvic floor muscles and anal sphincter during defecation, to ensure rectoanal coordination and to improve rectal sensitivity. It is a behavioral treatment method that includes re-education of the intestine, such as teaching the correct straining movements that have been learned incorrectly and explaining in detail exercises to strengthen the anus muscles. Along with these techniques, diet and lifestyle required for healthy bowel functions, anal and pelvic floor muscle exercises, verbal biofeedback treatments and visual/auditory biofeedback treatments using computer programs can also be applied. Approximately 6 months after biofeedback treatment, anorectal manometer was used again The patient is evaluated and his/her current condition is compared with the pre-treatment values.
How is the procedure performed?

The patient is placed in a supine position with knees bent. An anal probe that measures pressure is placed into the anus. Additionally, a probe is placed around the anus to measure the strength of the muscles. The patient is seated on a mock toilet-shaped chair so that he can see the computer on which special programs are installed. The technique and logic of the program are explained, and the patient is asked to contract and relax the anal muscles. The first test is called 'threshold test' and during this, maximum contraction and minimum relaxation are measured. Following this, the patient is instructed to squeeze his anus as much as he can and the 'tolerant squeeze pressure' is measured. Certain changes are made depending on the patient, and the anus is frequently contracted for 5 seconds and relaxed for 10 seconds, a total of 8 times.
Although each treatment session lasts approximately 30-45 minutes, the ideal number of treatment sessions varies from patient to patient, with an average of 4-6 sessions to strengthen the anus muscles and the defecation process, accompanied by these exercises.

Patients are advised that failure may occur from time to time, and failure to achieve complete results from an exercise once should not be considered a failure and should be repeated, especially after meals, which is the period when the gastrocolic reflex is stimulated.
The chance of success in cases such as gas and poop incontinence is around 50%, and it is reported that 60-90% success is achieved with biofeedback treatment in constipation.

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