Ano-rectal Physiology Tests current place in clinical practice

1. Ano-rectal Physiology Testscurrent place in clinical practice Bruce D George John Radcliffe Hospital Oxford

2. Research anatomy/physiology Research disease pathophysiology Routine clinical practice The purpose of anorectal physiology tests

3. IAS: smooth muscle Autonomic/local neural control EAS: skeletal muscle Voluntary/reflex control Pudendal nerve Anatomy revision

4. Rectal sensation distension indistinct ?wall ?pelvic floor pelvic parasympathetic Anal canal sensation precise sampling reflex pudendal nerve S234

5. Normal Continence The ability to perceive, to retain and to evacuate bowel contents at socially convenient times

6. Factors contributing to normal bowel function Colonic transit CNS co-ordination Sensation Mechanical barrier Ability to evacuate

7. Anal canal pressures Resting: IAS Squeeze: EAS Sensation Anal rectal Nerves Pudendal nerve Ultrasound Anorectal physiology tests

8. Faecal incontinence Constipation Prior to surgery which may damage sphincter mechanism Fistula Fissures Ileoanal pouch Routine clinical practice

9. To detect structural defects in internal or external sphincter To detect evidence of global pelvic floor failure To detect the normal sphincter mechanism Faecal incontinence

10. History Severity gas, liquids, solids effect on quality of life Other symptoms gastrointestinal (constipation), gynaecological, urological, Possible causes obstetric, local surgery, back, neurological

11. Examination General Abdominal Inspection at rest soiling, excoriation, scars, patulous, guttering squeeze straining perineal descent Rectal examination Proctoscopy and sigmoidoscopy

12. Structural defects Anal stretch Thin internal anal sphincter Anterior obstetric defect

13. Ideal patient isolated sphincter defect normal sensation, evacuation, pelvic floor function normal CNS severe incontinence Wrong patient generalised weakness of pelvic floor pelvic nerve damage inability to evacuate mild symptoms Selection of Patient for Sphincter Repair

14. Associated gynaecological prolapse/urinary incontinence Perineal descent Low pressures Impaired sensation Prolonged PNTML Global pelvic floor failure

15. Difficult problem Recheck history and examination Additional tests: MRI of lumbosacral spine MRI of pelvis Ambulatory colonic/rectal motility Faecal incontinence with normal ano-rectal physiology and ultrasound

16. Part of investigation of severe intractable constipation In combination with colonic transit studies, proctography Detect very rare adult Hirschprungs disease or internal sphincter hypertrophy Detection of associated psychological issues Constipation

17. Prior to anal fistula surgery

18. 38 consecutive patients undergoing EUA All pre-op physiology and ultrasound Surgeon blinded to results at time of EUA Surgeon shown results in theatre Surgical management affected in 7 (29% of fistulae) 2 occult sphincter defect 3 reclassification of fistula 2 identification of fistula Colorectal Disease 2002 4 118-22. Influence of anal ultrasound on management of anal fistula

19. Prior to anal fissure surgery • Lateral internal sphincterotomy • Gold standard after failed GTN/botulinum • 1 to 30% risk of incontinence

20. GTN/Botulinum 1st line therapy Persistent symptomatic fissure Female/previous anal surgery Male/no anal surgery Physiology + ultrasound defect Lateral internal sphincterotomy No defect Persistent medical therapy/ Conservative surgery

21. Effects of policy of physiology and ultrasound prior to internal sphincterotomy • Trend towards non-sphincter cutting management • Repeated use of botulinum • Combination therapy : GTN, botulinum, diltiazem • Fissurectomy + botulinum • Advancement flap • Truly informed consent

22. Anorectal physiology after internal sphincterotomy To investigate incontinence To investigate persistent fissure

23. Anatomy and physiology Clinical research Routine clinical practice Incontinence Constipation Fistula, fissure. Evolution of ano-rectal physiology and ultrasound