Surg Clin N Am 82 (2002) 1115–1123

Anorectal physiology
Alan G. Thorson, MDa,b,*
a
Section of Colon and Rectal Surgery, Creighton University School of Medicine,
2500 California Plaza, Omaha, NE 65178, USA
b
University of Nebraska College of Medicine, 986585 Nebraska Medical Center,
Omaha, NE, 68198-6585, USA

The normal function of the anorectum represents a complex interaction

between neurologic, myogenic, sensory, anatomic, and hormonal compo-
nents. Failure or weakness of any one part or combination of parts of this
array may lead to symptoms recognized as many common and some not so
common diseases and conditions seen in the clinical setting. When discus-
sing anorectal physiology, the conversation usually refers to simple tests
performed routinely in an anorectal physiology (ARP) laboratory. Such
laboratories are designed to provide information about the function of the
neurologic, sensory, and anatomic components of anorectal function.
Resting and squeeze pressures, the rectal-anal inhibitory reflex (RAIR),
dynamic proctography (DPG), contrast or balloon defecography, rectal
compliance, sensory thresholds, estimates of neurologic function (particu-
larly pudendal nerve terminal motor latency—PNTML), and assessment
of anatomy via transanal ultrasound serve as the basic ARP laboratory
tests. Various modifications of these tests and calculated values based on
them have been described, but few have achieved routine clinical acceptance
or application.
The role that an ARP laboratory should play in the diagnosis of abnor-
malities of the anorectum has long been an area of controversy. Although
such laboratories have been used for years in the research setting in attempts
to quantify normal and abnormal function, their clinical usefulness has not
been well accepted. Recent reviews have attempted to better define this role
[1–4].
The primary clinical focus of an ARP laboratory is the evaluation of
patients with either of the two extremes of bowel function: incontinence
or constipation, and, in some instances, the simultaneous presentation of

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E-mail address: crspecialists@msn.com

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1116 A.G. Thorson / Surg Clin N Am 82 (2002) 1115–1123

both. With this in mind, this article reviews the normal physiology of the
anorectum, identifies the abnormalities associated with these clinical presen-
tations, and considers how the ARP laboratory may provide useful assis-
tance in patient management.

Normal physiology
Bowel continence
Continence to stool represents a complex interaction of a rather large
number of variables. These variables include stool consistency, reservoir
capacity, rectal compliance, achievable sphincter pressures at rest and at
squeeze, and sensation.

Stool consistency
The loss of control of stool, if gradual or incomplete, will nearly always
first be noted with difficulties in controlling gas, then liquid stool, and finally
solid stool. The importance of understanding this rests in the knowledge
that a patient with incontinence to only gas or liquid stool may be corrected
simply by effectively treating diarrhea.
Reservoir capacity and compliance
The compliance and the capacity of the rectal reservoir are closely inte-
grated. Compliance refers to the ability of the rectum to distend. Although
difficult to measure, conceptually compliance is an important component
of the process of accommodation. In a normally functioning rectum, an
increasing volume of stool is associated with passive distention of the rectum
that allows intrarectal pressures to remain low. This accommodation can
continue until a maximum tolerable volume is reached, at which point intra-
rectal pressures will begin to rise and ultimately overcome the pressures gen-
erated by the sphincters. The end result of this series of events is evacuation
of the rectum.
Disease states associated with decreased compliance include acute procti-
tis associated with inflammatory bowel disease (IBD) and radiation, postop-
erative status and the fibrosis associated with chronic radiation change, and
chronic IBD. The latter chronic states can lead to permanently decreased
reservoir capacity.
IBD and other causes of diarrhea can overwhelm the continence mechan-
ism by sheer volume of stool alone. With large volumes entering the rectum
rapidly, the ability of the rectum to accommodate may reach its maximum
tolerable volume in short order, which may lead to incontinence. The same
can occur in cases of fecal impaction, where, due to the limits of accommo-
dation, only a small additional amount of stool may be all that is necessary
to reach maximum tolerable volume. Further aggravating the situation with
impaction is the possibility of a chronically relaxed internal sphincter due to
chronic rectal distention.
 A.G. Thorson / Surg Clin N Am 82 (2002) 1115–1123 1117

Sphincter pressures
The anal sphincter is composed of two major components that provide
for normal continence. Immediately surrounding the canal is the internal
anal sphincter, which accounts for approximately 80% to 85% of resting
tone. The internal sphincter is involuntary smooth muscle. When perform-
ing anorectal manometry (ARM), the mean maximum resting pressure is
largely a measure of internal sphincter function.
Surrounding the internal sphincter is the external sphincter. It is com-
posed of skeletal muscle. The external sphincter is responsible for enhance-
ment of anal canal pressures during the process of accommodation and
allows for the deferral of the call to stool. The exact structure and its rela-
tionship to the pelvic floor (levator ani) is still open to some debate; how-
ever, the puborectalis is generally felt to represent the superior component
of the functional external sphincter unit. The function of the external
sphincter is assessed in the ARP laboratory by measuring the maximum
mean squeeze pressure with ARM. Generally, maximum squeeze pressures
are twice the resting pressures. Maximum squeeze pressures can be main-
tained for less than one minute, however, before fatigue occurs. If accom-
modation can not occur within this time frame, evacuation of the rectum
is likely.

Sensation
Sensory components of the mechanism of continence are critical in allow-
ing an individual a satisfactory reaction time to react to a bolus of stool or
gas entering the rectum. Sensation is associated with the sampling reflex.
This reflex results in the transient relaxation of the internal sphincter, with
contraction of the distal external sphincter, theoretically allowing for dis-
crimination of the contents of the upper anal canal and rectum as either gas
or liquid or solid.
Two tests in the ARP laboratory can provide some assessment of this
function of the continence mechanism. The RAIR measures the transient
relaxation of the internal sphincter with distal contraction of the external
sphincter. The absence of this reflex is seen in the presence of Hirschprung’s
disease. A chronically relaxed internal sphincter (low resting pressures) and
failure to further relax may be associated with fecal impaction and overflow
incontinence. The minimum sensory threshold of distention can also be mea-
sured by sequentially inflating a balloon in the distal rectum to increasing
volumes until the patient senses the distention. Failure to sense a small
volume (2 cc–10 cc) is associated with anal leakage and can be a focus of
re-education in situations of relatively minor incontinence [5].

Constipation
To many patients’ minds, constipation represents the opposite end of the
spectrum from bowel incontinence. This is particularly true when discussing
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bowel problems with patients who may not admit to incontinence while
complaining bitterly of ‘‘diarrhea.’’ This is their polite way of stating that
they have ‘‘lost control.’’ In fact, the two problems (constipation and incon-
tinence) may coexist. It is not uncommon to find patients incontinent to
solid stool. Such patients generally represent the most severe form of
incontinence. To understand the role that the ARP laboratory can have
in the evaluation of these patients, it is helpful to review the normal act of
defecation.
The development of a mass peristaltic wave by the left colon distended
with stool results in the delivery of stool to the lower sigmoid colon and rec-
tum. Once entering the rectum, the reflex relaxation of the internal sphincter
and contraction of the distal external sphincter allows sampling and main-
tains continence. Assuming that accommodation does occur, the initial urge
to defecate may pass as intraluminal pressures fall below the tonic resting
pressure of the anal canal, so that voluntary contraction of the external
sphincter is not necessary to maintain continence.
If the urge occurs at a socially acceptable time to proceed with defecation,
or if accommodation has reached its limits and there is little choice as to
when to proceed with defecation, the individual will normally assume a
squatting or sitting position. The process of defecation then normally will
proceed with a straightening of the anorectal angle. Normally, intrarectal
pressures then rise in response to a voluntary increase in intra-abdominal
pressure due to a Valsalva maneuver. Normally there is a varying degree
of pelvic descent with this maneuver. As rectal pressure increases, there is
a combination of reflex and voluntary relaxation of the external sphincter
and reflex relaxation of the internal sphincter. Once intrarectal pressures rise
above the sphincter pressure, defecation can occur. If this process is accom-
panied by further mass peristalsis, the entire left colon may be evacuated. If
not, evacuation may occur in a piecemeal fashion, with several defecations
occurring in a 24-hour period. Following defecation, sphincter pressures,
intra-abdominal pressure, and the anorectal angle return to their normal
resting pressures and positions.
Constipation manifested as outlet obstruction may occur when any por-
tion of this process is interrupted. Such situations may occur when there is
failure of the puborectalis to relax (paradoxical puborectalis, anismus, leva-
tor syndrome), abnormally high resting pressure (nutcracker anus), exces-
sive accommodation (megarectum), external compression of the rectum
resulting in blockage (enterocele), incomplete evacuation (large rectocele),
or intussusception (overt or covert prolapse). In addition, excessive pelvic
descent may be associated with outlet problems. The exact role of abnormal
pelvic descent is frequently not clear. Whether the descent is a result of
chronic straining due to outlet problems of another etiology or a primary
cause of the complaint may be difficult to determine.
Constipation can also be a manifestation of a dysfunctional colon rather
than an outlet problem. Although the etiology of this problem lies outside of
 A.G. Thorson / Surg Clin N Am 82 (2002) 1115–1123 1119

the pelvis, evaluation of this type of constipation is often a part of the

evaluation in an ARP laboratory. A simple measure of colon transit using
radio-opaque markers is probably the most commonly used test for this in the
clinical setting [6].

Altered physiology
When patients present with symptoms associated with pelvic floor dys-
function, the most important first step is a careful assessment of their true
complaint. Because patients are frequently embarrassed by problems associ-
ated with the pelvic floor, they may try to protect themselves from that
embarrassment by speaking in protective terms, including the complaint
of ‘‘diarrhea’’ in lieu of incontinence, as mentioned previously. Once these
initial tentative steps are overcome, it is important to quantify and qualify
the complaints as much as possible. In the case of incontinence, frequency
and type (gas, liquid, solid) are important to sort out. In the case of consti-
pation, quality (hard or soft stool), type (excessive straining or failure to rec-
ognize a call to stool), and frequency may help direct the initial evaluation.
Once a careful history has been obtained, a simple physical assessment
may further define a role for the ARP laboratory. If a multiparous female
patient complaining of incontinence is found to have an obvious anterior
sphincter defect, further evaluation in the ARP laboratory may not be indi-
cated prior to an initial repair. The presence of a fecal impaction in a patient
with incontinence to smears of liquid stool as their primary complaint may
simply need a recommendation for an appropriate bowel management pro-
gram. An acute proctitis, an obstructing lesion, or an overt rectal prolapse
may all allow for immediate treatment planning. If the initial physical
assessment does not provide such obvious answers, however, an assessment
in the ARP laboratory may prove helpful.

Basic ARP physiology laboratory tests

For the purposes of an ARP laboratory devoted to a clinical practice, the
basic tests which have been found to be most useful include anorectal man-
ometry (ARM), anorectal electromyography (EMG), dynamic proctogra-
phy (DPG), colon transit time (CTT) and transanal ultrasound (TAUS).
Each will be considered in turn.

Anorectal manometry
Manometry is generally felt to be the least helpful of the physiologic tests
in the clinical setting. The test is most commonly used in assessing the RAIR
to rule out Hirschprung’s disease. It has been found to be complimentary in
1120 A.G. Thorson / Surg Clin N Am 82 (2002) 1115–1123

the assessment of sphincter injury and failed overlapping sphincteroplasty

[7–9]; however, its usefulness is secondary to TAUS in this setting.
For proper use, ARM must be assessed according to the appropriate sub-
group, because normal variation occurs between males and females and
between multiparous and nulliparous females. Males have longer sphincters
at rest and squeeze and generate greater pressures at squeeze. Females
and males have equal resting pressures but multiparous females have lower
resting pressures than nulliparous females [10].
ARM may also offer some insight into appropriate management of recur-
ring fissure following primary sphincterotomy. A patient with continued
abnormally high resting pressures is a candidate for repeat sphincterotomy.
In a patient with recurring fissure and normalized resting pressures follow-
ing sphincterotomy, greater effort may be required to look for something
other than an idiopathic etiology for the fissure. A functional stenosis with
very high resting pressures can occasionally be the source of a complaint
of outlet obstruction. Correction of the functional stenosis will relieve the
constipation in this setting.

Electromyography (EMG)
Anorectal EMGs consist of two basic evaluations. A measure of puden-
dal nerve terminal motor latency (PNTML) assesses the conduction time in
the pudendal nerve from Alcock’s canal to the end organ in the external
sphincter. Normal conduction occurs in 2.0  0.2 milliseconds. Prolonged
times suggest injury to the large fast-conducting fibers [11]. The significance
of prolonged PNTML is debatable, however. There is general agreement
that a single prolonged nerve has little impact on the expected functional
results following anterior sphincteroplasty for a disrupted sphincter. There
is less agreement on the effect of bilateral neuropathy, with some suggesting
that bilateral prolongation is associated with poor function, whereas other
studies show little correlation on a clinical or functional basis [4,12].
Functional assessment of pelvic floor activity can be obtained with an
anal surface electrode. This electrode is contained on the surface of a small
sponge, which, when inserted into the anal canal, will measure electrical
activity in the pelvic floor, including the puborectalis. The results represent
the ‘‘recruitment pattern.’’ With the electrode in place, the level of the pelvic
floor activity is recorded with the patient first at rest, then while squeezing
the anal sphincter, and finally while straining as if in an act of defecation.
Ideally the pattern should show a baseline activity at rest, with significant
augmentation at squeeze and then a fall below baseline at strain. With
straining, patients with paradoxical puborectalis show further enhancement
above the activity recorded at squeeze. This suggests further contraction
rather than relaxation of the puborectalis while attempting to defecate.
Single fiber EMG and electrophysiologic mapping have generally been
supplanted by the much more accurate and less painful TAUS in the assess-
 A.G. Thorson / Surg Clin N Am 82 (2002) 1115–1123 1121

ment of fecal incontinence. Both are used almost exclusively in the research
setting for the purposes of incontinence evaluation and management.

Dynamic proctography
Dynamic proctography (DPG) is used to evaluate function of the pelvic
floor at time of defecation. DPG has many variations in name as well as pro-
cedure. Video proctography, defecography, and defecating scintigraphy all
accomplish the same essential assessment. DPG is performed by placing a
thick mixture of barium contrast and methylcellulose in the rectum to simu-
late a stool. Additional liquid contrast is placed in the vagina. Generally the
patient sits on a special commode while evacuating the mixture under video-
flouroscopic monitoring. This test can demonstrate the existence and func-
tion of internal intussusception, paradoxical contraction of the puborectalis,
enteroceles, rectoceles, pelvic floor hernias, and incomplete evacuation.
The technique can be enhanced with the use of ‘‘triple contrast.’’ This
technique combines the use of the standard DPG, with contrast in the small
bowel hopefully timed to provide opacified loops of small bowel in the pelvis
at the time the DPG is performed. Alternatively, water soluble contrast can
be placed directly into the peritoneal cavity to outline the pelvis at the time
of DPG [13]. Such peritoneography is less dependent on the timing of con-
trast reaching the appropriate small bowel loops than is a small bowel series.
The third element of triple contrast is opacification of the bladder so that its
interaction with the pelvic floor at time of straining can also be evaluated.
This combination gives the most thorough evaluation of the pelvic floor
in states of dysfunction.

Colon transit time

Evaluation of total and segmental colon transit time is an important com-
ponent of the ARP laboratory evaluation. It is used to complement testing
of the pelvic floor in patients with constipation. It provides an evaluation for
colonic inertia. Because colonic inertia may coexist with outlet obstruction,
the evaluation of both must occur prior to embarking on surgical therapy
for constipation.
The test consists of the ingestion of 24 radio-opaque markers each day
for a three-day period. Abdominal radiographs are obtained on days four
and seven and the numbers and distribution of markers recorded [6]. The
transit time is then calculated for the right, left, and rectosigmoid regions,
and for total transit. Dispersement throughout the colon on the final day
is consistent with colonic inertia, whereas collection in the rectum suggests
an outlet problem. Passage of all of the markers does not suggest an abnor-
mal transit. An abnormal test showing inertia must be accompanied by a
pelvic outlet evaluation, however, as it is not uncommon to find inertia in
conjunction with pelvic floor dysfunction. A subtotal colectomy in a patient
with concomitant pelvic outlet obstruction will fail on a functional basis.
1122 A.G. Thorson / Surg Clin N Am 82 (2002) 1115–1123

Transanal ultrasound
Transanal ultrasound has become the primary ARP test in the assessment
of fecal incontinence [3,8]. It provides the most accurate and complete eval-
uation for detecting anal sphincter defects. Generally, a probe with a 10
MHz, 360 degree rotating transducer is used. Using the TAUS, the internal
sphincter is visualized as a hypoechoic band around the anal canal, and the
external sphincter as a band of mixed echogenicity. Defects in either band
can be readily identified and measured [7–9].

Summary
Anorectal physiology, as assessed in an ARP laboratory, can provide
helpful information in the management of patients with constipation and
bowel incontinence. Beyond the uses described in this review, however,
the ARP laboratory is most useful in the research setting. In this setting the
laboratory can expand our understanding of function associated with other
disease states, including anal fissure, fistula-in-ano, inflammatory bowel
disease, and postoperative states. The lab can also provide improved under-
standing of the complex interactions of the enteric nervous and gut hormone
systems with the smooth and skeletal muscle systems.
A part of the failure of the ARP laboratory to enjoy more clinical useful-
ness lies in a lack of standardization of test protocols for many of the tests.
Secondarily, there is a lack of normative data from large numbers of normal
patients [1]. Finally, there is the difficulty in reproducing tests in situations
where the patient has significant potential to compensate for deficits through
the recruitment of adjacent muscle groups and other maneuvers.
There is also some reluctance on the part of clinicians to make use of the
ARP laboratory if the testing is not readily available in their community.
Although the tests themselves are not difficult to learn to administer, lack
of familiarity with the testing process can act as a barrier to acceptance. This
is particularly true for clinicians that are used to making clinical decisions
without the added benefit of physiologic testing. Despite these obstacles, the
role of the ARP laboratory in the management of complex anorectal disease
is likely to grow in the years ahead.

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