Three-Dimensional Anorectal Manometry Enhances Diagnostic Gain by Detecting Sphincter Defects and Puborectalis Pressure

Shreya Raja, Francis C. Okeke, Ellen M. Stein, Sameer Dhalla, Monica Nandwani, Kristle L. Lynch, C. Prakash Gyawali, John O. Clarke

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


Background: Constipation and fecal incontinence (FI) are common and are often evaluated with anorectal manometry. Three-dimensional high-resolution anorectal manometry (HRAM) is a promising technology; however, implementation has been limited by lack of metrics and unclear clinical utility. Aim: To investigate the diagnostic utility of 3D HRAM compared to 2D HRAM. Methods: Three-dimensional HRAM studies performed from April 2012 to October 2013 were identified and re-interpreted by two blinded investigators examining 3D function. Disagreements were resolved by a third investigator. Puborectalis (PR) visualization, focal defects, and dyssynergy were reported. Differences between groups were analyzed with Fisher’s exact test. Discordance was analyzed with McNemar Chi-square test. Results: Two hundred and twenty-one 3D HRAM studies were identified. Mean age and BMI were 52.2 ± 17.4 and 27.1 ± 7.5 years (81% female, 74% white). Most common indications for 3D HRAM were constipation (65%) and FI (28%). PR function was visualized in 81% (rest), 97% (squeeze), and 73% (strain). PR was visualized less often at rest in FI than constipation (68 vs. 85%, p = 0.007). Defects were identified twice as often in FI than constipation (19 vs. 10%, p = 0.113). Twenty-nine defects (86% anterior) were visualized on 3D HRAM. Inter-reader agreement was moderate for PR function (κ = 0.471), but fair for focal defects (κ = 0.304). Conclusions: PR function and focal defects can be visualized on 3D-HRAM with added diagnostic benefit compared to 2D. Fair inter-reader agreement for focal defects highlights the need for quantitative metrics.

Original languageEnglish
Pages (from-to)3536-3541
Number of pages6
JournalDigestive diseases and sciences
Issue number12
StatePublished - Dec 1 2017


  • Anorectal manometry
  • Constipation
  • Dyssynergy
  • Fecal incontinence


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