Hello, and welcome to our live webcast, Anorectal Manometry, Concepts, Indications, and Implications. Thank you for joining us. My name is Gary, and I will be the operator for today's presentation. We are joined today by our moderator, Dr. Ludmilla Lipitskaya, a member of the Augs Education Committee, and our speaker, Dr. Jenny Speranza. At this time, I would like to turn things over to our moderator for opening remarks. Thank you so much, Gary. I'd like to welcome all of you to our next installment of our Augs virtual forum. This is a series of presentations by experts in our subspecialty from across the country focused on topics based on the learning objectives as well as relevant practice-related topics. The virtual format also provides Augs members the opportunity to interact with the speakers in real time. This presentation will then be captured and made available for view at any time on our Augs website. Upon completion of this program, you will be given the opportunity to provide some feedback, which we will value greatly. For this evening's presentation, it's my pleasure to introduce Jenny Speranza, Associate Professor in the Department of Colorectal Surgery at the University of Rochester. Her presentation today will be about the use of anorectal manometry. Thank you so much, Dr. Speranza, for being with us today. Thank you very much, Dr. Lipitskaya. Good evening, and thank you for the opportunity to discuss anorectal manometry concepts, indications, and implications. I hope you'll find it informative and helpful in understanding the posterior compartment as well as a few anorectal issues that may come up in your daily practice. I have no disclosures. Starting objectives, I am hoping to help you understand basic anorectal manometry, what it is, as well as the basics of how to perform anorectal manometry. Of note, the manometry machine that is demonstrated today is an older generation labory machine. There are multiple trade names and brands on the market at the current time. But overall, the concepts are the same, despite what unit you are using. In addition, when should you request anorectal manometry to be performed, and what disorders can best utilize anorectal manometry for diagnosis? I will give you a few case scenarios that are commonly seen in how the testing results can elucidate a diagnosis. This is a standard example of an anorectal manometry machine. It usually has computer-based software that will demonstrate pressure readings on a screen during the procedure, as well as generate a report that can be tailored to a practice or provider. In addition, there are disposable catheters that are purchased separately from the vendor, as well as electrodes for different tests that are performed on this machine. Often, normal values can be either obtained from the manufacturer, or baseline values can be obtained from your own practice on healthy volunteers. But this is quite laborious, and we usually will result from standard baseline pressure readings either through textbooks or through the vendor that have been established already. So we want to go through some anorectal manometry. The anorectum is very complex. The anal canal is approximately four centimeters in length. The anal canal starts at the anal verge, which is basically the anal opening, and consists of squamous mucosa. One to two centimeters proximal to the dentate line is the anal transition zone, and this is where the cells change from squamous to columnar, when the upper anal canal is columnar epithelium, which continues proximally throughout the rest of the rectum. The anal columns of morgagne are six to ten longitudinal mucosal folds in the upper part of the anal canal. The sphincter complex consists of the internal anal sphincter, the external anal sphincter, and the puborectalis muscle, and they are demonstrated here. Internal sphincter, external sphincter, and on the second image is the puborectalis muscle. The puborectalis muscle wraps around the rectum and inserts into the undersurface of the pubis. The angle at rest is approximately 90 degrees. With straining and squatting, the angle increases. The puborectalis muscle elongates and relaxes, which will straighten the anal rectum and allow for an easy defecation experience. Features of defecation can be seen when the puborectalis muscle does not relax and paradoxically tightens, closing off the anal canal. And basically this angle becomes hyperacute and it's very challenging to defecate. The internal anal sphincter accounts for approximately 50 to 60% of the resting tone, while the external anal sphincter is voluntary, striated muscle that contributes approximately 20% of baseline tone. Of note, hemorrhoidal tissue does contribute about 10% of a person's continence, so that has to be thought of when performing hemorrhoidectomy in patients who have baseline bowel control problems. Of note, the blood supply to the anus comes from the main branches of the superior and inferior hemorrhoidal arteries. Nervous innervation of the sphincter complex comes from the pudendal nerves. Anal rectomanometry is a simple, easy testing modality that can give information in real time about anal rectal function as well as help diagnose common anal rectal problems. There are multiple vendors, so there is significant variability in the readings and normal values as well as different types of manometry. The testing is nice because it can be done without sedation and has minimal discomfort to your patients. In addition, as previously stated, the results are in real time, so the results can be relayed to the patient immediately if so desired. As previously stated, there are many types of anal rectomanometry. The traditional systems have utilized water-perfused channels that use four to eight sensors. Newer solid-state and air-perfused sensors are also common. Many of these are disposable and are very easy to obtain. Newer 3D and high-resolution anal rectomanometry use hundreds of pressure sensors that provide improved definition of the sphincter function. Of note on these higher definition units, the normal values are typically higher. There is, once again, significant variability between the values obtained on different machines, so comparison between machines is usually not recommended, although globally you can look at the whole picture and see a patient's values and make assessment. One other thing of note is that women usually will have lower values than their male counterparts. Sphincter nulliparous women have manometric values that are closer to men. Anal rectomanometry can assess tone and function of the sphincter complex. It can determine a patient's pressure at rest and squeeze, compare that against normal values. In addition, it also can detect paradoxical activity of the puborectalis muscle in sphincter and can be assessed by instructing the patient to bear down or push. If during this assessment the patient develops high pressures, it indicates non-relaxation of the pelvic floor and dyssynergic defecation. The rectoanal inhibitory reflex, or RARE, is relaxation of the internal anal sphincter muscle caused by distention of the rectal lumen. This reflex allows for discrimination between stool and flatus and is also known as the sampling reflex. This reflex is lost in Hirschsprung's disease and is one of the ways to help aid in diagnosis of this disease. In addition, after proctectomy, many patients will no longer have this reflex as well. Rectal sensation and compliance is assessed by increasing distention of the rectum with a balloon at the tip of the manometry catheter. This will help determine the compliance of the rectum. Balloon expulsion is when the balloon is inflated and the patient is asked to expel an inflated balloon. This can be very helpful in diagnosing dyssynergic defecation, obstructive defecation in patients who have constipation. Electromyography studies the contraction and relaxation of the external anal sphincter. In addition, EMG can also assess paradoxical activity of the external anal sphincter, which can also indicate pelvic floor dysfunction and is often associated with difficulty with evacuation. Pudendal nerve terminal motor latency testing assesses the pudendal nerves. The pudendal nerves innervate the external anal sphincter. One or both of these nerves are often damaged during childbirth with stretching of the nerves as the baby comes through the birth canal. Prolonged conduction is often seen in patients who have fecal incontinence and long-standing rectal prolapse. When performing anorectal manometry, patients do not need to fast prior to the procedure. In addition, no sedation is necessary. For ease of testing, a Felice enema to cleanse the distal rectum is recommended. The test is virtually painless and the patients will only feel slight pressure unless they've had previous anorectal trauma or anal fissures or other disease states. The patient is usually placed in the left lateral decubitus position for comfort. When performing anorectal manometry, the patient will usually undergo a standardized informed consent. The patient is placed once again in the left side position. Of note, a digital rectal exam is always performed prior to insertion of any instrument into the anorectum to rule out obstructing lesions. Often, a digital rectal exam of a trained provider can very closely correlate with manometric findings. In addition, anoscopy can be done as well to assess the anal canal prior to the study, but it's not necessary. This is useful in patients with potential inflammatory bowel disease, rectal inflammation, and rectal bleeding to assess this prior to inserting catheters and other instruments. It is always a good idea to have adequate lubrication to avoid trauma to the mucosa and anoderm. So this is an anorectal manometry catheter. It's a small catheter. It's approximately the size of a thermometer with an attached balloon. Once again, it's lubricated and inserted into the anorectum. The catheter has incremental markings of a centimeter as well as four to eight air-perfused or water-perfused channels. This is what reads the pressure changes. Measurements are usually taken in centimeter increments from six centimeters proximal to the anal verge all the way to one centimeter proximal to the anal verge along the anal canal. Of note, there are different ways to gather this data. Some use a stationary versus continuous pull-through. Some individuals will manually adjust the length of the catheter. Ultimately, you do get multiple readings for different levels along the anal canal. And here is the balloon tip, which can be inflated for further testing, which we will talk about next. Here is an example of pressure recording on anorectal manometry. And here is baseline resting pressure. Then the patient is asked to squeeze, and the pressure increases. So this is a typical pressure reading. The patient occasionally will then also be asked to push, and there should be a resultant decrease or relaxation in pressure as well. Here is a demonstration of the rectoanal inhibitory reflex test. Once again, the balloon tip catheter is inserted into the anorectum approximately three centimeters and rapidly inflated and deflated with approximately 30 cc's of air or water. And as you can see here, you have baseline resting pressure. And when the balloon is rapidly inflated, it distends the anorectum and you have a resultant relaxation of the internal sphincter. This is transient and recovers after a few seconds. Once again, this is called the sampling reflex and is usually absent in Hirschsprung's disease, chronic rectal prolapse, and proctectomy. Sensation volumes are performed on anorectal manometry as well as interpretations of compliance of the rectum. The sensation volumes are performed by slowly instilling air into the balloon tip. The patient is asked to alert the provider when they feel the first sensation of the balloon, when they feel the first urge to defecate, and the maximum tolerable volume that they can hold prior to having an accident. Patients that have chronic constipation and defecatory disorders often have higher sensation volumes. On the contrary, increased sensation is associated with reduced rectal capacity and is often seen with fecal incontinence and urgency. In patients with constipation, there is a balloon expulsion test. Often, if patients have difficulty with evacuation, we will instill approximately 50 to 60 cc's of air into the balloon to descend the rectum and cause the urge to defecate. Then we ask the patient to expel the balloon as if passing stool. Often, patients with obstructive defecation cannot do this and there is a high degree of correlation with the inability to expel the inflated balloon and outlet type constipation with other defecatory disorders. Once again, you see the desplated balloon and you see an inflated balloon. This is appropriate for determining sensation volumes, rectal compliance, and the balloon can also be used for expulsion. Electromyography is one of the tests used to determine anal sphincter innervation and muscle activity of the external anal sphincter. There are many different ways of testing EMG. One such modality is needle EMG. This has fallen out of favor for obvious reasons, significant patient discomfort, and I currently do not do this procedure. But it is the only true way to document innervation of the muscle in the external sphincter. Most of the time, we use surface electrodes and surface EMG is more commonly performed. The electrodes are placed on the perianal skin adjacent to the anal verge bilaterally. The patient goes through a series of exercises and is instructed to rest, squeeze, and push. Of note, surface EMG cannot detect neurogenic injury, but can give a more global information of activation of muscle groups. In addition, paradoxical activity with push or contraction of the external anal sphincter when pushing is a pathologic finding and can indicate non-relaxation of the pelvic floor and defecation disorders. So these are the electrodes. There's usually a grounding pad that you put on the patient's buttock. And then the other two electrodes go on either side of the anus along the anal verge and it's surface EMG. Here is an example of a surface EMG tracing. So if you can make this out, there are small little red seven-second intervals. The red is resting pressure. This is baseline resting pressure. The patient is then asked to squeeze and you see an increase in pressure and muscle activity, which is normal. Then you see the green, and the green is when you ask the patient to push or bear down. The activity here should be close to zero. And in this patient, you can see they have significant paradoxical activity. And they should be relaxing at this point, but they're actually contracting this muscle. And this is very often seen in pelvic floor dysenergy. So we usually go through at least two cycles of this, unless it's very clearly demonstrated. So you have the rest, squeeze, push, and then we do another rest, squeeze, and push. And you can see this activity, once again, should be close to the baseline activity, which is back here. This is a St. Mark's electrode. This is used to determine the pudendal nerve terminal motor latency. It is attached to the provider's index finger that is then placed into the anal canal at the level of the coccyx and rotated bilaterally to one side and then the other, and electrical stimulus is generated. Then the resultant external anal sphincter contraction is measured in milliseconds down at the base of this finger. Normal values for these latencies is approximately two milliseconds. Prolongation is considered neuropathy. In one study, unilateral or bilateral prolonged latencies were shown to be associated with significant decreased resting and squeeze pressures, and we often see these nerves, at least one of them, damaged and not functioning in patients who have fecal incontinence. Indications. So when should anal rectomanometry testing be performed? It is a simple test that can be very helpful in patients who have fecal incontinence or come in for fecal urgency or smearing. In addition, this modality can be helpful to assess baseline continence in patients who may be undergoing surgery for restorative or reconstructive procedures for rectal cancer or J-pouch surgery. So therefore, often patients will be sent in prior to undergoing these procedures to see if they will be continent or have significant indications of poor sphincter tone. This test is also very helpful in determining outlet obstruction in constipation patients. So there are two main types of constipation, slow transit constipation and outlet obstruction. This can often help determine which type of constipation the patient has. In addition, it can help to demonstrate anal spasm, anal pain, and dyssynergy and pelvic pain syndrome. So there are many indications for manometry, and we'll go through some of the indications later. So now for a few of these case scenarios in patients who underwent actual anorectal manometry testing. A 38-year-old woman with two previous vaginal deliveries with episiotomy times two comes into the office complaining of stool urgency, gross soilage two times per week, as well as occasional passive fecal incontinence at night. On your exam, there is scarring along the perineal body that extends to the anal verge in the midline. Upon digital rectal exam, there is decreased resting pressure and the patient cannot elicit a squeeze. This patient is then sent for anal rectomanometry. So these are some of the results that you get back in your report. The patient has low resting pressures. This low resting pressure reflects the dysfunction in the internal anal sphincter. The patient may or may not have low squeeze pressures. This patient did not have good squeeze pressures and her values on her manometry report were low. Occasionally you can see normal pressures, but in this patient they were low. And this is usually a reflection of external anal sphincter function. The low resting baseline pressures are usually significant of the internal anal sphincter, whereas when the patient is asked to voluntarily squeeze, it is a function of the external anal sphincter. Paradoxical activity with push was also found on the stationary pull-through. And what this indicates is that there was some pelvic floor dysfunction. The puberectalis muscle did not relax and this is consistent with pelvic floor dyssynergy. The recto-anal inhibitory reflex was present in this patient, which one would expect. Sensation volumes were measured and they were found to be very low. This is often associated with frequent incontinence and urgency and usually reflects rectal compliance. The EMG study showed decreased amplitude in the squeeze pressure as well as some paradoxical activity. So this reflects that the external anal sphincter is not functioning well. In addition, there was some paradoxical contraction when there should have been relaxing. So the patient not only has a weak anal sphincter, but also a weak anal sphincter. When there should have been relaxing. So the patient not only has a weak external anal sphincter, they also have some paradoxical activity in pelvic floor dyssynergy, which are often seen together. Pudendal nerve terminal motor latency testing was performed and it showed prolonged conduction in the right pudendal nerve, which indicated a pudendal neuropathy. And as we stated before, pudendal neuropathy is often seen in fecal incontinence. There is a 24-year-old college student who's had lifelong constipation. The patient sits for extended periods of time on the toilet, up to two hours. The patient has to strain, change positions and has to occasionally use enemas to defecate. Upon inspection, there is no gross abnormality. But when the patient is asked to push, there is significant perineal descent. Your digital rectal exam reveals a normal resting tone. But once again, when the patient does push, you feel contraction of the pubertalis muscle. And once again, that should be relaxing when the patient pushes. So she has some pelvic floor dyssynergy just by your exam. The patient is subsequently sent for manometry testing. So on your manometry findings, the patient has normal resting pressure, which you would expect as the patient has never had any anorectal surgery, never had a vaginal birth, should have normal resting pressure. And that, once again, is an indication of internal sphincter function. The squeeze pressures can be normal or increased, usually normal. There's no reason to think that this patient would have an external anal sphincter problem. The patient was seen to have significant paradoxical activity with push on stationary pull-through. The patient's pubertalis muscle contracts when it should relax. That angle does not increase and it's very challenging for this patient to defecate. Once again, it's very commonly associated with a defecation. It's often associated with dyssynergic defecation. The rectal anal inhibitory reflex was present, which, once again, we would expect the patient has never had any surgical intervention. Sensation volumes often can be normal or high, which would indicate decreased rectal sensation. Many times these patients have rectums that are very capacious and they cannot evacuate the rectum, so therefore they get used to higher intrarectal volumes. So this is often seen in patients with chronic constipation. EMG, the patient once again demonstrated paradoxical activity when asked to push. This is very common. We saw this earlier on the stationary pull-through. And this correlates with her pelvic floor dysfunction and non-relaxation is common in patients with chronic straining. Because the patient did have constipation, because the patient did have constipation, we asked the patient to try to pass the 60 cc balloon. The patient could not perform this. She could not expel the balloon. And once again, this is very sensitive and specific for diagnosing difficulty with evacuation and defecation. In this patient, I most likely would not perform a pudendal nerve study. You could perform this and in a patient who's been straining all of their life, maybe one of their pudendal nerves may show neuropathy, although at this current point I would not have performed that test for that patient. So now we have a 58-year-old patient. She is two years out from a low, ultra-low anterior resection for rectal cancer. She underwent neoadjuvant treatment before her surgery. The patient is now complaining of chronic rectal pain, frequent stools, soilage, and a lack of oxygen in her bloodstream. And the patient is now complaining of chronic rectal pain, frequent stools, soilage in her underwear. On exam, there is some perianal excoriation from the chronic seepage. On digital rectal exam, there is weak resting sphincter pressure. And you ask the patient to squeeze and you can't feel the squeeze on your finger. You do palpate in an asthmatic staple line at four centimeters that is widely patent and not stenotic. So you send the patient out for manometry testing, but you also try to bulk up the stools and make the stools more formed. In the meantime, the patient also keeps a bowel journal prior to returning for her manometry test. So your manometry test reveals resting pressure values are markedly decreased. And this is an indication that the internal anal sphincter is not doing its job. In addition, the squeeze pressure values are decreased. So the patient has some dysfunction of the external anal sphincter as well. The patient did have some mild paradoxical activity. And anal spasm was seen on the pressure recording, which could contribute to the chronic discomfort. Sensation volumes were very low in this patient. And this is indicative of poor compliance and very often associated with fecal incontinence and urgency. The patient's recto-anal inhibitory reflex was absent. And this is something that I would expect, which is mostly likely due to the fact that the patient's recto-anal which is mostly likely it could be secondary to the resection of the rectum. It could also be secondary to the radiation. But I would expect the rare to be absent in a very low rectal resection. The EMG showed minimal change between rest and squeeze pressures, which shows that the external anal sphincter is not engaging and the global activity of this muscle is poor. In addition, the patient did have some mild paradoxical activity when asked to push. This once again demonstrates denervation and poor external anal sphincter function. The pudendal nerve terminal motor latency test was performed. And there was bilateral pudendal neuropathy. This could be secondary to numerous reasons, the patient's rectal resection, radiation, or even some previous birthing trauma earlier in life. Now we have a 31-year-old woman with a history of an anal fissure after forcible anal intercourse one year ago. The patient saw a colorectal surgeon and was treated conservatively and had resolution of her anal fissure. The patient still complains of pain after defecation that lasts for one to two hours. And occasionally she feels a sharp rectal pain, like a spasm in her rectum that is just very debilitating. So on inspection, the perineum, there is visualization of an anal fissure in the posterior midline when spreading the gluteal cheek. Digital rectal exam reveals a hypertonic sphincter tone with mild discomfort the patient can tolerate. Anoscopy reveals some hemorrhoids. She has a right anterior grade II hemorrhoidal bundle. She has a healed anal fissure in the posterior midline. The patient is sent for anal rectomanometry. And what we find on that anal rectomanometry, the patient has resting and squeeze pressures and the values are both increased. This is resultant hypertonicity of the sphincter complex. And this is commonly seen with anal fissures and post-anal fissures. The patient had significant paradoxical activity with push, which reveals non-relaxation of that puberectalis muscle and external sphincter muscle. The patient has significant anal spasm noted on hermenometry readings. This is consistent with the patient's complaint of chronic pain. The rectoanal inhibitory reflex is present, which we would expect. The patient's sensation volumes were also normal. Once again, the patient has no underlying disease state and therefore she probably has normal compliance and normal sensation volumes. The EMG does show paradoxical activity with push. Once again, showing non-relaxation of the external anal sphincter and through the anal fissure. And again, showing non-relaxation of the external anal sphincter and pelvic floor dysfunction. In this patient, I most likely would not perform pudendal nerve terminal motor latency testing. So now we have a 41-year-old man with a 10-year history of ulcerative colitis and a history to medical treatment by his gastroenterologist. He is having up to 12 loose bloody stools per day. He is having seepage and soiling and wears a sanitary napkin. He has never had any anorectal surgery. The patient is inquiring about surgery and wants to undergo a restorative proctocolectomy on the ileoanal J pouch to improve symptoms. The patient does have the leakage. His surgeon sends him for manometry testing because he's concerned about his bowel control. Upon inspection during your examination, the patient has significant perianal excoriation and stool staining. It's most likely because he's chronically leaking stool. Digital rectal exam reveals normal resting pressure and actually good squeeze pressure. So once again, if you do enough digital rectal exams, they should correlate with your manometric findings. So this gentleman's report shows... ...normal resting and normal squeeze values, which is what we would expect since he has never had any compromise to a sphincter. He's never had any surgery. But because of his seepage and incontinence, we do have to check this and make sure that the sphincters are functioning normally. The patient had mild paradoxical activity with push, so he's not having relaxation of pelvic floor, which is likely due to his frequency of stalling and his rectal inflammation. In addition, the patient has some anal spasm. Once again, his rectum is inflamed, irritated, and he has spasming of his pelvic floor and muscles. The recto-anal inhibitory reflex was present, which we would expect. After his surgery, most likely, we would not be able to elicit this. His sensation volumes were markedly decreased. And this is just indicative of the patient's severe proctitis. As well as, it's a measure of compliance. And his compliance is also poor because he's got a thickened, inflamed rectum. So therefore, the rectum is not compliant and his sensation volumes are very low. His EMG was overall normal. The patient was able to activate his external anal sphincter. And I did not perform predendal nerve terminal latencies in this patient, but I would expect them to be normal. In conclusion, anal rectomanometry is a very simple and inexpensive test that can reveal a significant amount of information. And it's a very simple test that can reveal a significant amount of information. A significant amount of information to help diagnose many pelvic floor disorders. It is a useful test to assess continence in all age ranges, as well as diagnosing constipation, helping to determine outlet type obstruction. It's very good also for chronic pelvic pain disorders to help determine if the patient has non-relaxing pelvic floor and anal rectal spasm. Once again, there is user and machine variability, but the global concepts are usually the same. Thank you for the opportunity to present this information. Thank you, Dr. Speranza. If you'd like to ask a question as a reminder, the Q&A window is located on the right-hand side of your screen. To submit a question, type your question in the small text box at the bottom. When finished, click the Send button. Please note that due to time constraints, our panel may not respond to all questions submitted. This time, I'll send it back to Dr. Lipitskaya for the Q&A portion of today's program. Hey, Danny, and thank you for a wonderful and very practical overview of anal rectal manometry. We do have some questions from the audience, and we have questions from Charles. He's asking if the balloon expulsion test is a reasonable screen for constipation to determine if patients need to have anal rectal manometry. What is your take on that? So my take on that would be it is a reasonable test to screen for constipation, but one thing I want to stress is that anal rectal manometry is a clustering of different tests. The balloon actually is on the tip of an anal rectal manometry catheter. So usually these patients will be undergoing anal rectal manometry anyway. But it is a good test, as I stated before, for determining a patient who has outlet obstruction. Very frequently, these patients will not be able to expel that balloon, and that is one of the keys to the diagnosis. Other possible options could be to send the patient for a SITS marker study along with the manometry and the balloon expulsion test, and that will either further delineate slow transit constipation versus outlet obstruction. Okay, great. The other question is about sacroineural modulation and anal rectal manometry for patients with fecal incontinence. Do you think everybody who is planning to have... You mentioned that the arm is very frequently helpful for patients who are about to undergo surgery. Do you think interesting is one of those surgeries, or it's not absolutely necessary in every given case? What do you think? Well, I think it's a nice test to help confirm your diagnosis. It gives you some objective information to say, yes, this patient has severe sphincter dysfunction. But once again, I did stress that a very highly trained digital rectal person who has performed many digital rectal exams is a very good judge. So if you don't have a manometry machine available, or if you don't have manometry available at your institution, if you can do a digital rectal exam and you can ask the patient to feel their tone at rest, feel their tone when they squeeze and when they push, you can get a good assessment. And that's the poor man's anal rectal manometry as a digital rectal exam. The other question is about the intra and interoperator variability of interpretations of the testing. So very frequently the manometry is done by a level nurse. And I was wondering what is your perspective on how much of the robot for interpretations and the error if the test is not interpreted by the physician? Usually in my practice and as well as some other practices, the test does not need to necessarily be performed by a physician. We often have a nurse practitioner performing this. A lot of offices do utilize a nurse to do the testing. But the nice thing about the manometry reports, they do have that computer generated report where they show you all the curves when the patient's resting, squeezing. They have all the numbers. And then basically it's up to the provider to actually interpret the report. So usually a provider will interpret the report. A technician can actually do the testing, but the report is pretty standard and it's relatively simple to read. So that's usually how we do it in my practice. They had a question about MRI difficulty. Do you think it's better, same, or not as much needed compared to anorexial manometry? Can you get the same information or is it superior to that? I think if you're comparing apples to oranges, the MRI is obviously much more specific. But MRI is very challenging. We don't even have MRI deficography at my institution. So places that do have MRI deficography, that's a great modality and I would definitely utilize that. But you do also have to understand that not only is it a better study, but it's also extremely expensive compared to anorectal manometry where all you really are paying for is the catheter. So, you know, if you have the luxury of having an MRI deficography, it's better information and it's more detailed. But baseline anorectal manometry is a very good test, especially for the price and the amount of information you receive from the test. Do you have any tips or recommendations for providers who are planning or are entertaining the idea of incorporating anorectal manometry in their practice? Any suggestions where to start, what to pay attention to for somebody who is not familiar but thinking of it as integrating in their practice? I think it's a great modality that is relatively easy to learn. The machines are not that expensive and I think it can be a very good adjunct to your practice. Many of your patients in urogynecology have defecatory disorders as well. And these tests can be performed, they can give you a lot of information about the pelvic floor. I think the learning curve is not tough at all. The machines usually come with training and there's a lot of good literature out there to learn about the procedure and how to interpret results. And I definitely think that it's a great study to have and it would be a great adjunct to your practice. Well, again, thank you for your fantastic presentation. Thank you. This is all about the questions. Thank you for you and participants for cutting out time and your busy days to participate in a virtual forum with our speaker and with each other. Upon completion of this program, we will be prompted to provide some feedback. Please do share your thoughts and impressions with us. Also, we are looking to our next program on May 10. We will be talking about use of buccal mucosal grafts in reconstructive surgery. Until then, be well and see you next month. Thank you, Dr. Speranza and Dr. Libitskaya. On behalf of AUGS, I would also like to thank everyone else for your participation in today's event. Again, a post-event survey will appear requesting your feedback. Please take a moment to complete the survey as it will help AUGS plan future web events. This concludes today's program. Again, we thank you and have a great night.

Anorectal Manometry

Concepts

Indications

Implications

Dr. Ludmilla Lipitskaya

Dr. Jenny Speranza

Basics of Anorectal Manometry

Procedure

Types of Manometry Machines