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Review
. 2023 Oct;21(11):2727-2739.e1.
doi: 10.1016/j.cgh.2023.05.025. Epub 2023 Jun 9.

Optimizing the Utility of Anorectal Manometry for Diagnosis and Therapy: A Roundtable Review and Recommendations

Satish S C Rao  1 , Nitin K Ahuja  2 , Adil E Bharucha  3 , Darren M Brenner  4 , William D Chey  5 , Jill K Deutsch  6 , David C Kunkel  7 , Baharak Moshiree  8 , Leila Neshatian  9 , Robert M Reveille  10 , Gregory S Sayuk  11 , Jordan M Shapiro  12 , Eric D Shah  5 , Kyle Staller  13 , Steven D Wexner  14 , Jason R Baker  15
Affiliations
Review

Optimizing the Utility of Anorectal Manometry for Diagnosis and Therapy: A Roundtable Review and Recommendations

Satish S C Rao et al. Clin Gastroenterol Hepatol. 2023 Oct.

Abstract

Background & aims: Anorectal manometry (ARM) is a comprehensive diagnostic tool for evaluating patients with constipation, fecal incontinence, or anorectal pain; however, it is not widely utilized for reasons that remain unclear. The aim of this roundtable discussion was to critically examine the current clinical practices of ARM and biofeedback therapy by physicians and surgeons in both academic and community settings.

Methods: Leaders in medical and surgical gastroenterology and physical therapy with interest in anorectal disorders were surveyed regarding practice patterns and utilization of these technologies. Subsequently, a roundtable was held to discuss survey results, explore current diagnostic and therapeutic challenges with these technologies, review the literature, and generate consensus-based recommendations.

Results: ARM identifies key pathophysiological abnormalities such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction, and is a critical component of biofeedback therapy, an evidence-based treatment for patients with dyssynergic defecation and fecal incontinence. Additionally, ARM has the potential to enhance health-related quality of life and reduce healthcare costs. However, it has significant barriers that include a lack of education and training of healthcare providers regarding the utility and availability of ARM and biofeedback procedures, as well as challenges with condition-specific testing protocols and interpretation. Additional barriers include understanding when to perform, where to refer, and how to use these technologies, and confusion over billing practices.

Conclusions: Overcoming these challenges with appropriate education, training, collaborative research, and evidence-based guidelines for ARM testing and biofeedback therapy could significantly enhance patient care of anorectal disorders.

Keywords: Anorectal Manometry; Biofeedback Therapy; Dyssynergic Defecation; Fecal Incontinence.

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Conflict of interest statement

Conflicts of interest

The authors disclose the following: Satish S.C. Rao has served on the advisory boards for Medtronic, Takeda Pharmaceuticals, Ironwood Pharmaceuticals, Sanofi Pharmaceuticals, Vibrant Ltd, and Salix Pharmaceuticals. Nitin K. Ahuja has served on a medical advisory board for GI Supply and Takeda; received research support from Vanda Pharmaceuticals and Nestlé; served a consultant for GlaxoSmithKline Consumer Healthcare; and received payment for educational events from Medtronic. Adil E. Bharucha has received funding from Minnesota Medical Technologies; has royalties/licenses from Medspira and Minnesota Medical Technologies; has served as a consultant for GI Supply and Medical Insights Group; has patents issued or pending with Medtronic, Minnesota Medical Technologies, and Medspira; and has received equipment from Cairn Diagnostics. Darren M. Brenner has served a consultant for AbbVie (Allergan), Ironwood, Takeda, RedHill Biopharma, Alnylam, AlphaSigma, Ardelyx, Bayer, Gemelli, Arena Pharmaceuticals, Vibrant, GI Health Foundation, IFFGD, and the Rome Foundation; and is sponsored by an unrestricted grant from the Irene D. Pritzker Foundation. William D. Chey has served a consultant for AbbVie, Ardelyx, Biomerica, Gemelli, IM Health, Ironwood, Nestlé, QOL Medical, Phathom, Progenity, RedHill BioPharma, Salix/Valeant, Takeda, Urovant, and Vibrant; has patents issued from My Nutrition Health, Digital Manometry, Rectal Expulsion Device; has served in a leadership or fiduciary role for the American College of Gastroenterology, Rome Foundation, and International Foundation for Gastrointestinal Disorders; has stock options in Isothrive, Kiwi Bioscience, and Modify Health; and has received research funding from Commonwealth Diagnostics International, the Food and Drug Administration, the National Institutes of Health, QOL Medical, and Salix/ Valeant. Jill K. Deutsch has received honorarium from GI Supply. David C. Kunkel has served a consultant for Palette Life Sciences, Allergan, Salix Pharmaceuticals, QOL Medical, RedHill Biopharma, Shire (Takeda), Arena Pharmaceuticals, Pfizer, and Portola Pharmaceuticals. Baharak Moshiree has received research support from reStalsis, Salix/Bausch Pharmaceuticals, Allergan/Ironwood, Takeda, Cairn Diagnostics, Alnylam, Atome, Nestlé, and Medtronic; has served on an advisory board and received honorarium from Allergan, Takeda, AbbVie, Salix/Bausch Pharmaceuticals, and Alnylam; has received payment for expert testimony; has a patent pending; and has served on the ACG Research Committee, on the ACG Minority Affairs Committee, as the ACG Governor of NC State, and as an American Neurogastroenterology and Motility Society council member. Leila Neshatian has received funding from the Stanford GI Department and Stanford Surgery Department; and served on the Rome Committee and International Continence Society. Robert M. Reveille has received honorarium from GI Supply and travel support from the American Foregut Society. Gregory S. Sayuk has served as a consultant and speaker for Salix Pharmaceuticals, AbbVie/Ironwood Pharmaceuticals, Alnylam, and the GI Health Foundation. Jordan M. Shapiro has received honorarium from GI Supply. Eric D. Shah has served a consultant for Salix Pharmaceuticals. Kyle Staller has received funding from Ironwood and Urovant; served a consultant for Ardelyx, Anji, Gelesis, Sanofi, Shire (Takeda), and GI Supply; and served on an advisory board for Arena Pharmaceuticals. Steven D. Wexner has royalties from Medtronic, Intuitive Surgical, Karl Storz Endoscopy America, and Unique Surgical Innovations LLC; has served a consultant for ICON Language Services, Intuitive Surgical, Stryker, Medtronic, Takeda, ARC Medical/Corvus, Astellas, Baxter, Olympus, AIS Channel, LivsMed, GI Supply, and Leading BioSciences; and has stock in Pragma/GibLib, Renew Medical, CRH Medical, and Intuitive Surgical. Jason R. Baker has served a consultant for GI Supply.

Figures

Figure 1.
Figure 1.
ARM system descriptions. (A). Air-filled balloon of Schuster. 1, aneroid manometer; 2, syringe for air insufflations; 3, pear-shaped balloon (for the external anal sphincter); 4, doughnut-shaped balloon (for the internal anal sphincter); 5, rectal balloon for eliciting the rectoanal inhibitory reflex. Reprinted with permission from Pfeifer and Oliveira. (B). Water-perfused system. Reprinted with permission from Solanki D, Hibberts F, Williams AB. Pelvic floor investigations for bowel dysfunction (part 2): anorectal physiology (manometry). Gastrointest Nurs. 2019;17:24. (C). Solid-state system. Reprinted with permission from Solanki D, Hibberts F, Williams AB. Pelvic floor investigations for bowel dysfunction (part 2): anorectal physiology (manometry). Gastrointest Nurs. 2019;17:24. (D). Comparison of ARM catheters. Reprinted with permission from Bharucha et al. aFor high-resolution ARM (HR-ARM) catheters that use solid-state sensors. 3D, 3-dimensional.
Figure 2.
Figure 2.
IAPWG protocol. *Optional threshold. DDV, desire to defecate volume; FCSV, first constant sensation volume; MTV, maximum tolerated volume; RAIR, rectoanal inhibitory reflex; SUV, sustained urgency volume.
Figure 3.
Figure 3.
BT: barriers to use and solutions. ANMS, American Neurogastroenterology and Motility Society; CPT, Current Procedural Terminology; HCP, healthcare provider.
See this image and copyright information in PMC

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