Prospective assessment of the clinical value of anorectal investigations

Background/Aim: Anorectal physiological testing and imaging have become par t of routine colorectal and gastro-enterological practice, but their clinic al value is controversial. We prospectively evaluated the new diagnostic in formation, impact on management and prognostic information provided by anor ectal testing. Methods: One hundred consecutive patients referred for testi ng were studied. The referring doctor's diagnosis, reason for referral, pla nned management and expectation of the value of investigations were recorde d. Incontinent patients underwent anorectal physiological testing and endo- anal ultrasound. Patients with constipation underwent anorectal physiologic al testing and a study of whole-gut transit time to distinguish between slo w and normal transit. Constipated patients over age 45, or those younger pa tients who digitated to assist defaecation, also underwent evacuation proct ography to identify large rectoceles. Results: Fifty-one patients had faeca l incontinence. Of 12 patients with suspected anterior external anal sphinc ter obstetric damage, all of whom were planned for surgical repair, 3 were unsuitable for repair, 3 had a normal sphincter, 2 had a weak but structura lly intact sphincter, and 1 had internal anal sphincter damage only. Of 6 p atients with failed anterior repair, 3 had a defect suitable for repeat rep air, 2 had intact repairs and good function, and 1 had extensive damage req uiring reconstructive surgery. The tests also influenced management for inc ontinent patients after haemorrhoidectomy surgery (n = 5), after fistula su rgery (n = 5), with congenital abnormalities (n = 3), after cerebrovascular accident (n = 1) and those with no presumptive diagnosis (n = 15). Of the 20 patients referred with constipation, demonstration of a recto-anal refle x in 1 patient with a megarectum excluded the need for full-thickness biops y. A further patient with altered electrosensation went on to have a neurol ogical lesion defined. Definition of slow transit in some patients did not immediately affect management. New information or a change in management wa s provided in patients referred for pre-operative assessment (n = 13). Info rmation was gained in only 1 of 7 patients with solitary rectal ulcer and i n none of the 8 patients with anal pain. Conclusion: Anorectal assessment p rovides important diagnostic and prognostic information and directly alters management in patients with benign anorectal disorders. Copyright (C) 2000 S. Karger AG. Basel.