title: Clinical examination remains more important than anorectal function tests to identify treatable conditions in women with constipation.
abstract: OBJECTIVE
  Many women with chronic constipation are referred for anorectal function tests (AFT) when they fail initial conservative treatment with lifestyle advice and laxatives. Our goal was to prospectively investigate the diagnostic potential of AFT in women with constipation in order to identify treatable conditions.
  
  
  METHODS
  Between May 2003 and June 2011, all women with constipation referred to our tertiary referral center completed a questionnaire regarding their perianal complaints and underwent physical examination and were evaluated according to our AFT protocol, including anorectal manometry (ARM) and anal endosonography.
  
  
  RESULTS
  One hundred and thirteen women were referred and classified as having idiopathic constipation (n = 100), neurological disorder (n = 8), or others (n = 5). Of the 100 women with idiopathic constipation, clinical examination identified 25 (25 %) with hypertonia of the pelvic floor (dyssynergic pelvic floor) and 15 (15 %) with a rectocele. In 37/100 women also complaining of impaired evacuation, the yield of rectocele was 15 (41 %) and of hypertonia 5 (14 %). Women with hypertonia were younger (40 vs. 51 years; P = 0.002) and had no rectoceles identified (P = 0.02), and fewer women could relax during straining on ARM (56 % vs. 92 %; P < 0.001) compared with women without pelvic hypertonia. Other ARM measurements showed no differences between women with evacuation disorders, rectoceles, or hypertonia. Anal endosonography showed no internal sphincter hypertrophia.
  
  
  CONCLUSIONS
  Potentially treatable conditions, such as rectocele and pelvic floor hypertonia, are found on clinical examination in 40 % of women with idiopathic constipation. Impaired evacuation is associated with the presence of a rectocele. AFT contributes little and should be reserved for selected cases.
authors.affiliation: Department of Gastroenterology and Hepatology, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands. tj.lam@vumc.nl
authors.forename: T J
authors.initials: TJ
authors.lastname: Lam
authors.forename: R J F
authors.initials: RJ
authors.lastname: Felt-Bersma
mesh_terms: D016009:Chi-Square Distribution; D003248:Constipation / Q000145:classification / Q000000981:diagnostic imaging / Q000503:physiopathology*; D019160:Endosonography; D005260:Female; D006801:Humans; D008365:Manometry; D008875:Middle Aged; D010808:Physical Examination; D011446:Prospective Studies; D012307:Risk Factors; D011795:Surveys and Questionnaires