During the first proctological examination for minor pathologies, for example the haemorrhoids, there is a critical point if the anamnesis is nagative for other anorectal disfunctions. Normally, after proctoscopy or colonscopy, the patient is undergone to a surgical treatment.

In the first proctological visit we can only detect the morphological aspects of the anus and the rectum but not their functionality. At present, no device allows us to suspect attendant diseases and also predict postoperative complications. Nowadays, with minor pathologies where manometry is not foreseen, no instrument is able to predict attendant diseases and postoperative complications.

The MFA is made up of a graduated anoscope and a catheter with latex balloon (Fig. 1).

It is basic underlining that the MFA doesn’t replace manometry, but it takes its place between nothing and manometry. It can test anorectal functionality and it’s an easy and fast device for the early patient’s selection.

The MFA is multifunctional: in addition to the anoscopy, it can perform: Rectal Sensation Test (RST), Balloon Expulsion Test (BET), the Extent of Prolapse Assessment (EPA) and finally the Length Measurement of the Anal Canal (LMAC).

1) RST. The Sims’ position will be preferred. The balloon is inserted into the rectum under vision 8 cm above the anal ring (fig. 2,3). The anoscope is removed (fig. 4). The Rectal Sensation Test (RST) will be started by insufflating air into the balloon by a 100 cc syringe (Fig. 5).

First Sensation, Defecatory Desire Volume and Maximum Tolerable Volume will be obtained according to what is reported by the patient, exactly like manometry. Normal values are: FS 30-60 , DDV 60-160 , MTV 160-270. These values are given in cc of air. If different from standard range, rectal Hypersensitivity or Hyposensitivity are identified (table 1).

Normal Values
First Sensation (FS)	30-60 cc air
Defecatory Desire Volume (DDV)	60-160 cc air
Maximum Tolerable Volume (MTV)	160-270 cc air
Values altered
RECTAL HYPERSENSITIVITY	FS < 30; DDV < 60; MTV < 160
RECTAL HYPOSENSITIVITY	FS > 60; DDV > 160; MTV > 270

So, the MFA use during the proctological examination, allows the selection of patients with hyper or hyposensitivity in a way that the proctologist can suspect the presence of attendant diseases. It will persuade him to carry out further examinations avoiding hurried surgical decisions. In fact, according to the literature, rectal hypersensitivity is more correlated with diseases such as external anal sphincter disfunctions, IBD, fecal incontinence and neuropathy (2)(3)(7). On the contrary, rectal hyposensitivity is mainly correlated with constipation, ODS, anismus, rectal solitary ulcer, hydiopathic fecal incontinence and megarectum (1)(8)(9)(13). Marc A. Gladman says (1): “…despite these observations, the presence of rectal hyposensitivity is not often considered when clinical decisions are made regarding the management of patients with functional bowel disorders, and perhaps more importantly, in the selection of patients for surgery”. And he continues: “…the findings of several anecdotal reports suggest that Rectal Hyposensitivity may be a predictor of poor outcome in patients undergoing colectomy for slow-transit constipation and patients undergoing sphincter reconstruction for faecal incontinence”(1).

2) BET. The Balloon Expulsion Test (BET) represents the second function of the MFA. The patient might be in the sitting position in the restroom or in the Sims’ one. The balloon is inflated with 60 cc of air and the patient is asked to expel it in a minute: so, we can detect the maximum expulsion time. In patients in whom rectal hyposensitivity is found (mostly correlated with constipation), the failure to expel the balloon can confirm the suspicion for ODS, anismus or more generally dyssynergia (11)(12)(13).

3) EPA.The third function of the MFA is the Extent of Prolapse Assessment (EPA) which can be important to decide whether to use one or two staplers for the prolassectomy (fig.6).

EPA allows us to draw up a precise informed consent. We suggest to do this test without the anoscope in order to avoid its opposition during the patient’s straining. The balloon is inflated with 150-160 cc of air and it must be placed as high as possible into the rectum.

The traction is performed during the patient squeeze. The EPA test also allows us to obtain more details about the perineum and to contemporary do a vaginal examination.

4) LMAC.The length measurement of the anal canal is the fourth function of the MFA: it is possible thanks to a graduated scale in centimeters.

Poong-Lyul Rhee reports that both an increased length of anal canal and an increased MTV are foreseen of the biofeedback failure in patients suffering from anismus (15).

Moreover, these data are important to evaluate the result after surgery for faecal incontinence as the sphincters repair operation (fig. 7).

MATERIALS AND METHODS.

Aims of our study was to demonstrate that the rectal sensitivity thresholds are the same if detected with MFA or with anorectal manometry and that the altered results of the Rectal Sensation Test could be an expression of attendant diseases and they could predict postoperative complications.

From January 2006 to September 2008 we have gathered 218 patients. 128 of them were suffering from mucosal prolapse and haemorroids, 61 from Obstructed Defecation Syndrome (ODS). All patients were studied both with MFA and manometry.

The correlation on the three parameters (FS, DDV and MTV) related to the measures detected with MFA and manometry, is very high (by Biostatistic Unit of the Genova University – Mrs. Mariapia Sormani) (Fig. 8).

Rectal sensitivity thresholds are the same if detected with MFA or anorectal manometry (R = 0,99 p<0,001).

In 189 people examined, Rectal Sensitivity Test (RST) has allowed to find out 30 patients with rectal hypersensitivity and 47 with rectal hyposensitivity.

Further diagnostic assessments (US, EMG, PNTHL, Defecography, Colonoscopy, Anorectal manometry) have allowed to find out 6 females and 1 male with external anal sphincter disfunctions, some cases of faecal incontinence, some cases of constipation with ODS… etcetera.

Table 2 shows the attendant diseases that have been found (Tab. 2).

30 with rectal hypersensitivity	6 females and 1 male with EAS disfunctions (23.3%) 1 male with RCU (3.3%)* 3 males and 7 fimales with MII (33.3%)
47 with rectal hyposensitivity   (IRA: Rectal Intussusceptions) (RA: Anterior Rectocele)	9 females with IRA+RA+ slow transit constipation (19.1%) 1 male with slow transit costipation (2.1%) 17 females with IRA+RA (36.1 %) 5 males and 3 females with puborectalis syndrome (17%) 1 female with faecal incontinences (gas and liquid stools) (2.1%) 1 female with both constipation and faecal incontinence (2.1%) 1 female only with rectocele (2.1%) - 2 females only with IRA (4.25%)

We have confirmed in this way the second point of our study, that is the rectal sensitivity threshold alterations could also hide attendant diseases even in case of minor pathologies.

We have operated 123 patients suffering from rectal prolapse and haemorrhoids by stapled prolassectomy and 43 patients with rectal intussusceptions and rectocele for STARR (Staped Trans Anal Rectal Resection). 30 of them had a rectal hypersensitivity, 47 hyposensitivity.

We have considered the faecal urgency as a complication to be foreseen, and we have arranged a six month follow-up. We have classified the urgency in Temporary (TU) that resolves itself within three weeks without consequences, Permanent (PU) that continues up to three months but also resolves itself without consequences and Severe (SU) that lasts more than three months and shows itself in an increase of the daily evacuations (but the urgency not disappear completely).

According to our study in 30 patients with hypersensitivity operated for stapled prolassectomy, 6 of them have had severe urgency (22,2%) (Tab. 3,4).

In particular, there is an important correlation between hypersensitivity and Permanent Urgency (p=0.02), between hypersensitivity and Severe Urgency (p=0.01) and not so important between hypersensitivity and Temporary Urgency (p=0.07). As a whole, the correlation between Hypersensitivity and Urgency is absolutely significant (p>0,001).

So, when the proctologist finds out a patient with rectal hyper or hyposensitivity must suspect the presence of attendant diseases and he can choose the best way to operate the patient. During the first proctological examination we suggest using this plan to fill in and add to the patient’s dossier (fig. 9).

In short, the use of the MFA at the first proctological visit allows: to perform Rectal Sensation Test in case of minor pathologies, too; to suspect attendant diseases; to foresee postoperative complications; to avoid hurried surgical decisions; to assess the correct prolapse extent and finally to foresee biofeedback results.

NOTES:

If you are interested in attending such courses concerning the MFA use, please click on the “Courses” on the Home Page.

REFERENCES

1. Marc A. Gladman, M.R.C.O.G., M.R.C.S. (Eng), S. Mark Scott, Ph.D., Christopher L.H. Chan, F.R.C.S., Norman S. Williams, M.S., F.R.C.S., Peter J. Lunniss, M.S., F.R.C.S.: “Rectal Hyposensitivity. Prevalence and Clinical Impact in Patients With Intractable Constipation and Fecal Incontinence”. D.C.R. 2003 Vol.46, N°2: 238-246.

2. Christopher L.H. Chan, F.R.C.S., S. Mark Scott, Ph.D., Norman S. Williams, F.R.C.S., Peter J. Lunnis, F.R.C.S. “Rectal Hypersensitivity Worsens Stool Frequency, Urgency and Lifestyle in Patients With Urge Fecal Incontinence”. D.C.R. 2005 Vol. 48, N°1: 134-140.

3. Emanuel Chrysos, M.D., Ph.D., Elias Athanasakis, M.D., John Tsiaoussis, M.D., Ph.D., Odysseas Zoras, M.D., Ph.D., Antonios Nickolopoulos, M.D., Joho Sophocles Vassilakis, M.D., Ph.D., Evaghelos Xynos, M.D., Ph.D., F.A.C.S.: “Rectoanal Motility in Crohn’s Disease Patients”. D.C.R. 2001 Vol.44, N° 10: 1509-1513.

4. Tetsuo Yamana, M.D., Masatoshi Oya, M.D., Junji Komatsu, M.D., Yasuo Takase, M.D., Noboru Mikuni, M.D., Hiroshi Ishikawa, M.D.: “Preoperative Anal Sphincter High Pressure Zone, Maximum Tolerable Volume and Anal Mucosal Electrosensitivity Predict Early Postoperative Defecatory Function After Low Anterior Resection for Rectal Cancer”.D.C.R. 1999 Vol.42 N° 9: 1145-1151.

5. Gloria Lacima, M.D., Miguel Pera, M.D., Josep Valls-Solé, M.D., Xavier Gonzales-Argenté, M.D., Montserrat Puig-Clota, M.D.: “Electrophysiologic Studies and Clinical Findings in Females With Combined Fecal and Urinary Incontinence: A prospective Study”. D.C.R. 2006 Vol. 49 N° 3: 353-359.

6. Paul Broens, M.D., Dirk Vanbeckevoort, M.D., Erwin Bellon, M.Sc., freddy Penninckx, M.D., Ph.D.: “Combined Radiologic and Manometric Study of Rectal Filling Sensation”. D.C.R. 2002 Vol. 45 N° 8: 1016-1022.

7. Paul M.A. Broens, M.D., Freddy M. Penninckx, M.D.: “Relation Between Anal Electosensitivity and Rectal Filling sensation and the Influence of Age”. D.C.R

8. M.J. Gosselink, M.D., Ph.D., W.R. Schouten, M.D., Ph.D.: “Rectal Sensory Perception in Females with Obstructed Defecation”. D.C.R.2001 Vol. 44 N° 9: 1337-1344.

9. M.D. Crowell, Ph.D., B.E.Lacy, M.D., Ph.D., V.A. Schettler, B.S.N., T.N. Dineen, M.D., K.W.Olden, M.D., N.J. Talley, M.D., Ph.D.: “Subtypes of Anal Incontinence Associated With Bowel Dysfunction: Clinical, Physiologic, and Psychosocial Characterization”. D.C.R. 2004 Vol. 47 N° 10 : 1627-1635.

10. Ann Kristin Orno, M.D., Andreas Herbst, M.D., Ph.D., Karel Marsal, M.D., Ph.D.: “Sonographic Characteristics of Rectal Sensation in Healthy Females”. D.C.R. 2007, Vol. 50 N° 1: 64-68.

11. James W. Fleshman, M.D., Zeev Dreznik, M.D., Edward Cohen, M.D., Robert D.Fry, M.D., Ira J. Kodner, M.D.: “Balloon Expulsion Test Facilitates Diagnosis of Pelvic Floor Outlet Obstruction Due to Nonrelaxing Puborectalis Muscle”. D.C.R. 1992 Vol. 35 N° 11: 1019-1025.

12. T. George Parks, M.Ch., F.R.C.S.Ed., F.R.C.S.G., F.R.C.S.I.: “The Usefulness of Tests in Anorectal Disease”. W.J.Surg. 16, 804-810, 1992.

13. G. Chiarioni, M.D., F. Chistolini, M.D., M. Menegotti, L. Saladini, I. Vantini,M.D., A. Morelli, M.D., G. Bassotti, M.D., Ph.D.: “One-Year Follow-Up Study on the Effects of Electrogalvanic Stimulation in Chronic Idiopathic Constipation With Pelvic Floor Dyssynergia“. D.C.R. 2004 Vol. 47 N° 3: 346-353.

14. W.R.Schouten, M.D., J.W.Briel, M.D., J.J.A.Auwerda, M.D., J.H.van Dam, M.D., M.J.Gosselink, M.D., A.Z.Ginai, M.D., W.C.J.Hop, M.Sc.: “Anismus: Fact or Fiction?”. D.C.R. 1997 Vol. 40 N° 9: 1033-1041.

15. Poong-Lyul Rhee, M.D., Moon Seok Choi, M.D., Young Ho Kim, M.D., Hee Jung Son, M.D., Jae Jun Kim, M.D., Kwang Cheol Koh, M.D., Seung Woon Paik, M.D., Jong Chul Rhee, M.D., Kyoo Wan Choi, M.D.: “An Increased Rectal Maximum Tolerable Volume and Long Anal Canal Are Associated with Poor Short-Term Response to Biofeedback Therapy for patients with Anismus with Decreased Bowel Frequency and Normal Colonci Transit Time”. D.C.R. 2000 Vol. 43 N° 10: 1405-1411.