Normal Variation in Anorectal
Manometry
Rebecca L. Cali, M.D., Garnet J. Blatchford, M.D., Richard E. Perry, M.B., Ch.B.,
Richard M. Pitsch, M.D., Alan G. Thorson, M.D., Mark A. Christensen, M.D.
From the Section of Colon and Rectal Surgery, Creighton University School of Medicine, Omaha,
Nebraska
A study was performed to define the normal range of
values for anorectal manometry. Normal volunteers were
divided according to gender and parity. There were 20
males, 21 nulliparous females, and 18 multiparous fe-
males among the 5 9 subjects. Anorectal manometry using
a radial eight-port catheter was performed during resting
and squeezing maneuvers of the anal sphincter. Comput-
erized data analysis and three-dimensional imaging were
used to calculate sphincter length at rest and squeeze,
mean maximum resting and squeeze pressures, and vector
symmetry index. The sphincter length at rest and with
squeezing in males was significantly greater compared
with the two female groups (P < 0.007). Mean maximum
squeeze pressures were also significantly elevated in the
male group compared with the female groups (P - 0).
Mean maximum resting pressures were significantly
higher in nulliparous women than in multiparous women
(P = 0.04). However, no difference in resting pressures
was found between males and nulliparous females. A
comparison of the symmetry of the anal canal revealed
no differences among the three groups. Ranges for normal
anorectal manometry are definable. Normal ranges are
distinct for subgroups of patients, particularly with regard
to gender and parity. Patients must be compared with
their normal subgroups to correctly identify manometric
abnormalities. [Key words: Anorectal manometry; Anal
sphincter function; Normal variation; Effect of gender;
Parity]
Cali RL, Blatchford GJ, Perry RE, Pitsch RM, Thorson AG,
Christensen MA. Normal variation in anorectal manome-
try. Dis Colon Rectum 1992;35:1161-1164.
A norectal m a n o m e t r y has b e c o m e a routine in-
vestigation for the evaluation of patients with
anorectal disorders. Although there is s o m e debate
about its value in clinical practice, recent studies
indicate that anorectal m a n o m e t r y can reveal pa-
t h o l o g y not d e t e c t a b l e by physical e x a m i n a t i o n
alone.1 3
The clinical utility of m a n o m e t r y ultimately de-
p e n d s on its p o w e r to discriminate b e t w e e n n o r m a l
and a b n o r m a l function. Several centers have en-
d e a v o r e d to delineate m a n o m e t r i c values for the
n o r m a l anal canal in o r d e r to better define the
abnormal. 4-1~ However, there are limitations in
Address reprint requests to Dr. Thorson: Creighton University
School of Medicine, Section of Colon and Rectal Surgery, 601
North 30th Street, Omaha, Nebraska 68131.
1161
c o m p a r i n g results a m o n g study centers b e c a u s e of
differences in e q u i p m e n t , technique, and defini-
tions of normality.
Study of a s y m p t o m a t i c subjects has disclosed
features distinct to subsets of n o r m a l patients. Sig-
nificant m a n o m e t r i c variations have b e e n de-
scribed in normal subjects chiefly with regard to
g e n d e r and age. Males have b e e n f o u n d to have
greater s q u e e z e pressures, greater resting pres-
sures, and longer sphincters c o m p a r e d with fe-
males.4 10 The effect of age on the anal sphincter
b e c o m e s evident a r o u n d the sixth d e c a d e with
d e c r e a s e d resting and s q u e e z e pressures as well as
p r o l o n g a t i o n of p u d e n d a l nerve conduction. 5' 7, 9, 10
In contrast to d i f f e r e n c e s b a s e d on g e n d e r and
age, the effect of parity on anorectal m a n o m e t r i c
p a r a m e t e r s has not b e e n well described. F e w stud-
ies of normal controls have sought m a n o m e t r i c
distinction b e t w e e n groups of parous and nullipa-
rous w o m e n . 4' 5
S y m m e t r y of the anal canal has b e e n u s e d at our
institution as a p a r a m e t e r for evaluating anorectal
pathology. A range for normal anal canal s y m m e t r y
has b e e n d e f i n e d in a previous study c o m p a r i n g
normal f e m a l e s with those having k n o w n sphincter
injuries. 11
The aim of this study was to establish normal
ranges for anorectal m a n o m e t r i c p a r a m e t e r s in
a s y m p t o m a t i c adults.
METHODS
Fifty-nine normal volunteers w e r e e x a m i n e d i.n
the anorectal p h y s i o l o g y laboratory after an exten-
sive s c r e e n i n g questionnaire d e t e r m i n e d that they
had no anorectal s y m p t o m s or previous anorectal
or colorectal surgery. T h e subjects w e r e divided
into groups of 20 m a l e s (age, 21-39 years; m e a n ,
29 years), 21 nulliparous f e m a l e s (age, 19-65 years;
mean, 30 years), and 18 m u l t i p a r o u s f e m a l e s (age,
28-59 years; m e a n , 40 years). Parity in the latter
g r o u p ranged f r o m one to five, with an average of
1162 CALI E T AL Dis Colon Rectum, December 1992

two births. All births were vaginal deliveries. There
was only one subject in each of the two female
groups over the age of 50.
Anorectal manometry was performed using a ra-
dial eight-port water-perfused catheter. Manomet-
ric symmetry was quantified by the vector symme-
try index (VSI). A VSI of 1.0 represents perfect
symmetry, while varying degrees of asymmetry lie
between 0 and 1.0. The manometric techniques
used have been previously described in detail. I1
Student's t-test was used for statistical compari-
sons, with significance established at a P value of
<0.05. The Pearson correlation coefficient was
used to determine the effect of age on mean max-
imum resting pressures.
RESULTS
peared greater for the nulliparous than for the
parous females, the difference was not significant
( P = 0.09) (Fig. 1).
Mean maximum resting pressure revealed the only
area of significant difference between nulliparous
and parous females. The mean maximum resting
pressure for nulliparous females was significantly
greater than that for the parous females and was
equal to that for the male group (Fig. 2).
The mean age for parous females was 10 years
greater than for the nulliparous group even though
only one patient in each group was over 50. A
Pearson correlation coefficient was not significant
for age vs. resting or squeeze pressures in either
of the female groups, demonstrating that the pres-
sure differences are not attributable to the effect of
age.

Sphincter Length
The male sphincter length at rest and with Squeeze Pressures
squeezing was significantly greater than that of 200

nulliparous and parous females. Parity had no ef- 175

sJS~'S- - , , ~,
fect on the female sphincter (Table 1). 150 .... Males s~.S ~".
125 ~ Nulliparousfemales sS
.... MuRiparousfemalestsS" /..." -X~
Anal Canal Pressures 100 .. "3
E
o 75 "/' '
Mean maximum squeeze pressures accounted
for the greatest difference between males and fe-
males (P = 0; males vs. both female groups). This I I I, I I I I I I I

difference was significant independent of the 6.0 5.5 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5
cm from anal verge
sphincter length. Although squeeze pressures ap-
Figure 1. Variation in average squeeze pressures between
subgroups. These curves reflect the differences between
Table 1. subgroups, but pressure values are not identical to those
Summary of Results stated in the text owing to individual variations in the
Females station level at which peak pressures occurred.
Males
Parous Nulliparous
Sphincter length (cm) Resting Pressures
Rest 3.0 2.8 3.5* 100

Squeeze 3.7 3.8 4.2*

Mean maximum rest (cm 83~r 102 102 75 .... Males s///s/'~s"~
H20)
Nulliparous females / /.." ". ~,~
Mean maximum squeeze 140 156 196" O~N ....
9
Multlparous females // J ./ ". ",~
(cm H20) -r 50 ,, ... ..
Vector symmetry index 0.75 0.77 0.80 sS ~
s/ . "
Statistically significant values in the male group as com-
.... .-:d :,~'~
pared with the female groups (*) were seen in sphincter
length at rest (P = 0.001 vs. nulliparous, P = 0.007 vs. I I I I I I I I I I
parous), sphincter length with squeezing (P = 0.005 vs. 6.0 5.5 5.0 4,5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5
cm from anal verge
nulliparous, P = 0.001 vs. parous), and mean maximum
squeeze pressures (P = 0.0 vs. both groups). The only Figure 2. Variation in average resting pressures between
area of statistical significance between the two female subgroups. These curves reflect the differences between
groups was found in resting pressures, where nulliparous subgroups, but pressure values are not identical to those
females had higher pressures than parous females (1-) (P stated in the text owing to individual variations in the
= 0.004). station level at which peak pressures occurred.
Vol. 35, No. 12 VARIATION IN ANORECTAL MANOMETRY
Vector Symmetry Index
The VSI for all groups ranged between 0.59 and
0.93. No normal volunteer demonstrated a perfect
symmetry of 1.0. There were no significant differ-
ences among any of the groups (Table 1).
DISCUSSION
The demonstration of a significant increase in
sphincter length and mean maximum squeeze
pressures in males over females is supported by
previous studies. 4q~ These differences may be at-
tributable to a greater male sphincteric muscle
mass.
Documented in this study was a significant de-
crease in mean maximum resting pressure in
asymptomatic parous females compared with nul-
liparous females. This suggests some long-term
subclinical injury to the anal sphincter from vaginal
delivery. Damage to the innervation of the striated
muscle of the pelvic floor after vaginal delivery is
documented. 12 Prolonged pudendal nerve laten-
cies can be seen in 42 percent of women directly
after vaginal delivery. Recovery occurs in 60 per-
cent. 13 Because the external anal sphincter is
thought to contribute approximately 20 percent of
the resting tone, ~4 one could speculate that occult,
permanent pudendal nerve injury would be impli-
cated in the lower maximum resting pressures.
Alternatively, the sympathetic stimulation of the
internal sphincter carried in the hypogastric (pre-
sacral) nerves may suffer injury during vaginal de-
livery that could contribute to a subclinical de-
crease in maximal resting pressures without affect-
ing the squeeze pressures.
An effect of parity on anal canal pressures was
sought by McHugh and Diamant, 4 and no signifi-
cance was found. Taylor e t al. 5 found significantly
lower resting pressures only in the most proximal
portion of the anal canal in parous females com-
pared with those without vaginal deliveries. Parous
females in the present study had lower resting
pressures than nulliparous females. This suggests
a definite, although not always measurable, effect
of vaginal delivery on the anal sphincter.
Previous studies have described differences in
resting and squeezing pressures beginning in
about the sixth decade. 4' 7, 9, 10 Additionally, Laur-
berg and Swash 7 demonstrated prolonged puden-
dal nerve latencies in the elderly, most pronounced
in females. The age range of the female groups in
1163
the present study did not allow for an analysis of
pressures based on age.
Alteration in the symmetry of the anal canal has
been previously demonstrated in patients with
sphincter injuries. 11 Clinically occult but sympto-
matic injuries can be identified by manometric
asymmetry and quantified by the VSI. Although
one might suspect subclinical alteration in the sym-
metry of parous females, our present study dem-
onstrated no significant differences between
groups. Normal anal canal symmetry is represented
by a VSI of 0.6 or greater.
SUMMARY
Study of manometric parameters in 59 normal
volunteers revealed significant differences be-
tween males and females as well as between nul-
liparous and parous females. Mean maximum
squeeze pressures and the length of the anal
sphincter at rest and with squeezing are signifi-
cantly greater in males than in females. Parous
females have a significant decrease in the mean
maximum resting pressures compared with nullip-
arous females. No differences were found between
subgroups of normal volunteers with regard to anal
canal symmetry as measured by the VSI.
CONCLUSION
Although anorectal manometric values for nor-
mal patients cover a wide range, they remain defin-
able with distinctions among subgroups of patients.
Categorization of these patients, particularly ac-
cording to gender and parity, is therefore essential
to correctly interpreting manometric results.
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