Dig Dis Sci
DOI 10.1007/s10620-015-3784-8
ORIGINAL ARTICLE
Three-Dimensional Anorectal Manometry Findings
in Primigravida
D. P. Wickramasinghe1 • C. S. Perera1 • H. Senanayake2 • D. N. Samarasekera1
Received: 7 May 2015 / Accepted: 22 June 2015
 Springer Science+Business Media New York 2015
Abstract
Background Vaginal delivery is an identified risk factor
for anal sphincter injury. Therefore, to identify postpartum
injury, an antepartum value or a normal range is required.
However, at present, the normal values of 3D manometry
are not available for primigravida or pregnant mothers.
Aims Our study aims at describing normal values of 3D
manometry in primigravida.
Methods We analyzed 3DARM data of 101 consecutive
primigravid mothers in the third trimester. 3DARM was
performed using the Given Imaging ManoScan system.
Results The mean age was 24.7 (SD 5.1) years. All
patients had a normal Cleveland Clinic Incontinence Score.
The mean resting pressure (RP) was 87.02 (SD 18.43)
mmHg and the maximum squeeze pressure (SP) was
179.21 (SD 52.96) mmHg. The mean length of the high-
pressure zone (HPZ) was 3.67 (SD 0.52) cm. Mean vol-
umes for initial rectal sensation, urge, and discomfort were
50.36 (±25.57), 76.70 (±35.17), and 143.40 (±66.26) ml,
respectively. The pressure asymmetry was highest in the
lower anal sphincter and lowest in the mid-sphincter. There
& D. N. Samarasekera
samarasekera58@yahoo.co.uk
D. P. Wickramasinghe
dakshithaw@hotmail.com
C. S. Perera
chamilasudarshi@gmail.com
H. Senanayake
senanayakeh@gmail.com
1
Department of Surgery, Faculty of Medicine, University of
Colombo, Kynsey Road, Colombo 8, Sri Lanka
2
Department of Obstetrics and Gynaecology, Faculty of
Medicine, University of Colombo, Colombo, Sri Lanka
was a statistically significant relationship between the HPZ
and RP (Pearson q -0.23, p = 0.01), height (Pearson q
0.22, p = 0.028), and weight (Pearson q 0.25, p = 0.012).
There were no statistically significant correlations between
age, height, or weight with RP, SP, or balloon fill volumes.
The characteristic appearance of the normal RP and SP was
clearly visualized in all patients.
Conclusions Normal 3DARM values for Sri Lankan
primigravid mothers have been established. These may be
used as reference values by other investigators.
Keywords Three-dimensional anorectal manometry

Primigravida
Pregnancy
Introduction
Anatomy and functioning of the human anal sphincter
complex (ASC) were first described by Galen [1, 2]. The
first-recorded illustrations of the ASC are by Versalius in
1543 [2]. Anorectal manometry (ARM) had first been used
in assessing patients in the 1980s [3–5], although more
complex procedures had been attempted several decades
previously [6]. Transducers had often been developed first
for esophageal manometry, and subsequently the same
technology was used to create devices for ARM. The initial
devices had a balloon [7], but subsequently water-perfused
[8] and solid-state [9] manometers had been used. Com-
pared to initial transducers, an exponential increase in the
resolution is also evident. This is because the first devices
had only a handful of transducers and were incapable of
acquiring the pressures of the entire circumference of the
anal canal simultaneously. With the advancement in elec-
tronics and miniaturization of sensors, more and more
sensors could be fitted into the probes and this resulted in
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the development of high-resolution anorectal manometry
(HRARM) in 2007 [10] and three-dimensional (3D)
anorectal manometry (3DARM) [11]. 3DARM, for the first
time, provided sufficient radial resolution to allow accu-
rate, simultaneous 360 assessment of the anal ASC. It is
also a static test and therefore minimizes motion artefacts
and other confounders.
Though these newer investigations have been available
for several years, there are no data available on pregnant
mothers. Authors who have looked at normal values of
3DARM [12, 13] have completely excluded pregnant
mothers from their studies or assessed them postpartum
only. In addition, Jones et al. [10] caution us that even
though there is a good correlation between water-perfused
manometry and HRARM, values obtained with HRARM
tend to be higher. Therefore, we felt that the normal values
obtained previously for pregnant mothers with water-per-
fused manometry cannot be directly used as reference
values for HRARM/3DARM assessments.
The primary objective of this study was to describe the
normal values of 3DARM in healthy Sri Lankan primi-
gravid mothers. In addition, we wanted to identify the
normal pressure morphology of the ASC during rest,
squeeze, and balloon fill.
Methods
Population and Sample
One hundred and one consecutive primigravid mothers
who presented to the antenatal clinic of the University
Obstetric and Gynaecology Unit of the Faculty of Medi-
cine, University of Colombo, Sri Lanka, in 2012 were
recruited for the study. They all underwent the assessment
between 30 and 32 weeks of gestation, and this was done
on one of the days of their routine antenatal clinic visit but
as a part of a study to identify obstetric anal sphincter
injuries. Basic demographic details and details of the ges-
tation were also recorded at the first visit. Anal continence
was assessed using the Cleveland Clinic Incontinence
Score [14]. Exclusion criteria were patients with symptoms
or treatment for any anorectal diseases (e.g., hemorrhoids),
previous anorectal trauma or surgery, or a previous diag-
nosis of a neuropathy or anal sphincter dysfunction.
Patients were assessed without using any bowel
preparation.
Ethical approval was obtained from the Ethics Review
Committee of the Faculty of Medicine, University of
Colombo, Sri Lanka, and informed written consent was
obtained accordingly.
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Dig Dis Sci
3DARM Equipment and Protocol
3DARM was performed with the patient in the left lateral
position. We used the ManoScan AR system by Given
Imaging (Yoqneam, Israel). The manometry probe is
10 cm in length and 10.75 mm in diameter. There are 256
transducers in the pressure-sensitive part of probe, which
is 64 mm in length and arranged in 16 rows with each
row having 16 circumferentially arranged sensors. The
linear spacing between transducers is 4 mm and circum-
ferential spacing is 2 mm. There is 1 balloon at the tip
which is inflated through the central lumen. The probe is
attached to the amplifier and recording system, and the
pressure plots are displayed in the proprietary software
(ManoView AR, Given Imaging, Yoqneam, Israel). The
recording frequency is 20 Hz, scan rate 10 Hz, and output
resolution 0.1 mmHg. [12, 15]. The software linearly
interpolates the spaces between the sensors to form a
continuous grid.
The probe was inserted into the anal canal after lubri-
cating and positioned to place the high-pressure zone
(HPZ) in the middle of the pressure-sensitive part and the
orientation marker at 6 o’clock. The orientation of the
probe in relation to the anterior midline, posterior midline,
left lateral, and right lateral orientation was maintained
throughout the procedure with the aid of the orientation
marker. HPZ is defined as the length of the anal canal with
a resting pressure (RP) at least 30 % higher than rectal
pressure [16]. After allowing the anal canal pressures to
stabilize, RP (one measurement lasting 20 s) and squeeze
pressure (SP) (three attempts for a duration of 20 s each)
were assessed. The rectoanal inhibitory reflex (RAIR) and
rectal sensation were simultaneously evaluated by dis-
tending the rectal balloon in 10-ml increments up to 200 ml
or to maximum tolerated volume. Threshold volumes for
first sensation, urgency, and maximum discomfort were
also recorded. Atmospheric pressure was the reference
point for all values.
Analysis for Asymmetry
The pressure plots were analyzed to identify asymmetry by
visual observation as well as comparing pressure values.
Measurements were taken at 4 levels of the HPZ—upper
border, middle, lower border, and level of peak pressure.
We used the pressure plot shown in Fig. 2c and set the
horizontal line at the desired level (shown at 1.4-cm level
in the diagram), and pressures values were obtained at 45,
90, and 135 and compared with values at 315, 270, and
225, respectively.
Dig Dis Sci
Statistical Analysis
The data were recorded and analyzed using SPSS version
20 (IBM Corp. Released 2011. IBM SPSS Statistics for
Windows, version 20.0. Armonk, NY: IBM Corp.).
All continuous data are described with the mean and
standard deviation. Correlations were identified using
Pearson correlation coefficient (Pearson q). The statistical
significance was set at p \ 0.05.
Results
Participants
There were 101 primigravida who underwent both
3DEAUS and 3DARM. The mean age was 24.7 (SD 5.1)
years. The mean height was 153.9 (SD 5.7) cm, and the
mean weight at the time of assessment was 59.4 (SD 10.3)
kg.
All patients had a normal Cleveland Clinic Incontinence
Score, and all participants tolerated the procedure well.
3DARM Values and Correlations
The mean RP was 87.02 (SD 18.43) mmHg, and the
maximum SP was 179.21 (SD 52.96) mmHg. The mean
length of the HPZ was 3.67 (SD 0.52) cm. Mean volumes
for initial rectal sensation, urge, and discomfort were
50.36 ± 25.57, 76.70 ± 35.17, and 143.40 ± 66.26 ml,
respectively.
The pressure asymmetry was highest in the lower anal
sphincter where the difference between the values which
were expressed as a proportion of the highest value was
approximately 40 % for RP and 50 % for SP. The asym-
metry was lowest in the mid-sphincter where the same
proportions were approximately 4 % for RP and 10 % for
SP.
The upper end of the HPZ extends more cranially in the
posterior midline with gradual tapering on either side,
giving the appearance of a truncated cylinder.
At the caudal end, the HPZ extends further inferiorly in
the anterior midline than the posterior midline, and at 3 and
6 o’clock positions more than anterior midline. During
squeeze, the length of HPZ increased in 78 participants. In
three participants, it remained the same and in 20, it
reduced.
There was a statistically significant inverse relationship
between the length of the HPZ and the mean RP (Pearson q
-0.23, p = 0.01). There also were statistically significant
correlations between length of HPZ and the height (Pear-
son q 0.22, p = 0.028) and weight (Pearson q 0.25,
p = 0.012).
There were no statistically significant correlations
between age, height, or weight with RP, SP, or ballon fill
volumes for first sensation, urgency, and maximum dis-
comfort on linear regression analysis.
3DARM Pressure Profiles
The software displays the pressures in two main windows.
The timeline window (Fig. 1) is a scrollable chronological
representation of the entire assessment. A subwindow
(Fig. 2) displays the complete set of data at the selected
point of time. This includes the pressure circles, a 3D
representation in the form of a cylinder, and a 2D repre-
sentation where the cylinder has been split at 12 o’clock
and laid open. The cylinder can show higher pressure as
either a decrease or an increase in the radius, and in our
laboratory, we prefer the latter (and has been used in
describing the appearances below).
The characteristic appearance of the normal RP in the
pressure cylinder is a spindle, with the lateral length longer
than anterior or posterior (Fig. 3). The 2D appearance is of
an inverted ‘‘V.’’ The SP appears like a lambda (k) in both
the 3D and 2D displays (Fig. 4).
Discussion
Assessment of the structure and function of the ASC is
essential in the evaluation of patients with a spectrum of
complaints ranging from constipation to anal incontinence.
In their review, the American Gastroenterological Associ-
ation has clearly identified the usefulness of ARM in the
evaluation of anorectal symptoms and disorders [17]. To
identify abnormalities, the normal ranges for the parame-
ters must first be identified. The available data at present
are for either water-perfused manometry [18–23] or high-
resolution (non-3D) manometry [13, 24]. The values are
considerably heterogeneous, which vary with age, gender,
height, and ethnicity. In addition, when using water-per-
fused manometry, the values also differ depending on the
technique of measurement [17, 25]. Rao et al. [25] there-
fore recommend that individual laboratories either consult
published data or establish their own normative data for
manometry values. We selected to perform the procedure
in the left lateral position because this is the position that
we and several other authors routinely use.
In summary, our results indicate that in Asian primi-
gravida, (1) normal morphology of the pressure plots
(dumbbell shaped during RP and sandy clock shaped at SP)
can be clearly visualized, (2) RP, SP, and HPZ length are
comparable but higher than the values for other Asian
females [12] but similar to those for Caucasian females
aged \50 years [13], and (3) there is circumferential and
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 Dig Dis Sci

Fig. 1 Main window of the ManoScan software, showing the timeline view. The following can be visualized. A Resting pressure recording. B A
short contraction to see patient understanding of the instructions. C, D Squeeze pressure recordings

Fig. 2 Subwindow of the

ManoScan software, showing
the timeline view. The
following can be visualized.
A Pressure circle. B 3D pressure
profile. C Cylinder of
(B) opened and unwrapped at 12
o’clock

axial asymmetry, highest in the LSL and lowest in the
MSL.
Age has been found to be inversely correlated with RP
[26], SP, or both [12, 19, 27, 28] by several authors. The
lack of correlation between age and manometry parameters
in our study is most likely to be due to the young age and
narrow age range in our participants. Since our inclusion
criterion was being primigravida, we feel this could not be
overcome. It is also possible that our sample size was not
large enough to detect any small but a significant correla-
tion. The samples in the above study had a wide range of
ages. The data published by the Central Intelligence

123
Dig Dis Sci
Fig. 3 Characteristic
appearance of the normal
resting pressure in the 3D
pressure profile is a spindle (A).
The 2D appearance is of an
inverted ‘‘V’’ (B)
Fig. 4 Squeeze pressure
appears like a lambda (k) in
both the 3D and 2D displays
Agency [29] also report a similar age at first child birth in
Sri Lanka.
Our 3DARM findings, however, did show a statistically
significant correlation between the length of the HPZ, and
height and weight.
The extension of the HPZ more inferiorly in the anterior
midline and more superiorly in the posterior midline has
been documented before [30]. Our findings also indicate
that the HPZ extends even more inferiorly on either side
and is likely to be due to the subcutaneous part of the EAS.
The anterior–posterior asymmetry is most likely due to the
3-sling pattern of muscle fibers of the ASC, where they fall
at an angle to the axis of the anal canal. The same authors
have also described the increase in the length of HPZ with
squeeze. However, in almost 20 % of our participants,
there was a decrease in the length of HPZ. It is possible that
this is a subgroup where the ASC condenses axially when it
contracts.
The participants of our study were all Sri Lankan
primigravida. Direct extrapolation of these values to Cau-
casians, males, or non-pregnant females may therefore
raise concerns. Nevertheless, this is the first study to
describe 3DARM and 3DEAUS in pregnant women or
nullipara. Previous studies have included either non-preg-
nant females only [13, 24], nulliparous females [30, 31], or
postpartum females [12, 32]. Therefore, we believe that our
data would be useful for clinical and research centers in the
Asian region in their patient assessment.
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It is interesting that all measured parameters in our study
resemble values published in the West than in Asia. The
most likely explanation is that Sri Lankans (and South
Asians) are Caucasoid, whereas citizens of the countries
where previous articles originated [12, 32] are mongoloid
[33]. Therefore, until reference values for pregnant mothers
in the West are established, we feel that our values can be
used by laboratories in the West also.
Conclusions
The study has provided 3DARM values for primigravida
which can be used as reference values for future studies.
The values resemble values reported in the West than in
Asia. There were no statistically significant correlations
between age, height, or weight with RP, SP, or ballon fill
volumes. There were statistically significant relationships
between the LHPZ and RP, height and weight. The normal
pressure morphology described by previous authors is also
well visualized in primigravida. We recommend the ref-
erence ranges for primigravida be established, for different
races, equipment, and methods.
Key Messages
• The normal pressure morphology described by previous
authors is well visualized in primigravida.
• This study provides a reference range of 3DARM
values for primigravida.
• Manometry values of Sri Lankan females correlate
better with values reported in the West than in Asia.
• The LHPZ and RP correlated well with height and
weight, but there were no statistically significant
correlations between anthropometric parameters with
RP, SP, or ballon fill volumes.
• We recommend the reference ranges for primigravida
be established at each laboratory.
Acknowledgments This study was supported by a Research Grant
and an Infrastructure Development Grant from the University of
Colombo. We thank Dr. S. Senaratne for his efforts in coordinating
the evaluation of the participants.
Compliance with Ethical Standards
Conflict of interest None of the authors have financial or other
competing interests.
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