Topographic and manometric characterization of the recto-anal inhibitory reflex

Background: Recto-anal inhibitory reflex (RAIR) is an integral part of normal defecation. The physiologic characteristics of RAIR along anal length and anterior-posterior axis are unknown. The aim of this study was to perform topographic and vector-graphic evaluation of RAIR along anal canal using high definition manometry (HDM), and examine the role of various muscle components. Methods: Anorectal topography was assessed in 10 healthy volunteers using HDM probe with 256 sensors. Recto-anal inhibitory reflex data were analyzed every mm along the length of anal canal for topographic, baseline, residual, and plateau pressures during five mean volumes of balloon inflation (15cc, 40cc, 71cc, 101cc, 177cc), and in 3D by dividing anal canal into 4×2.1mm grids. Key Results: Relaxation pressure progressively increases along anal canal with increasing balloon volume up to 71cc and thereafter plateaus. In 3D, RAIR is maximally seen at the middle and upper portions of anal canal (levels 1.2-3.2cm) and posteriorly. Peak residual pressure was seen at proximal anal canal. Conclusions & Inferences: Recto-anal inhibitory reflex is characterized by differential anal relaxation along anterior-posterior axis, longitudinally along the length of anal canal, and it depends on the rectal distention volume. It is maximally seen at internal anal sphincter pressure zone. Multidimensional analyses indicate that external anal sphincter provides bulk of anal residual pressure. Our findings emphasize importance of sensor location and orientation; as anterior and more distal location may miss RAIR.