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CLINCIAL TIPS? Which is more important, manometry or electromyography? (Part 2) Submitted by: David M. McGee, DPT, PhD, BCB PMD Ohio Valley Colon Rectal Surgery ? When EMG is the Gold Standard ? A very common problem encounter in pelvic floor dysfunction is constipation caused by some sort of outlet obstruction. Outlet obstructions come in many different forms. The two most popular functional examples are paradoxical sphincter activity during straining and collapse of anal sphincter complex from increased pelvic excursion during straining caused by severely weakened pelvic muscles. These are both very common problems and both produce an increase in anal pressures but have opposite causes and opposite treatments. Therefore an elevation of pressures in the anal canal above resting levels during straining maneuver can mean different things. So how do we tell them apart clinically? The answer, as you will see, is we compare EMG activity to manometry pressures. An outlet obstruction caused by a paradoxical sphincter contraction will demonstrate the active contraction on EMG. An outlet obstruction from pelvic collapse is a passive process and will not demonstrate nervous system activity. Examples of both follow: ? Patient #1. Complaint: constipation; Manometry Data ? ? ?? ? Note how average pressures in the anal canal increased while patient was straining. The thought is that this increase must come from a paradoxical sphincter contraction. But that is not the case as we look at EMG evaluation of the patient from the same day. (see below) ? Patient #1 EMG:? ? ? Again, note there is NO increase in sphincter activity during straining maneuver on EMG, yet the patient demonstrated an increase in intra anal pressures from that of resting when straining. Therefore, since there is no increase in sphincter motor activity during straining maneuver this cannot be a paradoxical sphincter contraction. A contraction is indicated by an active process.???? ? Patient #2: Complaint - con