Abstract

Anal dilatation in response to gentle parting of the buttocks has been advocated as a sign of sexual abuse in children, but nothing is known of the physiology of this response or its existence in normal subjects, in patients with spinal disease, and in patients with a weak sphincter and whether it can be elicited after training. To answer these questions we investigated the effect of parting the buttocks on anal function. Combined anal manometry and electromyography was conducted in six normal subjects (five men, one woman, aged 19-53 years), in 18 patients with faecal incontinence (three men, 15 women, aged 30-80 years), and in seven paraplegic patients (six men, one woman, aged 25-36 years), in four of whom the posterior sacral roots had been cut. Parting the buttocks in normal subjects reduced the pressure in the anal canal from 102 (20) to 14 (3) cm H2O (mean (SEM), p less than 0.00001), but did not cause the anus to gape. This drop in pressure was associated with increased electrical activity in the external anal sphincter. Normal subjects could consciously relax the external anal sphincter and reduce the anal pressure but not so as to result in anal gaping during traction on the buttocks, even after anal dilatation. Stimulation of the anal lining by moving a probe in and out of the anal canal increased the activity of the external anal sphincter, raising anal pressures. Paraplegic patients who had lost conscious control of their external sphincters showed anal gaping when the buttocks were parted. A similar phenomenon was seen in patients with faecal incontinence who had weakness of the external anal sphincter, while incontinent patients with weakness of both sphincters showed anal gaping even at rest. Inasmuch as the results of our study can be applied to children, the data suggest that reflex anal dilatation should only be used to support a diagnosis of sexual abuse if sphincter function is otherwise normal and there is no evidence of cerebrospinal disease. Although our results do not support the notion that children could become so conditioned to repeated digital or penile penetration of the anus that they can cause the anus to gape when the buttocks are parted, neither do they exclude it.