The diagnosis of NRPS is confirmed with a combination of anorectal manometry, electromyography (EMG), and cinedefecography. Cinedefecographic findings that suggest NRPS include obstructed defecation, a long and persistently closed anal canal, and the presence of a rectocele. Elec-tromyography studies can confirm persistent contraction during defecation and straining. The balloon expulsion test is another modality that can be used. This simple and inexpensive test has shown high reliability in diagnosing pelvic outlet obstruction resulting from nonrelaxation of the puborectalis muscle.1 However, these diagnostics should be interpreted with caution. In a prospective study,we found the sensitivity and specificity of EMG and cinedefecography to be suboptimal if applied individually to diagnose anismus.2 Others argue that paradoxical contraction of the puborec-talis muscle on EMG analysis is not a specific finding, being found in patients with solitary ulcer syndrome and idio-pathic perineal pain.3 Therefore,the diagnosis of NRPS must be made based on the patient's clinical findings, supported by more than one physiologic investigation.

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