We read the case report of Malouf and Kamm Gut ; 48 —9 with interest. However, we disagree with some of the science and suggest an alternative explanation for their findings. Firstly, there is much data to suggest that sympathetic innervation of the internal anal sphincter is in fact excitatory.
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The anal winkanal reflexperineal reflexor anocutaneous reflex is the reflexive contraction of the external anal sphincter upon stroking of the skin around the anus. A noxious or tactile stimulus will cause a wink contraction of the anal sphincter muscles and also flexion; the stimulus is detected by the nociceptors in the perineal skin to the pudendal nervewhere a response is integrated by the spinal cord sacral segments S2-S4. The absence of this reflex indicates that there is an interruption of the reflex arcor damage to the spinal cord,  which may be in the sensory afferent limb or the motor efferent limb ; the synapse between the afferent and efferent limbs occurs in the lowest sacral segments of the spinal cord.
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NCBI Bookshelf. Boston: Butterworths; A wag once remarked, with considerable truth, that a consultant is a doctor who makes a rectal examination.
A visible puckering at the margin of the external anal sphincter, evoked by stroking the perianal skin with a pin; absence of an anal wink reflex suggests a defect in either sensory or motor nerves or in the central pathways that mediate this reflex anal wink Contraction of the anal sphincter in response to pinprick stimulus of the perineum. This reflex is evidence of normal motor function at S4—S5. It is also known as the anal or anocutaneous reflex.
The anal winkanal reflexperineal reflexor anocutaneous reflex is the reflex ive contraction of the external anal sphincter upon stroking of the skin around the anus. A noxious or tactile stimulus will cause a wink contraction of the anal sphincter muscle s and also flexion. The stimulus is detected by the nociceptor s in the perineal skin to the pudendal nervewhere a response is integrated by the spinal cord sacral segment s S1-S3.
Appendix: Medication Information Abdominal pain Bowel and bladder dysfunction. The Rome IV criteria is a useful diagnostic tool for the diagnosis of functional constipation. Cow milk allergy Coeliac disease Hypercalcaemia Hypothyroidism. History of retentive posturing or excessive volitional stool retention i.