Rome V Anorectal Disorders: Gastroenterology | May 2026

The Rome V Anorectal Disorders chapter introduces several important revisions that substantially modernize the diagnostic and therapeutic approach to anorectal disorders within the disorders of gut–brain interaction (DGBI) framework. The chapter integrates symptom-based diagnosis with objective physiology, updates terminology, refines diagnostic thresholds, and more clearly defines the role of anorectal testing and neuromodulation in routine practice.

1. “Functional” Has Been Removed From Anorectal Disorders Terminology

One of the most important Rome V conceptual changes is the removal of the term “functional” from anorectal disorders, consistent with the broader Rome V framework.

This change applies across the anorectal disorders chapter:

functional anorectal disorders → anorectal disorders

functional defecation disorder → dyssynergic defecation

functional anorectal pain → anorectal pain disorders

This is more than semantic. It reflects the modern recognition that these disorders have measurable pathophysiology involving:

sensorimotor dysfunction,

pelvic floor discoordination,

visceral sensory dysfunction,

and gut–brain dysregulation.

2. Rome V Reclassifies Anorectal Disorders Into 4 Major Categories

Rome V organizes anorectal disorders into 4 major categories:

Fecal incontinence (FI)

Anorectal pain disorders

Dyssynergic defecation (DD)

Anorectal sensory dysfunction disorders

This classification is more clinically coherent and better aligned with anorectal physiology and test-based phenotyping than prior Rome versions.

3. Fecal Incontinence Criteria Have Been Refined and Tightened

Rome V substantially revises the diagnostic framework for fecal incontinence (FI).

FI is now defined as:

two or more episodes of uncontrolled passage of fecal material,

with ≥1 episode/month documented on a 4-week stool diary,

for the last 3 months,

with symptom onset ≥6 months before diagnosis.

This is an important refinement because prior definitions used the term “recurrent,” which was vague and poorly standardized. Rome V replaces this with a measurable frequency threshold to improve:

clinical consistency,

epidemiologic precision,

and trial enrollment standardization.

4. Stool Diary Documentation Is Now Built Into FI Diagnosis

One of the most practical updates is that Rome V explicitly incorporates a 4-week stool diary into the diagnostic criteria for FI.

This is clinically important because stool diaries:

reduce recall bias,

improve symptom quantification,

improve phenotyping,

and align diagnosis with trial methodology.

Rome V moves FI toward a more objective symptom-documentation model.

5. Fecal Incontinence Is Explicitly Recognized as a Heterogeneous Disorder

Rome V emphasizes that FI is heterogeneous and multifactorial, rather than simply a sphincter disorder.

The chapter highlights multiple contributing mechanisms:

internal anal sphincter weakness,

external anal sphincter dysfunction,

puborectalis dysfunction,

rectal hyposensitivity,

rectal hypersensitivity,

impaired rectal compliance,

neuropathy,

impaired rectosigmoid brake,

and psychological comorbidity.

This is a major conceptual advance because it shifts FI from a purely structural disorder to a multidimensional neurogastroenterologic disorder.

6. Rome V Strengthens the Role of Objective Physiology in FI

Rome V gives stronger emphasis to physiology-guided evaluation in FI.

Key tests include:

anorectal manometry (ARM),

anal ultrasound (AUS),

MRI,

defecography,

and neurophysiology testing.

The evidence summary table on pages 4–5 (Table 2) is one of the most clinically useful additions because it grades diagnostic utility and clarifies which tests are useful versus overused.

Most important takeaways:

ARM = high clinical utility (A1)

AUS = useful for structural sphincter injury

PNTML = rarely useful clinically

translumbosacral anorectal magnetic stimulation = emerging neurophysiology tool.

7. PNTML Is De-emphasized; Modern Neurophysiology Is Favored

Rome V de-emphasizes pudendal nerve terminal motor latency (PNTML) because of:

methodological limitations,

low sensitivity,

and interobserver variability.

This is a meaningful de-escalation.

Instead, Rome V highlights translumbosacral anorectal magnetic stimulation as a more promising neurophysiologic tool for detecting lumbosacral neuropathy in:

fecal incontinence,

levator ani syndrome,

spinal cord injury,

and mixed anorectal dysfunction.

8. Biofeedback Is Strongly Reinforced as First-Line Therapy in FI

Rome V gives stronger and more explicit support to biofeedback therapy (BT) for fecal incontinence.

This is one of the most important practical messages in the chapter.

Biofeedback is recommended because it:

improves anal squeeze strength,

improves squeeze duration,

improves rectal sensory discrimination,

corrects dyssynergia when present,

and improves quality of life.

The RCT summary on pages 8–14 (Table 3) is highly practice-relevant and shows consistent efficacy of biofeedback across multiple controlled trials.

9. Home Biofeedback Is Now Validated

A highly practical Rome V update is formal recognition that home biofeedback is non-inferior to office biofeedback in selected patients.

This is a major translational advance because it improves:

accessibility,

scalability,

adherence,

and real-world delivery of pelvic floor rehabilitation.

This is one of the most clinically implementable Rome V updates.

10. Neuromodulation Is Upgraded in FI Management

Rome V substantially expands the role of neuromodulation in FI management.

Major updates:

Sacral nerve stimulation (SNS) remains an important option in refractory FI

Percutaneous tibial nerve stimulation has weak evidence

Translumbosacral neuromodulation therapy (TNT) emerges as a promising newer therapy with sham-controlled supportive data.

The therapeutic schematic on page 7 (Figure 1) is especially useful because it visually summarizes current and emerging neuromodulation strategies.

11. Levator Ani Syndrome Is Better Defined and Mechanistically Reframed

Rome V improves the diagnostic clarity of levator ani syndrome (LAS).

LAS is now defined by:

chronic/recurrent anorectal pain,

episodes lasting ≥30 minutes,

puborectalis tenderness,

and exclusion of structural causes.

Rome V removes older restrictive descriptors (such as posterior traction emphasis) and broadens tenderness assessment to reflect more accurate examination findings.

Mechanistically, LAS is reframed as involving:

pelvic floor hypertonicity,

dyssynergia,

and lumbosacral neuropathy,

rather than being considered merely idiopathic pain.

12. Biofeedback Is Now the Preferred Therapy for Levator Ani Syndrome

One of the most clinically important updates in anorectal pain is that biofeedback is now the preferred evidence-based therapy for levator ani syndrome, especially when levator tenderness is present.

This is one of the clearest Rome V therapeutic upgrades.

In the cited RCT:

87% improved with biofeedback,

versus 45% with electrical stimulation,

and 22% with massage.

This makes biofeedback the strongest supported intervention for LAS.

13. Proctalgia Fugax Criteria Are Refined but Management Remains Conservative

Rome V retains proctalgia fugax with clearer criteria:

sudden severe anorectal pain,

lasting seconds to minutes,

complete resolution between episodes,

unrelated to defecation.

Management remains conservative:

reassurance is first-line,

inhaled salbutamol may help severe prolonged attacks,

but evidence remains limited.

14. Dyssynergic Defecation Is One of the Most Important Rome V Revisions

The Rome V revision of dyssynergic defecation (DD) is one of the most clinically important updates in the chapter.

Rome V makes several major changes:

removes “functional”

broadens symptom entry criteria

removes EMG from core diagnostic requirements

simplifies physiologic confirmation

eliminates older subtype complexity.

This is a major simplification with direct clinical relevance.

15. Rome V Lowers the Threshold for Diagnosing DD

This is one of the most practice-changing updates.

Rome V now allows diagnosis of DD when:

the patient has symptoms of difficult evacuation,

and one abnormal physiologic test is present.

Previously, Rome IV required ≥2 abnormal tests.

Rome V now classifies:

probable DD = 1 abnormal test

definite DD = ≥2 abnormal tests.

This is a major practical simplification that reduces diagnostic friction and unnecessary testing.

16. Rome V Prioritizes ARM and BET as Core Tests for DD

Rome V clarifies that the most useful core tests for DD are:

anorectal manometry (ARM)

balloon expulsion test (BET)

These are now the central diagnostic tests for routine evaluation.

Defecography is repositioned as:

supportive,

adjunctive,

and mainly useful when ARM/BET are inconclusive.

This is one of the most practical diagnostic updates in the chapter.

17. Biofeedback Remains the Gold Standard for Dyssynergic Defecation

Rome V strongly reinforces that biofeedback is the most effective treatment for DD.

This remains one of the strongest evidence-based interventions in all DGBI.

Across multiple RCTs, biofeedback consistently outperformed:

laxatives,

diazepam,

sham therapy,

counseling,

and standard care.

This remains one of the strongest therapeutic recommendations in Rome V.

18. Rome V Formally Defines Anorectal Sensory Disorders

Rome V now gives clearer diagnostic identity to anorectal sensory dysfunction disorders:

rectal hyposensitivity

rectal hypersensitivity

This is an important conceptual advance because these disorders are now formally recognized as distinct sensorimotor phenotypes rather than secondary physiologic observations.

Clinical Bottom Line

The Rome V Anorectal Disorders chapter modernizes anorectal DGBI by integrating symptom-based diagnosis with objective physiology, simplified testing pathways, and mechanism-based therapy.

The most practice-changing updates are:

“functional” terminology removed

anorectal disorders reorganized into 4 physiologic categories

FI criteria now standardized with stool diary incorporation

FI recognized as a heterogeneous sensorimotor disorder

PNTML is de-emphasized

biofeedback is strengthened as first-line therapy in FI, LAS, and DD

home biofeedback is validated

TNT emerges as a promising neuromodulation strategy

DD diagnosis is simplified (1 abnormal test = probable DD)

ARM + BET are now the core tests for DD

anorectal sensory disorders are formally recognized as distinct diagnostic entities.