936 examination by an experienced investigator is just as valuable as anorectal manometry [25] and therefore anorectal manom- etry for this indication is not necessary. Furthermore, we found in patients with atrophy a lower anal pressure, which con- forms with other studies [26, 27]. Does anal manometry have a predictive value with regard to the outcome of sphincter repair or other surgical modal- ities? The present study showed that anorectal manometry and anal endosonography findings do not correlate well with FI scores. We found a weak correlation between the Vaizey score and the MBP and the Vaizey score and MSP in patients with soft stools. In other recent studies, there was no correlation between the severity of FI and anorectal manometry results observed [28–30]. These findings again underscore the multi-factorial etiology of FI. Since there is no correlation with the severity of FI, little or no predictive value of anorectal manometry in the efficacy of the treat- ment for FI can be expected [29, 31]. An algorithm for the treatment of FI is given in Fig. 1. Assessment should begin with a thorough clinical work-up. A detailed medical history and clinical examination with a rectal examination are mandatory. In general, the etiology of FI becomes obvious. Patients with diarrhea or proctitis need further evaluation and targeted treatment. Following this, conservative measures (fibres, physiotherapy) should be applied. In the event of treatment failure, the patient should undergo anal endosonography to demonstrate or exclude a large sphincter defect. In cases of doubt, notwithstanding, patients who are eligible for surgical repair should be eval- uated by anorectal manometry, which allows an objective measurement of anal pressures, relaxation of the pelvic floor and RC. Patients who are motivated for other treatments such as SNS, gracilis plasty or artificial bowel sphincter creation, also need be fully evaluated pre-operatively [8, 9, 32, 33]. When all therapies fail, colostomy can be an option. In conclusion, the present study confirms the impor- tance of anal endosonography in revealing anal sphincter defects and consequently in selecting patients for surgical repair. Although anorectal manometry can provide addi- tional information, it should not be performed routinely in every patient who has failed conservative treatment for FI. Anorectal manometry should be performed in patients selected for surgical intervention to exclude functional abnormalities like dyssynergic floor or IBS with a small RC. In the current adverse economic climate where healthcare budgets are constrained, it is important to re- serve the use of tools such as anorectal manometry for those who may benefit from it. 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