Introduction Functional gastrointestinal disorders (FGID) including impaired rectal evacuation are common in patients with Hypermobility Spectrum Disorder (HSD) or Hypermobile Ehlers-Danlos Syndrome (hEDS). The effect of connective tissue pathologies on pelvic floor function in HSD/hEDS remains unclear. We aimed to compare clinical characteristics and anorectal pressure profile in patients with HSD/hEDS to those of age and sex matched controls. Methods We conducted a retrospective review of all FGID patients who underwent high resolution anorectal manometry (HR-ARM) and balloon expulsion test (BET) for evaluation of impaired rectal evacuation. Patients with HSD/hEDS were age and sex matched to a randomly selected cohort of control patients without HSD/hEDS. An abnormal BET was defined as the inability to expel a rectal balloon within 2 minutes. Wilcoxon rank sum test and Fisher’s exact test were used to make comparisons and logistic regression model for predictive factors for abnormal evacuation. Results A total of 144 patients (72 with HSD/hEDS and 72 controls) were analyzed. HSD/hEDS patients were more likely to be Caucasian (p < 0.001) and nulliparous. Concurrent psychiatric disorders; depression, and anxiety (p < 0.05), and somatic syndromes; fibromyalgia, migraine and sleep disorders (p < 0.001) were more common in these patients. Rate of abnormal BET were comparable among the groups. HDS/hEDS patients had significantly less anal relaxation and higher residual anal pressures during simulated defecation, resulting in significantly more negative rectoanal pressure gradient. The remaining anorectal pressure profile and sensory levels were comparable between the groups. While diminished rectoanal pressure gradient was the determinant of abnormal balloon evacuation in non HSD/hEDS patients, increased anal resting tone and maximum volume tolerated were independent factors associated with an abnormal BET in HSD/hEDS patients. Review of defecography data from a subset of patients showed no significant differences in structural pathologies between HSD/hEDS and non HSD/hEDS patients. Conclusions These results suggest anorectal pressure profile is not compromised by connective tissue pathologies in HSD patients. Whether concurrent psychosomatic disorders or musculoskeletal involvement impact the pelvic floor function in these patients needs further investigation.

Table 1. Baseline characteristics of patients with celiac disease Celiac Disease With Alzheimer's Disease (n [%]) Without Alzheimer's Disease (n [%]) Multivariate Analysis (aOR [95% CI]) Total 970 87800 5.38 (5.30-5.45) Risk factor Alcohol use 40 (4.1) 2900 (3.3) 1.01 (1.00-1.02) Obesity 180 (18.6) 30510 (34.7) 0.53 (0.53-0.53) Diabetes mellitus 390 (40.2) 29430 (33.5) 1.77 (1.77-1.78) Hypertension 810 (83.5) 38880 (44.3) 8.25 (8.21-8.28) Smoker 290 (29.9) 10460 (11.9) 1.12 (1.11-1.13) Caucasian 890 (91.7) 71120 (81.0) 1.31 (1.31-1.32) Senior (Age .65) 890 (91.7) 33050 (37.6) 4.18 (4.17-4.20) S1553

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Table 1. (continued) Variable All (n536) Female (n519) Male (n517) p-value Disorders of rectal sensation (Minor findings) Rectal Hyposensitivity 12 (33) 7 (37) 5 (29) 0.73 Rectal Hypersensitivity 3 (8) 2 (10) 1 (6) 1

Introduction Gastrointestinal dysfunction, particularly constipation, is among the most common non‐motor manifestations in Parkinson's Disease (PD). We aimed to identify high‐resolution anorectal manometry (HR‐ARM) abnormalities in patients with PD using the London Classification. Methods We conducted a retrospective review of all PD patients at our institution who underwent HR‐ARM and balloon expulsion test (BET) for evaluation of constipation between 2015 and 2021. Using age and sex‐specific normal values, HR‐ARM recordings were re‐analyzed and abnormalities were reported using the London Classification. A combination of Wilcoxon rank sum and Fisher's exact test were used. Results 36 patients (19 women) with median age 71 (interquartile range [IQR]: 69–74) years, were included. Using the London Classification, 7 (19%) patients had anal hypotension, 17 (47%) had anal hypocontractility, and 3 women had combined hypotension and hypocontractility. Anal hypocontractility was significantly more common in women compared to men. Abnormal BET and dyssynergia were noted in 22 (61%) patients, while abnormal BET and poor propulsion were only seen in 2 (5%). Men had significantly more paradoxical anal contraction and higher residual anal pressures during simulated defecation, resulting in more negative recto‐anal pressure gradients. Rectal hyposensitivity was seen in nearly one third of PD patients and comparable among men and women. Conclusion Our data affirms the high prevalence of anorectal disorders in PD. Using the London Classification, abnormal expulsion and dyssynergia and anal hypocontractility were the most common findings in PD. Whether the high prevalence of anal hypocontractility in females is directly related to PD or other confounding factors will require further research.