Aim: Assessment of: 1. Functional patterns in patients with refractory idiopathic constipation and its impact on treatment strategies. 2. Role of anorectal myectomy in outlet obstruction. 
Methods: Forty patients with refractory constipation were subjected to full clinical assessment, perineometry, standard 
proctography, measurement of the anorectal angle, assessment of colon motility, colon transit time, and anal manometry, assessment of rectal sensation, recto anal inhibitory reflex, electromyography, and rectal biopsy. Anorectal myectomy was performed as a therapeutic and diagnostic procedure. 
Results: Patients with normal CTT included 56.25% of children and 43.75% of adults. A significant difference was present in perineal descent between patients with delayed CTT and the control group. After anorectal myectomy, there was an overall significant fall in maximum resting anal pressure. The RAIR was present in 66.67% after anorectal myectomy. Rectal biopsy and histopathological examination revealed aganglionosis and diagnosis of ultrashort-segment Hirschsprung's disease in 31.25% with normal CTT and 16.7% with delayed CTT. 75% of patients with delayed CTT and without aganglionosis were initially improved by anorectal myectomy. Patients with ultrashort-segment were cured after anorectal myectomy. 
Conclusions: Anorectal myectomy is successful in outlet obstruction constipation and is perfect in detection and cure of 
ultrashort-segment Hirschsprung's disease presenting as refractory constipation.