Problem Investigated: A multitude of benign disorders affect the anorectal complex often resulting in significant morbidity. For many of these conditions the pathophysiology and clinical management continue to be debated. This is particularly so for anal fissures, anal incontinence and pelvic floor dysfunction. Procedures Followed: A series of clinical trials was performed. Anal Fissure: Two current management regimes for chronic anal fissure, Glyceryl Trinitrate and Botulinum Toxin, were prospectively assessed for manometric and clinical outcome. A new treatment regime, inducible nitric oxide, was prospectively assessed in an animal model and a new manometric observation in anal fissure patients, the Fast Wave, was validated. Anal Incontinence: The magnitude of the problem and the relative role of several previously identified risk factors was assessed from a manometric data-base. The impact of a standard treatment for Crohn???s disease, the seton, on anal continence was assessed via a retrospective cohort study. The long-term outcome of dynamic graciloplasty and re-do anal sphincter repair, two previously accepted treatments for anal incontinence, were also assessed retrospectively. A new intervention for treating anal incontinence, the magnetic ???Chair???, was prospectively trialed in incontinent patients. Pelvic Floor Dysfunction: A new treatment option for rectocoele, the laparoscopic repair, was compared with an accepted treatment option, the transanal repair via a matched cohort study. A further group of patients with multiple symptoms of pelvic floor dysfunction undergoing the same laparoscopic technique were then prospectively assessed for functional outcome across the pelvic floor compartments. General Results: Anal Fissure; The manometric effects of both glyceryl trinitrate and botulinum toxin, demonstrated in this thesis would imply that their mode of impact on the anal sphincter is other than that of anal pressure reduction. Fissure healing is dependent upon the pre-treatment anal resting pressure and fissure grade, not anal pressures following treatment. Inducible nitric oxide does not increase nitrate levels in the rat internal anal sphincter. A new manometric wave form in the hypertonic internal anal sphincter, the Fast Wave, has been validated. Faecal Incontinence; Faecal incontinence is multi-factorial. However, obstetric birth injuries are the most significant factor predisposing to faecal incontinence following age. Furthermore current government policies are failing to address the problem. The dynamic graciloplasty provides symptomatic long-term relief in only 16 percent of patients and results in significant co-morbidity in most patients. Re-do anal sphincter repair provides relief in 60 percent of patients without further side effects. The use of a seton in Crohn???s perianal disease prevents deterioration of patient continence. Extracorporeal magnetic stimulation, the Chair, may provide significant relief for patients with faecal incontinence. Pelvic Floor Dysfunction: The laparoscopic posterior compartment repair provides relief of bowel symptoms in 31 percent of patients. This does not compare favourably with the transanal long-term symptomatic improvement of 67 percent. The results of the laparoscopic pelvic floor repair in patients with multiple symptoms of pelvic floor dysfunction is disappointing, particularly for bowel and bladder symptom improvement. Major Conclusions: This thesis questions the accepted pathophysiology of anal fissure, highlights the long-term implications of obstetric childbirth injuries on faecal continence and raises concerns about current management strategies for faecal incontinence and pelvic floor dysfunction.

Problem Investigated: A multitude of benign disorders affect the anorectal complex often resulting in significant morbidity. For many of these conditions the pathophysiology and clinical management continue to be debated. This is particularly so for anal fissures, anal incontinence and pelvic floor dysfunction. Procedures Followed: A series of clinical trials was performed. Anal Fissure: Two current management regimes for chronic anal fissure, Glyceryl Trinitrate and Botulinum Toxin, were prospectively assessed for manometric and clinical outcome. A new treatment regime, inducible nitric oxide, was prospectively assessed in an animal model and a new manometric observation in anal fissure patients, the Fast Wave, was validated. Anal Incontinence: The magnitude of the problem and the relative role of several previously identified risk factors was assessed from a manometric data-base. The impact of a standard treatment for Crohn???s disease, the seton, on anal continence was assessed via a retrospective cohort study. The long-term outcome of dynamic graciloplasty and re-do anal sphincter repair, two previously accepted treatments for anal incontinence, were also assessed retrospectively. A new intervention for treating anal incontinence, the magnetic ???Chair???, was prospectively trialed in incontinent patients. Pelvic Floor Dysfunction: A new treatment option for rectocoele, the laparoscopic repair, was compared with an accepted treatment option, the transanal repair via a matched cohort study. A further group of patients with multiple symptoms of pelvic floor dysfunction undergoing the same laparoscopic technique were then prospectively assessed for functional outcome across the pelvic floor compartments. General Results: Anal Fissure; The manometric effects of both glyceryl trinitrate and botulinum toxin, demonstrated in this thesis would imply that their mode of impact on the anal sphincter is other than that of anal pressure reduction. Fissure healing is dependent upon the pre-treatment anal resting pressure and fissure grade, not anal pressures following treatment. Inducible nitric oxide does not increase nitrate levels in the rat internal anal sphincter. A new manometric wave form in the hypertonic internal anal sphincter, the Fast Wave, has been validated. Faecal Incontinence; Faecal incontinence is multi-factorial. However, obstetric birth injuries are the most significant factor predisposing to faecal incontinence following age. Furthermore current government policies are failing to address the problem. The dynamic graciloplasty provides symptomatic long-term relief in only 16 percent of patients and results in significant co-morbidity in most patients. Re-do anal sphincter repair provides relief in 60 percent of patients without further side effects. The use of a seton in Crohn???s perianal disease prevents deterioration of patient continence. Extracorporeal magnetic stimulation, the Chair, may provide significant relief for patients with faecal incontinence. Pelvic Floor Dysfunction: The laparoscopic posterior compartment repair provides relief of bowel symptoms in 31 percent of patients. This does not compare favourably with the transanal long-term symptomatic improvement of 67 percent. The results of the laparoscopic pelvic floor repair in patients with multiple symptoms of pelvic floor dysfunction is disappointing, particularly for bowel and bladder symptom improvement. Major Conclusions: This thesis questions the accepted pathophysiology of anal fissure, highlights the long-term implications of obstetric childbirth injuries on faecal continence and raises concerns about current management strategies for faecal incontinence and pelvic floor dysfunction.

Diss. (sammanfattning)--Linköping : Linköpings universitet, 2006. / Härtill 5 uppsatser.

BACKGROUND: Constipation is highly prevalent in older adults and may be associated with greater frequency of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We investigated the prevalence of lower defecation frequency (DF) and risk factors (including AECOPD) associated with lower DF among hospitalized elderly patients. METHODS: We conducted a retrospective case-control study in a community hospital of Southeast Ohio. Adults aged 65 years or older admitted during 2004 and 2006 were reviewed (N = 1288). Patients were excluded (N = 212) if their length of stay was less than 3 days, discharge diagnosis of Clostridium difficile-associated diarrhea, death or ventilator- dependent respiratory failure during hospitalization. Lower DF was defined as either an average DF of 0.33 or less per day or no defecation in the first three days of hospitalization; cases (N = 406) and controls (N = 670) were included for the final analysis. RESULTS: Approximately 38% had lower DF in this patient population. Fecal soiling/smearing of at least two episodes was documented in 7% of the patients. With the adjustment of confounders, AECOPD (adjusted odds ratio [AOR] =1.47, 95% confidence interval [CI] =1.01-2.13) and muscle relaxant use (AOR =2.94; 95% CI =1.29-6.69) were significantly associated with lower DF. Supplementation of potassium and antibiotic use prior to hospitalization was associated with lower risk of lower DF. CONCLUSIONS: Approximately 38% of hospitalized older adults had lower DF. AECOPD and use of muscle relaxant were significantly associated with lower DF; while supplementation of potassium and antibiotic use were protective for lower DF risk after adjusting for other variables.

Maior mamífero terrestre neotropical, a anta (Tapirus terrestris) possui hábitos solitários. É classificada como herbívora-frugívora, ingerindo grande quantidade de frutos com sementes de diversas espécies. Potencialmente, a anta é considerada um dispersor de sementes. Nesse trabalho, estudamos aspectos comportamentais da formação de latrinas por antas e sua efetividade na dispersão de sementes. No primeiro capítulo, abordamos aspectos comportamentais da formação de latrinas, que foi realizado através de marcadores plásticos adicionados no alimento. No segundo capítulo avaliamos a efetividade de dispersão de sementes, através dos locais de deposição de fezes e o potencial germinativo de duas espécies que compõe a sua dieta: Psidium guajava e Syagrus romanzoffiana. O estudo foi realizado no Centro de Visitantes do Parque Estadual da Serra do Tabuleiro, em Santa Catarina, que compreende uma área de 160 ha. Lá seis indivíduos de T. terrestris vivem em regime de cativeiro extensivo com alimentação suplementar, o que permite a realização de estudos com disponibilidade de habitat e densidade controladas. Observamos que 78% das fezes estavam agrupadas em latrinas e 22% isoladas. Oito unidades fecais (10%) continham marcadores, desde o primeiro até 18 dias após a ingestão. Em uma latrina evidenciamos o uso repetido pelo mesmo indivíduo. Não é possível afirmar se as latrinas são de uso individual ou coletivo, porém a taxa de defecação que encontramos em latrinas é superior a de um único indivíduo. Os locais de defecação estão associados à altura do dossel, refletindo a seleção de T. terrestris pela vegetação arbórea. As taxas médias de germinação de sementes de P. guajava que passaram pelo trato digestivo das antas não foram diferentes (p>0,41) das sementes despolpadas. Já a taxa de germinação das sementes de Syagrus romanzoffiana, fruto importante na dieta de antas, foi maior (p=0,05) quando ingeridas pelos animais, pois esses selecionam frutos sadios. Os resultados demonstram que T. terrestris é eficiente na dispersão de sementes, tanto por depositar suas fezes em locais seguros para a germinação, como por apresentar efeito neutro ou positivo na germinação de espécies após a passagem pelo trato digestivo. / Largest neotropical terrestrial mammal, the tapir (Tapirus terrestris) is a solitary animal. Regarding its food-habit type is classified as frugivore-herbivore, thus ingesting great amount of seedy fruits of diverse species. The tapir is considered to be a seed dispersor. In the present work, aspects related to tapir’s latrine behavior and its effectiveness on seed dispersal were studied. In the first chapter, tapir’s latrine behavior was studied through plastic markers added in the food. In the second chapter the aim was to evaluate the effectiveness of seed dispersal by tapirs, through the places of feces’ deposition and the germination potential of two species composing its diet: Psidium guajava and Syagrus romanzoffiana. The study was carried out in the Visitors Center of Serra do Tabuleiro State Park, in Santa Catarina state, a 160 ha area. There, six T. terrestris individuals live in extensive captivity regime with supplemental feeding, allowing the development of studies with controlled habitat availability and density. We observed that 78% of excrements were grouped in latrines and 22% were isolated. Eight fecal units (10%) were found with markers one to 18 days after marker’s ingestion. In a latrine we found evidence of repeated use by the same individual. Although it is not possible to state whether latrines are of individual or collective use, the defecation rate found is bigger of that of a single individual. The defecation places are associates with higher canopy, reflecting the T. terrestris election for forest vegetation. The germination rate of P. guajava seeds passing through the digestive tract of tapirs weren’t different (p>0,41) from those with pulp manually extracted. On the other hand, germination rate of Syagrus romanzoffiana, an important fruit on tapirs’ diet, was greater (p=0,05) when ingested by the animals, because they select healthy fruits. The results demonstrate tapir to be efficient in seed dispersal, not only for deposing their excrements in safe places for seed germination, as for presenting neutral or positive effect in the germination of seeds after passing their digestive tract.

Maior mamífero terrestre neotropical, a anta (Tapirus terrestris) possui hábitos solitários. É classificada como herbívora-frugívora, ingerindo grande quantidade de frutos com sementes de diversas espécies. Potencialmente, a anta é considerada um dispersor de sementes. Nesse trabalho, estudamos aspectos comportamentais da formação de latrinas por antas e sua efetividade na dispersão de sementes. No primeiro capítulo, abordamos aspectos comportamentais da formação de latrinas, que foi realizado através de marcadores plásticos adicionados no alimento. No segundo capítulo avaliamos a efetividade de dispersão de sementes, através dos locais de deposição de fezes e o potencial germinativo de duas espécies que compõe a sua dieta: Psidium guajava e Syagrus romanzoffiana. O estudo foi realizado no Centro de Visitantes do Parque Estadual da Serra do Tabuleiro, em Santa Catarina, que compreende uma área de 160 ha. Lá seis indivíduos de T. terrestris vivem em regime de cativeiro extensivo com alimentação suplementar, o que permite a realização de estudos com disponibilidade de habitat e densidade controladas. Observamos que 78% das fezes estavam agrupadas em latrinas e 22% isoladas. Oito unidades fecais (10%) continham marcadores, desde o primeiro até 18 dias após a ingestão. Em uma latrina evidenciamos o uso repetido pelo mesmo indivíduo. Não é possível afirmar se as latrinas são de uso individual ou coletivo, porém a taxa de defecação que encontramos em latrinas é superior a de um único indivíduo. Os locais de defecação estão associados à altura do dossel, refletindo a seleção de T. terrestris pela vegetação arbórea. As taxas médias de germinação de sementes de P. guajava que passaram pelo trato digestivo das antas não foram diferentes (p>0,41) das sementes despolpadas. Já a taxa de germinação das sementes de Syagrus romanzoffiana, fruto importante na dieta de antas, foi maior (p=0,05) quando ingeridas pelos animais, pois esses selecionam frutos sadios. Os resultados demonstram que T. terrestris é eficiente na dispersão de sementes, tanto por depositar suas fezes em locais seguros para a germinação, como por apresentar efeito neutro ou positivo na germinação de espécies após a passagem pelo trato digestivo. / Largest neotropical terrestrial mammal, the tapir (Tapirus terrestris) is a solitary animal. Regarding its food-habit type is classified as frugivore-herbivore, thus ingesting great amount of seedy fruits of diverse species. The tapir is considered to be a seed dispersor. In the present work, aspects related to tapir’s latrine behavior and its effectiveness on seed dispersal were studied. In the first chapter, tapir’s latrine behavior was studied through plastic markers added in the food. In the second chapter the aim was to evaluate the effectiveness of seed dispersal by tapirs, through the places of feces’ deposition and the germination potential of two species composing its diet: Psidium guajava and Syagrus romanzoffiana. The study was carried out in the Visitors Center of Serra do Tabuleiro State Park, in Santa Catarina state, a 160 ha area. There, six T. terrestris individuals live in extensive captivity regime with supplemental feeding, allowing the development of studies with controlled habitat availability and density. We observed that 78% of excrements were grouped in latrines and 22% were isolated. Eight fecal units (10%) were found with markers one to 18 days after marker’s ingestion. In a latrine we found evidence of repeated use by the same individual. Although it is not possible to state whether latrines are of individual or collective use, the defecation rate found is bigger of that of a single individual. The defecation places are associates with higher canopy, reflecting the T. terrestris election for forest vegetation. The germination rate of P. guajava seeds passing through the digestive tract of tapirs weren’t different (p>0,41) from those with pulp manually extracted. On the other hand, germination rate of Syagrus romanzoffiana, an important fruit on tapirs’ diet, was greater (p=0,05) when ingested by the animals, because they select healthy fruits. The results demonstrate tapir to be efficient in seed dispersal, not only for deposing their excrements in safe places for seed germination, as for presenting neutral or positive effect in the germination of seeds after passing their digestive tract.

Orientador: Nilton Carlos Machado / Resumo: Neste estudo foi realizada a primeira avaliação da Qualidade de Vida Relacionada à Saúde em um grupo de 100 crianças com Distúrbios da Evacuação (Grupo Total-GT), classificadas de acordo com os Critérios de Roma II, divididas em: 57 com Constipação Intestinal Funcional (CIF), 29 com Retenção Fecal Funcional (RFF) e 14 com "Soiling" Sem Retenção (SSR), homogêneas quanto às características demográficas. Utilizou-se o CHQ-PF50®, um instrumento genérico de medida de Qualidade de Vida Relacionada à Saúde, para se avaliar o impacto destes distúrbios na Qualidade de Vida dessas crianças, na percepção dos pais. Esse instrumento avalia o bem estar físico e psicossocial dos pacientes, por meio de 15 conceitos em saúde denominados Domínios, cada qual com uma escala de 0 a 100, com os maiores valores indicando melhor estado de saúde, bem estar e satisfação. Para a pontuação desse instrumento, obtém-se 2 escores agregados e sumários, o Escore Físico (PhS) e o Escore Psicossocial (PsS), através da transformação de 10 desses 15 Domínios. Os valores dos Escores Físico (PhS ) e Psicossocial (PsS ) das crianças do estudo comparados com aqueles das Populações de Referência: Normal e com Artrite Idiopática Juvenil, doença crônica com reconhecida repercussão da Qualidade de Vida, mostraram-se inferiores. Na comparação entre os diferentes subgrupos, obteve-se comprometimento somente do Escore Físico (PhS) entre Constipação Intestinal Funcional e "Soiling" Sem Retenção. No estudo de correlações entre os Escores Físico (PhS) e Psicossocial (PsS) com a Pontuação dos Distúrbios da Evacuação, correspondente à abordagem clínica e o Escore de Barr, correspondente à avaliação laboratorial, não houve correlação estatisticamente significante, mostrando... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: In this study we assessed a serie of 100 pediatric patients aged from 5 to 12 years. They were diagnosed with Defecation Disorders and classified as to The Rome II criteria, being 57 with Functional Constipation (FC), 29 with Functional Fecal Retention (FFR) and 14 with Non-retentive Fecal Soiling (NRFS). Socio-demographic variables were comparable in all the groups. Besides routine clinical approach with imaging, we explored measures of health assessment by the Child Health Questionnaire-Parent Form-50 item - CHQ - PF50 ® - a valid health related quality of life tool. The CHQ- PF50 ® was considered for objective measure of parentþs perception of health status and overall well being of their children. This is a multidimensional tool composed by 15 health concepts (domains) scored from 0 to 100, with higher scores meaning better health status and well being. Additionally, two aggregated summary scores - a Physical (PhS) and Psychosocial (PSS) scores were calculated by factorial analysis, by using 10 of 15 health concepts. The individual scores and the aggregated PhS and PsS scores were compared to reference values in healthy and arthritic Brazilian children, being worse in the children with Defecation Disorders. Comparisons among the 3 groups with Defecation Disorders indicated significant difference for PhS scores, which were lower in NRFS compared to FC cases. The PhS and PsS were not correlated with the clinical and imaging scoring; this might point to independency or non redundancy of these measures for the clinical decision. In conclusion, these scores provided by a generic health related quality of life tool were considered useful for clinical assessment of Defecation Disorders in children. As reported for other diseases, parents-by-proxy self-reported health status tools can be considered as outcome measure for treatment decision guidance. / Doutor

Maior mamífero terrestre neotropical, a anta (Tapirus terrestris) possui hábitos solitários. É classificada como herbívora-frugívora, ingerindo grande quantidade de frutos com sementes de diversas espécies. Potencialmente, a anta é considerada um dispersor de sementes. Nesse trabalho, estudamos aspectos comportamentais da formação de latrinas por antas e sua efetividade na dispersão de sementes. No primeiro capítulo, abordamos aspectos comportamentais da formação de latrinas, que foi realizado através de marcadores plásticos adicionados no alimento. No segundo capítulo avaliamos a efetividade de dispersão de sementes, através dos locais de deposição de fezes e o potencial germinativo de duas espécies que compõe a sua dieta: Psidium guajava e Syagrus romanzoffiana. O estudo foi realizado no Centro de Visitantes do Parque Estadual da Serra do Tabuleiro, em Santa Catarina, que compreende uma área de 160 ha. Lá seis indivíduos de T. terrestris vivem em regime de cativeiro extensivo com alimentação suplementar, o que permite a realização de estudos com disponibilidade de habitat e densidade controladas. Observamos que 78% das fezes estavam agrupadas em latrinas e 22% isoladas. Oito unidades fecais (10%) continham marcadores, desde o primeiro até 18 dias após a ingestão. Em uma latrina evidenciamos o uso repetido pelo mesmo indivíduo. Não é possível afirmar se as latrinas são de uso individual ou coletivo, porém a taxa de defecação que encontramos em latrinas é superior a de um único indivíduo. Os locais de defecação estão associados à altura do dossel, refletindo a seleção de T. terrestris pela vegetação arbórea. As taxas médias de germinação de sementes de P. guajava que passaram pelo trato digestivo das antas não foram diferentes (p>0,41) das sementes despolpadas. Já a taxa de germinação das sementes de Syagrus romanzoffiana, fruto importante na dieta de antas, foi maior (p=0,05) quando ingeridas pelos animais, pois esses selecionam frutos sadios. Os resultados demonstram que T. terrestris é eficiente na dispersão de sementes, tanto por depositar suas fezes em locais seguros para a germinação, como por apresentar efeito neutro ou positivo na germinação de espécies após a passagem pelo trato digestivo. / Largest neotropical terrestrial mammal, the tapir (Tapirus terrestris) is a solitary animal. Regarding its food-habit type is classified as frugivore-herbivore, thus ingesting great amount of seedy fruits of diverse species. The tapir is considered to be a seed dispersor. In the present work, aspects related to tapir’s latrine behavior and its effectiveness on seed dispersal were studied. In the first chapter, tapir’s latrine behavior was studied through plastic markers added in the food. In the second chapter the aim was to evaluate the effectiveness of seed dispersal by tapirs, through the places of feces’ deposition and the germination potential of two species composing its diet: Psidium guajava and Syagrus romanzoffiana. The study was carried out in the Visitors Center of Serra do Tabuleiro State Park, in Santa Catarina state, a 160 ha area. There, six T. terrestris individuals live in extensive captivity regime with supplemental feeding, allowing the development of studies with controlled habitat availability and density. We observed that 78% of excrements were grouped in latrines and 22% were isolated. Eight fecal units (10%) were found with markers one to 18 days after marker’s ingestion. In a latrine we found evidence of repeated use by the same individual. Although it is not possible to state whether latrines are of individual or collective use, the defecation rate found is bigger of that of a single individual. The defecation places are associates with higher canopy, reflecting the T. terrestris election for forest vegetation. The germination rate of P. guajava seeds passing through the digestive tract of tapirs weren’t different (p>0,41) from those with pulp manually extracted. On the other hand, germination rate of Syagrus romanzoffiana, an important fruit on tapirs’ diet, was greater (p=0,05) when ingested by the animals, because they select healthy fruits. The results demonstrate tapir to be efficient in seed dispersal, not only for deposing their excrements in safe places for seed germination, as for presenting neutral or positive effect in the germination of seeds after passing their digestive tract.

There are 2.6 billion people who have no access to "improved sanitation" all over the world, of which 814 million people live in India. As a result of this, people resort to open defecation and this causes serious damage to the people‟s health and also pollutes the surrounding environment. This thesis explores the sanitation situation in a village called Mohaddipur in the Bind Block of Nalanda district in the state of Bihar, India. This SIDA financed project will provide this village with a public toilet complex which will be constructed with the help of the community members and strive towards putting an end to open defecation which is practised by these community members of the study area. Through the sanitation facilities being provided it was also important to close the nutrient cycle loop between agriculture and sanitation and make this toilet complex sustainable in all aspects of sustainability: social, economic, environmental and cultural. The provision of Ecological Sanitation (ecosan) facilities through the implementation of CompostEra toilet units and technology, in the toilet complex, in both the „hardware‟ and the „software‟ aspects is studied in this thesis. Women and adolescent girls were sensitised through education on Menstrual Hygiene Management (MHM) to empower these women in this village of Mohaddipur to not only improve their health but to also get an opportunity to get an education and gain a livelihood. Participatory Action Research (PAR) method has been used in this study to empower the community of this village in order to increase the social, educational, gender and economic strength of the individuals. The results and subsequent discussion show the need to include communities in designing a sanitation facility and how capacity building is a very important step in this process. The findings suggest that the benefits of ecosan seem to be significant enough to outweigh the negative cultural sentiments regarding the use of human excrements.

No description available.