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.

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

Made available in DSpace on 2014-06-11T19:33:27Z (GMT). No. of bitstreams: 0 Previous issue date: 2005Bitstream added on 2014-06-13T18:45:10Z : No. of bitstreams: 1 faleiros_ftv_dr_botfm.pdf: 384853 bytes, checksum: cda6b367e0e32f3b9311c6875c4d8c18 (MD5) / 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... / 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.