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Abstract
Background- Defecography, along with other radiologic modalities, can be used to evaluate rectal abnormalities such as functional disorders of the rectum. It appears that ethnic habits can influence the evacuative function of the rectum. The main goal of this study was to compare Iranian and European habits of bowel evacuation on defecographic measurements. Methods- Thirty Iranian patients (21 male, 9 female) referred for barium enema were enrolled in the study. The patients were instructed to defecate using two types of toilet: an unraised, ground-level style (common in Iran), and a bowl with attached tank style (common in Western countries). Radiographs were taken of each patient while defecating into both types of toilet, during which the anorectal angle and other defecographic indices were measured. Results- Use of the Iranian-style toilet yielded a much wider anorectal angle, and a larger distance between the perineum and the horizontal plane of the pelvic floor than the European style. Bowel evacuation was also more complete using the Iranian-style toilet. Conclusion- Use of the Iranian-style toilet seems to be more a more comfortable and efficient method of bowel evacuation than the European style. Further studies are needed to ascertain the optimal approximation of the measurements to standard height of toilets for ordinary use.
... In some rural areas, it is still the common defecation position. Studies have demonstrated that defecation in the squatting position is more efficient with less straining force needed compared to the seated position [8][9][10][11]. However, data are scarce and it is not clear from all studies whether the subjects were accustomed to the squatting position during defecation or had a preference for either the squatting or seated position. ...
... Only a few studies have been conducted on the effect of position on defecatory parameters. In brief, differences were for found for the anorectal angle between seated and squatting in normal subjects [8][9][10][11] and in patients with fecal incontinence [8][9][10][11] and between the seated and "thinker" position in constipated patients [8][9][10][11]. The expulsion duration was faster in the squatting position than in the seated and lower seated positions [8][9][10][11]. ...
... Only a few studies have been conducted on the effect of position on defecatory parameters. In brief, differences were for found for the anorectal angle between seated and squatting in normal subjects [8][9][10][11] and in patients with fecal incontinence [8][9][10][11] and between the seated and "thinker" position in constipated patients [8][9][10][11]. The expulsion duration was faster in the squatting position than in the seated and lower seated positions [8][9][10][11]. ...
Background
Defecation is a complex process and up to 25% of the population suffer from symptoms of defecatory dysfunction. For functional testing, diagnostics, and therapy of anorectal disorders, it is important to know the optimal defecation position. is The aim of this study was to evaluate defecation pressure patterns in side lying, seated and squatting defecation positions in normal subjects using a simulated stool device called Fecobionics.Methods
The Fecobionics expulsion parameters were assessed in an interventional study design conducted from May 29 to December 9 2019. Subjects were invited to participate in the study through advertisement at The Chinese University of Hong Kong. The Fecobionics device consisted of a core containing pressure sensors at the front (caudal end) and rear (cranial end) and a polyester-urethane bag spanning most of the core length which also contained sensors. The Fecobionics bag was distended to 50 ml in the rectum of normal subjects (no present and past symptoms of defecatory disorders, no prior abdominal surgery, medication or chronic diseases). Studies were done in side lying (left lateral recumbent position), seated (hip flexed 90°) and squatting position (hip flexed 25°). Pressure endpoints including the rear-front pressure diagram and defecation indices were compared between positions.ResultsTwelve subjects (6 females/6 males, mean age 26.3 ± 2.6 [19.0–48.0] years) were included and underwent the planned procedures. The resting anal pressure for side lying and seated positions were 33.1 ± 4.1 cmH2O and 37.1 ± 4.0 cmH2O (p > 0.3). The anal squeeze pressure for side lying and seated positions were 98.4 ± 6.9 cmH2O and 142.3 ± 16.4 cmH2O (p < 0.05). The expulsion duration for the side lying, seated and squatting positions were 108.9 ± 8.3 s, 15.0 ± 2.1 s and 16.1 ± 2.9 s, respectively (p < 0.01 between lying and the two other positions). The maximum evacuation pressure for seated and squatting were 130.1 ± 12.4 cmH2O and 134.0 ± 11.1 cmH2O (p > 0.5). Rear-front pressure diagrams and distensibility indices demonstrated distinct differences in pressure patterns between the side lying position group and the other positions.Conclusions
The delay in expelling the Fecobionics device in the lying position was associated with dyssynergic pressure patterns on the device. Quantitative differences were not found between the seated and squatting position.Trial Registration http://www.clinicaltrials.gov Identifier: NCT03317938.
... Es el caso del estudio de los hábitos defecatorios llevado a cabo por el radiólogo iraní Rad (2002) en el que se expone la estrecha relación entre la postura y el ángulo del músculo puborrectal como principal responsable de la evacuación. En él también se muestran las diferencias entre la postura sedente y la de cuclillas basadas en las diferencias socio-culturales subyacentes. ...
... En ella, se exponen los diferentes valores adoptados por las palancas de salida en función de la variación del radio de las distintas curvaturas (C 1 , C 2 , C 3 y C 4 ) propuestas para el diseño de la polea excéntrica, así como los valores correspondientes de la variable altura de pies (FH). Éstos últimos serán además evaluados según el criterio de idoneidad aportado por los ensayos de Esnal & Serrano (2013) en base a los estudios de Rad (2002) en los que se demuestra la relación directamente proporcional entre la adopción de la postura de cuclillas con la relajación del músculo puborrectal. ...
The design methodology, especially the product design oriented, has been subject to a multitude of studies from different approaches in order to determine a coherent, global and systematic structuring of the design stages.
However, traditionally these design methods are limited to proposals of techniques and analysis tools based, in many cases, on the experiences acquired by the personal praxis of the engineers or designers, or in contrast, of theoretical academic models of scarce practical application. .
The absence of a generalized, structured and orderly method favors some possible deficiencies in the practice of the discipline of design such as the poor traceability between the initial requirements and the final attributes of the product, the lack of rigor in the design procedures, the disinformation in the decision-making or the omission of relevant aspects, especially in complex issues, such as the one presented here, constipation.
This thesis collects the research carried out on the modeling and design of a product from a holistic and integrating perspective -as it is the systemic- providing a sequenced work space that helps the designer to undertake the optimal development of the activity of the design, as far as the product is concerned. By means of the study of a case the development of the investigation on the implementation of such methodological frame is arranged, as much in the questions of abstract and conceptual nature as in the concrete ones and of detail, allowing this way the systematization of the processes of design.
The proposed case study is a therapeutic assistance device for helping reduction of idiopathic chronic or functional constipation. The purpose of this device is to address the functional pathophysiology of this condition by providing a functional-mechanical solution in the palliation of symptoms and, thereby, increase the quality of life of users, in addition to reducing the likelihood of suffering complications of greater severity.
For all these reasons, the main objective was to design an abdominal-intestinal assistance device to help reduce idiopathic functional constipation through the application of systemic methodology. Therefore, it is proposed the conception of a multifactorial study scenario capable of contemplating the product as a multivariable system and, in addition, allowing to carry out the development approach and the achievement of all the necessary stages and phases that the concurrent design proposes up to the achievement of the final product.
The methodology used in the research has a theoretical and qualitative character in the descriptive and exploratory stages of knowledge extraction and conceptual modeling of the subject; and a quantitative and experimental character in the stages of longitudinal application and analysis of the product system.
In the first place and due to the complexity of the subject matter, the conception of a theoretical framework was necessary through the collection of useful information thrown out by the exploratory research of the related literature. In it, different specialties were considered in the field of medicine, to know the magnitude of this condition under different approaches. As well as, the consideration of different types of sources related to engineering and the world of design, especially, product design and systemic.
The qualitative application of the different systemic techniques and tools, especially the goal oriented systemic model of product by Hernandis (2000), was used in the construction of the study scenario -proposing the established theme as the interrelation of the systems that comprise it-, with the identification of the intervening agents (variables and parameters), as well as in the contribution of the sequence of logical structuring of the design processes.
On the other hand, the Systems Dynamics was used for the identification and determination of the different behaviors of the variables that includes the system under study, as well as for the formalization and quantitative expression of the functions that they present.
We used demographic studies of potential users on the attributes and / or design characteristics of the proposed device for the collection of information on the system to be modeled. With the obtained data, a factorial study of the Principal Components (PCA) was carried out to identify the fundamental factors in which the proposed attributes are grouped and justify, in this way, their level of importance and participation in the modeling of the product. The opinion of experts in different areas of medicine and design (including systemic design) was considered to compare the data obtained from the factorial study, the pertinence of the research, the approach used and the hypotheses formulated.
The different theoretical, structural, formal and functional studies are part of the concurrent design methods that together with the Hernandis product model, not only served to achieve the design processes, but also as assessment and constant verification tools, both the model and the process of modeling the product system.
As a result of the research, the systemic model for an abdominal-intestinal assistance product, such as the one proposed, the intervening agents and the relationships between them were obtained in the first instance. In addition, three-dimensional geometric models representing each of the fundamental aspects were obtained through the study of the volumes of use, surfaces of use and boundary limits, as well as the geometric design space which represents all the possible configurations of the proposed product system.
The fundamental design requirements for this type of product were extracted from the literature and corroborated through the study of the opinion of the potential users, as well as the Principal Components Analysis that comprise them, validating in this way the hypothesis of a factorial regrouping as the proposal. From the contribution of the different techniques and tools used during the modeling, the specifications conceptual and technical requirements for the correct development of the design and, as such, resulted in the materialization of a proposal in the form of a possible design solution.
In addition, regarding the statistical results, a view was obtained of the profiles of the potential users and the demands that these as groups of consumers differ among them. It highlights the categorization of four population groups of greater interest such as women and men of middle age, young people under thirty and those over fifty. It was observed that middle-aged women emphasize the pragmatic qualities of use (space, effort and time), while men give greater importance to energy saving, sophistication and personalization. Among the antagonistic groups of young and old there is a common concern for supervised use and in health centers.
It is concluded that the integration of the different methods used, from the initial systemic approach with the construction of the scenario to the final resolution of the detail design, have a great affinity and complementarity between them, as well as a high suitability in the approach of each one of the different approaches proposed. For each stage or design process, where the particular study of the related aspects is required, there is an acolyte method that allows and facilitates its approach. The implementation of these techniques to the design process shows the flexibility and inclusiveness that the systemic methodology presents in all its areas of action, including product design. Additionally, it can be said that the exhaustive application of all the methods used sequentially provides a high degree of innovation and traceability both in the modeling of the system and in the design of the product.
Another noteworthy point is the use of statistical techniques applied to design as research epistemological tools, which have proved to be extremely important in the contribution of objectivity and rigor to a discipline, such as industrial design, which traditionally appeals to a greater subjectivity and personal inspiration and not to empiricism and the demonstration of the scientific method.
... There are many proposed advantages for squatting during defecation. Squatting makes elimination faster, easier, and more complete; and securely seals the ileocecal valve between the colon and the small intestine (11)(12)(13). As squatting reduces the pressure required for defecation, it has been recommended to alleviate constipation associated with benign anorectal diseases (e.g., HD and AF) (12)(13)(14). ...
... Squatting makes elimination faster, easier, and more complete; and securely seals the ileocecal valve between the colon and the small intestine (11)(12)(13). As squatting reduces the pressure required for defecation, it has been recommended to alleviate constipation associated with benign anorectal diseases (e.g., HD and AF) (12)(13)(14). In our study, no association was detected between benign anorectal diseases (e.g., HD and AF) and toilet types. ...
Background/aims:
An anal fissure (AF) is a linear tear in the distal anal canal and is one of the most common causes of anal pain. Hemorrhoidal disease (HD) is a symptomatic growth and distal displacement of normal anal cushions. Numerous studies have addressed the contributing factors of these conditions, yet the results remain controversial. In this study, we hypothesize that increasing patients' awareness of hidden risk factors could reduce the rate of HD and AF.
Materials and methods:
A questionnaire-based controlled study was planned. After power analysis, patients with HD (n=60) and AF (n=60) were enrolled consecutively into the study group and compared with the control group (n=60) of healthy individuals. The survey was designed to assess the participants' toilet and dietary habits and anxiety risk. Odds ratios were calculated and a binary logistic regression model was constructed to identify associated factors.
Results:
Hard stools, spending more than 5 minutes in the toilet, frequent straining during defecation, and increased spice intake were more frequent in the patients with HD; and hard fecal consistency, time elapsed in toilet greater than 5 min, straining during defecation, and high anxiety risk were more frequent in the patients with AF as compared to the control group (p<0.05).
Conclusion:
Possible associations were identified between habitual factors or conditions (i.e., fecal consistency, the time elapsed in the toilet, straining during defecation) and anxiety and benign anorectal diseases (i.e., HD and AF). Patients should be advised about these hidden threats.
... (13) C'3 = r'(θ) = -1,2 x10 -3 θ 3 + 2,43x10 -2 θ 2 + 9x10 -3 θ + 0,08; (14) C'4 = r'(θ) = -10 -3 θ 4 + 2,8x10 -2 θ 3 -0,329θ 2 + 1,434θ -1,946; (15) With the second derivative, the expressions for radius acceleration as a function of the rotation angle were obtained: C''1 = r''(θ) = -4,8x10 -3 θ 2 + 0,798 θ -0,195; (16) C''2 = r''(θ) = -7,2x10 -3 θ 2 + 0,145θ -0,438; (17) C''3 = r''(θ) = -3,6x10 -3 θ 2 + 4,86x10 -2 θ + 9x10 -3 ; (18) C''4 = r''(θ) = -10 -3 θ 4 + 2,810 -2 θ 3 -0,329θ 2 + 1,434θ -1,946; Source: The Authors. ...
... Proposed curvatures for essay. Source: The Authors relationship between the user position and the puborectalis muscle angle[18]. The optimal elevation value was established at 200-250 mm for an adult male user of 50 ± 5 percentile (≈1,740 mm, ≈1,660 mm in Spain) according to the UNE EN ISO 7250: 1998 standard[19] and the Instituto para la Salud e Higiene en el Trabajo, INSHT (Institute of Occupational Health and Safety)[20]. ...
This paper describes a case study carried out on the behaviour of an eccentric pulley transmission system housed in a manually operated abdominal-intestinal assistant device for human use. The aim is to establish a systemic framework that serves as a validation tool for mechanical systems in the initial stages of the product design processes. The proposed study system describes the device transmission process as a function of the input angle variation (dα), the height of the user’s feet (HF) and the pulley curvature function (C), resulting from the variation of its radius (dR) over time (dt). In order to explore and compare the different behaviours and identify possible solutions four different configurations of curvatures were proposed. Causal diagrams and differential equations describe the simulation scenario. The resulting application model supports the use of a systemic frame and methods as a pre-response to the validation of design proposals.
... The sitting position for the evacuation of faeces may be a co-factor in building faecal retention reservoirs. Squatting, compared to sitting, relaxes the puborectalis muscle and straightens the anorectal angle, as shown in a defaecographic study (211). ...
... For hundreds of thousands of years everyone used the squatting position for the evacuation of faeces (and childbirth). Squatting, compared to sitting, relaxes the puborectalis muscle and straightens the anorectal angle (211). Moreover, the weight of the torso presses against the thighs, possibly squeezing the caecum and the sigmoid colon. ...
The present studies explored whether faecal retention in the colon is a causative factor in functional bowel disease, appendicitis, and haemorrhoids. Faecal retention was characterized by colon transit time (CTT) after radio-opaque marker ingestion and estimation of faecal loading on abdominal radiographs at 48 h and 96 h. Specific hypotheses were tested in patients (n = 251 plus 281) and in healthy random controls (n = 44). A questionnaire was completed for each patient, covering abdominal and anorectal symptoms and without a priori grouping. Patients with functional bowel disorders, predominantly women, had a significantly increased CTT and faecal load compared to controls. The CTT was significantly and positively correlated with segmental and total faecal loading. The faecal load was equal at 48 h and 96 h, mirroring the presence of permanent faecal reservoirs. In these first clinical studies to correlate bowel symptoms with CTT and colon faecal loading, abdominal bloating was significantly correlated with faecal loading in the right colon, total faecal load, and CTT. Abdominal pain was significantly and positively correlated to distal faecal loading and significantly associated with bloating. A new phenomenon with a high faecal load and a normal CTT was observed in a subset of patients (n = 90), proving faecal retention as hidden constipation. The CTT and faecal load were significantly higher in the right-side compared to the left and distal segments. Within the control group of healthy persons, the right-sided faecal load was significantly greater than the left and distal load. The CTT and faecal load significantly positively correlated with a palpable mass in the left iliac fossa and meteorism. Cluster analysis revealed that CTT and faecal load positively correlated with a symptom factor consisting of bloating, proctalgia and infrequent defecation of solid faeces. On the other hand, CTT and faecal load negatively correlated with a symptom factor comprising frequent easy defecations, repetitiveness, and incompleteness with solid or liquid faeces. The majority of patients with a heavy faecal load but normal CTT had repetitive daily defecation, mostly with ease and with altering faecal consistence. Flue-like episodes co-existed in symptom factors with abdominal pain and meteorism, and these symptoms together with a palpable right iliac fossa mass and tenderness, and in other factors with seldom and difficult defecation, and with epigastric discomfort and halitosis. Patients with seldom and difficult defecation of solid faeces experienced abdominal pain significantly more often and presented a palpable mass in the right iliac fossa with tenderness and meteorism. The CTT was significantly prolonged and faecal load significantly increased. In patients with a normal CTT and increased faecal load, only patients with abdominal pain had a significant correlation between faecal loading and bloating. CTT and faecal load were shown for the first time to increase significantly with the number of colonic redundancies (colon length), which also resulted in significantly increased bloating and pain. Intervention with a bowel stimulation regimen combining a fibre-rich diet, fluid, physical activity, and a prokinetic drug was essential to proving that abdominal symptoms and defecation disorders are caused by faecal retention, with or without a prolonged CTT. The CTT was significantly reduced, as was faecal load. Bloating and pain were reduced significantly. The defecation became easy with solid faeces, towards one per day and with significant reductions in incompleteness and repetitiveness. Proctalgia and flue-like episodes were significantly reduced. The intervention significantly reduced the presence of a tender palpable mass in the right fossa and rectal constipation. In patients with a normal CTT but increased faecal load, the intervention did not significantly change the CTT or load, but bloating and pain were significantly reduced, just as defecation improved overall. The novel knowledge of faecal retention in the patients does not explain why faecal retention occurs. However, it may be inferred from the present results that a constipated or irritable bowel may belong to the same underlying disease dimension, where faecal retention is a common factor. Thus, measuring CTT and faecal load is suggested as a guide to a positive functional diagnosis of bowel disorders compared to the constellation of symptoms alone. Thirty-five patients underwent surgery after being refractory to the conservative treatment for constipation. They had a significantly prolonged CTT and heavy faecal loading, which was responsible for the aggravated abdominal and defaecatory symptoms. The operated patients presented with a redundant colon (dolichocolon) significantly more often. These patients also had an extremely high rate of previous appendectomy. Twenty-one patients underwent hemicolectomy, and 11 patients had a subtotal colectomy with an ileosigmoidal anastomosis; three patients received a stoma. However, some patients had to have the initial segmental colectomy converted to a final subtotal colectomy because of persisting symptoms. Six more subtotal colectomies have been performed and the leakage rate of all colectomies is then 4.9 % (one patient died). After a mean follow-up of 5 years, the vast majority of patients were without abdominal pain and bloating, having two to four defecations daily with control and their quality of life had increased considerably. A faecalith is often located in the appendix, the occlusion of which is responsible for many cases of acute appendicitis, which is infrequent in all except white populations. An effort to trace the origin of the faecalith to faecal retention in the colon was made in a case control study (56 patients and 44 random controls). The CTT was longer and faecal load greater in patients with appendicitis compared to controls, though the difference was not significant. Power calculations showed that more patients were needed to reach statistical significance for these parameters. The presence of a faecalith was most often associated with a gangrenous or perforated appendix. No significant differences were found between the CTT and faecal load of patients who had or did not have a faecalith. However, the right-sided faecal load was significantly higher than the left and distal load. Haemorrhoids are often a consequence of constipation and defaecatory disorders and were found in every second patient with functional bowel disorders. The present studies are the first Danish reports of a novel operation to cure this disease, stapled haemorrhoidopexy (n = 40 and 258 patients). The majority of patients had prolapsed haemorrhoids, and the durability of procedure was confirmed with a follow-up of up to 5 years, meaning a normal anus. The operation time was short, post-operative pain was low, and recovery was rapid. No incontinence was observed, and patient satisfaction was high and significantly correlated with the appearance of a normal anus without prolapse. The cumulative risk of re-operation was greatest in the first 2 years after the stapled haemorrhoidopexy. Patients with persisting haemorrhoidal prolapse had the procedure repeated with results as good as those obtained in the rest of the patients. It was shown in a statistical model that the preoperative severity of haemorrhoidal disease and the immediate postoperative result contributed significantly to predicting the outcome that is the durability of the operation. The most frequent post-operative complication was bleeding requiring surgical haemostasis. One serious complication occurred after an anastomotic leak from a highly placed anastomosis, resulting in retro rectal, retro- and intra-peritoneal, and mediastinal gas. The patient recovered after conservative treatment and without surgical intervention. The stapling technique now used has revolutionized the surgical treatment of prolapsing haemorrhoids. Finally, a common cause may be suspected for diseases constantly associated with one another. Epidemiological evidence has recognized that constipation, diverticulosis and IBS increase the risk of colon cancer (and adenomas), diseases exceedingly rare in communities exempt from appendicitis. Haemorrhoids are a colonic co-morbidity as well. Notably, the patients with a functional bowel disorder had a much higher rate of a previous appendectomy than the background population. In addition, the patients who had previously had an appendectomy had a significantly longer CTT compared to patients, who had not. The data points to the involvement of faecal retention in the origin of faecaliths and, thus, acute appendicitis. Faecal reservoirs were shown in the right and left colon segments in both patients and controls, which are the same areas bearing the highest incidences of adenomateous polyps and malignancies. Familial colorectal cancer occurred significantly more often in patients who had a higher faecal load than the controls. Four malignancies and 25 adenomas were identified. An increased faecal load in the colon with or without delayed transit will increase bacterial counts and create a chronic inflammation of the colonic mucosa, which is a risk factor for cancer onset. A functional bowel disorder is then likely to occur with gradually transition from a primary functional disease into specific organic diseases. A diet rich in fibre and regular physical activity have a therapeutic and preventive effect on colorectal diseases associated with faecal retention.
... 2 So far, several studies have been done on toilets separately and comparatively, and each of them investigated a specific aspect of toilets. Aspects, such as the history, evolution, and development of toilets, 3-8 cultural aspects, [9][10][11] microbial contamination and the role of toilet on the transmission of infectious diseases, [12][13][14][15][16][17][18][19] the ergonomic status and its effect on health, [20][21][22][23][24][25] and water saving, treatment and reusing [26][27][28][29] have been investigated. Georgios P. Antoniou 10 However, no study has accurately reviewed toilets in terms of health and environmental acceptability. ...
In general, two types of sitting and squatting toilets are used by people in the world, each of which has its own advantages and disadvantages from an environmental and health point of view. So far, no study has been done to compare these two types of toilets, precisely. Therefore, the precise comparison of these two types of toilets based on a simple literature review was the main purpose of this study. For this purpose, the amount of water consumption, toilet paper consumption, related diseases, ease of cleaning, odor problem, and the flexibility to equip with treatment and reuse systems in both types of toilets was compared. Squatting toilets is a better option in terms of water consumption, toilet paper consumption, ease of cleaning, and diseases related to body posture. In the case of infectious diseases, the sitting toilet has better conditions and in terms of flexibility to install the treatment and reuse systems, the conditions of both were almost similar. The odor problem in the sitting toilet is less than the squatting toilet. Since the advantages and disadvantages of both types of toilets are also complementary, the best option is to install both toilets together.
... Investigators have promoted the squatting posture owing to its health benefits from a physiological perspective [4][5][6][7][8]. Specifically, in the squatting posture, the anorectal angle is widened (100-110 • ) and the rectum is straightened, resulting in smoother defecation [2]. ...
Abstract: Sitting toilets are preferred globally because they afford a relatively comfortable posture. However, squat toilets are among the most common toilets in numerous public areas because of their advantages, including personal hygiene, easy cleaning, and health benefits. This study attempted to determine optimal toilet design parameters and recruited 50 Taiwanese and 50 Southeast Asian women and collected span between feet (SBF) data for participants squatting in their most comfortable posture, and also surveyed maximum outer width (MOW) data of 28 public squat toilets in Taipei. Finally, we compared the squatting stability levels of 40 female participants (20 Taiwanese and 20 Southeast Asians) who squatted for 2 min at comfortable SBF and MOW-based SBF values. The results revealed that the minimum and maximum SBFs of Taiwanese were 14.52 cm and 18.40 cm, and that of Southeast Asians were 15.64 cm and 20.40 cm, respectively. No significant difference was observed in the SBFs between the two groups was observed. The mean (range) MOW of the surveyed toilets was 27.7 (27–29) cm. Analysis of variance results showed no difference in stability between the two SBFs. This implies that the comfortable SBF (i.e., 16 cm between the participants’ heels) was narrower than the MOW, as commonly used, indicating that the comfortable SBF can be considered as an optimal toilet width parameter because of its constant stability.
... Some studies have compared squatting postures in the toilet with sitting postures in toilet. The results indicated that the squatting posture has benefits over sitting posture, specifically in health (Rad, 2002). The squatting-type toilet has also several benefits, for example, the squatting provides a natural body posture that allows better relaxation during body waste evacuation, which prevents diseases in the small intestines. ...
This study recruited one-hundred and six female participants (51 Taiwanese and 55 Southeast Asians) to collect their span between feet (SBF) when they squatted with the most stable and comfortable posture and surveyed twenty-one squatting-type toilets in the public areas in Taipei. The measurement was mainly taken the maximum outer width of these toilets. After that, an additional sample of five female participants was recruited and tested by the Biodex balance system to compare the postural stability when squatting for 3 min with their comfortable (data obtained from 106 samples) and the maximum outer width of the toilet (data obtained from 28 samples) postures, respectively. Results show that the minimum and maximum SBFs of Taiwanese were 11.1 cm and 18.2 cm, and that of Southeast Asians were 12.0 cm and 19.6 cm, respectively. No significant difference in all SBFs between the two groups was observed by an independent t-test (all p>0.05). The mean outer width of the toilets in public areas was 27.7 cm in a range of 27-29 cm. The paired t test showed that the stability scores in squatting with SBF were better than that with outer width (t=3.175, p<0.05). This implies the users may be forced to adopt an unnatural squatting for a public squatting toilet and may cause discomfort and instability. This study suggests that these public toilets need to be redesigned for squatting comfort and stability when people using the toilets.
... 8 Previous studies have documented that squatting improved the angle of the anorectal canal, reduced strain, increased sensation of adequate bowel emptying, and decreased time associated with defecation when compared with sitting. 1,4,9 Our study suggests that by emulating characteristics of squatting, DPMDs can provide similar benefits to patients. ...
Goals:
The goal of this study was to evaluate the influence of defecation postural modification devices (DPMDs) on normal bowel patterns.
Background:
The introduction of DPMDs has brought increased awareness to bowel habits in western populations.
Materials and methods:
A prospective crossover study of volunteers was performed that included real-time collection of data regarding bowel movements (BMs) for 4 weeks (first 2 wk without DPMD and subsequent 2 wk with DPMD). Primary outcomes of interest included BM duration, straining, and bowel emptiness with and without DPMD use.
Results:
In total, 52 participants (mean age, 29 y and 40.1% female) were recruited for this study. At baseline 15 subjects (28.8%) reported incomplete emptying, 23 subjects (44.2%) had increased straining, and 29 subjects (55.8%) noticed blood on their toilet paper in the past year. A total of 1119 BMs were recorded (735 without DPMD and 384 with DPMD). Utilizing the DPMD resulted in increased bowel emptiness (odds ratio, 3.64; 95% confidence interval (CI), 2.78-4.77) and reduced straining patterns (odds ratio, 0.23; 95% CI, 0.18-0.30). Moreover, without the DPMD, participants had an increase in BM duration (fold increase, 1.25; 95% CI, 1.17-1.33).
Conclusions:
DPMDs positively influenced BM duration, straining patterns, and complete evacuation of bowels in this study.
... This wide angle helps complete evacuation. 25 Our study also included individuals between aged between 40 and 75 years and all of them were from a rural district that both the age limitation and population selection can affect the prevalence. ...
BACKGROUND
Chronic constipation is one of the most common gastrointestinal disorders. It has negative effects on the patients’ quality of life, and their productivity, and results in a high economic burden on the healthcare services. The aim of the present study was to estimate the prevalence of chronic constipation and its associated factors in pars cohort study (PCS).
METHODS
A cross-sectional study was conducted on the baseline data of the PCS. Data gathering was done by structured questionnaire and physical examination. A total of 9264 subjects aged between 40 and 75 years were enrolled in the PCS. Diagnosis of chronic constipation was done using Rome IV criteria. Multivariable binary logistic regression was applied for data analysis.
RESULTS
A total of 752 (8.1%) participants were diagnosed as having chronic constipation (9.3% of female and 6.7% of male participants). Older age (OR: 1.55, 95% CI: 1.31-1.83), physical activity (OR: 0.56, 95% CI: 0.46-0.68), opium consumption (OR: 2.06, 95% CI: 1.63-2.60) , anxiety (OR: 1.38, 95% CI: 1.15-1.65), depression (OR: 1.22, 95% CI: 1.01-1.48), back pain or arthralgia (OR: 1.38, 95% CI: 1.14-1.67), insomnia (OR: 1.62, 95% CI: 1.36-1.93) and gastroesophageal reflux disease (OR: 1.51, 95% CI: 1.28-1.78) were associated with the prevalence of constipation in the multivariable analysis.
CONCLUSION
Chronic constipation was a common problem in the PCS population. Decreasing modifiable risk factors associated with constipation such as opium consumption and physical inactivity can reduce its prevalence and decrease burden of the disease.
... Less attention, however, has been directed towards understanding wellbeing and the mental and social consequences of changing defecation practices. "When someone is used to using a special type of toilet, suddenly changing his or her habit puts severe psychologic stress on the person and evacuation may not be complete in the new method" (Rad, 2002). This condition is termed parcopresis, psychogenic faecal retention or shy bowel. ...
This paper reports on a piece of research to investigate the effectiveness of defecation postures and anal cleansing method. The research compared how long each bowel movement took on a pedestal toilet with and without a footstool. Volunteers were asked to compare the two positions for speed as well as stress/strain on the body. The effectiveness of the method of anal cleansing was also rated by a subset of the volunteers. Although the study was conducted using volunteers in the UK, the findings have international relevance for sanitation marketing and hygiene promotion programmes.
The emergence of contemporary rebuke on allegedly problematic aḥādīth of the Prophet صلى الله عليه وسلم by many critics gives rise to claims that these narrations are illogical or conflicting with the Qur’ānic teachings. However, those narrations highlighted as problematic were systematically elaborated, discussed, and codified in detail by many outstanding Muslim scholars of the past. Among them was Ibn Qutaybah al-Dinawārī (d. 276AH. / 894CE). This paper applies a descriptive method through content analysis of Ibn Qutaybah’s book Taʾwīl Mukhtalif al-Ḥadīth to derive his method of synchronising the alleged mukhtalif al-ḥadīth with the Qur’ānic teachings. It also intends to develop the guidelines in dealing with the alleged problematic ḥadīth relevant for today’s consumption. This paper concludes that utilising the positive method of taʾwīl (allegorical interpretation) will increase the possibility of a positive approach in understanding and implementing the teachings of the Prophetic Tradition.
Hajj pilgrims encounter a great deal of tough physical and mental stress. Overcrowding, extreme temperatures and electrolytes imbalance are common among pilgrims. Approximately more than 2.5 million people from different parts of the world gathered in the holy sites Makka. These factors trigger the increased risk for communicable and non-communicable diseases. This study discusses health and religious factors in an attempt to assess the mandatory health requirements for public toilets in the holy places at Makkah city, that can be translated into toilet design for Hajj pilgrimage at Mecca with the purposes of integration of modern technologies. Articles related to toilet problems faced by the pilgrims published between 2013 to 2018 in some selected data bases were considered in this study. Only 20 studies were included, encompassing 12,000 respondents out of 300 articles. An evaluation requirement checklist was made to evaluate whether the toilet facilities conform to the local and international public toilet standards. Randomly, about 242 toilets were selected and assessed for the availability of essential hygienic items from Mina (54%), followed by Arafat (26%) and Muzdalifah (20%). The proposed conceptual toilets design for Arafat, Muzdalifah, and Mina in the Kingdom of Saudi Arabia is not only applied for Hajj purposes but also as a model to the development of toilet design in all Muslim countries. Sustainable design proposal with safety provisions, accessibility, hygiene, ventilated, lighted and cleaned public toilets during Hajj rituals would more likely protect pilgrims against adverse health effects. However, a definitive conclusion could not be drawn due to lack of existing studies related to this area. The contribution of this study is that the health and religious factors are very crucial in the consideration of toilet design whilst not forgetting modern technologies of the future.
Urinary incontinence (UI) and overactive bladder (OAB) are health conditions that have higher prevalence rates later in life and can lead to a profound negative effect on UI-related quality of life. Evidence is lacking on the effects of conservative multimodal physical therapy (PT) interventions for UI and OAB in the older population. This case study presents a multimodal PT intervention for a 71-year-old woman with UI and OAB. After 4 sessions, the patient demonstrated improved UI-related quality of life and significantly decreased urinary symptoms. Urinary Distress Index Short Form (UDI-6) scores improved from 54.6 to 16.67. Pelvic floor muscle performance improved with increased strength, endurance, and coordination. This case supports the use of multimodal PT interventions for older patients with UI and OAB.
Despite the fact that countless patients suffer from anal problems, there tends to be a lack of understanding of anal health care. Unfortunately, this leads to incorrect diagnoses and treatments. When treating a patient with an anal complaint, the primary goals are to first diagnose the etiology of the symptoms correctly, then to provide an effective and appropriate treatment strategy.The first step in this process is to take an accurate history and physical examination. Specific questions include details about bowel habits, anal hygiene, and fiber supplementation. Specific components of the physical examination include an external anal examination, a digital rectal examination, and anoscopy if appropriate.Common diagnoses include pruritus ani, anal fissures, hemorrhoids, anal abscess or fistula, fecal incontinence, and anal skin tags. However, each problem presents differently and requires a different approach for management. It is of paramount importance that the correct diagnosis is reached. Common errors include an inaccurate diagnosis of hemorrhoids when other pathology is present and subsequent treatment with a steroid product, which is harmful to the anal area.Most of these problems can be avoided by improving bowel habits. Adequate fiber intake with 30 g to 40 g daily is important for many reasons, including improving the quality of stool and preventing colorectal and anal diseases.In this Special Report, we provide an overview of commonly encountered anal problems, their presentation, initial treatment options, and recommendations for referral to specialists.
The topics on toilets, defecation and perianal cleansing may be perceived as taboo subjects in daily discussions but are markedly important from health and hygienical perspectives. In multicultural countries like Australia, no research attention has been given to domestic toilet hygienical requirements from the perspective of the society׳s cultural traditions or religious teachings. The Western sitting lavatories with toilet paper facilities are the most common toilet systems available in Australian homes, which may be contradictory to persons coming from non-Western backgrounds. Squat latrines used widely in many Asian countries are acknowledged to be more conducive for maintaining a healthy bowel system, but are unattractive to Westerners and also unsuitable for those with physical disabilities. Similarly, water is regarded as the most hygienical option for perianal cleansing in many cultures but is rarely used in Western cultures. This paper investigates the experiences of seven Muslim families living in Brisbane with respect to whether or not the Australian toilet systems in their homes meet their personal and familial requirements. This paper further explores whether modifications were made to their domestic toilets to meet these essential needs. Some design recommendations are presented, which are based on the extant literature on this topic as well as the findings from this study. These design options provide an opportunity for future research focussed on a universal toilet design solution that is adaptable and able to meet the needs of all users, especially for those countries with a multicultural population.
Purpose:
We hypothesized that bending the upper body into what we have termed "The Thinker" position facilitates defecation. This study aimed to assess the influence of "The Thinker" position on defecation.
Methods:
This is the prospective single-group study. Patients who could not evacuate the paste in normal sitting position on cinedefecography between January and June 2013 were enrolled in this study. Cinedefecography was first performed in the sitting position; if the patient was unable to evacuate the paste, images were obtained in "The Thinker" position. Patients who were able to evacuate the paste were excluded from the study. Anorectal angle (ARA), perineal plane distance (PPD), and puborectalis length (PRL) during straining in both positions were measured from the radiographs.
Results:
Twenty-two patients unable to evacuate the barium paste underwent cinedefecography in "The Thinker" position. Seventeen patients were female, average age of 56 (range 22-76) years. "The Thinker" position had significantly wider ARA than the sitting position (113° vs. 134°, respectively; p = 0.03), larger PPD (7.1 vs. 9.3 cm, respectively; p = 0.02), and longer PRL (12.9 vs. 15.2 cm, respectively; p = 0.005) during straining. Eleven patients could evacuate completely in "The Thinker" position.
Conclusion:
"The Thinker" position seems to be a more efficient method for defecation than the sitting position. This technique may be helpful when retraining patients with constipation.
Just as we had conceived the idea of this book, we decided that its text has to be different from other writings on health promotion available hitherto.Through this book we sought out to address the issues beyond the traditional tenets of what health promotion books should contain. We have also tried to instill a futuristic appeal in the book. This is because, today, we are living in a postmodern society with its tags of service economy; migration (both internal and external); slackening of orthodoxy yet evidence of flourishing fundamentalism/fanaticism; increased travel and eating out; increasing women workforce; weakening family ties, etc. There have been changes that are the hallmark of this century like information technology advancements, Biotechnology revolution etc. driven by the overarching phenomenon - globalization. The market has also entered in a big way in health care industry. Even the Wellness Industry has been galloping fast. Both Indian (Ayurvedic) and western (Allopathic) systems are vying for the attention of the masses. In view of this, we thought that our proposed book depicting health promotion efforts in the society has to be commensurate with the changing global scenario. At the same time, it should be relevant to the local context as well.
With all these radical changes happening world over, the public health fraternity cannot afford to adopt an ostrich-like attitude, refusing to see the signs of changing times. Though the vital role of the techniques like individual risk calculation, mathematical modeling with bizarre formulae in public health-related issues cannot be denied, they have distanced the public health experts from the common man who finds them incomprehensible. This way, we have fallen prey to a greed for sophistication where none was warranted. It is essential to keep a balance of technical finesse while not losing sight of he big picture or the broader aspects. Targeting the micro-level finer aspects, while ignoring the broader context would very much amount to reductionism, that most clinical disciplines are already finding themselves criticized of.
One of the essential skills of a public health expert is advocacy- being able to influence policy making. The argument of whether public health experts should just play a passive role of generating evidence or jump in as health activists is never ending. The bitter truth is that we do find us largely incapable of influencing policy to promote public health. This is quite evident in the apparent discordance between the provisions made by the government and the public expectations. While the government doctors, workers and health centers are falling short of people’s expectations, the private operators have opened up E-health centers (recruiting ANM, empanelling doctors, linking up with laboratory services) with video-conference based consultations.
We need to understand the dynamics of the changing society and tailor health promotion efforts in this direction. Health Promotion is no more (rather never was) just health education or IEC. Wider concepts of health promotion like advocacy and lobbying, policy development and evaluation of public health interventions need to understood and mastered while always keeping the individual in mind. The oft repeated quoted of Think Global and Act Local may hold good here. This book is a humble attempt towards addressing these issues.
This book has been written to cater to the interests of public health students and teachers worldwide, though it has examples and case studies of India. Amidst all the changes mentioned above, India has, in a way, taken up the role of world leader, i.e. the center stage in demonstrating the role and importance of social organization in sustaining the society. India has long since been an example to the developed world in being a delightful combination of traditional as well as modern outlook towards health and social issues. Strong family system and social structure of India has sustained and preserved the Indian society for more than 5000 years. The Ayurvedic principles for individual level health promotion and the views of Indian philosophy on a healthy and sane society are being (and need to be) re-emphasized. Hence we thought it appropriate to cite examples of India, the health promoting approach of the country, we best know of.
We wish to utilize this space to express our thanks to all the contributors, without whose help; this work would not have been possible. Thanks are also due to Dr Meenakshi Sharma (JRF), Mr CS Kawale (Senior Artist) and Mrs Satnam Kaur (Steno), for their help in bringing this work to a logical conclusion.
The areas and topics covered in the book may not be exhaustive. Feedbacks are sincerely solicited by the undersigned.
When we entered this discipline as aspiring public health students, the idea of health promotion was quite romantic. It instilled optimism in that it seemed like the ultimate cure to the many issues that had plagued our society. The concept looked so perfect and utopian. This book, we think , is a fitting tribute to the discipline whose principles we have grown to love and believe in.
Colic is generally defined as excessive crying in early infancy and can have negative consequences on the infant as well as on the infant’s family life. Excessive crying can result in escalating parental stress levels, abusive caregiver response, increased risk of shaken baby syndrome and parental postpartum depression. In addition to excessive crying, symptoms and descriptors of infant colic include inconsolable crying, screaming, legs drawn up against the abdomen, furrowing of eyebrows, distended abdomen, arched back, passing gas, post-feeding crying and difficulty defecating. There are few well-designed, reproducible, randomized, large-scale studies which demonstrate efficacy of any therapeutic method for colic. An unexplored etiology is that colic is functionally related to a decrease in stooling frequency. Gut distention may periodically result in intensifying discomfort for the infant and in concomitant inconsolable crying. Elimination communication (EC; also known as Natural Infant Hygiene and sometimes referred to as infant potty training, baby-led potty training or assisted infant toilet training) involves the use of cues by which the infant signals to the caregiver that the infant needs to micturate or defecate. Such cues can include types of crying, squirming, straining, wriggling, grimacing, fussing, vocalizing, intent look at caregiver, red face, passing gas and grunting, many of which are the same initial symptoms related to the onset of colicky infant states. A caregiver’s attentive and nurturant response to an infant’s cues involve uncovering the infant’s intergluteal cleft and cradling the infant gently and non-coercively in a supported, secure squatting position. This position will increase the infant’s anorectal angle thus facilitating complete defecation. It is hypothesized that effective and timely elimination will cause increased physical comfort for the infant; colic symptoms will concomitantly decrease.
Purpose:
Uroflowmetry is frequently used and simple urodynamic test, but it may be affected by various factors. Voiding position is one of the factors that can change the results. We tried to compare the uroflowmetric parameters in sitting and standing positions during urination.
Material and methods:
A total of 198 patients were enrolled to the study. All patients underwent an uroflowmetry in standing and sitting position at late afternoon (2-4 PM) of two corresponding days with a gravimetric uroflowmeter (Uroscan, Aymed, Turkey). A transabdominal ultrasonography was used to evaluate post voiding residue (PVR). All uroflowmetric parameters and PVR were compared with paired t test or Wilcoxon signed rank test.
Results:
The median age of study population was 58.0 (36-69) years. There was no statistically significant difference at voided volume of patients in standing and sitting position as it was 271.5 ± 81.8 mL and 274.8 ± 82.4 mL, respectively (P = .505). Mean maximum flow rate (Qmax) during urination at standing position was 15.3 ± 6.7 mL/s while it was 15.0 ± 7.0 mL/s at sitting position (P = .29). Mean average flow rate in standing position was 8.60 ± 4.0 mL/s and 8.25 ± 3.8 mL/s in sitting position (P = .054). There was a statistically significant difference between the median post-voiding residues in standing and sitting urination which was 29.5 (0-257) mL in standing and 47.5 (2-209) mL in sitting position (P < .0001). Other uroflowmetric parameters (time to maximum flow and voiding time) was not statistically different between groups.
Conclusion:
There are no clinically important uroflowmetric differences between voiding in sitting and standing positions so voiding position may be left to personal preferences during uroflowmetric evaluation.
The position that we adopt to evacuate "waste matters" may potentially have an impact on the efficiency with which these are expelled. Proponents of squatting have eloquently described associated "health benefits" and have hinted that nonsquatters may be prone to urological, gynecological, and colorectal disorders. In this original piece of research, the effects of posture on micturition have been studied in various positions with interesting results.
To investigate the effect of voiding position on uroflowmetric variables and postvoid residual urine (PVR) volume in healthy adult men without lower urinary tract symptoms (LUTS).
Men without LUTS were enrolled. Participants were asked to report to the urodynamic suite with comfortably full bladder for uroflowmetry. Each participant performed six voids into digital uroflowmeter (Solar Silver, Medical Measurement System, The Netherlands), all on separate occasions, twice in each of the standing, sitting, and squatting down positions. PVR was measured using transabdominal ultrasound (Siemens).
Total 72 participants were enrolled and 61 completed the study; their mean (+/-SD) age was 26.6 +/- 6.9 years. All of them but one was accustomed to void in standing and squatting positions. The mean maximal flow rates (Q(max)) and average flow rates (Q(ave)) were significantly lower in sitting position, than standing and squatting positions (Q(max): 19.8 +/- 7.4 vs. 23.8 +/- 7.7 and 24.4 +/- 8.1 ml/sec, respectively; P = 0.0001. Q(ave): 11.2 +/- 4.5 vs. 13.9 +/- 4.5, and 13.8 +/- 5.1 ml/sec, respectively; P = 0.0001). The corresponding values of voiding time were significantly higher (t(vv): 38.6 +/- 20.7 sec vs. 28.3 +/- 15.3 and 30.6 +/- 18.1 sec, respectively; P = 0.0001). The latter two positions were statistically similar in voiding characteristics. Voided volumes and PVR were statistically similar among all the three positions.
Uroflow parameters were higher in standing and squatting positions compared to sitting in individuals not accustomed to void in sitting position. Therefore, uroflowmetry should not be performed in a position the individual is not familiar with.
To investigate the effect of position on voiding using uroflowmetric variables and postvoid residual urine volume assessment in healthy normal women.
67 healthy females volunteered to participate in this study. Their mean age was 32 years. Each female attended the urodynamic suite on 2 separate days. They performed 2 voids, 1 in a sitting and another in a squatting posture each day. Maximum flow rate (Q(max)), average flow rate (Q(ave)), voided volume and corresponding postvoid residual urine (PVR) were compared for each position using paired Student's t test.
The mean Q(max) values obtained for sitting and squatting postures were 18.4 +/- 3.2 and 24.8 +/- 4.9 ml/s, respectively, and corresponding Q(ave) values were 9.2 +/- 1.9 and 12.3 +/- 3.3 ml/s, respectively. Mean PVR values for sitting and squatting were 51.8 +/- 22.2 and 21.6 +/- 12.7 ml, respectively.
The posture adopted for micturition affects uroflowmetric variables. The squatting posture is associated with a significantly higher maximum flow rate and a lower postvoid residue. Therefore, when low urine flow rates or high residual urine volumes are encountered during urodynamic study, the patients should be asked whether they normally micturate in a sitting or squatting position. If the former position is used, repeat studies with the patients squatting should be considered before accepting an abnormal test result as indicative of lower-urinary-tract dysfunction.
Posture on the toilet is an important consideration during micturition. The objective of this prospective study is to evaluate the effects of posture on micturition in the lean forward and squatting positions. The participants were 54 volunteers who acted as their own controls. Uroflowmetric parameters were studied in each position. The two issues that arose from the study were 'squatability' and the differences in uroflowmetric parameters. Essentially there were no statistically significant differences found in our study population but the ability to squat in our population of volunteers was quite poor.
A new evacuation proctography (defecography) seat and method of examination is described. The seat was constructed in association with the department of biotechnology. It is constructed of perspex and radiographic demonstration of the distal rectum and anal canal region is obtained without distracting artefacts.
Specialized tests of anorectal function are designed to complement but not to replace good clinical examination and sound professional judgement. The different methods of recording pressure changes have advantages and disadvantages. Poor correlation exists when data recorded using miniature balloons are compared with data from microtransducers. Prolonged ambulatory monitoring of anal sphincter and rectal pressure reveal that spontaneous transient episodes of sphincter relaxation are demonstrable in normal subjects. In the investigation of patients with possible traction injury to the pudendal nerve, electromyography and pudendal nerve terminal motor latency data are more precise than manometry data. Good correlation between noninvasive surface electromyography using an intra-anal plug electrode and anal manometry can be attained. Mapping of sphincter defects using concentric needle technology is reasonably accurate but distinctly painful. Dynamic defecography readily demonstrates abnormalities of the rectal wall. The division between what is normal and what is clinically relevant is rather imprecise. Comparative studies of sonographic and electromyographic mapping of sphincter defects give good correlation. Recent application of fine hooked electrodes have demonstrated periodic episodes of smooth muscle and sphincter relaxation. The saline infusion test and balloon expulsion test help to accurately quantify the difficulty patients experience in retention or evacuation, respectively. Perineometry is a simple, rapid, noninvasive method of measuring the extent of perineal descent on straining. Although reproducible, it tends to underestimate the degree of descent when compared with the radiological method but it avoids the use of ionized radiation.
Chronic constipation is probably the most common symptom resulting in a referral of patients for a dynamic radiologic investigation of the GI tract. The primary usefulness of defecography in chronic constipation is to provide details about the dynamic phenomenon of evacuation which cannot be elicited by any other medical technique. It is employed to demonstrate or rule out the presence of an anatomical deformity (prolapse, rectocele, intussusception) and/or a localized dysfunction (outlet obstruction, rectal inertia) of the distal GI tract. Defecography can distinguish between a grossly obstructed pattern and an overtly normal one, but a definitive diagnosis is made by manometry and electromyographic studies. On the other hand, it should be noted that a failure to show abnormalities by defecography does not necessarily imply a normal anorectal function. A better understanding of anorectal physiology is expected in the future from combined video-pressure studies, which will provide the exact timing between the pressure drop and barium passage through the distal colon.
In this study, the anatomy of the anorectum in relation to the surrounding structures and the anorectal angle were analyzed with magnetic resonance (MR) imaging at rest, during perineal contraction, and during straining in 10 asymptomatic subjects. The intra- and inter-observer and intra- and interpatient variations in the measurements of the anorectal angle, position of the anorectal junction, and position of the plica of Kohlrausch in the rectum were established at rest, during perineal contraction, and during straining. The values for the anorectal angle and position of the anorectal junction obtained with MR imaging were compared with standard radiography defecography findings. It was shown that MR imaging has the potential for measuring these parameters in a more precise and more patient-friendly way than defecography. Unlike dynamic defecography, MR imaging is able to depict the mobility of the posterior rectal wall. A descent of over 20 mm from rest to straining should be considered pathologic. This finding might play a role in patient selection for operation.
Evaluation of anal sphincter tonic activity is important in the proctologic clinic. However, manometric techniques are expensive, complex, and only available in some centers. Because there is often an in-office need for having objective measurements of anal tonic activity, in our clinic we introduced a simple method for measurement of anal pressures. This method is based on the flow of air in an open circuit by using a rubber probe with a side opening at one end. Pressure is assessed by an ordinary manometric gauge for arterial pressure. With this simple instrument, the following parameters are measured: 1) anal resting pressure, 2) squeeze pressure, 3) functional length of the anal canal, and 4) descent of the perineum on staining. After testing the technique in 100 healthy persons, it was applied to 130 patients with several proctologic disorders. Differences in pressures were found between controls and patients with anal fissure (high resting pressures), and patients with anal incontinence (low resting and/or squeeze pressures). A correlation was also found between the descending perineum measured by this method and by defecography. This simple instrument is useful in the office as the first approach to the function of the anal sphincters and the pelvic floor. Nowadays, so-called anal tonometry is part of the proctologic examination in our department, because it is simple, reliable, and takes only a few minutes.
Records from 20 patients on whom defecography and electromyography were performed simultaneously because of defecation disorders were analyzed. According to the electromyographic investigation, the patients could be divided into three main groups: 1) normal sphincter reaction; 2) paradoxical sphincter reaction; and 3) combined reaction. Group A was characterized by a marked reduction of muscular activity during emptying and a pronounced closing reflex after emptying. This was followed by return of normal tonic activity. Patients in group B had no relaxation of the sphincters during emptying but a pronounced increased activity in the external sphincter and the puborectalis muscle. They also had severe emptying difficulties at defecography. No closing reflex was seen. In group C the electrical activity in the sphincters increased during moderate straining and when emptying was complete a clear closing reflex was seen. In this study, a dynamic visualization of the defecation together with a registration of electromyographic activity in the striated anal sphincters was performed. It was shown that patients with paradoxical sphincter reaction were lacking a closing reflex after emptying was complete. This has not been reported previously and is important evidence for the paradoxical defecation pattern. It was also shown that the patients with rectoceles had paradoxical sphincter reaction.
After description of the performance, physiology and normal findings of defecography, the main pathology is discussed as intra-anal rectal intussusception, extra-anal rectal intussusception, mucosal prolapse, rectocele, descending perineum syndrome, spastic pelvic floor syndrome and the solitary rectal ulcer syndrome. Finally, the radiation dose and pitfalls are reported.
Anal endosonography, including measurements of anal sphincter size, was performed in 16 patients with obstructed defecation. The findings were compared with those at defecography and anal manometry. Patients with rectocele and intussusception had a normal endosonographic appearance. One patient with puborectalic spasm had normal sonography. There was no correlation between sphincter size and anal manometry. The external sphincter muscle was thicker and the cross-sectional area larger in patients with obstructed defecation than in healthy controls (p < 0.05). Two patients with sphincter spasm and impaired rectal emptying at defecography had clearly thickened internal sphincters which may be the cause of their defecatory disorder. Three patients with previous anal dilatation or hemorrhoidectomy had sphincteric defects. Anal endosonography may be considered in patients with obstructed defecation to identify patients with internal sphincter hypertrophy.
Tests of anorectal function have evolved into clinically useful investigations, and they should no longer be regarded as esoteric tools. This transformation has led to major advances in understanding, diagnosis, and treatment of defecation disorders, such as constipation. Because constipation is a heterogeneous condition, it cannot be assessed by a single test. Judicious use of anorectal manometry, colon transit study, a test of simulated defecation, and defecography may provide invaluable pathophysiological information. Undoubtedly, examination of rectal and anal pressure activity, rectal sensation, rectoanal reflexes, and the functional morphology of the defecation unit provides more information than any other test of gastrointestinal motor function; however, there is no uniform criteria for defining manometric abnormalities. There is also an urgent need for establishing international standards for manometric techniques and for diagnosis. Nevertheless, knowledge and experience have paved the way for innovative diagnostic techniques and therapeutic approaches for patients with constipation.
The pathophysiology of defecation disorders is multifactorial. An ideal test should identify the underlying cause(s) and provide guidelines for treatment. Unfortunately, there is no such single test. But several techniques are available that could provide comprehensive information regarding the changes in defecation dynamics. Among these, anorectal manometry offers the most useful test for clinicians. Manometry may provide objective evidence for impaired rectal sensation, poor rectoanal coordination, weak anal sphincters or changes that support a diagnosis of obstructive defecation. Other tests such as the balloon expulsion test may serve as screening tools for patients with constipation. In a patient with fecal incontinence, anal endosonography may localize the sphincter defect and aid surgical reconstruction. The pudendal nerve latency test may provide a pathophysiological basis for a weak anal sphincter. Imaging techniques such as defecography may provide useful information regarding rectal prolapse or levator ani dysfunction. Ideally, the clinician should utilize these tests either to confirm a clinical suspicion or to provide new information that could aid management. This review provides an update regarding the various tests that are available for assessing defecation and provides some practical guidelines for performing manometry.
Fecal incontinence is a silent affliction that often leads to self-imposed ostracism. For many years, a lack of understanding regarding its pathophysiology and a lack of empathy among many physicians has bedeviled this problem. However, during the last two decades, remarkable strides have been made, both in the evaluation and in the treatment of incontinence. These advances stem from the ability to perform a detailed and comprehensive assessment of anorectal physiology. Anorectal manometry has spearheaded this renaissance. Manometry is not a single test but consists of a series of measurements that include an assessment of anal sphincter function, rectal sensation, rectoanal reflexes, and rectal compliance. Electrophysiological assessments such as pudendal nerve terminal latency can provide additional information regarding neuromuscular integrity. Newer techniques such as vectography, saline continence test, impedance planimetry, and prolonged ambulatory anorectal manometry have added a new dimension to the overall assessment. Radiological tests such as defecography and anal endosonography can provide complimentary information. These tests of anorectal function have advanced immensely our understanding of the pathophysiological mechanisms that are responsible for fecal incontinence. Equipped with sound objective information, today, it is possible to treat most incontinent patients with novel treatments that include medical, biofeedback, or surgical therapies. This is the second article in a two-part evaluation of defecation disorders that discusses the manometric evaluation of fecal incontinence.
The purpose of this study was to validate the use of transvaginal sonography for anal sphincter evaluation, compare this technique with the more commonly used transanal technique, and explain a publication that suggested that transvaginal sonography is unreliable.
The study population consisted of 50 women, of whom 44 prospectively underwent transanal and transvaginal sonography. The six remaining patients with surgical confirmation underwent only transvaginal sonography. All images were interpreted by the examining radiologist and then reviewed by a second radiologist who was unaware of the first radiologist's interpretations. Defects in the external and internal anal sphincters, the status of the perineal body, and any perianal collections or fistulas were documented.
Twenty-five of the 50 patients showed sphincteric defects. Twenty-two had a defect in the external anal sphincter, of whom 16 had a matching internal anal sphincter defect. Four patients had an isolated internal anal sphincter defect. Surgery in nine of these 22 patients confirmed the defects seen on sonography. The 10th patient who underwent surgery had scar tissue rather than a tear in the external anal sphincter that corresponded with the defect seen on sonography. Defects were identified in all patients presenting with fecal incontinence who had undergone either a primary repair or an anterior sphincteroplasty. Of the 25 patients with intact sphincters on both transvaginal and transanal sonography, four had other significant findings including two perianal abscesses and two T3 rectal carcinomas. In 40 of the 44 patients who were prospectively imaged using both techniques, the sonographic findings were in agreement. Review, performed by a second radiologist who was unaware of the first radiologist's interpretations, verified the findings resulting in an 88.6% interobserver agreement. In all patients, perineal body assessment and assessment of perianal inflammatory disease was more accurate with the transvaginal technique.
Transvaginal sonography is a reliable method for evaluating the anal sphincter, with an accuracy equivalent to that of the transanal technique. Transvaginal sonography is preferable for evaluation of the perineal body and perianal inflammatory processes.
To assess endoanal ultrasonography (US) and endoanal magnetic resonance (MR) imaging for mapping of anal sphincter defects that have been validated at surgery in patients with fecal incontinence.
US, MR imaging, and surgical findings in 22 women with fecal incontinence who underwent sphincter repair were retrospectively reviewed. US and MR imaging had been performed before surgery. The findings were evaluated separately and validated with surgical results.
Endoanal MR imaging findings showed better agreement with surgical results than did endoanal US findings for diagnosis of lesions of the external sphincter (kappa value, 0.85 vs 0.53) and of the internal sphincter (kappa value, 0.64 vs 0.49). Endoanal US could not accurately demonstrate thinning of the external sphincter. MR imaging results correlated moderately with US results (kappa = 0.39). If endoanal MR images alone had been considered, the correct surgical decision would have been made in 21 (95%) patients; if endoanal US images alone had been considered, the correct decision would have been made in 17 (77%) patients.
MR imaging is more accurate than US for demonstration of sphincter lesions. MR imaging provides higher spatial resolution and better inherent image contrast for lesion characterization. Endoanal MR imaging allows more precise description of the extent and structure of complex lesions and is superior for help in decisions about optimal therapy.