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Observations on handwashing and defecation practices in a shanty town of Lima, Peru.

Following a two-year cohort study of diarrhoeal diseases in children aged 0-35 months from a shanty town in Lima, 62 families were chosen for detailed observation of hygiene practices. All handwashing and defecation episodes which occurred during a 10-hour observation period (8am-6pm) were recorded. The youngest child in each family was selected as the index child for observation. Handwashing was seen on 483 occasions with 71% of the index children and 80% of mothers observed at least once. The use of clean water, soap and the thoroughness of the handwashing varied according to the purpose, with "better" behaviour observed more frequently when the person was preparing to go out. Forty-five index children (72%) were observed to defecate at least once. Infants defecated in their diapers or clothes; toddlers defecated more indiscriminately around the home area. Handwashing after defecation was rare (11% of occasions) and usually without soap. Faeces were often left accessible to children and animals (42% of occasions), especially when defecation occurred around the home/yard, and the data suggested this occurred more frequently in "higher" diarrhoea households. Stools deposited on the floor were usually just swept aside, covered with earth or eaten by dogs. Those deposited outside the home were frequently left untouched during the observation period or similarly cleared. Soiled clothes were usually left or washed separately, and stools in potties were thrown in latrines. These results suggest hygiene interventions might focus on clearance of stools from home surroundings, increased utilisation of potties and separate washing of soiled clothes.

Child, Preschool↗

Does defecography help in diagnosis and clinical decision-making in defecation disorders?

Defecography is used to investigate patients with defecation disorders, especially obstructed defecation and anal incontinence. We studied 73 consecutive patients who complained of difficult defecation, anal incontinence, or idiopathic anorectal pain. The following defecographic parameters were recorded and compared in different patient groups: anorectal angulation, pelvic floor descent, formation of rectocele, and rectal invagination. Increasing number of childbirths correlated with pelvic floor descent in defecograms (r = 0.319, p < 0.05). There were no significant differences in defecographic parameters in patients with obstructed defecation, anal incontinence, or idiopathic anorectal pain. Thus, we conclude that defecography may be useful as an investigative tool in clinical research of defecation disorders, but it is of minor value in clinical diagnosis and decision-making.

Anal Canal↗

Relaxation biofeedback conditioning as treatment of a disturbed defecation reflex. Report of a case.

The case history is presented of a patient with a disturbed defecation reflex by viral encephalopolyradiculoneuritis. The inability to defecate was thought to be due to hyper-reflexibility and, hence to increased spasm of the external anal sphincter. Normal defecation was eventually brought about by an operant learning technique, as described originally by Haskell and Rovner. The patient was conditioned to relax his external anal sphincter once he felt rectal fullness and the urge to defecate. Defecation was initiated by a Dulcolax suppository.

Adult↗

Influence of severity of illness, medication and selective decontamination on defecation.

OBJECTIVE: To describe the pattern of defecation in critically ill ventilated patients and the influence of selective decontamination (SDD) and other medication. DESIGN: Descriptive cohort study. SETTING: Mixed surgical-medical ICU in a university Hospital. PATIENTS: Ventilated patients with a length of stay >or=7 days taking part in a study on SDD. MEASUREMENTS: Daily registration of defecation, SOFA (sepsis-related organ failure assessment score) score, administration of dopamine, noradrenaline, morphine and other medications. RESULTS: The first defecation occurred after a mean of 6.2 days. Patients with defecation within 6[Symbol: see text]days had lower mean SOFA scores, received more cisapride and lactulose and less dopamine, noradrenaline and morphine, and had a shorter duration of mechanical ventilation and ICU stay. On 57% of the days, no stools were produced; on 31% diarrhea, and on 12%, normal stools. Patients receiving SDD had more days with normal stools and less with diarrhea. Diarrhea was preceded by the administration of lactulose in the majority of patients. CONCLUSION: Time to first defecation correlated with severity of illness, vasoactive medication, administration of morphine, cisapride and lactulose, duration of mechanical ventilation and length of stay. Diarrhea seemed at least partially iatrogenic.

Adult↗

The association of obstructive defecation, lower urinary tract dysfunction and the benign joint hypermobility syndrome: a case-control study.

It has been suggested that, apart from obstetric trauma, chronic straining at stool may also result in pudendal nerve damage, contributing to the etiology of genuine stress incontinence (GSI). The benign joint hypermobility syndrome (BJHS) has been associated with rectal as well as uterovaginal prolapse, suggesting that connective tissue abnormalities may also be implicated. This study was undertaken in order to further investigate whether - and if so, why - an association may exist between symptoms of obstructive defecation, lifetime constipation, chronic heavy lifting and lower urinary tract (LUT) dysfunction. Cases were female patients referred for urodynamic assessment with symptoms of LUT dysfunction. Controls were age-, sex- and postcode-matched community controls. Both cases and controls were assessed using a detailed questionnaire that also asked about symptoms of BJHS. Cases were also divided into their urodynamic classification of LUT dysfunction. All symptoms of obstructive defecation (52.3% vs 33.6%, P=0.00003), as well as chronic straining at stool (38.6% vs 23.4%, P=0.0005), were significantly more common in women with LUT dysfunction than in community controls. BJHS, chronic heavy lifting and a history of uterovaginal prolapse were significantly associated with patients with LUT and obstructive defecation compared to those with LUT dysfunction alone. Overall, symptoms of obstructed defecation were not more prevalent in any one urodynamic diagnostic group than in others. However, childhood constipation and current constipation were significantly more prevalent in women with voiding dysfunction than in those with other urodynamic diagnoses (16.7% vs 5.5%, P = 0.0030 and 13.0% vs 5.7%, P = 0.017). We concluded that women with LUT dysfunction are more likely to have symptoms of obstructive defecation than are community controls. Connective tissue disorders such as BJHS may be an important factor in this association.

Case-Control Studies↗

Neuroleptic-induced emotional defecation: effects of pimozide and apomorphine.

Neuroleptics, such as haloperidol, have been found to produce dysphoria, anxiety and akathisia in humans. In animals, these effects have rarely been reported since the decreased movement produced by these drugs can confound the study of many behavioral indices of emotionality. In fact, most investigators have found a decrease in emotional defecation in rats given neuroleptics in novel environments, supporting their action as a major tranquilizer. We have found, however, that in rats a profound increase in emotional defecation can result from haloperidol administration in well habituated environments, such as the homecage. In male rats, defecation was measured for a one hour test period following various doses of the neuroleptic, pimozide, and the dopamine receptor agonist, apomorphine. Apomorphine and pimozide (a dopamine receptor antagonist) were both found to increase levels of fecal boli excretions. In addition, when apomorphine was combined with haloperidol, defecation levels were also increased suggesting that this phenomenon is not directly mediated by dopamine receptors. It is suggested that this drug-induced defecation is a consequence of the agent's interaction with the affective state of the animal, creating a dysphoric or anxious state in the animal.

Animals↗

Cardio-vascular events at defecation: are they unavoidable?

Cardio-vascular events at defecation are to a considerable degree the consequence of an unnatural (for a human being) seating defecation posture on a common toilet bowl or bed pan. The excessive straining expressed in intensively repeated Valsalva Maneuvers is needed for emptying the bowels in sitting position. The Valsalva Maneuver adversely affecting the cardio-vascular system is the causative factor of defecation syncope and death. The cardio-vascular system of a healthy man withstands the intensive and repeated straining at defecation, while the compromised cardio-vascular system may fail resulting in syncope or even death. The squatting defecation posture is associated with reduced amounts of straining and may prevent many of these tragic cases.

Cardiovascular Physiological Phenomena↗

The defecation reflex in rats: fundamental properties and the reflex center.

While pharmacological and physiological studies in rats are now increasing, physiological properties of their defecation have been scarcely investigated. This study was performed to define the properties of defecation in decerebrate rats, with special reference to the pontine defecation reflex center, which has been postulated in dogs. Intraluminal pressure was recorded from the colon and rectum with balloon-pressure transducer method using balloons of 15-20 mm in length and 0.1-0.3 ml in volume. Distention of a balloon in the descending colon and rectum with an additional injection of 0.03-0.1 ml air induced propulsive contractions on the descending colon and rectum. The mean of threshold pressures to induce propulsive contraction was 17.0 +/- 5.8 mm Hg (mean+/-S.E.) in the proximal part and 18.3 +/- 3.3 mm Hg in the distal part of the descending colon, and 11.8 +/- 1.3 mm Hg in the rectum. The maximum amplitude of propulsive contractions was 55 mm Hg in the rectum, 47 mm Hg in the distal part of the descending colon and 38 mm Hg in the proximal part. Similar colorectal propulsive contractions were produced by gastric distention (5-10 ml, 20-30 mm Hg) and electrical stimulation of the anal canal. Contrarily, spontaneous contractions of the proximal colon were suppressed by rectal distention and anal-canal stimulation. These results suggest that the descending colon and rectum, but not the proximal colon, were innervated by the pelvic afferent and efferent fibers mediating the defecation reflex. Pontine transection at the cerebellar peduncle level abolished colorectal propulsive contractions induced by distention of the stomach, descending colon and rectum, and stimulation of the anal canal, although much smaller contractions were still induced after the pontine transection. These results suggest that the pontine defecation reflex center exists and works in rats, as in dogs.

Animals↗

Self-perceived normality in defecation habits.

BACKGROUND: Available information on normal bowel habits was mainly gathered by means of telephone interviews or mailed questionnaires. AIMS: We undertook a prospective study to evaluate the defecatory habits in subjects perceiving themselves as normal concerning this function. SUBJECTS AND METHODS: A questionnaire (4-week diary with "yes-no" daily answers to six questions concerning bowel habits) was distributed to 204 subjects perceiving their defecation behaviour as normal. RESULTS: The completed questionnaire was returned by 140 subjects. No significant differences were found between sexes or age groups for any variable, even though straining at stool and feeling of incomplete and/or difficult evacuation showed a trend to increase with age. No subject had less than three bowel movements per week or more than three per day. The percentage of symptoms linked to an abnormal defecatory behaviour was well below 10%. Fifty-five percent of subjects reported at least one parameter of abnormal functioning; the most frequent was straining at stool and the rarer was the manual manoeuvres to help defecation. CONCLUSIONS: In normal subjects the prevalence of symptoms considered in Rome II criteria as part of an abnormal defecatory behaviour (in more than 25% of defecations) is well below 10%, manual manoeuvres are almost never used to help defecation, and the frequency of defecations is at least three per week.

Adolescent↗

Investigation of the effects of YM-31636, a novel 5-HT3 receptor agonist, on defecation in normal and constipated ferrets.

We examined the effects of YM-31636 (2-(1H-imidazol-4-ylmethyl)-8H-indeno[1,2-d]thiazole monofumarate), a newly synthesized 5-HT(3) receptor agonist, on defecation in normal and constipated ferrets, and evaluated it as an agent against constipation. YM-31636 facilitated defecation without inducing diarrhea or emetic episodes. This effect occurred within 1 h after oral administration, mostly within 30 min, whereas sodium picosulfate, a widely used laxative, tended to increase the frequency of defecation for several hours with much lower peak incidence than that of YM-31636, and induced diarrhea. UK14304 (brimonidine), an alpha2 receptor agonist, and morphine reduced the frequency of defecation and YM-31636 restored it. These effects of YM-31636 were antagonized by ramosetron, a 5-HT(3) receptor antagonist. These results suggest that YM-31636 could be promising in the treatment of constipation. Because of an early and reliable onset of action compared with sodium picosulfate, YM-31636 could make it easier to control the time of defecation.

Animals↗

Cooperative roles of colon and anorectum during spontaneous defecation in conscious dogs.

Colorectal motility during spontaneous defecation was investigated using force strain gauge transducers implanted in the proximal colon, distal colon, rectum, and anus in six dogs. One 24-hr recording and several defecation recordings were made in each dog. During 24-hr recordings, 29 giant contractions were observed in the distal colon. The giant contractions, which propagated to the rectum, accompanied evacuation more frequently than those that stopped at the distal colon (P < 0.05). Of 66 episodes of defecation, 63 (95%) were accompanied by a giant contraction of the distal colon. Of these, 57 (90%) propagated to the rectum. In three events, giant contraction originated at the rectum. The rectum relaxed prior to the contraction. The internal anal sphincter also relaxed. Migration of giant contraction to the rectum, rectal relaxation-contraction sequence and sphincter relaxation played important roles during defecation. Defecation is a consequence of successive phenomena occurring in both the colon and anorectum.

Anal Canal↗

Chronic visceral hypersensitivity renders defecation more susceptible to stress via a serotonergic pathway in rats.

Visceral hypersensitivity, intestinal dysmotility, and stress play major roles in irritable bowel syndrome. However, the significance of visceral hypersensitivity in stress-induced changes of colorectal motor function is not conclusive. A rat model of chronic visceral hypersensitivity was induced by mechanical colorectal irritation during postnatal development. Defecation and colonic transit time were not different between the visceral hypersensitivity and the control groups at baseline. Stress and a 5-hydroxytryptamine (5-HT) agonist both resulted in a significant increase in defecation in the visceral hypersensitivity group compared with the controls. Prior administration of granisetron, a 5-HT3 receptor antagonist, inhibited stress-induced changes in defecation in the visceral hypersensitivity group as well as the controls. Stress-induced acceleration of colonic transit was not significantly different between the two groups. Our results indicate that chronic visceral hypersensitivity can modulate the effect of stress on defecation via a serotonergic pathway and suggest that visceral hypersensitivity may be related to the susceptibility of the defecative response to stressful events in patients with irritable bowel syndrome.

Animals↗

Colorectal transport during defecation in patients with lesions of the sacral spinal cord.

Normal defecation involves reflexes between the colorectum and sacral spinal cord. Lesions of the conus medullaris or cauda equina interrupt such reflex arches and cause constipation. The aim of the study was to compare colorectal transport during defecation in patients with sacral spinal cord lesions and healthy volunteers. Ten patients with sacral spinal cord lesions (six men and four women, age 21-57 y, median = 36) and 16 healthy volunteers (10 men and six women, age 22-42 y, median = 30) took one or two doses of 111In-labelled polystyrene pellets perorally to mark colorectal contents. Abdominal scintigraphy was performed before and after defecation. Total colorectal emptying and segmental antegrade or retrograde transport was computed. Median colorectal emptying during normal defecation was 81% of the rectosigmoid (range: 53% of the rectosigmoid to complete emptying of the rectosigmoid and 40% of the descending colon) in healthy volunteers and 27% of the rectosigmoid (range: 0-44% of the rectosigmoid) in patients with conal/cauda equina lesions (P < 0.001). Median antegrade transport was 82% (control group) vs 27% (patients) of the rectosigmoid (P < 0.001), 38% vs 4% of the descending colon (P < 0.02), 13% vs 1% of the transverse colon (P = 0.28), and 4% vs 2% of the caecum/ascending colon (P = 0.76). It is concluded that damage to reflex arches between the colorectum and the sacral spinal cord significantly reduces emptying of the rectosigmoid and descending colon during defecation.

Adult↗

Defecation in utero: a physiologic fetal function.

OBJECTIVE: The objective of this study was to investigate the occurrence of in utero defecation as a normal function in the human fetus. STUDY DESIGN: The anuses of 240 fetuses were studied sonographically between weeks 15 and 41 of gestation. Fetal defecation was defined as the expulsion of rectal contents through the anus into the amniotic fluid. The diameter and area of the anus were measured sonographically at times of maximum anal aperture. RESULTS: One or more defecations were documented in all fetuses. The frequency of defecations was highest between week 28 and 34 of gestation. CONCLUSION: This study confirms that defecation in utero is a normal function and supports the view that the evacuation of rectal contents into the amniotic fluid is no departure from normal fetal physiologic behavior.

Amniotic Fluid↗

FLR-4, a novel serine/threonine protein kinase, regulates defecation rhythm in Caenorhabditis elegans.

The defecation behavior of the nematode Caenorhabditis elegans is controlled by a 45-s ultradian rhythm. An essential component of the clock that regulates the rhythm is the inositol trisphosphate receptor in the intestine, but other components remain to be discovered. Here, we show that the flr-4 gene, whose mutants exhibit very short defecation cycle periods, encodes a novel serine/threonine protein kinase with a carboxyl terminal hydrophobic region. The expression of functional flr-4::GFP was detected in the intestine, part of pharyngeal muscles and a pair of neurons, but expression of flr-4 in the intestine was sufficient for the wild-type phenotype. Furthermore, laser killing of the flr-4-expressing neurons did not change the defecation phenotypes of wild-type and flr-4 mutant animals. Temperature-shift experiments with a temperature-sensitive flr-4 mutant suggested that FLR-4 acts in a cell-functional rather than developmental aspect in the regulation of defecation rhythms. The function of FLR-4 was impaired by missense mutations in the kinase domain and near the hydrophobic region, where the latter allele seemed to be a weak antimorph. Thus, a novel protein kinase with a unique structural feature acts in the intestine to increase the length of defecation cycle periods.

Alleles↗

Control of defecation in patients with spinal injuries by stimulation of sacral anterior nerve roots.

OBJECTIVE: To observe the effects of stimulation of the sacral anterior roots on anorectal and low colonic pressures and to programme implanted stimulators to produce defecation. DESIGN: Prospective study of 12 consecutive patients. SETTING: Spinal injuries unit and university gastrointestinal physiology department. PATIENTS: 12 Patients with complete supraconal spinal cord lesions. Their injuries had been sustained at least two years before the study. INTERVENTIONS: A Brindley-Finetech intradural sacral anterior root stimulator was implanted in all patients. Three months postoperatively the stimulator settings were adjusted after measurement of simultaneous anorectal and low colonic pressures. MAIN OUTCOME MEASURES: Full defecation. RESULTS: Six patients achieved complete rectal evacuation of faeces using the implant and subsequently did not require manual help for defecation. For all but one of the patients the total time taken to complete defecation was reduced, and all were free from constipation, the most prevalent gastrointestinal symptom in patients with spinal injuries. CONCLUSIONS: Sacral anterior root stimulators can be programmed to achieve complete unassisted defecation and can considerably improve the quality of life of patients with spinal injuries.

Adult↗

The timing of defecation within the sleep-wake cycle of humans during temporal isolation.

Data were collected from 14 human subjects who lived singly in an isolation unit without temporal cues. The subjects used buttons to signal the times when they woke up, took a meal, defecated, and retired. Under these conditions, the "free-running" circadian rhythms (e.g., the sleep-wake cycles and the rhythm of body temperature) remained internally synchronized in 7 subjects (mean circadian period = 24.47 hr); in the remaining 7 subjects the sleep-wake cycle lengthened beyond 28 hr, desynchronizing from the rhythm of body temperature (internal desynchronization; mean sleep-wake cycle = 33.45 hr). In all subjects, the interval from wake-up to defecation increased with the duration of wake time (alpha); on average, the interval varied proportionally with alpha. Furthermore, the interval from the last main meal (dinner) to defecation the following day was proportional to the sleep-wake cycle--either that which included dinner but preceded the defecation, or that which followed the dinner but included the defecation. It is concluded that a lengthening of the sleep-wake cycle (and of the wake time) results in a slowing down of the processes of digestion and evacuation of the bowels, in parallel with an apparent reduction of total energy expenditure.

Adult↗

[An experimental study of the diurnal changes in colonic motility centering on defecation].

The following findings have been obtained as a result of making an assessment regarding the diurnal changes in colonic motility by means of continuous measurement of contractile waves by using strain gauge force transducers and roentgenographic observation in conscious dogs. 1. Before defecation, the contractile force of the wave was weak, frequency of its emergence was also small, and transfer of intestinal content was slow, showing decrease of colonic motility. 2. After defecation, the gradually increasing and decreasing contractile wave groups became clear, and the contractile force was intensified concurrently with increase of its emerging frequency. Transfer of intestinal content to the anal side was rapid, and recovery of colonic motility was observed. 3. The recovery of the colonic motility after defecation was observed regardless of digestive or interdigestive state. 4. By intake of food, increase of the colonic motility corresponding to gastrocolic response was observed, but it was due to the increase of emerging frequency of contractile wave, for which no change was observed in contractile force or duration in each individual waves. 5. It was suggested that the contractile motion which undergoes gradual increase and decrease is the basic pattern in the colonic motility and that the colonic motility changes by the differences of amount, shape and hardness of intestinal content, and decreases gradually along with increase of intestinal content, but the basic pattern of contractile motion is restored by inflow of intestinal content into the colon which became empty after defecation. From the above it was considered to be inadequate to use the pattern classification of digestive and interdigestive state for the analysis of colonic motility and that assessments should be made centering on defecation.

Animals↗