**Author details**

Ong Meng Chuan1 \* and Kamaruzzaman Yunus2

1 School of Marine and Environmental Sciences, Universiti Malaysia Terengganu, Kuala Nerus, Terengganu, Malaysia

2 Kulliyyah of Science, International Islamic University Malaysia, Kuantan, Pahang, Malaysia

\*Address all correspondence to<EMAIL_ADDRESS>
© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


*Diagnostic Approaches of Dysfunctional Anorectum and Pelvic Floor Disorders DOI: http://dx.doi.org/10.5772/intechopen.102693*

system (e.g., Wexner, Pescatori, and Altomare) [24–26]. Thus, clinical evaluation is complemented by anorectal physiology tests (anorectal manometry, anal endosonography (AES), pudendal nerve terminal motor latency (PNTML), defecography, electromyography (EMG), and MRI) which provide objective patients' assessment and accurate diagnosis of the incontinence cause contributing to the appropriate treatment. However, in clinical practice, anorectal manometry, AES, and PNTML have been shown to be the most useful tests in diagnosis and after-treatment follow up [27, 28]. Anorectal manometry is the first investigation for anorectal physiology which may assess the anal sphincters function (at rest and squeeze), rectal sensation, and rectoanal reflex. In incontinence, anal canal pressures (at rest and squeeze) are low with or without impaired rectal sensation. Rectal sensation disorder may be managed by biofeedback [29]. AES is another examination in the diagnosis of anorectal incontinence, providing information about the anal sphincters integrity [30]. PNTML assesses the pudendal nerve function. Prolongation of PNTML is considered the diagnostic evidence of idiopathic incontinence [31]. Defecography is a useful test which may show anatomical and functional abnormalities of the anorectum and pelvic floor contributing to the anorectal angle assessment that is obtuse in idiopathic incontinence patients [32]. However, the recently used dynamic MRI of the pelvic floor in defecatory disorders may be a more efficient alternative to traditional defecography [33]. Furthermore, recent studies suggest that the defecography can also be replaced by perineal ultrasound [34]. EMG may detect functional anal sphincter abnormalities in incontinent patients with normal AES [35]. In constipated patients, the history may derive valuable information concerning the characteristics of patient's symptoms, the duration, and severity (difficult, painful, incomplete, or impossible defecation) but also the stool frequency, stool consistency, and stool size. A past medical history, obstetric, surgery, neurological, psychological, or medicines should be recorded. However, a recent history of severe constipation or overflow diarrhea in elderly should be carefully investigated to exclude an organic pathology (neoplasm) or impacted stool. Physical examination includes examination of the abdomen, perineum, and anorectum. Abdomen examination should exclude an intra-abdominal mass or tenderness. Perineal inspection may reveal a patulous anus, soiling, scars, prolapsing hemorrhoids, fistulas, or fissure. Digital examination may detect stool (fecal impaction), stricture, or neoplasm and at the same time should be done an anal sphincter function assessment (at rest, squeeze, and straining). If not observed pelvic floor dysfunction (pelvic outlet obstruction or dyssynergia), unusual perineum bulging or rectal prolapse may be noticed. Furthermore, an anterior rectocele or enterocele should be sought. Physical examination should always be followed by rectosigmoidoscopy which can identify anorectal and colonic pathologies (stricture, neoplasm, internal rectal prolapse, megarectum, inflammatory bowel disease, or solitary rectal ulcer). However, diagnostic approach of constipated patient is completed by selected specialized investigations which can diagnose and differentiate with accuracy and objectivity the constipation causes of obstructed defecation leading to optimal treatment. Specialized tests include colonic transit time test, anorectal manometry, defecography, balloon expulsion test, and EMG. In addition, new specialized techniques as high-resolution anorectal manometry, dynamic MRI, and dynamic perineal ultrasound have been used and proved useful in the diagnostic attempt of the dysfunctional disorders cause of the anorectum, pelvic floor, and colon [36–39]. Colonic transit time is estimated by an abdominal X-ray 5 days after using radiopaque markers. Retention of the markers in the rectosigmoid colon suggests a dyssynergic pelvic floor and pelvic outlet obstruction [40].

Anorectal manometry (at rest and straining) may show motor dysfunction of the anorectum (impaired anal relaxation-anal resting pressure unchanged) or (paradoxical anal contraction-anal resting pressure increases), or both [41, 42] and sensory dysfunction of anorectum (impaired rectal sensation and high distensibility-threshold for first sensation and for call to defecate elevated) in constipation of obstructed defecation [43, 44]. Rectoanal inhibitory reflex is usually present except in Hirschsprung's disease that is absent [45]. However, the new technique of highresolution anorectal manometry seems to have more advantages compared with conventional manometry (easier use, more accurate values of the anorectal pressures, complete anorectal imaging, and automatic analysis of the recording results with color morphology) allowing a most comprehensive diagnostic approach of the dysfunctional anorectum and pelvic floor disorders as idiopathic incontinence, dyssynergic pelvic floor, and Hirschsprung's disease [46–48]. Defecography, in patients with functional obstructed defecation, may show acute anorectal angle as an inability of puborectalis muscle relaxation or a spastic pelvic floor [49, 50]. However, recently, dynamic MRI of the pelvic floor and dynamic perineal ultrasound can be considered an alternative to traditional defecography [51]. In balloon expulsion test, patients with obstructed defecation are unable to expel the balloon [52]. EMG can recognize a dysfunctional puborectalis or/and external anal sphincter, in cases with obstructed defecation (anismus or dyssynergia) during straining, recording to increased their pathological activity [53, 54]. In patients with perineal pain syndromes, in the diagnostic approach of patients with chronic perineal pain an important place occupy the thorough history, careful physical examination, and selected specialized tests. Perineal pain syndromes are clinically distinguished by the duration of painful episodes, frequently, and characteristics. However, perineal pain of dysfunctional pelvic floor syndromes should be distinguished by pelvic pain. Pelvic pain usually relates to pathological conditions such as gynecological or urological diseases, infection, irritable bowel disease, and neurological disorders. All these pathological conditions may affect the perineal muscles (pelvic floor, anal, and urethral sphincters) and sometimes may pretend dysfunctional syndromes with perineal pain, as the levator ani syndrome. So, the history may give useful information about the characteristics of pain, the location, duration, frequency, provocative factors, and factors of worsening the pain. Furthermore, the past medical history (medicines, pelvic injury, surgical procedures, excessive physical activity, psychological distress, anxiety, psychical trauma, sexual abuse, and psychical disease) should be recorded. Physical examination includes inspection and palpation of the perineum. Digital rectal and vaginal examination is significant in the assessment of the anorectum and levator ani muscle (puborectalis). The diagnosis of dysfunctional pelvic floor syndromes is based on characteristics symptoms, digital examination findings of levator ani palpation (tenderness, contraction, or sensitive trigger points), pathological tests as electromyography and exclusion of the anorectal or endopelvic organic disease with perineal pain. Nevertheless, the diagnosis of these syndromes may be difficult because they constitute overlapping functional entities. The differential diagnosis of chronic perineal pain includes neoplasms of anorectum, anal fissure, anorectal abscess, thrombosed external hemorrhoids, proctitis, cystitis, endometriosis, internal rectal prolapse, descending perineum syndrome, solitary rectal ulcer, leukemia, and neurological disorders spinal column or spinal cord [23].

In conclusion, diagnostic approaches of dysfunctional anorectum and pelvic floor disorders include the history, a careful physical examination and selected specialized

tests as well as the exclusion of the anorectal or endopelvic organic disease that contribute to objective and accurate diagnosis of their pathological cause leading to the optimum treatment.


**Preface to "Advances in Cross-Coupling Reactions"**

Metal-catalyzed cross-coupling reactions stand among the most important synthetic tools in Chemistry for the preparation of a wide variety of organic compounds, from bioactive compounds to new organic materials. This methodology relies on the high versatility, the chemoselectivity, and the stereoselectivity to build most of the carbon–carbon type bonds, particularly between unsaturated carbons, and carbon–heteroatom bonds using heteronucleophiles. Therefore, a variety of organic compounds can be used and the reactivity tuned by choosing an adequate metal catalyst and ligands. As a consequence, this methodology has been applied in industrial processes using classical and non-classical reaction conditions. Despite these remarkable synthetic properties, new ways to extend the selectivity and improve the efficiency and sustainability of the coupling reactions are continuously being discovered. This Special Issue aims to highlight the most recent advances in cross-coupling reactions. This Special Issue will cover new leaving groups, nucleophiles, catalysts, and non-classical reaction conditions. We hope that this Special Issue will stimulate authors and readers as much as it has the Editors.

> **Jos´e P´erez Sestelo, Luis A. Sarandeses** *Editors*


**3.1 Step 1: opportunity analysis**

For any start-up or mature company wishing to enter a value-based contract, the essential first step is to assess the financial opportunity. Payers are subject to multiple new opportunities weekly; a provider or HCM must make a compelling economic case to gain attention. The compelling economic case begins with **opportunity.** Said differently, does what the provider or HCM intend to contract for address sufficient healthcare spending to be interesting to the payer? Opportunity analysis requires a detailed analysis of healthcare spending on the condition or procedure that the provider or HCM intends to manage. This type of analysis requires detailed healthcare spending (claims) data for the business segment in which the provider or HCM operates. Analysis should address condition prevalence and utilization of the targeted condition(s) and estimate the addressable cost they impose. To gain a payer's attention the provider/ HCM must address an economic concern, which in turn combines two elements:

Some conditions impose one but not the other of these elements: for example, in an employer population, an episode of stroke is very high cost but occurs with sufficiently low frequency that the average employer may not have experienced a recent stroke in its population. Employees that suffer strokes experience lengthy episodes, during which another payer (such as Social Security disability, or a retirement plan) may become responsible for reimbursement. As a result, the employer may not view strokes as a concern. Cancer, in the other hand, imposes high costs episodically but with cancer diagnoses occurring frequently enough for a payer to be concerned with managing cancer costs.

Modeling opportunity, particularly for individual diagnoses, requires access to large databases. These may be purchased from data vendors, or providers/HCMs may contract with a consultant for this phase of work.