Comparison between male and female pelvis.
\\n\\n
IntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\\n\\nIntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
\\n\\nLaunching 2021
\\n\\nArtificial Intelligence, ISSN 2633-1403
\\n\\nVeterinary Medicine and Science, ISSN 2632-0517
\\n\\nBiochemistry, ISSN 2632-0983
\\n\\nBiomedical Engineering, ISSN 2631-5343
\\n\\nInfectious Diseases, ISSN 2631-6188
\\n\\nPhysiology (Coming Soon)
\\n\\nDentistry (Coming Soon)
\\n\\nWe invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
\\n\\nNote: Edited in October 2021
\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/132"}},components:[{type:"htmlEditorComponent",content:'With the desire to make book publishing more relevant for the digital age and offer innovative Open Access publishing options, we are thrilled to announce the launch of our new publishing format: IntechOpen Book Series.
\n\nDesigned to cover fast-moving research fields in rapidly expanding areas, our Book Series feature a Topic structure allowing us to present the most relevant sub-disciplines. Book Series are headed by Series Editors, and a team of Topic Editors supported by international Editorial Board members. Topics are always open for submissions, with an Annual Volume published each calendar year.
\n\nAfter a robust peer-review process, accepted works are published quickly, thanks to Online First, ensuring research is made available to the scientific community without delay.
\n\nOur innovative Book Series format brings you:
\n\nIntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\n\nIntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
\n\nLaunching 2021
\n\nArtificial Intelligence, ISSN 2633-1403
\n\nVeterinary Medicine and Science, ISSN 2632-0517
\n\nBiochemistry, ISSN 2632-0983
\n\nBiomedical Engineering, ISSN 2631-5343
\n\nInfectious Diseases, ISSN 2631-6188
\n\nPhysiology (Coming Soon)
\n\nDentistry (Coming Soon)
\n\nWe invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
\n\nNote: Edited in October 2021
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"9357",leadTitle:null,fullTitle:"Narrative Transmedia",title:"Narrative Transmedia",subtitle:null,reviewType:"peer-reviewed",abstract:"The transmedia narrative is a format that will renew interest in reading and stories, and also allow innovation in various educational fields, if you know how to apply and combine with innovative teaching methodologies that support and encourage play. The transmedia narrative offers a new educational and communicative landscape in a society that is discovering the possibilities offered by platforms and new digital narrative formats. This book is written by creative authors and contains many examples of innovation through transmedia narrative.",isbn:"978-1-78985-686-6",printIsbn:"978-1-78985-685-9",pdfIsbn:"978-1-83968-391-6",doi:"10.5772/intechopen.83753",price:119,priceEur:129,priceUsd:155,slug:"narrative-transmedia",numberOfPages:104,isOpenForSubmission:!1,isInWos:1,isInBkci:!1,hash:"a807a1b8bf5959b85ffc4a4e67269186",bookSignature:"Beatriz Peña-Acuña",publishedDate:"January 8th 2020",coverURL:"https://cdn.intechopen.com/books/images_new/9357.jpg",numberOfDownloads:3835,numberOfWosCitations:2,numberOfCrossrefCitations:2,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:2,numberOfDimensionsCitationsByBook:0,hasAltmetrics:1,numberOfTotalCitations:6,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 12th 2019",dateEndSecondStepPublish:"March 29th 2019",dateEndThirdStepPublish:"May 28th 2019",dateEndFourthStepPublish:"August 16th 2019",dateEndFifthStepPublish:"October 15th 2019",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"194887",title:"Dr.",name:"Beatriz",middleName:null,surname:"Peña-Acuña",slug:"beatriz-pena-acuna",fullName:"Beatriz Peña-Acuña",profilePictureURL:"https://mts.intechopen.com/storage/users/194887/images/system/194887.jpg",biography:"Beatriz Peña-Acuña enjoys discovering scientific and human\naspects of reality. She is an Assistant Professor (Tenure). She teaches in the Faculty\nof Education of the University of Huelva. Her interests are\ninterdisciplinar. She has an\nExtraordinary Doctorate Award (2012) with European mention\nin English. Her scientific production is prolific. She participates as a editorial board in several\njournals of impact (Isi Web and Scopus). She has visited several international universities (New York\nUniversity, UEA, University of London, etc.). She also gives international conferences. The academic has been awarded the President’s Lifetime Achievement Award (2015). She also received an Honoris Causa from UFA University (Russia, 2016) and Catholic\nUniversity of New Spain (USA, 2019).Actually she participates in an European Cost Project. Beatriz is an expert evaluator of\nErasmus plus programs in the Spanish SEPIE agency.",institutionString:"University of Huelva",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"3",institution:{name:"University of Huelva",institutionURL:null,country:{name:"Spain"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1329",title:"Media",slug:"media"}],chapters:[{id:"68482",title:"Introductory Chapter: Narrative Transmedia as a New Social and Cultural Phenomenon",doi:"10.5772/intechopen.88510",slug:"introductory-chapter-narrative-transmedia-as-a-new-social-and-cultural-phenomenon",totalDownloads:654,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:null,signatures:"Beatriz Peña-Acuña and Alba Maria Martinez Sala",downloadPdfUrl:"/chapter/pdf-download/68482",previewPdfUrl:"/chapter/pdf-preview/68482",authors:[{id:"194887",title:"Dr.",name:"Beatriz",surname:"Peña-Acuña",slug:"beatriz-pena-acuna",fullName:"Beatriz Peña-Acuña"},{id:"316359",title:"Dr.",name:"Alba-María",surname:"Martínez-Sala",slug:"alba-maria-martinez-sala",fullName:"Alba-María Martínez-Sala"}],corrections:null},{id:"67690",title:"Interactivity in Fiction Series as Part of Its Transmedia Universe: The Case of Black Mirror: Bandersnatch",doi:"10.5772/intechopen.86881",slug:"interactivity-in-fiction-series-as-part-of-its-transmedia-universe-the-case-of-black-mirror-bandersn",totalDownloads:1040,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:1,abstract:"The special episode Black Mirror: Bandersnatch (Brooker and Slade, 2018) is one of the few interactive experiences that can be found in a fictional series episode. Interactivity, as a generator of transmediality, can be considered in two ways: interactivity with respect to content, content interaction, when contributions, recognized and/or rewarded, are interventions by the user but directed and controlled, without intervening the main plot of the piece, and influential interactions, which can influence the course of history. 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Why storytelling mindfulness? Storytelling is dynamic, imaginative, and interactive. It has a way of reaching a part of the mind and body that integrates us and helps us feel whole. It deepens our understanding of who we are and the skills we already have inside. 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The main goal of this emerging area is to engineer entire synthetic genomes from scratch using pre-designed building blocks obtained by chemical synthesis and rational design. This has opened the possibility to further improve our understanding of genome fundamentals by considering the effect of the whole biological system on biological function. Moreover, the construction of non-natural biological systems has allowed us to explore novel biological functions so far not discovered in nature. This book summarizes the current state of Synthetic Genomics, providing relevant examples in this emerging field.",isbn:"978-1-83969-639-8",printIsbn:"978-1-83969-638-1",pdfIsbn:"978-1-83969-640-4",doi:"10.5772/intechopen.94713",price:119,priceEur:129,priceUsd:155,slug:"synthetic-genomics-from-biobricks-to-synthetic-genomes",numberOfPages:104,isOpenForSubmission:!1,isSalesforceBook:!1,hash:"eb1cebd0b9c4e7e87427003ff7196f57",bookSignature:"Miguel Fernández-Niño and Luis H. 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The healthy pelvic floor support is greatly affected by pregnancy and delivery. The healing of birth trauma is compromised by defecation, predisposing women to complications of organ prolapse, urinary incontinence, obstructive constipation, and sexual dysfunction due to stretch weakness of the supporting muscular and connective tissue structures. The importance of natural healthy pelvic floor support for normal functioning of urinary, reproductive, and intestinal systems is beyond doubt. The weakened and sagged pelvic floor will lead to pelvic floor disorder (PFD). PFD has wide spectrum of manifestations which include urinary and anal incontinence [1], pelvic organ prolapse (POP) [2], obstructed defecation, frequent UTI, constipation, sexual dysfunction, chronic pain syndromes, and associated problems like hemorrhoid [3–5]. PFD symptoms are strongly associated with female gender [6]. It was estimated that one in every three women who delivered a baby experienced PFD and 50% over 50 years old will suffer POP [7]. A total of 46.2% of women would have some major PFD in their life [6]. Based on the logic, there are various type of artificial supports used in management of wide range of medical problems associated with pelvic floor muscle weakness. These artificial supports are not limited to reconstructive surgery of pelvic floor. Perineal support during vaginal delivery is a good example of pelvic floor support with therapeutic role. Evidences also show certain manual support and mechanical support on pelvic floor that have significant therapeutic role deserve more attention in medical world.
Pelvis is the lowest part of human trunk, below the abdomen. Pelvic bone is formed by a pair of hip bone and a sacrum. Each hip bone consists of three sections, ilium, ischium, and pubis. Anteriorly, the two hip bones are joined at pubic symphysis. Posteriorly, they are joined to sacral bone by sacroiliac joints. The cavity bounded by these bones is called pelvic cavity. Superiorly, the cavity opens to abdominal cavity. The combined cavity is referred to as abdominopelvic cavity. Pelvic organs refer to the bladder, prostate, and bowel in men (Figure 1), and bladder, bowel, and uterus in women (Figure 2). Because pelvic cavity is open to and below abdominal cavity, part of small intestine, which is an intra-abdominal organ, is also found in pelvic cavity. Inferiorly, pelvic cavity is closed with a diaphragm which is also called pelvic floor. In reality, it forms the floor of the big abdominopelvic cavity.
Pelvic anatomy in man (in standing position).
Pelvic anatomy in women (in standing position).
Pelvic floor is also commonly referred as “hammock” which stretches from the front to the back. Superior to pelvic floor is pelvic cavity and inferior to it is perineum. Anterior part of the pelvic floor is naturally reinforced with support by perineal membrane and muscles in perineal pouch. The perineal membrane is a thick, triangular fascial sheet that fills the space between the arms of the pubic arch, and has a free posterior border. The posterior part of pelvic floor does not have the similar additional reinforcement.
Pelvic floor is a broad sling of muscles that stretch from pubic bone at the front of the body, to the base of spine at the back. These muscles support the pelvic organs and span the bottom of the pelvis. It is the lowest boundary of abdominopelvic cavity. Its largest component is formed by levator ani muscles: two levator ani muscles which attach peripherally to the pelvic walls and join each other at the midline by connective tissue raphe to form a funnel shape with diaphragm. Posterior aspect of the diaphragm is completed by coccygeus muscles. Anteriorly, there is a “U” shaped hiatus in the diaphragm named as levator hiatus. Through the hiatus, urinary, reproductive, and bowel system open exteriorly. This is the largest hiatus in human body and at the floor of the biggest cavity of human body. In healthy individual, the brim of hiatus is reinforced with thicker puborectalis which is a common sphincter muscle for three systems. With the grip of sphincter, the larger parts (bladder, uterus, and rectum) are well supported in their respective healthy position. Through this hiatus, baby is delivered and through the same hiatus sexual intercourse, urination, defecation, and all the pelvic organs prolapse take place (Figure 3).
Pelvic floor inferior view: right showing pelvic floor (levator ani) and left showing urogenital diaphragm and part of pelvic floor.
A healthy pelvic floor support is essential for normal functioning of urinary and reproductive system as well as normal defecation function. When the support is weakened, the three systems will malfunction and give rise to wide range of problems of PFD, such as descending perineum syndrome, urinary incontinence, pelvic organs prolapse, constipation, etc.
The female pelvic floor serves multiple functions: pleasure and sexuality, parturition, urination and urinary continence, defecation and fecal continence, and keeping the pelvic organs in position.
The functions of pelvic floor:
Provide direct support to pelvic organs and indirect support to intra-abdominal contents.
Continence function of urinary system.
Sexual performance during sexual intercourse.
Process of defecation and continence function of anus.
Pudendal nerve is the main nerve supply. It carries sensation from the perineum as well as motor supply for the pelvic floor muscle. Pudendal nerve derives from nerve root S2–4 which forms two cords before uniting to form the pudendal nerve. It crosses over the lateral part of the sacrospinous ligament and reenters the pelvis running on lateral pelvic wall contained in sheath of obturator fascia called pudendal canal. In the canal, it divides into inferior rectal nerve and perineal nerve before comes out from the canal to continue with their separate routes. Inferior rectal nerve supplies lower segment of rectum, anal canal, anal sphincter, and sensory to adjacent skin. Perineal nerve supplies the genitalia of both male and female. Injury of the nerves would lead to sensory and motor dysfunction of the affected area. When pelvic floor sagged, pudendal nerve tends to be stretched because the part traveling horizontally in the canal has very restricted mobility. Depending on the nature and severity of the nerve injury, the symptoms may include perineal pain to anal incontinence.
Male and female pelvis differs in the following aspects (Table 1).
Male | Female | |
---|---|---|
Pelvis | Smaller | Bigger (typically gynecoid pelvis) |
Prostate | Present (prevent over push of feces during defecation) | Absent (most of the anterior anal fissure sufferer are women) |
Vaginal (the only parous opening: remain opened) (urethra and anus are only potential opening: normally remain closed) | Absent | Present (important reason for pelvic organs prolapse. Various organs prolapse into vaginal canal: i. Cystocele: bladder ii. Urethrocele: urethra iii. Uterus prolapse: uterus iv. Rectocele: rectum v. Enterocele: small intestine) |
Risk of birth trauma | No | Yes (exposed to more medical problem in pelvic area not limited to pelvic floor and anorectal disorders) |
Comparison between male and female pelvis.
Pelvic floor support exposed to different severity of loading and challenges under different circumstances.
Pelvic floor descends during defecation even in healthy individual [8]. Pelvic floor muscle relaxes which is part of normal reflex of defecation. With relaxation of puborectalis and descend of pelvic floor, anorectal angle opens and creates a natural smooth passage for feces to be easily pushed down by peristalsis and causes increase in intra-abdominal pressure by straining. Feces in rectum is guided by smooth curvature of sacrococcyx bone, beyond which the load is on anococcygeal part of pelvic floor. The load would be more in squatting position, because of additional load contributed by the mechanism of squatting explained above (Figure 4). Collectively, this challenges the pelvic floor support specifically on the posterior aspect and contributes to obstructed defecation [9].
Condition of pelvic floor, anorectal angle, and anal mucosa in sagittal and coronal plane during contraction and relaxation.
Lumbar verterbra in lordosis during standing position because of this, pelvic floor is not directly under the load of abdominal contents (Figure 5)
Condition of pelvic floor during standing, sitting, and squatting.
Forward flexion of spine in sitting position brings the pelvic floor directly under whole content of abdominopelvic cavity. This is the rational why one should not have habit sitting too long on toilet seat (e.g., reading in toilet) and most in squatting position (Figure 5).
In squatting position, abdominal cavity with the spine further flexed forward plus abdominal wall is compressed by two thighs. This increases intra-abdominal pressure forcing the contents downward. The pressure on rectal wall would help in process of bowel emptying but the force on pelvic floor would progressively sag pelvic floor and predispose to pelvic organs prolapse in later part of life (Figure 5).
In standing position, anus is hidden deep in intergluteal cleft, in between two thighs. As we flex the thighs to sit and to squat, anus is tugged anteriorly by continuality of skin with that of the two thighs. The gluteal maximus muscles or buttock displaced laterally to allow us to sit with ischial tuberosities directly under the skin and fat. As a result of these, the perianal skin is stretched anteriorly and laterally. Since skin is clearly tougher than the anal mucosa, the stretches pull and expose anal mucosa and cause downward migration of even normal hemorrhoidal bed. The exposure of hemorrhoidal bed predisposes for pathological hemorrhoid formation if there is chronic straining during defecation. This also contributes to the rationale of increase of hemorrhoid among those with weak and sagged pelvic floor.
As a result of progesterone hormone, pelvic floor relaxes as part of nature preparation to enable vaginal delivery. With increase in intra-abdominal content and pressure, the relaxed pelvic floor sags. Sagged pelvic floor bends terminal rectal passage and contributes to obstructive defecation. Pregnancy increases incidence of constipation, urinary incontinence, perineum pain, hemorrhoid, and also anal fissure similar to that of pelvic floor disorders: pregnancy with relaxed and sagged pelvic floor, PFD with weakened and sagged pelvic floor [10, 11].
Progesterone also relaxes smooth muscle in the wall of blood vessel to increase intravascular capacity to accommodate 40–50% increase in blood volume. Due to the same, hemorrhoidal veins also engorge.
Progesterone is widely associated as a cause of constipation. It may or may not be due to its direct effect, but sagged pelvic floor due to progesterone also contributes to increased incidence of constipation among pregnant women. Collectively, these clearly explained increased incidence of constipation and hemorrhoid during pregnancy.
The main difference between straining during weight lifting and defecation is pelvic floor. Pelvic floor is relaxed and descended as part of normal physiology of reflex defecation. Straining during defecation, abdominal wall and diaphragm contracts increase intra-abdominal pressure with relaxed and descended pelvic floor and expose hemorrhoidal bed (Table 2). This plays an important role in pathogenesis of hemorrhoid.
Straining during weight lifting | Straining during defecation | |
---|---|---|
Diaphragm | Contract | Contract |
Abdominal wall | Contract | Contract |
Pelvic floor | Contract | Relax |
Pelvic floor changes during weight lifting and defecation.
During weight lifting, pelvic floor muscle contracts together with diaphragm and abdominal wall. Without anal mucosa migration, hemorrhoidal bed is compressed in anal canal, straining would not allow engorgement of hemorrhoidal vein except in those with preexisting third to fourth degree of hemorrhoid or weight lifting in extreme squatting position.
Gender
Aging
Pregnancy
Birth trauma
Obesity
Constipation
Chronic cough
Position of defecation
Lack of sexual activity
Women suffer from pelvic floor related disorders much higher than men. The main reason is because of vaginal delivery. Even without delivery, women have a bigger hiatus with vaginal passage on their pelvic floor. Severe constipation and urinary incontinence are more common in elderly women, with rates of constipation two to three times higher than that of their male counterparts [12–15].
With muscle dystrophy due to aging and accumulative effect from chronic constipation, the pelvic floor support weaken and this may lead to increase in incidence of pelvic floor related disorders.
A population-based study reported that the cumulative incidence of chronic constipation (CC) is higher in the elderly compared to a younger population [12].
The proportion of women with one or more pelvic floor disorder dramatically increased from 6.3% (95% CI 5.0, 7.8) in women aged 20–29 to 31.6% (95% CI 28.3, 35.1) for women 50–59 years to 52.7% (95% CI 48.1, 57.2) for women aged 80 years and more [16].
Pregnancy alone without birth trauma is an independent factor contributing to weaken pelvic floor [17]. Prevalence of urinary incontinence (UI) in women with vagina delivery increases by 100% (21% of vaginal delivery, compared to nulliparous, 10.1%) [18]. The same study also revealed that prevalence of UI among those who had caesarian section increases by 50% (15.9% of caesarian section, compared to nulliparous, 10.1%) This clearly implies half of the weakening of pelvic floor is not due to birth trauma but due to physiological changes in pregnancy which remain as residual damage and contribute to PFD as delayed complications. Physiological weakened pelvic floor with permanent damage manifests practically the same symptoms as found in PFD, such as constipation, UI, haemorrhoid, anal fissure, and perineal pain.
Pelvic floor is traumatized due to overstretching by newborn with or without episiotomy wound. Objective evaluations of pelvic floor muscle strength revealed a significant decrease after vaginal delivery compared to nulliparous patients [19]. Risk of urinary incontinence significantly increases among those experiencing vaginal delivery [18]. First delivery is the most significant and its prevalence increases with parity [20]. It is undeniable fact that birth trauma is an important factor for pelvic floor damage. But if it is compared to bigger trauma to other part of body (e.g., extensive laparotomy wound), birth trauma alone is not sufficient to give rational explanation for the pathogenesis of chronic pelvic floor disorders and the reason why pelvic floor which is very rich in neurovascular supply is not having satisfactory recovery after birth trauma which is years apart.
Overweight and obesity were the most common disorders affecting urogynecological patients (72.6% overall). In a Chinese population-based, cross-sectional study conducted by Zhu et al. [21] on a group of 5300 randomly selected female residents, obesity described by BMI is a strong risk factor for all types of urinary incontinence in women. The associations of BMI and waist circumference with urinary incontinence were also evaluated in the Nurses’ Health Study. Waist circumference was associated with stress UI, suggesting that overweight and obesity results in higher risk of that pathology. Increased body weight is also a predictor of severity of future symptoms. Comparing women with BMI of 35 kg/m2 or higher with lean women (BMI 21–22.9 kg/m2), the odds ratio (OR) for at least monthly incontinence was 2.11 (95% CI 1.84–2.42) [22].
Pelvic floor muscle relaxes and descends during defecation; with straining, it descents further. Perineal descent was first described by Parks in 1966 [23]. Chronic repetitive straining for constipation would accumulatively lead to descending perineum syndrome and pelvic organs prolapse [23]. Further descent would result in stretching of pudendal nerve and lead to incontinence. CT defecography showed pelvic floor not only descends but also the levator hiatus opens during defecation [24]. Great majority of constipation is obstructive in nature secondary to weakness in pelvic floor support, especially the posterior aspect and patients with pelvic floor disorders usually present with constipation [3, 9, 25]. Collectively, these evidences clearly show straining during defecation or constipation and damage of pelvic floor support forming a vicious cycle and leading to various pelvic floor and constipation related disorders (Figure 6).
Constipation leading to descending perineum syndrome and incontinence.
Cough causes impulsive, sudden increase in intra-abdominal pressure and challenges the continence function of pelvic floor muscle and results in stress urinary incontinence. Chronic cough accumulatively weakens pelvic floor support and leads to more PFD not limited to UI [26, 27].
Refer to Section 2.6.1.
Sexual activity is an exercise for pelvic floor muscle just like Kegel’s exercise for pelvic floor muscle. Refer Section 2.8.4.
PFD—anterior, middle, and posterior
Descending perineal syndrome
Constipation and constipation related anorectal disorders (e.g., hemorrhoid and anal fissure)
Sexual dysfunction
Urinary incontinence
Pudendal nerve stretching
Pelvic organ prolapse
Fecal incontinence
Academically, they are considered different from one another, but actually they are just different descriptions of the partially or fully the same problem from various different prospective.
Theoretically, pelvic floor is also divided into three compartments:
Anterior compartment (bladder and urethra)
Middle compartment (vagina and uterus)
Posterior compartment (anus and rectum)
Since pelvic floor support is essentially for normal functioning of all the three compartments, weakness of the pelvic floor would lead to malfunction and manifest with symptoms from urinary system, reproductive, and also anorectal system [28].
Manifestations or symptoms of PFD:
Constipation and related problems
Urinary incontinence
Recurrent urinary tract infection
Perineal pain
Pelvic organ prolapse
Fecal incontinence
Sexual dysfunction
Patient may present with symptom of one compartment but study show 95% of PFD patients had abnormalities in all three compartments [28].
Descending perineum syndrome (also known as levator plate sagging) refers to a condition where the
Urinary incontinence (UI) is undoubtedly the most popular presentation of PFD but constipation is actually the earliest and the commonest manifestation of PFD. Constipation is the manifestation of posterior compartment in pelvic floor disorders. Even though posterior pelvic floor is complete compared to anterior part with levator hiatus, posterior pelvic floor does not have secondary support like urogenital diaphragm which provides additional support to pelvic floor muscle.
During defecation, feces guided by sacrococcyx bone beyond which it pushed down pelvic floor and bend terminal passage of defecation contribute to obstructive defecation. Outlet obstruction, secondary to pelvic floor dysfunction, accounts for 50% or more cases of constipation in adults [25]. This explains why constipation is commonest manifestation of PFD [3]. In another study in 786 women with urinary symptoms and/or genital prolapse, bowel dysfunction correlates exclusively with posterior aspects of the pelvic floor support [9].
Anal fissure may be the associated problem. Anal mucosa tears occur when the anal mucosa is overstretched by hard stool or even forceful diarrhea [30].
A strong pelvic floor is associated with higher rates of sexual activity as well as higher sexual function scores [31]. In sexually active women, poorer sexual functioning was associated with more symptom distress and with pelvic floor surgery [32].
Urinary incontinence (UI) is involuntary leakage of urine. It is the manifestation of anterior compartment in PFD. Worldwide over 200 million people have an incontinence problem, which is encountered often in healthy persons, especially in women. Its prevalence is between 15 and 50% [33–35].
Theoretically, UI are divided into three types:
Stress UI
Urge UI or overactive bladder
Mixed type
Practically, they may not be clearly differentiated. Stress UI constitutes most of the UI. Stress urinary incontinence refers to situation of leakage when there is extra pressure on bladder on coughing or sneezing. It occurs due to weakness of pelvic floor support at the bladder neck area.
Urge UI or overactive bladder, as the name indicates, is due to overactivity of the urinary bladder. Practically, it can be quite difficult to put blame on the weak sphincteric action as in stress UI or overactive bladder or in urge UI. One thing that is clear is with healthier strong pelvic floor muscle it helps to reduce the incidence of mixed UI [36].
Like PFD, risk of recurrent UTI is associated with women, age, and constipation. With weakened pelvic floor support, residual urine occurs. Constipation is also another problem associated with PFD. Constipation increases chances of
Interstitial cystitis (IC) or bladder pain syndrome (BPS) is a chronic bladder health issue. It is referred to as a feeling of pain and pressure in the bladder area or pelvic area. Along with this pain are lower urinary tract symptoms which have lasted for more than 6 weeks, without having an infection or other clear causes [38]. The exact cause is still considered unclear in medical world but obviously pudendal nerve would be stretched as PFD or perineum descend leading to pain and incontinence depending on the severity [23].
In PFD, the pelvic floor not only descends, the sphincteric grip of puborectalis (thicken muscle which forms the brim of levator hiatus) also relaxes and results in descend from their original position and prolapse of the pelvic organs through the common levator hiatus and to exterior usually to vagina orifice.
These organs are the uterus, vagina, bowel, and bladder.
Symptoms may include:
a sensation of a bulge or something coming down or out of the vagina, which sometimes needs to be pushed back,
discomfort during sex,
problems passing urine—such as slow stream, a feeling of not emptying the bladder fully, needing to urinate more often, and leaking a small amount of urine when you cough, sneeze, or exercise (stress incontinence).
Fecal incontinence could happen due to traumatized anal sphincter as in third degree perineal tear or due to damage of its nerve supply as in descending perineal syndrome. There is a 20–40% association between pelvic floor prolapse and fecal incontinence [4, 39, 40]. With weakened pelvic floor, descended anococcygeal part of pelvic floor constitutes to constipation in PFD. The constipation may in turn contribute to fecal overflow incontinence, which is a very common type of fecal incontinence. When pelvic floor descends further, it may cause stretching and damage nervous supply of the anal sphincter and lead to anal incontinence [23].
Pelvic floor strength can be measured subjectively and objectively using different approaches.
It is a subjective measurement [41]. Laycock developed the Modified Oxford Grading System to evaluate the strength of the pelvic floor muscles by using vaginal palpation [42]. It consists of a six-point scale: 0 = no contraction, 1 = flicker, 2 = weak, 3 = moderate, 4 = good (with lift), and 5 = strong. This measurement scale is widely used by physiotherapists since it can be used with vaginal palpation in the clinical evaluation. For its correct use, manual skill of the physiotherapist is considered essential. All assessments should be carried out by the same physiotherapist. It is an easy method to use and does not require expensive equipment [43]. Inter-rater reliability for vaginal palpation was high (
Perineometer or vaginal manaometer is an objective measurement of pelvic floor strength. It is a pressure device inserted into vagina and connected to a pressure manometer [45].
Similar to vaginal manometry or perineometer, manometry is performed to quantify muscle tone and contractility of pelvic muscles using a pressure sensor inserted through the anal sphincter [46].
Electromyography is performed using an internal vaginal or rectal sensor and surface patch electrodes to evaluate accessory muscle activity. Two EMG surface electrodes are placed on the rectus abdominal muscle, two fingerbreadths apart and medial to the anterior superior iliac spine (ASIS), and one ground electrode is placed on the hipbone. With the internal sensor inserted, the patient is asked to repetitively contract and relax the pelvic floor muscles. Measurements are recorded and analyzed in four phases: (1)
These tests include anal (or vaginal) manometry and electromyography (EMG). Manometry is performed to quantify muscle tone and contractility of pelvic muscles using a pressure sensor inserted through the anal sphincter. On verbal command, the patient is asked to voluntarily contract and relax the anal sphincter muscles. The series of contractions and relaxations are repeated and the results are recorded over a specific time interval. Baseline manometric results can identify altered pelvic muscle function and categorize the pelvic floor syndrome into two broad categories: hypotonic and hypertonic.
Depending on severity and the compartment of pelvic floor involved. PFD manifests with various symptoms and this may fall under the care of different specialists: urologist, gynecologist or coloproctologist.
Conservative options for pelvic floor disorders are practically the same, they are as follows:
Increase water and fiber intake to ease defecation.
Regular bowel habit.
Pelvic floor exercise—pelvic floor exercises are recommended for problems from urology, sexual, gynecology, and also anorectal disorder for both genders.
Weight reduction.
Conservative approaches are generally targeted at their common etiological factors which are to strengthen pelvic floor and to ease defecation. Even though the concepts behind the conservative approaches are very logical, there is still lots of room to be explored before go to the next level of management. Beyond common conservative options, treatment for PFD is mainly to target at the manifestation. Medication has very limited role except for symptom relieving and management of associated problem like urinary tract infection. Antibiotic for UTI would eliminate the bacteria causing the infection but residual urine due to sagged bladder would predispose to similar infection again. Constipation associated with PFD is obstructive in nature mainly due to sagging of posterior part of pelvic floor. Laxative just improves the peristalsis in reflex of defecation but the rectal passage remains bent. Hemorrhoid may not be typically pelvic floor disorders but it is strongly associated with PFD. Medication for haemorrhoid normally targets on the pathological site to help in tissue recovery and relieve symptoms, however if the reason for frequent straining uncorrected, the recurrence would be eminent.
The individual problems of the three pelvic organs are actually just part of the manifestation of weakness of pelvic floor support. Practically, all surgical options are confined to a system or a compartment out of the three compartments of pelvic floor and mainly target at the manifestation level. This should be the reason why prognosis of surgical treatment of the problems in pelvic floor area is generally poor and also associated with higher risk of complication.
Sling surgery for UI in anterior pelvic floor to reconstruct the bladder neck support effectively corrects the UI but the associated posterior pelvic floor sagging is uncorrected. The associated obstructed defecation due to sagged posterior pelvic floor exposes the patient to frequent straining during defecation and overloading the surgical site and cause complication.
Hemorrhoid and anal fissure are indirectly related to sagged pelvic floor. Hemorrhoid surgery just removes the diseased part but not the disease mechanism. Lateral sphincterotomy for anal fissure may eliminate the ability of anal spasm and help constipation. With sagged pelvic floor and the obstructed defecation, straining and overstretching of anal mucosa will still happen and lead to recurrence of hemorrhoid and anal fissure, respectively.
In relation to surgically reconstructed support, sling surgery and mesh implantation are recommended as gold standard surgery to be effective in treating urinary incontinence and POP symptoms. But, these surgeries are facing largest medical complications in medical world. There are hundreds of thousands of such procedures performed in the USA so far and thousands of them end up in complications and lawsuits [47, 48]. This has raised the concern for public about the safety of surgical procedures in treating POP.
Why for sling surgery, an evidence based intervention can end up in such a big catastrophic complication? Mesh or sling is a synthetic non-stretchable material that holds up the urethra or pelvic organ to correct the UI or POP symptoms. During defecation while the rest of pelvic floor is descended during defecation, the surgical site is loaded more than what it can hold. In early postoperative period, prognosis is usually good, but as time passed with aging and straining due to constipation, the rest of pelvic floor descends to overload the surgical site. The synthetic material does not fail to support but only the supported sites gradually erode and migrate and cause excruciating pain when the synthetic material touches the nerve plexus. This has led to world’s largest medical complications, involving billion dollar lawsuit. The worse is yet to come, as urogynecologists are yet to find a reliable solution.
There are various forms of pelvic floor supports available in modern medicine. Individually, they are widely accepted and used in clinical practice but probably they have never been grouped together for their common synthetic therapeutic purpose for natural pelvic floor support.
In 1948, Dr. Arnold Kegel, an American gynecologist, published an article describing a nonsurgical method of toning the pelvic floor in order to help women control incontinence following childbirth. He explained that by exercising the pubococcygeus muscles (PC muscles) of the pelvic floor, women can reduce their likelihood of experiencing bladder problems after pregnancy and birth.
Today, pelvic floor exercises are regarded as the first line of treatment for stress incontinence, as recommended by the National Institute for Heath and Care Excellence (NICE). While people usually associate Kegel’s with women, men can also benefit from these exercises. Another great thing about Kegel’s is that they can improve sexual gratification for both men and women. Studies also found pelvic floor exercises benefit constipation [49], sexual dysfunction in both sexes (including erectile dysfunction) [50].
Vaginal cone and ball are also used to improve pelvic floor exercise performance [51]. Pelvic floor exercises can also be done with passive stimulation directly onto pelvic floor or indirectly through stimulation of sacral nerve (sacral neuromodulation) or peripheral nerve stimulation of posterior tibial nerve. The stimulation can be done with electrical stimulation (e.g., transcutaneous electrical nerve stimulation (TENS)), electromagnetic wave, or acupuncture needle stimulation. Pelvic floor is supplied by sacral nerves. Sacral nerve stimulation as in sacral neuromodulation and peripheral nerve stimulation of posterior tibial nerve share the same nerve roots that supply pelvic floor and are found to have therapeutic benefit to various pelvic floor disorder and constipation.
Perineal support during labor
Perineal support is an important step routinely practiced during final stage of vaginal delivery to minimize pelvic floor damage by vaginal delivery. Clinical intervention program focusing on a manual protecting the perineum, the incidence of anal sphincter ruptures has been successfully reduced from 4.1% to 2.3% [52].
Manual pelvic floor support or massage during defecation
Manual perineal or pelvic floor splinting or support was found to significantly improve constipation among women with defecatory dysfunctions [53].
Bowel aid is a generic name coined by the authors, refer to aids to facilitate defecation. Bowel aid is a special toilet seat with additional supporting means (HPS = Hai’s Perianal support).
It is based on the rationale that majority of constipation or straining during defecation is obstructive type due to sagging of pelvic floor, especially the posterior aspect. Also, repeated downward stretching of pelvic floor accumulatively leads to weakening of pelvic floor support as in PFD. And constipation and PFD in turn lead to multiple disorders in pelvic floor region.
Feces in its terminal passage in rectum are guided by strong sacrococcyx curvature. Beyond the tip of coccyx, feces push down anococcygeal part of pelvic floor and contribute to obstructive defecation.
HPS just provides an external posterior perianal support to counter the pressure by the incoming feces and descend of pelvic floor. It is easier to understand by just comparing to perineal support during delivery (Table 3).
Perineal support | Perianal support | |
---|---|---|
Type of support | Manual | Mechanical or manual |
Time of application | Labor | Defecation |
Area to support | Posterior to vaginal opening | Posterior to anus |
Facilitate passage of | Baby | Feces |
Passing through | Levator hiatus via vagina | Levator hiatus via anal canal |
Benefit: to protect | Protect vaginal and pelvic floor | Protect anus and pelvic floor |
Frequency needed | Few times in a life time | Daily to few times a week |
Likely location of tear if the support is not applied | 6 o’clock position of vagina | 6 o’clock position of anus |
Comparison between perineal support and perianal support.
This conservative approach has being clinically proven to have multiple therapeutic potential. It is proven to successfully manage 100% of subject with chronic idiopathic posterior anal fissure without any side effects, in a controlled study compared with lateral sphincterotomy in the controlled arm which was found to associate with anal incontinence in 17% of the subjects [54].
Posterior anal fissure accounts for more than 90% of anal fissure, very promising to be resolved with the HPS bowel aid [54]. For anterior anal fissure, based on the similar concept, anterior perianal support manually is recommended.
Overstretching of anal mucosa is the cause of the ulcer initiation beyond doubt. Repeated stretching with normal defecation, worse with overstretching as in chronic constipation would interrupt normal healing of the ulcer leading to chronic anal fissure. HPS bowel aid by just providing counter pressure adjacent to the fissure prevents repeated stretching, allowing the fissure to heal naturally without interruption.
In another study, HPS bowel aid alone significantly managed hemorrhoid in pregnancy, without reproductive risk as in oral or topical medication [55].
The same HPS bowel aid also reported to successfully manage pain complication associated with sling surgery for urinary incontinence [56].
Mechanisms of actions of HPS bowel aid:
Prevent downward descend of pelvic floor—smoothen defecation process, prevent anal mucosa migration attributed to perineal descend, and minimize straining.
Enhance reflex of defecation by mechanically exaggerating stimuli of feces onto pressure receptor in rectal wall (Figure 7).
Prevent backward overstretching of anal mucosa which is responsible for majority of anal fissure.
As a supplementary pelvic floor support to prevent premature loading or overloading of surgical site as in episiotomy and sling surgery, respectively.
Bowel aided defecation: smoother defecation and enhanced reflex of defecation.
There are many surgical procedures developed for various circumstances and disorders in pelvic floor area. The basic intention of the procedure mainly to repair, to reposition the prolapse organs, or reconstruct the weaken support. The following are some of the commonly performed surgical procedures in pelvic floor area:
1. Episiotomy wound repair
It is surgical cut made at perineum to widen vagina passage during last stage of childbirth. The purpose of episiotomy is to facilitate easier, faster delivery of the baby and also prevent irregular tear and rupture of tissue and allow better repair of perineum and better healing. Quality of healing of pelvic floor muscle plays an important role in determining the risk of pelvic floor disorders in later life.
2. Obliterative surgery
Obliterative surgery narrows or closes off the vagina to provide support and prevent prolapse of the pelvic organs through vagina orifice. Sexual intercourse is not possible after this procedure.
3. Reconstructive surgery for POP
Pelvic organ prolapse is a common disorder that affects urinary, bowel, and sexual functions in women. The lifetime risk of surgery for pelvic organ prolapse and urinary incontinence is estimated to be 11%, with a 29% rate of reoperation [57].
Reconstruction of pelvic floor may be just by repairing weakened tissue or with graft. The graft use can be autologous (fascia) or synthetic (mesh or sling).
Followings are types of the reconstructive surgery for POP:
Fixation or suspension using patient’s own tissues (uterosacral
Anterior and posterior
Levatorplasty is a reconstructive surgery to strengthen the general pelvic floor support. In the procedure, both sites of the pelvic floor muscles (levator ani) are stitched together to elevate and strengthen levator plate.
Surgery using vaginally placed mesh—mesh placed through the vagina has a significant risk of complications, including mesh erosion, pain, and infection. Because of these risks, vaginally placed mesh for pelvic organ prolapse usually is reserved for women in whom previous surgery has not worked, who have a medical condition that makes abdominal surgery risky, or whose own tissues are too weak to repair without mesh.
4. Sling surgery for urinary incontinence
The two most common types of bladder slings are the TOT sling (transobturator tape sling) and the TVT sling (tension-free vaginal tape sling). Both based on the same basic principle is to provide synthetic support to the urethra, lacking of which is the cause of urinary incontinence. In TOT, the sling is placed through the two obturator foramen. In TVT, the sling is placed behind pubic bone. These sling surgeries have almost wiped out every other surgical incontinence procedures and became gold standard for UI. One may be better than the other but both associated with serious complications.
Except for levatoplasty, generally surgery in pelvic floor area has separate specific reason. Sling surgery aims to reconstruct the support of the urethra specifically to correct UI. Cystocele and rectocele is corrected with anterior and posterior colporrhaphy, respectively. Hemorrhoidectomy and lateral internal sphincterotomy may not be typically referred to as pelvic floor surgery, but problems it meant for are closely associated with pelvic floor disorders. Hemoorhoidectomy removed hemorrhoid. Lateral sphincterotomy means specific for chronic anal fissure.
On the other hand, therapeutic benefits of levatoplasty for descending perineal syndrome are more general. Perineal descent of more than 1.5 cm significantly increases the frequency of all the functional troubles related to the perineum. Retroanal levatorplasty levator plate myorrhapohy is a reconstructive surgery done at pelvic floor posterior anus but benefits all the symptoms [58]. It facilitates easier defecation as well as manage anal incontinence. The benefits not only confine to posterior compartment symptoms but also to that of anterior and middle compartment pelvic floor disorders (stress urinary incontinence, frequency, urgency, dysuria, anal incontinence, dyschesia, dyspareunia, perineodynia, and prolapse).
A vaginal pessary is a removable device placed into the vagina. It is designed to support areas of pelvic organ prolapse. A variety of pessaries are available, including the ring, inflatable, doughnut, and Gellhorn. Pessaries are conservative alternative to surgical repair for pelvic organ prolapse (POP) as well as stress urinary incontinence. Difficulty with self-removal and insertion may be limiting more widespread use of currently available pessaries.
Three issues related to pelvic floor support are discussed:
Episiotomy—to cut or not to cut
Interstitial cystitis
Hemorrhoid during pregnancy
Mesh surgery complication
Episiotomy is an incision on the female perineum that is performed just prior to crowning of the fetal head to increase the diameter of pelvic outlet, thus expediting delivery of the fetus [59]. It is one of the most common surgical procedures experienced by women [60]. Historically, episiotomy was introduced as a strategy to prevent fetal trauma and maternal perineal injury and its routine use gained popularity as it was endorsed by prominent obstetricians in the early 1900s [61, 62]. Early advocates of routine episiotomy argued that it protects the mother’s perineum, resulting in better postpartum pelvic organ support [63, 64]. Recent evidence shows routine practice of episiotomy was not found to be protective against urinary incontinence, fecal incontinence, prolapse, or decreased pelvic floor muscle strength [65]. Researchers tried to look into every aspects not limited to position of episiotomy, suturing method, suture material, postpartum care and pelvic floor exercise. Till recently, there is yet to have any conclusion and the role of episiotomy remains debatable and requires further investigation.
Interstitial cystitis (IC) or painful bladder syndrome (PBS) affects more than 1 million persons in the USA [38]. This condition often affects women of child-bearing age. Its symptoms include suprapubic pelvic and/or genital area pain, dyspareunia, urinary urgency and frequency, and nocturia. The disease is still poorly understood in modern medicine and the cause is unknown. The diagnosis is mainly by history and questionnaire. There is no specific reliable test to confirm the diagnosis. It is important to exclude other organic causes before coming to the diagnosis. Treatment options include oral medications, intravesical instillations, and dietary changes and supplements. Pentosan polysulfate sodium is the only oral therapy and dimethyl sulfoxide is the only intravesical therapy with U.S. Food and Drug Administration approval for the treatment of interstitial cystitis/painful bladder syndrome. During pregnancy, medication should be avoided. To date the disease is poorly understood naturally, the prognosis is still poor, modern medicine is still in the dark and evidence shows no single treatment option with A level evidence (
Pregnancy and vaginal delivery predisposes women to develop hemorrhoids because of hormonal changes and increased intra-abdominal pressure. It has been estimated that 25–35% of pregnant women are affected by this condition [11, 66]. In certain populations, up to 85% of pregnancies are affected by hemorrhoids in the third trimester [67].
Hemorrhoid and constipation are among the most common morbidities that can seriously affect the quality of life of pregnant women. At present, there are no reproductive safety data available for any of the compounds commonly used for hemorrhoids. Hemorrhoids in pregnancy should be treated by increasing fiber content in the diet, administering stool softeners, increasing liquid intake, and training in toilet habits. If these do not work, patients should receive topical treatment. Situation can be so serious that certain percentage of cases will require a surgical evaluation during pregnancy or after delivery. In short, hemorrhoid and constipation are very common problems among pregnant women and the world is yet to have a satisfactory solution.
Since the 1950s, surgical mesh has been used to patch the wall in abdominal hernias repair. In the 1990s, gynecologists began using surgical mesh to patch the floor in surgical treatment of stress urinary incontinence (SUI) and vaginal repair of POP. The use of mesh in SUI repair, referred to as slings or tape became popular, in 1998, based on the work by Ulmsten and colleagues which proved to cure up to 84% of stress urinary incontinence after up to 2 years of follow up [68]. With these, the devices were approved through the FDA’s 510(k) process, which allowed them to go to market without clinical testing.
The evidence only proved the effectiveness and safety of the product up to 2 years of implantation but the device is meant to last lifelong in the women body. The reconstructive surgery only corrects the part responsible for UI and POP while the obstructive constipation associated with posterior compartment on pelvic floor disorders was not attended effectively. The reconstructed pelvic floor continues to expose to increasing challenge due to chronic straining during defecation and aging. It is not logical to expect the same result and prognosis after decades.
From 2005 to 2008, American FDA receives over 1000 reports of transvaginal mesh injuries [69].
2008: FDA issues its first vaginal mesh safety alert, advising doctors of the reports of complications associated with the implants, though the agency states that complications are “rare.”
July 2011: FDA issues warning about high rates of transvaginal mesh complications in treating POP. The agency reports a fivefold increase in vaginal mesh injuries from various models of the devices.
September 2011: The Obstetrics and Gynecology Devices advisory panel to the FDA recommends that transvaginal mesh be reclassified to a high risk device. Manufacturers will have to undergo rigorous testing and get premarket approval studies for new transvaginal mesh devices.
As of 17 January 2017, more than 100,000 lawsuits had been filed in the federal court system claiming complications from vaginal mesh and bladder sling medical devices.
Mesh and sling surgery remain the useful solution for UI and POP which affect up to one third of women population. Their prevalence actively increases with aging of global population [70].
There is still plenty of room for improvement in management of diseases or disorders in pelvic or perineum area. The diseases are named after the manifestation rather than the cause and their managements are focused on the manifestation rather than the cause. In managing uterus prolapse, hysterectomy only removes the uterus not the cause of uterus prolapse. UI is due to weakness of pelvic floor support system at urethra site. Sling surgery effectively substitutes the weakness of the urethra support. If chronic factor that continues to challenge the pelvic floor support system is not managed properly, failure of the surgery and complication logically will happen. Hemorrhoidectomy removed the disease site (pathologically dilated vein) but if the disease causes (chronic straining for defecation) remain, recurrence of hemorrhoid is bound to happen.
Normal healthy pelvic floor support is essential for normal functioning of urinary, sexual and reproductive, and anorectal system. When the support weakens, it manifests like urinary incontinence, sexual dysfunction, pelvic organs prolapse, constipation, and associated problem. These clearly imply that so-called diseases are actually manifestations that arise from a common cause or factor. The causes of the pelvic floor damage are multifactorial, thus we should focus on the factors that are common, and any changes implemented that may positively influence the outcome of the management.
Weakness of pelvic floor is common among all these PFD manifestation and PFD is closely related with constipation. Majority of constipation is obstructive type due to sagged pelvic floor. PFD commonly presents with constipation. Chronic straining due to constipation would accumulatively damage the pelvic floor causing more descend in the pelvic floor. This in turn worsens the severity of associated obstructed defecation. They form a vicious cycle to worsen the situations.
When pelvic floor related problems are viewed holistically removing the boundary of urology, gynecology, and coloproctology, the common factor in their etiopathology is the vicious cycle (sagged pelvic floor—constipation—straining). For better understanding and better management, the diseases should be named by the cause not manifestation. Defecatory perineal disorders (DPD) refer to disorders of perineal region due to weakness of pelvic floor support and chronic straining during defecation. With this understanding, so-called diseases like urinary incontinence, pelvic organs prolapse, and hemorrhoid are actually just manifestations of the disease called DPD. The terminology of DPD may be used for the first time in second Eurasia Colorectal Technology Association Scientific Meeting 2011 in Italy, but the basic concept can be traced back to 1966 by Parks who was the first to describe descending perineal syndrome. Henry et al. explored the idea that constant straining and the resulting perineal descent stretched the pudendal nerve and lead to incontinence [71]. Study shows descend of pelvic floor by merely 1.5 cm that would increase frequency of all the functional troubles related to the perineum including constipation [72].
Birth trauma is widely blamed in etiopathogenesis of PFD. The rationale should be based on the reason why birth trauma heals with so much of complication despite pelvic floor and perineum is very rich in blood and nerve supply. With DFD, understanding the birth trauma is just a popular triggering factor that causes the injury. Defecation loads the newly repair episiotomy wound or birth trauma before healing takes place and compromised natural healing leading to clinical and subclinical wound dehiscence. With the defect, the pelvic descends and contributes to obstructive defecation (a posterior compartment problem of PFD). Chronic straining due to the obstructive defecation, pelvic floor descend further gradually stretches levator hiatus and loosens the sphincter function and gradually leads to urinary incontinence and pelvic organs prolapse (anterior and middle compartmental problem of PFD).
To explain DFD in women with only lower segment cesarean section (LSCS), no vaginal delivery, the significant percentage of damage of pelvic floor actually started during pregnancy by normal physiological changes (raised progesterone hormone and increase intra-abdominal pressure) that sag the pelvic floor and constitute to obstructed defecation. Repeated straining during defecation prevents proper remodeling and results in residual defect and ends up in the same vicious cycle that may be with lesser severity. For those nulliparous, DPD can be contributed by constipation of other causes. As a result of chronic straining for constipation of whatever causes, the pelvic floor sags and enters into the same vicious cycle with relatively lesser severity (Figure 8). Muscular dystrophy due to aging and menopause which is independent factor contributes to worsen DPD.
Flow chart shows the interrelation of contributing factor to defecatory perineal disorders DPD and how the manifestation is caused.
Break the vicious cycle.
1. Prevent constipation
Conservative measures like cultivate regular bowel habit, increase water and fiber intake should be regularly practiced. Use of laxative to treat constipation should be avoided.
2. Protect and enhance pelvic floor support holistically
Kegel’s pelvic floor exercise
Manual support or splint
Mechanical support—bowel aid
Surgical reconstruction—it has no role in pregnant women. For gynecological cases, surgical option should also be kept as last option. Even if surgical option is indicated, it should always be supplemented with other synthetic support like manual and mechanical wherever possible.
3. Special recommendations:
i. Pelvic floor care during pregnancy
Evidence has showed pelvic floor damage responsible for PFD in later life that contributed significantly by even normal physiological changes of pregnancy which cause sagged pelvic floor and constipation. So, preventive measures should be started early during pregnancy to support the pelvic floor and eliminate constipation by optimizing the conservative option discussed above.
Since pregnancy increases the incidence of all major manifestations of PFD and anorectal disorders, usage of drug should be avoided. Even though drugs may be used in desperate situation in management of hemorrhoid during pregnancy but actually there is no preparation available in market with reproductive safety proven. So in this situation, conservative method as mentioned above should be optimized. Instead of using drug to treat the engorged hemorrhoidal bed, it is better to correct the obstructed defecation that associated with constipation during pregnancy.
ii. Management
Since reproductive risk is an important issue, conservative treatment with supplementary pelvic floor support with bowel aided defecation should be recommended in the management of hemorrhoid and constipation besides pelvic floor protection.
iii. Episiotomy wound care
Even after a perfect method of repair and with the best suture material, the pelvic floor muscle has to be protected. It is not sufficient by just abstaining from sex because pelvic floor is challenged most during defecation, especially during constipation. Support of pelvic floor, manual or with bowel aid should be strongly recommended right from first defecation after episiotomy wound repair (Figure 9).
Episiotomy wound is protected with pelvic floor support.
iv. Post-op care of mesh or sling surgery
Mesh or sling serves the purpose well to reconstruct the defective support but when it is repeatedly overloaded during defecation, the surgical site would ultimately fail. Supplementation with all the measure recommended for prevention of DPD would enhance therapeutic outcome. Bowel aid would protect the surgical site during defecation like how a walking aid or crutches protect surgical site after orthopedic surgery of lower limp (Figure 10).
Protected surgical site/sling with pelvic floor support.
v. Interstitial cystitis (IC)/painful bladder syndrome (PBS)
Evidence shows muscle pain (myalgia and fibromyalgia) and constipation are associated with IC/PBS [73]. Conservative management above includes bowel aided defecation which targets on mechanisms to protect pelvic floor muscle and ease defecation which should serve some therapeutic benefit to the IC/PBS. Bowel aid has helped patient with sling surgery complication pain by protecting the surgical site from being stretched, it should serve the purpose on IC/PBS by preventing pudendal nerve stretching which is one of the mechanisms of the perineum pain in IC/PBS. After all, it is just a conservative option without any predicted risk or any reported complication since it was first used for anorectal condition in 2006.
Defecatory perineal disorders (DPD) include conventionally understood PFD and constipation related disorders in normal individuals and also similar problems in pregnant women. With this understanding, the complicated multidisciplinary problems became simple: the disease is DPD and the main etiopathological mechanism is a vicious cycle (constipation—straining—descend perineum); and lack of healthy pelvic floor support is the main component of the vicious cycle. So, it is clear that the focus should be on how to improve, supplement, or protect the pelvic floor support. In evidenced-based medicine, there is actually wide range of synthetic pelvic support available, ranging from exercise, manual, and mechanical to surgical reconstructed supports. Mesh surgery for UI and POP is facing largest complication in history. They are actually base on a similar, logical concept too. The associated complication with the surgery should not be interpreted as failure. Collective scientific evidences actually clearly imply that the surgical support alone may not be sufficient. With chronic straining for defecation and aging, the surgical site is subjected to increasing load. Optimal supplementation with other options, for instance, pelvic floor supports would improve prognosis of the management. Conservative options like Kegel’s exercise, manual, and mechanical support should be better explored before considering surgical option. For those indicated for surgery should be properly educated about manual and supplementary pelvic floor support with bowel aid, to prevent overloading of surgical site. For better outcome, the conservative approaches, including bowel aid defecation should be emphasized and implemented early enough to minimize harmful effects of physiology of pregnancy on pelvic floor and to facilitate optimal recovery from birth trauma. Bowel aid defecation during pregnancy and during postpartum period can be compared to preventive role of walking aid in prevention knee damage and supplementary role in postoperative period in management of orthopedic problems of lower limbs.
In short, with better understanding (with DPD concept) and more holistic approach (optimal pelvic floor supports), it is very promising to witness better prognosis in prevention and management of otherwise complicated pelvic floor and constipation associated perineal disorders. This approach is free of reproductive risk, thus suitable even for the relatively helpless situation of antenatal period.
Lakes and reservoirs are bodies of water that often serve multiple beneficial uses, such as water supply for municipal and agricultural use, recreation use, fishery enhancement, flood control, and power generation. Their physical, biological and chemical characteristics determine to a large extent how those beneficial uses are met. Survey texts, such as Wetzel [1] and Hutchinson [2], describe the important limnological processes that affect lake and reservoir water quality. An overview of reservoir dynamics and water quality is well-summarized in Martin et al. [3].
\nLakes are different from man-made reservoirs where outlet (and perhaps inlet) hydraulic structures regulate the flow rates and often internal hydrodynamics of the reservoir. Not only does this flow regulation affect the reservoir temperature stratification, but also in consequence affects its water quality. An important distinction between rivers and lakes/reservoirs is the cycle of stratification that can occur throughout the year since most rivers are well-mixed vertically.
\nIn some river systems though, stratification can occur if there are natural pools. For example, in the Chehalis River basin in Washington, USA, the Chehalis River is usually well-mixed except in pools of slow-moving water. This is shown where a large area of the Chehalis river has little to no channel slope and exhibits lake-like characteristics in Figure 1.
\nElevation drop along the Chehalis River, WA, USA, showing a section that is lake-like where summer stratification occurs. Sampling sites (multi-colored dots) are also shown.
Stratification in turn is related to the density of water as a function of temperature and dissolved substances. The progression of stratification during a summer period is shown in Figure 2 in a mountain lake during a summer period where the upper well-mixed layer, the epilimnion, is separated from the lower layer, the hypolimnion, by the strong density (temperature) gradient. Figure 3 shows the typical inverse stratification in the wintertime. Oftentimes, ice formation on the surface can impede gas transfer and create winter-time oxygen deficits even though there is reduced biological activity as a result of the cold temperatures.
\nProgression of stratification in summer of Bull Run Lake, OR, USA, during 1997.
Bull Run Lake, OR, USA, temperature profile on January 19, 1993.
The progression of summer stratification can also influence the progression of dissolved oxygen depletion (see Figure 4 for Tenkiller Reservoir, OK, USA). This seasonal depletion in Figure 4 includes both the metalimnetic minimum (caused by hydrodynamic interflow of low-dissolved oxygen water at the base of the epilimnion) and the hypolimnetic depletion as a result of sediment oxygen demand.
\nTenkiller reservoir dissolved oxygen profiles in 2006 showing progression of summer oxygen depletion.
Also, as a result of internal seiching, wind dynamics, surface cooling, and solar radiation input, the vertical profiles for water quality parameters can vary during the day. For example, Hemlock Lake temperature and dissolved oxygen vertical profiles are shown in Figures 5 and 6, respectively, for the morning (9 am) and early afternoon (1 pm). Variation of 1–2°C and 4–5 mg/l dissolved oxygen concentrations were noted over the 4-hour time difference between profiles.
\nHemlock Lake, NY, USA temperature profile July 13, 2013 at 9 am and 1 pm.
Hemlock Lake, NY, USA dissolved oxygen profile July 13, 2013 at 9 am and 1 pm.
Showing the effect of diurnal wind on seiching dynamics, Figure 7 shows a temperature buoy at a depth of 15 m in Chester Morse Lake, WA, USA, where variations of 2–3°C can be common diurnally as wind-induced seiching occurs.
\nInternal seiching as evident in temperature dynamics at a depth of 15 m in Chester Morse Lake, WA, USA. Variations of 2°C occur at a diurnal time scale are evident during the later spring and summer as a result of wind seiching and closeness to vertical temperature gradient.
In order to describe these changes in water quality in a lake or reservoir, the next section describes the mathematical framework for modeling lakes and reservoirs.
\nThe basic governing equations for hydrodynamics and water quality were discussed by Wells et al. [4] and summarized and simplified here. The hydrodynamic governing equations include conservation of water mass and momentum. The water quality governing equations include conservation of constituent mass and heat including processes such as advection, turbulent diffusion, molecular diffusion (and dispersion if there is spatial averaging). An equation of state is used to relate the water density to salinity, temperature, and suspended solids that can affect fluid momentum.
\nThe equations for fluid motion are based on mass and momentum conservation. The development of the governing equations is based on a control volume of homogeneous properties. The conservation of fluid mass is the change in fluid mass within the control volume equaling the sum of mass inflows to the control volume and the sum of mass outflows from the control volume. The conservation of momentum is based on evaluating the sum of forces acting on a control volume in
Example of a force acting on a control volume resulting in the acceleration of the fluid within the control volume.
The general coordinate system used in the development of the governing equations is shown in Figure 9. The rotation of the coordinate system can result in significant horizontal accelerations of fluids. This is usually restricted to large water bodies such as large lakes (such as the Great Lakes in the USA) and oceanic systems. The body force that causes horizontal accelerations because of the spinning coordinate system is termed the Coriolis force.
\nDefinition sketch of coordinate system for governing equations where x is oriented east, y is oriented north, and z is oriented upward opposite gravity, Ω is the angular velocity of the earth spinning on its axis and ϕ is the latitude.
The continuity (or conservation of fluid mass) and the conservation of momentum equations for a rotating coordinate system [5, 6, 7] are the governing equations used to determine the velocity field and water level.
\nThe final form of the governing equations is obtained by making the following assumptions:
the fluid is incompressible, where \n
the centripetal acceleration is a correction to gravitational acceleration,
the Boussinesq approximation (which is related to the incompressibility assumption) is applied to all terms in the momentum equation except those dealing with density gradient induced accelerations, i.e. \n
all velocities and pressure are turbulent time averages, i.e., \n
The governing equations become after time averaging and simplifying:
\nwhere \n
where: \n
where: \n
where: \n
The conservation of constituent mass in a control volume is a sum of all the fluxes (advective and diffusive) into and out from the control volume plus sources and sinks (chemistry, biology, physics, withdrawals, inputs) within the control volume. Summing up the fluxes in each direction, assuming that the fluid is incompressible and that the molecular diffusivity, D, is homogeneous and isotropic, the advective diffusion equation becomes
\nwhere c is the concentration [M/L−3], S is the sources and sinks of reactions occurring in the control volume, or the reaction rate [ML−3 T−1].
\nThis equation is a 3-D, unsteady equation that applies to all flow conditions: laminar and turbulent. Since we cannot determine the instantaneous velocity field, the x-y-and z momentum equations were time averaged and hence were only able to practically predict the temporal mean velocity. Similarly, we time average the conservation of mass/heat equation using time averages of the velocity field.
\nThe instantaneous velocity and concentration are decomposed into a mean and an unsteady component. Similar to the velocity field shown earlier, for concentration, c, this becomes \n
Substituting the time average and fluctuating components of concentration and velocities into the 3D governing equation and time averaging we obtain:
\nwhere the turbulent mass fluxes in x, y and z were assumed to be defined as a gradient, diffusion-type process, such as \n
In turbulent fluids, Ex, Ey, and Ez >> D, and D can be neglected (except at boundaries or density interfaces where turbulent intensity may approach zero). The turbulent diffusion coefficients can be thought of as the product of the velocity scale of turbulence and the length scale of that turbulence. These coefficients are related to the turbulent eddy viscosity. In general, these turbulent diffusion coefficients are non-isotropic and non-homogeneous.
\nSpatial averaging of this equation leads to the introduction of “dispersion” coefficients which account for the transport of mass as a result of spatial irregularities in the velocity field.
\nThese equations are also valid for heat transport and temperature modeling by substituting the concentration of heat, \n
where DT is the molecular thermal conductivity for heat and Ex, Ey, and Ez are the heat and mass turbulent eddy diffusivities assuming they are of the same order of magnitude.
\nSince density is an important variable for the momentum equation to account for density-driven flows, the computation of density is accomplished through an equation of state where density is computed from dissolved and suspended solids concentrations (\n
Typical equations of state for fresh and saltwater have been published by Gill [8] and Ford and Johnson [9].
\nThere are six equations (continuity or conservation of fluid mass, conservation of momentum in x, y and z, and conservation of constituent mass or heat, equation of state) that we are solving for six unknowns: turbulent time average concentration (or temperature), velocities in x, y, and z, density and turbulent time average pressure (or water surface), i.e. \n
Determination of the turbulent eddy viscosities and eddy diffusivities is often based on what are termed closure models that are based on the turbulent Schmidt number (\n
Determination of turbulent eddy viscosities have been based on multiple approaches: (1) eddy viscosity models as a function of water stability [13, 14, 15, 16], (2) Mixing length models [17, 18], (3) One equation models for turbulent kinetic energy [19], (4) Two-equation k-ε models for turbulent kinetic energy and dissipation [11] and (5) Reynolds stress and algebraic stress models [11]. In many models, once the turbulent eddy viscosity is known, then the turbulent diffusion coefficients are computed from \n
Vertical boundary conditions for the hydrodynamic model usually involve a surface shear stress condition for the wind and a bottom shear stress condition for frictional resistance based on a specified friction coefficient (for example, Chezy or Manning’s). Vertical boundary conditions for temperature and water quality constituents are assumed to be known fluxes at the surface and bottom.
\nHorizontal boundary conditions for mass or heat include mass or heat fluxes as a result of advection and for hydrodynamics include water level (or head) or flow conditions. The flow conditions in outlets to stratified reservoirs can be complicated because of local vertical accelerations in the vicinity of the outlet. In many models, the vertical acceleration of a fluid parcel is assumed to be much less than the horizontal accelerations and hence the vertical momentum equation simplifies to the hydrostatic equation. In order to model the complicated outlet hydraulics in a reservoir, special selective withdrawal algorithms are often used [21, 22]. These allow the computation of flow from multiple vertical layers without having to solve the full-vertical momentum equation.
\nTypical assumptions of the flow field and water quality model are related to the dimensionality of the system (one, two or three-dimensions), whether the flow field is dynamic or steady-state, and the turbulence closure approximation. Based on the model assumptions, the model grid is developed where the governing equations are satisfied at points (differential equation representation) or over control volumes (integral representation). The resulting equations are then solved using numerical methods.
\nThe source-sink term in the mass and heat conservation equation can be either positive or negative and is determined by each water quality state variable. The units of \n
State variable | \nTypical source-sink term | \nDescription | \n
---|---|---|
Temperature | \n\n\n | \nφ is the heat flux in units of W/m2 transmitted through the water body. This is the short-wave solar radiation transmitted through the water and is a function of light extinction. The variable z is assumed to be positive downward. | \n
Salinity or conservative substance | \n\n\n | \nNo sources and sinks | \n
Suspended solids | \n\n\n | \nwss is the settling velocity of particles as a positive velocity, cSS is the concentration of suspended solids of a given size fraction. Often multiple size fractions are modeled independently using Stokes’ law for settling velocity, wss. The variable z is assumed to be positive downward. | \n
CBOD | \n\n\n \n\n \n\n | \nSource/sink terms are shown for dissolved CBOD (cCBODd) and particulate CBOD (cCBODp), kCBOD is a BOD decay rate for dissolved and particulate CBOD, and wCBOD is the settling velocity for particulate BOD. Models of CBOD usually use CBODultimate. Many models also track the P and N associated with this organic matter. Many models track multiple CBOD groups. | \n
Algae | \n\n\n | \nSource sink terms include the algae growth rate μgrowth [T−1] (this is a complicated function of light, limiting nutrient and temperature), μrespiration [T−1] the “dark” respiration rate, μexcretion [T−1] the rate of excretion or biomass loss, μmortality [T−1] the mortality rate (which often can include zooplankton grazing as a separate loss rate based on zooplankton populations and zooplankton food preferences), and walgae the algae settling rate (this also can have complicated expressions especially for cyanobacteria and other species which migrate up and down in the water column). Often models include multiple algae groups. Calgae is the concentration of algae. | \n
Ammonia-N | \n\n\n | \nThe source/sink terms shown include algae uptake and release (where δaN is the stoichiometric equivalent of algae to ammonia-N, but the N source can be nitrate), organic matter release as particulate and dissolved CBOD decay (where δCBODdN is the stoichiometric equivalent of cBODd to N and δCBODpN is the stoichiometric equivalent of cCBODp to N), and sediment oxygen demand release under anoxic conditions (where SODN is the rate of N release in mass/area/time and V is the volume of the computational cell and A is the area of the sediment), nitrification decay rate knitr [T−1], and cammonia is the total ammonia concentration. | \n
Dissolved oxygen | \n\n\n | \nThe source/sink term includes algae production and respiration (where \n | \n
Nitrate-Nitrite-N | \n\n\n | \nThe source/sink terms include algae uptake (where \n | \n
PO4-P | \n\n\n | \nThe source/sink terms shown include algae uptake and release (where δaP is the stoichiometric equivalent of algae to P), organic matter release as particulate and dissolved CBOD decay (where δCBODdP is the stoichiometric equivalent of cCBODd to P and δCBODpP is the stoichiometric equivalent of cCBODp to P), and sediment oxygen demand release under anoxic conditions (where SODP is the rate of P release in mass/area/time and V is the volume of the computational cell, calgae is the algae concentration, and A is the area of the sediment). Other models include adsorption of P onto inorganic particles. | \n
Typical source-sink terms for temperature and some eutrophication water quality state variables.
There are many models used to simulate reservoir and lake water quality. A summary of modeling approaches for lakes is shown in Mooij et al. [24] and Janssen et al. [25]. Table 2 shows a listing of some common lake and reservoir models.
\nModel name | \nDescription | \nReference | \n
---|---|---|
DYRESM and CAEDYM | \n1D model based on mixed layer dynamics, separate temperature and water quality models | \nTanentzap et al. [26] | \n
CE-QUAL-W2 | \n2D longitudinal-vertical, open source, eutrophication model, hydrodynamics and water quality solved together | \nWells [20] | \n
CE-QUAL-R1 | \n1D vertical | \nEnvironmental Laboratory [27] | \n
W3 | \n3D, hydrodynamics and water quality solved together | \nAl-Zubaidi and Wells [28] | \n
EFDC and WASP | \n3D, hydrodynamics and water quality solved separately, both sigma stretch and z coordinate models | \nHamrick [29], Tetra Tech [30] | \n
GLM | \n1D | \nHipsey et al. [31] | \n
ELCOM and CAEDYM | \n3D-mixed layer dynamic model, hydrodynamics and water quality solved separately | \nHipsey et al. [32], Hodges and Dallimore [33] | \n
List of common lake and reservoir water quality models.
The choice of a correct framework is dependent on several considerations: (1) dimensionality of the lake/reservoir system (even though all water bodies are in essence 3D, 2D and 1D models can often represent the important processes of water quality and temperature gradients), (2) documentation (up-to-date user manual with example problems), (3) ease of use and expertise required (all models require a degree of file manipulation and many include GUI interfaces that often facilitate running the model for new users), (4) established record of successful projects (as documented in papers and conference proceedings and technical reports) and (5) model processes represent important lake/reservoir processes (for example, if macrophyte growth is an important ecological consideration, does the model represent macrophytes).
\nIn many cases, 3D models do not often do better than other model frameworks. One reason may be that the data and parameter uncertainty increase in higher dimensional models [34]. In a comparison of 2D and 3D models, many examples have shown [28, 35, 36] that 2D models often better represent temperature profiles than some 3D models. There may be many reasons for this, but the important message is that more complicated models do not necessarily mean better model predictions. Another issue with 3D models is the excessive computational time compared to lower dimensional models. In one comparison between a 2D and 3D model, the 3D model took 30× longer than the 2D model. This will vary depending on model configuration and model. This is becoming more of an issue as models are being used for multiple-decade simulations evaluating climate change and long-term changes in model boundary conditions.
\nUsing the CE-QUAL-W2 model [20] as an example, consider an application to Folsom Reservoir, CA, USA, as presented in Martinez et al. [37].
\nFolsom lake, located near Sacramento California USA, is a deep-storage reservoir that provides municipal water, power generation and cold water for primarily salmonid fish in the lower American River (see Figure 10). The reservoir has multiple outlets that allow the operator to choose different water levels for downstream temperature control.
\nFolsom reservoir bathymetry showing the north fork and south fork of the American River channels. Axes are labeled in m.
The model was set-up and calibrated to a 10-year period between January 1, 2001 and December 31, 2011. Boundary conditions for flow, meteorological data, and outflow during this period were developed. A very detailed approach for filling in data gaps was undertaken to provide a good set of boundary conditions. Typical model predictions compared to field data are shown for temperature in Figure 11 in 2002 and 2007 at multiple longitudinal stations in the reservoir. Error statistics for temperature profiles over the 10-year period using about 27,000 data comparisons were an average mean error of 0.004°C, an average absolute mean error (AME, average absolute value of the error) of 0.56°C, and a root mean square (RMS) average error of 0.71°C. The R2 correlation between modeled and predicted temperature was 0.996.
\nFolsom reservoir model temperature predictions compared to field data on August 20, 2002 (left) and October 31, 2007 (right) at 6 different stations in Folsom reservoir.
In other examples of predicting the thermal regime, Cole [38] has shown that typical errors (AME, RMS) for temperature should often be well less than 1°C with a mean error of close to zero with minimal calibration if the boundary condition data are well-specified.
\nOftentimes, the success of modeling other water quality state variables is first dependent on obtaining good temperature calibration results. For example, in a higher elevation pristine lake, Chester Morse Lake, WA, USA, Ceravich and Wells [39] have shown dissolved oxygen profiles mimicking the unusual behavior of the dissolved oxygen profile in a lake with little algae growth as shown in Figure 12. Error statistics for dissolved oxygen, which integrates all the water quality processes, were a ME of 0.15 mg/l, a AME of 0.42 mg/l, and a RMS error of 0.49 mg/l for 551 data-model comparisons.
\nPredictions (solid lines) and field data (dots) of dissolved oxygen at one sampling site for Chester Morse Lake in 2015. Dates shown are Julian days since January 1, 2015.
The complexity of existing models has often exceeded our capacity in the field to verify model coefficients usually because of cost and time. Deterministic water quality models require an incredible amount of information that is rarely measured. In the CE-QUAL-W2 model, for each algal group the model user must specify approximately 25 values describing rate coefficients for growth, respiration, excretion, mortality, stoichiometry, temperature preferences, N preferences, light saturation limits, and settling velocities. Even though this model has no limit to the number of algal groups one can represent mathematically, in a practical sense modeling living populations and their impact on nutrients, organic matter, pH, temperature, and oxygen is very complex. In the end, the model user tries to balance the known field data with literature values of the coefficients with the goal that if the boundary conditions are well-specified, the model requires little calibration.
\nIf one cannot understand and interpret field data, then it will be challenging for a model to match field measurements. Hence, knowing and understanding the field data as one is setting up the model is important for making sure the model is agreeing with field data trends.
\nIn other cases though, the model is able to discern complex interactions between water quality state variables that may be difficult for the model user to piece together a priori. For example, the unusual dissolved oxygen profiles in the field data and model shown in Figure 12 is one example where it was unclear the reasons for the unusual vertical profile until the combination of a sharp thermocline, algae growth within the metalimnion, and slow sediment oxygen demand caused the model to match the field data vertical trend.
\nWater quality models are adding more and more complex algorithms to reproduce admittedly complex phenomena. But this increasing complexity does not necessarily mean a better model or one that better reproduces field data. One example is the use of a complex model of bacterial populations on the Snake River in ID/OR, USA, from Harrison [40]. The bacterial populations were modeled based on Reichert et al. [41] as shown in Figure 13 and compared to a model with only a first order decay rate for organic matter decay (basically neglecting all the complex bacterial dynamics). In predicting the impact of organic matter on dissolved oxygen, the simpler model neglecting bacterial dynamics performed better. This does not mean that complex models may not be useful for research purposes, but more complicated does not mean a better model.
\nBacterial dynamics model compartments in the Snake River from Harrison [
Hence, to improve water quality models, one of the most fruitful areas is working on obtaining better boundary condition data by “smart” filling in of data gaps in time series of field data. This is still a critical component of modeling lakes and reservoirs. In addition, measuring field data on-site for lakes and reservoirs helps tremendously in understanding better the impact of hydrodynamics on water quality.
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\\n"}]'},components:[{type:"htmlEditorComponent",content:'Copyright is the term used to describe the rights related to the publication and distribution of original Works. Most importantly from a publisher's perspective, copyright governs how Authors, publishers and the general public can use, publish, and distribute publications.
\n\nIntechOpen only publishes manuscripts for which it has publishing rights. This is governed by a publication agreement between the Author and IntechOpen. This agreement is accepted by the Author when the manuscript is submitted and deals with both the rights of the publisher and Author, as well as any obligations concerning a particular manuscript. However, in accepting this agreement, Authors continue to retain significant rights to use and share their publications.
\n\nHOW COPYRIGHT WORKS WITH OPEN ACCESS LICENSES?
\n\nAgreement samples are listed here for the convenience of prospective Authors:
\n\nDEFINITIONS
\n\nThe following definitions apply in this Copyright Policy:
\n\nAuthor - in order to be identified as an Author, three criteria must be met: (i) Substantial contribution to the conception or design of the Work, or the acquisition, analysis, or interpretation of data for the Work; (ii) Participation in drafting or revising the Work; (iii) Approval of the final version of the Work to be published.
\n\nWork - a Chapter, including Conference Papers, a Scientific Article and any and all text, graphics, images and/or other materials forming part of or accompanying the Chapter/Conference Paper.
\n\nMonograph/Compacts - a full manuscript usually written by a single Author, including any and all text, graphics, images and/or other materials.
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\n\nScientific Journal – Periodical publication intended to further the progress of science.
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\n\nAll Works published on the IntechOpen platform and in print are licensed under a Creative Commons Attribution 3.0 Unported and Creative Commons 4.0 International License, a license which allows for the broadest possible reuse of published material.
\n\nCopyright on the individual Works belongs to the specific Author, subject to an agreement with IntechOpen. The Creative Common license is granted to all others to:
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\n\nAll Works are published under the CC BY 3.0 and CC BY 4.0 license. However, please note that book Chapters may fall under a different CC license, depending on their publication date as indicated in the table below:
\n\n\n\n
LICENSE | \n\t\t\tUSED FROM - | \n\t\t\tUP TO - | \n\t\t
\n\t\t\t Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported (CC BY-NC-SA 3.0) \n\t\t\t | \n\t\t\t1 July 2005 (2005-07-01) | \n\t\t\t3 October 2011 (2011-10-03) | \n\t\t
\n\t\t\t Creative Commons Attribution 3.0 Unported (CC BY 3.0) \n\t\t\t | \n\t\t\t5 October 2011 (2011-10-05) | \n\t\t\tCurrently | \n\t\t
\n\t\t\t Creative Commons 4.0 International (CC BY 4.0) – for Journal Articles \n\t\t\t | \n\t\t\t15 March 2022 | \n\t\t\tCurrently | \n\t\t
The CC BY 3.0 and CC BY 4.0 license permits Works to be freely shared in any medium or format, as well as the reuse and adaptation of the original contents of Works (e.g. figures and tables created by the Authors), as long as the source Work is cited and its Authors are acknowledged in the following manner:
\n\nContent reuse:
\n\n© {year} {authors' full names}. Originally published in {short citation} under {license version} license. Available from: {DOI}
\n\nContent adaptation & reuse:
\n\n© {year} {authors' full names}. Adapted from {short citation}; originally published under {license version} license. Available from: {DOI}
\n\nReposting & sharing:
\n\nOriginally published in {full citation}. Available from: {DOI}
\n\nRepublishing – More about Attribution Policy can be found here.
\n\nThe same principles apply to Works published under the CC BY-NC-SA 3.0 license, with the caveats that (1) the content may not be used for commercial purposes, and (2) derivative works building on this content must be distributed under the same license. The restrictions contained in these license terms may, however, be waived by the copyright holder(s). Users wishing to circumvent any of the license terms are required to obtain explicit permission to do so from the copyright holder(s).
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\n\nAll rights to Books and Journals and all other compilations published on the IntechOpen platform and in print are reserved by IntechOpen.
\n\nThe copyright to Books, Journals and other compilations is subject to separate copyright from those that exist in the included Works.
\n\nAll Long Form Monographs/Compacts are licensed under the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0) license granted to all others.
\n\nCopyright to the individual Works (Chapters) belongs to their specific Authors, subject to an agreement with IntechOpen and the Creative Common license granted to all others to:
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\n\nThe CC BY-NC 4.0 license permits Works to be freely shared in any medium or format, as well as reuse and adaptation of the original contents of Works (e.g. figures and tables created by the Authors), as long as it is not used for commercial purposes. The source Work must be cited and its Authors acknowledged in the following manner:
\n\nContent reuse:
\n\n© {year} {authors' full names}. Originally published in {short citation} under {license version} license. Available from: {DOI}
\n\nContent adaptation & reuse:
\n\n© {year} {authors' full names}. Adapted from {short citation}; originally published under {license version} license. Available from: {DOI}
\n\nReposting & sharing:
\n\nOriginally published in {full citation}. Available from: {DOI}
\n\nAll Book cover design elements, as well as Video image graphics are subject to copyright by IntechOpen.
\n\nEvery reproduction of a front cover image must be accompanied by an appropriate Copyright Notice displayed adjacent to the image. The exact Copyright Notice depends on who the Author of a particular cover image is. Users wishing to reproduce cover images should contact permissions@intechopen.com.
\n\nAll Video Lectures under IntechOpen's production are subject to copyright and are property of IntechOpen, unless defined otherwise, and are licensed under the Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) license. This grants all others the right to:
\n\nShare — copy and redistribute the material in any medium or format
\n\nUnder the following terms:
\n\nUsers wishing to repost and share the Video Lectures are welcome to do so as long as they acknowledge the source in the following manner:
\n\n© {year} IntechOpen. Published under CC BY-NC-ND 4.0 license. Available from: {DOI}
\n\nUsers wishing to reuse, modify, or adapt the Video Lectures in a way not permitted by the license are welcome to contact us at permissions@intechopen.com to discuss waiving particular license terms.
\n\nAll software used on the IntechOpen platform, any used during the publishing process, and the copyright in the code constituting such software, is the property of IntechOpen or its software suppliers. As such, it may not be downloaded or copied without permission.
\n\nUnless otherwise indicated, all IntechOpen websites are the property of IntechOpen.
\n\nAll content included on IntechOpen Websites not forming part of contributed materials (such as text, images, logos, graphics, design elements, videos, sounds, pictures, trademarks, etc.), are subject to copyright and are property of, or licensed to, IntechOpen. Any other use, including the reproduction, modification, distribution, transmission, republication, display, or performance of the content on this site is strictly prohibited.
\n\nPolicy last updated: 2016-06-08
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This chapter describes a tiered approach to NFM, commencing with strategic modelling to identify a range of NFM opportunities (tree-planting, distributed runoff attenuation features, and soil structure improvements), and their potential benefits, before engagement with catchment partners, and prioritisation of areas for more detailed hydrological modelling and uncertainty analysis. NFM measures pose some fundamental challenges in modelling their contribution to flood risk management because they are often highly distributed, can influence multiple catchment processes, and evidence for their effectiveness at the large scale is uncertain. This demands we model the ‘upstream’ in more detail so that we can assess the effectiveness of many small-scale changes at the large-scale. We demonstrate an approach to address these challenges employing the fast, high resolution, fully-distributed inundation model JFLOW, and visualisation of potential benefits in map form. These are used to engage catchment managers who can prioritise areas for potential deployment of NFM measures, where more detailed modelling may be targeted. We then demonstrate a framework applying the semi-distributed Dynamic TOPMODEL in which uncertainty plays an integral role in the decision-making process.",book:{id:"6018",slug:"flood-risk-management",title:"Flood Risk Management",fullTitle:"Flood Risk Management"},signatures:"Barry Hankin, Peter Metcalfe, David Johnson, Nick A. Chappell,\nTrevor Page, Iain Craigen, Rob Lamb and Keith Beven",authors:[{id:"203276",title:"Dr.",name:"Barry",middleName:null,surname:"Hankin",slug:"barry-hankin",fullName:"Barry Hankin"}]},{id:"55369",doi:"10.5772/intechopen.68924",title:"One- and Two-Dimensional Hydrological Modelling and Their Uncertainties",slug:"one-and-two-dimensional-hydrological-modelling-and-their-uncertainties",totalDownloads:2718,totalCrossrefCites:3,totalDimensionsCites:12,abstract:"Earth processes, which occur in land, air and ocean in different environment and at different scales, are very complex. Flooding is also a part of the complex processes, which need to be assessed accurately to know the accurate spatial and temporal changes of flooding and their causes. Hydrological modelling has been used by several researchers in river and floodplain modelling for flood analysis. In this chapter, factors affecting flash flood, possible options of basic input parameters in one- and two-dimensional hydrological models in data sparse environment, some case studies and uncertainty in hydrological modelling were discussed. This discussion will help the readers to understand the flooding factors, selection of input parameters in data sparse environment, a brief insight of one- and two-dimensional hydrological models and uncertainties in their input and model parameters and model structures.",book:{id:"6018",slug:"flood-risk-management",title:"Flood Risk Management",fullTitle:"Flood Risk Management"},signatures:"Mohd Talha Anees, Khiruddin Abdullah, Mohd Nawawi Mohd\nNordin, Nik Norulaini Nik Ab Rahman, Muhammad Izzuddin Syakir\nand Mohd. Omar Abdul Kadir",authors:[{id:"11196",title:"Dr.",name:"Khiruddin",middleName:null,surname:"Abdullah",slug:"khiruddin-abdullah",fullName:"Khiruddin Abdullah"},{id:"151303",title:"Prof.",name:"Nik Norulaini",middleName:null,surname:"Ab Rahman",slug:"nik-norulaini-ab-rahman",fullName:"Nik Norulaini Ab Rahman"},{id:"151344",title:"Prof.",name:"Mohd Omar",middleName:null,surname:"Ab Kadir",slug:"mohd-omar-ab-kadir",fullName:"Mohd Omar Ab Kadir"},{id:"201647",title:"Mr.",name:"Mohd Talha",middleName:null,surname:"Anees",slug:"mohd-talha-anees",fullName:"Mohd Talha Anees"},{id:"203217",title:"Prof.",name:"Mohd Nawawi",middleName:null,surname:"Mohd Nordin",slug:"mohd-nawawi-mohd-nordin",fullName:"Mohd Nawawi Mohd Nordin"},{id:"203218",title:"Dr.",name:"Muhammad Izzuddin",middleName:null,surname:"Syakir Ishak",slug:"muhammad-izzuddin-syakir-ishak",fullName:"Muhammad Izzuddin Syakir Ishak"}]},{id:"55735",doi:"10.5772/intechopen.69139",title:"Understanding Flood Risk Management in Asia: Concepts and Challenges",slug:"understanding-flood-risk-management-in-asia-concepts-and-challenges",totalDownloads:1941,totalCrossrefCites:6,totalDimensionsCites:11,abstract:"In this chapter, an attempt is made to review the behavior of flood in Asian region and mechanism of flood risk management adopted among Asian nations. Flood is the most frequent natural disaster at present and vulnerability is widespread across the globe. Though, Asian region is on a knife-edge. Distribution of natural disasters in Asia followed by economic damage and human killing is illustrated in this chapter. In addition, discourse of China, Pakistan, India, Bangladesh, Indonesia, Nepal, Vietnam, and Sri Lanka on flood risk management is examined. Flood risk management policies framed by these nations over the period of time are synthesized. Research and investment on forecasting, planning, preparedness, assessment, evaluation, and mitigation of flood risk are explained. This synthesis can present a pathway for better response and flood management for debated Asian countries through filling the identified policy gaps. This chapter also urges a need of holistic and inter-countries research and cross country analysis followed by increased funding for sustainable management of risk.",book:{id:"6018",slug:"flood-risk-management",title:"Flood Risk Management",fullTitle:"Flood Risk Management"},signatures:"Saleem Ashraf, Muhammad Luqman, Muhammad Iftikhar, Ijaz\nAshraf and Zakaria Yousaf Hassan",authors:[{id:"202027",title:"Dr.",name:"Muhammad Saleem",middleName:null,surname:"Ashraf",slug:"muhammad-saleem-ashraf",fullName:"Muhammad Saleem Ashraf"}]},{id:"45003",doi:"10.5772/55472",title:"Impact of Hurricane Katrina on the Louisiana HIV/AIDS Epidemic: A Socio-Ecological Perspective",slug:"impact-of-hurricane-katrina-on-the-louisiana-hiv-aids-epidemic-a-socio-ecological-perspective",totalDownloads:1909,totalCrossrefCites:2,totalDimensionsCites:6,abstract:null,book:{id:"3507",slug:"natural-disasters-multifaceted-aspects-in-management-and-impact-assessment",title:"Natural Disasters",fullTitle:"Natural Disasters - Multifaceted Aspects in Management and Impact Assessment"},signatures:"William T. Robinson",authors:[{id:"161386",title:"Associate Prof.",name:"William",middleName:null,surname:"Robinson",slug:"william-robinson",fullName:"William Robinson"}]},{id:"55628",doi:"10.5772/intechopen.68912",title:"Flood Risk Mapping in the Amazon",slug:"flood-risk-mapping-in-the-amazon",totalDownloads:1639,totalCrossrefCites:3,totalDimensionsCites:6,abstract:"Floods are part of the natural and cultural life in the Amazon. However, the issues and management of fluvial-disaster risks are poorly studied. Among the reasons for the lack of studies, the Amazon region has several gaps in information ranging from inadequate regional maps to spatially unsystematic local data. Flood patterns differ in urban and rural areas. Severe large-scale flooding took place during the previous and the current decades, such as those that occurred in 2009 and 2012. Between 1991 and 2010, official recorded data indicate about 3,292,888 people were affected in 6 regional states of the Amazon (Acre, Amapá, Amazonas, Pará, Rondônia, and Roraima) considering 7 different hazards. Because of the extensive damages, the national government started a mapping program for cities in Brazil that have a history of facing significant flood risks. The aim of this chapter is to analyse the flood-risk mapping conditions in the Amazon.",book:{id:"6018",slug:"flood-risk-management",title:"Flood Risk Management",fullTitle:"Flood Risk Management"},signatures:"Milena Marília Nogueira de Andrade, Iris Celeste Nascimento\nBandeira, Dianne Danielle Farias Fonseca, Paulo Eduardo Silva\nBezerra, Ádanna de Souza Andrade and Rodrigo Silva de Oliveira",authors:[{id:"203296",title:"Dr.",name:"Milena",middleName:"Marília Nogueira De",surname:"Andrade",slug:"milena-andrade",fullName:"Milena Andrade"},{id:"203302",title:"MSc.",name:"Iris Celeste Nascimento",middleName:null,surname:"Bandeira",slug:"iris-celeste-nascimento-bandeira",fullName:"Iris Celeste Nascimento Bandeira"},{id:"203352",title:"Mr.",name:"Paulo Eduardo Silva",middleName:null,surname:"Bezerra",slug:"paulo-eduardo-silva-bezerra",fullName:"Paulo Eduardo Silva Bezerra"},{id:"203353",title:"Mrs.",name:"Ádanna",middleName:null,surname:"Andrade",slug:"adanna-andrade",fullName:"Ádanna Andrade"},{id:"203354",title:"Mr.",name:"Rodrigo",middleName:null,surname:"Oliveira",slug:"rodrigo-oliveira",fullName:"Rodrigo Oliveira"},{id:"203421",title:"Mrs.",name:"Dianne",middleName:null,surname:"Fonseca",slug:"dianne-fonseca",fullName:"Dianne Fonseca"}]}],mostDownloadedChaptersLast30Days:[{id:"56370",title:"Flood Risk Management in Mexico",slug:"flood-risk-management-in-mexico",totalDownloads:1575,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Mexico receives an average annual rainfall of 740 mm, which are distributed in the hydrological cycle as follows: 72% evapotranspiration, 21% becomes runoff and 6% as aquifer recharge. Within the Mexican territory, exist a great diversity of climates and high spatial and temporal variability in water resources availability. In the period 2000–2015, damages from hydrometeorological phenomena in Mexico represented between 60 and 99% of total damages and losses at national level due to natural and socioorganizational events. Considering global climate change impact on the selection, design and implementation of flood control measures, represents a major challenge, since the level of certainty regarding its influence on the variables involved, remains insufficient. This chapter provides a description of the main elements directly linked to flooding in México, such as a high spatial and temporal variability in water resources availability and presence of tropical cyclones in both coasts and climate change. A brief summary of the main disasters caused by hydrometeorological phenomena, the annual cost of the damages, the main non‐structural measures for flood control and the intervention from the Mexican Institute of Water Technology in the use, development and spread of technology focused on flood risk management are also included.",book:{id:"6018",slug:"flood-risk-management",title:"Flood Risk Management",fullTitle:"Flood Risk Management"},signatures:"Felipe I. Arreguín-Cortés and Claudia Elizabeth Cervantes-Jaimes",authors:[{id:"203037",title:"Dr.",name:"Felipe I.",middleName:null,surname:"Arreguin-Cortés",slug:"felipe-i.-arreguin-cortes",fullName:"Felipe I. Arreguin-Cortés"},{id:"204319",title:"M.Sc.",name:"Claudia Elizabeth",middleName:null,surname:"Cervantes-Jaimes",slug:"claudia-elizabeth-cervantes-jaimes",fullName:"Claudia Elizabeth Cervantes-Jaimes"}]},{id:"55369",title:"One- and Two-Dimensional Hydrological Modelling and Their Uncertainties",slug:"one-and-two-dimensional-hydrological-modelling-and-their-uncertainties",totalDownloads:2716,totalCrossrefCites:3,totalDimensionsCites:12,abstract:"Earth processes, which occur in land, air and ocean in different environment and at different scales, are very complex. Flooding is also a part of the complex processes, which need to be assessed accurately to know the accurate spatial and temporal changes of flooding and their causes. Hydrological modelling has been used by several researchers in river and floodplain modelling for flood analysis. In this chapter, factors affecting flash flood, possible options of basic input parameters in one- and two-dimensional hydrological models in data sparse environment, some case studies and uncertainty in hydrological modelling were discussed. This discussion will help the readers to understand the flooding factors, selection of input parameters in data sparse environment, a brief insight of one- and two-dimensional hydrological models and uncertainties in their input and model parameters and model structures.",book:{id:"6018",slug:"flood-risk-management",title:"Flood Risk Management",fullTitle:"Flood Risk Management"},signatures:"Mohd Talha Anees, Khiruddin Abdullah, Mohd Nawawi Mohd\nNordin, Nik Norulaini Nik Ab Rahman, Muhammad Izzuddin Syakir\nand Mohd. Omar Abdul Kadir",authors:[{id:"11196",title:"Dr.",name:"Khiruddin",middleName:null,surname:"Abdullah",slug:"khiruddin-abdullah",fullName:"Khiruddin Abdullah"},{id:"151303",title:"Prof.",name:"Nik Norulaini",middleName:null,surname:"Ab Rahman",slug:"nik-norulaini-ab-rahman",fullName:"Nik Norulaini Ab Rahman"},{id:"151344",title:"Prof.",name:"Mohd Omar",middleName:null,surname:"Ab Kadir",slug:"mohd-omar-ab-kadir",fullName:"Mohd Omar Ab Kadir"},{id:"201647",title:"Mr.",name:"Mohd Talha",middleName:null,surname:"Anees",slug:"mohd-talha-anees",fullName:"Mohd Talha Anees"},{id:"203217",title:"Prof.",name:"Mohd Nawawi",middleName:null,surname:"Mohd Nordin",slug:"mohd-nawawi-mohd-nordin",fullName:"Mohd Nawawi Mohd Nordin"},{id:"203218",title:"Dr.",name:"Muhammad Izzuddin",middleName:null,surname:"Syakir Ishak",slug:"muhammad-izzuddin-syakir-ishak",fullName:"Muhammad Izzuddin Syakir Ishak"}]},{id:"55139",title:"Estimating Flood Quantiles on the Basis of Multi-Event Rainfall Simulation",slug:"estimating-flood-quantiles-on-the-basis-of-multi-event-rainfall-simulation",totalDownloads:1391,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"This chapter provides an insight into a new approach to estimating the flood quantiles based on rainfall-runoff modelling using multiple rainfall events. The approach is based on the prior knowledge about the probability distribution of annual maximum daily totals of rainfall in catchments, random disaggregation of the totals into hourly values and rainfall-runoff modelling. The new presented method called MESEF (Multi-Event Simulation of Extreme Flood) combines design event method based on single-rainfall event modelling and continuous simulation method used for estimating the maximum discharges of a given exceedance probability using rainfall-runoff models. The MESEF method considers varied moisture conditions in model catchment before the occurrence of rainfalls. To verify the efficiency of the proposed method, a comparison was carried out between the values of flood quantiles estimated by the MESEF method and the flood quantiles estimated by direct method. The proposed approach was tested in two catchments in the Upper Vistula River basin. The results of the MESEF method in both catchments were satisfactory; however, in order to verify its effectiveness, more research is needed within catchments of diverse features and landscape. Special attention should be paid to the proportion of moisture conditions that is a crucial factor in future use of the MESEF method in uncontrolled catchments.",book:{id:"6018",slug:"flood-risk-management",title:"Flood Risk Management",fullTitle:"Flood Risk Management"},signatures:"Elżbieta Jarosińska and Katarzyna Pierzga",authors:[{id:"202772",title:"Ph.D.",name:"Elżbieta",middleName:null,surname:"Jarosińska",slug:"elzbieta-jarosinska",fullName:"Elżbieta Jarosińska"},{id:"202833",title:"MSc.",name:"Katarzyna",middleName:null,surname:"Pierzga",slug:"katarzyna-pierzga",fullName:"Katarzyna Pierzga"}]},{id:"55735",title:"Understanding Flood Risk Management in Asia: Concepts and Challenges",slug:"understanding-flood-risk-management-in-asia-concepts-and-challenges",totalDownloads:1936,totalCrossrefCites:6,totalDimensionsCites:10,abstract:"In this chapter, an attempt is made to review the behavior of flood in Asian region and mechanism of flood risk management adopted among Asian nations. Flood is the most frequent natural disaster at present and vulnerability is widespread across the globe. Though, Asian region is on a knife-edge. Distribution of natural disasters in Asia followed by economic damage and human killing is illustrated in this chapter. In addition, discourse of China, Pakistan, India, Bangladesh, Indonesia, Nepal, Vietnam, and Sri Lanka on flood risk management is examined. Flood risk management policies framed by these nations over the period of time are synthesized. Research and investment on forecasting, planning, preparedness, assessment, evaluation, and mitigation of flood risk are explained. This synthesis can present a pathway for better response and flood management for debated Asian countries through filling the identified policy gaps. This chapter also urges a need of holistic and inter-countries research and cross country analysis followed by increased funding for sustainable management of risk.",book:{id:"6018",slug:"flood-risk-management",title:"Flood Risk Management",fullTitle:"Flood Risk Management"},signatures:"Saleem Ashraf, Muhammad Luqman, Muhammad Iftikhar, Ijaz\nAshraf and Zakaria Yousaf Hassan",authors:[{id:"202027",title:"Dr.",name:"Muhammad Saleem",middleName:null,surname:"Ashraf",slug:"muhammad-saleem-ashraf",fullName:"Muhammad Saleem Ashraf"}]},{id:"71247",title:"Dealing with Local Tsunami on Pakistan Coast",slug:"dealing-with-local-tsunami-on-pakistan-coast",totalDownloads:592,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Tsunami originating from a local source can arrive at Pakistan coastline within minutes. In the absence of a comprehensive and well-coordinated management plan, the fast-approaching tsunami might wreak havoc on the coast. To combat such a threat, a wide range of short- and long-term mitigation measures are needed to be taken by several government and private sector organizations as well as security agencies. Around 1000-km coastline is divided administratively into two provinces of Baluchistan and Sindh and further into seven districts. Most of the coastal communities were severely affected by an earthquake of magnitude 8+ on 28 November 1945 followed by a devastating tsunami. In contrast to the level of posed hazard and multiple-fold increase in vulnerabilities since then, the risk mitigation efforts are trivial and least coordinated. It is important to provide stakeholders with a set of prerequisite information and guidelines on standardized format to develop their organizational strategies and course of action for earthquake and tsunami risk mitigation in a well-coordinated manner, from local to the national level.",book:{id:"8979",slug:"tsunami-damage-assessment-and-medical-triage",title:"Tsunami",fullTitle:"Tsunami - Damage Assessment and Medical Triage"},signatures:"Ghazala Naeem",authors:[{id:"193736",title:"Ms.",name:"Ghazala",middleName:null,surname:"Naeem",slug:"ghazala-naeem",fullName:"Ghazala Naeem"}]}],onlineFirstChaptersFilter:{topicId:"665",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:0,limit:8,total:null},allSeries:{pteSeriesList:[],lsSeriesList:[],hsSeriesList:[],sshSeriesList:[],testimonialsList:[]},series:{item:{id:"22",title:"Business, Management and Economics",doi:"10.5772/intechopen.100359",issn:"2753-894X",scope:"\r\n\tThis series will provide a comprehensive overview of recent research trends in business and management, economics, and marketing. Topics will include asset liability management, financial consequences of the financial crisis and covid-19, financial accounting, mergers and acquisitions, management accounting, SMEs, financial markets, corporate finance and governance, managerial technology and innovation, resource management and sustainable development, social entrepreneurship, corporate responsibility, ethics and accountability, microeconomics, labour economics, macroeconomics, public economics, financial economics, econometrics, direct marketing, creative marketing, internet marketing, market planning and forecasting, brand management, market segmentation and targeting and other topics under business and management. This book series will focus on various aspects of business and management whose in-depth understanding is critical for business and company management to function effectively during this uncertain time of financial crisis, Covid-19 pandemic, and military activity in Europe.
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