Tag Archives: fecal incontinence

Population-Based Study: Prevalence of Bowel and Bladder Dysfunction in Early Childhood (Good Bowel Control is Happening Later)

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SJ Verkuijl et al. JPGN 2023; 77: 47-54. Open Access! The Prevalence of Bowel and Bladder Function During Early Childhood: A Population-Based Study

Methods: This cross-sectional questionnaire study (n=791 Dutch children) up to age 7 yrs of age.

Key findings:

  • The mean age at which parents/caregivers considered their child fully toilet-trained was 5.1 ± 1.5 years. “Compared to studies performed 15 years ago, we found toilet training to be completed at an older age (23,26–28).”
  • Prevalence of fecal incontinence among toilet-trained children was 12%.
  • Prevalence of constipation was 14%, with excessive stool retention (75.9%) and painful/hard stools (78.7%) as the 2 most common symptoms.
  • The prevalence of urinary incontinence among all toilet-trained children was 40%. The majority of these urinary incontinent children suffered from daytime incontinence (56%). Enuresis occurred in 22% and the other 22% suffered from combined daytime incontinence and enuresis.
  • There were significant associations between fecal incontinence and constipation [odds ratio (OR) = 3.88], fecal incontinence and urinary incontinence (OR = 5.26), and constipation and urinary incontinence (OR = 2.06)
  • Half of the children with constipation and almost all the children with fecal incontinence remained untreated.
Stool Frequency by age (Figure 1 B)

In the discussion, the authors note “treatment of constipation and/or fecal incontinence often leads to the resolution of urinary incontinence (34).”

In my experience, many families sent by urologists have been told that the constipation is causing urinary incontinence. For many children, the explanation is more complicated; association of constipation does not indicate causation. A lot of children have limited sensation of response to both bowel and bladder, rather than the rectum pushing on the bladder. Most children that I see with constipation/encopresis do not have urinary incontinence. However, behavior approaches to toileting can be helpful for both.

My take: This is a useful study providing an updated view on when to expect good toileting and highlighting the frequency of bowel/bladder dysfunction (which is often untreated).

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Do You Know the Best Way to Use Antegrade Enemas?

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Currently, there is no best way to use antegrade enemas.  This is the obvious conclusion after reading a study by S Kuizenga-Wessel et al (JPGN 2016; 62: 71-9).  In this study, the authors reviewed 21 articles and also surveyed 23 physicians involved in the care of children who receive antegrade continence enemas (ACE). While the study provides a lot of details, the bottom-line is that there is wide variation in outcomes, definition of success, workup prior to institution of ACE, and irrigation solutions (16 out of 23 used saline).  The only areas of agreement seem to be the following:

  • use of ACE daily: 22 of 23
  • use of antibiotics with placement: 23/23 (though wide variation in specific regimen)
  • indications for ACE were largely in agreement, including constipation with fecal incontinence (21 of 23), anorectal malformations (22 of 23) and spinal abnormalities (23 of 23); however, only 8 of 23 considered due to functional non-retentive fecal incontinence as an acceptable indication

With regard to the type of enema, the vast majority of physicians (19 of 23) only add a stimulant to the solution after initial failure.  Though, one study (J Pediatr 2012; 161: 700-4) has reported “that subjects who use stimulants from the very beginning had significantly better outcomes.”

My take: Like of a lot areas in medicine and throughout pediatric gastroenterology, there is wide variation in clinical treatment approaches.  Variation in treatment is obvious in the use of ACE.  Collaborative work and consensus building in management would improve success; that is, after we define what success looks like.

In the same issue a link to “History of Pediatric Endoscopy” is provided.  This is a ~15 minute video with interviews with many pioneers/leaders in pediatric gastroenterology.

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Golden Gate Bridge

Golden Gate Bridge

Soiling Stinks!

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The initial title of this post was too boring: “Documenting the Detrimental Effects of Fecal Incontinence on Quality of Life”

In perhaps one of the least surprising conclusions, the authors of a recent study (Kovacic K, et al. J Pediatr 2015; 166: 1482-7) have shown that “fecal incontinence significantly decreases quality of life compared with functional constipation alone in children.”  This multicenter prospective study surveyed families of 410 children (2-18 years).

Despite the obvious findings, I still think that the burden of fecal incontinence is underestimated by families and practitioners.  Here is an excerpt from this article’s discussion:

“Fecal incontinence impairs general functioning for children and their families…[it] is an insidious burden with substantial economic impact and adverse effects on quality of life…this effect increases as children approach adolescence…The devastating effect of fecal incontinence on quality of life and social functioning make it imperative that health professionals address defecation disorders proactively.  When aggressive and appropriate medical therapies are unable to provide a satisfactory outcome, then a multidisciplinary approach or a surgical option (e.g. cecostomy tube for antegrade enema) may be justified.”

Bottomline: Soiling stinks!  We need to keep working on this problem even if aggressive interventions are needed.

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Not Letting Go of a Log

Not Letting Go of a Log -Can Lead to Problems

Do Enemas Help Nonretentive Encopresis?

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No –according to a recent study (J Pediatr 2013; 162: 1023-7).

In this study, 71 children (76% boys, median age 9 years) with functional nonrententive fecal incontinence (FNRFI) were randomized to receive conventional therapy (control group) or conventional therapy along with daily enemas for 2 weeks.  Conventional therapy was considered education, toilet training, behavioral strategies, and a daily bowel diary with reward system. All children were instructed to defecate on toilet for 5 minutes after each meal.  Treatment success was defined as <2 episodes of fecal incontinence (FI) per month.  Outcomes were measured at 6 weeks, 12 weeks, 6 months, and 12 months after the start of treatment.

Results:

  • At the start, median FI was 6.1 per week and median defecation frequency was 7.0 per week.
  • In both the control group and the treatment group, there was improvement.  After the initial 6 weeks of treatment, FI episodes were 2.0/week in the control group and 1.0/week in the treatment group.
  • The treatment success at long-term followup was 17% for both groups.

In the discussion, the authors note that a longer course of enemas (> 3 months) could be needed to improve long-term outcomes.  They also note a high rate of daytime (31%) and night time (35%) urinary incontinence in these children; “we hypothesize that children with FNRFI not only deny or neglect their urge to defecate but exhibit the same behavior toward micturation.”

Take-home message: Both treatments improved the frequency of FI (and urinary incontinence); however, neither were highly effective.  Short-term use of enemas is not likely to have a meaningful effect.  Better treatment strategies are needed.

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