Functional nonretentive fecal incontinence: do enemas help?

Biofeedback Therapy in Managing Functional Fecal Incontinence in Children: A Literature Review

This literature review explores the role of biofeedback therapy (BFT) in managing functional fecal incontinence (FFI) in children - a common condition with a substantial impact on the quality of life. FFI diagnosis relies primarily on medical history and thorough physical examination and is categorized by the Rome IV criteria into functional constipation (FC) and functional nonretentive fecal incontinence (FNRFI). Treatment options for FFI remain limited, particularly for FNRFI. BFT employs electronic or mechanical devices, such as rectal probes or surface electrodes, to provide real-time feedback on muscle activity and rectal pressure. This feedback allows patients to better understand and control their pelvic floor muscles, improving coordination between contraction during stool retention and relaxation during defecation. It also plays a role in rectal sensory awareness, enabling patients to respond appropriately to the urge to defecate. BFT has been considered an option in refractory cases, although evidence supporting its routine use is still emerging. We conducted a comprehensive literature search focusing on studies from the past 24 years that evaluated BFT for pediatric FFI. Five relevant studies were identified and analyzed, each utilizing BFT in combination with various treatment modalities. Two studies, both randomized controlled trials (RCT) and with the largest sample, focused on the treatment of FNRFI, both concluding that BFT should be used in FNRFI refractory to conventional treatment. Another two studies, one RCT and a retrospective study, focused on patients with FC. The first did not show any additional value in the use of BFT, while the second showed positive results. Comparing both studies, they had very different methodologies and treatment plans, but besides these results, in both studies, they concluded that when selecting a treatment plan for a child with FFI, an alternative or additional treatment with BFT should be considered. Finally, the last study, a quasi-experimental study, did not differentiate between FC or FNRFI and compared the use of BFT to percutaneous tibial nerve stimulation (PTNS). Although they showed that there were slightly better results when using PTNS, they concluded that both PTNS and BFT are effective modalities in treating children with FFI in addition to conventional treatment. Overall, BFT showed positive outcomes, with no safety issues reported. BFT appears to be a useful, non-invasive option for pediatric FFI, both FC and FNRFI, especially in cases unresponsive to conventional therapies. When used in a tailored, multimodal approach, BFT holds the potential to improve continence and quality of life in children with this challenging condition, and given that 15% of children with FFI, specifically FNRFI, continue to experience symptoms into adulthood, it is crucial to consider these treatment options early to potentially reduce this rate. Besides this, more research is needed to conclude the long-term effects and to establish standardized pediatric rehabilitation protocols.

Role of Hypoxic Secretome from Mesenchymal Stem Cells in Enhancing Tissue Repair: Regulatory Effects on HIF-1α, VEGF, and Fibroblast in a Sphincterotomy Rat Model

Background

Fecal incontinence (FI) is the inability to control bowel movements, resulting in fecal leakage. If left untreated, FI can seriously impact the long-term well-being of individuals affected. Recently, using secretome has become a promising new treatment method. The secretome combines growth factors released outside cells during stem cell development, such as mesenchymal stem cells. It consists of soluble proteins, nucleic acids, fats, and extracellular vesicles, which contribute to different cell processes. The primary aim is to assess the impact of hypoxic secretome administration on accelerating wound healing through the HIF-1α pathway in a post-sphincterotomy rat model.

Methods

The study was conducted with two distinct groups of 10 rats each, the control and treatment groups, which were injected with hypoxic secretome at 0.3 mL. The inclusion criteria for the rats were as follows: male gender, belonging to the Sprague-Dawley strain, aged between 12 to 16 weeks, with an average body weight ranging from 240 to 250 grams.

Results

There was an increase in HIF-1α gene expression in both groups. The treatment group 37 was significantly higher on day 42 (p = 0.001). VEGF increased significantly in the treatment 38 group on day 42 (p = 0.015). The neovascularization score increased significantly in the treatment 39 group during the first 24 hours (p = 0.004). The fibroblast score increased significantly in the 40 treatment group in the first 24 hours (p = 0.000) and 42 days (p = 0.035). After being given secretome, there was a higher increase in % collagen area and collagen area (µm2) in the treatment group compared to the control group (27,77 vs 11.01) and (419.027,66 vs 186.694,16).

Conclusion

The use of hypoxic secretome has a significant effect as a choice for the treatment of anal sphincter injury after sphincterotomy through the HIF-1α-VEGF-Fibroblast pathway.

Faecal incontinence: Retentive, non-retentive and when to suspect organic pathology

BACKGROUND

Faecal incontinence is a highly prevalent and very distressing condition that occurs throughout the entire paediatric age.

AIM

To summarise advances in the understanding of the epidemiology, pathophysiology, evaluation and treatment of children with faecal incontinence due to either disorders of gut-brain interaction or organic diseases.

METHODS

Literature review on prevalence, impact, diagnosis and treatment options for children with faecal incontinence, interspersed with observations from the author's lifelong career focused on evaluation of children with motility disorders.

RESULTS

Faecal incontinence in children is most commonly due to unrecognised or insufficiently treated functional constipation with overflow incontinence. Non-retentive faecal incontinence (NRFI) is probably more common than previously thought and is particularly challenging to treat. Organic diseases such as anorectal malformations (ARMs), Hirschsprung disease and spinal defects are often associated with faecal incontinence; in these conditions, faecal incontinence has a profound impact on quality of life. Recognition of the different pathophysiologic mechanisms causing the incontinence is essential for a successful treatment plan. A thorough physical examination and history is all that is needed in the diagnosis of the causes of faecal incontinence related to disorders of gut-brain interaction. Colonic transit studies or x-rays may help to differentiate retentive from NRFI. Manometry tests are helpful in determining the mechanisms underlying the incontinence in children operated on for ARMs or Hirschsprung diseases. Multiple behavioural, medical and surgical interventions are available to lessen the severity of faecal incontinence and its impact on the daily life of affected individuals.

CONCLUSIONS

Recent advances offer hope for children with faecal incontinence.

Non-retentive faecal incontinence in children: Conventional therapy alone or combined electrical stimulation

AIMS

To compare the effects of functional electrical stimulation (FES) with conventional therapy and conventional therapy alone on improvement of faecal incontinence (FI) symptoms in a number of children with functional non-retentive FI.

METHODS

Data of 28 children with FI were accepted for this retrospective study. The case group (n = 14) underwent FES + conventional therapy and the control group (n = 14) received conventional therapy only. Data of children with faecal retention, inflammatory, anatomic, metabolic and neurological disorders were excluded. Children were assessed with a paediatric FI score questionnaire, and a bowel habit diary both before treatment sessions, after they ended, and after 6 months. A FI quality of life questionnaire was completed before and after treatment for all children.

RESULTS

Full response to the treatment (100% reduction in FI episodes) was significantly observed in 8/14 (57.1%) of children in the case group compared to 2/14 (14.2%) of children in the control group after the ending of treatment sessions (P = 0.005). The baseline mean ± SD of FI episodes per week was 3.7 ± 2.1 among both groups which significantly decreased after the ending of treatment sessions in the case group compared to the control group (1.4 ± 2.1 vs 3 ± 2.7; P = 0.05). Mean ± SD of FI score was significantly reduced in the case group compared to the controls after the ending of treatment sessions (3.9 ± 4.5 vs 8 ± 4.7; P = 0.02) and maintained after 6 months (P = 0.05).

CONCLUSIONS

Functional electrical stimulation is a safe, effective, non-invasive, inexpensive, reproducible and easy-to-use modality for treatment of functional non-retentive faecal incintinence in children.

Comparative Efficacy of Transcutaneous Functional Electrical Stimulation With or Without Biofeedback Therapy on Functional Non-retentive Fecal Incontinence in Children: A Randomized Clinical Trial

BACKGROUND

We compared the effects of transcutaneous functional electrical stimulation (TFES) and biofeedback therapy with TFES alone in a cohort of children with functional non-retentive fecal incontinence (FNRFI).

METHODS

This prospective, single-center randomized clinical trial was performed on 40 children with FNRFI. Patients were randomly allocated into two equal treatment groups. Group A (n = 20) underwent TFES + biofeedback therapy, and group B (n = 20) received TFES alone. All patients were assessed with a pediatric fecal incontinence (FI) score questionnaire, a visual pain score, and a bowel habit diary both before and at the end of treatment sessions and also at 6 months of follow-up. In addition, a FI quality-of-life (QoL) questionnaire was recorded for all patients before and 6 months after the treatment.

RESULTS

FI significantly improved in 13/20 (65%) patients in group A and 11/20 (55%) patients in group B (P < 0.05). A significant reduction in FI score was seen in each group at the end of treatment sessions and maintained at 6 months of follow-up (P < 0.05). A significant improvement in FI-QoL scores was seen in both groups at 6 months of follow-up in which there was no significant difference in terms of FI-QoL scores improvement between both groups after treatment.

CONCLUSIONS

The use of electrical stimulation in combination with other treatment methods improves symptoms in patients with FNRFI who are refractory to conventional treatment.

Functional Fecal Incontinence in Children: Epidemiology, Pathophysiology, Evaluation, and Management

Functional fecal incontinence (FI) is a worldwide problem in children and comprises constipation-associated FI and nonretentive FI. Irrespective of pathophysiology, both disorders impact negatively on the psychological well-being and quality of life of affected children. A thorough clinical history and physical examination using the Rome IV criteria are usually sufficient to diagnose these conditions in most children. Evolving investigations such as high-resolution anorectal and colonic manometry have shed new light on the pathophysiology of functional FI. Although conventional interventions such as toilet training and laxatives successfully treat most children with constipation-associated FI, children with nonretentive FI need more psychologically based therapeutic options. Intrasphincteric injection of botulinum toxin, transanal irrigation and, in select cases, surgical interventions have been used in more resistant children with constipation-associated FI.

Prevalence of Functional Defecation Disorders in Children: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically review the literature regarding the epidemiology of functional constipation and functional nonretentive fecal incontinence (FNRFI) in children. Secondary objectives were to assess the geographical, age, and sex distribution of functional constipation and FNRFI and to evaluate associated factors.

STUDY DESIGN

The Cochrane Library, PubMed, and Embase databases were searched from 2006 until September 2017. The following inclusion criteria were applied: (1) prospective studies of population-based samples; (2) reporting on the prevalence of functional constipation or FNRFI according to the Rome III/IV criteria; (3) in children aged 0-18 years; and (4) published in full manuscript form. A quality assessment of included studies was conducted. Random effect meta-analyses with meta-regression analyses of study characteristics were performed.

RESULTS

Thirty-seven studies were included, of which 35 reported on the prevalence of functional constipation and 15 of FNRFI. The reported prevalence of functional constipation ranged from 0.5% to 32.2%, with a pooled prevalence of 9.5% (95% CI 7.5-12.1). The prevalence of FRNFI ranged from 0.0% to 1.8%, with a pooled prevalence of 0.4% (95% CI 0.2-0.7). The prevalence of functional constipation was 8.6% in boys compared with 8.9% in girls (OR 0.99, 95% CI 0.9-1.4). Geographical location, dietary habits, and exposure to stressful life events were reported to be associated with the prevalence of functional constipation. Data on FNRFI were scarce and no associated factors were identified.

CONCLUSION

Functional constipation is common in childhood and is associated with geographical location, lifestyle factors, and stressful life events. FNRFI is rare, and no associated factors were identified.

Encopresis in Children: An Overview of Recent Findings

The term ‘encopresis’, derived from ancient Greek ἐγκόπρησις / egkóprēsis, which means stool, was first introduced in 1926 by Weissenberg to describe the loss of stool in underwear as the faecal equivalent of enuresis. The soiling of underwear is defined as the accidental passage of very small amounts of faeces into underpants. Quantitatively, the content of stool between encopresis and soiling is difficult to determine, and it is especially difficult for parents assess it. Therefore, a new term was adopted – faecal incontinence – that encompasses both encopresis and soiling.

Faecal incontinence is defined as the discharge of faeces in socially awkward situations at least once per month in children ≥ 4 years old. In approximately 95% of cases, faecal incontinence in children is not organic in origin, but instead appears as a functional gastrointestinal disorder. In 80% of children with functional faecal incontinence, the symptoms are associated with functional constipation. The remaining 20% of the cases involve no signs of faecal retention and are defined as non-retentive functional faecal incontinence.

This paper aims to present the latest findings within this area of paediatric gastroenterology.

Management of functional nonretentive fecal incontinence in children: Recommendations from the International Children's Continence Society

BACKGROUND

Fecal incontinence (FI) in children is frequently encountered in pediatric practice, and often occurs in combination with urinary incontinence. In most cases, FI is constipation-associated, but in 20% of children presenting with FI, no constipation or other underlying cause can be found - these children suffer from functional nonretentive fecal incontinence (FNRFI).

OBJECTIVE

To summarize the evidence-based recommendations of the International Children's Continence Society for the evaluation and management of children with FNRFI.

RECOMMENDATIONS

Functional nonretentive fecal incontinence is a clinical diagnosis based on medical history and physical examination. Except for determining colonic transit time, additional investigations are seldom indicated in the workup of FNRFI. Treatment should consist of education, a nonaccusatory approach, and a toileting program encompassing a daily bowel diary and a reward system. Special attention should be paid to psychosocial or behavioral problems, since these frequently occur in affected children. Functional nonretentive fecal incontinence is often difficult to treat, requiring prolonged therapies with incremental improvement on treatment and frequent relapses.