Randomised trial of biofeedback training for encopresis

How to use the Bristol Stool Chart in childhood constipation

Constipation in children is common and is a frequent cause for healthcare attendances in both primary and secondary care. The Bristol Stool Chart has become ubiquitous as an aid in the diagnosis and treatment of constipation, but many clinicians may not be aware of its origins or strengths and weaknesses. In this article, we outline the history and rationale behind the development of the Bristol Stool Chart and how it should be used in childhood constipation.

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

ABSTRACT

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.

The effectiveness of biofeedback therapy in managing Bladder Bowel Dysfunction in children: A systematic review

PURPOSE

The purpose of this study was to examine the effects of biofeedback therapy as a non-invasive intervention to treat Bladder Bowel Dysfunction in pediatrics.

METHODS

Six databases were searched between February 2016 and September 2016. Biofeedback studies for children aged 4-16 with idiopathic urinary or fecal incontinence were included. Articles were excluded on subjects' medical histories, study design, timeline of study, and lacking expert review. Quality was determined using Sackett's Levels of Evidence and the PEDro scale.

RESULTS

Twelve articles were included in the review. Quality of evidence was moderate, as the average PEDro score of the selected articles was 5.3. The participants' ages ranged from 4-16 years old. Studies demonstrated that a multifactorial approach consisting of biofeedback therapy and behavioral modification can be successful in resolving Bladder Bowel Dysfunction.

CONCLUSION

Biofeedback is a beneficial treatment for children with dysfunctional voiding and functional fecal incontinence. More conclusive research needs to be completed to explore the effects of biofeedback therapy treatment to make more concrete conclusions. Healthcare professionals should consider biofeedback as an alternative approach in conjunction with traditional treatments. A multidisciplinary approach is best when treating dysfunctional voiding and functional fecal incontinence in the pediatric population.

Evidence-Based Psychosocial Treatments for Pediatric Elimination Disorders

Pediatric elimination disorders are common in childhood, yet psychosocial correlates are generally unclear. Given the physiological concomitants of both enuresis and encopresis, and the fact that many children with elimination disorders are initially brought to their primary care physician for treatment, medical evaluation and management are crucial and may serve as the first-line treatment approach. Scientific investigation on psychological and behavioral interventions has progressed over the past couple of decades, resulting in the identification of effective treatments for enuresis and encopresis. However, the body of literature has inherent challenges, particularly given the multicomponent nature of many of the treatment packages. This review identified 25 intervention studies-18 for nocturnal enuresis and 7 for encopresis-over the past 15 years and classified them according to the guidelines set forth by the Task Force on the Promotion and Dissemination of Psychological Procedures. For nocturnal enuresis, the urine alarm and dry-bed training were identified as well-established treatments, Full Spectrum Home Therapy was probably efficacious, lifting was possibly efficacious, and hypnotherapy and retention control training were classified as treatments of questionable efficacy. For encopresis, only two probably efficacious treatments were identified: biofeedback and enhanced toilet training (ETT). Best practice recommendations and suggestions for future research are provided to address existing limitations, including heterogeneity and the multicomponent nature of many of the interventions for pediatric elimination disorders.

Determinants of quality of life in children with colorectal diseases

BACKGROUND

Health related Quality of Life (HRQoL) is an important outcome in medical care. The aim of our study was to identify characteristics associated with lower HRQoL scores in children with anorectal malformation (ARM) and Hirschsprung disease (HD).

METHODS

Patients younger than 18years, with HD or ARM, who were evaluated at our center from April 2014 to August 2015, were identified. The results of comprehensive questionnaires regarding diagnosis, symptoms, comorbidities and previous medical/surgical history, and validated tools to assess urinary status, stooling status and HRQoL were evaluated.

RESULTS

In children aged 0-4years, vomiting and abdominal distension were found to be associated with a significant reduction in total HRQoL scores. In children >4years of age, vomiting, nausea, abdominal distension, and abdominal pain were also associated with a significantly lower HRQoL. The strongest predictor of lower HRQoL scores on regression tree analysis, in all age groups, was the presence of a psychological, behavioral or developmental comorbidity.

CONCLUSION

Patients with either HD or an ARM who have a psychological, behavioral or developmental problem experience significantly lower HRQoL than children without such problems, suggesting that provision of behavioral/developmental support as part of the multidisciplinary care of these children may have a substantial impact on their HRQoL.

Conventional treatment of functional constipation has a positive impact on the behavioural difficulties in children with and without faecal incontinence

AIM

Constipation studies have only evaluated behavioural difficulties in children with faecal incontinence. This study evaluated changes in behavioural difficulties in childhood with functional constipation (FC) with and without faecal incontinence, based on treatment outcomes.

METHODS

Children aged five to 16 years who fulfilled the Rome III criteria for FC received conventional treatment. The Strength and Difficulties Questionnaire was completed at inclusion and at the 12-month follow-up.

RESULTS

We included 116 children. The behaviour scores decreased in successfully treated boys (10.3 versus 7.9; p < 0.001) and girls (10.0 versus 7.4; p = 0.0001) with and without faecal incontinence. There was no decrease in the behaviour scores in children with unsuccessful outcomes. Unsuccessfully treated boys had significantly higher behaviour scores than successfully treated boys at inclusion (13.2 versus 10.3; p = 0.006) and after 12 months (11.4 versus 7.9; p = 0.02). No difference was found between unsuccessfully treated and successfully treated girls at inclusion (10.5 versus 10.0; p = 0.77) or after 12 months (10.3 versus 7.4; p = 0.18).

CONCLUSION

Our findings indicate that conventional treatment of FC had a positive impact on behavioural difficulties in constipated children with and without faecal incontinence. This study highlights the importance of proactive detection and treatment of FC in paediatric patients.

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.

Psychometric properties of PedsQL generic core scales for children with functional constipation in the Netherlands

OBJECTIVES

The aim of the study was to evaluate the psychometric properties of the Dutch translation of the Pediatric Quality of Life Inventory version 4.0 Generic Core Scales (PedsQL) in children with functional constipation (FC).

METHODS

The PedsQL was completed by children with FC ages 5 to 18 years and by the parents of children ages 2 to 18 years. To assess construct validity, all of the parents and children completed the PedsQL Gastrointestinal Symptoms Module (GI module) and children ages 8 to 18 years completed the defecation disorder list. Item response distributions, internal consistency reliability, patient-parent agreement, and discriminating ability were evaluated.

RESULTS

Overall, 269 children were enrolled. The PedsQL showed minimal missing responses (self-report: 5.3% with >50% missing, parent report: 2.6% with >50% missing) and achieved satisfactory internal consistency for the total (self-report: α = 0.86, parent report: α = 0.88), physical health (self-report: α = 0.75, parent report α = 0.83), and psychosocial health (self-report: α = 0.80; parent report: α = 0.85) scores. Internal consistency was less convincing for those ages 5 to 7 years (α = 0.53-0.77) than for older individuals. Self-reported health-related quality of life was lower than parent reported, with the exception of children ages 5 to 7 years. Interrater reliability intraclass correlations were 0.52 to 0.61 for the overall population. Correlations among the PedsQL, GI module, and defecation disorder list were consistent with a priori hypotheses and generally supported construct validity. The PedsQL distinguished between a previously published healthy reference sample and children with FC, and between those with mild and severe symptoms (P < 0.05).

CONCLUSIONS

The self-reported and proxy reported PedsQL demonstrated satisfactory measurement properties in Dutch children with FC ages 8 to 18 years. Further research is needed to establish internal consistency and validity in those ages 5 to 7 years.

The effect of pelvic physiotherapy on reduction of functional constipation in children: design of a multicentre randomised controlled trial

Background

Functional constipation is a common disorder worldwide and is found in all paediatric age groups. Functional constipation can be caused by delayed colonic transit or dysfunction of the pelvic floor muscles. Standard medical care in paediatric practice is often based on clinical experience and mainly consists of a behavioural approach and toilet training, along with the prescription of laxatives. Evidence to evaluate the effectiveness of pelvic physiotherapy for this complaint is lacking.

Methods/design

A two-armed multicentre randomised controlled trial has been designed. We hypothesise that the combination of pelvic physiotherapy and standard medical care will be more effective than standard medical care alone for constipated children, aged 5 to 17 years. Children with functional constipation according to the Rome III will be included. Web-based baseline and follow-up measurements, scheduled at 3 and 6 months after inclusion, consist of the numeric rating scale in relation to the perceived severity of the problem, the Strength and Difficulties Questionnaire and subjective improvement post-intervention (global perceived effect). Examination of the pelvic floor muscle functions, including digital testing and biofeedback, will take place during baseline and follow-up measurements at the physiotherapist. The control group will only receive standard medical care, involving at least three contacts during five months, whereas the experimental group will receive standard medical care plus pelvic physiotherapy, with a maximum of six contacts. The physiotherapy intervention will include standard medical care, pelvic floor muscle training, attention to breathing, relaxation and awareness of body and posture. The study duration will be six months from randomisation, with a three-year recruitment period. The primary outcome is the absence of functional constipation according to the Rome III criteria.

Discussion

This section discusses the relevance of publishing the study design and the development of the presented physiotherapy protocol. It also addresses difficulties when interpreting the literature with regard to the effectiveness of biofeedback, potential confounding, and future research indications. To our knowledge, this article is the first to describe the design of a randomised controlled trial among children with constipation to assess the effect of pelvic physiotherapy as an add-on to standard medical care.

Trial registration

Current Controlled Trials NL30551.068.09

Functional nonretentive fecal incontinence: do enemas help?

OBJECTIVE

To assess the current treatment of functional nonretentive fecal incontinence, which consists of education, toilet training, and positive motivation.

STUDY DESIGN

Patients, age 6 years and older, referred for fecal incontinence (FI) and diagnosed with functional nonretentive fecal incontinence were eligible candidates. Seventy-one children (76% boys, median age 9.3 years) were randomized to receive conventional therapy (control group) or conventional therapy in addition to daily enemas during 2 weeks. Treatment success was defined as <2 episodes of FI/month without use of enemas.

RESULTS

At intake, the median FI frequency was 6.1 per week, whereas the median defecation frequency was 7.0 per week. At the end of the treatment period, the median number of FI episodes was significantly decreased in both groups: from 7.0 (IQR 4.0-11.5) to 1.0 (IQR 0.5-2.0) in the intervention group and from 6.0 (IQR 4.0-10) to 2.0 (IQR 0.5-3.5) in the control group. No statistical difference was found between the groups at the end of the treatment period (P = .08) nor during additional follow-up (average success rate 17% for both groups, P = .99).

CONCLUSION

Temporarily application of additional rectal enemas did not significantly improve treatment success compared with conventional therapy alone.

Anorectal functional abnormalities in Egyptian children with chronic functional constipation

BACKGROUND AND STUDY AIMS

Chronic functional constipation represents 95% of the cases of paediatric constipation. Epidemiologic data, pathophysiology and anorectal functional abnormalities vary greatly among different reports across different populations. The aim of this study was to evaluate these data in Egyptian children with chronic functional constipation.

PATIENTS AND METHODS

This study included 150 children with chronic functional constipation (101 males, 49 females; mean age 6 ± 3.1 years); a control group of 50 age- and sex-matched healthy children were enrolled for standardisation of the manometry technique. A structured symptom questionnaire and clinical examination including digital rectal examination in addition to anorectal manometry were done for all included children. Defaecation dynamics were assessed in all children 5 years or older using anorectal manometry with integrated electromyogram of the external anal sphincter and the puborectalis muscle.

RESULTS

The maximal tolerable volume was significantly higher in the constipated children than in the control group (p=0.03). No significant differences existed between constipated and control children regarding other anorectal manometric parameters. Abnormal defaecation dynamics were detected in 35 out of 95 tested patients (36.8%).

CONCLUSION

Increased maximal tolerable volume is the most striking manometric feature in Egyptian children with chronic functional constipation. Abnormal defaecation dynamics were detected in about one-third of the tested patients. Standardisation of the measurement techniques and obtaining normal ranges for anorectal manometric parameters for each laboratory are recommended.

Psychological treatments in functional gastrointestinal disorders: a primer for the gastroenterologist

The functional gastrointestinal disorders (FGIDs) often show inadequate response to usual medical care. Psychological treatments can help improve functional gastrointestinal disorder patient outcomes, and such treatment should be considered for patients who have moderate or severe symptoms after 3-6 months of medical care and those whose symptoms are clearly exacerbated by stress or emotional symptoms. Effective psychological treatments, which are based on multiple randomized controlled trials, include cognitive behavioral therapy and hypnosis for irritable bowel syndrome and pediatric functional abdominal pain, cognitive behavioral therapy for functional chest pain, and biofeedback for dyssynergic constipation in adults. Successful referral by the gastroenterologist for psychological treatment is facilitated by educating the patient about the rationale for such treatment, reassurance about the diagnosis and continuation of medical care, firm doctor-patient therapeutic alliance, and identification of and communication with an appropriate psychological services provider.

Review article: faecal incontinence in children: epidemiology, pathophysiology, clinical evaluation and management

BACKGROUND

Faecal incontinence (FI) in children is a significant gastrointestinal problem, with great personal and social impacts. It is characterised by recurrent loss of faecal matter into the underwear. Both functional and organic causes contribute to its aetiology with the former predominating.

AIM

To review the epidemiology, pathophysiology, clinical evaluation and management of functional faecal incontinence in children.

METHODS

A PubMed search was conducted using search terms f(a)ecal incontinence, and encopresis. Articles on epidemiology, pathophysiology, clinical evaluation, investigation and management of functional FI in children were retrieved and assessed.

RESULTS

Community prevalence of this distressing problem ranges from 0.8% to 7.8% globally. Male: female ratio varies from 3:1 to 6:1. The diagnosis of FI is often based on established clinical criteria. The majority (82%) have constipation associated functional FI. Biopsychosocial factors play a crucial role in the pathogenesis. Limited physiological testing of anorectal function is recommended in the diagnostic procedures, particularly in children with atypical symptoms and possible organic disorders. Management of FI needs a multidisciplinary approach which includes establishment of an effective doctor-patient partnership, understanding the underlying mechanisms, pharmacotherapy and behavioural treatment. Approximately 15% of children with functional nonretentive faecal incontinence (FNRFI) had the same symptoms at the age of 18 years.

CONCLUSION

Significant therapeutic advances have been made for retentive faecal incontinence, but treatment options for functional nonretentive faecal incontinence are limited. Limited long-term outcome data show that the majority outgrow faecal incontinence. A substantial proportion of children progress to adulthood with faecal incontinence.

Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults

BACKGROUND

Faecal incontinence is a particularly embarrassing and distressing condition with significant medical, social and economic implications. Anal sphincter exercises (pelvic floor muscle training) and biofeedback therapy have been used to treat the symptoms of people with faecal incontinence. However, standards of treatment are still lacking and the magnitude of alleged benefits has yet to be established.

OBJECTIVES

To determine the effects of biofeedback and/or anal sphincter exercises/pelvic floor muscle training for the treatment of faecal incontinence in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 24 January 2012) which contains trials from searching CENTRAL, MEDLINE and handsearching of conference proceedings; and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials evaluating biofeedback and/or anal sphincter exercises in adults with faecal incontinence.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the risk of bias of eligible trials and two review authors independently extracted data from the included trials. A wide range of outcome measures were considered.

MAIN RESULTS

Twenty one eligible studies were identified with a total of 1525 participants. About half of the trials had low risk of bias for randomisation and allocation concealment.One small trial showed that biofeedback plus exercises was better than exercises alone (RR for failing to achieve full continence 0.70, 95% CI 0.52 to 0.94).One small trial showed that adding biofeedback to electrical stimulation was better than electrical stimulation alone (RR for failing to achieve full continence 0.47, 95% CI 0.33 to 0.65).The combined data of two trials showed that the number of people failing to achieve full continence was significantly lower when electrical stimulation was added to biofeedback compared against biofeedback alone (RR 0.60, 95% CI 0.46 to 0.78).Sacral nerve stimulation was better than conservative management which included biofeedback and PFMT (at 12 months the incontinence episodes were significantly fewer with sacral nerve stimulation (MD 6.30, 95% CI 2.26 to 10.34).There was not enough evidence as to whether there was a difference in outcome between any method of biofeedback or exercises. There are suggestions that rectal volume discrimination training improves continence more than sham training. Further conclusions are not warranted from the available data.

AUTHORS' CONCLUSIONS

The limited number of identified trials together with methodological weaknesses of many do not allow a definitive assessment of the role of anal sphincter exercises and biofeedback therapy in the management of people with faecal incontinence. We found some evidence that biofeedback and electrical stimulation may enhance the outcome of treatment compared to electrical stimulation alone or exercises alone. Exercises appear to be less effective than an implanted sacral nerve stimulator. While there is a suggestion that some elements of biofeedback therapy and sphincter exercises may have a therapeutic effect, this is not certain. Larger well-designed trials are needed to enable safe conclusions.

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children

BACKGROUND

Faecal incontinence is a common and potentially distressing disorder of childhood.

OBJECTIVES

To assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 October 2011), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings, and the reference lists of relevant articles. We contacted authors in the field to identify any additional or unpublished studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children.

DATA COLLECTION AND ANALYSIS

Reviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta-analysis when appropriate.

MAIN RESULTS

Twenty one randomised trials with a total of 1371 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by trials addressing the same comparisons.Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow-up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children (OR 1.40 95% CI 0.72 to 2.73 at 24 months).In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65).

AUTHORS' CONCLUSIONS

There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence in children with functional faecal incontinence associated with constipation.

Coexistence of constipation and incontinence in children and adults

The coexistence of constipation and fecal incontinence has long been recognised in paediatric and geriatric populations, but is grossly underappreciated in the rest of the adult population. In children, functional fecal incontinence is usually associated with constipation, stool retention and incomplete evacuation, and is frequently allied to urinary incontinence. Pathophysiology of the incontinence is incompletely understood, although both in children and adults, it is thought to be secondary to overflow, while in adults it may also be related to pelvic floor dysfunction and denervation. Incontinence has an important impact on quality of life and daily functioning, and in children may be associated with behaviour problems. The treatment of underlying constipation usually results in improvement in incontinence. This review broadly addresses the epidemiology and pathophysiology of coexistent constipation and incontinence in both children and adults, and also reviews clinical presentation and treatment response in pediatrics.

Constipation-associated and nonretentive fecal incontinence in children and adolescents: an epidemiological survey in Sri Lanka

OBJECTIVES

Fecal incontinence (FI) has a great effect on quality of life of children with the condition. Epidemiological data related to FI from developing countries are sparse. Studies differentiating functional nonretentive and retentive (constipation-associated) FI are not available.

PATIENTS AND METHODS

This was an island-wide, cross-sectional study. Information was collected from children (ages 10-16 years) from 5 randomly selected schools in 3 geographically and socioeconomically different provinces in Sri Lanka, using a validated, self-administered questionnaire. FI was defined as defecation into places inappropriate to the social context, at least once per month, for a minimum period of 2 months. Constipation was diagnosed using Rome III criteria.

RESULTS

A total of 2770 questionnaires were distributed and 2686 (97.0%) were included in the analysis. Of them, 55 (2.0%) had FI (mean age 11.96 years, SD 1.59 years, 43 [78.2%] boys). Forty-five (81.8%) had constipation-associated FI and 10 (18.2%) had nonretentive FI. The highest prevalence of FI was seen in children aged 10 years (5.4%). A significant negative correlation was observed between age and the prevalence of FI (r = -0.893, P = 0.007). FI was significantly higher in boys (boys 3.2%, girls 0.9%), those exposed to recent school- and family-related stressful life events, and those from lower social classes (P < 0.05).

CONCLUSIONS

FI is not uncommon among children and adolescents of 10 to 16 years of age in Sri Lanka with a male predilection. Some predisposing factors, such as exposure to stressful life events and being bullied at school, which are similar to those described in the literature for FI, could be clearly recognized.

Prevalence and associated clinical characteristics of behavior problems in constipated children

OBJECTIVE

Behavior problems are common in children with functional constipation. This study assessed the prevalence of overall, internalizing, and externalizing behavior problems in children with functional constipation and explored which clinical characteristics of constipation are associated with these behavior problems.

METHODS

Children who had functional constipation, were aged 4 to 18 years, and were referred to the gastrointestinal outpatient clinic at the Emma Children's Hospital were eligible for enrollment. This study made use of baseline data of 133 children who participated in a randomized, controlled trial that evaluated the clinical effectiveness of behavioral therapy compared with conventional treatment. Prevalence of behavior problems was assessed by the Child Behavior Checklist. Univariate and multivariate logistic regression models were used to test the association between clinical characteristics and behavior problems.

RESULTS

The prevalence rate of overall, internalizing, and externalizing behavior problems was considerable: respectively 36.8%, 36.1%, and 27.1% compared with 9% in the Dutch norm population. A long duration of treatment was found to have the strongest association with overall and externalizing behavior problems in children with constipation. Children with constipation and nighttime urinary incontinence have an increased risk for having overall behavior problems. Fecal incontinence and the production of large stools seemed to be exclusively related to externalizing behavior problems.

CONCLUSIONS

Behavior problems are common in children who have constipation and are referred to gastrointestinal outpatient clinics, suggesting that a behavioral screening should be incorporated into the diagnostic workup of children with constipation.

No role for increased rectal compliance in pediatric functional constipation

BACKGROUND & AIMS

Increased rectal compliance has been proposed to contribute to pediatric functional constipation (FC). We evaluated the clinical relevance of increased rectal compliance and assessed whether regular use of enemas improves rectal compliance in children with FC.

METHODS

A prospective longitudinal study was conducted on children (8-18 years old) with FC. Pressure-controlled rectal distensions were performed at baseline and at 1 year. Rectal compliance was categorized into 3 groups: normal, moderately increased, or severely increased. Patients were randomly assigned to groups given conventional therapy or rectal enemas and conventional therapy. Clinical success was defined as >or=3 spontaneous defecations per week and fecal incontinence <1 per week.

RESULTS

Baseline measurements were performed in 101 children (11.0 +/- 2.1 years); rectal compliance was normal in 36%, moderately increased in 40%, and severely increased in 24%. Patients with severely increased rectal compliance had lower defecation frequency (P = .03), more fecal incontinence (P = .04), and more rectal fecal impaction (P < .001). After 1 year, success values were similar between groups: 42% normal, 41% moderately increased, and 40% with severely increased compliance. Barostat studies performed after 1 year in 80 children (37 conventional therapy and 43 rectal enemas in addition to conventional therapy) revealed that rectal compliance had not changed in either group and had not improved in successfully treated patients.

CONCLUSIONS

Constipated children with severely increased rectal compliance have severe symptoms. However, increased rectal compliance is not related to treatment failure. Regular use of enemas to avoid rectal fecal impaction does not improve rectal compliance in pediatric FC.

Prospective evaluation of comorbidity and psychosocial need in children and adolescents with anorectal malformation. Part one: paediatric surgical evaluation and treatment of defecating disorder

INTRODUCTION

Anorectal malformations represent a continuing challenge for the paediatric surgeon. Faecal and urinary incontinence can occur even with an excellent anatomic repair. We undertook a prospective evaluation of comorbidity and psychosocial needs in children and adolescents with anorectal malformation to test the hypothesis whether psychosocial workup in concert with an improved continence situation would lead to a better functional outcome in patients suffering from defecating disorders. Treatment of defecating disorder was based on differentiation between overflow pseudo-incontinence and true faecal incontinence.

MATERIALS AND METHODS

Patients who presented with soiling regardless of the type of anomaly were included in the study: 44 patients were investigated, 14 patients did not meet the criteria of the study, 30 patients aged 4-18 were evaluated. The surgical diagnostic program comprised a careful clinical history, physical examination, exact classification of the malformation, evaluation for associated defects, stool protocol.

RESULTS

Patients were grouped in two different management programs according to their continence situation. Patients with pseudo-incontinence were treated with enemas, diet, anal hygiene, behavioural therapy and physiotherapy. Patients with true faecal incontinence were included in a bowel management program: 28 patients were free of symptoms of soiling after 3 days of hospital treatment and remained free of symptoms 6 months and 1 year later at re-evaluation. Two patients did not follow the therapeutic regime and therefore did not show an improved condition concerning soiling in the long run.

CONCLUSION

Differentiating between overflow pseudo-incontinence and true faecal incontinence is the basis of an effective treatment of defecating disorders. All patients born with anorectal malformation can be kept clean of stool if they are subjected to an adequate treatment. A multidisciplinary approach is a valuable supplement to standard therapy.

Manometric tests of anorectal function in 90 healthy children: a clinical study from Kuwait

BACKGROUND/PURPOSE

Anorectal manometry is a noninvasive test used to evaluate conditions like slow-transit constipation, anorectal outlet obstruction, and Hirschsprung disease and to assess postoperative results after Hirschsprung and anorectal malformations. This cross section study was designed to have normal manometric values of anorectal function in healthy children of different ages in Kuwait so that control values are available for comparisons with various pathological states.

METHOD

Anorectal manometry was conducted in 90 children aged 3 days to 12 years without any symptoms related to lower gastrointestinal tract. They were divided in 3 age groups (group 1-neonates up to 1 month, group 2-infants from 1 month to 1 year, and group 3-children more than 1 year). Water perfused system with anorectal catheter with 4 side holes was used to record length of anal canal or high-pressure zone, resting pressure of anal canal, and rectoanal inhibitory reflex (RAIR).

RESULT

Anorectal manometry was successfully done in all 90 children of different age groups without any complications. High-pressure zone or anal canal length was 1.67 +/- 0.34 cm in neonates, 1.86 +/- 0.6 cm in infants, and 3.03 +/- 0.52 cm in children. Mean resting pressure of anal canal was 31.07 +/- 10.9 mm Hg in neonates, 42.43 +/- 8.9 mm Hg in infants, and 43.43 +/- 8.79 mm Hg in children. Rectoanal inhibitory reflex was present in all of them. Mean RAIR threshold volumes of 9.67 +/- 3.6, 14.0 +/- 9.5, and 25.0 +/- 11.6 mL was required for noenates, infants, and children, respectively.

CONCLUSION

Resting pressure of the anal canal, manometic anal canal length, and RAIR volume varies with the age. Normal values anorectal manometry at different age groups should be obtained to compare with pathological states of anorectum.

Children with constipation: what happens to them when they grow up?

Constipation and soiling are common complaints in childhood and often cause distress to the children and their parents. The treatment for these symptoms is oral and sometimes rectal laxatives or behavioural therapy. Until now, there have been few randomized controlled trials to evaluate the efficacy of the different treatment regimens. Moreover, there is a lack of information regarding what happens to these children with constipation when they grow up. A recent long-term follow-up study in The Netherlands showed that 30% of the children followed beyond puberty continued to have severe complaints of constipation such as a low defecation frequency and soiling. Long-lasting support and the development of improved therapeutic regimens are necessary to treat these difficult patients more effectively.

Health related quality of life in children with constipation-associated fecal incontinence

OBJECTIVES

With a disease-specific questionnaire, this study aimed to evaluate health-related quality of life (HRQoL) in children with constipation in association with clinical characteristics.

STUDY DESIGN

Children with constipation-associated fecal incontinence (n = 114), 8 to 18 years, filled out the Defecation Disorder List at a Dutch tertiary hospital. Correlations and linear regression analysis between clinical characteristics and scores on emotional and social functioning were calculated. Specific concerns of children were described by individual item scores of these domains.

RESULTS

Higher frequency of fecal incontinence episodes was associated with lower emotional and social functioning. Linear regression analysis showed a significant association between social functioning and fecal incontinence, but the variance of the model was low (adjusted R(2)= 0.08). Between 70% to 80% of children were concerned about experiencing fecal incontinence unnoticeably and the attendant social consequences. Children did not report having fewer friends and participated well in social events.

CONCLUSION

Lower HRQoL regarding disease-specific emotional and social functioning was reported in children with frequent episodes of constipation-associated fecal incontinence. However, other nonspecified factors may also influence HRQoL of these children. Most children reported relatively more emotional concerns than social consequences.

Functional nonretentive fecal incontinence in children: a frustrating and long-lasting clinical entity

Fecal incontinence is defined as the passage of stools in an inappropriate place at least once per month, for a minimum period of 2 months. This frustrating symptom is a source of considerable distress and embarrassment for the child and the family. According to the Rome III criteria fecal incontinence can be subdivided into constipation-associated fecal incontinence and functional nonretentive fecal incontinence. This short review mainly addresses functional nonretentive fecal incontinence in children. Definition, prevalence, pathophysiology, and recent updates on treatment and long-term follow-up of fecal incontinence are discussed.

Psychosocial co-morbidity affects treatment outcome in children with fecal incontinence

Fecal incontinence is a common disorder in children. Many children with fecal incontinence have psychosocial co-morbidity. In this study, the effect of psychosocial co-morbidity on the treatment outcome of children with fecal incontinence was evaluated. One hundred and fifty children with fecal incontinence were treated in a multidisciplinary program. All children had been treated unsuccessfully for at least one year before entering the program. The treatment consisted of laxative treatment, psychosocial interventions, and biofeedback training. Psychosocial co-morbidity was classified according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). One hundred and forty-one children were completely analyzed (102 boys, mean age 9.6 (range 6.5-16.5) years). Of these, 31 (22%) children had fecal incontinence without constipation and 110 (78%) children had fecal incontinence associated with constipation. In 95% of children, at least one psychosocial co-morbidity was present. Treatment was successful at 12 months in 69% of patients. Treatment was less successful in children with attention deficit hyperactivity disorder (ADHD), in children with parent-child relational problems, and in mentally retarded children. The results indicate that the early assessment and treatment of psychosocial co-morbidity might improve treatment response in children with fecal incontinence. Children with fecal incontinence are treated less successfully in the first year if they have ADHD, parent-child relational problems, or mental retardation. Psychosocial evaluation and the early assessment and treatment of psychosocial co-morbidity is indicated in order to improve response rate. Family counseling--aimed at improving parent-child relations--should be an integral part of a multidisciplinary treatment program for fecal incontinence.

The role of biofeedback in the treatment of gastrointestinal disorders

Biofeedback is a form of treatment that has no adverse effects and can be provided by physician extenders. The therapy relies on patients' ability to learn how to influence their bodily functions through dedicated machinery and teaching. This Review provides a comprehensive overview of all potential therapeutic applications of biofeedback for functional constipation, fecal incontinence, functional anorectal pain, IBS, functional dyspepsia, and aerophagia. Practical clinical applications of biofeedback therapy supported by randomized, controlled trials (RCTs) are limited to fecal incontinence and dyssynergic defecation. For fecal incontinence, RCTs suggest that biofeedback combining strength training and sensory discrimination training is effective in approximately 75% of patients and is more effective than placebo. However, verbal feedback provided by a therapist during extended digital examination may be equally effective, and children whose fecal incontinence is associated with constipation plus fecal impaction do no better with biofeedback than medical management. For dyssynergic defecation, RCTs show that biofeedback combining pelvic floor muscle relaxation training, practice in defecating a water-filled balloon, and instruction in effective straining is effective in approximately 70% of patients who have failed to respond to laxative treatment. For both incontinence and dyssynergic defecation, the benefits of biofeedback last at least 12 months.

Behavioral therapy for childhood constipation: a randomized, controlled trial

OBJECTIVE

It has been suggested that the addition of behavioral interventions to laxative therapy improves continence in children with functional fecal incontinence associated with constipation. Our aim was to evaluate the clinical effectiveness of behavioral therapy with laxatives compared with conventional treatment in treating functional constipation in childhood.

PATIENTS AND METHODS

In this randomized, controlled trial conducted in a tertiary hospital in The Netherlands, 134 children aged 4 to 18 years with functional constipation were randomly assigned to 22 weeks (12 visits) of either behavioral therapy or conventional treatment. Primary outcomes were defecation frequency, fecal incontinence frequency, and success rate. Success was defined as defecation frequency of > or = 3 times per week and fecal incontinence frequency of < or = 1 times per 2 weeks irrespective of laxative use. Secondary outcomes were stool-withholding behavior and behavior problems. Outcomes were evaluated at the end of treatment and at 6-months follow-up. All of the analyses were done by intention to treat.

RESULTS

Defecation frequency was significantly higher for conventional treatment. Fecal incontinence frequency showed no difference between treatments. After 22 weeks, success rates did not differ between conventional treatment and behavioral therapy (respectively, 62.3% and 51.5%), nor did it differ at 6 months of follow-up (respectively, 57.3% and 42.3%). The proportion of children withholding stools was not different between interventions. At follow-up, the proportion of children with behavior problems was significantly smaller for behavioral therapy (11.7% vs 29.2%).

CONCLUSION

Behavioral therapy with laxatives has no advantage over conventional treatment in treating childhood constipation. However, when behavior problems are present, behavioral therapy or referral to mental health services should be considered.

[Encopresis]

Encopresis is defined as functional faecal incontinence at 4 years of age or older and affects 1-3% of all school children. The two most important subtypes are encopresis with and without constipation. In preschoolers toilet refusal syndrome can occur. Comorbid behavioural disorders and urinary incontinence are common. The current state-of-the-art regarding aetiology, assessment and therapy is presented in this overview. A symptom-oriented behavioural approach (toilet training) is most successful, with the addition of laxatives (polyethylene glycol) if constipation is present. Biofeedback is not effective. Other forms of psychotherapy are indicated only in case of comorbid behavioural disorders. The long-term outcome has been poor and needs improvement.

Functional nonretentive fecal incontinence in children

Fecal incontinence, the loss of feces in the underwear after age 4 years, is a frustrating phenomenon for children and their parents. It is difficult to treat, presenting as a single symptom without any organic cause or signs of constipation. This review addresses the definition of functional nonretentive fecal incontinence and provides an overview of its epidemiology, pathophysiology, clinical features, diagnostic work-up and prognosis.

Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Constipation, defined as a delay or difficulty in defecation, present for 2 or more weeks, is a common pediatric problem encountered by both primary and specialty medical providers. The Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) has formulated a clinical practice guideline for the management of pediatric constipation. The Constipation Guideline Committee, consisting of two primary care pediatricians, a clinical epidemiologist, and pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee developed two algorithms to assist with medical management, one for older infants and children and the second for infants less than 1 year of age. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management, and indications for consultation by a specialist. The Constipation Guideline Committee also provided recommendations for management by the pediatric gastroenterologist.

Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults

BACKGROUND

Faecal incontinence is a particularly embarrassing and distressing condition with significant medical, social and economic implications. Anal sphincter exercises and biofeedback therapy have been used to treat the symptoms of people with faecal incontinence. However, standards of treatment are still lacking and the magnitude of alleged benefits has yet to be established.

OBJECTIVES

To determine the effects of biofeedback and/or anal sphincter exercises/pelvic floor muscle training for the treatment of faecal incontinence in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 27 February 2006) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised trials evaluating biofeedback and/or anal sphincter exercises in adults with faecal incontinence.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the methodological quality of eligible trials and two reviewers independently extracted data from included trials. A wide range of outcome measures were considered.

MAIN RESULTS

Eleven eligible studies were identified with a total of 564 participants. In all but three trials methodological quality was poor or uncertain. No study reported a major difference in outcome between any method of biofeedback or exercises and any other method, or compared to other conservative management. There are suggestions that rectal volume discrimination training improves continence more than sham training and that anal biofeedback combined with exercises and electrical stimulation provides more short-term benefits than vaginal biofeedback and exercises for women with obstetric-related faecal incontinence. Further conclusions are not warranted from the available data.

AUTHORS' CONCLUSIONS

The limited number of identified trials together with their methodological weaknesses do not allow a definitive assessment of the possible role of anal sphincter exercises and biofeedback therapy in the management of people with faecal incontinence. We found no evidence of biofeedback or exercises enhancing the outcome of treatment compared to other conservative management methods. While there is a suggestion that some elements of biofeedback therapy and sphincter exercises may have a therapeutic effect, this is not certain. Larger well-designed trials are needed to enable safe conclusions.

Barostat testing in children with functional gastrointestinal disorders

Children and adolescents with chronic defecation disorders and chronic abdominal pain without obvious organic etiology form a challenging group of patients for pediatric health-care professionals. The pathophysiologic mechanisms underlying such functional gastroenterology disorders are poorly understood. Research studies on the use of the barostat have been aimed to increase our knowledge in this area. Barostat testing allows defining visceral hyper- or hyposensitivity, contractility, and compliance of the gut. This review focuses on rectal barostat studies performed in children with abdominal pain, constipation, and fecal incontinence.

Psychological differences between children with and without soiling problems

OBJECTIVES

Previous studies, based on clinic samples, report that childhood soiling is associated with behavior problems and reduced self-esteem. This population-based study investigates the prevalence of psychological problems associated with childhood soiling.

METHODS

A total of 8242 children aged 7-8 years born to mothers in the United Kingdom-based Avon Longitudinal Study of Parents and Children were studied. Parents completed postal questionnaires assessing common childhood emotional and behavioral problems, and children were asked questions at a research clinic concerning their behavior, friendships, bullying, and self-esteem. The rate of psychological problems was compared in children who soil frequently (once a week or more), those who soil occasionally (less than once a week), and those with no soiling problems (controls). Analyses were adjusted for developmental delay, gender, sociodemographic background, and stressful life events.

RESULTS

Children who soil were reported by their parents to have significantly more emotional and behavioral problems compared with children who do not soil. Children who soil frequently had significantly more problems than those who soil occasionally. The rate of attention and activity problems, obsessions and compulsions, and oppositional behavior was particularly high in frequently soiling children. Children with soiling problems reported significantly higher rates of involvement in overt bullying (as both perpetrator and victim) and antisocial activities compared with controls.

CONCLUSIONS

The current study finds significantly higher rates of behavior and emotional problems, bullying, and antisocial activities in children who soil compared with those who do not soil. Children who soil frequently are more likely to have these problems than those who soil occasionally.

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children

BACKGROUND

Faecal incontinence is a common and potentially distressing disorder of childhood.

OBJECTIVES

To assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 1 February 2006).

SELECTION CRITERIA

Randomised and quasi-randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children.

DATA COLLECTION AND ANALYSIS

Reviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta-analysis when appropriate.

MAIN RESULTS

Eighteen randomised trials with a total of 1168 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by trials addressing the same comparisons. Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow-up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children (OR 1.40 95% CI 0.72 to 2.73 at 24 months). In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65).

AUTHORS' CONCLUSIONS

There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence in children with functional faecal incontinence associated with constipation.

Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia

BACKGROUND & AIMS

Uncontrolled trials suggest biofeedback is an effective treatment for pelvic floor dyssynergia (PFD), a type of constipation defined by paradoxical contraction, or inability to relax, pelvic floor muscles during defecation. The aim was to compare biofeedback to laxatives plus education.

METHODS

Patients with chronic, severe PFD were first treated with 20 g/day fiber plus enemas or suppositories up to twice weekly. Nonresponders were randomized to either 5 weekly biofeedback sessions (n = 54) or polyethylene glycol 14.6-29.2 g/day plus 5 weekly counseling sessions in preventing constipation (n = 55). Satisfaction with treatment, symptoms of constipation, and pelvic floor physiology were assessed 6 and 12 months later. The biofeedback group was also assessed at 24 months. Laxative-treated patients were instructed to increase the dose of polyethylene glycol from 14.6 to 29.2 g/day after 6 months.

RESULTS

At 6 months, major improvement was reported by 43 of 54 (80%) biofeedback patients vs 12 of 55 (22%) laxative-treated patients (P < .001). Biofeedback's benefits were sustained at 12 and 24 months. Biofeedback also produced greater reductions in straining, sensations of incomplete evacuation and anorectal blockage, use of enemas and suppositories, and abdominal pain (all P < .01). Stool frequency increased in both groups. All biofeedback-treated patients reporting major improvement were able to relax the pelvic floor and defecate a 50-mL balloon at 6 and 12 months.

CONCLUSIONS

Five biofeedback sessions are more effective than continuous polyethylene glycol for treating PFD, and benefits last at least 2 years. Biofeedback should become the treatment of choice for this common and easily diagnosed type of constipation.

New insight into rectal function in pediatric defecation disorders: disturbed rectal compliance is an essential mechanism in pediatric constipation

OBJECTIVE

To evaluate rectal sensitivity in patients with pediatric constipation (PC) and nonretentive fecal soiling (FNRFS) using pressure-controlled distention (barostat).

STUDY DESIGN

Thresholds for rectal sensitivity (first sensation, urge to defecate, and pain), and rectal compliance were determined using a barostat.

RESULTS

A total of 69 patients with PC (50 males; mean age, 10.9 +/- 2.2 years) and 19 patients with FNRFS (15 males; mean age, 10.0 +/- 1.9 years) were compared with 22 healthy volunteers (HVs) (11 males; mean age, 12.7 +/- 2.6 years). Sensitivity thresholds were not significantly different among the 3 groups. Rectal compliance was increased in 58% of the patients with PC (P < .0001 vs HVs). Rectal compliance did not differ between patients with FNRFS and HVs. Children with PC with abnormal rectal function required significantly larger rectal volumes at urge to defecate.

CONCLUSIONS

Increased compliance is the most prominent feature in patients with PC. Because of higher compliance in these children, larger stool volumes are required to reach the intrarectal pressure of the urge to defecate. Children with FNRFS have normal rectal function.

The Leech method for diagnosing constipation: intra- and interobserver variability and accuracy

BACKGROUND

The data concerning the value of a plain abdominal radiograph in childhood constipation are inconsistent. Recently, positive results have been reported of a new radiographic scoring system, "the Leech method", for assessing faecal loading.

OBJECTIVE

To assess intra- and interobserver variability and determine diagnostic accuracy of the Leech method in identifying children with functional constipation (FC).

MATERIALS AND METHODS

A total of 89 children (median age 9.8 years) with functional gastrointestinal disorders were included in the study. Based on clinical parameters, 52 fulfilled the criteria for FC, six fulfilled the criteria for functional abdominal pain (FAP), and 31 for functional non-retentive faecal incontinence (FNRFI); the latter two groups provided the controls. To assess intra- and interobserver variability of the Leech method three scorers scored the same abdominal radiograph twice. A Leech score of 9 or more was considered as suggestive of constipation. ROC analysis was used to determine the diagnostic accuracy of the Leech method in separating patients with FC from control patients.

RESULTS

Significant intraobserver variability was found between two scorers (P=0.005 and P<0.0001), whereas there was no systematic difference between the two scores of the other scorer (P=0.89). The scores between scorers differed systematically and displayed large variability. The area under the ROC curve was 0.68 (95% CI 0.58-0.80), indicating poor diagnostic accuracy.

CONCLUSIONS

The Leech scoring method for assessing faecal loading on a plain abdominal radiograph is of limited value in the diagnosis of FC in children.

Longitudinal follow-up of children with functional nonretentive fecal incontinence

BACKGROUND & AIMS

Functional nonretentive fecal incontinence (FNRFI), incontinence in the absence of signs of fecal retention, is a frustrating phenomenon in children. No data on long-term outcome are available. The aim was to investigate the long-term outcome of FNRFI patients after intensive medical treatment.

METHODS

Between 1990 and 1999, 119 patients (96 boys) with FNRFI were enrolled in 2 prospective, randomized trials investigating the effect of biofeedback training and/or laxative treatment. Follow-up (FU) was performed at 6 months, 1 year, and thereafter annually until September 2004. A standardized questionnaire was used to evaluate symptoms. Success was defined as a fecal incontinence frequency <1 per 2 weeks.

RESULTS

Median age (25th-75th percentiles) was 9.2 years (range, 7.9-11.6 years). A 90% FU was achieved at all stages of the study. After 2 years of intensive therapy, 33 of 112 (29.5%) patients were successfully treated. The cumulative success percentage after 7 years of FU was 80%. At the biologic ages of 12 and 18 years, 49.4% (40/81) and 15.5% (9/58), respectively, of the patients still had fecal incontinence. Duration of fecal incontinence, with 4 years of age as the starting age for fecal incontinence (when a child should be toilet trained), was not related to successful outcome or relapse. Relapse occurred in 37% of patients.

CONCLUSIONS

Only 29% of the patients with FNRFI were successfully treated after 2 years of intensive treatment. Despite recovery in the majority of patients beyond puberty, at age 18 years, 15% continued to have fecal incontinence.

Bio-feedback treatment of fecal incontinence: Where are we, and where are we going?

Fecal incontinence is a disabling disease, often observed in young subjects, that may have devastating psycho-social consequences. In the last years, numerous evidences have been reported on the efficacy of bio-feedback techniques for the treatment of this disorder. Overall, the literature data claim a success rate in more than 70% of cases in the short term. However, recent controlled trials have not confirmed this optimistic view, thus emphasizing the role of standard care. Nonetheless, many authors believe that this should be the first therapeutic approach for fecal incontinence due to the efficacy, lack of side-effects, and scarce invasiveness. Well-designed randomized, controlled trial are eagerly awaited to solve this therapeutic dilemma.

The prevalence of encopresis in a multicultural population

BACKGROUND

Population-based studies on the prevalence of encopresis in children are scarce and generally outdated. Prevalence estimates based on clinical studies are unreliable because parents tend to be reticent to seek medical help for this problem. Professional help is necessary, however, because encopresis can lead to serious psychosocial health problems. The authors examined the prevalence of encopresis in children, the frequency of visits made to general practitioners for encopresis and the psychosocial health problems of encopretic children.

METHODS

This population-based study involved 13,111 parents and their 5- to 6-year-old children and 9,780 parents and their 11- to 12-year-old children, all residents of Amsterdam, the Netherlands.

RESULTS

The prevalence of encopresis was 4.1% in the 5-to-6 age group and 1.6% in the 11-to-12 age group. Encopresis was more frequent among boys and children from the very depressed areas of the city. Encopresis was less frequent among Moroccan and Turkish children. A defecation frequency of less than three per week was found in 3.8% of the 5- to 6-year-olds and 10.1% of the 11- to 12-year-olds with encopresis. Only 37.7% of the 5- to 6-year-olds and 27.4% of the 11- to 12-year-olds who had encopresis had ever been taken to see a doctor for this problem. Psychosocial problems were far more common among children with encopresis than among normal children.

CONCLUSIONS

Encopresis is a common condition that is often associated with psychosocial health disorders but only a small proportion of the children with encopresis are taken to a general practitioner to discuss their problem.

Chronic constipation in children: organic disorders are a major cause

Diagnostic tools for paediatric chronic constipation have been limited, leading to over 90% of patients with treatment-resistant constipation being diagnosed with chronic idiopathic constipation, with no discernible organic cause. Work in our institution suggests that a number of children with intractable symptoms actually have slow colonic transit leading to slow transit constipation. This paper reviews recent data suggesting that a significant number of the children with chronic treatment-resistant constipation may have organic causes (slow colonic transit and outlet obstruction) and suggests new approaches to the management of children with chronic treatment-resistant constipation.

Comorbidity of functional urinary incontinence and encopresis: somatic and behavioral associations

PURPOSE

Functional urinary incontinence and encopresis are common comorbid disorders in childhood. We analyze the specific somatic and behavioral symptoms associated with functional enuresis/urinary incontinence and encopresis when they occur together.

MATERIALS AND METHODS

A total of 167 consecutive children 5 to 10 year olds, with day and/or night wetting were examined prospectively with ultrasound, uroflowmetry, electroencephalography, the Child Behavior Checklist, Culture Fair Intelligence Test and ICD-10 child psychiatric diagnoses.

RESULTS

The main findings for the comorbid group (20 patients) with wetting and soiling were a significantly higher rate of daytime incontinence and micturition problems, thickened bladder walls and pathological electroencephalography. There were higher, although not significant, rates of previous urinary tract infections, antibiotic prophylaxis, residual volume and abnormal uroflow curves in this group. Behaviorally, hyperkinetic syndromes, and emotional and conduct disorders (according to ICD-10) were more common. Of the 20 patients 65% had a Child Behavior Checklist total score (greater than 90th percentile) in the clinical range. The externalizing, internalizing, delinquent and anxious/depressed problem scales were also significantly higher.

CONCLUSIONS

This risk group requires detailed assessment and specific treatment. In addition to the symptomatic treatment of the wetting and soiling, many of these children are in need of specific behavioral, psychotherapeutic and pharmacological treatment.