Fecal Incontinence in Children

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.

Management of Functional Constipation in Children with Lower Urinary Tract Symptoms: Report from the Standardization Committee of the International Children's Continence Society

The rectosphincteric responses of 22 spina bifida (SB) children, aged 3.0 to 11.0 years, with frequent neurogenic faecal incontinence were investigated by clinical and anomanometric techniques and a bowel habilitation programme based on the physiological rationale of timed regular and complete evacuations, regulation of bowel habit and faecal consistency by diet and biofeedback conditioning of rectosphincteric responses. Eighteen patients had perianal anaesthesia, flail anus and absent anorectal reflex, but some degree of (reduced) rectal sensation. Four had reduced perianal sensation and normal to high pressure external sphincter and a megarectum apparently causing an absence of rectal sensation. Twenty were unable to expel the rectal balloon voluntarily. After biofeedback exercises (2-5 sessions) and a home programme of evacuation and diet, 21 of the 22 achieved satisfactory continence over 2-6 months with improved rectal sensation and ability to evacuate voluntarily. This experience suggests that early anorectal evaluation and a comprehensive bowel habilitation programme may be an effective approach to the prevention of disability due to faecal incontinence in SB children.

This study prospectively assessed whether positive screening surveys for autism spectrum disorders (ASDs) in children with functional defecation disorders (FDDs) accurately identify ASD. Parents of children (4–12 years) who met Rome III criteria for functional constipation (FC), FC with fecal incontinence (FI) and functional nonretentive FI (FNRFI) completed two ASD screening surveys. Children with positive screens were referred for psychological evaluation, and a year later, follow-up surveys were conducted. Of the 97 study participants, 30.9 % were diagnosed with FC, 62.9 % with FC with FI, and 6.2 % with FNRFI. ASD surveys were positive for 27 children (27.8 %). New DSM diagnoses were made in 10 out of the 15 children that completed further evaluation. Two (2.1 %) met criteria for ASD, and 12 (12.4 %) met criteria for other behavioral disorders. Average SRS and SCQ-L scores were higher in subjects with FC with FI as compared to FC alone and in those who reported no improvement versus those who reported improvement 1 year later.Conclusion: While positive ASD screening surveys did not correctly identify ASD in the majority, it did help to identify other unrecognized behavioral disorders in children with FDD. High screening scores were more common in children with FC with FI and in children with poorer responses to current medical treatments.What is Known:•A prior study found that 29 % of children with FDD scored positive on ASD screening questionnaires.•Whether positive screens correctly identify ASD in children with FDD is unknown.What is New:•This study shows that positive ASD screens do not correctly identify ASD in children with FDD. However, the use of ASD screening questionnaires can identify previously unrecognized and untreated behavioral/developmental disorders in children with FDD.•High screening scores are more common in children with FC with FI and in children with poorer responses to current medical treatments.

Objectives:The objective of this study is to investigate long-term outcomes of antegrade continence enema (ACE) treatment in children with constipation or fecal incontinence.Methods:Prospective cohort study including pediatric patients with organic or functional defecation disorders who started ACE treatment. Data were collected at baseline and at follow-up (FU) from 6 weeks until 60 months. We assessed parent and patient-reported gastrointestinal health-related quality of life (HRQoL) using the Pediatric Quality of Life Inventory Gastrointestinal Symptoms Module (PedsQL-GI), gastrointestinal symptoms, adverse events, and patient satisfaction.Results:Thirty-eight children were included (61% male, median age 7.7 years, interquartile range 5.5–12.2). Twenty-two children (58%) were diagnosed with functional constipation (FC), 10 (26%) with an anorectal malformation, and 6 (16%) with Hirschsprung disease. FU questionnaires were completed by 22 children (58%) at 6 months, 16 children (42%) at 12 months, 20 children (53%) at 24 months, and 10 children (26%) at 36 months. PedsQL-GI scores improved overall with a significant increase at 12- and 24-month FU for children with FC and a significant increase in parent reported PedsQL-GI score at 36-month FU for children with organic causes. Minor adverse events, such as granulation tissue, were reported in one-third of children, and 10% of children needed a surgical revision of their ACE. The majority of all parents and children reported that they would “probably” or “definitely” choose ACE again.Conclusion:ACE treatment is perceived positively by patients and parents and can lead to long-term improvement in gastrointestinal HRQoL in children with organic or functional defecation disorders.

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.

We aimed to study constipation and fecal incontinence in terms of prevalence, recognizing the disorders, help-seeking behavior, and associated symptoms. In this cross-sectional study, 240 children (8 to 18 years) from the general Dutch population completed a questionnaire about defecation disorders. After exclusions for anorectal/pelvic surgery or comorbidities, we analyzed 212 children. The prevalence of constipation was 15.6%; in a quarter of the cases, it co-occurred with fecal incontinence. We found 3% fecal incontinence without constipation. Even though children with a defecation disorder rated their bowel habits worse compared to children without defecation disorders (P < 0.001), 46% constipated children and 67% fecally incontinent children rated their bowel habits as good or very good. Moreover, 21 to 50% of children with a defecation disorder did not mention their symptoms to anybody. Interestingly, most constipated children had “normal” stool frequencies (64%) and consistencies (49%).Conclusion: The prevalence of constipation and fecal incontinence is quite high in children. Stool frequency and consistency is normal in half the constipated children, which may complicate the recognition of constipation. Finally, a considerable number of children does not recognize their disorders as constituting a problem and does not seek help, which leads to an underestimation of these disorders.What is Known:• Constipation and fecal incontinence are common in children, but their prevalence rates may be underestimated due to a variety of reasons.• Diagnosing these disorders remains challenging owing to the variety of symptoms and co-existence with other diseases.What is New:• The prevalence of constipation and fecal incontinence in children is high.• Many children do not recognize their defecation disorders as constituting a problem and do not seek help, which leads to an underestimation of the problem of these disorders.

The management of the fecal incontinence in children is difficult, and its social consequences are usually devastating. The general objectives of any bowel program are to produce social continence, predictability, and eventually independence. How to achieve those goals depends in part on the underlying condition. In children, fecal incontinence can occur from a variety of conditions. The most common is overflow incontinence from functional fecal retention, but it can also occur in otherwise healthy children with functional nonretentive fecal soiling or in children with organic causes of fecal incontinence, such as congenital malformations, or any other condition affecting the anorectum, anal sphincters, or the spinal cord. The therapeutic regimen that is recommended in patients with nonretentive fecal soiling consists of explanation and support for the child and parents, a nonaccusatory approach, and a toilet training program with a rewarding system. Biofeedback does not play an important role, and laxatives need to be used with caution, as they may exacerbate the incontinence. For those patients with congenital/neuropathic incontinence a combination of maneuvers to change stool consistency, colonic transit, anorectal function, and rectosigmoid evacuation is used. Stool consistency can be changed with the use of dietary interventions or medications. Stool transit can be slowed (antimotility agents) or accelerated (laxatives) with the use of medications. Anorectal function can be improved with the use of biofeedback or procedures to alter sphincter pressure, and the production of a bowel movement can be induced with maneuvers to empty the sigmoid (suppositories, enemas). With the recent advent of the Antegrade Colonic Enema (ACE), the patient is then able to be predictable and independent. This procedure creates a continent conduit from the skin to the cecum that can be catheterized or accessed for self-administration of enemas. The ACE has revolutionized the treatment of children with fecal incontinence.

The bowel management tube: An effective means for controlling fecal incontinence

TAI is an effective, well-tolerated, and safe choice in children with FC. No clinical parameters seemed to predict response to treatment. The number of children with FNRFI was low, but TAI seemed effective in this group of children. What is Known: • Functional fecal incontinence (FFI) is a frequent, chronic condition with significant impact on children's quality of life. • Transanal irrigation (TAI) is used in children with neurogenic bowel dysfunction but less studied in children with functional defecation disorders. What is New: • TAI seems an effective, well-tolerated, and safe choice in children with FFI due to functional constipation. • Albeit the number of children with functional non-retentive fecal incontinence was low in our study, TAI seems effective also in this group of children.

ObjectivesFunctional retentive overflow incontinence (retentive FI) is the most common cause of fecal soiling in children. Based on the clinical experiences, the treatment of retentive FI in patients with comorbid psychiatric disorders was accelerated when Risperidone was used as treatment for their psychiatric comorbidities; therefore, this study was conducted to evaluate the effect of risperidone in the treatment of retentive FI in children and adolescents.MethodsIn this double-blind, randomized, placebo-controlled trial, 140 patients aged 4–16 years eligible for the study were randomized into two groups, receiving either 0.25–0.5 mg of Risperidone syrup (n = 70) or maltodextrin syrup (placebo group, n = 70) every 12 h daily for 12 weeks. Sociodemographic data, including age, sex, weight, height, BMI, BMI z-score, and socioeconomic status, was recorded, and the number of nocturnal FI, diurnal FI, and painful defecations was measured.Results136 participants (69 on Risperidone and 67 on placebo) were included in the study. Mean age of participants in the intervention and placebo groups were 7.2 ± 2.4 years and 8.0 ± 3.1 years, respectively. The mean number of nocturnal FI (Ptrend=0.39) and diurnal FI (Ptrend=0.48) in patients without psychiatric comorbidities, and the number of painful defecations for participants with and without psychiatric comorbidities (P = 0.49, P = 0.47, respectively) were not significantly different between the groups, but a significant effect was observed in diurnal FI after Risperidone treatment in patients with psychiatric comorbidities (P < 0.001).ConclusionRisperidone, when used along with other non-pharmacological interventions, may be helpful in treating FI in pediatric patients with psychiatric comorbidities.

[Histology was performed in the central or primary lymphoid tisues (thymus and bursa of Fabricius) of the twelve 25-days-old “Kasila” broilers by observation of H & E stained sections in the Department of Anatomy and Histology, Faculty of Veterinary Science, Bangladesh Agricultural University, Mymensingh during the period from March to October 201. Study revealed that the thymus was covered by a thin conective tisue capsule. Numerous fine septa of conective tisue originated from the capsule and divided the organ into many incompletely separated lobules. Each lobule was divided into a peripheral cortex and a central medula. The population of the immunocompetent cels (lymphocytes and immunoglobulin containing plasma cels) in the cortex were denser rather than that of medula of the thymic lobule. The bursa of Fabricius was consisting of long thick mucosal folds (plicae). Numerous folicles filed the lamina propria of each fold and each bursal folicle was composed a peripheral cortex and a central medula. The population of the immunocompetent cels in the cortex of the bursal folicle were denser rather than that of medula of the bursal folicle. The length and width of the thymic lobules were 391.63 ± 25.874 μm and 202.50 ± 15.580 μm, bursal folicles were 594.38 ± 41.205 μm and 464.75 ± 17.721 μm respectively. This study helps to understand the distribution of immunocompetent cels in the central lymphoid organ of broiler.

The results of treatment of eleven children aged six to eleven years with fecal incontinence were traced. It was found that nine of them did not have an organic cause of the disease. Regular irrigation of the rectum in this group of patients contributed to the elimination of the encopresis.

Constipation is a prevalent issue among children and is generally treatable with simple therapeutic approaches. However, a considerable proportion of these children experience severe constipation that necessitates more invasive treatments, including surgical interventions. This study is designed to examine the effects of administering the Bowel Management Program (BMP) in the treatment of fecal incontinence and soiling among children with chronic refractory constipation. The research involved 24 patients who presented at the Children's Medical Center exhibiting symptoms of functional constipation and fecal incontinence. Each patient was enrolled in the study after a thorough review of their medical history, a physical examination, and other paraclinical measurements like barium enema or rectal manometry, ruling out the organic causes of constipation. The bowel management program was subsequently established for these patients. This study examined 24 children, including 14 girls (58.3%) and 10 boys (41.7%), with a mean (SD) age of 4.8 (1.2) years for the girls and 5.4 (1.2) years for the boys. The analysis revealed that there was no significant correlation between symptom duration and treatment duration in relation to gender, as indicated by a p-value greater than 0.05. Spearman's correlation test showed a significant relationship between the children's age and their treatment duration (p<0.001, r=0.54) and also between their age and their clinical symptom duration (p<0.001, r=0.59). The results showed that the children's age was significantly correlated with their treatment duration and clinical symptom duration. The bowel management program can be an effective treatment for overflow incontinence in children with chronic refractory constipation.

The ACE procedure for the management of recalcitrant constipation and fecal incontinence in children with neurogenic bowel has been highly successful with reported fecal continence rate of over 90 %. Complications occur but in experienced hands can usually be solved with conservative measures or minor surgical procedures. Informed consent is a crucial part of preoperative management. Thorough discussions of the procedure, expectations and the care for the ACE stoma cannot be overemphasized and a dedicated team member such as a nurse practitioner for such patients is a necessary asset. Even after years of noncompliance with the use of the ACE, clinical consequences are typically inconsequential and the ACE can be salvaged to help improve the patient’s quality of life.