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One of the most powerful messages that comes from Jaffray's paper is the impact that ongoing faecal incontinence as a result of severe childhood constipation has on the quality of afflicted young people's lives. This paper is an excellent example of never giving up on patients whose symptom control seems hopeless. However, there is a risk that the very invasive surgery that is described will appear attractive at too early a stage to professionals and parents alike when faced with the frustration of managing this remitting and relapsing condition. It is stressed in Jaffray's paper that this radical surgery is only considered when a programme of medical and more minor surgery has failed and when all the factors are weighed by an independent clinician. The debate on the relative roles of surgery versus psychological management goes back for 50 years. When it became histologically possible to diagnose short segment Hirschsprung disease as a cause of megarectum leading to severe constipation, all the others were considered to be primarily behavioural in origin. However, it became clear that a very high capacity rectum for whatever cause posed considerable physical problems to the child and very easily compounded by pain and fear. This recognition of the vicious cycle of faecal accumulation, overflow faecal incontinence, painful defaecation and fear with active withholding has led to the drive to recognise and treat difficult defaecation early in childhood and with a minimum of stressful treatments. Fortunately, better oral disimpaction regimens have reduced the likelihood of psychologically risky enemas given under duress. However, a number of children cannot be stimulated effectively to empty their rectums even with the most carefully administered laxative regimens. Even with this subset of children, it is essential to check that adequate volumes of laxative are being used and in the correct order. …
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