Gastroenterology

Gastroenterology

Volume 126, Supplement 1, January 2004, Pages S33-S40
Gastroenterology

State of the art: pathophysiology
Pathophysiology of pediatric fecal incontinence

https://doi.org/10.1053/j.gastro.2003.10.012Get rights and content

Abstract

This article addresses the diagnosis and treatment of pediatric fecal incontinence in 4 main categories: (1) Functional fecal retention, the withholding of feces because of fear of painful defecation, results in constipation and overflow soiling. Treatment includes dietary changes, use of laxatives, and cognitive and behavioral interventions such as toilet training, which diminishes phobia and provides positive reinforcement through a rewards system. (2) For functional nonretentive fecal soiling (encopresis), antidiarrheal agents can increase the consistency of stools and facilitate continence. Anorectal biofeedback for children has been proposed, but its efficacy remains unproven. Parents should be educated to conduct nonaccusatory toilet training and help children alleviate guilt and enhance self-esteem. Appropriately constructed trials are necessary to gauge the effect of adding prolonged use of enemas to an intensive toilet training program. (3) Surgery can correct minor congenital anorectal anomalies by identifying the external sphincter, separating the rectum from the genitourinary tract, and reconstructing the anus. However, there is great variation in postsurgical functional outcomes for anorectal malformations. Double-blinded, randomized controlled trials could help define the role of appendicostomy, cecostomy, sphincter reconstruction, colostomy, and artificial sphincters. (4) Children with spina bifida and fecal incontinence may benefit from techniques that teach them how to defecate. A continent appendicostomy (Malone procedure) is a promising treatment that completely cleanses the colon, increases the child’s autonomy, and decreases the chance of soiling. A cecostomy can be performed surgically, endoscopically, or radiologically to provide some of the same benefits.

Section snippets

Functional fecal retention with overflow soiling

Functional fecal retention, the most common chronic defecation disorder in children, is the withholding of feces because of fear of painful defecation. This condition is responsible for up to 25% of visits to pediatric gastroenterologists and 3% to 5% of visits to general pediatricians.2 Typically, it develops at the time of toilet training or when the child starts school. Functional fecal retention is most likely the result of long-standing stool retention in the rectum. The increasing

Functional nonretentive fecal soiling

A subset of patients (male to female ratio of 4:1) lacks a history of functional fecal retention and instead has voluntary or involuntary evacuation of fairly large bowel movements in their underwear. According to the Rome II criteria,8 children older than age 4 years who present with this symptom at least once a week are considered to have functional nonretentive fecal soiling (FNRFS). Children with FNRFS often have daily bowel movements in the toilet and have a nearly complete stool

Anorectal malformations

Anorectal anomalies are congenital defects that occur once in 3000 to 5000 live births and are more common in boys. They can range from minor defects that require simple surgery to complex lesions requiring a high degree of skill and technical expertise to correct. These anomalies may be attributed to defective development of the lower rectum, urogenital tract, and anus in utero.

Spinal problems

Spina bifida occurs in about 1 in 1000 live births, making it the most common birth defect after trisomy.19 Typically, it is characterized by paralysis and lack of sensation below the level of the lesion. Myelomeningocele, the most common type of open spina bifida, usually affects the lumbosacral region and is associated with bowel and bladder dysfunction. Urinary and bowel incontinence are common because the rectoanal inhibitory reflex is preserved but the urge for defecation may be lost. The

Miscellaneous causes

Hirschsprung disease (congenital aganglionosis) is the most common cause of lower intestinal obstruction in neonates. Theoretically, surgical removal of the aganglionic segment is a lifesaving procedure that can correct Hirschsprung disease and normalize defecation. However, defecatory problems are common even years after surgery: Up to 50% of children have constipation or fecal incontinence, regardless of the surgical technique used.27 The high prevalence of defecatory disturbances after

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