Treatment of fecal incontinence with a comprehensive bowel management program

doi:10.1016/j.jpedsurg.2009.02.047

Journal of Pediatric Surgery

Volume 44, Issue 6, June 2009, Pages 1278-1284

https://doi.org/10.1016/j.jpedsurg.2009.02.047 Get rights and content

Abstract

Purpose

Many articles describe the antegrade continence enemas (ACEs), but few refer to a bowel management program. A successful ACE may not help a patient without such management. Valuable lessons were learned by implementation of bowel management in 495 fecally incontinent patients.

Methods

We previously reported 201 patients. Thereafter, another 294 patients participated in our program. On the basis of a contrast enema and symptoms, they were divided as follows: (a) 220 constipated patients and (b) 74 patients with tendency toward diarrhea. Colonic stool was monitored with abdominal radiographs, modifying the management according to the patient's response and radiologic findings. For constipated patients, the emphasis was on using large enemas. For patients with tendency toward diarrhea, we used small enemas, a constipating diet, loperamide, and pectin. Diagnoses included anorectal malformation (223), Hirschsprung's (36), spina bifida (12), and miscellaneous (23).

Results

The management was successful in 279 patients (95%)—higher in constipated patients (98%) and less successful in patients with tendency toward diarrhea (84%).

Conclusions

The key to a successful bowel management program rests in tailoring the type of enema, medication, and diet to the specific type of colon. The best way to determine the effect of an enema is with an abdominal film. The ACE procedures should be recommended only after successful bowel management.

Section snippets

Material and methods

We reviewed the medical records of 294 patients who participated in our bowel management program for the treatment of fecal incontinence. They were divided into 2 groups as follows: (a) patients with a tendency toward constipation and a dilated colon on hypaque contrast enema (Fig. 1) (220 patients) and (b) patients with a tendency toward diarrhea and a nondilated or short colon seen on the hypaque contrast enema (Fig. 2) (74 patients).

The treatment was implemented for a period of 1 week,

Results

The management was successful in 279 patients (95%). We improved our overall success rate when comparing this series with our previous publication [13] (95% vs 88.9%; P = .0173) (Table 2). Follow-up ranged from 6 months to 3 years. Age range for initiation of bowel management was 3 to 31 years.

In this study, the success rate was higher in patients with tendency toward constipation (217 [98%]) than in patients with tendency toward diarrhea (62 [84%]). Fifteen patients (5%) did not improve. The

Discussion

We believe that the improvement in our overall success rate is a reflection of our increased experience. We were less successful in cases with tendency toward diarrhea, and we feel that this was because more complicated patients are now being referred to our bowel management program. Our recommended time to start bowel management is when the child would normally begin wearing normal underwear (age 3-5 years). Of course, we met many patients after that ideal age at the time of their referral to

Conclusions

We believe that the key to a successful bowel management program resides in tailoring the type of enema, medication, and diet according to the characteristics of each patient as to tendency toward constipation or tendency toward diarrhea. The best way to determine the cleaning effect of an enema is with an abdominal film (Fig. 3). Patients who received a “colostomy for life” can be adequately evaluated for the possibility of a pull-through or a colostomy closure by performing bowel management

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Citation Excerpt :
Children with stool withholding behavior who have normal sphincter pressure and sensation may experience worsening of the behavioral problem if given retrograde enemas or any other kind of anal manipulation.28 Children without constipation who have hyperperistalsis of the pulled-through colon or abnormal sphincter function or sensation benefit from a constipating diet, bulking fiber, and medications such as loperamide.28 The use of stool softeners in this patient population is likely to exacerbate the incontinence.
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AAP PaperTreatment of fecal incontinence with a comprehensive bowel management program

Abstract

Purpose

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Discussion

Conclusions

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Urol

J Pediatr Surg

Lancet

J Pediatr Surg

Urol

AAP Paper
Treatment of fecal incontinence with a comprehensive bowel management program