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THE FIRST INTERNATIONAL CONSENSUS CONFERENCE ON FECAL INCONTINENCE: A REPORT Robert
W. Collins, PhD, PC |
| This
page originated in 1999 and was aging to such a degree that I recently revisited
it on 03/03/2006 to consider deleting it. However, it remains such a highly
significant event in the history of treating encopresis and it is so educative
in nature that I have decided to retain it indefinitely. Parents and professionals
are well advised to read it through for basic facts and issues regarding
encopresis. RWC |
| Introduction Overall Impressions Diagnostic Issues An Aside on Simple Anatomy and Function Some Interesting Statistics The Necessity of "Clean Outs" A Report and Comments on the Oral Laxative and the Soiling Solutions Training Approaches Motility Problems |
| Introduction: William E. Whitehead, PhD, (Psychologist and Research Professor of Medicine, UNCarolina at Raleigh) led off the conference noting that there are only 10-20 centers which do Anorectal studies and treatment in the US and then they have a relatively low volume by contrast to other disorders. I attended all sessions of the conference with some other 400-500 attendees. |
| This
conference was held at the Pfister Hotel in Milwaukee, WI on April 20-21,
1999. The joint sponsors were The International Foundation for Functional
and Gastrointestinal Disorders (IFFGD) and the University of Wisconsin Medical
School. It was supported by the American College of Gastroenterology and
the American Society of Colon and Rectal Surgeons along with some pharmaceutical
companies. |
| The IFFGD constitutes the most prestigious, true non-profit information exchange for a wide range of functional gastrointestinal disorders, including encopresis. I strongly recommend going to its web site at www.iffgd.org . Adults having problems and needing support can also find help there over the phone. Check out its various Fact Sheets, which cost $1.00 apiece and are well worth the money. By all means refer your doctor to this source site. The founder and director of IFFGD (in 1991), Nancy Norton, is a wonderful individual for whom all at the conference had the utmost respect. She kept the highflying and hard driving university and surgeon types grounded in human quality of life issues. She was warm, quietly effective, and an impressive coordinator of people and information. |
| Overall
Impressions: Parents may be surprised to realize that the problem of encopresis in children was not a major focus of the conference and that only 3-5 speakers of a total of about 30 specifically addressed the problems of children. The percentage of adults who suffer from encopresis is in the range of 2-4% for an ambulatory population, but climbs up toward 50% in nursing homes. Women bear some risk because of damage which can occur from childbirth, but men appear to have the problem of soiling just as much. The speaker from the Mayo Clinic, which runs the largest GI clinic in the US dropped a relevant clue about why men are also at risk in noting that 20+ years of overstraining to eliminate can be very damaging and a source of encopresis. Some of the surgical techniques discussed involved repair for damage from childbirth where the external sphincter can be damaged in 20% or so of cases from birth delivery. Biofeedback received plenty of attention and was viewed as a major modality for addressing soiling before and/or after surgery. Biofeedback was not seen as necessary in the vast majority of cases of childhood encopresis where establishing a bowel habit was viewed as the central approach. |
| Diagnostic
Issues: This received a lot of attention, but surprisingly little emphasis was pointed toward assessing GI motility as such (but it was noted). The role of constipation or "overflow incontinence" was certainly acknowledged for all age ranges, but the emphases on assessment centered on the properties and functions of the rectum and the anal sphincter muscles. These appear to be the major source of difficulties in soiling, which can be more readily altered. Thus, there was talk about "sensitivity" to filling the rectum or anal canal, strength of sphincter or puborectalis muscle contractions, and weakness of the pelvic floor muscles. Several times speakers noted the suspicion that chronic constipation and resistance to voiding resulted in inhibition of the Internal Anal Sphincter (IAE) allowing leakage to occur easily. The overflow being more liquid in nature may be much more difficult for the child too discriminate from the passing of gas, which could contribute to some accidents. Note how careful we adults have to be when ill about whether we will pass gas or liquid stool. Also, the External Anal Sphincter (EAS), which is the last defensive barrier (see ASIDE next) may just exhaust or habituate to the constant leakage. |
| An
Aside on Simple Anatomy and Function: Think of the anal opening as a dual-lined sleeve from inside to out. The inner sleeve is the Internal Anal Sphincter (IAE) which is typically in a static/passive state of constriction. This is smooth muscle and not usually thought of as being under voluntary control. It contains our feces quite adequately and routinely as we go about the ordinary conduct of our lives. However, another layer or sleeve outside of the IAE is mostly striated or voluntary muscle which can be called on to handle emergencies or urge sensations by constricting and holding back feces. This phasic muscle action is done by the External Anal Sphincter (or EAS) which can be injured in childbirth or by other means of accumulated damage over time and be thus weakened and become inadequate for emergencies. This muscle can be "tightened up" in surgery (overlapping sphinterotomy) so it will close more effectively. Other recent innovations can take a muscle from elsewhere in the body (the nearby gracilis muscle of the inner thigh) to substitute for the EAS--but it may require facilitated neural-muscular stimulation from an electronic device or even re-routing of the Pudendal nerve (the latter just done in studies on dogs). The puborectalis muscle(PRM) is a sling muscle just above the anus which also can close off fecal loss. Indeed, kids may be "fighting" this muscle (the PRM) when they strain too hard to void by contracting it at the same time as they are trying to let the EAS relax so that they can void. What a paradox as this only promotes more constipation and unsuccessful attempts to void! The stool will even back up into the colon enlarging it and resulting in a condition called "megacolon", which is simply Greek for a "Giant colon". Many children also may reflexively defend against any urges to void by clamping up the EAS, a condition called "anismus". Often the children become frightened and very concerned about accidents such that they over learn "clamping up" without thinking about it or understanding that this is what they are doing. Simple reasoning with the child will not correct this condition. My toilet training program emphasizes having children relax as they toilet and then only for relatively short sittings so that they eventually lose their fear and begin to release and let their body function as it should. If conditions are right, which my program enhances, then they will just go much more easily and routinely with training over time. |
| Some
Interesting Statistics: Ninety to 95% of encopretic children are of the constipated, enlarged colon variety. This is the so-called retentive form of encopresis and the children are sometimes graphically referred to as "stool hoarders". Vera Loening-Baucke, MD, of the University of Iowa noted a 2.8% incidence of encopresis for 4 y/o's, 1.9% for 6 y/o's, and 1.6% for 10-11 y/o's. The male to female ratio for encopresis ranges from 2.5:1 to 6:1. She states that 95% of constipation is basically functional in nature (i.e., not associated with physical abnormalities or intake of medications). This is the population that I seek to reach from my practice and this website. Incidentally, you will find many references to the University of Iowa if you use the search term "encopresis" on the internet. |
| The
Necessity of "Clean Outs": Over and over again the necessity for the complete clean outs of encopretic children with suppositories and enemas were noted before undertaking any bowel training program and redoing it, if necessary. Parents must remain on the alert for maintaining good toileting habits for a good year to avoid relapses. My program has emphasized this and may have the additional advantage of assuring daily cleanouts by virtual of its design and the explicit use of suppositories and enemas as back up conditioning aids if the child does not respond to his natural gastrocolic urges in time every day. (ASIDE--I have seriously reconsidered this position as my program contains automatic elements of a clean out where significant daily bowel movements are assured on a day by day basis over the course of treatment. I would reserve a clean out only to instances where it is clear that the child is quite impacted before treatment is initiated. If a child has been on Miralax and is eliminating only very soft, unformed stools then an initial clean out likely is not needed, but the Miralax should be tapered off fairly quickly once the Clean Kid Treatment is adopted to promote normally formed stools that can be better recognized by the sub-mucosal lining of the colon-rectum). RWC. |
| A
Report and Comments on the Oral Laxative and the Soiling Solutions Training
Approaches: Philip Miner, MD, President and Director of the Oklahoma Center for Digestive Medicine in reporting on the oral laxative training approach noted a preference for the use of Osmotic Agents over the oral stimulant laxatives (see my Diet and FAQ's page at this site for more insights about the problems with "stimulant laxatives" derived from certain plants). He also objected to the use of mineral oil because of its liquid nature, which causes children difficulty in discriminating it from gas thereby contributing to accidents. Most presenters noted how so many parents promote fiber as a kind of end-all solution for helping children to become continent. They were clearly unimpressed. It may be helpful to have more bulk and softer stools, but targeted training is clearly needed in addition. |
| The
use of the oral route predominated in recommendations for training a daily
bowel habit. I believe that route to be relatively ineffective theoretically
because of the conditioning timing principles involved. In fact, I am surprised
that it does work as well as it is reported to and I wonder if this is true
in actual practice by ordinary practitioners. There is just way too much
time between ingestion and voiding urges down the line in time for reliable
learning to occur. My approach with a suppository and then an enema, if
necessary, at just the proper times after a meal leads to almost immediately
producing the relevant sensation of bowel pressure and guarantees very timely
voiding. Some of the attendees knew of my classical study on the conditioning
alarm for bedwetting which showed that any delays in the alarm sounding
after bladder pressure cues are present completely rendered the alarm ineffective
in training kids to become dry. I believe that the same principle of the
importance of immediate responding in making learning possible is true in
learning bowel control as well. In general, I kept a fairly low profile
at the conference, partly because of the existing bias for the use of the
oral mediated training approach which does have some effectiveness and I
don't have the controlled research to back-up for my own approach. I believe
that I could probably enhance the effectiveness of the oral route by taking
advantage of timing variables for sitting and the likely times of urges
that naturally occur. This is covered in my 2nd revised Clean Kid Manual. I was particularly gratified to hear over and over again the emphasis on the necessity to "establish a bowel habit" as a key to soiling prevention in all age ranges. Several very key people showed a considerable interest in my Clean Kid Manual and I gave some copies away. I am hopeful that one of these powerful academic types will subject my ideas to controlled, comparison studies. |
| Motility
Problems: This author recognizes that motility disorders can be independently diagnosed and may have a variety of causes which are currently being explored. One concern is that overuse of stimulant, vegetable laxatives may cause motility problems, something that my program should be good at avoiding. Also, if a severe motility disorder is present the only treatment alternative currently available is the ACE procedure. |
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