Soiling Solutions

Very Recent Scientific Abstracts:

My article, Soiling Solutions(R): An Internet and Manual Based Approach to Treating Encopresis was published in the Spring, 2009 issue of "Digestive Health Matters," a publication of the International Foundation for Functional Gastrointestinal Disorders. It warranted a special Editorial Comment by Paul E Hyman, MD, a leading Pediatric Gastroenterologist. Reprints are available as a pdf attachments upon request. My contact information is on this website at the bottom of all of our pages. RWC.

The abstracts which follow are narrowly focussed on issues and mechanisms pertinent to encopresis, enuresis, and toilet training. Scroll down to find each of the sections on Encopresis, Enuresis, and Toilet Training. In general, more recent articles are posted at the end of each section, but this is not always true if there appears to be a good fit with a prior article. The completeness of the updating of course is limited to the cited search terms and cited authors that I have used to this date with my subscribed literature retrieval service (Thomson Scientific).

My weekly computer updates received through 02/01/2010 have been reviewed for significant abstracts to post. The last posting(s) was made on 02/02/2010. I recently deleted all abstracts from 2005 and 2006 as well as some later ones in the Encopresis and Enuresis sections. This was truly painful, but the list was just getting too long. Many very interesting articles on encopresis/constipation appeared in the October, 2009 issue of Neurogastroeterology and Motility which I simply do not have the time to reformat and post. Researchers would be well advised to check that issue out.

This page receives my strong, personal attention. It is oriented toward professionals and not the general public.  Of couse, everyone is free to examine it and parents may find it interesting to see the latest research in the area of encopresis and enuresis.  RWC.

Anal plugs for the management of fecal incontinence in children and adults - A randomized control trial

Bond,C.,* Youngson,G., MacPherson,I., Garrett,A., Bain,N., Donald,S., & Macfarlane,T.V. Univ Aberdeen, Dept Gen Practice & Primary Care, Fosterhill Hlth Ctr, Westburn Rd, Aberdeen AB25 2AY, Scotland

Search Terms: Anal plug, encopresis.

Goals: To evaluate the contribution of the anal plug to the management of fecal incontinence in children and adults.
Background: Effective management of fecal incontinence remains problematic. Previous studies of an anal plug have yielded conflicting results.
Study: A randomized controlled trial was conducted. The intervention was the Conveen anal plug (Coloplast Limited) used for 12 months.
Outcomes measures included: generic measures of child health [Functional Status II-R, Child Health Questionnaire (CHQ-PF50) and Dartmouth Primary Care Cooperative Information Project Charts]; generic measures of adult health for patients and carers (the SF-36, and Patient Generated and Carer Generated indices); condition-specific measures for adults and children; qualitative interviews, bowel charts, and diaries. The main outcome measure was a condition-specific score on a 0 to 100 scale, where 0 was the most severe and 100 was the least severe incontinence.
Results: Thirty-one intervention and 17 control patients were recruited. Fecal incontinence was due to I of 3 reasons: congenital, acquired, and neurogenic. At baseline, patients managed their condition preemptively or protectively. Intervention patients used the plug as a complete management substitute or as an adjunct to existing management. The majority of intervention respondents retained the plug most of the time. There was greater improvement from baseline in mean condition-specific score in intervention group compared with control group but this difference was not statistically significant (t test P = 0.053). Complete data analysis using analysis of covariance showed the mean difference between the treatment groups in condition-specific score of 9.9 (95% confidence interval-1.4, 21.1). Intention to treat analyses using imputation showed similar results. There was generally greater improvement in intervention groups subjects using other measures for children, adults, and caretakers.
Conclusions: The anal plug is of benefit to the majority of patients. It does not suit all eligible patients with in situ plug retention being a problem for some.

This struck me as the ultimate in a simplistic biomechanical aid for dealing with encopresis. The very consideration of such a device suggests that this bodily waste is so aversive than any net gain in eliminating its occurrence is sought after. My soiling solutions protocol is very effective for the early elimination of soiling plus a conditioning protocol which leads to a lasting and natural solution. I think it should be tried before this kind of intervention is even considered. DrC.

*****************************

Jan, 2007 DIGESTIVE DISEASES AND SCIENCES (v52,1), Pp.64-69. Posted on 02/17/2007.

Long-term outcome of functional childhood constipation.

Khan,S.,* Campo,J., Bridge,J.A., Chiappetta,L.C., Wald,A., di Lorenzo,C.
Alfred I DuPont Hosp Children, Div Gastroenterol & Nutr, 1600 Rockland Rd, Wilmington, DE 19803 USA

Search Terms: constipation, IBS, encopresis, restrospective.

We investigated whether functional childhood constipation (FCC) is an early expression in the continuum of functional disorders such as adult constipation, irritable bowel syndrome (IBS), and dyspepsia. Adults >= 18 years with a diagnosis of FCC verified by one pediatric gastroenterologist participated in the questionnaire-based study. Controls were comprised of adults who underwent tonsillectomy as otherwise healthy children during the period corresponding to the FCC diagnosis. The prevalence of constipation, IBS, and dyspepsia was determined by the Bowel Disease Questionnaire. Twenty FCC adults (8 females), median age 22 years, were compared with 17 adult controls (10 females), median age 22.9 years. The frequency of constipation in FCC adults was not different from that in controls (25% versus 23.5%). The frequency of IBS in FCC adults was higher than in controls (55% versus 23.5%; P < 0.05). Dyspepsia was reported by 25% of both groups. The median follow-up period of the FCC adults was 14 years. In a long-term follow-up of a small sample, the prevalence of constipation in FCC adults is comparable to that in controls. Childhood constipation appears to be a predictor of IBS in adulthood.

This study is too small for generalizing with confidence, but it is interesting that childhood constipation is NOT a predictor of young adult constipation, but is predictive for Irritable Bowel Syndrome (IBS). RWC

*****************************

At what age is a suction rectal biopsy less likely to provide adequate tissue for identification of ganglion cells?

Croffie,J.M.*, Davis,M.M., Faught,P.R., Corkins,M.R., Gupta,S.K., Pfefferkorn,M.D., Molleston,J.P., & Fitzgerald,J.F. Indiana Univ, Sch Med, James Whitcomb Riley Hosp Children, Div Pediat Gastroenterol Hepatol & Nutr, 702 Barnhill Dr, Room ROC 4210, Indianapolis, IN 46202 USA

Search Terms: Hirschsprung disease, constipation.

Objective: The objective of this study was to determine at what age suction rectal biopsy is less likely to provide adequate tissue to detect submucosal ganglion cells in a child being evaluated for Hirschsprung disease.
Patients and Methods: Children >= 1 year of age undergoing a rectal biopsy at a single children's hospital had 1 biopsy each obtained simultaneously with a suction biopsy device and a grasp biopsy forceps. The biopsies were examined by 2 pathologists for adequacy of the submucosa (none, scant, adequate, or ample) and the presence of ganglion cells. The 2 specimens were compared with each other.
Results: One hundred fifty-two children I to 17 years of age were included. Fifty-three were female. Subjects were grouped into 4 age categories: 1 to 3 years (group A), 4 to 6 years (group 13), 7 to 9 years (group C), and > 10 years (group D). Similar numbers of patients were recruited for each group. Ganglion cells were identified in 73% and 90% by the suction and grasp devices, respectively, in group A. In groups B through D, ganglion cells were identified in 50% to 53% vs 92% to 97% of the suction and grasp biopsies, respectively (P < 0.001). Submucosa was present in 88% (suction) vs 98% (grasp) in group A, 70% vs 95% in group B, 69% vs 94% in group C, and 45% vs 92% in group D.
Conclusion: The suction rectal biopsy is less likely to provide adequate submucosa for identification of ganglion cells after 3 years of age.

A very basic study which provides good information for Pediatric Gastroenterologists suggesting a best technique in confirming Hirschsprungs disease. This is especially relevant for those rare instances of a suspicion and need to rule out Hirschsprungs in older children. RWC

*****************************

Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation

Rao,S.S.C.*, Seaton,K., Miller,M., Brown,K., Nygaard,I., Stumbo,P., Zimmerman,B., & Schulze,K. Univ Iowa Hosp & Clin, 200 Hawkins Dr,4612 JCP, Iowa City, IA 52242
U1 - Article English

Search Terms: Biofeedback, encopresis.

Background & Aims: Constipation is a common disorder, and current treatments are generally unsatisfactory. Biofeedback might help patients with constipation and dyssynergic defecation, but its efficacy is unproven, and whether improvements are due to operant conditioning or personal attention is unknown.
Methods: In a prospective randomized trial, we investigated the efficacy of biofeedback (manometric-assisted anal relaxation, muscle coordination, and simulated defecation training; biofeedback) with either sham feedback therapy (sham) or standard therapy (diet, exercise, laxatives; standard) in 77 subjects (69 women) with chronic constipation and dyssynergic defecation. At baseline and after treatment (3 months), physiologic changes were assessed by anorectal manometry, balloon expulsion, and colonic transit study and symptomatic changes and stool characteristics by visual analog scale and prospective stool diary. Primary outcome measures (intention-to-treat analysis) included presence of dyssynergia, balloon expulsion time, number of complete spontaneous bowel movements, and global bowel satisfaction.
Results: Subjects in the biofeedback group were more likely to correct dyssynergia. (P < .0001), improve defecation index (P < .0001), and decrease balloon expulsion time (P = .02) than other groups. Colonic transit improved after biofeedback or standard (P = .01) but not after sham. In the biofeedback group, the number of complete spontaneous bowel movements increased (P < .02) and was higher (P < .05) than in other groups, and use of digital maneuvers decreased (P = .03). Global bowel satisfaction was higher (P = .04) in the biofeedback than sham group.
Conclusions: Biofeedback improves constipation and physiologic characteristics of bowel function in patients with dyssynergia. This effect is mediated by modifying physiologic behavior and colorectal function. Biofeedback is the preferred treatment for constipated patients with dyssynergia.

This program at the University of Iowa was successful in showing the effective application of biofeedback for adults with encopresis. It promoted more competent and frequent bowel movements cross-validating this method with other biofeedback studies at other centers, e.g., Croffie at Indiana University and Whitehead at the University of North Carolina at Raleigh. RWC.

*****************************

Dynamic MR assessment of the anorectal angle and puborectalis muscle in pediatric patients with anismus: Technique and feasibility

Chu,W.C.W.*, Tam,Y.H., Lam,W.W.M., Ng,A.W.H., Sit,F., & Yeung,C.K. Chinese Univ Hong Kong, Prince Wales Hosp, Dept Diagnost Radiol & Organ Imaging, 30-32 Ngan Shing St, Shatin, Hong Kong, Peoples R China

Search Terms: encopresis, anismus, RAIR, puborectalis, constipation

Purpose: To assess the feasibility of dynamic breath-hold MRI for evaluating changes in the anorectal angle and movements of the pelvic-floor musculature (puborectalis) during resting and straining states in pediatric patients presenting with anismus.
Materials and Methods: Six pediatric patients (7-13 years old) with chronic constipation and manometric evidence of anismus were assessed by dynamic breath-hold MRI. Changes in the anorectal angle, the degree of pelvic-floor descent, and the thickness and length of the puborectalis muscles were measured during rest and straining. The findings were compared with those obtained in six age- and sex- matched controls.
Results: The children with anismus had a smaller anorectal angle during straining, and the angle decreased from rest to defection. The puborectalis also became paradoxically shortened and thickened during straining in the anismus group. There were significant differences between the two groups in terms of the change of degree of the anorectal angle, and the thickness and length of the puborectalis muscle during straining.
Conclusion: Fast dynamic MRI is feasible for evaluating pelvic-floor movement in pediatric patients. Preliminary results suggest that children with anismus have a smaller anorectal angle and a different puborectalis configuration compared to controls.

Seeing is believing! The puborectalis is under voluntary control and has long been speculated to strangulate the bowel in preventing evacuation. It appears to be implicated here in that role. My own protocol would help to countercondition that effect as well as that of the External Anal Sphincter, both of which appear to be activated by past deep conditioning. RWC.

*****************************

Botulinum toxin, a new treatment modality for chronic idiopathic constipation in children: long-term follow-up of a double-blind randomized trial.

Keshtgar,A.S.*, Ward,H.C., Sanei,A., Clayden,G.S. Univ Hosp Lewisham, Natl Hlth Serv Trust, Dept Pediat Surg, London SE13 6LH, England

Search Terms: Botulinum, encopresis, constipation, IAS,

Background: Myectomy of the internal anal sphincter (IAS) has been performed on some children after failure of medical treatment to treat idiopathic constipation. The aim of this study was to compare botulinum toxin injection with myectomy of the IAS in the treatment of chronic idiopathic constipation and soiling in children.
Methods: This was a double-blind randomized trial. Patients between 4 and 16 years old were included in the study if they had failed to respond to laxative treatment and anal dilatation for chronic idiopathic constipation. All study patients had anorectal manometry and anal endosonography under ketamine anesthesia. Outcome was measured using a validated symptom severity (SS) scoring system, with scores ranging from 0 to 65.
Results: Of 42 children, 21 were randomized to the botulinum group and 21 were randomized to the myectomy group. At the 3-month follow-up, the median preoperative SS score improved from 34 (range = 19-47) to 20 (range 2-43) in the botulinum group (P < .001) and from 31 (range = 18-49) to 19 (range = 3-47) in the myectomy group (P <.002). At the 12-month follow-up, the scores were 19 (range = 0-45) and 14.5 (range = 0-41) for the botulinum group and the myectomy group, respectively (P < .0001). There was no complication in both groups.
Conclusion: Botulinum toxin is equally effective as and less invasive than myectomy of the IAS for chronic idiopathic constipation and fecal incontinence in children.

This is an important study for the increased use of Botulinum toxin and idenfiying one of the mechanisms for idiopathic constipations, that is, the IAS remaining in too contracted a state making the voiding of stool difficult. This implies a mechanism other than the EAS frequently cited and associated with the RAIR (Rectal Anal Inhibitory Reflex). However, I would still argue for the Soiling Solutions protocol before defaulting to this neurotoxin to weaken the IAS. Clearly, conditioning is possible for smooth muscle tissue such as the IAS. RWC.

*****************************

July 2007 ARCHIVES OF DISEASE IN CHILDHOOD (v92,6), Pp. 486-489. Posted on 08/18/2007

Prevalence rates for constipation and faecal and urinary incontinence.

Loening-Baucke,V., Univ Iowa, Childrens Hosp, JCP 2555,200 Hawkins Dr, Iowa City, IA 52242 USA

Search Terms: Enuresis, Encopresis, epidemiology, constipation.

Objective: To evaluate the prevalence rates for constipation and faecal and urinary incontinence in children attending primary care clinics in the United States.
Methods: Retrospective review of case records of all children, 4-17 years of age, seen for at least one health maintenance visit during a 6 month period and followed from birth or within the first 6 months of age in our clinics. We reviewed all charts for constipation, faecal incontinence and urinary incontinence.
Results: We included 482 children in the study, after excluding 39 children with chronic diseases. The prevalence rate for constipation was 22.6% and was similar in boys and girls. The constipation was functional in 18% and acute in 4.6%. The prevalence rate for faecal incontinence (>= 1/week) was 4.4%. The faecal incontinence was associated with constipation in 95% of our children. The prevalence rate for urinary incontinence was 10.5%; 3.3% for daytime only, 1.8% for daytime with night-time and 5.4% for night-time urinary incontinence. Faecal and urinary incontinence were significantly more
commonly observed in children with constipation than in children without constipation.
Conclusion: The prevalence rates were 22.6% for constipation, 4.4% for faecal incontinence and 10.5% for urinary incontinence in a US primary care clinic. Children with constipation had higher prevalence rates for faecal and urinary incontinence than children without constipation. Boys with constipation had higher rates of faecal incontinence than girls with constipation.

The generally higher incidence rate for encopresis in this study may have been associated with the selection bias inherent in studying children being seen at a primary care center as opposed to children surveyed in the general population (2-3%). The association of encopresis with constipation as well as enuresis is worthy of note as well. The observation on boys being more at risk for encopresis with constipation than girls is also of interest. RWC.

*****************************

Chronic childhood constipation: A review of the literature and the introduction of a protocolized behavioral intervention program.

van Dijk,M.*, Benninga,M.A., Grootenhuis,M.A., Onland-van Niettwenhuizen,A.M., & Last,B.F.

Emma Childrens Hosp, Acad Med Ctr, Psychosocial Dept, Room G8-224,POB 22700, NL-1100 DE Amsterdam, Netherlands

Search Terms: Encopresis, constipation.

Objective: To release a newly protocolized behavioral intervention program for children with chronic constipation aged 4-18 years with guidance from literature about underlying theories from which the treatment techniques follow.
Methods: Articles until July 2006 were identified through electronic searches in Medline, PsychInfo and Picarta. There was no limit placed on the time periods searched. Following keywords were used: constipation, encopresis, fecal incontinence, psychotherapy, emotions, randomized controlled trials, parent-child relations, parents, family, psychology, behavioral, behavioral problems, psychopathology, toilet, social, psychosocial, pain, retentive posturing. stool withholding, stool toileting refusal, shame, stress, anxiety. A filter was used to select literature referring to children 0-18 years old. Key constructs and content of sessions for a protocolized behavioral intervention program are derived from literature.
Results: Seventy-one articles on chronic childhood constipation are critically reviewed and categorized into sections on epidemiology, symptomatology, etiology and consequences, treatment and effectivity, and follow-up on chronic childhood constipation. This is followed by an extensive description of our protocolized behavioral intervention program.
Conclusion: This is the first article on childhood constipation presenting a full and transparent description of a behavioral intervention program embedded in literature. In addition, a theoretical framework is provided that can serve as a trial paradigm to evaluate intervention effectiveness.
Practice implications: This article can serve as an extensive guideline in routine practice to treat chronically constipated children. By releasing our protocolized behavioral intervention program and by offering a theoretical framework we expect to provide a good opportunity to evaluate clinical effectivity by both randomized controlled trials and qualitative research methods. Findings will contribute to the implementation of an effective treatment for chronic constipation in childhood. (C) 2007 Elsevier Ireland Ltd. All rights reserved.

I have read the full paper which offers 2 separate protocols to treat encopresis, one for 4-8 year olds and one for 8-18 year olds. They are very complex involving behavior therapy and the medical supervision of a clean out followed by maintenance laxatives (oral-top down) for a minimum of 3 months and some 12 sessions over the course of 22 weeks. The protocols contain many of the elements noted in the University of Virginia UCANPOOPTOO internet based program headed by Dr. Ritterband and reported elsewhere on this website. The authors note that the protocol length may need to be extended, especially for the older children. My impression is that the ability to carry out such a complete protocol will be well beyond the reach of many office settings or even many insitutions. The Clean Kid protocol is much more succinct, aggressive, and results in a more complete and early cessation of soiling which strongly reinforces all concerned and helps them to continue the program as long as necessary. Desensitization is much more rapid with the bottoms-up approach and reinforcing with sensations of relief and voiding competence. Any failures at compliance result in immediate relapses (feedback) and the parents are very insightful and supportive in promoting ongoing compliance on their exclusive CKM Parents' Forum. I continue to be very impressed at the attention paid worldwide to this very vexing problem and these authors deserve much credit for their efforts. I just hope that some day they and others may pay attention to the Clean Kid Protocol and overcome their squeamishness about the use of the bottoms up approach which must be properly and carefully done. DrC.

*****************************

Anal ultraslow waves and high anal pressure in childhood: a clinical condition mimicking Hirschsprung disease

Yoshino,H., Kayaba,H.*, Hebiguchi,T., Morii,M., Itoh,W., Chihara,J., & Kato,T. Akita Univ, Sch Med, Dept Pediat Surg, Akita 010, Japan

Search Terms: ultra slow wave, USW, manometry, constipation.

Purpose: Anal ultraslow waves (USWs) have been described in several clinical conditions closely related to chronic constipation associated with high anal pressure; however, USW-related clinical manifestations in childhood are poorly understood. The purpose of this study is to elucidate the clinical relevance of USWs in childhood.
Methods: Manometric recordings of 118 cases including 70 children with constipation and 16 patients with Hirschsprung disease were analyzed.
Results: Ultraslow waves were seen in 4 of 70 children with constipation. None of the controls or patients with Hirschsprung disease exhibited USWs. The 4 patients comprised 2 infants with marked abdominal distension mimicking Hirschsprung disease and 2 children (aged 4 and 8 years) with intractable constipation accompanying hemorrhoid or anal fissure. The manometric findings of the USW-positive patients showed a markedly high anal resting pressure and high frequency of slow waves compared to controls, patients with constipation not accompanied by USWs or patients with Hirschsprung disease.
Conclusion: Children with USWs exhibit symptoms mimicking Hirschsprung disease in infants and chronic intractable constipation in older children. In manometric studies of children, more attention should be paid not only to rectoanal reflex, but also USWs.

This is a finding I have not heard of before and I will be checking it out with other sources. DrC.

*****************************

Rectoanal sensorimotor response in humans during rectal distension

De Ocampo,S., Remes-Troche,J.M., Miller,M.J., Rao,S.S.C.* Univ Iowa Hosp & Clin, Dept Internal Med, GI Div, JCP 4612, 200 Hawkins Dr, Iowa City, IA 52242 USA

Search Terms: Encopresis, IAS, defecation, anorectal function, awareness, continence, reflex, transit, urge recognition, manometry.

PURPOSE: Rectal perception facilitates maintenance of continence and defecation. Whether perception is associated with motor changes in anorectum is unclear. We examined sensory and motor responses of the anorectum during rectal distention.
METHODS:Stepwise graded rectal balloon distensions were performed in 23 healthy subjects by placing a six-sensor probe in the anorectum. Manometric changes, rectoanal reflexes, and sensory thresholds were assessed. Studies were repeated in six subjects.
RESULTS:All subjects showed rectoanal inhibitory and contractile reflexes, but rectal perception was associated with an anal contractile response (sensorimotor response). In 4 subjects (17 percent) the sensorimotor response first occurred synchronously with a sensation of fullness (Group 1) and in 19 (83 percent) with a desire to defecate (Group 2). Mean balloon volume for inducing the sensorimotor response in Groups 1 and 2 were 80+/-14 ml and 96+/-26 ml (P>0.05). The onset, amplitude, duration, and area under curve of the response were similar in both groups. At higher volumes of balloon distention, all subjects (n=23) reported a desire and an urge to defecate. The sensorimotor response associated with an urge to defecate had higher amplitude (P=0.01) and higher area under curve (P=0.001) compared with that associated with a desire to defecate. Repeat studies showed good reproducibility (intraclass correlation coefficient=0.9; P<0.05).
CONCLUSIONS:A desire to defecate is associated with a unique, consistent, and reproducible anal contractile response: the sensorimotor response. This response could play an integral role in regulating anorectal sensation and function.

This is an important confirmatory study demonstrating well what Bill Whitehead of the U of N Carolina had pointed out and demonstrated with research some years ago while he was at Johns Hopkins. RWC.

*****************************

Psychological profiles and quality of life differ between patients with dyssynergia and those with slow transit constipation.

Rao,S.S.C.*, Seaton,K., Miller,M.J., Schulze,K., Brown,C.K., Paulson,J., Zimmerman,B.
Univ Iowa Hosp & Clin, 200 Hawkins Dr,4612 JCP, Iowa City, IA 52242 USA

Search Terms: Transit, retentive, encopresis, psychological

Background: Pathophysiological characteristics differ between slow transit constipation (STC) and dyssynergic defecation, but whether psychological profiles and quality of life (QOL) are altered and whether they differ among these constipation subtypes are unknown.
Methods: We prospectively evaluated psychological profiles and QOL in 76 patients with dyssynergia, 38 patients with STC, and 44 control subjects using the Revised 90-item, Symptom Checklist and 36-item Short-Form Health Survey. In addition, we examined the correlations of psychological and QOL domains with constipation symptoms and pathophysiological subtypes.
Results: Symptom scores for hostility and paranoid ideation were higher (P<.001) in patients with dyssynergic defecation than in patients with STC and control subjects. Scores for other psychological domains were higher (P<.0001) in patients with dyssynergic defecation and those with STC than in control subjects. Most QOL subscores were impaired (P<.05) in patients with dyssynergic defecation and some were impaired in patients with STC as compared with control subjects, but the two patient groups did not differ on these. The QOL subscores were strongly correlated (r(c)approximate to.9) with the psychological subscores in patients with dyssynergic defecation and those with STC, although more QOL subscores among patients with dyssynergic defecation and more psychological subscores among patients with STC primarily contributed to the canonical correlations. A set of six commonly reported constipation symptoms showed significant correlations with QOL and psychological subscores, more so among patients with STC than among patients with dyssynergic defecation.
Conclusions: Patients with dyssynergic defecation had greater psychological distress and impaired health-related QOL as compared with patients with STC and control subjects. Both patient groups were also more affected as compared with the control group. There was a strong correlation between psychological dysfunction and impaired QOL, and both also correlated with constipation symptoms.

Unfortunately, it is not clear if this was a pediatric or adult population. I suspect the latter. If anything this recommends more urgency for successfully treating these issues earlier in the lives of children.RWC.

*****************************

Polyethylene glycol 3350 plus electrolytes for chronic constipation in children: a double blind, placebo controlled, crossover study.

Thomson,M.A.*, Jenkins,H.R., Bisset,W.M., Heuschkel,R., Kalra,D.S., Green,M.R., Wilson,D.C., & Geraint,M. Sheffield Childrens Hosp, Ctr Paediat Gastroenterol, Western Bank, Sheffield S10 2TH, S Yorkshire, England

Search Terms: Encopresis, PEG, polyethelene glycol 3350, Miralax, Glycolax.

Purpose: To assess the efficacy and safety of polyethylene glycol 3350 plus electrolytes ( PEG+ E) for the treatment of chronic constipation in children.
Design: Randomised, double blind, placebo controlled crossover trial, with two 2- week treatment periods separated by a 2-week placebo washout. Setting: Six UK paediatric departments.
Participants: 51 children ( 29 girls, 22 boys) aged 24 months to 11 years with chronic constipation ( lasting >= 3 months), defined as >=2 complete bowel movements per week and one of the following: pain on defaecation on 25% of days; >= 25% of bowel movements with straining; > 25% of bowel movements with hard/ lumpy stools. 47 children completed the double blind treatment.
Main outcome measures: Number of complete defaecations per week ( primary efficacy variable), total number of complete and incomplete defaecations per week, pain on defaecation, straining on defaecation, faecal incontinence, stool consistency, global assessment of treatment, adverse events and physical examination.
Results: The mean number of complete defaecations per week was significantly higher for children on PEG+ E than on placebo ( 3.12 ( SD 2.05) v 1.45 ( SD 1.20), respectively; p< 0.001). Further significant differences in favour of PEG+ E were observed for total number of defaecations per week ( p = 0.003), pain on defaecation ( p = 0.041), straining on defaecation ( p < 0.001), stool consistency ( p < 0.001) and percentage of hard stools ( p =0.001). Treatment related adverse events ( all mild or moderate) occurred in similar numbers of children on PEG+ E ( 41%) and placebo during treatment ( 45%).
Conclusions: PEG+ E is significantly more effective than placebo, and appears to be safe and well tolerated in the treatment of chronic constipation in children.

This study contrasting PEG (Miralax and Glycolax) with a placebo in a double blind crossover trial demonstrates good evidence for its applicabiltiy in an oral-based approach for treating encopresis. Other studies contrasting its fewer side effects with other oral agents have been entered above. Miralax has already been well-established by earlier studies, but it is relevant to see additional confirmation. I continue to view an oral approach to be the first treatment of choice for encopresis while retaining the Soiling Solutions protocol as a default alternative. RWC.

*****************************

Tegaserod use in children: A single-center experience

Liem,O.*, Mousa,H.M., Benninga,M.A., Di Lorenzo,T. Columbus Nationwide Childrens Hosp, Dept Pediat Gastroenterol & Nutr, 700 Childrens Dr, Columbus, OH 43205 USA

Search Terms: constipation, Tegaserod, Zelnorm, Zelmac, encopresis, fecal incontinence.

Background: Tegaserod (Zelnorm or Zelmac) is increasingly prescribed by pediatric gastroenterologists even though there are few published data concerning its use in children. The aim of this study was to describe the authors' experience with tegaserod in children.
Patients and Methods : Patients treated with tegaserod from 2004 through 2006 were included in this study. Defecation and fecal incontinence frequency and global assessment of relief of symptoms were assessed.
Results: Seventy-two patients (44 girls) ranging in age from 1.1 to 18.3 years constitute the patient sample of this report. The median age was 10 years and the median follow-up after initiation of tegaserod treatment was 11.3 months (range 2.3-45.2 months). Indications to prescribe tegaserod were constipation (58%) and a variety of other conditions including functional dyspepsia or inflammatory bowel disease (42%). Defecation frequency increased after tegaserod use (1 vs 7/week, P < 0.001) and presence of fecal incontinence decreased (47% vs 23%, P < 0.001) in the constipation group. Parents rated relief of constipation as moderate or significant in 71% of cases in the constipation group. In the group with other indications to start tegaserod therapy, moderate or significant relief of abdominal pain and bloating was noted in 64% and 68% of patients, respectively. The median dose of tegaserod prescribed was 0.22 mg.kg(-1).day(-1) (range 0.05-0.87 mg.kg (-1).day(-1)). Adverse events were observed in 32% of the patients. The most common side effects were self-limiting diarrhea (20%) and abdominal pain (8%). Only one patient discontinued tegaserod because of side effects; this patient experienced pain at his cecostomy site.
Conclusions: Tegaserod seems to relieve a variety of functional gastrointestinal symptoms in children. Further randomized controlled studies are needed to support the specific pediatric target of prescribing tegaserod.

This study is another variation on the “top down” approach using a medication which is a motility stimulant, achieving its desired therapeutic effects through activation of the 5-HT4 receptors of the enteric nervous system in the gastrointestinal tract. It also stimulates gastrointestinal motility and the peristaltic reflex, and allegedly reduces abdominal pain. Abdominal pain in children is often associated with constipation. The idea that there is a reduction in fecal incontinence frequency from 47% to 23%, while statistically significant, is not likely to be of much comfort to parents who desire soiling to completely cease. The abstract does not indicate the percentage for patients who completely overcame fecal incontinence and whether or not after medication discontinuation if the continence is continued? RWC

*****************************

In patients with slow transit constipation, the pattern of colonic transit delay does not differentiate between those with and without impaired rectal evacuation.

Zarate,N.*, Knowles,C.H., Newell,M., Garvie,N.W., Gladman,M.A., Lunniss,P.J., & Scott,S.M. Royal London Hosp, Ctr Acad Surg, GI Physiol Unit, 3rd Floor,Alexandra Wing, London E1 1BB, England

Search Terms: Transit, Motility, Constipation,

BACKGROUND: Severe constipation may be subclassified on the basis of speed of colonic transit and efficacy of rectal evacuation. It is hypothesized that rectal evacuatory disorder (RED) may be associated with a secondary transit delay.
OBJECTIVES: To determine whether scintigraphy can discriminate between slow transit constipation (STC) with or without coexistent RED on the basis of progression of isotope throughout the colon and by analyses of specific regions of interest.
METHODS: One hundred ninety-six patients with STC (radio-opaque marker study) were subclassified according to results of proctography into those with a RED (STC-RED N = 30) or normal (STC-ONLY N = 4:1) evacuation. Patients subsequently underwent colonic scintigraphy. Distribution of generalized or left-sided patterns of colonic transit was assessed. Severities of transit delay and regional transit at specific time points were also evaluated.
RESULTS: Time-activity curves and severity of global transit delay were similar between groups as were the incidences of generalized and left-sided patterns of delay. Percentage of radioisotope retention in the right colon at 18 h was higher for the STC-ONLY group (P < 0.05), but this was poorly discriminative. No differences were observed for the percentage of radioisotope retained in the left colon at later scans.
CONCLUSIONS: Global and regional assessment of colonic transit by scintigraphy failed to discriminate between patients with STC with or without coexistent RED. Thus, RED is not associated with a specific pattern of transit delay and scintigraphy alone cannot predict the presence or absence of RED, knowledge of which is important for
management.

This would appear to be a very important study although I cannot determine the length of delay considered to be “slow” transit constipation. This would be an important variable as overly slow transit of 100 hours or more indicates a poor response to treatment. Also, see the first two abstracts in this section. I would think that it implies that a significant delay in transit does not affect difficult or normal voiding. This would appear to imply that voiding can be successfully promoted even in slow transit constipation? I have requested a copy of the paper and will comment later. RWC.

*****************************

March 2008, NUTRITION & DIETETICS (v65, 1), Pp.29-35. Posted on 04/19/2008.

Evidence for a role of cow's milk consumption in chronic functional constipation in children: Systematic review of the literature from 1980 to 2006

Crowley,E., Williams,L., Roberts,T., Jones,P., & Dunstan,R. No institutional address indicated.

Search Terms: Cow’s milk, allergy, constipation, motility, encopresis.

Aim: This article examines the evidence for a role of cow's milk protein in chronic functional constipation in children.
Methods: A literature search was conducted using Ovid and Pubmed, the Cochrane data bases, CINHAHL and EBSCO. Keywords searched included: constipation, cow's milk, intolerance, allergy, children and intestinal motility. This systematic review focused on dietary intervention studies in children (aged from 7 days to 15 years) with chronic functional constipation. All articles were required to include measures of cow's milk protein allergy or intolerance and include resolution of constipation as an outcome measure.
Results: The keyword search identified 125 articles. Seven of these articles met the criteria for inclusion, including one double-blind, randomised controlled trial. The results of this review provide support for the hypothesis that a proportion of children with chronic functional constipation respond well to the removal of cow's milk protein from the diet, particularly if serum analysis shows abnormalities of immune mechanisms.
Conclusion: The evidence surrounding cow's milk constipation was limited with only one of the assessed studies being at level II of evidence according to the NHMRC. In order to develop evidence-based guidelines, further high-level evidence is required to clarify the physiological, immunological and biochemical changes that occur in some constipated children who respond to the removal of cow's milk protein from the diet.

Parents using the soiling solutions protocol can better assess the effects of diet because they are assuring a daily voiding with a stool in a more natural state which they can observe and record. This would be impossible to assess with the current standard pediatric interventions using top down stool softners like Miralax. Milk contains many protein fractions (allergens) that cause allergic reactions. The two main components are whey and casein. An elimination diet of ordinary dairy may be sufficient to observe changes within the soiling solutions approach. This need only be tried if the encopresis is very resistant to change or constant relapses occur. Some parents have gone to greater lengths in an elimination diet and report that whey is an ingredient that is very hard to avoid in many foods on our shelves. I’m fairly convinced that milk allergy can be significant in a very low percentage of cases. The parents report finding consistent changes in stool quality as they reintroduce dairy (or the child cheats) and when they “test” by removing it from time to time. DrC.

*****************************

Feb, 2008 EUROPEAN JOURNAL OF PEDIATRIC SURGERY (v18, 1), Pp. 38-43 Posted on 04/19/2008.

Quality of life of patients with Hirschsprung's disease at 5-20 years post pull-through operations.

Niramis,R.*, Watanatittan,S., Anuntkosol,M., Buranakijcharoen,V., Rattanasuwan,T., Tongsin,A., Petlek,W., & Mahatharadol,V. Childrens Hosp, Queen Sirikit Natl Inst Child Hlth, Dept Surg, 420-8 Rajavithi Rd, Bangkok 10400, Thailand

Search Terms: Hirschsprung's disease, encopresis, fecal incontinence.

Purpose: The aim of this study was to evaluate the bowel habits and quality of life with respect to faecal continence of patients with Hirschsprung's disease (HD) who had undergone pull-through operations more than 5 years previously.
Materials and Methods: Four hundred and sixty-seven patients who underwent pull-through operations for HD during the period of 1987-1999 were followed up for evaluation. A questionnaire including demographic data and a qualitative clinical scoring method as described by Holschneider was used for the evaluation of faecal continence. The scoring system did not require a physical examination. Outcomes of the 3 major procedures (Swenson, Duhamel and Soave technique) were analysed. The research was undertaken from October 2004 to September 2006. Patients with neurological defects and total colonic aganglionosis (TCA) were excluded from the analysis. Only patients with typical HD were evaluated, and they were divided into 3 groups based on the length of the period since surgery: 5-10 years in Group A; 10-15 years in Group 13; and 15-20 years in Group C.
Results: Only 204 patients (male to female ratio: 169:35) returned to the Queen Sirikit National Institute of Child Health for evaluation. Twenty-six patients were excluded because of TCA in 13, Down's syndrome in 9 and cerebral palsy in 4. The remaining 178 patients were evaluated and divided into Group A (n=67), Group B (n=75) and Group C (n = 36). Excellent results (14 points), good results (10-13 points) and fair results (5-9 points) were noted in Group A in 52.2%, 34.3% and 7.5% of cases respectively, in Group B in 68%, 28% and 4% of cases, respectively, and in Group C in 88.9%, 11.1% and 0% of cases, respectively. Five cases (7.5%) in Group A and 3 cases (4%) in Group B with fair results still had problems such as constant soiling and an inability to hold back defecation. They experienced marked limitations in their social life because of their dependence on diapers and frustration because of teasing by their friends.
Conclusion: Faecal incontinence still remains a problem in some patients with HD at 5-15 years after surgical correction. However, nearly all patients who were operated on more than 15 years previously had nearly normal faecal continence and a normal social
life.

I have chosen this abstract because many parents in this internet age encounter the term, Hirshsprung’s disease, and suffer from much anxiety about its possibility. These findings at least may lend a realistic perspective about long term outcomes if surgery is required. DrC.
.
*****************************

Colonic washout enemas for persistent constipation in children with recurrent urinary tract infections based on dysfunctional voiding

Chrzan,R.*, Klijn,A.J., Vijverberg,M.A.W., Sikkel,F., & de Jong,T.P.V.M. UMC Utrecht, Univ Childrens Hosp, Dept Pediat Urol, Paediat Renal Ctr, Lundlaan 6, NL-3584 EA Utrecht, Netherlands

Search Terms: Encopresis, enuresis, enema.

OBJECTIVES To describe the use of colonic washout enema, for persistent constipation in children treated for dysfunctional voiding by cognitive and biofeedback training.
METHODS We treated 50 children, who had dysfunctional voiding and persistent dilatation of the rectum notwithstanding adequate oral laxatives, with colonic washout enemas. We performed retrograde filling of the rectum with 20 mL/kg water, starting once daily for 2 weeks, then 3 times per week for 6 to 12 months.
RESULTS During the 6-month follow-up, 30 children were free from urinary tract infections. In 20 children we observed partial relief of complaints. On ultrasound all children showed a normalized diameter of the rectum. In 33 patients washout treatment could be stopped with continuing Success. Relapse of a distended rectum triggered the need for chronic intermittent enema therapy in 17 patients. A few patients reported pain during enema treatment; otherwise, we noted no counter-effect.
CONCLUSIONS Dysfunctional voiding combined with constipation in children can be cured by washout enemas if oral laxatives fail.

The relationship between encopresis and the occurrence of urinary tract infections has been well established and occurs more frequently in girls than boys (in this study, 44 girls vs. 6 boys). The distance between the urinary tract and the anal canal is shorter for girls making infection more likely. It was interesting to see ultrasound used and that it showed a normalizing of the rectum with the cognitive and biofeedback-based treatment for the encopresis inside of 6 months. Also, it should be noted that there appears to have been very little concern for “enema dependence”. It is unclear as to what contribution was made by the wash out enemas to the remission of encopresis. This is a very intensive and long-term regimen and I suspect that the Soiling Solutions Protocol would be much less intensive and not require as lengthy an intervention. RWC.

*****************************

Quality of life in children with slow transit constipation.

Clarke,M.C.C., Chow,C.S., Chase,J.W., Gibb,S., Hutson,J.M., & Southwell,B.R.*
Murdoch Childrens Res Inst, Melbourne, Vic 3052, Australia

Search Terms: Encopresis, slow transit, constipation, motility

Background: Slow transit constipation (STC) causes intractable symptoms not readily responsive to laxatives, diet, or life-style changes. Children with STC have irregular bowel motions associated with colicky abdominal pain and frequent uncontrollable soiling. This study assessed the physical and psychosocial quality of life (QOL) in children with long-standing (>= 2 years) STC vs healthy controls.
Methods: Children (aged 8-18) were recruited from gastrointestinal and surgical clinics and a Scout Jamboree. After informed consent was obtained, the questionnaire (Pediatric Quality of Life Inventory) was administered. This consists of parallel child and parent self-report scales encompassing physical functioning, emotional functioning, social functioning, and school functioning. Higher scores indicate better QOL. P value less than .05 was considered statistically significant.
Results: In 51 children with STC (mean, 11.5 years; male/female, 2:1) and 79 controls (mean, 12.1 years; male/female, 1.9:1), Pediatric Quality of Life Inventory QOL score was significantly lower in the STC group (72.90 vs 85.99; P <.0001). In addition, parents of children with STC reported a significantly lower QOL score than their child compared with the child's own report (64.43 vs 72.90; P=.0034). Parents of controls did not (84.25 vs 85.99; P =.12).
Conclusions: Slow transit constipation is a debilitating condition affecting both physical and emotional functioning in children. Parental perception of QOL is significantly worse, highlighting the considerable family impact of constipation and uncontrollable soiling. (C) 2008 Elsevier Inc. All rights reserved.

This research group had focused a lot of research on slow-transit constipation which they argue is much more prevalent than commonly assumed. This study is important for documenting the effects of an ongoing and difficult course of dealing with this problem. I remain frustrated that they and other research centers are not undertaking a trial of the Soiling Solutions protocol for encopresis. RWC.

*****************************

May, 2008 GUT (v57-5) Pp. 599-603. Posted on 04/29/2008.

Rectal compliance and rectal sensation in constipated adolescents, recovered adolescents and healthy volunteers.

van den Berg,M.M.*, Voskuijl,W.P., Boeckxstaens,G.E., Benninga,M.A., Emma Childrens Hosp, Acad Med Ctr, Dept Pediat Gastroentereol & Nutr, Room C2-D12,Meibergdreef 9, NL-1105 AZ Amsterdam, Netherlands

Search Terms: Constipation, motility, transit, manometry

Objectives: A subgroup of children with functional constipation (FC) are unresponsive to conventional treatment. Abnormal rectal function due to increased distensibility (compliance) might be an underlying mechanism of therapy-resistant FC. It is hypothesised that rectal compliance is normal in patients who are successfully recovered from FC (RC).
Methods: Using a barostat, a pressure-controlled intermittent distension protocol was performed in FC patients, RC subjects free of symptoms for at least 4 years and healthy volunteers (HVs). Rectal compliance was calculated using a non-linear mixed-effect model for volume-pressure curves.
Results: Forty- seven FC patients, median (range) age of 12 (11-17) years, and 20 RC subjects, 15 (11-18) years, were studied and compared with 22 HVs, 14 (8-16) years. The median (5th-95th percentile) rectal compliance in HVs was 16 (12-20) ml/mm Hg.FC patients had a median rectal compliance of 25 (13-47) ml/mm Hg and RC subjects 20 (12-35) ml/mm Hg, which was significantly higher compared with HVs (p, 0.001 and p = 0.003). RC subjects had lower rectal compliance when compared with FC patients (p = 0.02). Forty- five percent of RC subjects had a rectal compliance above the upper limit of normal (> 95th percentile of HVs), which was significantly less compared with 75% of FC patients (p = 0.02).
Conclusion: While rectal compliance in RC subjects is lower when compared with adolescents with FC, almost half of the RC subjects showed an increased rectal compliance. The role of rectal compliance in therapy-resistant FC seems limited, because recovery is possible despite an increased rectal compliance.

Basically, the idea is that children unresponsive to conventional “top down” treatment for constipation/encopresis have rectums (and likely higher up) that are too stretched out by comparison to children who have never had this problem and children who have recovered from it. But, the recovered children show a lasting effect (4 years later) of still having a more stretched out rectum, just not as much. The encouraging finding is that children can recover with a still stretched out rectum using the standard “top down” laxative/stool softener approaches. Would it be even more effective with the Soiling Solutions protocol which has shown so much promise with older, long term encopretic children even after standard “top down” treatments have failed? Should the SS protocol have been attempted earlier for all children who demonstrate encopresis or chronic constipation? Might it still be effective even with failure of the "top down" treatment and a weakened, stretched rectum have failed? Should the SS protocol have been attempted earlier for all children?
RWC

*****************************

Transabdominal ultrasound of rectum as a diagnostic tool in childhood constipation

Joensson,I.M.*, Siggaard,C., Rittig,S., Hagstroem,S., and Djurhuus,J.C. Skejby Univ Hosp, Dept Pediat A, DK-8200 Aarhus N, Denmark
U1 - Article English

Search Terms: Encopresis, constipation, ultrasound

Purpose: We tested whether transverse rectal diameter measured by ultrasound could identify rectal impaction, investigated whether transverse diameter is enlarged in constipated children compared to healthy children and evaluated transverse diameter during treatment of constipation.
Materials and Methods: A total of 51 children 4 to 12 years old were included in the study. Of the children 27 (mean age 7.0 +/- 1.8 years) had been diagnosed with chronic constipation by Rome III criteria and 24 (9.1 +/- 2.7 years) were healthy controls. All patients underwent a thorough medical history. and physical examination, including digital rectal examination and measurement of rectal diameter by transabdominal ultrasound. Constipated children underwent repeat investigations after 4 weeks of laxative treatment.
Results: Average rectal diameter of children with negative digital rectal examination was 21 +/- 4.2 mm (mean +/- SD), leading to the approximation that a value greater than 29.4 mm (mean +/- 2 SD) indicates rectal impaction. All children with rectal impaction identified by digital examination had a rectal diameter larger than 29.4 mm. Moreover, constipated children had a significantly larger rectal diameter (42.1 +/- 15.4 mm) than healthy children (21.4 +/- 6.0 mm, p < 0.001). After 4 weeks of laxative treatment constipated children had a significant reduction in rectal diameter (mean 26.9 +/- 5.6 mm, p < 0.001).
Conclusions: Transverse rectal diameter seems to be a valuable tool to identify rectal impaction and may replace digital rectal examination. Constipated children have a significantly larger rectal diameter compared to healthy children, and when constipation is treated the diameter is reduced significantly.

The findings of changes in the rectum with constipation were not that surprising. However, the suggestion that an ultrasound would be preferable over a digital exam is something of a surprise because of the expense. This also fits into a natural reluctance to use an invasive procedure, especially in this culturally sensitive region of the body. However, an ultrasound does have the advantage of no radioactivity and having better definition over the standard abdominal X-Ray. The study’s findings of a significant return from an expanded colon (megacolon) back to a more normal state after 4 weeks of laxative treatment is of interest. Studies vary widely on the length and degree of a return toward a normal diameter of the rectum. Lay readers may not understand that all scientific reports use metric measurements. To translate, the rectal diameter for children identified with constipation was 1.7 inches by comparison to 1.1 inches for healthy children. DrC.

*****************************

Trajectories of daytime wetting and soiling in a United Kingdom 4 to 9-year-old population birth cohort study

Heron,J.*, Joinson,C., Croudace,T., and von Gontard,A. Univ Bristol, Dept Social Med, Avon Longitudinal Study Parents & Children, 24 Tyndall Ave, Bristol BS8 1TQ, Avon, England

Search Terms: epidemiology, encopresis, enuresis, longitudinal

Purpose: This longitudinal, population based study describes trajectories of daytime wetting and soiling in children 4.5 to 9.5 years old.
Materials and Methods: Participants consisted of a cohort of nearly 11,000 children forming part of the United Kingdom population based cohort study known as ALSPAC (Avon Longitudinal Study of Parents and Children). Repeated measures of parentally reported incidents of daytime wetting and soiling were modeled using longitudinal latent class analysis.
Results: Developmental variation could be adequately described by 4 trajectories for each of daytime wetting and daytime soiling. Trajectory shapes could be interpreted as normative (daytime wetting 86.2%, daytime soiling 89.0%), delayed (6.9%, 4.1%), persistent (3.7%, 2.7%) and relapsing (3.2%, 4.1%). There were gender differences among many of the nonnormative groups defined by these trajectories. In particular, girls outnumbered boys by a ratio of 1.25:1 among those with persistent wetting and a ratio of 1.39:1 among those who suffered a relapse in daytime wetting. In contrast, boys outnumbered girls by a ratio of 1.63:1 among those who were delayed in bowel continence, 1.93:1 among those with persistent soiling and 1.80:1 among those who suffered a relapse in soiling.
Conclusions: Identification of trajectories of daytime wetting and soiling in children is an essential starting point in understanding the development of bladder and bowel control. These findings can be used to examine risk factors for the different trajectory groupings identified in the study.

I found the delayed, persistent, and relapsing percentages of children who had daytime wetting (diurnal enuresis) and soiling (encopresis) to be of interest. The figures are not all that different between the two diagnoses. DrC.

*****************************

May 2008, PEDIATRICS (v121,5) Pp. E1334-E1341. Posted on 06/10/2008.

Behavioral therapy for childhood constipation: A randomized, controlled trial

van Dijk,M.*, Bongers,M.E.J., de Vries,G.J., Grootenhuis,M.A., Last,B.F. & Benninga,M.A. Univ Amsterdam, Acad Med Ctr, Emma Childrens Hosp, Psychosocial Dept, Room G8-224,POB 22700, NL-1100 DE Amsterdam, Netherlands

Search Terms: encopresis, constipation, behavioral therapy.

OBJECTIVE. It has been suggested that the addition of behavioral interventions to laxative therapy improves continence in children with functional fecal incontinence associated with constipation. Our aim was to evaluate the clinical effectiveness of behavioral therapy with laxatives compared with conventional treatment in treating functional constipation in childhood.
PATIENTS AND METHODS. In this randomized, controlled trial conducted in a tertiary hospital in the Netherlands, 134 children aged 4 to 18 years with functional constipation were randomly assigned to 22 weeks (12 visits) of either behavioral therapy or conventional treatment. Primary outcomes were defecation frequency, fecal incontinence frequency, and success rate. Success was defined as defecation frequency of >= 3 times per week and fecal incontinence frequency of <= 1 times per 2 weeks irrespective of laxative use. Secondary outcomes were stool-withholding behavior and behavior problems. Outcomes were evaluated at the end of treatment and at 6-months follow-up. All of the analyses were done by intention to treat.
RESULTS. Defecation frequency was significantly higher for conventional treatment. Fecal incontinence frequency showed no difference between treatments. After 22 weeks, success rates did not differ between conventional treatment and behavioral therapy (respectively, 62.3% and 51.5%), nor did it differ at 6 months of follow-up (respectively, 57.3% and 42.3%). The proportion of children withholding stools was not different between interventions. At follow-up, the proportion of children with behavior problems was significantly smaller for behavioral therapy (11.7% vs 29.2%).
CONCLUSION. Behavioral therapy with laxatives has no advantage over conventional treatment in treating childhood constipation. However, when behavior problems are present, behavioral therapy or referral to mental health services should be considered.

This is a rather distressing finding about the lack of a significant contribution from behavioral therapy to treating encopresis via the “top down” method. The University of Virginia’s website, www.ucanpooptoo.com, utilizing behavioral techniques in its Enhanced Toilet Training (ETT) “top down” approach was shown to be superior to conventional treatment so this appears to be in direct contradiction to their findings. Both groups are to be congratulated for their controlled research, but these findings must be discussed and evaluated by both groups. It is possible that the Netherlands group did not contain some of the behavioral elements present in ETT. I will seek a reprint of this study for later comment and request inputs from both research groups. DrC.

*****************************

Antegrade continence enema (ACE): current practice

Sinha,C.K.,* Grewal,A., & Ward,H.C. Royal London Hosp, London E1 1BB, England

Search Terms: ACE, encopresis

The purpose of this study was to assess current status of antegrade continence enema (ACE) procedure taking into account the recent improvement in the technique and outcome. Reviewing our record of 48 patients with ACE procedure performed between January 2002 and May 2007, we found that the underlying diagnoses were idiopathic constipation in 56%, anorectal malformation in 31%, spina bifida in 8% and Hirschsprung's disease in 4%. Mean age of operation was 10.7 years. Appendix was used as stoma in 73% of cases. Stomal stenosis requiring revision was seen in 6% of cases and continence was achieved in 92% of cases. A systematic search of database was performed for the same period. Twenty-four studies describing 676 patients were found. The mean age was 10 years and various sites used for ACE were, right side of abdomen in 71%, umbilicus in 15% and left side of abdomen in 14%. The incidence of open and laparoscopic procedures were 87 and 13%, respectively. Appendix was used for stoma in 76% procedures. Other operative modalities were retubularised colon, retubularised ileum, caecal button and caecostomy tube, etc. The mean volume of enema fluid used was 516 ml. The mean evacuation time was 42 min. Stomal stenosis requiring revision was seen in 13% of cases. Continence was achieved in 93% of cases. There has been significant improvement in the outcome during last 5 years in comparison to the outcome published in late 1990s. Advancements in techniques, better-trained stoma care nurses and better stoma appliances could have played major role in this success.

OK, a rather extreme surgical procedure is applied here for what appears to be the functional disorder of encopresis constituting the majority condition for which this surgery was applied (56%). I find this astonishing when my protocol has been described as too aggressive with the use of suppositories and enemas in a rational, protocolized treatment program. RWC.

*****************************

Botulinum toxin for the treatment of chronic constipation in children with internal anal sphincter dysfunction

Irani,K., Rodriguez,L., Doody,D.P., & AM Goldstein* Harvard Univ, Massachusetts Gen Hosp, Sch Med, Pediat Intestinal Rehabil Program,Dept Pediat Sur, Warren 1153, Boston, MA 02114 USA

Search Terms: Botulinum, botox, internal anal sphincter, constipation, encopresis

Internal anal sphincter (IAS) dysfunction is a cause of refractory constipation in children. The goal of this study was to determine whether intrasphincteric injection of botulinum toxin is effective in the treatment of constipation in pediatric patients with IAS dysfunction. A retrospective review was performed of 24 pediatric patients with intractable constipation. All patients had abnormal anorectal manometry, with either elevated IAS resting pressure (>=100 mm Hg) or an absent or diminished rectoanal inhibitory reflex. Patients with Hirschsprung's disease were excluded. All patients underwent botox injection into the IAS and were followed for a minimum of 6 months. Of 24 patients, 22 experienced significant improvement in their constipation lasting greater than 2 weeks. The duration of effect was variable, with 12 patients demonstrating benefit lasting at least 6 months. Transient postoperative incontinence occurred in five patients. Intrasphincteric injection of botox is a safe and effective treatment for intractable constipation in children with IAS dysfunction.

*****************************

May 2008 JOURNAL OF PEDIATRIC SURGERY, (v43,5), Pp. 899-905) Posted 11/19/2008.

Long-term bowel function and quality of life in children with Hirschsprung's disease

Mills,J.L.A., Konkin,D.E., Milner,R., Penner,J.G., Langer,M., & Webber,E.M.* Univ British Columbia, Dept Surg, Div Pediat Surg, Vancouver, BC V6H 3V4, Canada

Search Terms: Hirschsprung’s, constipation, encopresis, longitudinal, QOL

Background/Purpose: Little is known about the quality of life (QOL) of children with Hirschsprung's disease (HD) as they grow older. The purpose of this study was to measure the QOL and bowel function of these children as they mature.
Methods: All children who were surgically treated for HD at British Columbia Children's Hospital, Vancouver, British Columbia, Canada between 1986 and 2003 were invited to participate. Each family was sent 3 previously validated questionnaires exploring current QOL and bowel function.
Results: Fifty-one families participated (49%), with children between the ages of 3 and 21 years. Fecal continence improved significantly with age (P = .04) and was the strongest predictor of QOL scores of all variables in our study. There was no statistically significant difference in QOL scores between children with HD and healthy children, although a clinically relevant impairment in QOL may be present, especially in psychosocial scores.
Conclusions: Fecal continence is an important predictor of overall QOL in children surgically treated for HID. Although continence tends to improve with age, a number of older children still have ongoing continence problems, and they seem to be a group at risk for impaired QOL. Our study indicates that interventions for children with incontinence may offer gains in QOL as well as bowel function.

I have treated surgically corrected HD children with success using my protocol. Biofeedback also appears to be effective with adults who have relapsed to fecal incontinence, typically because of an overholding response and failure to relax the pelvic floor for defecation. {Digestive Health Matters, (v17,3) Pp. 7-9} DrC

*****************************

Clinical significance of quantitative assessment of rectoanal inhibitory reflex (RAIR) in patients with constipation.

Xu,X.H., Pasricha,P.J., Sallam,H.S., Ma,L., & Chen,J.D.Z.* Univ Texas Galveston, Med Branch, Div Gastroenterol, 221 Microbiol Bldg,Route 0632,301 Univ Blvd, Galveston, TX 77555 USA

Search Terms: RAIR, IAS, constipation, encopresis.

Background: Rectoanal inhibitory reflex (RAIR) is routinely assessed in anorectal manometry and is of clinical value in the diagnosis of patients with constipation. However, no quantitative analysis is currently available for the assessment of RAIR. The aim of this study as to evaluate the diagnostic value of quantitative assessment of RAIR in patients with constipation.
Methods: Nine healthy subjects, 22 constipation patients (CO) and 26 fecal incontinence patients (FI) were enrolled in this study. RAIR was solicited by inflating the balloon with various volumes from 10 to 50mL. The percentage of relaxation was determined on the basis of the rectal resting sphincter pressure and residual pressure with the balloon distention.
Results: Percentage of internal sphincter relaxation induced by rectal distention in constipation patients was significantly lower with distention of 20, 30, 40, and 50mL in comparison with that in healthy subjects (Mixed model, P < 0.05). The volume of distention required to achieve a relaxation of 50% was significantly higher in patients with CO (37.3 +/- 3.1 mL) than that in healthy subjects (27.8 +/- 2.6 mL, P < 0.03) or FI (26.3 +/- 2.3 mL, P < 0.05). It was also found that the percentage of relaxation could be used to differentiate the patients with constipation with a specificity of 64% and a sensitivity of 67%.
Conclusions: Patients with CO have impaired RAIR in comparison with healthy subjects and patients with FI. Quantitative assessment of RAIR is valuable in the diagnosis of patients with CO and may be incorporated in the clinical anorectal manometric test.

This demonstrates the role of the IAS in the RAIR. DrC.

*****************************

September, 2008, PEDIATRIC RESEARCH (v64,3), Pp. 308-311. Posted on 11/24/2008.

The impact of constipation on growth in children

Chao,H.C., Chen,S.Y., Chen,C.C., Chang,K.W., Kong,M.S., Lai,M.W., & Chiu,C.H.*
Chang Gung Univ, Coll Med, Chang Gung Childrens Hosp, Dept Pediat, 5 Fu Hsin St, Tao Yuan 33305, Taiwan

Search Terms: Constipation, Encopresis, Growth, Development,

The observation oil the impact of constipation oil nutritional and growth status in healthy children was never reported. During a 4-yr period. we evaluated the consequence of constipation oil growth in children. The enrolled children were aged between 1 and 15 y with constipation. Medical response of constipation to treatment Was evaluated by the scoring of constipation symptoms. The correlation of therapeutic effect of constipation with growth status at 12 wk and 24 wk was Statistically evaluated. About 2426 children (1284 boys, 1142 girls) with a mean age of 7.31 +/- 3.65 (range 1.1-14.9) y were enrolled. After 12-wk treatment, significant increase of z-scores of height-for-age, weight-for-age, and body mass index-for-age were all found in patients with good medical responses (1377 cases) than in those with poor medical responses (1049 cases). The 1049 patients with poor medical response received advanced medications; significant increase of z-scores of height-for-age, weight-for-age, and body mass index were also found in these patients. A marked increase of appetite was significantly correlated with better gain oil height and weight after treatment. We conclude that chronic constipation may retard growth Status in children. and a long-term medication for constipation in children appears beneficial to their growth status.

I have long suspected growth as a possible consequence of successful treatment which is suggested by this study with a very good number of subjects. DrC.

*****************************

Pathophysiology of chronic constipation of the slow transit type from the aspect of the type of rectal movements

Hagiwara,N. & Tomita,R.* Nippon Dent Univ Tokyo, Sch Dent Tokyo, Dept Surg, Chiyoda, Ku, 2-3-16 Fujimi, Tokyo 1028158, Japan

Search Terms: rectal motility, motility, manometry, gastrocolic reflex, constipation.

Background/Aims: The aim of this study was to analyze the defecation function, in particular the development of the gastrocolic reflex arising in coordination with the upper gastrointestinal tract, in patients with chronic constipation of the slow transit type (STC).
Methodology: The rectal movement types in adult patients with STC were compared with those in normal subjects as a control. A force transducer was inserted transanally into the rectum of 10 patients with STC (Group A), and the intrarectal pressure waveforms were recorded for 2 hours before and after the ingestion of test diets. Similar recordings were obtained from control subjects who had no abnormalities of defecation (Group B).
Results: On the basis of the recordings obtained pre- and postprandially, the waveforms in the Group B subjects were classified into 4 types (Type I, continuous waves of low amplitude; Type II, continuous waves of high amplitude or with elevation of basal tone; Type III, only elevation of the basal tone; Type IV, monophasic contraction waves). In fasting state, only Type I waves were recorded in both Group A and B subjects. Postprandially, all the subjects in both the groups showed Type I waveforms. In addition, the frequency of this type of waveform was significantly increased in Group B (p <0.01). Type III and IV waveforms were also recognized only in Group B. There was no difference in the frequency of Type If waveforms between Groups A and B, but the time required for the appearance of Type 11 waveforms After ingestion of the test diet was significantly (p < 0.01). shorter in Group B than in Group A. Thus, there were no differences in the preprandial movement type between the 2 groups. However, postprandially, in Group A, the appearance of continuous waves of high amplitude was delayed, although their frequency was not significantly increased, as compared to those in Group B, and there were few giant contraction waves.
Conclusions: Functional disturbances of the rectal movements were recognized after food ingestion in patients with STC, and this result was considered to be attributable to decreased strength of the gastrorectal reflex.

This is a small N for adult subjects and I can’t tell from this summary if they ruled out megacolon or if the STC is confirmed throughout the length of the colon? If it is true STC then this information just appears to indicate a continuation of weak propagation into the rectal area contributing to the weak gastrocolic reflex. DrC.

*****************************

Dyssynergic defecation and biofeedback therapy.

SSC Rao, Univ Iowa Hosp & Clin, Div Gastroenterol Hepatol, Univ Iowa, Carver Coll Med, 4612 JCP,200 Hawkins Dr, Iowa City, IA 52242 USA

Search Terms: biofeedback, constipation, encopresis

Constipation caused by dyssynergic defecation is common and affects up to one half of patients with this disorder. It is possible to diagnose this problem through history, prospective stool diaries, and anorectal physiologic tests. Randomized controlled trials have now established that biofeedback therapy is not only efficacious but superior to other modalities and that the symptom improvement is caused by a change in underlying pathophysiology. Development of user friendly approaches to biofeedback therapy and use of home biofeedback programs will significantly enhance the adoption of this treatment by gastroenterologists and colorectal surgeons.

This is a significant endorsement for the use of biofeedback in treating constipation or encopresis by a leading researcher. Again, my issue is that my Soiling Solutions protocol is much cheaper and less complex with fewer personnel and less instrumentation than is required by biofeedback and should be tried clinically before biofeedback or surgery is employed. I support research on comparison treatment trials using randomly assigned subjects and regret that I do not have the resources to do so. The existence of the recently revised Clean Kid Manual (4th revision) should assist in providing a good basis for guiding treatment in clinical trials. RWC.

*****************************

American Neurogastroenterology and Motility Society consensus statement on intraluminal measurement of gastrointestinal and colonic motility in clinical practice.

Camilleri,M.,* Bharucha,A.E., Di Lorenzo,C., Hasler,W.L., Prather,C.M. Rao,S.S., Wald,A. Mayo Clin, CENTER Program, Charlton 8-110,200 1st St SW, Rochester, MN 55905 USA

Search Terms: manometry, constipation, encopresis, motility, transit

Tests of gastric, small intestinal and colonic motor function provide relevant physiological information and are useful for diagnosing and guiding the management of dysmotilities. Intraluminal pressure measurements may include concurrent measurements of transit or intraluminal pH. A consensus statement was developed and based on reports in the literature, experience of the authors, and discussions conducted under the auspices of the American Neurogastroenterology and Motility Society in 2008. The article reviews the indications, methods, performance characteristics, and clinical utility of intraluminal measurements of pressure activity and tone in the stomach, small bowel and colon in humans. Gastric and small bowel motor function can be measured by intraluminal manometry, which may identify patterns suggestive of myopathy, neuropathy, or obstruction. Manometry may be most helpful when it is normal. Combined wireless pressure and pH capsules provide information on the amplitude of contractions as they traverse the stomach and small intestine. In the colon, manometry assesses colonic phasic pressure activity while a barostat assesses tone, compliance, and phasic pressure activity. The utility of colonic pressure measurements by a single sensor in wireless pressure/pH capsules is not established. In children with intractable constipation, colonic phasic pressure measurements can identify patterns suggestive of neuropathy and predict success of antegrade enemas via cecostomy. In adults, these assessments may be used to document severe motor dysfunction (colonic inertia) prior to colectomy. Thus, intraluminal pressure measurements may contribute to the management of patients with disorders of gastrointestinal and colonic motility.

Consensus statements typically reflect the state of the art or science in an area of concern, and this is no exception. The authors are well known and respected in the field. This statement reflects the maturity and the state of excellent progress in the use of manometry for GI assessment. My hope is that it will help to shed some light on differences in colonic function between retentive and non-retentive encopresis. The latter appears to be more resistant to treatment and that is why the ACE surgical approach is sometimes recommended for it. My issue is that perhaps my Soiling Solutions protocol should be attempted first before these intrusive measurements and surgery is recommended. RWC.

*****************************

Prevalence of atopy in children with chronic constipation

Simeone,D., Miele,E., Boccia,G., Marino,A., Troncone,R., & Staiano,A.* Univ Naples Federico 2, Dept Pediat, Via Pansini 5, I-80131 Naples, Italy

Search Terms: constipation, encopresis, allergy, milk

Objectives: To evaluate the prevalence of chronic constipation (CC) in unselected children, its association with atopy and the efficacy of a cow's milk protein (CMP) elimination diet on refractory constipation.
Study design: The study was conducted by six primary care paediatricians, serving a population of 5113 children aged from birth through to 12 years; only 2068 children were 6 months to 6 years. During a 3- month period, prevalence of CC was determined for the entire study population, ages 0-12 years. In the second part of the study, all patients aged 6 months to 6 years with CC, and age- and sex-matched controls, were evaluated for atopy and its association with CC. A questionnaire was completed including personal and family history of atopy and bowel-movement characteristics. Patients were tested for atopy by specific serum IgE and/or skin-prick tests. Constipated patients, refractory to osmotic laxatives, underwent a 4-week CMP elimination diet.
Results: 91 (1.8%) children had CC, and 69 (3.3%) of the 6 months to 6 years age group fell into the atopy study age range. All 69 constipated children (mean age 34.9 (18.0) months) and 69 controls completed the questionnaire. Twelve of the 69 constipated children (17.3%) and 13 out of the 69 control children (18.8%) had a diagnosis of atopy. Eleven out of 69 (15.9%) constipated children were refractory to constipation treatment, and three (27.3%) of these had atopy. The 4-week trial of dietary elimination did not result in improvement in any of these 11 children.
Conclusions: In our study group, prevalence of atopy among children with CC is similar to that in the general population. The level of refraction of CC does not seem to be related to cow's milk allergy.

This large scale study contradicts the usual assumptions of parents about the possibility of cow’s milk allergy contributing to the chronic constipation or encopresis in their children. This assumption resembles an “illusory correlation” or the “aberrant actuary” phenomenon noted in research on clinical judgment and it is very hard to counter in any rational way. RWC.

****************************

February 9, 2009 ARCHIVES OF DISEASE IN CHILDHOOD (v94,2), Pp. 117-131). Posted on 02/24/2009.

Currently recommended treatments of childhood constipation are not evidence based: a systematic literature review on the effect of laxative treatment and dietary measures

Pijpers,M.A.M.,* Tabbers,M.M., Benninga,M.A., & Berger,M.Y. Erasmus MC, Dept Gen Practice, Room Ff323,POB 2040, NL-3000 CA Rotterdam, Netherlands

Search Terms: Constipation, encopresis, PEG, Lactulose, softeners. Review

Introduction: Constipation is a common complaint in children and early intervention with oral laxatives may improve complete resolution of functional constipation. However, most treatment guidelines are based on reviews of the literature that do not incorporate a quality assessment of the studies.
Objective: To investigate and summarise the quantity and quality of the current evidence for the effect of laxatives and dietary measures on functional childhood constipation.
Methods: The Medline and Embase databases were searched to identify studies evaluating the effect of a medicamentous treatment or dietary intervention on functional constipation. Methodological quality was assessed using a validated list of criteria. Data were statistically pooled, and in case of clinical heterogeneity results were summarized according to a best evidence synthesis.
Results: Of the 736 studies found, 28 met the inclusion criteria. In total 10 studies were of high quality. The included studies were clinically and statistically heterogeneous in design. Most laxatives were not compared to placebo. Compared to all other laxatives, polyethylene glycol ( PEG) achieved more treatment success ( pooled relative risk (RR): 1.47; 95% CI 1.23 to 1.76). Lactulose was less than or equally effective in increasing the defecation frequency compared to all other laxatives investigated. There was no difference in effect on defecation frequency between fibre and placebo (weighted standardised mean difference 0.35 bowel movements per week in favour of fibre, 95% CI -0.04 to 0.74).
Conclusion: Insufficient evidence exists supporting that laxative treatment is better than placebo in children with constipation. Compared to all other laxatives, PEG achieved more treatment success, but results on defecation frequency were conflicting. Based on the results of this review, we can give no recommendations to support one laxative over the other for childhood constipation.

The lack of placebo comparisons for assessing the effectiveness of “top down” laxatives in the treatment of encopresis/constipation was a bit of a surprise, but the comparative treatment studies and the usual longitudinal demonstration of improved outcomes lends assurance that laxatives are useful in the usual pediatric conventional treatments. The findings on fiber as ineffective alone in treatment is consistent with the literature as I know it. Of course, I remain hopeful that my “bottom up” protocol will be adequately tested in time. RWC.

****************************

February 9, 2009 ARCHIVES OF DISEASE IN CHILDHOOD (v94,2), Pp.156-160. Posted on 02/24/2009.

Macrogol (polyethylene glycol) laxatives in children with functional constipation and faecal impaction: a systematic review.

Candy,D.,* & Belsey,J. Royal W Sussex NHS Trust, Paediat Gastroenterol Serv, Chichester PO19 6SE, W Sussex, England

Search Terms: Constipation, Encopresis, PEG

As the evidence base supporting the use of laxatives in children is very limited, we undertook an updated systematic review to clarify the issue. A comprehensive literature search was carried out to identify randomised controlled trials of polyethylene glycol ( PEG) versus either placebo or active comparator, in patients aged,18 years with primary chronic constipation. Outcomes were assessed as either global assessments of effectiveness or differences in defaecation rates. Seven qualifying studies involving 594 children were identified. Five were comparisons of PEG with lactulose, one with milk of magnesia and one with placebo. Study duration ranged from 2 weeks to 12 months. PEG was significantly more effective than placebo and either equivalent to ( two studies) or superior to ( four studies) active comparator. Differences in study design precluded meaningful meta-analysis. Lack of high quality studies has meant that the management of childhood constipation has tended to rely on anecdote and empirical treatment choice. Recent publication of well designed randomised trials now permits a more evidence-based approach, with PEG-based treatments having been proven to be effective and well-tolerated first-line treatment.

This study and the one above it basically confirms my comments above. I like the observation that the “top down” PEG-based treatment is a “well-tolerated first-line treatment”. My complaint is that there really is no viable second-line of treatment which I believe my “bottom up” protocol to be! It should be studied given my report which is shortly to appear in “Digestive Health Matters”, a publication of the International Foundation of Gastrointestinal Disorders (www.iffgd.com). RWC.

****************************

June 30, 2008 JOURNAL OF MEDICAL INTERNET RESEARCH (v10,2), Pp. 78-88. Posted on 02/24/2009.

Real World Use of an Internet Intervention for Pediatric Encopresis

Ritterband,L.M.,* Ardalan,K., Thorndike,F.P., Magee,J.C., Saylor,D.K., Cox,D.J., Sutphen,J.L., & Borowitz,S.M. Univ Virginia Hlth Syst, Dept Psychiat & Neurobehav Sci, POB 801075, Charlottesville, VA 22908 USA

Search Terms: Encopresis, internet, U1 - Article English

Background: The Internet is a significant source of medical information and is now being shown to be an important conduit for delivering various health-related interventions.
Objective: This paper aimed to examine the utility and impact of an Internet intervention for childhood encopresis as part of standard medical care in a "real world" setting.
Methods: Patients diagnosed with encopresis were given a Web-based information prescription to use an Internet intervention for pediatric encopresis. A total of 22 families utilized the intervention between July 2004 and June 2006. A chart review and phone interview were undertaken to collect user characteristics; defecation-related information, including frequency of soiling, bowel movements (BMs) in the toilet, and amount of pain associated with defecation; and information on computer/Internet usage. Three questionnaires were used to examine the utility of, impact of, and adherence to the Internet intervention. Program utilization was obtained from a data tracking system that monitored usage in real time.
Results: Overall, parents rated the Internet intervention as enjoyable, understandable, and easy to use. They indicated that the Internet intervention positively affected their children, decreasing overall accidents and increasing child comfort on the toilet at home. Of the 20 children who initially reported fecal accidents, 19 (95%) experienced at least a 50% improvement, with a reduction of accident frequency from one fecal accident per day to one accident per week. Although it is not clear whether this improvement is directly related to the use of the Internet intervention, patient feedback suggests that the program was an important element, further establishing Internet interventions as a viable and desirable addition to standard medical care for pediatric encopresis.
Conclusions: To our knowledge, this is the first time a pediatric Internet intervention has been examined as part of a "real world" setting. This is an important step toward establishing Internet interventions as an adjunctive component to treatment of pediatric patients in a clinical setting, particularly given the positive user. feedback, possible cost savings, and significant potential for large-scale dissemination.

This is an important demonstrational study on the use of the internet as a disseminator for the treatment of the “top down” approach to treating encopresis. This would fit into the “first-line” method of treatment for encopresis and should help pediatricians to have a source to refer parents to while doing periodic and reinforcing monitoring visits for progress. My own Soiling Solutions (SS) “bottom up” protocol substitutes a manual for the internet equivalent here, but then my Clean Kid Manual parent’s forum would provide continuous and ready support by other parents using the SS protocol. The physician would thus have the opportunity to serve as a back up monitor for any difficulties that may arise, while reducing unnecessary office visits. RWC
****************************

March 9, 2009 GUT Prucalopride (Resolor) in the treatment of severe chronic constipation in patients dissatisfied with laxatives. (v58,3), Pp. 357-365. Added on 03/22/2009.

Tack,J.,* van Outryve,M., Beyens,G., Kerstens,R., & Vandeplassche,L. Univ Hosp Gasthuisberg, Dept Internal Med, Div Gastroenterol, Herestr 49, B-3000 Louvain, Belgium

Search Terms: Prucalopride, Resolor, encopresis, constipation, laxatives

Objective: To determine the efficacy, impact on quality of life (QOL) and safety of prucalopride, a selective, high-affinity 5-HT4 receptor agonist, in patients with chronic constipation.
Methods: In this multicentre, randomised, placebo controlled, parallel-group, phase III study, patients with chronic constipation (two or fewer spontaneous complete bowel movements (SCBM)/week) received 2 mg or 4 mg prucalopride or placebo, once daily, for 12 weeks. The primary efficacy endpoint was the proportion of patients reaching three or more SCBM/week. The key secondary efficacy endpoint was the proportion of patients having an increase of one or more SCBM/week. The primary QOL endpoint was the patient assessment of constipation QOL satisfaction subscale score. Safety parameters included adverse events, laboratory values and cardiovascular events.
Results: Efficacy was evaluated over 713 patients. Averaged over 12 weeks, higher proportions of patients on prucalopride 2 mg (19.5%; p<0.01), 4 mg (23.6%; p<0.001) had three or more SCBM/week (or normalisation of bowel function) compared with placebo (9.6%). Similar results were seen in the subgroup (83%) of patients dissatisfied with previous laxative treatment. Both doses of prucalopride also significantly improved secondary efficacy and QOL endpoints, including the proportion of patients with an increase of one or more SCBM/week, evacuation completeness, perceived disease severity and treatment effectiveness and QOL. Prucalopride 4 mg significantly reduced the need for straining versus placebo (p<0.05). The most frequent treatment-related adverse events were headache and diarrhoea. Both doses of prucalopride were safe and well tolerated.
Conclusion: Prucalopride significantly and consistently improved bowel function, associated symptoms and satisfaction in chronically constipated patients.

I suspect that this study was for adults only and I include it because of concern for those parents with encopretic children who are unusually resistant even to the SS protocol and may have severe chronic constipation into adulthood. DrC.

****************************

02/09/2009 JOURNAL OF PEDIATRICS Health Utilization and Cost Impact of childhood Constipation in the United States. (v154,2), Pp. 258-262. Added on 03/22/2009.

Liem,O., Harman,J., Benninga,M., Kelleher,K., Mousa,H., & Di Lorenzo,C. (No address or institution indicated, Benninga is at Emma Children’s Hospital in Amsterdam, Netherlands and C Di Lorenzo is at Nationwide Childrens Hosp, Dept Pediat, 700 Childrens Dr, Columbus, OH 43205 USA).

Search Terms: encopresis, consitipation, cost.

Objective: To estimate the total health care utilization and costs for children with constipation in the United States.
Study design: We analyzed data from 2 consecutive years (2003 and 2004) of the Medical Expenditure Panel Survey (MEPS), a nationally representative household survey. We identified children who either had been reported as constipated by their parents or had received a prescription for laxatives in a given year. Outcome measures were service utilization and expenditures.
Results: The MEPS database included a total of 21 778 children age 0 to 18 years. representing 158 million children nationally. An estimated 1.7 million US children (1.1%) reported constipation in the 2-year period. No differences with respect to age, sex, race. And socioeconomic status were found between the children with constipation and those without constipation. The children with constipation used more health services than children without constipation, resulting in significantly higher costs: $3430/year vs $1099/year. This amounts to an additional cost for children with constipation of $3.9 billion/year.
Conclusions: This study demonstrates that childhood constipation has a significant impact on the use and cost of medical care services. The estimated cost per year is 3 times than that in children without constipation. which likely is an underestimate of the actual burden of childhood constipation.

Here is a economic argument strongly recommends going to the SS protocol much earlier than is typical for medical practice today. DrC.

****************************

03/09/2009 JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Bowel Habits and Toilet Training in a Diverse Population of Children (v48,3), Pp.294-298). Added on 03/22/2009.

Wald,E.R., Di Lorenzo,C.,* Cipriani,L., Colborn,D.K., Burgers,R., & Wald,A.
Nationwide Childrens Hosp, Dept Pediat, 700 Childrens Dr, Columbus, OH 43205 USA

Search Terms: encopresis, constipation, toilet training

Objectives: To gather data concerning bowel habits and toilet training of developmentally normal children ages 5 to 8 years.
Methods: A questionnaire containing information on age, race, and sex was completed anonymously by parentsin 9 pediatric practices. Recall information was elicited about onset and completion of toilet training, frequency and quality of stooling, size of bowel movements, and behavioral components of defecation.
Results: Questionnaires were completed for 1142 children. When all of the children were considered together, toilet training started at a mean of 27.2 months and was completed at a mean of 32.5 months. It began and was completed nearly 3 months earlier for girls than for boys (P < 0.001). African American children started and completed toilet training at least 6 months earlier than white children (P <0.001). Of the children, 95% defecated either daily or every other day. Straining at defecation and infrequent stooling were reported significantly more often for girls, whereas staining of underclothes and passage of large bowel movements were reported more often in boys. Approximately 10% of children fulfilled criteria for functional constipation.
Conclusions: Most of the children between 5 and 8 years of age have a medium-size bowel movement daily or every other day without straining or withholding. Although African American children toilet train at an earlier age than do white children, bowel habits appear to be similar. A sizeable subgroup of children presenting to primary care providers have a history that is consistent with constipation.

This is a basic epidemiological study which is of interest for showing sex and racial/cultural differences in toilet training. It was of interest that 10% of the children had functional constipation. DrC.

****************************

02/09/2009 EUROPEAN JOURNAL OF PEDIATRIC SURGERY Update on Paediatric Faecal Incontinence (v19,1), Pp. 1-9. Posted on 03/23/2009.

Levitt,M.,* & Pena,A. CCHMC, Dept Pediat Surg, Colorectal Ctr, 3333 Burnet Ave, Cincinnati, OH 45229 USA

Search Terms: fecal incontinence, faecal incontinence, incontinence, encopresis, constipation, enema

Purpose: Faecal incontinence represents a devastating problem; it is often a barrier to social acceptance. It can affect many children including those with prior surgery (for anorectal malformations and Hirschsprung's disease) as well as those with spinal problems or injuries. Management involves distinguishing between true and pseudoincontinence, and then determining the proper protocol of teatment.
Methods: An extensive review of the authors' series of over 500 patients who presented with soiling was undertaken with the goal of determining helpful algorithms of treatment.
Results: Treatment begins first with proper categorisation of patients. Pseudoincontinence (encopresis) can be treated with disimpaction followed by laxative therapy. True incontinence requires an enema programme, with treatment tailored to either hypo or hypermotile colons. Surgery for pseudoincontinence, rarely required, takes the form of colonic resection but only for patients with a demonstrated ability to have voluntary bowel movements, albeit with enormous laxative requirements. Removal of the rectosigmoid in this situation can reduce or eliminate the need for laxatives. Surgery for true faecal incontinence involves changing the route for a successfully demonstrated enema programme to an antegrade, i.e., a Malone appendicostomy.
Conclusion: The keys to success in helping a faecally incontinent child are dedication and sensitivity on the part of the medical team. The basis of the bowel management programme is to clean the colon (either with medical treatment for patients with the potential for bowel control, or artificially with enemas for patients with true faecal incontinence), and then keep the colon quiet for 24 hours until the next treatment, thereby ensuring that the patient is clean and no longer soiling. The programme is an ongoing process of trial and error that responds to the individual patient and differs for each child. We carry out this programme over the course of one week with daily abdominal radiographs as we tailor the regimen. More than 95% of the children who follow this programme are clean and dry. The clinician must embrace the philosophy that it is unacceptable to send a child with faecal incontinence to school in diapers when their classmates are already toilet trained. Proper treatment to prevent this is perhaps more important than any surgical procedure.

I was impressed by the first author’s strong advocacy for fine tuning a bowel management program so as to prevent fecal incontinence in children before going to school. This priority suggests that surgery is a default procedure only for a limited number of children facing extreme refractory cases of fecal incontinence or pseudo-incontinence. DrC.

****************************

02/09/2009 JOURNAL OF PEDIATRIC SURGERY Decreased colonic transit time after transcutaneous interferential electrical stimulation in children with slow transit constipation. (v44,2), Pp. 408-412. Posted on 03/23/2009.

Clarke,M.C.C., Chase,J.W., Gibb,S. Robertson,V.J., Catto-Smith,A., Hutson,J.M.,
Southwell,B.R.* Royal Childrens Hosp, Gut Motil Lab, Surg Res Grp, Murdoch Childrens Res Inst, Melbourne, Vic 3052, Australia

Search Terms: transit, STC, encopresis

Purpose: Idiopathic slow transit constipation (STC) describes a clinical syndrome characterised by intractable constipation. It is diagnosed by demonstrating delayed colonic transit on nuclear transit studies (NTS). A possible new treatment is interferential therapy (IFT), which is a form of electrical stimulation that involves the
transcutaneous application of electrical current. This study aimed to ascertain the effect of IFT on colonic transit time.
Methods: Children with STC diagnosed by NTS were randomised to receive either 12 real or placebo IFT sessions for a 4-week period. After a 2-month break, they all received 12 real IFT sessions-again for a 4-week period. A NTS was repeated 6 to 8 weeks after cessation of each treatment period where able. Geometric centres (GCs) of activity were calculated for all studies at 6, 24, 30, and 48 hours. Pretreatment and posttreatment GCs were compared by statistical parametric analysis (paired t test).
Results: Thirty-one pretreatment, 22 postreal IFT, and 8 postplacebo IFT studies were identified in 26 children (mean age, 12.7 years; 16 male). Colonic transit was significantly faster in children given real treatment when compared to their pretreatment NTS at 24 (mean CG, 2.39 vs 3.04; P <= .0001), 30 (mean GC, 2.79 vs 3.47; P = .0039), and 48 (mean GC, 3.34 vs 4.32; P = .0001) hours. By contrast, those children who received placebo IFT had no significant change in colonic transit.
Conclusions: Transcutaneous electrical stimulation with interferential therapy can significantly speed up colonic transit in children with slow transit constipation.

I continue to advocate the standard pediatric laxative/stool softener “top down” approach for initial treatment, followed by my soiling solutions “bottom up” to condition awareness protocol, and only then defaulting to assessment for STC and biofeedback, IFT, or surgery if these behavioral interventions fail. DrC.

****************************

02/09/2009 JOURNAL OF PEDIATRIC SURGERY What happens to children with idiopathic constipation who receive an antegrade continent enema? An actuarial analysis of 80 consecutive cases. (v44,2), Pp. 404-407. Posted on 03/23/2009.

B Jaffray, Newcastle Univ, Royal Victoria Infirm, Dept Child Hlth, Sir James Spence Inst, Newcastle Upon Tyne NE1 4LP, Tyne & Wear, England

Search Terms: ACE, constipation, encopresis.

Introduction: There is uncertainty about the prognosis for children with idiopathic constipation who opt for treatment by colonic lavage using ail antegrade continent enema (ACE). The aim of this study was to perform an actuarial analysis of the outcomes of the ACE in children consecutively referred to our unit for this procedure, who suffered from idiopathic constipation and who had failed to respond to 3 years of medically supervised conservative management.
Methods: This study is a prospective analysis of the outcomes of 80 children with uncontrolled idiopathic constipation who underwent construction of an ACE by 1 surgeon.
Results: Twelve children were able to stop using their ACE because of resolution of their symptoms. The probability of a child who has idiopathic constipation being able to stop colonic lavage was 0.2, 6.2 years after construction of the ACE. In this group, the estimated mean time to have an ACE reversed was 8.8 years. Twelve children did not achieve satisfactory colonic lavage and either gave up (4) or deteriorated and had alternative treatment for their symptoms (8). The probability of ACE failure is 0.3 at 8.5 years after construction. Girls were significantly more likely to fail than boys, and colonic transit time was significantly longer among children who subsequently required alternative treatment for their symptoms.
Conclusions: Children with idiopathic constipation whose symptoms fail to resolve with medical management and who are treated with an ACE have 0.2 probability of cure, 0.3 probability of failure, and 0.5 probability of having to continue with colonic lavage after 6 years of colonic lavage.

This is the largest follow up study on outcomes for children suffering from encopresis who have undergone the ACE procedure which I have come across to date. It had been hoped that the colons for these children would undergo some shrinkage and recovery of normal size and tonus over time which would allow a recovery of bowel control. These results are disappointing and I believe well justifies my more aggressive Soiling Solutions approach much earlier to avoid a megacolon and surgery. DrC.

****************************

Bongers,M.E.J.*, Benninga,M.A., Maurice-Stam,H., & Grootenhuis,M.A. Univ Amsterdam, Acad Med Ctr, Emma Childrens Hosp, Dept Pediat Gastroenterol & Nutr, Meibergdreef 9, NL-1105 AZ Amsterdam, Netherlands

Search Terms: Encopresis, Incontinence, Constipation

Background: Children with functional constipation report impaired Health-related Quality of Life (HRQoL) in relation to physical complaints and long duration of symptoms. In about one third of children with constipation, symptoms continue into adulthood. Knowledge on HRQoL in adults with constipation persisting from childhood is lacking.
Objectives: To assess HRQoL in adults with constipation from early childhood in comparison to that of their peers. Furthermore to gain insight into the specific social consequences related to continuing symptoms of constipation and/or fecal incontinence at adult age.
Methods: One HRQoL questionnaire and one self-developed questionnaire focusing on specific consequences of symptoms of constipation continuing into adulthood were administrated to 182 adults with a history of childhood constipation. Successful clinical outcome was defined as a defecation frequency three or more times per week with less than two episodes of fecal incontinence per month, irrespective of laxative use. HRQoL of both adults with unsuccessful and successful clinical outcome were compared to a control group of 361 peers from the general Dutch population.
Results: No differences in HRQoL were found between the whole study population and healthy peers, nor between adults with successful clinical outcome (n = 139) and the control group. Adults with an unsuccessful clinical outcome (n = 43) reported significantly lower HRQoL compared to the control group with respect to scores on bodily pain (mean +/- SD 77.4 +/- 19.6 versus 85.7 +/- 19.5, p = 0.01) and general health (67.6 +/- 18.8 versus 74.0 +/- 18.1, p = 0.04). Adults with an unsuccessful clinical outcome reported difficulties with social contact and intimacy (20% and 12.5%, respectively), related to their current symptoms. Current therapy in these adults was more often self-administered treatment (e. g. diet modifications) (60.4%) than laxatives (20.9%).
Conclusion: Overall, young adults with constipation in childhood report a good quality of life, as HRQoL of adults with successful clinical outcome was comparable to that of their peers. However, when childhood constipation continues into adulthood, it influences HRQoL negatively with social consequences in 20% of these adults.

Another excellent study from this research group out of the Emma Children's Hospital in Amsterdam, the Netherlands. This study looked at the effects of encopresis extending into adulthood. This is a question that often comes up from parents of children with encopresis. The negative effect on social contact and intimacy in a substantial minority of cases would be expected as this is such an offensive and foul bodily waste product. This condition deserves more aggressive attention in childhood. DrC.

*****************************

Helping Patients Make Informed Choices About Probiotics: A Need for Research

Sharp,R.R.*, Achkar,J.P., Brinich,M.A., & Farrell,R.M. Cleveland Clin, Dept Bioeth, JJ 60, Cleveland, OH 44195 USA

Search Terms: constipation, encopresis, probiotics

Applications of probiotics in the treatment of gastrointestinal disorders are gaining acceptance among patients, despite evidence that probiotics can present substantial health risks, particularly for patients who are immunocompromised or seriously ill. Patients will likely formulate their attitudes and beliefs about probiotics therapies with reference to interpretive frameworks that compare probiotics with more familiar therapeutic modalities, including complementary and alternative medicines, pharmacological therapies and gene-transfer technologies. Each of these frameworks highlights a different set of benefit-to-risk considerations regarding probiotics usage and reinforces extreme characterizations of both the therapeutic promise and peril of probiotics. Considerable effort may be required to help patients make informed choices about probiotics therapies.

I have noticed that probiotics are becoming very popular among parents on various email forums and are being used very freely for constipation and encopresis. This is often done without physician approval or recognition. I have entered probiotics as one of my search terms for weekly citation alerts. DrC

*****************************

Health Related Quality of Life in Children with Constipation-Associated Fecal Incontinence.

Bongers,M.E.J.*, van Dijk,M., Benninga,M.A., & Grootenhuis,M.A. Univ Amsterdam, Acad Med Ctr, Dept Pediat Gastroenterol & Nutr, Room C2-312,Meibergdreef 9, NL-1105 AZ Amsterdam, Netherlands

Search Terms: Constipation, encopresis, Quality of Life, QoL

Objectives: With a disease-specific questionnaire, this study aimed to evaluate health-related quality of life (HRQoL) in children with constipation in association with clinical characteristics.
Study design: Children with constipation-associated fecal incontinence (n = 114), 8 to 18% years, filled out the Defecation Disorder List at a Dutch tertian, hospital. Correlations and linear regression analysis between clinical characteristics and scores on emotional and social functioning were calculated. Specific concerns of children were described by individual item scores of these domains.
Results: Higher frequency of fecal incontinence episodes was associated with lower emotional and social functioning. Linear regression analysis showed a significant association between social functioning and fecal incontinence, but the variance of the model was low (adjusted R-2 = 0.08). Between 70% to 80% of children were concerned about experiencing fecal incontinence unnoticeably and the attendant social consequences. Children did not report having fewer friends and participated well in social events.
Conclusion: Lower HRQoL regarding disease-specific emotional and social functioning was reported in children with frequent episodes of constipation-associated fecal incontinence. However. Other nonspecified factors may also influence HRQoL of these children. Most children reported relatively more emotional concerns than social consequences.

Reprint requested from the authors. RWC

*****************************

April, 2009 JOURNAL OF PEDIATRIC SURGERY (v 44,4), Pp.773-782. Posted on 05/14/2009.

Mucosal nerve deficiency in chronic childhood constipation: a postmigration defect?

Wendelschafer-Crabb,G.*, Neppalli,V., Jessurun,J., Hodges,J., Vance,K., Saltzman,D., Acton,R., Kennedy,W.R., Univ Minnesota, Sch Med, Dept Neurol, Minneapolis, MN 55455 USA

Search Terms: encopresis, cells

Purpose: Idiopathic chronic childhood constipation (ICCC) includes children who are severely constipated and who are resistant to behavioral or medical treatments. These children are distinguished from those with Hirschsprung's disease (HSCR) by the presence of enteric ganglia in rectal biopsy specimens. We investigated potential autonomic dysfunction by examining nerves in rectal mucosa.
Methods: Immunostaining, confocal microscopy, and nerve analysis were performed on formalin-fixed and on Zamboni-fixed rectal biopsy specimens from children who were severely constipated. A computer-assisted neuron tracing technique was used to determine mucosal nerve density in Zamboni-fixed biopsy sections.
Results: Nerves in Zamboni-fixed biopsy specimens were better stained than in formalin-fixed biopsy specimens. Regardless of fixation method, a deficiency of mucosal nerves was observed in ICCC when compared to children who are not constipated. Analysis of autotraced mucosal nerves confirmed the deficiency in ICCC biopsy specimens. Mucosal nerves were also severely deficient in patients with HSCR, even in transitional segments that contained ganglia.
Conclusions: Most patients with ICCC had decreased innervation of the rectal mucosa. Because mucosal nerves are critical for the peristaltic reflex, water secretion, and absorption, their deficiency can be related to patient constipation. Mucosal nerve density provides a pathologic basis for diagnosis of dysfunction in children who do not have HSCR but are chronically constipated. The study validates the neuron tracing method for objective evaluation of mucosal innervation.

Which came first, the decreased innervation causing the constipation or the constipation for whatever reason causing the decreased innervation? DrC.

*****************************

Treatment of fecal incontinence with a comprehensive bowel management program

Bischoff,A., Levitt,M.A.*, Bauer,C., Jackson,L., Holder,M. & Pena,A. Cincinnati Childrens Hosp, Med Ctr, Dept Pediat Surg, Colorectal Ctr Children, Cincinnati, OH 45229 USA

Search Terms: Encopresis, ACE, suppository, enema

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 ill 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 f 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. (C) 2009 Elsevier Inc. All rights reserved.

Dr Bischoff's report demonstrates the effectiveness of the repeated use of the "bottoms up" approach for cases where there is no alternative to producing BMs. Repeated use of phosphate enemas available over the counter did lead in 5 cases to indications of "colitis". This is the first reported instance of this consequence that these authors were aware of. Defaulting to glycerin and ____ enemas ameliorated the colitis. The authors' position that an adequate bowel management program should be implemented before ACE is considered is well taken. RWC.

*****************************

Improvement of quality of life in children with slow transit constipation after treatment with transcutaneous electrical stimulation

Clarke,M.C.C., Chase,J.W., Gibb,S., Hutson,J.M., & Southwell,B.R.* Murdoch Childrens Res Inst, Dept Surg Res, Melbourne, Vic 3052, Australia

Search Terms: STC, encopresis, electrical stimulation, constipation

Background: Slow transit constipation (STC) causes intractable symptoms not responsive to medical treatment. Children have irregular bowel motions, colicky abdominal pain, and frequent soiling. Transcutaneous electrical stimulation using interferential current (interferential therapy [IFT]) is a novel treatment of STC. This Study assessed quality of life (QOL) in STC children before and after IFT treatment.
Methods: Eligible STC children were randomized to receive either real or placebo IFT (12 sessions for 4 weeks). Questionnaires (Pediatric Quality of Life Inventory) were administered before and 6 weeks after treatment, with parallel parent and child self-report scales. Higher scores indicate better QOL. Holschneider and Templeton scores were also obtained. The QOL scores were compared using paired t tests.
Results: Thirty-three children (21 male), with a mean age of 11.8 years (range, 7.4-16.5 years), were recruited; 16 received real IFT. Child-perceived QOL was improved after real IFT compared with baseline (81.1 vs 72.9, P = .005) but not after placebo IFT (78.1 vs 74.9, P = .120). The Holschneider score improved after real IFT(10 vs 8, P = .015) but not after placebo IFT(9 vs 8, P = .112). Parentally perceived QOL was similar after real IFT (70.1 vs 70.3, P = .927) and placebo IFT (70.2 vs 69.8, P = .899). There were no differences in Templeton scores.
Conclusion: Interferential therapy is a novel therapy for children with STC that improves their self-perceived QOL. (C) 2009 Elsevier Inc. All rights reserved.

This group has focussed on STC which has been relatively resistant to treatment. This abstract alone is not adequate to understand the procedure, its equipment, and clinical setting for the actual treatment. I have requested a reprint and will revisit this abstract at a future time if it is sent. RWC

***************************

Transanal rectosigmoid resection for severe intractable idiopathic constipation

Levitt,M.A.*, Martin,C.A., Falcone,R.A. Jr., & Pena,A.

MA Levitt, Cincinnati Childrens Hosp, Med Ctr, Colorectal Ctr Children, Div Pediat Gen & Thorac Surg, Cincinnati, OH 45229 USA

Search Terms: Constipation, encopresis, surgery, incontinence, transanal rectosigmoid resection, megacolon.

Introduction: Idiopathic constipation is a source of significant morbidity in children. A Subset of patients is refractory to medical therapy and requires Surgical intervention. We present a novel surgical technique for the management of these patients.
Methods: We reviewed the records of 288 patients with severe idiopathic constipation and soiling. Patients who were refractory to medical management and had a megarectosigmoid underwent a transanal full-thickness rectosigmoid resection with a primary colo-anal anastomosis.
Results: Fifteen patients underwent a transanal rectosigmoid resection. The preoperative contrast enema demonstrated an enormously dilated rectosigmoid in 14. An average of 43 cm (range, 8-98 cm) of rectosigmoid was resected. Of 14 patients with more than 3 months of follow-up, the preoperative laxative dose was 68 mg of senna/d (range, 52-95 mg), which decreased to 8.6 mg postoperatively (P <.001). Nine patients are clean without soiling, I is more prone to diarrhea, but is clean. Two patients soil occasionally, but are noncompliant, and 2 were lost to follow-up.
Conclusion: Transanal rectosigmoid resection for medically intractable idiopathic constipation resulted in a dramatic reduction or elimination in laxatives use while preserving continence. It is a useful alternative to surgical options Such as other colonic resections, antegrade enemas, and stomas. (C) 2009 Elsevier Inc. All rights reserved.

*****************************

August, 2009 BEST PRACTICE & RESEARCH IN CLINICAL GASTROENTEROLOGY V23, 4), Pp. 477-485. Posted on 09/09/2009

The physiology of continence and evacuation

Bajwa,A.*, & Emmanuel,A. Univ Coll Hosp, 235 Euston Rd, London NW1 2BU, England

Search Terms: encopresis, physiology, anal sphincter

Continence is maintained by the coordinated function of the pelvic floor, rectum and anal sphincters. Evacuation occurs through a relaxed pelvic floor. The rectum acts to either store or expel stool both of which require cortical sensory awareness acting in conjunction with intramural and spinal reflexes that ensure timely defecation. The anal sphincters act individually and in unison in response to rectal distension and the sensation of rectal filling. Reflex relaxation of the internal anal sphincter has an additional sensory function in allowing sampling of rectal contents in the upper anal canal. Voluntary control of the external anal sphincter is key in the voluntary deferring of evacuation until a socially opportune moment. This review describes the physiological roles of each of these continence organs in order to understand the complex process of defecation (C) 2009 Elsevier Ltd. All rights reserved.

*****************************

August, 2009 ASIAN BIOMEDICINE (v3, 4), Pp. 391-399. Posted on 09/09/2009.

Polyethylene glycol 4000 without electrolytes versus milk of magnesia for the treatment of functional constipation in infants and young children: a randomized controlled trial

Ratanamongkol,P.*, Lertmaharit,S., & Jongpiputvanich,S. Bhumibol Adulyadej Hosp, Dept Pediat, Pediat Gastroenterol Unit, Bangkok 10220, Thailand

Search Terms: MOM, Milk of Magnesia, Miralax, PEG-3350 or 4000?, encopresis,

Background. Functional constipation is a common pediatric problem. Polyethylene glycol and milk of magnesia are osmotic agents used to treat constipation. There were few studies comparing the two laxatives for the treatment of functional constipation in infants and young children.
Objective: To compare two laxatives, polyethylene glycol 4000 without electrolytes (PEG) and milk of magnesia (MOM), by evaluating the effectiveness, adverse effects, and patient compliance.
Materials and methods: A randomized controlled trial was performed in 94 patients aged one-four years who attended at the pediatric outpatient clinic of Bhumibol Adulyadej Hospital and met the Rome III criteria for functional constipation receiving either PEG or MOM for four weeks. The primary outcome evaluation was the improvement rate. The secondary outcomes included the improvement of stool frequency, adverse effects, and compliance rate.
Results: Eighty-nine patients completed the study, including 46 in the PEG group and 43 in the MOM group. Baseline characteristics of age, body weight, sex, initial stool frequency, and duration of constipation were similar between groups. At the four week follow-up visit, 91% of PEG-treated patients and 65% of the MOM-treated patients exhibited improvement (p=0.003). Patients in the PEG group had greater increase of stool frequency after treatment than patients in the MOM group. Overall, adverse effects were mild, transient and not different among groups, but there was more diarrhoea in MOM treated patients. No serious adverse effects were observed. Compliance rates were 89% for PEG and 72% for MOM (p = 0.041).
Conclusion: PEG was more effective and had greater patient compliance than MOM for the management of functional constipation in infants and children aged one-four years.

PEG or Miralax has become the dominant prescription for encopresis, yet many parents are extremely suspicious and alienated from its use with no clear alternatives offered by their physicians. This study is useful in looking at a comparison treatment for another stool softening agent. Most studies appear to give the nod to PEG as having fewer side-effects and maintaining a greater rate of compliance. This latter could be because of continuing support and assurance by the prescribing physician.

*****************************

Correlation of bowel symptoms with colonic transit, length, and faecal load in functional faecal retention

D Raahave, N*, Christensen,E., Loud,F.B. & Knudsen,L.L. Sealand Hosp, Colorectal Lab, Dept Surg, DK-3000 Helsingor, Denmark

Search Terms: Constipation, Transit time

Introduction: Abdominal pain, bloating, and defecation disturbances are common complaints in gastrointestinal functional disorders. This study explores whether bowel symptoms are correlated to colon transit time (CTT), faecal loading (coprostasis), and colon length; and whether prokinetic intervention can reduce CTT, faecal retention, and symptoms.
Methods: This observational and interventional study includes 281 patients, and 44 asymptomatic controls. Evaluations included symptoms, physical signs, CTT, faecal loading, barium enema, endoscopy, sonography, anal manometry and biochemistry. Interventions included a low-fat, high-fiber diet, cisapride or domperidone, and exercise for a mean of 21.6 months.
Results: The mean CTT was 40.71 h in patients vs 24.75 h in controls (p = 0.013). In patients, faecal loading was significantly greater than in controls (p < 0.001). Bloating correlated significantly positively with CTT (r = 0.174, p = 0.009), and faecal load. Abdominal pain correlated significantly positively with distal faecal loading (r = 0.151; p = 0.036). The mean CTTs in patients with zero to four colon redundancies were: 36.26 h, 43.80 h, 41.65 h and 52.27h, respectively (p = 0.030), and symptoms increased significantly with increase in the number of redundancies (p < 0.001). A subgroup of patients (n = 90) with normal CTTs (= 24.75 h) had significantly higher faecal loading compared to controls (p = 0.033). Factor analysis showed that bloating correlated significantly with abdominal pain and defecation rate (p < 0.05) and that CTT and faecal load correlated inversely with daily defecation rate, ease, incompleteness, repetitiveness, and faecal consistency. Intervention significantly reduced CTT, faecal loading, bloating, abdominal pain, and improved defecation patterns (p < 0.05).
Conclusions: Faecal retention with or without increased CTT, caused bloating, abdominal pain and altered defecation patterns in patients with bowel symptoms. An elongated colon aggravated the symptoms. Measurements of CTT, faecal load and the number of colon redundancies can be useful guides in clinical practice. Prokinetic intervention reduces abdominal and anorectal symptoms, and improves quality of life.

This is an important study in setting out parameters of the colon which contribute to difficulties in bowel control. Fortunately, these apparently can be conpensated for using prokinetic interventions (laxatives, stool softeners, etc.). RWC.

*****************************

Oct 2009 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY (v7,10), Pp. 1069-1074. Posted on 11/03/2009.

A Randomized Controlled Trial of Enemas in Combination With Oral Laxative Therapy for Children With Chronic Constipation

Bongers,M.E.J., van den Berg,M.M., Reitsma,J.B., Voskuijl,W.P., & Benninga,M.A.* Univ Amsterdam, Acad Med Ctr, Emma Childrens Hosp, Dept Pediat Gastroenterol & Nutr, Room G8-261,Meibergdreef 9, NL-1105 AZ Amsterdam, Netherlands

Search Terms—Encopresis, Incontinence, Fecal, Constipation, Enema

BACKGROUND & AIMS: After 5 years of intensive oral laxative use, up to 30% of constipated children still have an unsuccessful outcome. Children refractory to oral laxatives might benefit from regular rectal evacuation by enemas. This randomized controlled trial compared the effects of additional treatment with rectal enemas (intervention) with conventional treatment alone (oral laxatives, control) in severely constipated children. METHODS: In a tertiary hospital in the Netherlands, 100 children, aged 8-18 years, with functional constipation for at least 2 years were randomly assigned to intervention or control groups. The control group received education, behavioral strategies, and oral laxatives. The intervention group was also given 3 rectal enemas/week, reduced by I enema/week every 3 months. Outcome measures were defecation and fecal incontinence frequency and overall success at 12, 26, 39, and 52 weeks. Overall success was defined as 3 or more defecations/week and less than 1 fecal incontinence episode/week, irrespective of laxative use.

RESULTS: Defecation frequency normalized in both groups but was significantly higher in the intervention group compared with controls at 26 and 52 weeks (5.6 vs 3.9/week, P = .02, and 5.3 vs 3.9/week, P = .02, respectively). There were no significant differences between groups in reduction of fecal incontinence episodes (P = .49) and overall success rates (P = .67). After 1 year of treatment, the overall success rate was 47.1% in the intervention group versus 36.1% in the control group.

CONCLUSIONS: There is no additional effect of enemas compared with oral laxatives alone as maintenance therapy for severely constipated children.

Interesting, here is an admission of up to a 30% failure rate for 5 years of “top down” laxative use in dealing with fecal incontinence for severely constipated children. This is the same research group that showed the colon does not completely restore even after 4 years of the successful remission of fecal incontinence! Their innovation here was to add enemas to their standard treatment protocol. No training aspect was introduced, just so called “maintenance therapy” to assure repeated "clean outs?" Really, does the medical profession wish to "maintain" fecal incontinence? How odd! This would appear to be a variation on, "First do no harm," but adding on, "and do no good?" I view this as a “brainless” approach to the treatment of encopresis or fecal incontinence. The authors leave out the critical component of a normal reflex arc engaging colo-rectal signals>>a brain connection with sitting on toilet stool cues>>voiding reflex. The authors appear to be trying to improve on “maintaining” the dominant prepotent sequence of colo-rectal signals>>brain-wherever, including the toilet stool>>holding reflex! My hope is that now they will do a follow up with the Soiling Solutions protocol to reprogram the necessary and desired BRAIN mediated reflex arc. I would be pleased to offer free copies of my Clean Kid Manual for any such research project. DrC.

*****************************

Dec, 2009 PEDIATRICS. Rectal Fecal Impaction Treatment in Childhood Constipation: Enemas Versus High Doses Oral PEG. (v124,6), Pp. E1108-E1115. Added 12/07/2009.

Bekkali,N.L.H.,* van den Berg,M.M., Dijkgraaf,M.G.W., van Wijk, M.P., Bongers,M.E.J., Liem,O., & Benninga,M.A. Emma Childrens Hosp, Acad Med Ctr, Motil Ctr, Dept Pediat Gastroenterol & Nutr, Off C2-312,Meibergdreef 9, NL-1105 AZ Amsterdam, Netherlands

Search Terms: PEG, Miralax, Constipation, Encopresis, STC

OBJECTIVE: We hypothesized that enemas and polyethylene glycol (PEG) would be equally effective in treating rectal fecal impaction (RFI) but enemas would be less well tolerated and colonic transit time (CTT) would improve during disimpaction.
METHODS: Children (4-16 years) with functional constipation and RFI participated. One week before disimpaction, a rectal examination was performed, symptoms of constipation were recorded, and the first CTT measurement was started. If RFI was determined, then patients were assigned randomly to receive enemas once daily or PEG (1.5 g/kg per day) for 6 consecutive days. During this period, the second CTT measurement was started and a child's behavior questionnaire was administered. Successful rectal disimpaction, defecation and fecal incontinence frequencies, occurrence of abdominal pain and watery stools, CTTs (before and after disimpaction), and behavior scores were assessed.
RESULTS: Ninety-five patients were eligible, of whom 90 participated (male, n = 60; mean age: 7.5 +/- 2.8 years). Forty-six patients received enemas and 44 PEG, with 5 dropouts in each group. Successful disimpaction was achieved with enemas (80%) and PEG (68%; P = .28). Fecal incontinence and watery stools were reported more frequently with PEG (P < .01), but defecation frequency (P = .64), abdominal pain (P = .33), and behavior scores were comparable between groups. CTT normalized equally (P = .85) in the 2 groups.
CONCLUSION: Enemas and PEG were equally effective in treating RFI in children. Compared with enemas, PEG caused more fecal incontinence, with comparable behavior scores. The treatments should be considered equally as first-line therapy for RFI.

This study was oriented to the use of enemas versus the most commonly employed stool softener (Polyethelene Glycol-PEG or Miralax (trade name) in the USA). Both were equally effective for “first-line therapy” or purposes of a “clean out” as commonly employed before going to a maintenance regimen. What I found interesting was that the drop out rate was not any higher for the enema vs. PEG, usually the former is viewed as more difficult and more likely to be rejected by parents. I think this reflects the persuasive and authoritative voice of the physician when they make a recommendation. I also take note of the increased incidence of added fecal incontinence and watery stools with the use of PEG than the enemas. I would expect that with the “top down” liquification of the stool and less ability to discriminate between gas and liquid in the rectum. This is why I believe that a bowel retraining regimen with suppositories and enemas, “bottom up” would be more effective and immediately morale boosting for the parents and the children. Also, the addition of the physician’s authority would make acceptance and maintenance of the suppository/enema retraining of the total hold-void reflex arcs sequence more effective. DrC.

*****************************

Dec, 2009 PEDIATRIC SURGERY INTERNATIONAL (v 25,12), Bowel management for the treatment of pediatric fecal incontinence. Pp. 1027-1042. Posted on 01/18/2010.

Bischoff,A., Levitt,M.A., & Pena,A.* Cincinnati Childrens Hosp, Colorectal Ctr Children, Med Ctr, 3333 Burnet Ave,ML 2023, Cincinnati, OH 45229 USA
Search terms: Encopresis, Enemas, incontinence.

Fecal incontinence is a devastating underestimated problem, affecting a large number of individuals all over the world. Most of the available literature relates to the management of adults. The treatments proposed are not uniformly successful and have little application in the pediatric population. This paper presents the experience of 30 years, implementing a bowel management program, for the treatment of fecal incontinence in over 700 pediatric patients, with a success rate of 95%. The main characteristics of the program include the identification of the characteristics of the colon of each patient; finding the specific type of enema that will clean that colon and the radiological monitoring of the process.

This group's work has been outstanding in taking an even more aggressive approach than that of my Soiling Solutions protocol in treating encopresis with the use of powerful purging enemas with considerable success. Their intervention appears to be much more predicated on a biomechanical medical model of encopresis than my more gradual daily approach with a reconditioning or learning model approach spread over a longer period of time and done by the parents at home with the support of other parents on the exclusive SS parent's forum. So, interestingly, as my approach has been repudiated by many authorities as too aggressive, here is an even more aggressive approach. But, the important thing is that we have more choices to offer families!

*****************************

Jan, 2007 NEUROUROLOGY AND URODYNAMICS (v26,1), Pp. 90-102. Posted on 02/17/2007.

The standardization of terminology of lower urinary tract function in children and adolescents: Report from the standardization committee of the International Children's Continence Society (ICCS)

Neveus,T.,*, von Gontard,A., Hoebeke,P., Hjalmas,K., Bauer,S., Bower,W., Jorgensen,T.M., Rittig,S., Van de Walle,J., Yeung,C.K., & Djurhuus,J.C.
Uppsala Univ, Childrens Hosp, Sect Pediat Nephrol, S-75185 Uppsala, Sweden

Search Terms: Enuresis, bladder capacity, urodynamics, terminology, consensus

Purpose: We updated the terminology in the field of pediatric lower urinary tract function.
Materials and Methods: Discussions were held in the board of the International Children's Continence Society and an extensive reviewing process was done involving all members of the International Children's Continence Society, the urology section of the American Academy of Pediatrics, the European Society of Pediatric Urology, as well as other experts in the field.
Results and Conclusions: New definitions and a standardized terminology are provided, taking into account changes in the adult sphere and new research results.

This is an important consensus statement of interest to urologists. RWC

*****************************

Nocturnal enuresis: Application of evidence-based medicine in community practice

Cutting,D.A.*, & Pallant,J.F. Paediat Practice, 102 Anderson St, Lilydale, Australia

Search Terms: Enuresis, desmopressin.

Aim: To report the outcomes and follow-up at 2 years of children with monosymptomatic nocturnal enuresis (MNE) managed in a private paediatric community practice utilising body-worn alarms and supportive programmes.
Methods: 522 consecutive children presenting with MNE were assessed and managed with a comprehensive supportive programme and body-worn alarm. Data were recorded prospectively and outcomes assessed at 6 and 24 months.
Results: 505 proceeded with management. A total of 79.0% achieved initial dryness within a median of 10 weeks. Of those achieving initial dryness 73.0% had remained dry at 6-month follow-up and 64% had remained dry at 24 months. A total of 99.2% follow-up was achieved. Nineteen per cent of children required more than 16 weeks management with 56% achieving dryness. More girls achieved dryness than boys and in a shorter time. There was no gender difference in relapse rates at 6 and 24 months. No difference in achieving initial success was found with respect to initial severity of wetting, nor age. Relapse rates were unrelated to gender, age, or initial severity.
Conclusion: MNE can be successfully managed using body-worn alarms achieving good initial and long-term complete dryness, without the need for expensive pharmacologic intervention. A strong supportive programme can make the management less arduous for child and family.

Dr Cutting is a truly unique private practice pediatrician in Australia with his devotion to careful management and record keeping for outcomes data. This illustrates the usefulness and likely cost effectiveness of using the bedwetting alarm for long-term benefit over the more temporary effects of popular medication approaches.

*****************************

Is second-line enuretic alarm therapy after unsuccessful pharmacotherapy superior to first-line therapy in the treatment of monosymptomatic nocturnal enuresis?

Tuygun,C., Eroglu,M., Bakirtas,H., Gucuk,A., Zengin,K., & Imamoglu,A. (No address or affiliation listed for the authors).

Search Terms: Enuresis, Alarm

Introduction: We aimed at comparing the success rates of primary enuretic alarm therapy with those of secondary alarm therapy after failed pharmacotherapy in the treatment of monosymptomatic nocturnal enuresis (MNE).
Patients and Methods: We randomly applied enuretic alarm therapy in 35 MNE patients (group 1) and desmopressin therapy in 49 MNE patients (group 2). The success and rebound rates after 3 and 6 months were determined. We also applied enuretic alarm therapy as a secondary treatment in 19 group 2 patients with complete rebound after 6 months (group 3). The success rates of patients who have received primary and secondary enuretic alarm therapy were compared.
Results: The success rates for groups 1 and 2 were 82.65 and 81.63%, respectively (p = 0.885) at 3 months and 54.28 and 26.53%, respectively (p =0.007) at 6 months. The success rates in group 3 were 84.21 and 52.63%, respectively, at 3 and 6 months. When these success rates were compared between groups 1 and 3, no statistically significant difference was found (p = 1.000).
Conclusion: Prior pharmacotherapy did not increase success rates of alarm therapy in our MNE patients.

A "complete rebound" for group 3 here appears to mean a complete relapse back to pretreatment weekly frequencies of bedwetting. There were no apparent "savings" for the original benefit of the MNE therapy following a relapse. The lower relapse rate for the alarm accords with prior studies. RWC

**************************

Modulation of arousal reaction in children with nocturnal enuresis.

Limbach,A.*, Huckel,D., Gelbrich,G., Merkenschlager,A., Kiess,W., & Keller,E. Univ Leipzig, Hosp Children & Adolescents, Oststr,21-25, D- 04137 Leipzig, Germany

Search Terms: Enuresis, EEG, ADH

Background: Disturbances of central regulatory processes of sleep and arousal are potential causes of nocturnal enuresis.The intranasal application of an ADH analogue is an established therapeutic option to influence nocturnal enuresis.
The aim of the study was to evaluate effects of an ADH analogue on sleep and arousal in patients suffering from primary nocturnal enuresis. Patients and Methods: In our study the influence of ADH analogue on sleep architecture was investigated by polysomnographic studies before and during therapy in 24 patients.
Results: In polysomnography arousal index and movement time were significantly improved after 6 weeks, sleep stages 1 to 4 did not change significantly. Treatment reduced the frequency of nocturnal wetting significantly and this effect lasted for another 6 weeks.
Conclusion: The long lasting effect of ADH to reduce enuresis could possibly be caused by changes in arousal reaction and a normal wake up facilitation.

ADH, the anti-diuretic hormone (analog thereof), may in part be successful for its effects on abetting more ready arousal. This would be in addition to its abetting the concentration of the urine during sleep. DrC.

*****************************

Sept 2007 JOURNAL OF UROLOGY (v178, 3 Pt 1), Pp. 1048-1051. Posted on 10/22/2007.

Partial response to intranasal desmopressin in children with monosymptomatic nocturnal enuresis is related to persistent nocturnal polyuria on wet nights

Raes,A.*, Dehoorne,J., Van Laecke,E., Hoebeke,P., Vande Walle,C. Vansintjan,P., Donckerwolcke,R., & Vande Walle,J. State Univ Ghent Hosp, Dept Pediat Nephrol, SK6,Pintelaan 185, B-9000 Ghent, Belgium

Search Terms: Enuresis, DDAVP, ADH.

Purpose: The anti-incontinence effect of desmopressin resides in its concentrating capacity and antidiuretic properties. We compared nighttime urine production on wet and dry nights in a highly selected study population of children with monosymptomatic nocturnal enuresis associated with proved nocturnal polyuria who responded only partially to intranasal desmopressin.
Materials and Methods: We retrospectively analyzed 39 home recordings of nocturnal urine production and maximum voided volume in children 7 to 19 years old (median 8.9) with monosymptomatic nocturnal enuresis with nocturnal polyuria who had a partial response to desmopressin. Nocturnal diuresis volume and maximum voided volume were documented at baseline (14 days) and during 3 months of followup.
Results: Baseline nocturnal urine output (439 +/- 39 ml) was significantly higher than the maximum voided volume (346 93 ml, p<0.01). During desmopressin treatment nocturnal urine output on wet nights (405 +/- 113 ml) differed significantly from that on dry nights (241 +/- 45 ml). During treatment nocturnal urine output on wet nights did not differ from baseline values.
Conclusions: Persistence of nocturnal polyuria on wet nights in partial desmopressin responders may be related to an insufficient antidiuretic effect. In addition to poor compliance and suboptimal dosing, the poor bioavailability of intranasal desmopressin may be a pathogenic factor. Further prospective studies are needed.

But note the alerting function for an ADH agonist just noted in the study immediately above. Still this study does raise some interesting questions about the inconsistency of the concentrating function over the course of treatment when desmopressin (synthetic ADH-anti-diuretic hormone) is used. RWC.

*****************************

The effect of obesity on treatment efficacy in children with nocturnal enuresis and voiding dysfunction.

Guven,A., Giramonti,K.*, Kogan,B.A. Albany Med Coll, Div Urol, Sect Pediat Urol, 23 Hackett Blvd, Albany, NY 12208 USA

Search Terms: Enuresis, Obesity

Purpose: Obesity continues to be a leading public health concern in the United States. Our previous studies have suggested that there is a high rate of obesity in children with dysfunctional voiding, especially nocturnal enuresis. We investigated the correlation between body mass index and the efficacy of treatment in obese patients.
Materials and Methods: We evaluated retrospectively records from patients seen with a diagnosis of nocturnal enuresis or dysfunctional voiding between January 2004 and July 2005. Bladder and bowel symptoms and urinary diary data were evaluated, and body mass index percentile was determined. Response to treatment was evaluated and correlated with body mass index percentile.
Results: We evaluated 250 children, of whom 96 (38%) had nocturnal enuresis and 154 (62%) had dysfunctional voiding. Body mass index was normal in about half of the patients, and half were above the 85th percentile for body mass index. Patients with a body mass index above the 85th percentile had a reduced response to therapy. After treatment patients with a normal body mass index bad a lower nocturnal accident frequency than those above the 85th percentile. Similarly, in those with voiding dysfunction the response rate was 65% in association with a normal body mass index vs 35% with a high body mass index. Furthermore, patients with a normal body mass index had a significantly higher rate of completing a urinary diary compared to those with a high body mass index.
Conclusions: Obesity correlates with a lower voiding diary completion rate and lower efficacy of treatment in children with nocturnal enuresis or dysfunctional voiding.

My own research on enuresis with the bedwetting alarm found a lower diary completion rate for treatment failures. I did not look at obesity as a factor and don't recall any observations about it at the time. This was years ago before obesity became a major problem in our culture. Why obesity is associated with lower diary completion rate and a poor response rate is unclear. I will avoid speculation, but the finding is interesting in its own right. RWC.

*****************************

October 2007 JOURNAL OF UROLOGY (v178, 4 Pt 2), Pp. 1758-1761. Posted on 10/22/2007.

Office management of pediatric primary nocturnal enuresis: A comparison of physician advised and parent chosen alternative treatment outcomes.

Saldano,D.D.*, Chaviano,A.H., Maizels,M., Yerkes,E.B., Cheng,E.Y., Losavio,J., Porten,S.P., Sullivan,C., Zebold,K.F., Hagerty,J., & Kaplan,W.E. Childrens Mem Hosp, 2300 Childrens Plaza, Chicago, IL 60614 USA

Search Terms: Enuresis, Pediatric, Alarm.

Purpose: We compared the remission of pediatric primary nocturnal enuresis in groups of children who used a physician advised practice plan vs a parent chosen alternative.
Materials and Methods: Between January 2004 and January 2006 there were 119 patients with primary nocturnal enuresis enrolled in this prospective, nonrandomized study. For this study primary nocturnal enuresis was defined as wetting at night during sleep during any 6-month interval without any known causative problem. A total of 76 children received the physician advised treatment plan and used an alarm, oxybutynin, desmopressin, an elimination diet and a bowel program, as indicated. A total of 43 children received a parent chosen alternative treatment plan, which consisted of any single or combination of treatments involving an alarm, oxybutynin, desmopressin and an elimination diet or bowel program. Parents from each group completed an intake survey that measured functional bladder capacity using a 3-day home diary and they identified demographic variables. Followup occurred at 2 weeks and then monthly for 12 weeks to study end.
Results: We found that the probability of remission by the end of the study for the physician advised treatment group was significantly higher than that of the parent choice group (88% vs 29%, Kaplan-Meier curve p <0.0001).
Conclusions: The group of children who followed physician advised treatment for primary nocturnal enuresis showed significantly earlier remission of primary nocturnal enuresis than children who followed the parent choice treatment (25th percentile 2 vs 10 weeks).

This was an interesting comparison. It would also be interesting to know if diary completion was significantly difference between the two groups (see study immediately above). Were the physicians more invested and demanding of compliance for their own treatment plan versus one chosen by their patient? RWC.

*****************************

Overactive bladder in children. Part 2: Management

Franco,I. Pediat Urol Associates PC, 19 Bradhurst Ave,Suite 2575, Hawthorne, NY 10532 USA

Search Terms: bladder, constipation, overactive bladder, enuresis, encopresis

Purpose: The management of pediatric overactive bladder syndrome has relied primarily on anticholinergics and a bowel regimen. In many cases the results have been ineffective and they have frustrated many parents, patients and practitioners. We explored other treatment modalities that may be more effective than the regimens that we currently use. A thorough understanding of the causes of overactive bladder syndrome are essential to help us find the appropriate treatment for individuals.
Materials and Methods: We looked at numerous treatment modalities that are being used for overactive bladder syndrome and matched them to a specific cause of overactive bladder syndrome that would be best suited to treat the problem. The treatment of constipation as a mainstay for pediatric overactive bladder syndrome was explored as well as its different options. New treatment modalities involving electrical stimulation were explored as well as botulinum A toxin injections.
Results: The effectiveness of each treatment was assessed, thereby providing the reader with a foundation for choosing the appropriate treatment.
Conclusions: The treatment of pediatric overactive bladder syndrome is not as simple as placing children on anticholinergics and, if there is no response, simply saying that they will outgrow it. The causes of overactive bladder syndrome are multifactorial and a better understanding of the pathophysiology will allow us to target treatments appropriately for individuals.

I find it important to closely question parents on any signs of constipation with daytime bladder accidents and then treat for it if there are any signs of encopresis--many parents tend to just dismiss "tire tracks" or smears as failing to wipe carefully after a BM. Otherwise I would refer to a urologist for diagnosis and treatment. This study is a good heads up for closely examining any daytime bladder issues.

*****************************

Exploring potential mechanisms in alarm treatment for primary nocturnal enuresis

Butler,R.J.*, Holland,P., Gasson,S., Norfolk,S., Houghton,L., & Penney,M. Leeds Prim Care Trust, Child & Adolescent Mental Hlth Serv, Dept Clin Psychol, Lea House, Gateway,Whackhouse Lane,Yeadon, Leeds LS19 7XY, W Yorkshire, England

Search Terms: enuresis, alarm, desmopressin, osmality.

Objective. In the treatment of childhood nocturnal enuresis the enuresis alarm has consistently proved effective. However, the various proposals advanced to explain its therapeutic mechanism generally lack empirical support. In this clinical trial we investigated the hypothesis that the alarm promotes reduced nocturnal urine production through increased urine concentration (enabling the child to sleep through the night).
Material and methods. Measurements of urinary vasopressin and osmolality were made pre- and post-alarm treatment in a group (n = 12) of outpatient children (aged 7-12 years) with severe (more than four times a week) nocturnal enuresis.
Results. Of the study group, 75% achieved the success criteria, with 89% predominantly sleeping through the night on dry nights, confirming that arousability is unlikely to be the principal mode of action. All those becoming dry showed an increase in urine concentration post-treatment. For half this was associated with an increase in post-treatment vasopressin whilst for the rest, although increases in osmolality were observed, there was no associated increase in vasopressin.
Conclusions. Although based on a small sample this study offers an insight into possible therapeutic mechanisms of an enuresis alarm. It suggests that most children who become dry sleep through the night and that increased nocturnal urine concentration (and thus reduced urine volume) is likely to be the means whereby this is achieved. Furthermore, the study suggests two possible mechanisms whereby nocturnal urine concentration is achieved: either increased production of vasopressin or enhanced water transport across the urothelium.

This has been a long anticipated and hoped for study by yours truly. I never had the resources to measure morning osmality during the course of a bedwetting alarm study and have long thought that increased osmality could well be an effect of the alarm treatment. An increase in bladder capacity has long been demonstrated in my research and that of others over the course of treatment, but that increased volume never appeared to be anywhere near normal daytime voiding volumes. Osmality had never been assessed to my knowledge. I speculated that an internal biofeedback mediated process for added concentration could result from nighttime holding triggered by the alarm. RWC.

*****************************

Jan/Feb, 2008 JOURNAL OF PAEDIATRICS AND CHILD HEALTH (v44, 1-2), Pp. 19-27. Posted on 01/19/2008.

The frequency of constipation in children with nocturnal enuresis: a comparison with parental reporting.

McGrath,K.H., Caldwell,P.H.Y.*, Jones,M.P. Univ Sydney, Childrens Hosp, Ctr Kidney Res, NHMRC Ctr Clin Res Excellence Renal Med, Locked bag 4001, Westmead, NSW 2145, Australia

Search Terms: constipation, enuresis, encopresis

Aim: To identify the prevalence of constipation in children with nocturnal enuresis presenting to a tertiary paediatric outpatient service and to assess parental and clinician recognition of constipation.
Methods: A prospective cross-sectional study of children with nocturnal enuresis at presentation to a continence service. Data relating to the child's bowel habits, pattern of enuresis and other history items were obtained from parental questionnaires and paediatrician assessments. Presence and severity of constipation was assessed independently by parents and clinicians. Kappa was used to compare agreement between parental reporting and clinician assessment of constipation.
Results: Of the 277 participants aged 4.8-17.5 years (median 8.6 years), 36.1% (n = 95) were identified as constipated by the clinician-based scoring method ('Constipation Score') compared with 14.1% from parental reporting (Kappa = 0.155, P = 0.003). Despite the poor overall recognition of constipation by parents, parental and clinician assessment of frequency of bowel motions (Kappa = 0.804) and soiling (Kappa = 0.384) were similar. Major factors influencing parental reporting of constipation were frequency of bowel motions and soiling with less emphasis on straining and stool consistency.
Conclusions: Prevalence of constipation was high among children with nocturnal enuresis as assessed by clinicians despite poor identification by parents. This may limit optimal diagnosis and management.

The evidence is clearly mounting of an association between enuresis and encopresis and this study documents a failure of parental or professional insight into this connection. This finding accords strongly with my clinical impressions where further questioning elicits surprise by parents that occasional smears and “tire tracks” in undies may be an issue for their child’s bedwetting. They had largely dismissed such signs as irrelevant and never had an idea of their possible indications for the presence of constipation and it's possible contribution to bedwetting. My current edition of the Dry Bed Manual makes very strong statements not to proceed with treatment unless the encopresis or constipation is managed as a first priority. RWC.

*****************************

Toilet training of healthy young toddlers: A randomized trial between a daytime wetting alarm and timed potty training

Vermandel,A., Weyler,J., De Wachter,S., & Wyndaele,J.J.* Univ Antwerp, Dept Urol, Wilrijkstr 10, B-2650 Edegem, Belgium

Search Terms: alarm, daytime, enuresis

Objective: Toilet training (TT) is important for every child, but there is no agreement on what is the best training method. We evaluated in a randomized way the comprehensive use of a daytime wetting alarm at home for 5 days in healthy children and compared it with timed potty training.
Methods: Thirty-nine children, between 20 and 36 months of age, were randomized to wetting alarm diaper training (WAD-T; n = 20) or timed potty training (TP-7; n = 19). Toilet behavior was observed by parents and independent observers before, at the end, and after 2 weeks of training. Late evaluation at 1 month was done by telephone.
Results: The WAD-T group did significantly better than the UP-T group at the end training (p =.041), at 14 days (p = .027), and 1 month after training (p = .027). Independent bladder control was achieved in 88.9% of the WAD-T group.
Conclusions: The WAD-T method is a structured, child-friendly, highly effective option for TT young healthy children. it offers the parents clear guidelines, a limited time needed to complete TT, a high success rate, and minor emotional conflicts. Results must now be confirmed in a larger sample size.

The bedwetting alarm has been show to be effective for nocturnal enuresis over the years by a variety of comparison treatment studies, including my own. The application to daytime wetting is quite innovative and looks to be very promising for young children. I should think that any indications of encopresis should be ruled out first. DrC.

*****************************

The Efficacy of a Wetting Alarm Diaper for Toilet Training of Young Healthy Children in a Day-Care Center: A Randomized Control Trial

Vermandel,A., Van Kampen,M., De Wachter,S., Weyler,J., & Wyndaele,J.J.*
Univ Antwerp, Dept Urol, Fac Med, Wilrijkstr 10, B-2650, Edegem, Belgium

Search Terms: enuresis, alarm, daytime enuresis, diurnal enuresis, bedwetting

Aims: To evaluate, in a randomized controlled way, the use of a daytime wetting alarm in a day-care center during three consecutive weeks in healthy children.
Methods: Thirty-nine healthy young children, between 18 and 30 months old, were selected at random for a wetting alarm diaper training (n = 27) or control wearing a placebo alarm (n = 12). Toilet behavior was observed during a period of 10 hr by independent observers before, at the end of, and 2 weeks after training. Children were defined as completing daytime toilet training when the child wore undergarments, showed awareness of a need to void, initiated the toileting without prompts or reminder from the trainer and had maximum one leakage accident per day.
Results: Children in the wetting alarm diaper training group achieved independent bladder control in 51.9% and did significantly better than in the control group (8.3%) (P = 0.013). The results were sustained during the following 14 days (P = 0.013).
Conclusion: The wetting alarm diaper training is an effective option for toilet training young healthy children in a day-care center. It offers day-care providers clear guidelines and limits the time to complete toilet training in many children without putting too much burden on the child and the day-care center activities.

The efficacy of the bedwetting alarm has been well-documented in the literature which also included a placebo alarm device treatment comparison which I reported on long ago in several scientific reports.. It only makes sense that this would work for the daytime as well and now that more miniaturized devices are available it is more practical for application. The use in a day-care center is of particular note and should be very helpful for parents. DrC.

*****************************

Month?, 2009, SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY, (v43,5), Pp. 365-368. Reboxetine in therapy-resistant enuresis: A retrospective evaluation. Added 12/07/2009.

Lundmark,E.*, & Neveus,T. Uppsala Univ, Childrens Hosp, Nephrol Unit, SE-75185 Uppsala, Sweden
Search Terms: Enuresis, Imipramine, Reboxetine.

Objective. Imipramine is the only evidence-based treatment available for enuretic children resistant to standard therapy. The drug's antienuretic effect is probably due to noradrenergic facilitation. The drug is, however, potentially cardiotoxic. In this study, the non-cardiotoxic noradrenergic antidepressant reboxetine was tested as an alternative to imipramine.
Patients and methods. 61 patients, aged 7-19 years, with enuresis-resistant to desmopressin, the alarm, urotherapy and anticholinergics, were given 4-8 mg reboxetine at bedtime, if necessary combined with desmopressin.
Results. 32 patients became dry on reboxetine treatment, although 21 of them required combination treatment with desmopressin to achieve this. Eighteen children did not respond and eight children discontinued because of side-effects before treatment could be evaluated. No serious adverse events occurred.
Conclusions. These results need to be confirmed with randomized controlled studies, but indicate that reboxetine will become a safe and efficient treatment alternative for enuretic children resistant to standard therapy.

This article is important in coming up with an alternative to the use of imipramine, an old trycyclic antidepressant, because of its cardiotoxic effects which has caused deaths primarily in children under 2 years of age residing in chaotic households. DrC.

*****************************

Feb, 2010 Journal of Urology. Evaluation of and Treatment for Monosymptomatic Enuresis: A Standardization Document From the International Children's Continence Society. (v183,2), Pp. 441-447. Added 02/02/2010.

Neveus,T.,* Eggert,P., Evans,J., Macedo,A., Rittig,S., Tekgul,S., Walle,J.V., Yeung,C.K., & Robson,L. Uppsala Univ, Childrens Hosp, Nephrol Unit, S-75185

Search Terms: enuresis, alarm, ADH, imipramine.

Purpose: We provide updated, clinically useful recommendations for treating children with monosymptomatic nocturnal enuresis.
Materials and Methods: Evidence was gathered from the literature and experience was gathered from the authors with priority given to evidence when present. The draft document was circulated among all members of the International Children's Continence Society as well as other relevant expert associations before completion.
Results: Available evidence suggests that children with monosymptomatic nocturnal enuresis could primarily be treated by a primary care physician or an adequately educated nurse. The mainstays of primary evaluation are a proper history and a voiding chart. The mainstays of primary therapy are bladder advice, the enuresis alarm and/or desmopressin. Therapy resistant cases should be handled by a specialist doctor. Among the recommended second line therapies are anticholinergics and in select cases imipramine.
Conclusions: Enuresis in a child older than 5 years is not a trivial condition, and needs proper evaluation and treatment. This requires time but usually does not demand costly or invasive procedures.

I very much appreciated the observation that enuresis is “not a trivial condition….” coming out of an international consensus report. Note too that the enuresis alarm is listed among the mainstays of primary therapy. From my experience this readiness to recommend the enuresis alarm on a more equal par with medication is much more likely in other countries. DrC.

*****************************

How to toilet train healthy children? A review of the literature

Vermandel,A., Van Kampen,M., Van Gorp,C., & Wyndaele,J.J.* Univ Antwerp, Dept Urol, Wilrijkstr 10, B-2650 Edegem, Belgium

Search Terms: Toilet training; diapers, encopresis, enuresis.

Aims: To review the literature on toilet training (TT) in healthy children.
Methods: Through an extended literature search, all data on developmental signs of readiness for TT, TT methods, definitions of being toilet trained, TT problems, and predictive factors for success were reviewed.
Results: Specific studies on this topic are few. Two main methods for TT have been described so far in the last decades: the gradual child-oriented training and the structured, endpoint-oriented training. In the former method parents mainly respond to the child's signals of toileting "readiness". The latter method consists of actively teaching several independent toileting behaviors. Data are too few to be able to compare the methods. Literature does not give a consensus about the optimal age for starting nor on the expected mean age of completing TT. Recent studies show most children to start training between 24 and 36 months of age with a current trend toward a later completion than in previous generations. The consequence of this can be stress for the parents and more use of diapers, with its negative effect on the environment.
Conclusion: There are as yet little data to be found on this important topic, only few studies have been published in peer-reviewed journals. Standardization of terminology and critical evaluation of the described techniques in large sample sizes is needed. With this approach, general. principles of training, evidence based and easy to use in the majority of children, may become available to parents.

The authors' classifications of two main methods for toilet training is reasonable. However, the first method of "readiness" has been challenged by adherents of infant potty training or "elimative communication"which has been noted in the foreword to my Clean Kid Manual. The review and observations do show a lack of research in this area, unfortuanately economic forces and backing for research just does not exist in the main for behavioral interventions over and against the interests of diaper manufacturers and pharmaceutical companies. The delay in training in my view actually fosters prolonged incontinence and dependence on diapers and desperate parents later seeking medications. RWC.

*****************************

A Prospective Study of Age at Initiation of Toilet Training and Subsequent Daytime Bladder Control in School-Age Children

Joinson,C.*, Heron,J., Von Gontard,A., Butler,U., Emond,A., & Golding,J. Univ Bristol, Dept Community Based Med, Cotham House,Cotham Hall, Bristol BS6 6JL, Avon, England

Search Terms: Toilet training, enuresis, bladder

Objective: This study investigates the association between age at initiation of toilet training and development of daytime bladder control. The main aim is to examine whether initiation of toilet training after 24 months is associated with increased odds of daytime wetting in school-age children.
Method: The study is based on more than 8000 children, aged 4.5 to 9 years, from a UK birth cohort-The Avon Longitudinal Study of Parents and Children. Using multinomial logistic regression, the analysis examined the association between age at initiation of toilet training and 4 previously established trajectory groups representing different patterns of development of daytime bladder control (described as "normative development," "delayed acquisition," "persistent daytime wetting," and "relapse").
Results: Compared with children whose toilet training was initiated between 15 and 24 months, initiation of toilet training after 24 months was associated with higher odds of membership to the trajectory groups representing persistent daytime wetting (1.52 [1.23-1.88], p < .001), delayed acquisition of daytime bladder control (1.47 [1.29-1.66], p < .001), or relapse in daytime wetting (1.52 [1.28-1.80], p < .001). Adjustment for confounding variables, including sex, developmental delay, difficult temperament, and the mother's self-reported depression, did not alter the main conclusions.
Conclusion: There is evidence that initiating toilet training after 24 months is associated with problems attaining and maintaining bladder control. it is possible that delaying the onset of toilet training until after 2 years prolongs the exposure time to potential stressors that could interfere with the acquisition of bladder control, resulting in delays in achieving continence and susceptibility to relapses in daytime wetting.

I have long maintained and have read other literature suggesting that delays in toilet training actually results in subsequent difficulties for the onset of encopresis. It is interesting to see this confirmed in a larger scale study, but with enuresis instead of encopresis. DrC
*****************************

Check back for monthly and occasional weekly updates. I may miss some relevant publications out there. I would deeply appreciate your calling my attention to any that you come across that you believe to be uniquely relevant. If you are an active investigator/author, please forward a preprint or reprint to me. Also, your comments, speculations, and suggestions would be very much appreciated. This includes you parents who have gotten this far! RWC