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 06/22/2009 have been reviewed for significant abstracts to post. The last posting(s) was made on 05/14/2009. I recently deleted all abstracts from 2004 and selected out some later ones in the Encopresis and Enuresis sections. This was truly painful, but the list was just getting too long.

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.

The antegrade continence enema successfully treats idiopathic slow-transit constipation

King,S.K., Sutcliffe,J.R., Southwell,B.R., Chait,P.G., Hutson,J.M.* Royal Childrens Hosp, Dept Gen Surg, Parkville, Vic 3052, Australia

Search Terms: slow-transit, constipation, low motility, malone, antegrade continence enema (ACE), encopresis, cecostomy, appendicostomy.

Background: Antegrade continence enemas (ACE) are successful for constipation and/or fecal incontinence caused by anorectal malformations or spina bifida but have been thought to be less successful in the treatment for patients with colonic dysmotility. We studied the long-term efficacy of ACE in a large group of patients with idiopathic slow-transit constipation (STC).
Methods: We identified 56 children with an appendicostomy for ACE with radiologically proven STC. An independent investigator (SKK) performed confidential telephone interviews.
Results: We assessed 42 of 56 children (31 boys) of mean age 13.1 years (range, 6.9-25). Mean follow-up was at 48 months (range, 3-118). Mean symptom duration before appendicostomy was 7.5 years (range, 1.4-17.4). Indications for appendicostomy were soiling (29/42), inadequate stool evacuation (7/42), and recurrent hospital admissions for nasogastric washouts (6/42). Both quality of life (Templeton quality of life [P <.0001]) and continence (modified Holschneider continence score [P <.0001]) improved with ACE. Soiling frequency decreased in 32 of 42 (11/32 completely continent). Thirty-seven of 42 children had reduced abdominal pain severity (P <.0001) and frequency (P <.0001). Complications included granulation tissue (33/42), stomal infection (18/42), and washout leakage (16/42). Fifteen of 42 children ceased using the appendicostomy (7/15 symptoms resolved). Thirty-five of 42 families felt that their aspirations had been met.
Conclusions: Antegrade continence enemas were successful in 34 (81%) of 42 children with STC, contradicting views that ACE are less effective in patients with colonic dystomility. (c) 2005 Elsevier Inc. All rights reserved.

This group or researchers emphasize low motility as central for many cases of encopresis. Most authorities believe encopresis is due to stool retention or holding. There is a case to be made for encopresis being either low motility dominant or holding dominant or a mixture of the two. The surgical ACE procedure appears to be the treatment of choice for low transit disorders. I hardly view the use of suppositories and enemas in a programmed way to end encopresis as more drastic than this surgical approach! My protocol should used first and if not successful a specific low motility study should certainly be done before going to the ACE procedure. DrC.

Treatment of childhood constipation by primary care physicians: Efficacy and predictors of outcome.

Borowitz,S.M.*, Cox,D.J., Kovatchev,B., Ritterband,L.M.,Sheen,J. Univ Virginia, Div Pediat Gastroenterol & Nutr, Dept. Pediat, Box 800386 HSC, Charlottesville, VA 22908 USA

Objective. Childhood constipation accounts for 3% of visits to general pediatric clinics and as many as 30% of visits to pediatric gastroenterologists. The majority of children who experience constipation and whose caregivers seek medical care are seen by primary care physicians such as pediatricians or family physicians. Little is known about how primary care physicians treat childhood constipation or the success of their treatments. With this study, we prospectively examined which treatments primary care physicians prescribe to children who present for the first time with constipation and how effective those treatments are.
Methods. A total of 119 children who were between 2 and 7 years of age ( mean: 44.1 +/- 13.6 months) and presented to 26 different primary care physicians ( 15 pediatricians and 11 family physicians) for the treatment of constipation for the first time participated in this study. Parents completed daily diaries of their child's bowel habits for 2 weeks before starting treatment recommended by their primary care physician and again 2 months after treatment. The prescribed treatment was identified by reviewing office records of the treating physicians.
Results. After 2 months of treatment, 44 (37%) of 119 children remained constipated. In the majority (87%) of cases, physicians prescribed some form of laxative or stool softener. The most commonly prescribed laxatives were magnesium hydroxide (77%), senna syrup (23%), mineral oil (8%), and lactulose ( 8%). In nearly all cases, a specific fixed dose of laxative was recommended; in only 5% of cases were parents instructed clearly to adjust the dose of laxative up or down to get the desired effect. In approximately half of the cases, physicians recommended some sort of dietary intervention. Some form of behavioral intervention was mentioned in the office records of approximately one third of cases; however, in most cases, little detail was provided. In 45% of cases, physicians prescribed disimpaction using oral cathartics, enemas, or suppositories followed by daily laxatives. In 35% of cases, physicians prescribed daily laxatives without any disimpaction procedure. In the remainder, physicians prescribed only dietary changes ( 5%), the use of intermittent laxatives (9%), or no therapy (7%). Treatment success corresponded to how aggressively the child was treated. Specifically, children who underwent some form of colonic evacuation followed by daily laxative therapy were more likely to have responded to treatment than were those who were treated less aggressively.
Conclusion. Primary care physicians tend to undertreat childhood constipation. After 2 months of treatment, nearly 40% of constipated children remain symptomatic. (C) 2005 Elsevier Inc. All rights reserved.

No Comment! RWC

Double-blind randomized evaluation of clinical and biological tolerance of polyethylene glycol 4000 versus lactulose in constipated children

Dupont,C.AU* - Leluyer,B.AU - Maamri,N.AU - Morali,A.AU - Joye,J.P.AU - Fiorini,J.M.AU - Abdelatif,A.AU - Baranes,C.AU - Benoit,S.AU - Benssoussan,A.AU - oussioux,J.L.AU - Boyer,P.AU - Brunet,E.AU - Delorme,J.AU - Francois-Cecchin,S.AU - ottrand,F.AU - Grassart,M.AU - Hadji,S.AU - Kalidjian,A.AU - Languepin,J.AU - Leissler,C.AU - Lejay,D.AU - Livon,D.AU - Lopez,J.P.AU - Mougenot,J.F.AU - Risse,J.C.AU - Rizk,C.AU - Roumaneix,D.AU - Schirrer,J.AU - Thoron,B.AU - Kalach,N. Hop St Vincent de Paul, Serv Neonatol, 74-82,Ave Denfert Rochereau, F-75674 Paris, France

Objectives: To assess the safety of a polyethylene glycol (PEG) 4000 laxative without additional salts in pediatric patients.
Study Design: This was a 3-month multicenter, randomized, double-blind, double-dummy, lactulose-control led, parallel study enrolling 96 ambulatory constipated children aged 6 months to 3 years, treated daily with 4-8 g PEG or 3.33 g-6.66 g lactulose. Total protein, albumin, iron, electrolytes, and vitamins B9 (folates), A and D (250HD(3)) were measured in blood before and after treatment (day 84) in a central laboratory.
Results: The percentage of children with at least one value out of normal range at day 84 with respect to baseline status (with or without at least one value out of normal range), i.e. the primary endpoint, was 87% and 90% in the PEG and lactulose groups, respectively, without any difference between groups. The whole blood parameters showed no qualitative or quantitative treatment-related changes. Vitamin A values were above normal range in 56% and 41% of children at baseline versus 33% and 36% at day 84 in the PEG and lactulose groups, respectively. Iron values were similarly under normal range in 47% and 5 1% at baseline versus 42% and 51% at day 84. Clinical tolerance was similar for both treatments except for vomiting and flatulence, which were significantly higher with lactulose. Significantly higher improvements were evidenced with PEG regarding stool consistency, appetite, fecaloma and use of additional laxatives.
Conclusion: This 3-month study in 96 constipated children aged 6 months to 3 years confirms the long-term tolerance of PEG 4000 in pediatrics and indicates a PEG efficacy similar to or greater than that of lactulose.

This is a significant study and appears to support the use of Miralax for safety, efficacy, and fewer side-effects over Lactulose. RWC

Using the Internet to provide information prescriptions

Ritterband,L.M.*, Borowitz,S., Cox,D.J., Kovatchev,B., Walker,L.S., Lucas,V., & Sutphen,J. Univ Virginia Hlth Syst, Dept Psychiat Med, Ctr Behav, Med Res, POB 800223, Charlottesville, VA 22908 USA

Introduction. An information prescription is the provision of specific information to a patient on how to help manage a health problem. The Internet is being used increasingly as a source for information prescriptions, with clinicians directing patients to specific Web sites. As with any health care intervention, patients' lack of compliance is a barrier to the effectiveness of Web-based information prescriptions (WebIPs). WebIPs cannot be helpful if patients do not review the information prescribed for them.
Objective. The main objective of this study was to quantify the percentage of families who visit a Web site that was specifically prescribed by their physician. In addition, the use of an e-mail reminder was used to determine if it increases the likelihood that families will visit the prescribed Web site. Finally, barriers to accessing the prescribed Web site were identified.
Methods. Children were eligible if they presented to the pediatric gastroenterology clinic with chronic constipation and/or encopresis and their family had an active e-mail account and access to the Internet in their home. During their clinic visit, physicians instructed families to visit a Web site that provided educational information pertinent to their child's problem. Families were given a form with the Web-site address and a log-in identification number. Two days after their clinic visit, half of the families received an e-mail reminding them to visit the Web site. Families were contacted 1 week after their clinic visit to identify barriers to accessing the Web site.
Results. Eighty-three families participated in the study. Of the 83 families, 54 (65%) visited the prescribed Web site within 1 week of their clinic visit. Families who received e-mail reminders were significantly more likely to visit the Web site than families who did not receive an e-mail reminder (77% vs 53%). This difference could not be explained by the type or speed of Internet connection or how frequently they accessed the Internet or e-mail. The most common reasons that families cited for not accessing the Web site were "I forgot" and "I didn't have time." Few families cited technical reasons for not accessing the Web site.
Conclusions. Almost two thirds of the families given a WebIP logged on to the prescribed Web site. The probability that families would access the site was increased by 45% with an e-mail reminder. Clearly, e-mail prompts improve compliance to WebIPs. As content and treatment programs continue to proliferate on the Web, it is important to identify barriers and solutions to them to improve overall compliance.

This University of Virginia group is leading the way in researching the effects of internet-based interventions for encopresis and other problems. I stay in regular touch with them and have recently opened my own parent's forum for parent's who purchase the Clean Kid Manual. RWC

Mental and somatic health in a non-clinical sample 10 years after a diagnosis of encopresis

Hulten,I., Jonsson,J., Jonsson,C.O., Address not available.

The aim of this study was to assess the relation between the diagnosis of encopresis at 8 and 10 years of age, and mental and somatic health 10 years later. The importance of type of encopresis (primary or secondary) at 8 years was also studied. Subjects were a non-clinical encopretic sample (N=73) and control subjects (N=75) [2]. Seven assessment variables from conscription surveys provided information about mental and somatic health status at 18 years of age. Former encopretics (n=66) did not differ significantly from the controls (n=67) at 18 years of age, although there were consistent, small negative differences. The boys who at 10 years of age had still been encopretic did not differ significantly at 18 years of age from the boys who at 10 years had recovered from encopresis, and the signs indicating the small differences varied. For former primary and secondary encopretic boys, there were two significant differences, the men in the secondary group being more often exempted from conscription than the primary group and the control cases. The results indicate that boys with non-clinical encopresis show only small, if any, mental and somatic disturbances at the beginning of adulthood. Comprehensive investigations of encopretic patients are recommended as important clinical problems, in addition to encopresis, might be present.

It was relatively resassuring to see no effects of encopresis at 18 y/o.

Cecostomy in children with defecation disorders.

Mousa,H.M.*, Van Den Berg,M.M., Caniano,D.A., Hogan,M., Di Lorenzo,C., Hayes,J.
Childrens Hosp, Div Pediat Gastroenterol, 700 Childrens Dr,ED 426, Columbus, OH 43205 English

Search Terms: Antegrade enema, cecostomy, encopresis, fecal incontinence, Hirschsprung’s disease, imperforate anus, tethered spinal cord

Administration of antegrade enemas through a cecostomy is a therapeutic option for children with severe defecation disorders. The purpose of this study is to report our 4-year experience with the cecostomy procedure in 31 children with functional constipation (n =9), Hirschsprung's disease (n = 2), imperforate anus (n = 5), spinal abnormalities (n = 8), and imperforate anus in combination with tethered spinal cord (n = 7). Data regarding complications, antegrade enemas used, symptoms, and quality of life were retrospectively obtained. Placement of cecostomy tubes was successful in 30 of 31 patients. Soiling episodes decreased significantly in children with functional constipation (P = 0.01), imperforate anus (P < 0.01), and spinal abnormalities (P = 0.04). Quality of life improved in patients with functional constipation and imperforate anus. No difference in complications was found between percutaneous and surgical placement. Use of antegrade enemas via cecostomy improved symptoms and quality of life in children with a variety of defecation disorders.

I found it interesting that a significant sub-sample of these surgical cases was for encopresis, a functional disorder. Elsewhere it has been reported that when the cecostomy is closed the children can continue on a much improved basis. DrC.

Effect of micturition on the external anal sphincter: Identification of the urethro-anal reflex

Shafik,A., El Sibai,F., Shafik,I., & Shafik,A.A. No address or source given.

Search terms: Enuresis, Encopresis, EMG, micturition, defecation, sphincter, EAS.

Background/Objective: A study on the response of the external anal sphincter (EAS) to the passage of urine through the urethra during micturition could not be found in the literature. We investigated the hypothesis that urine passage through the urethra effects EAS contraction to guard against possible flatus or stool leakage during micturition.
Methods: The study was performed in 23 healthy volunteers (age, 38.6 +/- 10.8 [SD] years; 14 men and 9 women). The EAS electromyogram (EMG) was performed during micturition by surface electrodes applied to the EAS. Also, the EAS EMG response to urethral stimulation by a catheter-mounted electrode was registered. The test was repeated after individual anesthetization of the EAS and urethra.
Results: The EAS EMG recorded a significant increase (P < 0.01) during micturition and on urethral stimulation at the bladder neck. Stimulation of the prostatic, membranous, or penile urethra produced no significant change in the EAS EMG. Urethral stimulation after individual EAS and urethral anesthetization did not cause any changes in the EAS EMG.
Conclusions: Urine passing through the urethra or urethral stimulation at the vesical neck produced an increase in the EAS EMG, which presumably denotes EAS contraction, which seems to guard against flatus or fecal leakage during micturition. EAS contraction on urethral stimulation is suggested to be mediated through a urethro-anal reflex. Further studies on this issue may potentially prove the diagnostic significance of this reflex in micturition and defecation disorders.

This finding identifies a new reflex arc between bowel and bladder sphincter function. This is very interesting in view of my clinical obversations and some limited earlier reports that there is some association between disorders of bladder and bowel control. A recent epidemiological study in Japan is reported by Kajiwara below toward the end of the ENURESIS section which presented findings on the concurrence of diurnal enuresis, nocturnal enuresis and encopresis and its developmental course. DrC.

New insight into rectal function in pediatric defecation disorders: Disturbed rectal compliance is an essential mechanism in pediatric constipation

Voskuijl,W.P.,* Van Ginkel,R., Benninga,M.A., Hart,G.A., Taminiau,J.A.J.M., & Boeckxstaens, G.E.Univ Amsterdam, Acad Med Ctr, Dept Pediat Gastroenterol & Nutr, Dept Biostat & Gastroenterol, Meibergdreef 9, NL-1105 AZ Amsterdam, Netherlands

Search Terms: constipation, megacolon, manometry, encopresis

Objective: To evaluate rectal sensitivity inpatients with pediatric constipation (PC) and nonretentive fecal soiling (FNRFS) using pressure-controlled distention (barostat).
Study design: Thresholds for rectal sensitivity (first sensation, urge to defecate, and pain), and rectal compliance were determined using a barostat.
Results: A total of 69 patients with PC (50 males; mean age, 10.9 +/- 2.2 years) and 19 patients with FNRFS (15 males; mean age, 10.0 +/- 1.9 years) were compared with 22 healthy volunteers (HVs) (11 males; mean age, 12.7 +/- 2.6 years). Sensitivity thresholds were not significantly different among the 3 groups. Rectal compliance was increased in 58% of the patients with PC (P < .0001 vs HVs). Rectal compliance did not differ between patients with FNRFS and HVs. Children with PC with abnormal rectal function required significantly larger rectal volumes at urge to defecate.
Conclusions: Increased compliance is the most prominent feature in patients with PC. Because of higher compliance in these children, larger stool volumes are required to reach the intrarectal pressure of the urge to defecate. Children with FNRFS have normal rectal function.

My clinical observations accord well with this "new insight" . Occasionally, I have to recommend to parents of children to use my voiding protocol on an every other day basis. This is because in my program, if the children do not transition properly to going on their own after daily trials on my protocol it is evident that there is not a sufficient "natural" urge stimulus available for them to respond to. I had reasoned some time ago that the urge sensations should be more salient with a two day accumulation of stool and that, accordingly, the children are more likely to "sense" the build up so that there is a potential Conditioned Stimulus available for being properly conditioned to release stool as occurs with the suppository or enema in my program which serve as Unconditioned Stimuli for a voiding reflex. The children in a sense tune up to their natural urge sensations by using the urge sensations associated with the suppositories or, if necessary, an enema which almost surely produces the voiding reflex (typically overcoming anismus which becomes less over trials as the child becomes less habitually defensive). As the Pavlovian process takes over the gentler urge of the glycerin suppository becomes adequate and then the childs natural urges to accumulating stool becomes sufficient. This then can proceed to daily evacuations eventually as the enlarged colon begins to shrink with more regular voidings and a lesser accumulation may become a sufficient trigger. Dr Whitehead with Dr. Marvin Schuster sometime ago noted the importance of sensory awareness for effective biofeedback interventions. RWC

Longitudinal follow-up of children with functional nonretentive fecal incontinence

Voskuijl,W.P.,* Reitsma,J.B., van Ginkel,R., Buller,H.A., Taminiau,J.A.J.M., & Benninga,M.A. Univ Amsterdam, Acad Med Ctr, Dept Pediat Gastroenterol & Nutr, Meibergdreef 9,Room C2-312, NL-1105 AZ Amsterdam, Netherlands

Search Terms: CONSTIPATION, Encopresis, Non-retentive form

Background & Aims: Functional nonretentive fecal incontinence (FNRFI), incontinence in the absence of signs of fecal retention, is a frustrating phenomenon in children. No data on long-term outcome are available. The aim was to investigate the long-term outcome of FNRFI patients after intensive medical treatment.
Methods: Between 1990 and 1999, 119 patients (96 boys) with FNRFI were enrolled in 2 prospective, randomized trials investigating the effect of biofeedback training and/or laxative treatment. Follow-up (FU) was performed at 6 months, 1 year, and thereafter annually until September 2004. A standardized questionnaire was used to evaluate symptoms. Success was defined as a fecal incontinence frequency < 1 per 2 weeks.
Results: Median age (25th-75th percentiles) was 9.2 years (range, 7.9-11.6 years). A 90% FU was achieved at all stages of the study. After 2 years of intensive therapy, 33 of 112 (29.5%) patients were successfully treated. The cumulative success percentage after 7 years of FU was 80%. At the biologic ages of 12 and 18 years, 49.4% (40/81) and 15.5% (9/58), respectively, of the patients still had fecal incontinence. Duration of fecal incontinence, with 4 years of age as the starting age for fecal incontinence (when a child should be toilet trained), was not related to successful outcome or relapse. Relapse occurred in 37% of patients.
Conclusions: Only 29% of the patients with FNRFI were successfully treated after 2 years of intensive treatment. Despite recovery in the majority of patients beyond puberty, at age 18 years, 15% continued to have fecal incontinence.

This is a very important study which probably could not be done in our country with our fragmented and proprietary health care systems with less centralized record keeping, a highly mobile population, two working parents, single working parents, market beseiged individuals guarding their privacy, and the longer distances involved. I've had some limited success with email follow ups with parents, but have not analyzed that data as yet. Also, this study is important because the population of concern here has appeared to be very resistant to effective interventions. I am wondering if my protocol, which is so much more definitive in terms of a tight, well-timed conditioning process to a particular time of day, might not be more successful than all of the standard operant behavioral and other approaches that have been tried. I don't appear to get enough of this variety of encopresis to form an impression. The children coming in to my site are likely somewhat self-selected by reading the materials at my website that focus much more extensively on the retentive form of encopresis which is addressed by the Clean Kid Manual-III. RWC.

February, 2006 NATURE CLINICAL PRACTICE GASTROENTEROLOGY & HEPATOLOGY (v3,2), Pp. 90-100. Posted on 02/27/2006.

Pathophysiology, diagnosis and current management of chronic constipation

A Wald, Univ Pittsburgh, Med Ctr, PUH, Mezzanine Level,C Wing,200 Lothrop St, Pittsburgh, PA 15213 USA

Search Terms: Constipation, Encopresis, Low Motility, Slow Transit, laxatives, megacolon

Chronic constipation is prevalent in Western countries and is a complaint that is commonly seen in clinical practice. Only a relatively small percentage of constipated patients seek medical evaluation and most can be managed satisfactorily with first-line, conservative therapy. In patients with severe, refractory constipation, additional studies of colonic and anorectal function
have clinical utility, as such patients are candidates for therapies not given to most constipated patients. This article reviews the modern principles and therapies used to manage chronic constipation of varying severities.

This review is included for its likely value as a comprehensive review of methods for treating Slow Transit disorders. It appears that he is emphasizing "first-line, conservative" therapies. I have reported on more esoteric research methods higher up on this page. RWC.

The relevance of fecal soiling as an indicator of child sexual abuse: A preliminary analysis

Mellon,M.W.*, Whiteside,S.P., & Friedrich,W.N. Mayo Clin, Dept Psychiat & Psychol, 200 1st St SW, Rochester, MN 55905 USA

Search Terms: abuse, encopresis, sexual abuse, constipation, chronic constipation

Encopresis is typically characterized as resulting from chronic constipation with overflow soiling but has been portrayed as an indicator of sexual abuse. The predictive utility of fecal soiling as an indicator of sexual abuse status was examined. In a retrospective analysis of three comparison groups of 4-12 year olds, we studied 466 children documented and treated for sexual abuse; 429 psychiatrically referred children with externalizing problems and 641 normative children recruited from the community, with the latter two samples having abuse ruled out. Standardized parent report measures identified soiling status and sexual acting out behaviors. Multiple regression analysis was used to predict abuse status in each group. Reported soiling rates were 10.3% (abuse), 10.5% (psychiatric), and 2% (normative), respectively. The soiling rate in the abused group differed significantly from that of the normative group, but not from the psychiatric group. Similar rates of soiling were reported among abused children, with and without penetration, and the psychiatric sample. Rates of sexualized behavior were reported significantly more often by the abused group versus both the psychiatric and normative groups and were a better predictor of abuse status. The positive predictive value of soiling as an indicator of abuse was 45% versus 63% for sexual acting out. The psychiatric sample displayed
significantly more dysregulated behavior than the sexually abused sample. The predictive utility of fecal soiling as an indicator of sexual abuse in children is not supported. Soiling seems to represent one of many stress-induced dysregulated behaviors. Clinicians should assume the symptom of soiling is most likely related to the typical pathology and treat accordingly.

I receive occasional enquiries about the likelihood of sexual abuse based on the mere presence of encopresis. In the not too recent past there was often a rush to judgment based on symptomatology to prosecute for child sexual abuse. This public hysteria has lessened somewhat and courts now require independent and direct observations and evidence of sexual abuse. This study helps to reinforce a more reasoned, evidence-based review for the presence of sexual abuse. I have certainly seen many, many cases of encopresis which derive from such ordinary triggers as toilet training, starting school, stressful changes in the family, and bouts of constipation. Indeed, my sense is that the very distressed reactions to encopresis in and of itself are what may to lead to physical abuse, though not sexual abuse. The aura of anal intrusion with suppositories or enemas and a child’s strong reactions to this often leads to concerns by parents that this is a form of sexual abuse in its own right. The paradox of course is that the childrens’ very withholding and reflexive sphincter contractions against voiding are the cause of the disorder itself and of resisting the suppository or enema!! They don’t want anything to go in or out! The child’s eventual acceptance and desensitization to the application of the suppositories and enemas, properly done, likely generalizes and eases the reflexive resistance to voiding at the same time. The very fact that the child experiences success in voiding, clean clothes, pleasing his parents, and feels better physically and psychologically overtime will consolidate the learning to void more naturally. RWC.

Urinary excretion of polyethylene glycol 3350 during colonoscopy preparation.

Rothfuss,K.S.*, Bode,J.C., Stange,E.F., & Parlesak,A. Robert Bosch Krankenhaus, Abt Gastroenterol Hepatol & Endokrinol, Auerbachstr 110, D-70376 Stuttgart, Germany

Search Terms: Miralax, PEG, encopresis.

Background: Whole gut lavage with a polyethylene glycol electrolyte solution (PEG) is a common bowel cleansing method for diagnostic and therapeutic colon interventions. Absorption of orally administered PEG from the gastrointestinal tract in healthy human beings is generally considered to be poor. In patients with inflammatory bowel disease (IBD), intestinal permeability and PEG absorption were previously reported to be higher than in normal subjects. In the current study, we investigated the absorption of PEG 3350 in patients undergoing routine gut lavage.
Methods and Results: Urine specimens were collected for 8 hours in 24 patients undergoing bowel cleansing with PEG 3350 for colonoscopy. The urinary excretion of PEG 3350, measured by size exclusion chromatography, ranged between 0.01 and 0.51% of the ingested amount, corresponding to 5.8 and 896 mg in absolute amounts, respectively. Mean PEG excretion in patients with impaired mucosa such as inflammation or ulceration of the intestine (0.24% +/- 0.19, n = 11) was not significantly higher (p = 0.173) compared to that in subjects with macroscopically normal intestinal mucosa (0.13% +/- 0.13, n =13).
Conclusion: The results indicate that intestinal absorption of PEG 3350 is higher than previously assumed and underlies a strong inter-individual variation. Inflammatory changes of the intestine do not necessarily lead to a significantly higher permeability of PEG.

This study runs counter to the general wisdom that PEG is not well-absorbed which has generally been considered a positive factor in terms of lessening potential side-effects. More research is clearly needed and possibly this finding will help to direct attention to looking for side-effects more closely. RWC.

Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia

Chiarioni,G.,* Whitehead,W.E., Pezza,V., Morelli,A., & Bassotti,G. Univ Verona, Div Riabilitaz Gastroenterol, Azienda Osped Verona, Ctr Osped Clinicizzato, I-37067 Valeggio Sul Mincio, VR, Italy

Search Terms: Miralax, PEG, biofeedback, encopresis.

Background & Aims: Uncontrolled trials suggest biofeedback is an effective treatment for pelvic floor dyssynergia (PFD), a type of constipation defined by paradoxical contraction, or inability to relax, pelvic floor muscles during defecation. The aim was to compare biofeedback to laxatives plus education.
Methods: Patients with chronic, severe PFD were first treated with 20 g/day fiber plus enemas or suppositories up to twice weekly. Nonresponders were randomized to either 5 weekly biofeedback sessions (n = 54) or polyethylene glycol 14.6-29.2 g/day plus 5 weekly counseling sessions in preventing constipation (n = 55). Satisfaction with treatment, symptoms of constipation, and pelvic floor physiology were assessed 6 and 12 months later. The biofeedback group was also assessed at 24 months. Laxative-treated patients were instructed to increase the dose of polyethylene glycol from 14.6 to 29.2 g/day after 6 months.
Results: At 6 months, major improvement was reported by 43 of 54 (80%) biofeedback patients vs 12 of 55 (22%) laxative-treated patients (P <.001). Biofeedback's benefits were sustained at 12 and 24 months. Biofeedback also produced greater reductions in straining, sensations of incomplete evacuation and anorectal blockage, use of enemas and suppositories, and abdominal pain (all P <.01). Stool frequency increased in both groups. All biofeedback-treated patients reporting major improvement were able to relax the pelvic floor and defecate a 50-mL balloon at 6 and 12 months.
Conclusions: Five biofeedback sessions are more effective than continuous polyethylene glycol for treating PFD, and benefits last at least 2 years. Biofeedback should become the treatment of choice for this common and easily diagnosed type of constipation.

Wonderful study contrasting a rational behavioral set of techniques (biofeedback) affecting physical function to specifically assist the proper concert of muscle groups by comparison to a laxative-mediated training with 5 counseling sessions to abet toileting efforts. The laxative use with education likely resembles standard practice by most physicians. Biofeedback requires more equipment and specialized training by its practitioners. Now if only I could persuade university programs to test my protocol as another treatment alternative with off-the-shelf preparations. My Clean Kid Manual would help to assure comparability across practitioners and parents in applying a treatment.

An example of psychological adjustment in chronic illness: Hirschsprung's disease

Athanasakos,E.,* Starling,J., Ross,F., Nunn,K., & Cass,D. Royal London Hosp, Dept Paediat Surg, London E1 1BB, England

Search Terms: Hirschsprung's disease, encopresis, soiling, psychosocial outcomes, pull-through, surgery.

The aim of this study was to investigate the outcomes after definitive surgical correction for children with Hirschsprung's disease (HD) and the psychosocial impact of HD on the child and family. The total sample comprised 72 children with HD along with their families. The development of a condition-specific questionnaire measured the functional and psychosocial outcomes for children with HD with parental perception of their child's condition. Psychiatric
measures were also examined to assess psychiatric morbidity. The greatest functional problem after definitive surgery for HD was faecal soiling (76%). The principle findings of the study were that (1) HD did not have a significant impact on the child's rate of psychiatric morbidity and levels of hopefulness in comparison to the normal population, (2) surgical and psychosocial functioning improved with increasing age and, (3) families remain troubled about their future with HD and dealing with psychosocial difficulties related to the condition (such as distress because of faecal soiling). Specifically, faecal soiling was found to be physically, emotionally and psychosocially distressing complication. Bowel functioning and psychosocial distress improves with increasing age and parental and medical professional support. Despite the significant impairment of faecal continence, we found that children/young adults with HD have minimal psychiatric morbidity, yet experience condition-specific psychosocial problems (e.g. embarrassment and distress/discomfort). HD does not increase the rate of clinical psychiatric morbidity in children and families with HD, but does determine the context of their daily distress and concern.

Parents have many concerns about any kind of surgical intervention and this should help to allay their fears even if subsequent training/diet interventions do not work quickly. Again, this is where I would like to see either biofeedback in the abstract just above this one to be employed or my protocol used. I believe both would be more effective because of their specific, rational interventions than the usual use of laxatives or diet alone with urgings to toilet frequently. RWC.

Psychological differences between children with and without soiling problems.

Joinson,C.*, Heron,J., Butler,U., & von Gontard,A. Avon Longitudinal Study Parents & Children, Dept Community Based Med, Unit Perinatal Paediat Epidemiol, 24 Tyndall Ave, Bristol BS8 1TQ, Avon, England.

Search Terms: Encopresis, Behavior, self-esteem, epidemiology.

OBJECTIVES. Previous studies, based on clinic samples, report that childhood soiling is associated with behavior problems and reduced self-esteem. This population-based study investigates the prevalence of psychological problems associated with childhood soiling.
METHODS. A total of 8242 children aged 7 - 8 years born to mothers in the United Kingdom - based Avon Longitudinal Study of Parents and Children were studied. Parents completed postal questionnaires assessing common childhood emotional and behavioral problems, and children were asked questions at a research clinic concerning their behavior, friendships, bullying, and self-esteem. The rate of psychological problems was compared in children who soil frequently (
once a week or more), those who soil occasionally ( less than once a week), and those with no soiling problems ( controls). Analyses were adjusted for developmental delay, gender, sociodemographic background, and stressful life events.
RESULTS. Children who soil were reported by their parents to have significantly more emotional and behavioral problems compared with children who do not soil. Children who soil frequently had significantly more problems than those who soil occasionally. The rate of attention and activity problems, obsessions and compulsions, and oppositional behavior was particularly high in frequently soiling children. Children with soiling problems reported significantly higher rates of involvement in overt bullying ( as both perpetrator and victim) and antisocial activities compared with controls.
CONCLUSIONS. The current study finds significantly higher rates of behavior and emotional problems, bullying, and antisocial activities in children who soil compared with those who do not soil. Children who soil frequently are more likely to have these problems than those who soil occasionally.

No real surprises in the findings of more behavioral problems for encopretic children. The more interesting question for me is do these behavioral issues dissipate with symptom remission when there are fewer demands or less tension associated with soiling? RWC.

Does "stubbornness" have a role in pediatric constipation?

Burket,R.C.*, Cox,D.J., Tam,A.P., Ritterband,L., Borowitz,S., Sutphen,J., Stein,C.A., & Kovatchev,B. Univ Virginia, Hlth Sci Ctr, Box 801076, Charlottesville, VA 22908 USA

Search Terms: encopresis, constipation, stubbornness, toileting, behavior

The objective of this study was to determine if children with constipation are more stubborn, both in general and specifically regarding toileting behaviors, than children without constipation. A secondary objective was to determine if constipated children who are more stubborn are less likely to respond to routine therapeutic interventions than less stubborn constipated children. One hundred one children aged 2 to 6 years, who were first-time presenters (never received treatment) to their primary care physician (PCP) with constipation, were compared with 84 nonconstipated control children of similar age range. Comparison measures included general stubbornness and toilet-specific stubbornness (active resistance to participating in appropriate toileting behaviors). Measures of stubbornness were generated from retrospective questionnaires, prospective toileting diaries completed by the parents, and direct experimenter observations. The constipated children were treated by their PCP for 2 months and then reassessed. Constipated children were perceived by their parents to be significantly more stubborn than control children generally and specifically in terms of toileting. Some study evidence suggested that constipated children who continued to have difficulties after 2 months of treatment by their PCPs were perceived by their parents to have significantly more general stubbornness than constipated children who responded to treatment. Parent-perceived toilet-specific stubbornness significantly improved after successful treatment of the constipation by their PCP. The finding that constipated children had more parent-perceived stubbornness than children without constipation is notable because it may play a role in the development and/or maintenance of this bowel dysfunction as well as being an obstacle in treatment compliance.

The oft observed parental observation that their encopretic child is stubborn received some support in this University of Virginia study and may hinder treatment compliance because of refusal to cooperate. RWC

April 2006 CLINICAL PEDIATRICS (v45, 3), Pp. 251-256. Posted on 06/05/2006

Variability in the management of childhood constipation

Focht,D.R. III*, Baker,R.C., Heubi,J.E., Moyer,M.S., Tripler Army Med Ctr, Dept Pediat, 1 Jarrett White Rd, Honolulu, HI 96859 USA

Search Terms: Miralax, PEG, Constipation, Encopresis

To assist primary care providers, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) published clinical practice guidelines for management of childhood constipation. A cross-sectional survey of pediatricians from across the United States was conducted to assess pediatricians' constipation management strategies, whether pediatricians are familiar with the NASPGHAN constipation guidelines, and reasons pediatricians refer constipated patients to a pediatric gastroenterologist. Overall, 75% of pediatricians used polyethylene glycol without electrolytes to treat childhood constipation, 8% of pediatricians were aware NASPGHAN had published constipation guidelines, and parental pressure was just one reason pediatricians referred constipated patients to a pediatric gastroenterologist.

Doesn't look like much variability to me with 75 percent of pediatiricians using Miralax or its generic form. RWC.

Colonic manometry as predictor of cecostomy success in children with defecation disorders.

van den Berg,M.M., Hogan,M., Caniano,D.A., Di Lorenzo,C., Benninga,M.A., & HM Mousa*, Childrens Hosp, Div Pediat Gastroenterol, Columbus, OH 43205 USA

Search Terms: ACE, manometry, Slow Transit, Encopresis, Constipation

Purpose: The aim of this study was to define the predictive value of colonic manometry and contrast enema before cecostomy placement in children with defecation disorders.
Methods: Medical records, contrast enema, and colonic manometry studies were reviewed for 32 children with defecation disorders who underwent cecostomy placement between 1999 and 2004. Diagnoses included idiopathic constipation (n = 13), Hirschsprung's disease (n= 2), cerebral palsy (n = 1), imperforate anus (n = 6), spinal abnormality (n = 6), and anal with spinal abnormality (n = 4). Contrast enemas were evaluated for the presence of anatomic abnormalities and the degree of colonic dilatation. Colonic manometry was considered normal when high-amplitude propagating contractions (HAPC) occurred from proximal to distal colon. Clinical Success was defined as normal defecation frequency with no or occasional fecal incontinence.
Results: Colonic manometry was done on 32 and contrast enema on 24 patients before cecostomy. At follow-up, 25 patients (78%) fulfilled the success criteria. Absence of HAPC throughout the colon was related to unsuccessful outcome (P = .03). Colonic response with normal HAPC after bisacodyl administration was predictive of success (P = .03). Presence of colonic dilatation was not associated with colonic dysmotility.
Conclusion: Colonic manometry is helpful in predicting the outcome after cecostomy. Patients with generalized colonic dysmotility are less likely to benefit from use of antegrade enemas via cecostomy. Normal colonic response to bisacodyl predicts favorable outcome.

The ACE procedure is a dramatic procedure to employ and it was used here for 13 patients with functional constipation. The importance of HAPC was confirmed and it was of relevance to see that responsiveness to bisacodyl is very promising if this procedure has to be implemented. RWC.

Rectal hyposensitivity

Gladman,M.A., Lunniss,P.J., Scott,S.M., & Swash,M. No address listed.

Search Terms: Encopresis, Anorectal, Hyposensitivity, Rectal, Slow Transit, Constipation, Sensory, Biofeedback

Rectal hyposensitivity (RH) relates to a diminished perception of rectal distension that is diagnosed during anorectal physiologic investigation. There have been few direct studies of this physiologic abnormality, and its contribution to the development of functional bowel disorders has been relatively neglected. However, it appears to be common in patients with such disorders, being most prevalent in patients with functional constipation with or without fecal incontinence. Indeed, it may be important in the etiology of symptoms in certain patients, given that it is the only '' apparent '' identifiable abnormality on physiologic testing. Currently, it is usually diagnosed on the basis of elevated sensory threshold volumes during balloon distension in clinical practice, although such a diagnosis may be susceptible to misinterpretation in the presence of altered rectal wall properties, and thus it is uncertain whether a diagnosis of RH reflects true impairment of afferent nerve function. Furthermore, the etiology of RH is unclear, although there is limited evidence to support the role of pelvic nerve injury and abnormal toilet behavior. The optimum treatment of patients with RH is yet to be established. The majority are managed symptomatically, although ''sensory-retraining biofeedback '' appears to be the most effective treatment, at least in the short term, and is associated with objective improvement in the rectal sensory function. Currently, fundamental questions relating to the contribution of this physiologic abnormality to the development of functional bowel disorders remain unanswered. Acknowledgment of the potential importance of RH is thus required by clinicians and researchers to determine its relevance.

Many parents report that their encopretic children claim to have no awareness of the urge to "go". This observation tends to support that claim and "sensory-retraining biofeedback" would appear to be a rational treatment response. However, it is my contention that my protocol based on the Pavlovian conditioning paradigm accomplishes this same purpose by conditioning awareness of toileting urges to a degree where the child becomes aware of his/her ordinary urges and ties them into the necessary bodily responses associated with successful voiding. This can be seen in a stepwise fashion with my protocol when these children can only go with an enema and then find a gentle glycerin suppository sufficient before transitioning to going completely on their own. My procedure also associates and reinforces the appropriate precise behaviors for facillitating a successful and timely bowel movement. RWC.

Pelvic Floor: Anatomy and function

Bharucha,A.E., Mayo Clin & Mayo Fdn, Coll Med, Clin Enter Neurosci Translat & Epidemiol Res Prog, Charlton 8-110,200 1st St SW, Rochester, MN 55905 USA

Search Terms: encopresis, sphincter, anal sphincter, pelvic floor, anatomy, chronic constipation.

The pelvic floor is a dome-shaped striated muscular sheet that encloses the bladder, uterus, and rectum, and, together with the anal sphincters, has an important role in regulating storage and evacuation of urine and stool. This article reviews the anatomy, nerve supply, pharmacology, and functions of the anal sphincters and the pelvic floor. The internal and external anal sphincters are primarily responsible for maintaining faecal continence at rest and when continence is threatened, respectively. Defecation is a somato-visceral reflex regulated by dual nerve supply (i.e. somatic and autonomic) to the anorectum. The net effects of sympathetic and cholinergic stimulation are to increase and reduce anal resting pressure, respectively. Faecal incontinence and functional defecatory disorders may result from structural changes and/or functional disturbances in the mechanisms of faecal continence and defecation.

This looks like an excellent teaching aid. DrC.

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children.

Brazzelli,M., Griffiths,P. No address listed.

Search Terms: Encopresis, Incontinence, Review, Biofeedback

Background: Faecal incontinence is a common and potentially distressing disorder of childhood.
Objectives: To assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children.
Search strategy: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 1 February 2006).
Selection criteria: Randomised and quasi-randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children.
Data collection and analysis: Reviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta-analysis when appropriate.
Main results: Eighteen randomised trials with a total of 1168 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by
trials addressing the same comparisons.
Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow-up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children
(OR 1.40 95% CI 0.72 to 2.73 at 24 months). In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65).
Authors' conclusions: There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence in children with functional faecal incontinence associated with constipation.

This is a meta-analytic study combining results from a variety of studies after conducting a thorough literature review. This methodology is controversial within the literature when it comes to making sweeping or specific conclusions.

June 2006 CLINICAL PEDIATRICS (v45,5), Pp. 411-414. Posted on 08/23/2006.

Digital rectal examination and the primary care physicians: A lost art?

Safder,S., Rewalt,M., & Elitsur,Y.* Marshall Univ, Joan C Edwards Med Sch, Dept Pediat, Pediat Gastroenterol Div, 1600 Med Ctr Dr, Huntington, WV 25701 USA

Search Terms: CONSTIPATION, encopresis, Digital rectal examination

Digital rectal examination (DRE) in children is crucial to differentiate between simple (habitual) and complicated constipation. Previous experience suggests that primary care physicians (PCPs) avoid DRE in children with constipation before referral. We evaluated the rate of DRE performance by West Virginian PCPs in patients referred to our gastroenterology clinic. Data were collected from the physicians' referral letters and parental reports. We found that the vast majority (85%) of WV-PCPs do not perform DRE before referring their patients, resulting in missed diagnoses and treatment. We concluded that the lack of DRE in children with constipation may result in unnecessary referral to the specialist. To improve standard of care for children with constipation, an educational campaign for PCPs is clearly warranted.

A very similar study was done earlier by Gold, D.M., Levine J., Weinstein, T.A., Kessler, B.H., & Pettei, M.J. (1999). Frequency of digital rectal examination in children with chronic constipation. Archives of Pediatric and Adolescent Medicine, 153(4), 377-379 at the Schneider Childrens Hospital on Long Island, NY and cited in a couple of my publications (including the preface to my Clean Kid Manual-III which is on this website--see the home page). This study helps to document the intimidation of pediatricians that may have been fostered by a couple of influential articles which established the current dominant popular "top down" approach with oral agents in treating encopresis. Applications of enemas in treatment was described in those earlier articles as a form of "anal assault". Since that time articles have emphasized oral agents as a form of "gentle" treatment for encopresis. This bias is unfortunate and may bias against DRE's and the highly effective treatment protocol which I have established using suppositories and enemas when they are needed in a very structured and timed format to reestablish a proper voiding reflex. Parent and pediatricians have become very "stuck" when their standard "top down" treatment approach fails. Often they confuse my treatment as merely a "clean out" procedure and not part of a structured treatment program to end encopresis. RWC.

Treatment of faecal impaction with polyethelene glycol plus electrolytes (PGE+e) followed by a double-blind comparison of PEG+e versus lactulose as maintenance therapy

Candy,D.C.A.,* Edwards,D., & Geraint,M., Royal W Sussex NHS Trust, Paediat Gastroenterol Serv, Chichester PO19 6SE, England

Search Terms: Encopresis, constipation, PEG, Lactulose

Objectives: To assess the efficacy of polyethylene glycol 3350 plus electrolytes (PEG + E; Movicol((R))) as oral monotherapy in the treatment of faecal impaction in children, and to compare PEG + E with lactulose as maintenance therapy in a randomised trial.
Patients and Methods: An initial open-label study of PEG + E in the inpatient treatment of faecal impaction (phase 1), followed by a randomised, double-blind comparison between PEG + E and lactulose for maintenance treatment of constipation over a 3-month period (phase 2) in children aged 2 to 11 years with a clinical diagnosis of faecal
impaction.
Results: Disimpaction on PEG + E was achieved in 58 (92%) of 63 of children (89% of 2-4 year olds and 94% of 5-11 year olds) without additional interventions. A maximum dose of 4 sachets (for 2-4 year olds) or 6 sachets (for 5 - 11 year olds) was required; median time to disimpaction was 6 days (range, 3-7 days). Seven children (23%) reimpacted whilst taking lactulose, whereas no children reimpacted while taking PEG + E (P = 0.011). The total incidence rate of adverse events seen was higher in the lactulose group (83%) than in the PEG + E group (64%).
Conclusions: PEG + E is safe and highly effective in the management of childhood constipation. It allows a single orally administered laxative to be used for disimpaction without recourse to invasive interventions. It is significantly more effective than lactulose as maintenance therapy, both in efficacy in treating constipation and efficacy in preventing the recurrence of faecal impaction.

This is an important comparison study for the traditional "top down" approach using the two major hypermolar agents for both "clean outs" and maintenance therapy. The advantage of PEG (Miralax) over Lactulose in such usage is supported here. RWC

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Gastrointestinal motility disorders: An update.

Lacy,B.E.,* &Weiser,K. Dartmouth Coll, Hitchcock Med Ctr, Div Gastroenterol & Hepatol, 1 Med Ctr Dr,Area 4C, Lebanon, NH 03756 USA

Search Terms: slow transit, motility, encopresis

Gastrointestinal motility disorders encompass a wide array of signs and symptoms that can occur anywhere throughout the luminal gastrointestinal tract. Motility disorders are often chronic in nature and dramatically affect patients' quality of life. These prevalent disorders cause a tremendous impact both to the individual patient and to society as a whole. Significant progress has been made over the last 5 years in understanding the etiology and pathophysiology of gastrointestinal motility disorders. This clinical update will focus on seven of the most common gastrointestinal motility disorders (achalasia, non-achalasia esophageal motility disorders, dyspepsia, gastroparesis, chronic intestinal pseudo-obstruction, irritable bowel syndrome, and chronic constipation) with an emphasis on current treatment options and new therapeutic modalities.

See the abstracts at the beginning of this section on encopresis for the importance of slow-transit problems and their possible contribution to encopresis/chronic constipation. I’m looking forward to reading this as a general review on motility disorders. RWC.

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August, 2006 JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION (43, 2), 206-208. Posted on 08/28/2006.

Functional fecal soiling without constipation, organic cause or neuropsychiatric disorders?

Pakarinen,M.P.,* Koivusalo,A., & Rintala,R.J. Univ Helsinki, Childrens Hosp, Pediat Surg Sect,
Stenbackinkatu 11 PL281, Helsinki 00029, Finland

Search terms: encopresis, laxatives

Background: The aetiology of fecal incontinence in children has traditionally been attributed to idiopathic constipation, structural defects or neuropsychiatric disorders. We describe a new subgroup of otherwise healthy children who have fecal soiling without any underlying cause for the incontinence.
Methods: The hospital records of children with fecal incontinence were screened to detect patients without any history, signs or symptoms of constipation or an organic, neurological or psychiatric cause for the incontinence. Anorectal manometry findings were compared with those of age-matched children with idiopathic constipation and soiling.
Results: Eight boys and 5 girls were identified. The median age at diagnosis was 7.9 years. Soiling had lasted median of 4.1 years, occurred at least every other day in 9, at least once a week in 2 and occasionally in 2 and required change of underwear or use of protective pads. Abdominal x-ray and barium enema showed normal findings. Sacral x-ray and/or MRI of the spinal cord showed normal bony spine and spinal cord. Five children had coexisting night and/or
daytime wetting. Impaired rectal sensation was the only identifiable abnormality that was detected. The median volume required for the first sensation was 45 mL (range, 15-100 mL; normal, < 15 mL). Anorectal manometry alone was unable to differentiate patients with functional fecal soiling from those with idiopathic constipation associated soiling. The median follow-up time after the diagnosis was 9.1 months. Treatment of fecal soiling consisted of education, dietary modification or stimulatory laxatives to establish regular toileting routines. Treatment improved fecal continence in 6 out of 8 cases with follow-up longer than 6 months.
Conclusions: There is a small subgroup of children with fecal soiling who are otherwise healthy without constipation or any other underlying cause for the incontinence. These children seem to have isolated impairment of rectal sensation. In most, the prognosis is good with conservative treatment.

I have certainly had cases that might fit into this group of children just from parental histories. They have responded well to my program which appears to enhance sensory awareness via Pavlovian conditioning using immediate acting and pronounced UCS prompts. RWC

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A randomized, prospective, comparison study of polyethylene glycol 3350 without electrolytes and milk of magnesia for children with constipation and fecal incontinence

Loening-Baucke,V.,* & Pashankar,D.S. Childrens Hosp Iowa, JCP 2555,200 Hawkins Dr, Iowa
City, IA 52242 USA

Search Terms: PEG, MOM, encopresis, constipation.

OBJECTIVE. Our aim was to compare 2 laxatives, namely, polyethylene glycol 3350 without electrolytes and milk of magnesia, evaluating the efficacy, safety, acceptance, and 1-year outcomes.
METHODS. Seventy-nine children with chronic constipation and fecal incontinence were assigned randomly to receive polyethylene glycol or milk of magnesia and were treated for 12 months in tertiary care pediatric clinics. Children were counted as improved or recovered depending on resolution of constipation, fecal incontinence, and abdominal pain after 1, 3, 6, and 12 months. An intent-to-treat analysis was used. Safety was assessed with evaluation of clinical
adverse effects and blood tests.
RESULTS. Thirty- nine children were assigned randomly to receive polyethylene glycol and 40 to receive milk of magnesia. At each follow-up visit, significant improvement was seen in both groups, with significant increases in the frequency of bowel movements, decreases in the frequency of incontinence episodes, and resolution of abdominal pain. Compliance rates were 95% for polyethylene glycol and 65% for milk of magnesia. After 12 months, 62% of polyethylene glycoltreated children and 43% of milk of magnesia-treated children exhibited improvement, and 33% of polyethylene glycol-treated children and 23% of milk of magnesia-treated children had recovered. Polyethylene glycol and milk of magnesia did not cause clinically
significant side effects or blood abnormalities, except that 1 child was allergic to polyethylene glycol.
CONCLUSIONS. In this randomized study, polyethylene glycol and milk of magnesia were equally effective in the long-term treatment of children with constipation and fecal incontinence. Polyethylene glycol was safe for the long-term treatment of these children and was better accepted by the children than milk of magnesia.

PEG or Miralax has moved far ahead in physician’s preferences for the use of a “top down” medication for treating encopresis. MOM (Milk of Magnesia) is an old standard. The compliance rate was higher for PEG which is likely one reason for the preference. What interested me was the low rate of recovery for PEG at 33% and MOM at 23% after one year!

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Evaluation and treatment of constipation in children: Summary of updated recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Baker,S.S.*, Liptak,G.S., Colletti,R.B., Croffie,J.M., Di Lorenzo,C., Ector,W., Nurko,S. NASPGHAN, 1501 Bethlehem Pike,POB 6, Flourtown, PA 19031 USA

Search Terms: Encopresis, Motility, Chronic constipation, milk.

Constipation is a common pediatric problem. To assist health care professionals who care for children with constipation, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) previously published a clinical guideline based on an integration of medical evidence with expert opinion. To evaluate studies published since then, the NASPGHAN Constipation Guideline Committee performed a comprehensive and systematic review of the medical literature since 1997, to identify, review and rate the quality of new evidence. Based on this review, the recommendations of the original clinical guideline were reaffirmed with several modified according to the new evidence. Below is a summary of the evidence reviewed for this update. The complete revised guideline is available online in its entirety.

Go to http://www.naspghan.org/PDF/PositionPapers/constipation.guideline.2006.pdf for a complete copy of these guidelines. Some salient points from this source are:
1. Parental concerns about abnormal voiding are responsible for 3% of visits to Pediatricians and 25% of Pediatric Gastroenterology consultations.
2. The most common form of constipation is “functional” or non-organic in basis with retention or withholding.
3. Constipation is a delay or difficulty in defecation, present for 2 or more weeks and sufficient to cause significant distress to the patient. (Often the child is in denial and it is more evident that it is the parents who are in distress if soiling is present!—DrC.)!
4. 1.2 stools daily on the average at 4 y/o and later.
5. At least one digital (finger) anorectum examination is recommended.
6. “soiling…is not a willful and defiant maneuver.” (Pg. e6).
7. “The use of soap suds, tap water, and magnesium enemas is not recommended because of their potential toxicity.” (Pg. e7).
8. “The incidence of Hirschsprung disease is approximately 1 in 5000 live births.” (Pg. e10). “…in 8% to 20% of children, Hirschsprung disease remains unrecognized after the age of 3 years.” (Pg. e10).
9. “For children unresponsive to conventional medical and behavioral management consideration may be given to a time limited trial of cow’s milk-free diet.” (Pg. e11).
10. The guidelines indicate that the findings are too weak to support a definite recommendation for the use of fiber in treating constipation.

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Adult Hirschsprung's disease diagnosed during forensic autopsy

Chatelain,D.*, Manaouil,C., Marc,B., icard,J., Brevet,M., Montpellier,D., Defouilloy,C., & Jarde,O. Ctr Hosp Univ Amiens, Dept Pathol, Pl Victor Pauchet, F-80054 Amiens 01, France

Search Terms: Encopresis, Hirschsprung's disease, Adult, Megacolon, Forensic, autopsy

We report a case of fatal Hirschsprung's disease (HD) discovered at autopsy. A 20-year-old man collapsed at home. Emergency medical personnel found him in cardiac arrest and all resuscitative efforts failed. He had a past history of chronic constipation since infancy. Forensic autopsy revealed a megacolon full of gas and stools. Microscopic examination showed absence of ganglion cells in a short segment of the rectum and enterocolitis in the left and transverse colon. HD is rarely described in adults. In many cases, patients complained of constipation since infancy but the affection remained misdiagnosed. The relative good tolerance of the disease is usually
due to a short aganglionic bowel segment. Enterocolitis is a frequent and severe complication of HD in children but is rarely described in adults. This case suggests the importance of HD diagnosis in childhood in order to avoid fatal complications with forensic consequences.

This was a report on the death in a 20 year old due to short segment Hirschsprung’s disease, which was discovered only at autopsy. I suspect that this case may have a considerable impact on checking for short segment HD earlier in a difficult case of encopresis that resists treatment even beyond my protocol. RWC.

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December 2006 INTERNATIONAL JOURNAL OF COLORECTAL DISEASE (v21, 8), Pp. 826-833. Posted on 11/30/2006.

Colonic response to food in constipation.

Bouchoucha,M.,* Devroede,G., Faye,A., Le Toumelin,P., Arhan,P., & Arsac,M. Univ Paris 05, Hop Broussais, Lab Physiol Digest, 96,Rue Didot, F-75014 Paris, France

Search Terms: Encopresis, Transit, motility, constipation, obstruction.

Question: Is colonic response to food abnormal in constipation.
Methods: The colonic response to food was evaluated in 323 patients and 60 healthy subjects by following the movements of radiopaque markers after ingestion of a standard 1,000-cal test meal. Constipated patients were divided into four groups: one with a normal, and three with a delayed colorectal transit time. When the delay was found mainly in the ascending colon, the group was labeled as suffering from "colonic inertia". In "hindgut dysfunction", the delay was predominantly found in the descending colon, whereas the term "outlet obstruction" was reserved for constipated patients whose major site of delay was the rectosigmoid area. Colonic response to food was quantified by evaluating the variation of markers in a given abdominal region and the evolution of the geometric center on the entire plain film of the abdomen.
Results: Emptying of the caecum-ascending colon and filling of the rectosigmoid area characterize the colonic response to food in healthy subjects. Constipated patients also filled the rectosigmoid, but different patterns were found in the colon. In constipated patients with transit in the normal range, there was a frequent (41%) absence of colonic response to food as compared to controls (13%) and constipated patients with delayed transit (p < 0.0001). The response to food of patients with colonic inertia was similar to that of healthy subjects in terms of distal progression, but less marked. The hindgut dysfunction group emptied the entire left colon but failed to empty the caecum and ascending colon. In the outlet obstruction group, there was no distal progress of the geometric center after meal.
Conclusions: Abnormal colonic response to food is frequently found in constipated patients, with different patterns according to the type of constipation.

This is an interesting study on the triggering of motility in response to food intake. In my own protocol I have largely called into question the value of a "top down approach" for triggering a timely voiding response from which a child could learn to respond to his/her gastrocolic urges. This is why I prefer the "bottoms up" suppository or enema approach to assure training an adequate and timely voiding response to colonic urges. However, this study is also fascinating for looking at the contribution of motility at different segments of the colon to constipation and responses to food ingestion. DrC.

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November, 2006 ALIMENTARY PHARMACOLOGY & THERAPEUTICS (v.24, 9), Pp. 1295-1304. Posted on 11/30/2006.

Review article: chronic constipation and food hypersensitivity – an intriguing relationship

Carroccio,A.* & Iacono,G, Policlin Polermo, Via Vespro 141, I-90127 Palermo, Italy

Search Terms: Milk, Allergy, Encopresis, Constipation, Laxatives

Background: Chronic constipation is common in the general population. Some studies have shown that in children cow's milk protein hypersensitivity can cause chronic constipation unresponsive to laxative treatment.
Aims: To review the literature and summarize the data that point to a relationship between refractory chronic constipation and food hypersensitivity, and to discuss the hypothesis that the pathogenesis of constipation due to food hypersensitivity.
Methods: A search in the U.S. National Library of Medicine was performed, matching the key words 'chronic constipation, food intolerance and allergy'.
Results: Thirty-three papers were found but only 19 of them were related to the topic of this review. Most of the data indicated a relationship between constipation and food allergy in a subgroup of paediatric patients with 'idiopathic' constipation unresponsive to laxative treatment. There was only one study in adults that demonstrated the resolution of chronic constipation on hypoallergenic diet in four patients.
Conclusions: An increasing number of reports suggest a relationship between refractory chronic constipation and food allergy in children. Similar data in adults are scarce and need to be confirmed. Further studies should be performed to obtain firmer evidence for the role of allergy in constipation and clarify the pathogenetic mechanisms involved.

Popular parent forums tend to obsess over allergy issues and accord them great weight. This meta-analytic study indicates an increasing awareness of the potential contribution of food allergies to chronic constipation. DrC.

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December, 2006 AMERICAN JOURNAL OF GASTROENTEROLOGY (v101,12), Pp.2790-2796. Posted on 12/18/2006.

Influence of body position and stool characteristics on defecation in humans.

Rao,S.S.C., Kavlock,R., & Rao,S.* Univ Iowa, Dept Internal Med, Div Gastroenterol Hepatol, Carver Coll Med, 4612 JCP,200 Hawkins Dr, Iowa City, IA 52242 USA

Search Terms: Posture, voiding reflex, defecation, constipation, sleep, encopresis, adults

BACKGROUND: Whether defecation is influenced by body position or stool characteristics is unclear.
AIM: We investigated effects of body position, presence of stool-like sensation, and stool form on defecation patterns and manometric profiles.
METHODS: Rectal and anal pressures were assessed in 25 healthy volunteers during attempted defecation either in the lying or sitting positions and with balloon-filled or empty rectum. Subjects also expelled a water-filled (50 cc) balloon or silicone-stool (FECOM) either lying or sitting and rated their stooling sensation.
RESULTS: When attempting to defecate in the lying position, a dyssynergic pattern was seen in 36% of subjects with empty rectum and 24% with distended rectum. When sitting, 20% showed dyssynergia with empty rectum and 8% with distended rectum. More subjects (p < 0.05) showed dyssynergia in lying position. When lying, 60% could not expel balloon and 44% FECOM. When sitting, fewer (p < 0.05) failed to expel balloon (16%) or FECOM (4%). FECOM expulsion time was quicker (p < 0.02). Stool-like sensation was more commonly (p < 0.005) evoked by FECOM than balloon.
CONCLUSIONS: In the lying position, one-third showed dyssynergia and one-half could not expel artificial stool. Whereas when sitting with distended rectum, most showed normal defecation pattern and ability to expel stool. Thus, body position, sensation of stooling and stool characteristics may each influence defecation. Defecation is best
evaluated in the sitting position with artificial stool.

I found this to be an interesting study on adults with possible application for encopresis in children. This study on the effects of posture on defecation for prone vs. sitting postures would not appear to be very relevant to the postures assumed by children who withhold. However, the very fact of a postural effect is of importance. Also, the difficulty of voiding prone may relate to the relatively rare occurrence of reported soiling in sleep. I would like to see a naturalistic study of children withholding postures and a study of the incidence of soiling in sleep vs. awake. Bill Whitehead in a personal communication did not find this study to be particularly interesting noting that biofeedback is done in both positions and that it is understood that the prone position while convenient for the examiner to train would not be optimal for voiding from a social and familiarity perspective with little implication for etiology. RWC.

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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.

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Lubiprostone: Chloride channel activator for chronic constipation

Rivkin,A.,* & Chagan,L. Arnold & Marie Schwartz Coll Pharm & Hlth Sci, 75 DeKalb
Ave, Brooklyn, NY 11201 USA

Search Terms: lubiprostone, constipation, encopresis, motility

Background: Chronic constipation is a common and costly health problem occurring in similar to 4.5 million Americans. Current management of constipation is suboptimal and requires a stepwise approach using a combination of laxatives to decrease symptoms.
Objective: The objective of this review was to describe the efficacy and safety of a new therapeutic entity, lubiprostone, recently approved by the US Food and Drug Administration for the treatment of chronic idiopathic constipation.
Methods: Computerized searches of MEDLINE and International Pharmaceutical Abstracts were conducted (1966-July 10, 2006). Search terms utilized were lubiprostone, RU-0211, and chronic constipation. References of selected articles were searched for additional articles or abstracts. All relevant published literature regarding
lubiprostone was included in this review. Pertinent abstracts presented at meetings of the American College of Gastroenterology and Digestive Diseases Week were also included.
Results: Lubiprostone activates a chloride channel (le, subtype 2) and increases chloride and fluid secretion into the intestines, resulting in relief of constipation. It is poorly absorbed after oral administration, and its metabolism occurs primarily in the stomach and Jejunum. Lubiprostone was evaluated in 6 placebo-controlled, double-blind, randomized Phase II or III clinical trials. Overall, in clinical trials, > 1400 patients were exposed to 24 mu g of lubiprostone BID for up to 48 weeks. It improved the number of bowel movements, stool consistency, bloating, and global assessment of constipation compared with placebo (P < 0.05). Nausea was the most common adverse effect reported in clinical trials, occurring in 30.9% of patients. However, nausea was dose dependent and decreased when lubiprostone was given with food.
Conclusions: Lubiprostone is the first in its class of chloride channel activators that results in improvement of symptoms of constipation. It has not been compared with other laxatives but, based on the available placebo-controlled studies, its efficacy is superior to placebo and its safety is acceptable. Considering the currently available laxatives, lubiprostone will become an additional option for the treatment of patients with chronic constipation.

An interesting new agent for promoting GI motility. NOT approved for children. RWC.

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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

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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

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Long-term results of bowel function after treatment for Hirschsprung's disease: a 29-year review

Menezes,M., Corbally,M., & Puri,P.* Our Ladys Hosp Sick Children, Childrens Res Ctr, Dublin 12, Ireland

Search Terms: Hirschsprung's disease, encopresis. FollowUp, Down’s Syndrome

Although various surgical procedures have been described to treat Hirschsprung's disease (HD), few studies have evaluated the long-term results of these children. The purpose of this study was to assess the long-term clinical outcome and bowel function of patients with HD. The hospital records of 259 consecutive patients with a confirmed histological diagnosis of HD during 1975-2003 were examined. Data was assessed for age at presentation, sex, clinical presentation, associated anomalies, level of aganglionosis, surgical procedures, complications and bowel function. Follow up was carried out by personal/telephone interviews with patients or their parents. Of the 259 patients with HD, 200 were males (77.2%) and 59 females (22.8%). Intestinal obstruction was the presenting feature in 147 patients (56.8%), intestinal perforation in 5 (1.9%), enterocolitis in 30 (11.6%) and constipation in 77 (29.7%). Thirty-nine patients (15.1%) had associated Down's syndrome. Two hundred and nine patients (80.7%) had rectosigmoid disease, 31 (12%) had long segment disease and 19 (7.3%) had total colonic aganglionosis. Forty-three patients (16.6%) had preoperative enterocolitis. Primary colostomy was performed in 160 patients and a primary pull through in 90. Seven patients had a sphincteromyectomy for ultrashort HD. Two patients died prior to treatment. Various pull through procedures were performed in these patients. Postoperative complications included: pelvic abcess in 2, rectal stricture in 10, perianal excoriation in 7, anastomotic leak in 8, intestinal obstruction in 3, wound dehiscence in 1, stomal prolapse/stenosis in 5, rectovesical fistula in 2 and enterocolitis in 56. Five patients underwent a redo pull through and 46 required a post pull through sphincterectomy. At the time of follow-up, 27 were lost to follow-up, 9 died, 18 had permanent stomas and 4 were too young to assess bowel function. Of the remaining 194 patients, bowel function was normal in 132 (68%). Twenty patients (10.3%) had soiling and 42 (21.7%) had constipation requiring laxatives or enemas. There was no difference in bowel function in relation to type of pull through operation. Only 34% of patients with Down's syndrome had normal continence. The majority of patients with HD continue to have disturbances of bowel function for many years before attaining normal continence.

This was a significant study for the number of cases involved and the length of the follow up. Parents would be well-informed if these results were shared out to them on the prospects for their child with HD. RWC.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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.
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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.

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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.

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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

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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.

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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
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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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

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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

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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.

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Nocturnal enuresis at 7.5 years old: prevalence and analysis of clinical signs

Butler,R.J.,* Golding,J., & Northstone,K., Dept Clin Psychol, Unit 2,Gateway,Whackhouse Lane, Leeds LS19 7XY, W Yorkshire, England

OBJECTIVE--To determine the prevalence of nocturnal enuresis (NE) in a large cohort of children at 7.5 years old, and to examine the frequency of variables such as gender, severity, associated elimination problems, and clinical signs within the identified group.
SUBJECTS AND METHODS--Of an original cohort of 13 971 infants alive at 12 months, 11 251 who were still active in the Avon Longitudinal Study of Parents and Children (ALSPAC) survey, were followed at 91 months. The mother or main carer was given a questionnaire which asked, amongst other items, about the presence and frequency of bedwetting, other elimination problems, and signs related to the wetting behaviour; 8269 (73.5%) questionnaires were returned and 8151 contained information on the frequency of bedwetting.
RESULTS--In all, 1260 children (15.5%) at 7.5 years wet the bed, but most wet once or less a week, and only 215 (2.6%) met the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) criteria of NE (wetting at least twice a week). A higher prevalence was reported in boys than girls and 266 children (3.3%) had both daytime wetting and bedwetting, with 189 (2.3%) having both daytime soiling and bedwetting. Daytime urgency increased with severity of bedwetting and occurred in 28.9% of children with NE.
CONCLUSION--At 7.5 years old the incidence of bedwetting is high, but only 2.6% of this large population-based sample wet at a frequency meeting the definition of NE. Although a small percentage of children had both daytime wetting and bedwetting, the evidence suggests that these are discrete problems. Amongst children with NE, indicators of bladder overactivity were present, supporting the view of heterogeneity and the importance of individual assessment in deciding on appropriate treatment.

Parents tend to be distressed by even occasional bedwetting accidents which may not meet recognized diagnostic criteria. Fortunately, an overlearning protocol can be implemented using the bedwetting alarm for children who wet the bed infrequently with considerable success. This procedure is described in my interventions as an option for parents. RWC

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Combination therapy with alarm and drugs for monosymptomatic nocturnal enuresis not superior to alarm monotherapy

Naitoh,Y., Kawauchi,A.*, Yamao,Y., Seki,H., Soh,J., Yoneda,K., Mizutani,Y., & Miki,T. Kyoto Prefectural Univ Med, Grad Sch Med Sci, Dept Urol, Kamigyo Ku, Kyoto 6028566, Japan

Objectives. To evaluate the effectiveness of alarm-based combination therapy using desmopressin and imipramine for primary monosymptomatic nocturnal enuresis.
Methods. Of the 105 patients, 37, were treated with alarm monotherapy (monotherapy group), 35 were treated with desmopressin combined with an alarm (desmopressin group), and 33 were treated with imipramine combined with an alarm (imipramine group). The therapeutic effects were evaluated at 3 and 6 months. The relapse rates and predictive factors of the therapies were also studied.
Results. No significant differences were found in the changes in the frequency of wet nights among the three groups, although the frequencies in all three groups decreased significantly with the therapeutic duration. Although the improvement rates at 3 months did not differ among the three groups, the improvement rate of 80% in the desmopressin group and 79% in the imipramine group at 6 months were greater than the 59% rate in the monotherapy group. After cure, no patients relapsed in the monotherapy group, and 3 (43%) each did so in the desmopressin and imipramine groups. In comparing the improved cases in each group, no significant differences were found in background factors.
Conclusions. Desmopressin and imipramine combined with an alarm was no more effective than alarm monotherapy. As for alarm monotherapy, other therapeutic modalities should be considered if it has not proved effective after 3 months. In such a situation, combination therapy may be effective as a second choice. No predictive factors for the therapeutic effects in the three modalities were found.

There were no relapses on Follow up with the bedwetting alarm by contrast to a 43% relapse rate with the use of the two most commonly used medications for bedwetting! The finding of no added benefit of using the medications in combination with the bedwetting alarm has been true of earlier and much older studies. The remission rate was lower that that commony reported which is usually in the 80%+ range. There could be some cultural factors operating to suppress the rates--e.g., smaller homes, closer sleeping proximity within the family, compliance issues, etc. ? The use of Follow-Up assessments is commendable. DrC.

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November 2005 CHILD CARE HEALTH AND DEVELOPMENT (v.31, 6) Pp 659-667. Posted on 10/25/2005.

Nocturnal enuresis: a survey of parental coping strategies at 7 ½ years

Butler,R.J.*, Golding,J., & Heron,J. Dept Clin Psychol, Unit 2, Gateway, Whackhouse Lane, Leeds LS19 7XY, W Yorkshire, England

Background: Childhood nocturnal enuresis is a potentially distressing experience. Parents have been found to adopt many approaches designed to help their child become dry at night. This study sought to understand, through a large cohort of children at 7(1)/(2) years of age, the strategies parents adopt, both during the child's development and currently, to help their child overcome bed-wetting.
Methods: A longitudinal cohort of 13 971 children with expected date of delivery between April 1991 - December 1992, in the County of Avon (Bristol) formed the population study group. At 7(1)/(2) years parents were asked, as part of a regular self-report questionnaire, what methods they had tried or were currently using to help their child stop bed-wetting. Eleven options were supplied.
Results: Of 8269 parents responding to the questionnaire, 3376 (40.8%) indicated they had tried at least one of 11 strategies, with restricting night-time fluids and lifting being the predominant methods employed. Amongst strategies employed in the past, lifting and showing displeasure were used significantly more by parents of children with nocturnal enuresis than by those with children dry at 7(1)/(2) years. However, a greater proportion of parents of dry children encouraged their offspring to toilet more regularly in the daytime than parents of those with nocturnal enuresis or infrequent wetting. In terms of treatment interventions, the enuresis alarm had been employed with 19.2% and medication with 13.1% of those with nocturnal enuresis, although only 31.9% of those with nocturnal enuresis had seen a health worker. The results are discussed in relation to preventative and clinical implications.

This was an enlightening survey on the usage of the bedwetting alarm which is likely much greater than in the USA. I don’t know of a similar parallel survey in the USA. The usage of the alarm in a greater proportion to the use of medications was also surprising and I suspect less likely in the USA where medication is almost surely used much more. My impression is that the BW alarm is more often recommended in England, Australia, New Zealand, and the Scandanavian countries than here in the USA with its cultural preference for oral medications to solve problems. The failure to report a child's enuresis to a health care worker in the majority of cases is apparently true for most cultures. RWC

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Enuresis alarm treatment

Butler,R.J.,* & Gasson, S.L. E Leeds Primary Care Trust, Dept Clin Psychol, Unit 2a, Child & Adolescnet Mental Hlth Serv, Whackhouse Lane, Leeds LS19 7XY, W Yorkshire, England

Objective. Treatment for childhood nocturnal enuresis emphasizes either a psychological or pharmacological approach. The enuresis alarm, in comparative studies, has emerged as the most effective psychological treatment. In this review we investigate both outcome rates and influential factors from recently published studies.
Material and methods. A search of papers published between 1980 and 2002 in the English language involving at least 10 children in which the enuresis alarm was employed as a stand-alone intervention revealed 38 studies.
Results. Heterogeneity in terms of inclusion and outcome parameters made comparison between studies problematic. The most frequently adopted definitions were "wet at least 3 times a week" in terms of severity at inclusion, "14 consecutive dry nights" as a success criterion and ">1 wet night a week" as a relapse criterion. Success rates across all studies ranged from 30% to 87% and were influenced by the type of enuresis, the treatment duration and the success criteria adopted. In an homogenous subset of 20 studies, 65% success with alarm treatment was found. Further analysis revealed equivalence between different forms of alarm, pre- and within-treatment predictors of outcome and possible mode of action. Relapse rates (ranging between 4% and 55%) were reported in 20 studies, with an homogeneous subset indicating that 42% of children relapsed following alarm treatment.
Conclusions. The enuresis alarm is an effective intervention for children with nocturnal enuresis. There are a number of factors, both pre- and within-treatment, that appear to influence its effectiveness and may assist clinical decisions concerning its appropriateness for any particular child.

I have requested a reprint from Dr. Butler and look forward to the details on the factors that bear on pre- and within-treatment factors that appear to affect outcome. RWC.

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Nov. 2005 ACTA PAEDIATRICA (v94, 11), Pp. 1619-1625. Posted on 12/12/2005

Attention-deficit/hyperactivity disorder (ADHD) as a risk factor for persistent nocturnal enuresis in children: A two-year follow-up study

Baeyens,D.*, Roeyers,H., Demeyere,I., Verte,S., Hoebeke,P., & VandeWalle, J State Univ Ghent, Fac Psychol & Educ Sci, Dept Psychol, Henri Dunantlaan 2, B-9000 Ghent, Belgium

Aims: A previous prevalence study indicated that the prevalence of ADHD is highly increased in enuretic children. In the current 2-yr follow-up study we investigate the relationship between both disorders further. Our goal is to determine whether the ADHD diagnoses can be reconfirmed and whether children with ADHD are more at risk for difficult-to-cure enuresis. Moreover, we explore the effect of medical enuresis parameters on the course of the voiding problem.
Methods: Eighty-six children with enuresis were screened twice on the presence of ADHD with a 2-y interval. A multi-method, multi-informant assessment of ADHD was used, the child's medical file was consulted, and a parent questionnaire on the child's current voiding problems was completed.
Results: Although 73% of all children with a 2-y-old diagnosis of ADHD still meet the disorder's criteria, only 66% of all subtype diagnoses can be reconfirmed. The odds that a child with ADHD still has voiding problems after 2 y are 3.17 times higher than for a child without ADHD. Although a slightly increased number of prescribed therapies in the ADHD group was noticed, no other significant differences in enuresis treatment methods were found between the groups. The medical parameters were not associated with treatment outcome.
Conclusion: Since 73% of ADHD diagnoses can be reconfirmed, the data suggest that the prevalence of the ADHD syndrome rather than reactive ADHD symptomatology is increased in enuretic children. Children with ADHD are at risk for persistent enuresis. Two-year-old medical enuresis parameters seem to have little effect on the current presence/absence of enuresis.

There is reference to "prescribed therapies" suggesting that these children were indeed treated specifically for their enuresis, but the number involved is too small to determine which treatment method, if any, might have been more successful. The observation of increased resistance to treatment and persistence of the enuresis after two years for children with ADHD over non-ADHD children is disappointing. Also, the study raises the question if treating the ADHD is beneficial for treating the enuresis either alone or by potentiating a subsequent specific treatment for the enuresis. Interested readers can contact or write the authors noted above. DrC.

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Alarm interventions for nocturnal enuresis in children - art. no. CD002911.pub2

Glazener,C., Evans,J.H.C., Peto, R.E., No address given, available on the internet.

Background: Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15 to 20% of five year olds, and up to 2% of young adults.
Objectives: To assess the effects of alarm interventions on nocturnal enuresis in children, and to compare alarms with other interventions.
Search strategy: We searched the Cochrane Incontinence Group specialised trials register (searched 22 November 2004) and the reference lists of relevant articles.
Selection criteria: All randomised or quasi-randomised trials of alarm interventions for nocturnal enuresis in children were included, except those focused solely on daytime wetting. Comparison
interventions included no treatment, simple and complex behavioural methods, desmopressin, tricyclics, and miscellaneous other methods.
Data collection and analysis: Two reviewers independently assessed the quality of the eligible trials, and extracted data.
Main results: Fifty five trials met the inclusion criteria, involving 3152 children of whom 2345 used an alarm. The quality of many trials was poor, and evidence for many comparisons was inadequate. Most alarms used audio methods. Compared to no treatment, about two thirds of children became dry during alarm use (RR for failure 0.38, 95% CI 0.33 to 0.45). Nearly half who persisted with alarm use remained dry after treatment finished, compared to almost none after no treatment (RR of failure or relapse 45/81 (55%) vs 80/81 (99%), RR 0.56, 95% CI 0.46 to 0.68). There was insufficient evidence to draw conclusions about different types of alarm, or about how alarms compare to other behavioural interventions. Relapse rates were lower when overlearning was added to alarm treatment (RR 1.92, 95% CI 1.27 to 2.92) or if dry bed training was used as well (RR 2.0, 95% CI 1.25 to 3.20). Penalties for wet beds appeared to be counter-productive. Alarms using electric shocks were unacceptable to children or their parents.
Although desmopressin may have a more immediate effect, alarms appear more effective by the end of a course of treatment (RR 0.71, 95% CI 0.50 to 0.99) and there was limited evidence of greater long-term success (4/ 22 (18%) vs 16/24 (67%), RR 0.27, 95% CI 0.11 to 0.69). Evidence about the benefit of supplementing alarm treatment with desmopressin was conflicting. Alarms were better than tricyclics during treatment (RR 0.73, 95% CI 0.61 to 0.88) and afterwards (7/12 (58%) vs 12/12 (100%), RR 0.58, 95% CI 0.36 to 0.94).
Authors' conclusions: Alarm interventions are an effective treatment for nocturnal bedwetting in children. Alarms appear more effective than desmopressin or tricyclics by the end of treatment, and subsequently. Overlearning (giving extra fluids at bedtime after successfully becoming dry using an alarm), dry bed training and avoiding penalties may further reduce the relapse rate. Better quality research comparing alarms with other treatments is needed, including follow-up to determine relapse rates.

The conclusions and findings contained no surprises and is consistent with my understanding of the literature. The full report will likely be most helpful for bringing researchers up to a base knowledge level. DrC.

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Nocturnal enuresis and overactive bladder in children: An epidemiological study

Kajiwara,M.,*, Inoue,K., Kato,M., Usui,A., Kurihara,M., & Usui,T. Hiroshima Univ, Grad Sch Biomed Sci, Programs Biomed Res, Dept Urol,Div Frontier Med Sci, Mnami Ku, 1-2-3 Kasumi, Hiroshima 7348551, Japan

Search Terms: Enuresis, Constipation, Epidemiology, Overactive Bladder,

Aims: To investigate the prevalence and characteristics of nocturnal enuresis (NE) and to examine the prevalence of overactive bladder (OAB) symptoms in primary schoolchildren.
Methods: After conducting an anonymous questionnaire survey about voiding habits and bowel habits in primary schoolchildren, a total of 6917 schoolchildren belonging to 11 primary schools were randomly enrolled in the survey. According to the International Continence Society, we defined NE as any involuntary loss of urine during sleep, occurring more frequently than once per month. Children with NE were subdivided into two groups, monosymptomatic NE (MNE) and enuretic syndrome (ES). To evaluate the characteristic differences of MNE and ES, we assessed the relationships between NE and voiding habits, and episodes of cystitis and constipation. Overactive bladder was defined as increased daytime frequency and/or urge urinary incontinence, and its prevalence was investigated.
Results: The response rate to the questionnaire was 76.4%. The prevalence of NE was 5.9% and was inversely related to increasing age. Monosymptomatic NE comprised 59.4% of NE cases. The annual spontaneous resolution rate of MNE was higher than that of ES. Increased daytime frequency, a history of cystitis and infrequent bowel habits were not related to MNE, but were significantly related to ES. The prevalence of OAB was 17.8%. Children with a history of cystitis had a significantly higher rate of OAB than children without it.
Conclusions: Overall, NE and OAB were detected in 5.9% and 17.8% of primary schoolchildren, respectively. The link between NE and OAB symptoms, urinary tract infections and constipation deserves more attention.

This is an extremely significant paper for looking at the concurrence of diurnal enuresis, nocturnal enuresis and encopresis and its developmental course. It suggests directions for future research on the effects of disease or learning factors involved on bladder and bowel control or failure. Interestingly, in this same weekly alert, there was a report on a phyiological connection/reflex arc between the bladder sphincter and the external
anal sphincter (EAS). That report is noted above toward the end of the Encopresis section. DrC.
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The prevalence of ADHD in children with enuresis: Comparison between a tertiary and non-tertiary care sample

Baeyens,D.*, Roeyers,H., D'Haese,L., Pieters,F., Hoebeke,P., & Vande Walle,J. Ghent Univ, Fac Psychol & Educ Sci, Dept Psychol, Henri Dunantlaan 2, B-9000 Ghent, Belgium

Search Terms: Enuresis, ADHD, Epidemiology

Objective: The main aim of the current study was to determine reliable comorbidity rates of ADHD for enuretic children admitted either to non-tertiary care or to a specialized paediatric clinic, i.e. tertiary care, since previous research has failed to incorporate a possible setting effect in this comorbidity; and to use a multi-method multi-informant assessment of ADHD.
Material and methods: Eighty children, aged between 6 and 12 y, admitted to non-tertiary care with enuresis and 120 children referred to tertiary care were screened for the presence of ADHD using a multi-method (diagnostic interview, questionnaires) multi-informant (parents, teachers) assessment.
Results: Enuretic children from the tertiary care sample have a 3.4 times increased chance of having comorbid ADHD when compared to children with enuresis admitted to non-tertiary care, corresponding to a prevalence rate of 28% and 10%, respectively. Overall, the tertiary care sample was older, showed more daytime incontinence and revealed an increasing prevalence of ADHD with older age when compared with the non-tertiary care group.
Conclusion: The prevalence rate of ADHD is increased in an enuretic population compared to community samples (3-5%). Moreover, enuretic children admitted to tertiary care show significantly higher comorbidity than non-tertiary care patients. The ADHD prevalence in the former group increases with older age, suggesting therapy resistance and a negative prognosis for enuresis in the case of comorbidity.

While this study suggests that ADHD suggests a poorer prognosis for the treatment of enuresis, it would appear to be all the more important to use the most effective interventions targeting the enuresis itself. ADHD medications have been shown to improve academic performance and intelligence measures such that they may be a helpful if not critical for successful treatment. RWC

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Bladder voiding in sleeping infants is consistently accompanied by a cortical arousal

Zotter,H.*, Sauseng,W., Ktschera,J., Mueller,W., & Kerbl,R.

Med Univ Graz, Dept Pediat, Div Neonatol, Auenbruggerpl 30, A-8036 Graz, Austria

Search Terms: Sleep, Arousal, EEG, enuresis, bladder

The aim of the study was to find out whether bladder voiding in healthy sleeping infants was accompanied by any arousal reaction. Polygraphic recordings were performed in 21 healthy infants (11 female) born at term. The infants' age at study entry was 42 +/- 4 days and actual body weight was 4852 +/- 689 g (mean +/- SD). Bladder voiding was recorded by an adapted enuresis detector which was connected to the polygraphic computer unit. Arousals were defined as suggested by the 'International Paediatric Work Group on Arousals'. Awakenings were excluded from the study. Bladder voiding was recorded at a mean time of 68 +/- 7 min after the infant had fallen asleep and occurred during quiet sleep (QS). Electroencephalogram frequency (P <0.01) and heart rate (P < 0.05) were higher during the 5-s period before and after bladder voiding when compared with a 30-s interval before voiding. Furthermore, bladder voiding was accompanied by body movements in all infants. Respiratory frequency did not change significantly. We could demonstrate for the first time in sleeping infants, that bladder voiding during QS was accompanied by a cortical arousal.

Intriguing finding confirming a mediating brain mechanism serving as a basis for children gradually becoming continent at night. They, so to speak, have a built in natural alarm for anticipating voiding which will work for the vast majority of children toward becoming dry at night. It would serve as a basis for the effectiveness of the bedwetting alarm should it become necessary to condition continence.

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Neurophysiology of nocturnal enuresis: evoked potentials and prepulse inhibition of the startle reflex

Freitag,C.M., Rohling,D., Seifen,S., Pukrop,R., & von Gontard,A.* Saarland Univ Hosp, Dept Child & Adolescent Psychiat, Homburg, Germany

Search Terms: Enuresis, Evoked Potentials, micturition, sleep, arousal

Nocturnal enuresis is a genetically determined maturational disorder of the central nervous system. Lack of arousal and an inhibition deficit of the micturition reflex have been found as the main dysfunctions leading to wetting during sleep. Both are mediated by nuclei in the brainstem. Therefore, evoked potentials (brainstem auditory evoked potential [BAEP], visual evoked potential [VEP], event-related late acoustic-evoked potential [P300]), and the prepulse inhibition (PPI) of the startle reflex were assessed to further evaluate the brainstem deficit compared with cortical function. Thirty-seven children with nocturnal enuresis, aged 8 years to 14 years 8 months (mean age 10y 7mo [SD 1y 10mo]; 27 males, 10 females) were compared with 40 controls (mean age 10y 7mo [SD 1y 6mo]; 17 males, 23 females). Left interpeak latencies I-III and I-V of the BAEP were increased in children with nocturnal enuresis. VEP measures did not differ between patients and controls. However, children with a positive family history of enuresis showed a shorter latency towards N75 and P100 than children without such a family history. P300 and PPI measures did not differ. We conclude that this strongly supports the postulation of a maturational deficit of the brainstem in nocturnal enuretic children. The increased interpeak latencies I-M and I-V of the BAEP support the hypothesis of an arousal deficit mediated by delayed maturation of brainstem function. Differences in VEP latencies might point towards functional cortical differences in children with a family history of nocturnal enuresis.

This finding with an electrical signature characteristic of enuretic children may be illustrative of a habit deficiency, perhaps occasioned by a maturational delay, but wouldn't it be interesting to see if an application of the bedwetting alarm would restore a more typical, mature signature? RWC.

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The evaluation and treatment of therapy-resistant enuresis: A review

T Neveus, Univ Uppsala, Childrens Hosp, S-75185 Uppsala, Sweden

Search Terms: enuresis, bedwetting

Children with enuresis that neither responds to the alarm or to desmopressin medication usually have nocturnal detrusor over-activity combined with high arousal thresholds as a cause for their bedwetting.

The evaluation of these children is focused on 1) excluding underlying pathology such as kidney disease, urinary tract infection or neurogenic bladder, 2) looking for concomitant day-time bladder problems or constipation, and 3) detecting possible reasons for failure of alarm treatment. A bladder diary is essential, but blood tests, radiological examinations or invasive procedures are seldom informative.

The non-pharmacologic treatment of these children consists of eradication of constipation, if present, and the provision of advice regarding sound drinking and toilet habits. Such treatment is
essential but not uniformly sufficient by itself.

The first-line pharmacologic treatment of therapy-resistant enuresis is anticholinergic medication, although this is, as yet, not evidence-based. Anticholinergics can be combined with desmopressin for better efficiency. For children failing all these measures there is still a place for tricyclic antidepressant therapy, provided that adequate safety precautions are strictly observed.

This accords well with my own observations, but I believe in testing the limits and utilize special "intensification" procedures to abet arousal and conditioning bladder control in my interventions before any consideration of going to medications. Also, I emphasize the use of volume measures over the course of treatment to monitor and adjust my intervention as needed which is not typically done for most behavioral interventions. RWC.

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Prospective evaluation of inpatient and outpatient bladder training in children with functional urinary incontinence

Heilenkotter,K., Bachmann,C., Janhsen,E., Stauber,T., Lax,H., Petermann,F. & Bachmann,H.*
Klinikum Links Weser, Dept Pediat, Senator Wessling Str 1, D-28277 Bremen, Germany

Search Terms: Enuresis, Bedwetting

Objectives. To evaluate, in a prospective study, the effectiveness of a bladder training program. Daytime and/or nighttime wetting as a consequence of functional urinary incontinence is a common problem in childhood. Various treatment options are available, including with cognitive-behavioral "bladder training."
Methods. Sixty patients (age 8 to 12 years) with urge incontinence or dysfunctional voiding were evaluated. After a no-treatment control period (average 6 months), patients underwent a 6-day bladder training course, which was offered either as inpatient or outpatient training, leaving the choice to the patients' parents. Clinical assessments were recorded at the beginning of the control period, at training entry and training completion, and after 1 (inpatient training group only), 3, and 6 months.
Results. Six months after training completion, 64.1% and 64.7% of the inpatient and outpatient groups with daytime wetting and 51.5% and 17.7% of the inpatient and outpatient groups with nighttime wetting were cured or had improved, respectively. The spontaneous cure rate during the 6-month control period was 0% to 20.5%. Of the inpatient group with urge incontinence, the functional bladder capacity increased by 15%. The children aged 9 to 12 years in the inpatient
group had significantly greater cure rates than the 8-year-old children.
Conclusions. Compared with the control period, the bladder training program evaluated in this study resulted in significantly greater success rates. The results lead to the assumption that children with nighttime wetting treated in the inpatient training will succeed better than those in outpatient training. The cure and improvement rates of daytime wetting were greater than those for nighttime wetting.

I have requested a reprint from the authors to acquire more specific information on their interventions. I must say I can’t imagine inpatient training as possible in US society today under all of the pressures for controlling health care costs. DrC.

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Detection of neurogenic detrusor contractions from the activity of the external anal sphincter in cat and human.

Wenzel,B.J., Boggs,J.W., Gustafson,K.J., Creasey,G.H. & Grill,W.M.* Duke Univ, Dept Biomed Engn, Hudson Hall,Rm 136,Box 90281, Durham, NC 27708 USA

Search Terms: Enuresis, external anal sphincter, detrusor m, EMG, neurogenic bladder KW -

Aims: Individuals with spinal cord injury or neurological disorders may develop bladder contractions at low volumes (neurogenic detrusor overactivity), which can lead to significant health problems. Present devices can inhibit unwanted contractions through continuous electrical stimulation of sensory nerves, but do not enable conditional stimulation only at the onset of bladder contractions. The objectives of this study were to determine the relationship between the electrical activity of external anal sphincter (EAS) and bladder pressure during neurogenic detrusor contractions and to determine whether EAS activity could be used to detect the onset of bladder contractions.
Methods: Bladder pressure and EAS electromyogram (EMG) were recorded in nine adult male cats. Retrospective clinical data consisting of bladder pressure and EAS EMG from 41 spinal cord injured individuals with neurogenic detrusor overactivity were analyzed. A CUSUM algorithm was used to detect the onset of bladder contractions from the EAS EMG. Results: EAS EMG activity increased at the onset of bladder contractions in six cats (dyssynergic) and decreased (synergic) in three cats. The onset of bladder contractions was detected within 3 sec of the start of the contraction for both the synergic and dyssynergic data sets. The onset of bladder contractions was detected within 1 sec of the start of the bladder contraction for both synergic and dyssynergic human subjects.
Conclusions: Recordings of the EAS EMG can be used to detect robustly the onset of neurogenic detrusor contractions. The EAS EMG is a suitable signal to control closed-loop inhibitory electrical stimulation to maintain urinary continence.

This was an interesting finding to me because of the role of the EAS in signaling bladder contractions. This could be an underlying basis for why bladder incontinence may accompany encopresis. My speculation is that the EAS is constantly triggered by voluntary, overlearned stool hoarding efforts which may interfere with or confuse EAS contractions to bladder contractions. Coordination difficulties in EAS and urinary sphincter activation to bladder contractions may result in both bowel and bladder accidents. In any event this study has important clinical implications for children with spinal cord or other neurological conditions which can be independently diagnosed. RWC.

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Half-day urotherapy improves voiding parameters in children with dysfunctional emptying.

Bower,W.F.*, Yew,S.Y., Sit,K.Y.F., Yeuny,C.K. Chinese Univ Hong Kong, Prince Wales Hosp, Dept Surg, Shatin, Hong Kong, Peoples R China

Search terms: bladder, enuresis,

Objective: Children with voiding dysfunction benefit from intensive bladder emptying re-education; however, hospitalization for such training is not always financially viable or realistic. The aim of this study was to evaluate whether half-day voiding re-education in pairs improved immediate and mid-term voiding parameters.
Methods: 48 children (mean age, 8.9 years; 54% male) identified in the urotherapy clinic as having either (1) abnormal uroflow curves, (2) a postvoid residual urine (PVRU) > 10% of voided volume, or (3) proven dysfunctional voiding, were recruited and age- and gender-matched. Training over a half day included postural instruction, abdominal wall muscle pattern recognition, pelvic floor muscle relaxation training, and supervised voiding. Data from the initial clinic visit was compared to that after training, and at 1 and 3 mo follow-up. Families completed a questionnaire after the session.
Results: Urine flow curves were abnormal in 76.2% of initial clinic visit voids, 14% of patients after the half-day training session, and 11.7% of children at the 3-mo follow-up. Initial emptying efficiency voided volume as a percentage of total bladder volume for that void) and mean PVR significantly improved following half-day training with gains maintained at both follow-up visits.
Conclusion: Training children in pairs over a half day resulted in significantly improved bladder emptying that was sustained at the 3-mo follow-up. (c) 2005 Elsevier B.V. All rights reserved.

This emphasis on successful, more complete voiding is of considerable interest for daytime bladder incontinence training. In some ways it resembles mechanisms that may underlie stool hoarding on the bowel evacuation/encopresis side. RWC.

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Internalizing and externalizing problem behavior in children with nocturnal and diurnal enuresis: A five-factor model perspective

Van Hoecke,E.*, De Fruyt,F., De Clercq,B., Hoebeke,P., & Vande Walle,J. Ghent Univ Hosp, Pediat Uro Nephrol Ctr, Pintelaan 185, B-9000 Ghent, Belgium

Search Terms: Enuresis, behavior problems, personality.

Objectives: To describe personality traits, internalizing, and externalizing problems of 6- to 12-year-old children with nocturnal and diurnal enuresis, examining differences from healthy referents, and investigating the association between personality traits and problem behavior.
Methods: Eighty-five children with combined nocturnal and diurnal enuresis were compared with 56 children with nocturnal enuresis and 155 healthy children on personality characteristics and problem behavior.
Results: Post hoc analyses of multivariate analyses indicated that parents of children with combined nocturnal and diurnal enuresis reported on average lower conscientiousness and higher neuroticism scores in their children than parents of healthy children, although the magnitude of these differences was moderate. Considerable differences in mean scores were found for the Child Behavior Checklist (CBCL) total problem scale and moderate differences for internalizing, externalizing, and attention deficit hyperactivity disorder (ADHD) problems in children with nocturnal and diurnal enuresis compared with healthy referents. Regression analyses across enuretic and healthy groups demonstrated that personality trait and problem behavior scales share substantial variance.
Conclusion: Moderate to substantially higher levels of problem behavior is demonstrated in children with nocturnal and diurnal enuresis, who also display slightly higher neuroticism and lower conscientiousness scores.

This study was valuable in demonstrating differences in behavior associated with enuresis vs. its absence, but it does not indicate if it is a cause or an effect of the enuresis itself. Any study on enuresis should routinely assess for changes in behavior following treatment. My own research shows a reduction in many symptoms (an average of 4 fewer behavioral symptoms) across the board with treatment. RWC.

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May 2006 BJU INTERNATIONAL (v97, 5), Pp. 1069-1073. Posted on 06/05/2006.

Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study.

Yeung,C.K.*, Sreedhar,B., Sihoe,J.D.Y., Sit,F.K.Y., & Lau,J. Chinese Univ Hong Kong, Dept Surg, Div Paediat Surt & Paediat Urol, Prince Wales Hosp, Shatin, Hong Kong, Peoples R China

Search Terms: enuresis, epidemiology, children, adolescents,

AIMS: To evaluate any differences in the characteristics of primary nocturnal enuresis (PNE) between younger enuretic children and adolescents.
SUBJECTS AND METHODS: In all, 21 000 questionnaires designed to determine the presence or absence of bed-wetting, diurnal incontinence, frequency of wetting, systemic illness, and family history, were sent to children aged 5-19 years from 67 kindergartens, primary schools and secondary schools randomly selected by a computer from different areas in Hong Kong. In addition, questions were asked to evaluate when and how the parents became aware that bed-wetting is a significant medical problem deserving attention in children after the age of 5 years.
RESULTS: Of the 21 000 questionnaires distributed, 16 512 (78.6%) were completed. Among the respondents, 512 children (302 boys, 210 girls) had PNE; of these, 106 (20.7%) also had daytime incontinence. There was a marked reduction in the overall prevalence of PNE with advancing age. At 5 years old, 16.1% of children had PNE (20.7% boys, 10.8% girls; at age 9 and 19 years, 3.14% and 2.2% of children had PNE, respectively. However, this reduction was significantly more apparent among those with mild enuretic-symptoms (wet < 3 nights/week) than in those with more frequent bed-wetting. Furthermore, younger enuretic children behaved very differently from adolescents and older patients. As age increased there was a significant tendency towards more severe enuretic symptoms. At age 5 years, 14.3% of enuretic children wet 7 nights/week, compared with 48.3% at age 19 years (P < 0.001). In addition, significantly more adolescent boys aged > 10 years had daytime urinary incontinence than had enuretic children aged <= 10 years (32% vs 14.6%, respectively, P< 0.001). Most (89%) parents only became aware that bed-wetting was a significant medical problem deserving attention through material in the mass media over the past 3-4 years.
CONCLUSIONS: The present finding suggesting that PNE spontaneously resolves with increasing age probably applies only to those with mild enuretic symptoms. There are significant differences in characteristics between younger enuretic children and older subjects. As age increases there is an increasing proportion of enuretic patients with more severe bed-wetting. Enuretic children aged > 10 years and adolescents have significantly more daytime urinary symptoms and incontinence. The previously reported low prevalence of PNE in Hong Kong was probably due to parental indifference to the problem.

The divergence in the percentage of severe enuresis for the older children in contrast to younger ages were quite striking and surprising. This was a remarkable study and the degree of parental cooperation was remarkable. The incidence of enuresis reported appears to be in line with other studies done in other countries. RWC.

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The daytime alarm: A useful device for the treatment of children with daytime incontinence

Van Laecke,E.,* Wille,S., Walle,J.V., Raes,A., Renson,C., Peeren,F., Hoebeke,P.
State Univ Ghent Hosp, Paediat Uronephrol Ctr, Dept Pediat Urol, Pintelaan 185, B-9000 Ghent, Belgium

Search Terms: Enuresis, Diurnal, Daytime, Alarm

Purpose: We present the results of the use of a daytime wetting alarm as treatment for therapy resistant daytime wetting in children with an overactive detrusor.
Material and Methods: In a retrospective study we reviewed the files of 63 children treated with a daytime alarm because of persistent daytime wetting. Results were considered a complete success when the children were completely dry after treatment, a partial success when there was greater than 50% improvement in daytime wetting and a failure when no change was observed in daytime symptoms.
Results: During a study period of 25 months 63 children were treated with a daytime alarm at the department of pediatric urology. The mean treatment period was 14 days. At a followup of 12 months treatment failed in 20 children (32%), 21 (33%) had partial success and 22 (35%) were successfully treated.
Conclusions: In children with therapy resistant daytime wetting and an overactive detrusor the daytime alarm may be a useful treatment tool. Complete cure of daytime incontinence can be attained in 35% of patients, almost a third have improvement in their complaints and training fails in a third.

This study has been much needed and awaited by many of us. I like it because it is the classical conditioning paradigm applied to the daytime wetting problem as it has been applied to nighttime wetting. The diagnosis of an overactive detrussor really biases against success, so it is clearly not a panacea for these children, but may be even more successful for those who are not so diagnosed. The difficulty I would see is parental and child acceptance in our country because of possible embarassment from an alarm going off. Possibly a vibration signal would suffice. I've never done this in my treatment programs, but now would consider case studies for doing it.

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The effect of botulinum-A toxin in incontinent children with therapy resistant overactive detrusor

Hoebeke,P.,* De Caestecker,K., Walle,J.V., Dehoorne,J., Raes,A., Verleyen,P., Van Laecke,E.
State Univ Ghent Hosp, Dept Pediat Urol, Pintelaan 185, B-9000 Ghent, Belgium

Search Terms: Daytime, diurnal, enuresis, overactive, bladder, botulinum

Purpose: We determined the effect of detrusor injection of botulinum-A toxin in a cohort of children with therapy resistant nonneurogenic detrusor overactivity. This prospective study included therapy resistant children with overactive bladder.
Material and Methods: During the study period of 19 months 10 boys and 11 girls were included. All patients showed decreased bladder capacity for age, urge and urge incontinence. Main treatment duration before inclusion was 45 months. A dose of 100 U botulinum-A toxin (Botox (R)) was injected in the detrusor.
Results: Side effects were evaluated in all 21 included patients. The side effects reported were 10-day temporary urinary retention in I girl and signs of vesicoureteral reflux with flank pain during voiding in I boy, which disappeared spontaneously after 2 weeks. No further examinations were done since the boy refused. Two girls experienced I episode each of symptomatic lower urinary tract infection. Eight girls and 7 boys with a minimum followup of 6 months represent the study group for long-term evaluation. In this study group after 1 injection 9 patients showed full response (no more urge and dry during the day) with a mean increase in bladder capacity from 167 to 271 ml (p < 0.001). Three patients showed a partial response (50% decrease in urge and incontinence) and 3 remained unchanged. Eight of the 9 full responders were still cured after 12 months, while 1 of the initially successfully treated patients had relapse after 8 months. The 3 partial responders and the patient with relapse underwent a second injection with a full response in the former full responder and in 1 partial responder.
Conclusions: Botulinum-A toxin injection in children with nonneurogenic overactive detrusor is an excellent treatment adjunct, leading to long-term results in 70% after 1 injection.

This study on the overactive bladder was done by the same group just proceeding this abstract using the daytime alarm. These results are very encouraging. RWC

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Breastfeeding during infancy may protect against bed-wetting during childhood.

Barone,J.G.,* Ramasamy,R., Farkas,A., Lerner,E., Creenan,E., Salmon,D., Tranchell,J., & Schneider,D. Univ Med & Dent New Jersey, Robert Wood Johnson Med Sch, Dept Urol, 1 Robert Wood Johnson Pl,MEB 588E, New Brunswick, NJ 08901USA

Search Terms: enuresis, breastfeeding, nursing, mothers

OBJECTIVE. Our goal was to test the hypothesis that children who exhibit bed-wetting during childhood were less likely to be breastfed during infancy compared with normal controls.
METHODS. A case-control study was conducted in a pediatric continence center and a general pediatric practice. Cases (n = 55) were recruited from the continence center and defined as children 5 to 13 years of age who experienced lifetime involuntary voiding of urine during nighttime sleep at least 2 times a week in the absence of defects of the central nervous system or urinary tract. Age- and gender-matched controls (n = 117) who did not exhibit bed-wetting were enrolled from a general pediatric practice. Infant feeding practices were measured as breastfeeding (yes/no) and, for those who were breastfeed, by the duration of breastfeeding and the time of formula supplementation.
RESULTS. Among the case subjects, 45.5% were breastfed, whereas among the controls 81.2% were breastfed. The controls reported higher household incomes than the case subjects, and their mean family size (number of children) was slightly lower. After adjusting for race, income, and family size, the odds ratio was 0.283, indicating that case subjects were significantly less likely than controls to be breastfeed. Among all the study subjects who were breastfed, controls were breastfed for a significantly longer period than case subjects (an average of 3 months longer). Although breastfed controls were less likely to be supplemented with formula than breastfed case
subjects, this difference was not statistically significant.
CONCLUSIONS. Breastfeeding longer than 3 months may protect against bed-wetting during childhood. Breast milk supplemented with formula did not make a difference in the rate of enuresis.

I’m including this study out of general interest and because my wife was a long-time La Leche League leader. The theory behind the hypothesis being tested was not made at all clear in this abstract. This finding at least adds to many of the known benefits of breastfeeding when done for a sustentative period of time. DrC.
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December, 2006 INTERNATIONAL JOURNAL OF CLINICAL PRACTICE (v60,Sup1), Pp. 27-32. Posted on 12/12/2006.

Extended experience with the use of botulinum toxin A in children with non neurogenic voiding dysfunction

Patel,A.K., Patterson,J.M., & Chapple,C.R. Royal Hallamshire Hosp, Sheffield Teaching Hosp NHS Trust, Urol Res Dept, J Floor,Glossop Rd, Sheffield S10 2JF, S Yorkshire, England

Search Terms: Enuresis, overactivity, bladder, detrusor, urgency, botulinum, botox, anti-spasmodic

Recently there has been considerable original research into the use of the botulinum neurotoxins in idiopathic detrusor overactivity (DO). This common condition underlies the overactive bladder syndrome in a significant proportion of cases and was previously known as idiopathic detrusor instability. Failure of initial pharmacotherapy in this condition leaves few effective conservative/medical treatment options. Early reports of botulinum toxin (BoNT) therapy have been extremely promising, and the therapy appears to bridge the gap in such patients, before resorting to invasive surgical procedures. Approximately 30 studies have been reported often with widely differing techniques and some clinicians are beginning to administer BoNT for this unlicensed indication. This has led to the urgent need to critically review all available evidence to assess efficacy, safety and technique. In addition to performing a systematic Medline review, all abstracts presented to urological, urogynaecological and incontinence meetings that reported BoNT usage in idiopathic DO were analysed. Remarkable efficacy has been demonstrated in the vast majority of reported series and the treatment has also been used safely in paediatric and elderly populations. Side effects in all populations appear to be minimal and short lived. However, all the series are small and there remains a considerable number of fundamental questions to be answered. Hopefully large-scale robust randomised controlled trials will provide the necessary answers to facilitate the widespread adoption of this technique. Until then caution must be exercised in this unlicensed indication.

If my protocol for night and daytime wetting fails and anti-spasmodic medications for the bladder fail or are not tolerated because of side-effects, then the use of Botox might be considered. Its use is off-label and must still be considered experimental. RWC.

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December 2006 Journal of Pediatric Urology 2(6): 579-582

Refractory Enuresis Related To Alarm Therapy

Kawauchi A, Naitoh Y, Yoneda K, Soh J, Seki H, Okihara K, Mizutani Y, Miki T

UroToday.com- A study from Japan evaluated refractory enuresis related to alarm therapy. The group evaluated the possibility of predicting refractory cases, the effectiveness of alarm therapy for these cases and the prognosis of non-responders to alarm therapy. They tested the effectiveness of alarm therapy in 55 monosymptomatic patients and 29 patients with daytime symptoms. They also treated 37 patients with monosymptomatic nocturnal enuresis also by alarm therapy. They compared possible predictive factors between these groups. They also evaluated the effect of alarm monotherapy for non-responders to pharmacotherapy. They also studied the prognosis of non-responders to alarm therapy at a 6 month interval.

The group found that in 55 monosymptomatic patients, the total effective rate at 3 months was 59%. In the 29 patients with daytime symptoms, it was 38%. The 37 patients with monosymptomatic nocturnal enuresis had no significant differences between the effective patients and the no change patients in relation to predictive factors. In patients who previously had pharmacotherapy, the effective rate of alarm therapy was 64%. This was not statistically significant when compared to the 57% effectiveness in patients without previous therapy. The pharmacotherapy that was studied was DDAVP and imipramine. The group found that the effective rates of these 2 drugs for non-responders to alarm monotherapy was only 25% for the DDAVP and 33% for the imipramine group.

The group concluded that daytime symptoms were the only predictive factor for alarm therapy. Alarm therapy was effective for cases refractory to pharmacotherapy. Non-responders to alarm therapy were also refractory to pharmacotherapy. It appears from this study that the alarm therapy may be a good first line choice in the treatment of nocturnal enuresis in the motivated patient population.

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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

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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.

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Assisted infant toilet training in a Western family setting.

Sun,M., & *Rugolotto,S., Policlin, Pediat Clin, Via Menegone 10, I-37134 Verona, Italy

In the Western world, independent toilet training usually starts at age 18 months or later. In Asia and Africa, assisted toilet training traditionally starts between one and three months and is completed within approximately one year. This article reports a male infant who started caregiver-assisted toilet training at age 33 days in a Western family setting. During the first days, the caregiver made observations of the infant's bowel movement schedule and the cues he provided, from which she learned when to assist him to eliminate in the bathroom. During the elimination process, the infant was held in an "in-arms" position, with close contact between the infant's back and the caregiver's chest. Meanwhile, the caregiver gave vocal signals to prompt the infant to eliminate. Successful bowel training was completed at five months. This case report shows that early infant toilet training is possible in a Western family setting if the caregiver properly learns the infant's natural elimination timing and signals.

This is an important professional acknowledgement about a cultural training practice that I have usually heard associated with grandmothers looking after children in China. There is a website devoted to this practice by an American mom and I have talked with her, but have lost track of her. I found her! See the next article. RWC.

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Extended diaper wearing: Effects on continence in and out of the diaper.

Tarbox,R.S.E., *Williams,W.L., & Friman,P.C. Univ Nevada, Dept Psychol, Reno, NV 89557 USA

Diaper use is widespread and possibly even increasing across diverse populations in the United States, ranging from infants to very old adults. We found no reports of an experimental analysis of the effect of wearing diapers on the frequency of urinary accidents and the attainment of continence skills (e.g., urinating in the toilet). In this study, we used a withdrawal design to evaluate the effect of wearing diapers on daily urinary accidents and successful voids for an adult who had been diagnosed with mental retardation. Results indicated that wearing diapers increased the rate of accidents and decreased the rate Of Successful voids. Clinical implications of these results are discussed.

This is a nice supportive finding for the negative consequences of keeping children in diapers, which I have mentioned in my writings and citations on encopresis and in the introductory paragraph under the Diagnosis tab at the top of all of these pages. I was surprised to see this expanded to the training for bladder control. I was asked to be a spokesperson at one time for a diaper manufacturer about 20 years ago, they were surprised at my intense negative reaction. Sigh-h-h-h, I would have been assurred a more secure retirement! It is also the basis for my Dump Diapers logo and domain (which only points to this site). However, the disposable diaper manufacturers are very successful and expanding their lines to diaper even larger children! RWC.

Factors associated with difficult toilet training.

Schonwald,A.*, Sherritt,L., Stadtler,A., & Bridgemohan,C. Childrens Hosp, Div Gen Pediat, 300 Longwood Ave,Fegan 10, Boston, MA 02115 USA

Objective: To identify temperament and behavioral patterns in children with difficult toilet training and to compare those children with same-aged toilet-trained children.
Methods: We compared 46 referred clinic patients who were difficult toilet trainers (DTT) with 62 comparison children ( CC) using the Carey-McDevitt Behavioral Style Questionnaire, the Parenting Scale, and a questionnaire of toilet-training history.
Results: CC were more likely to have easy temperaments (odds ratio [OR]: 33.51). DTT were more likely to be less adaptable ( OR: 3.12), more negative in mood ( OR: 2.79), less persistent ( OR: 2.97), and lower in approach ( OR: 1.85). DTT were more likely than CC to be constipated ( OR: 3.52), although 55% of CC were constipated. Parenting styles did not differ between the groups.
Conclusions: Although the referral population may be inherently biased, these data suggest that difficult toilet training is associated with difficult temperamental traits and constipation in affected children.

The most repeated findings I have encountered predictive of encopresis comes from the observation above that: DTT were likely to hide to stool (74%) and to ask for pull-ups in which to leave stool (37%). I see a lot of these temperament traits in encopretic children, but I don't know how "causal" they are. RWC.

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During toilet training, constipation occurs before stool toileting refusal.

Blum,N.J.*, Taubman,B., & Nemeth,N. Univ Penn, Childrens Hosp Philadelphia, Sch Med, Div Child Dev & Rehabil, Childrens Seashore House,3405 Civ Ctr Blvd, Philadelphia, PA 19104 USA

Background: Previous studies demonstrated that constipation and painful defecation are associated with stool toileting refusal (STR), but whether they are the result of STR or occur before this behavior is not known.
Objective: To determine whether constipation and painful defecation occur as a result of STR or occur before STR.
Methods: Three hundred eighty children between 17 and 19 months of age participated in a prospective longitudinal study of toilet training. Children were monitored with telephone interviews every 2 to 3 months until the completion of daytime toilet training. Information obtained in follow-up interviews included parents' reports on the presence and frequency of hard bowel movements, painful defecation, and child toilet training behaviors. Children were defined as completing daytime toilet training when they were experiencing < 4 urine accidents per week and &LE; 2 episodes of fecal soiling per month. Children were defined as having frequent hard bowel movements if the parents reported a hard bowel movement approximately once per week in &GE; 2 follow-up telephone interviews or more than once per week in 1 follow-up telephone interview.
Results: The mean age at the completion of daytime toilet training was 36.8 +/- 6.1 months (range: 22 - 54 months). Ninety-three children (24.4%) developed STR. Parents of children who developed STR, in comparison with the rest of the sample, were more likely to report that the child had experienced hard bowel movements (67.7% vs. 50.9%), frequent hard bowel movements (29.0% vs 14.3%), and painful defecation (41.9% vs. 27.9%). Of the children who experienced both STR and hard bowel movements, 93.4% demonstrated constipation before the onset of STR. In that group, parents reported hard bowel movements at almost one-half of all follow-up telephone interviews before the onset of STR. Of the children who experienced both STR and painful defecation, 74.4% experienced the first episode of painful defecation before the onset of STR. Children with frequent hard bowel movements demonstrated a longer duration of STR (9.0 +/- 6.5 vs 4.8 +/- 3.0 months).
Conclusions: When hard bowel movements or painful defecation is associated with STR, the first episode of constipation usually occurs before the STR. The fact that hard bowel movements frequently occur before the onset of STR suggests that for many of these children constipation is a chronic problem that is not being treated effectively. Therefore, hard bowel movements and painful defecation are factors that potentially contribute to the STR and for the majority of children are not caused solely by the STR behavior. Additional studies are needed to determine whether earlier and more effective treatment of constipation could decrease the incidence of STR.

This is a very key finding and a real cautionary note for what parents should look out for during toilet training. Though it could well be too late when it is realized. That is why I wrote the Clean Kid Manual for kids 4 y/o and older. Until then, see a pediatrician and read all of the articles above under Encopresis and Toilet Training. RWC.

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Blum,N.J.*, Taubman,B., & Nemeth,N. Univ Penn, Childrens Hosp Philadelphia, Div Child Dev & Rehabil, Sch Med, 3405 Civ Ctr Blvd,Childrens Seashore House, Philadelphia, PA 19104

Recent studies suggest that children are completing toilet training much later than the preceding generation. Our objective was to identify factors associated with later toilet training. Children between 17 and 19 months of age (n = 406) were enrolled in the study. At enrollment, parents completed the Parenting Stress Index and the Receptive-Expressive Emergent Language Scale. Follow-up parent interviews were conducted every 2 to 3 months until children completed daytime toilet training. Information obtained at follow-up interviews included steps parents were taking to toilet train their child, child toilet training behaviors, presence and frequency of constipation, birth of a sibling, and child care arrangements. In a stepwise linear regression model predicting age at completion of toilet training, 3 factors were consistently associated with later training: initiation of toilet training at an older age, presence of stool toileting refusal, and presence of frequent constipation. Models including these variables explained 25% to 39% of the variance in age at completion of toilet training. In conclusion, a later age at initiation of toilet training, stool toileting refusal, and constipation may explain some of the trend toward completion of toilet training at later ages.

Interesting findings. Are children intimidating their parents to back off? Are their inadequate interventions for toilet refusal and constipation? Could the reverse be true, that more powerful cultural issues and practices are delaying the onset of toilet training resulting in toileting refusal and constipation? That is, two working parents, overwhelmed single parents, the ready availability and convenience of diapers and pull-ups, could be working to delay the onset of training. The finding of initiating toilet training at an older age is a relevant finding in this regard. How did Blum enroll these families? If a notice went out for parents to enroll in toilet training program this could well have introduced a selection bias. Then the factors that emerged would have been more likely, though they are important findings that would contribute to “completing toilet training”. That is toilet training would be much more protracted. This study has provocative implications both more broadly and within families. RWC.

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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.

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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