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Fecal Incontinence Bowel Management: Pediatric Bowel Management 2013
With Dr. Todd Ponsky
Chapter 1 of 4 · Fundamentals
Incontinence types
True vs. Pseudo Fecal Incontinence: Definitions and Causes
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
True fecal incontinence patients lack bowel control ability either congenitally or from acquired damage; pseudo incontinence is constipation with overflow soiling.
Congenital true incontinence includes myelomeningocele, large sacrococcygeal tumors, absent sacrum, and anorectal malformations with sacral ratio <0.4, presacral mass, or tethered cord.
Acquired true incontinence occurs in Hirschsprung patients with damaged anal canal or ARM patients with good prognosis who had complications (dehiscence) requiring reoperation.
Treatment for true fecal incontinence is enema to artificially clean the colon and prevent bowel movements for 24 hours.
Pseudo fecal incontinence patients have bowel control ability but suffer from constipation; treatment is laxatives, not enemas.
A sacral ratio less than 0.4 predicts true fecal incontinence.
Removing a presacral mass does not improve continence because the nerve damage from the sacral defect is the cause of incontinence, not the mass itself.
If a presacral mass causes severe rectal compression and stricture, removing the mass does not cure the stricture; the stricture area must be resected and normal rectum pulled through.
Presacral masses must be resected because they can cause infection leading to meningitis or may be malignant, not to improve continence.
Tethered cord release does not improve bowel control; some neurosurgeons believe it may help bladder function, but this is controversial.
There is no scientific consensus on tethered cord management; some neurosurgeons operate aggressively, others do not, and outcomes vary widely regardless of intervention.
Myelomeningocele patients typically have non-dilated or redundant colons on contrast enema, not dilated colons, even when constipated and incontinent.
Neuronal intestinal dysplasia (NID) lacks scientific validity: no topographic studies define disease extent, no standard treatment exists, and pathologists disagree on diagnosis.
For idiopathic constipation with megarectum, 85% respond to laxative protocol; the remaining 15% may be offered sigmoid resection as a last resort with 50% improvement rate.
Giant Duhamel pouch after Hirschsprung pull-through causes constipation; patients are treated with laxatives, not enemas.
Achalasia of the anal sphincter is a manometric concept, not an anatomic one; the internal sphincter is a functional concept like the lower esophageal sphincter.
Contrast enema without bowel prep reveals two patient groups: dilated colon (slow motility) and non-dilated colon (hypermotility).
Dilated colon patients need large-volume, concentrated enemas to clean but the colon stays quiet for 23 hours afterward.
Non-dilated (hypermotile) colon patients need small-volume saline enemas plus loperamide, fiber, and constipating diet to keep the colon quiet.
Enema base is saline 200–1000 mL; irritants are liquid glycerin 10–30 mL, Castile soap 9–36 mL, and phosphate (Fleet) as last resort due to risk of colitis.
Fleet enema doses: ages 3–4 years use half pediatric Fleet (33 mL), 4–10 years one pediatric Fleet (66 mL), over 10 years adult Fleet (133 mL) to avoid electrolyte disturbances.
Enema titration is a one-week trial-and-error process monitored by daily abdominal X-rays; the goal is a clean left colon and rectum post-enema.
Never give laxatives and enemas simultaneously in fecal incontinence patients; laxatives cause unpredictable bowel movements after the enema, worsening incontinence.
If underwear is soiled and X-ray shows stool in left colon, increase enema volume or concentration.
If enema takes over 1 hour to produce bowel movement, increase concentration to make it more irritant.
If patient has pain, nausea, or vomiting during enema with clean X-ray, decrease concentration; if X-ray not clean, slow administration and warm solution instead.
If colon is clean on X-ray but patient still has accidents, the colon is hypermotile; add loperamide and constipating diet.
Bowel management is about quality of life determined by the patient, not the doctor; some patients prefer managing through a stoma rather than undergoing pull-through.
Initial enema volume can be estimated by asking the radiologist how much contrast was needed to reach the splenic flexure during the unprepped enema.
Typical enema volumes range from 200–250 mL in small children to 1000–1500 mL in large patients with huge colons.
Glycerin dosing ranges from 10 mL starting dose up to 40 mL maximum; Castile soap ranges from 9 mL to 27–36 mL.
Malone procedure should only be offered after demonstrating that enema works; doing Malone without prior bowel management trial is incorrect.
Saline is used as enema base instead of tap water because the colon absorbs water, risking electrolyte disturbances.
Saline-only enemas often fail to produce bowel movements; irritants (glycerin, soap) are needed to provoke colonic contraction.
For fecal impaction, disimpact with three concentrated enemas per day, not saline-only enemas.
When evaluating post-enema X-rays, focus on left colon and rectum; stool in transverse or right colon is acceptable as it takes 24 hours to reach the rectum.
If a patient has a clean colon radiographically but continues passing accidents, the enema is too irritating; decrease irritant concentration.
Long-term Fleet enema use can cause spastic colon with severe colitis visible on endoscopy.
Hypermotile colon patients should limit snacking to three meals per day to reduce gastrocolic reflex and minimize accidents.