Bowel Management for the Urologist

Thank you, Doctor Reddy. Thank you to the entire urology faculty and team at Cincinnati Children's and uh everyone for joining today. I do want to start by saying a couple of things. Um, first and foremost, and it's really hard to Um, say this enough, and, but working together as a team. Can't be, you could put it on a slide, you could talk about it in a breakout room, but until you implement it and make it reality, you can't appreciate it. And so, I had the privilege of joining the Cincinnati Children's faculty, um, a decade plus ago in 2008. And that's when I learned what collaboration was, and I did not know what collaboration was before. Just getting on a phone call and talking about a patient in between cases and, and in between clinic patients is good. It's always good to communicate. But true collaboration where we um meet every Wednesday for an hour and review the patients coming up in the OR, review new patients, review clinic patients coming, um, is really what sets the precedent for giving the ultimate care for our patients and families. And so, I thank the urology team and other teams that I work with, um, Allowing that opportunity because I've now learned what true collaboration is and so thank you promoting your team for helping teach me that, that and making it really a reality. That being said, thank you. Uh, it's really a great thing. So for those starting centers or, or, or starting practices or even in practice. You have to set aside time. And really, we're all busy, and we all wanna write papers, and we all have cases to do, and we all have academic um meetings we have to attend and, and obligations. But if you set aside time, And really focus on what your agenda is. I, it works, and the, and the families feel it, and the patients feel it, and the outcomes, most importantly, see, you see it in your outcomes. So, if I could stress that enough, that'll be great. The other thing I have to tell everyone is within the last 3 weeks, I have been a patient and a family member of a severely ill patient in the last 3 days. Um, so I'm stuck in a little, uh, studio apartment that I rented in Manhattan. I'm trying to care for my father, but, um, being on the other side is eye-opening and learning, and so I don't wish it on anyone, but it's certainly a learning opportunity for all. So, um, I hope no one has to go through the three weeks I've just done, but, uh, I'm excited to present. The one thing I'm sad that people aren't in person. I've been a part of this course many times, and it's always great meeting new faces and meeting other colleagues throughout the country, but I can tell you, I grew up and did all my training in New York. But when I got invited to interview for a faculty position in Cincinnati, I could not point to it on a map. So, you may have been shown a map of the United States before, but Cincinnati is in the southwest corner of Ohio. And if you ever fly here, you actually land in Kentucky. Kentucky is our southern border, uh, state, and so, I just wanted to bring that to your attention because 15 years ago, I could not have done that. It's an interesting fact. It's a beautiful city. Uh, so I hope one day when the pandemic and everyone stays healthy, uh, that I hope you can join us. So, now to the nuts and bolts and hooping and what my children love to talk about at our dinner table. Um, but I do wanna say I have no disclosures, but a lot of the therapies that I talked about are not. Um, the typical, uh, therapies that we talk about for these, uh, agents that we use, so they are certainly off-label. My goals today are really understanding the principles of a bowel management program, treatment strategies using enemas, treatment strategies using laxatives, and then I talk a little bit about sacral nerve stimulation because I think a lot of urologists throughout the country are involved in neuromodulation and so I wanted to talk about it from the uh poop side. Again, as Doctor Reddy mentioned, I'd love to answer questions the way we're doing it today is you're going to do it in your chat room and then at the end of my presentation, we'll try to answer as many questions as possible and I look forward to them. Please contribute. Um, at the end of the day, you have to keep the lights on in the building and understand how, um, hospital finances work, and constipation and fecal incontinence are a massive problem within the United States. In the pediatric world, the prevalence of constipation is somewhere between 3 and 30%. About 3 to 5% of all pediatrician visits are on constipation and a third of GI visits. From a cost standpoint, about $3.9 billion is spent annually on patients due to constipation and fecal incontinence. And the average pediatric patient that shows up to a practitioner with constipation costs about almost $3500. Uh, to our, um, healthcare finances, so it is a major problem within our country. Where does it rank amongst um illnesses within the United States? You talk about asthma, diabetes, and then it's fecal incontinence. Lower on the totem pole is osteoporosis and Alzheimer's. So it is a huge problem in our adult population, as well as our, our pediatric population. When we talk about bowel management, and I'll show you pictures of my team, but it is a dirty job. And you, you have to embrace it. If you don't embrace it and you fear it, It's just going to be a burden and your patients won't be successful, and you're going to be a frustrated participant in the care of these patients. So, the first thing I, I, I shared a slide that was passed on to, from my mentors, um, This was a cover of uh New York Magazine many, many years ago. It's a child who obviously had open heart surgery and a chest tube scar, uh, showing that, you know, he's funny and happy. And, and plenty of parents now with social media will be happy to post on their Facebook pages, etc. that their child survived a tetrology of flow repair or VSD closure. No one goes in. I've yet to see any of my parents or patients post that my son did enemas all week and is now clean in his underwear. I haven't seen it. So, it is a personal, but they all suffer from it, and I'll show you in the next few slides how they suffer, uh, quantitatively, but it is something that's hidden and kept within the household, um, but is, but eats away at families. The patients that we often treat are those with interectal malformations which we share with our urology colleagues. Hirschprung's disease. Spina bifida is a huge population that we take care of, um, and certainly plays a role in bowel management, uh, SCTs, trauma, and just patients with idiopathic constipation. So here I mentioned a few moments ago about quality of life or how it impacts the family. The dark blue uh slot uh bar graph, part of the bar graph is those patients with fecal incontinence and the light blue is those without, and clearly and obviously that patients who have fecal incontinence have a lower quality of life. The other thing we did in a study I performed about 5 years ago, and we published is, how does it affect the parental unit within these families. And so, we took 170 caregivers of patients between age 3 and 12 and did Some quality of life analysis and compared it to other chronic illnesses and, and diseases with high disease burden, and it ranked in the ninety-ninth percentile of stress for parents in this age group, or caregivers in this age group. It ranked higher than inflammatory bowel disease. And just under cancers. It is extremely stressful for those of you that have children. Once your kid starts getting school age, kindergarten, first grade, and if they're not potty trained, It becomes a major stress. Schools put stress on the families, the families put stress on the children, and it becomes a very impactful time during uh development for these children. As I mentioned at the very beginning of my talk, collaboration is key for taking care of these patients. And we work with our urology and gynecology colleagues, as well as GI motility, but really, I make these circles smaller, but they actually should be larger. Huge parts of our collaboration are behavioral medicine. Physical therapy, which I think gave a talk yesterday. Sarah Fox is an awesome partner. Nutrition and our registered dietitians play a huge part, and radiology, helping with diagnosis, um, are tremendous parts of our collaboration in helping take care of these patients. And we have a combined clinic with all of these partners every Friday, uh, to help these children. So let's talk about bowel management and what it means. The word bowel management has lots of meanings to lots of people. All I use the term bowel management for it is a structured program to deliver treatment for children suffering from fecal incontinence and or constipation. That's it. Some say bowel management equals enemas. Some say bowel management is just giving any medication. Use the term any way you want. But for today, we're gonna use it as just a structured program. Within that structured program, you could have patients that need laxatives, or patients that need enemas, and we'll talk about how we choose which way, or how we decide what program that they will go into. And just because you go into enemas. When you start our program, doesn't mean 3 months from now, or 3 years from now, or 15 years from now, you can't switch and go into different types of management programs that work best for you. I will also say, um, when I showed some data, I'll talk about it more. What is A better quality of life, in my mind, isn't necessarily true for what the family and patients believe. And so you really have to listen to your families of what they want and what their goal is in the program, and that's how you tailor the program to be successful. The other thing that makes us successful is that we have a team. Just in, within colorectal, I have 6 nurses and 2 nurse practitioners and admins. It is a tremendous undertaking. If one person tries to take this on, it could be Herculean task to answer all the family questions and calls and concerns. Cause every time that child has a soiling accident, they often pick up the phone or MyChart you or email you, and so, Really handholding the families through this process is key, and you need a team to do that. So, I'm gonna go over about 5 concepts that sort of really Um, indoctrinate what bowel management is. And if you could stay with these concepts and tailor it to your own program and the needs of your, uh, situation, you'll start off with doing great, um, care for your patients. So the first concept that we talked about is to differentiate pseudoincontinence versus true fecal incontinence. That really pertains A little bit less so to our pediatric colleagues that are pediatricians in the community, because most of those patients are just constipation patients. But a lot of patients we see have anatomic, um, and congenital issues that really we need to divide our patients into these two categories to help guide us in what treatment and therapy we prescribe for our families. So, Patient comes to you that has soiling issues, we need to define true incontinence versus pseudo-incontinence, and let's talk about that. In order to define true incontinence, you have to know, hey, what does it take to, what do you need to be continent? So there are a few things that you need to be continent, and I listed some of them here. You have to have an intact anal canal. So if someone has damaged your anal canal from a surgical procedure, a patient was born with a sacrococcygeal teratoma, and it's resected due to involvement in the tumor, um, a traumatic injury. You might damage or injure that anal canal. The anal canal is where the squamous epithelium go, all the way keratinized, unkeratinized, and then the anal canal ends when it turns to cuboidal tissue, and you're starting to be in the rectum. All the nerves and muscles are located within that area, including the anal sphincters, and so if that gets damaged, obviously it could impact fecal continence. Intact anal sphincters. 1, congenital issues like I mentioned before, but 2, during surgery. If you stretch those anal sphincters too much and too long, They don't automatically. Coil back to their normal um capabilities, and so, You have to be careful when operating. How long you're stretching the anal canal and anal sphincters, uh, cause it could cause long-term damage. The intact rectal reservoir, the rectum is a reservoir. If that gets resected. For some reason, um, you're doing an anorectal malformation and it doesn't reach, and then you have to bring the colostomy down and, you know, things like that, resecting that rectal reservoir could have Tremendous impact on a patient's fecal continence and so you really have to um think about what you're doing for long-term functional outcomes when you're operating on a uh neonatal infant, uh, for whatever reason. Resecting that rectal reservoir, I highly uh try to avoid at all costs. Colonic motility, a little bit tougher to assess, and we'll talk about it in a few minutes. Easy ways to get a, a sense of what colonic motility and more fancy ways of doing it, but getting an understanding of colonic motility. But a lot of our patients, such as anorectal malformation patients, spina bifida patients, Although their actual congenital issue is not with the entire colon, we have found that many, many of these patients do not have normal colonic motility. And so that will affect how they evacuate and affect how we give treatment. Obviously, intact cognitive function, going along with age plays a role. When a one year old comes to your office, you're not going for treatment of fecal continence, you're really trying to treat usually constipation and impaction at that time because you're not going to get a one year old fecally incontinence. So a little bit about the workup that we do, and I'm not saying every patient needs this complete workup, but just having and knowing what tools are available. Around your center or even a refer referring possible institutions, it's good to know, one, to help with treatment, but I also find that some of these tests, although don't always change my treatment, are very helpful in explaining to the family what's going on, so that they have buy-in and what the treatment plan is. Though obviously a detailed history on defecation and incontinence, a good exam uh in clinic. Uh, to see anatomy, and I'll show you pictures of things that we've seen that could blow your mind away, how, how they could be missed, uh, sometimes. Colonic transit studies, I'll show you some easy ways to do that, not very difficult or expensive. Water-soluble contrast enemas, um, there, the backbone, there are, um, I don't know, ultrasound of the kidney for colorectal, um, anorectal manometry, then more intense exams with exams under anesthesia and colonic manometry as a very fancy tool, uh, that is available. So the external exam is obvious. Um, please don't skip it. It's a pain sometimes to get the patient undressed and they sometimes fight it. But if you see a patient with the anal canal and anal opening on the patient on the left of the screen, this big patchulless anus, where the, this patient has had surgery, and anal canal has been injured. I can tell you this patient has true fecal incontinence, and it's going to change the way I counsel a family and treat this child versus a patient who has a normal anal canal. The picture on the right, a little bit different. It's not the true anal wink that you see. There is a little bit patchlessness to the anal canal, but it's not severe, and that's a tougher one and a discussion you have to have with the family of, I'm not sure if there's gonna be true fecal incontinence versus pseudoincontinence. When I say pseudoincontinence, I, I skip defining that in that the patient has all the tools to be continent, but they're incontinent, and usually that's due to constipation and impaction, distal and the In the GI tract and causing Pseudo-incontinence by liquid stool leaking around. So, but we're really looking to try to make sure we can find the true fecal incontinence, and then this way we can counsel the families properly. Again, examining the patient, these are some patients I've seen in clinic where they've had a perineal fistula, the the, the anal opening is not in a proper position, nor likely the proper size, but missed for some time. Patients who've had surgery and have severe prolapse could have issues, or they've had an anal reconstruction likely from an anorectal malformation or imperforrate anus, and the anus is not positioned properly and not positioned within the muscle complex, thereby potentially causing a true fecal incontinence. So I mentioned briefly about transit time and some tests to do. Um, this is really, we're trying to learn how do things move through the colon. I typically say to families that Stool enters the colon on the right side, if you have a full complement of your colon as liquid stool, and it should exit as more formed stool. The main job of the colon is to absorb water. In the adult patient, it's over 1 L of water absorbed per day in the colon. And so if you're missing parts of your colon, that will be affected, or if the colon doesn't work properly. Uh, that will be affected. And so, some easy ways, really the easiest way, uh, and a great test that I think is completely underutilized is something called the SIS marker. This is usually there's 25 to 30 of these radio opaque little rings located within a capsule that is dissolvable. The child or any patient swallows it, and you could You could take X-rays at interval times. Usually, definitely by day 5, you take an X-ray, you could take X-rays on day 13, and 5 to see how things move. But however you want to do it, these are pretty cheap. Easy to get usually, and can give you some good examples of colonic transit time. And so, here's two X-rays here, um, looking at colonic transit. If you look at the X-ray on the left, this is what's great, and you really could help you with therapy, and that, look, the all the rings have made it to the rectum. But the patient has been evacuated. So this is an outlet problem. This is a, a, this is where Sarah Fox and our physical therapist really work hard on the patient with the patients to help with outlet problems, or you might use Botox or other um ways to help with treating the outlet problem for these patients. And that would change the way we do therapy versus the picture on the X-ray on the right, demonstrating. The rings throughout the colon, um, after a 5-day X-ray, and that should showing me a slower transit time. So, by 5 days without question, all the rings should be evacuated. We say there should be less than 5 for certain by day 5. So if you see more than that, that's an abnormal study. There are fancier things, so smart pills, which are really expensive and give you a little bit more data. But like I said, I think the SIS marker test is a great test to look for transit time. The other test that I do is a water-soluble contrast enema. And this To me is the most important test that you could do for your patients cause you get a tremendous amount of data. I stressed by saying water soluble contrast and not using barium. We do that for a number of reasons. This test gives me for Obviously, a roadmap of the patient's colon. I get to see, are there areas of dilation, are there narrowings, are there strictures, are there any anatomic problems. Two, the water-soluble contrast enema is an osmotic agent. So it's like MiraLax, a PEG 3350 or wherever you're from, a, a, a, a water absorbing agent that brings water into the colon, softens the stool, and helps to disimpact the patient. The contrast enema gives me information, which is great for showing the families. The families love seeing the contrast enema. I often Always show it or always show it to my patients and their families in the clinic. I show them their stool burden. I show them anatomic issues, and they really get a better understanding of what's going on. Especially for those families that come into my office and say, my kid's stools every day, he's not constipated, but he's constantly soiling. And then I show him a contrast enema that is full of And impacted with stool, and, and they have it, they, they believe me more than before. So, um, the other thing that water-soluble contrast enema does tying it to transit time is I usually get an X-ray the next day. So I get to see, is it a poor man's transit study. I get to see if the contrast has been evacuated or not, because within 24 hours, the contrast should be evacuated from the colon, and if it's still sitting there, and where it's sitting, gives me an idea of the colonic motility. And so it's a great test that gives us a tremendous amount of information. Another test that we started using more frequently, recently, um, and is becoming more and more available at multiple institutions is anorectal manometry. I wanna be clear, this is anorectal manometry, different from colonic manometry, which gives us motility information throughout the colon. This is anorectal manometry, does not require a trip to the operating room. There's a catheter with a balloon at the end and pressure sensors, and you get a sense of how the muscle. Uh, is working, um, within the child. The more developed and more cognitively developed the patient is, you could do more testing, seeing if they squeeze and relax and is that coordinated or not, but at a minimum, you can get resting pressures and some basic information from the patient, which could be very helpful. Here's some fancy pictures from uh anorectal manometry, the top looking at a normal, healthy squeeze, and then you can see a patient with fecal incontinence where the squeeze is much. is, is less significant. Um, you could look at patients who have had surgery. Is there, is there muscle weaknesses on one side versus the other. It's really helpful to understand. It helps the physical therapist out with understanding what they need to work on, and it helps to explain to the family why their child might be having problems. Again, now that um this is a slide on colonic monometry, very different, much more invasive, requires a trip to the operating room. A total colon, uh, colonoscopy to place these catheters. These are catheters that are placed throughout the colon, have multiple pressure sensors, very fancy, um, not as widely available and expensive, but in certain patients is definitely something that could be helpful and it, it gives, shows how the neuroenteric system. The nerves within the GI tract coordinate with the muscles within the GI tract to see if you get a coordinated um propulsion of the colon and is that working well, um, to help coordinate evacuation of school. Another tool that we use in patients with anorectal malformations or patients who have sacral developmental issues is something called the sacral ratio. Um, it's described, developed here. It's a basic calculation, you do it in your AP and I think I show lateral, yes, I show it lateral here. Um, you get your AP and lateral measurements, and this really helps, it, it's based on the theory that the bony development of the sacrum is In conjunction with the neurodevelopment of your sacral nerves, which obviously are helping coordinate with the function of your organs within the pelvis. And so the less developed the bone is, the less developed the nerves are in that region and the lower chance of uh fecal continence. And so, predecessors of mine have determined that. Normal sacre ratio is from 0.0.7 to 1. A sacral ratio between 0.4 and 0.7 is that gray zone, and the patient may or may not be fecally continent, and a sacral ratio less than 0.4, it's extremely rare for us to have a patient that we could have true continence in those patients with a sacral ratio of less than 0.4. Take a drink for a second, sorry. These apartments in Manhattan are quite dry. So, you might also be able to tell, going back to that first tenant, that that first rule of trying to decide fecal, true fecal incontinence versus pseudo incontinence, if you know what the congenital malformation is. That can help guide you into where this patient might fall in the ability of being continent. So, in patients with anorectal malformations, which is how our bowel management program started, the patients with a good prognosis, such as those with a perineal fistula, a vestibular fistula, a bulbar, a urethral bulbar, Rectal fistula and short cloacas, short channel cloacas less than 3 centimeters, typically have good prognosis. With fecal comments, except If they have other issues. So, we're saying they have good prognosis if they have a normal sacrum. I described the sacral ratio just a moment ago. And if they do not have a tethered cord, and I know uh Doctor Stevenson will be talking about that in the next section, but if you do have an abnormal sacrum and or a tethered cord, that lowers the probability of a good prognosis from a fecal continence standpoint. But if we typically see a patient with these lower malformations or better prognosis malformations, and no other issues with the sacrumal cord, we would say the likely issue is pseudoincontinence. We just have to evacuate the colon and use typically laxatives to help treat these patients. That's in contrast to patients who have more likely to have true fecal continence. These are patients with a bad prognosis or, and these are patients with higher anorectal malformation, such as a bladder neck fistula, cloaca, uh, with a common channel greater than 3 centimeters. I didn't put prostatic fistula on there cause that's sort of a gray zone. A prostatic fistula has about a 50 to 60% chance of of comments. So, in the anorectal malformations in boys. A perineal fistula has nearly close to 100%. Prognosis for, for fecal control. Again, that's if the sacrum is normal and the cord is normal. A bulbar fistula is about 80%, a prostatic fistula is 60%, and a bladder neck fistula only 20% chance of fecal continence if all things else are normal. In the girls, a perineal fistula again, close to 100%. Chance of fecal continence, a vestibular fistula. Vestibular is often people say vaginal fistula. We don't like using that term because it's in the vestibule. It's outside the hymenal tissue where this fistula almost always occurs, so it's in the vestibule. That's about 80%. And then the cloa is like I've described, the short channels, better chance of continence, the longer channels greater than 3 centimeters. Uh. A less chance of fecal continence and more of a true incontinent, true fecal incontinence. So patients with the true fecal incontinence, we usually go to an enema program. OK, uh, patients with tethered cord, myelomeningocele, much less chance of having fecal control, and we typically at least start with an enema program to have better success. So here's a, a case. seven year old male patient born and operated due to a rectal bladder neck fistula and had their reconstruction is now complaining of fecal incontinence. So the first question is, is this true fecal incontinence or fecal pseudoincontinence? And I, I'm not sure if we're able to get the polls going cause I was in New York and dealing with things, so, uh, I'll just let everyone answer on their own. But I think we talked about is this, a patient with a bladder neck fistula has about a 20% chance of control, and so this is more likely going to be true fecal incontinence, whether they have a a tethered cord or not. Now we add a tethered cord, and sacral um. The sacrum didn't develop properly, which likely is the case in these patients, their chance of fecal incontinence is even lower. So, for this patient, I would say most likely true fecal incontinence. Uh, again, I bring up a patient with spina bifida, same idea. Most patients with spina bifida, not all, but most. Have true fecal incontinence, and do not have the ability to have control, um, on their own. So that we just talked about concept #1, trying to define true fecal incontinence versus pseudo incontinence. Now concept number 2. We, like I mentioned, we like to look at the contrast enema. Contrast enema gives us a tremendous amount of information like I discussed before, um, but we also look at is the contrast enema dilated. Or is it a more narrow, uh, type of, uh, picture, and I'll show you pictures of that in a second. But those that are dilated typically are more of the constipation variety, tend to have a slow-moving colon, and more of a pseudoincontinence, whereas the, uh, and more of a a just a constipation picture versus those patients that are non-dilated. Might be a spasm, spasmodic-like colon, and might actually be a hyperactive colon. I caution in one instance. Patients who have neurogenic bowel, which is a lot of the patients that this audience deals with. Also looks like that, that spasm-looking colon. They don't often dilate like patients with myelomeningoceles don't have these big mega rectosigmoids for some reason, yet obviously they suffer from severe constipation issues. And so, Excuse me. And so, I, I caution you and I, I ask you to use a grain of salt when looking at these enemas and looking at whether it's dilated or not. Here's a picture or a contrast enema of a patient with a large dilated mega rectosigmoid. Contrast is in white. You can see the filling defects, huge stool burden within this patient. Great to show to families so they have an understanding cause this child, I bet you, is having 5 bowel movements a day and leaking stool around these stool balls and. Um, but it's great to show these families, and this is the dilated colon. I'm expecting the colon to move slowly. You can see the distal colon and rectum are dilated, but the rest of the colon is actually normal appearing, but clearly having an issue distally. Now, if this is a patient with an anal rectal malformation, I wanna make sure there's no stricture. Is there an outlet problem that has caused this? It might be, or often we see this in patients with innerectal malformations anyway because for 9 months in utero, there was an outlet obstruction and their colon was just chronically dilated in this segment and has left the congenitally is just born this way and the colon and the integrity of the wall muscle of, of this uh rectum has not recovered. That's indifference to this. Um, so again, dilated colon, slow moving colon. If we are thinking that we're gonna use enemas, we would use a large volume, uh, enema. Excuse me for a second. Again, in contrast to this picture which I'm showing you now, which shows a non-dilated colon, looks very spasm, uh, troublesome, um, and, and this patient again, having 5, 10 bowel movements a day, but for a different reason. This is probably a hypermodal colon. Colon's moving too fast, there's too much activity for whatever reason, uh, and these, these are harder patients to treat. It's harder to diagnose sometimes, and we don't always crack the code right away, but in the end, the, the treatment algorithm for this, um, again with multiple trial and error steps that I'll go over, but the big picture in these patients that have hypermodal colons is that we use, we constipate them, and then we use small enemas to evacuate them. So we give them loperamide, fiber, constipating diet, trying to Fill that distal colon with stool, and then we, in a coordinated effort, evacuate that stool at a time that's convenient. So when I talk about enemas, you have to understand what we use, and we use a high volume enema program, um, that uses saline as its base typically. We use glycerin as our stimulant, our primary stimulant. We use castile soap as a secondary stimulant, phosphate as a Rare stimulant Excuse me, we worry about using phosphate. Especially in patients with renal insufficiency or renal um compromise, because that phosphate can cause some electrolyte abnormalities that can be obviously quite troublesome. Sometimes we use Golightly as our base, and sometimes we use bisocodol as a stimulant, and, and different places might have access to different resources. I do a lot of mission work in Africa. You can't get, you can get saline, but you can't get glycerin castile soup, and we use Johnson baby shampoo as our stimulant. So, whatever works for you and you'll trial and error within your, your facility and your, your, your region where you're working. Um, just be consistent and you'll learn how those agents act. We've just been using these agents for quite some time, and so we're comfortable using them. I'm gonna, this is, this X-ray, this slide shows concept number 3. This is by far, I think the most important. You must start your bowel management program for your patient, whether you're starting with enemas or laxatives with a clean X-ray. This is the same patient, I promise you, this is the same patient. This is my patient that I took care of, and the X-ray on the left shows a person, it's a woman. And you can tell it's a woman cause there's an IUD in there, but a person who has A tremendous stool burden on this X-ray. I mean, it is just riddled with stool. And if you start giving laxatives from above and causing the colon to squeeze and spasm, etc. whatever agent you're using, this person will have severe pain, and it just won't work. And then they'll say to you, and they'll come to your office and say, ah, you gave me bisycodone. It doesn't work. It caused severe pain and nothing came out. You have to disimpact this patient. However that might be, from below, from above, using cleanouts, using however your system is to clean them out, but this is the same patient. And if you look at the dates on these X-rays, this patient was April 17th. And I did not get her clean till April 25th. That's when I started her bowel management program. You have to start with a clean colon, or you're gonna be unsuccessful. The patients are going to not buy into the program and you're not going to have a good outcome at the end. Concept number 4, something that makes us a little different than other programs and we can have a discussion about this, but we regularly monitor the results of the enema program throughout the week. So, we prescribe an enema, let's say we prescribe 400 of saline, 20 glycerin. And they do the enema, and they take an X-ray the next day, and they give us a report saying, OK, we did the enema, but we had 3 accidents throughout the day, um, and a little bit of pain. What should we do? Well, it could be one of two things. It could be that the enema was so good that we overstimulated this colon, and we're pushing stuff too fast through the colon, and the colon is completely clean on the X-ray, and in that situation, I would weaken our enema. The other possibility is that the enema did not evacuate all the stool, the stool, the stool still remained, and there was stool leaking around some of the stool, and we, the enema was not strong enough, but the patient had the same clinical effect at the end. Of having bowel movements. In between the enemas, which is not our goal. When we give an enema, we typically say, we give the enema, and for the next 23 hours, because remember, it takes a day typically for the colon to evacuate, we do not have to worry about evacuating stool. But if I get an X-ray and I see a colon full of stool after they've done their enema, well, then I know my enema is not strong enough, and I have to make a stronger, stronger, uh, enema recipe. And that's the real trial and error of it. We do not have a, um, a grid, an Excel sheet that says exactly what. to do, but we use some, some of the information and just long-term knowledge. But the other thing you could use, another great part of the contrast enema, is you could, and this is when working with your radiologist and all being on the same team, ask them, how much contrast did it take. To fill the colon. And let's say it took 800 mLs to fill the colon. Well, I typically start my enema a half to a third, the, the standard volume of what it takes to fill the whole colon, cause I just need to empty the left side of the colon to be clean for the day cause the stool on the right side's tomorrow's poop. Excuse me. So, if I get NOAA contrast enema, had 800 or 1000 mLs to fill the colon, I'll start somewhere in the 3 to 400 range uh of my base solution uh when prescribing um the enema recipe. And again, it's a trial and error process. There is no exact method. Just be consistent with what you do, and it's basic science. Change one variable at a time. If you start changing more than one variable, you're not gonna know what's working and not working. And during the course of our week, like I said, we, we get clinical data, we get X-rays, and we use these, this information to help make educated um recommendations to our families uh with a trial and error process, and we're very upfront telling the families this is what we're doing to um make sure that uh we, we get a clean program at hopefully at the end of the week. Now we do, and there's, I know there's an international audience, and we often get asked about X-rays for the patients. We get X-rays when we think we do not know what's going on. If we have a clear understanding of what's going on, 3 days into the program, things are moving, then we stop getting the X-rays. We also um are looking into other ways to try to do this. There are people, if you have access to ultrasound, you could use uh a way of not uh delivering X-rays. The other thing to know about X-rays is, if you have one patient who comes in with abdominal pain because of constipation and issues, and they get a CAT scan, that's 150 to 300 X-rays. So, I, in my mind, have justified that if I get 3 or 5 X-rays on a child, and it prevents getting a CAT scan, I think the risk of that radiation is low enough that I, I believe that the risk-benefit ratio is there. That being said, I absolutely applaud trying to look at other ways to not using radiation, and we're working with our radiologists to try to figure out how to use ultrasound in a way you could, there are people working. Uh, I know I've worked with a team from UCSD that are now at Stanford, uh, with electrical impedance. Um, those are things that are in the works but not there yet. But certainly, I understand the concern of radiation, but also understand the benefits. I'm going to talk about laxatives in a minute, and I worry about showing this slide, but The basic premise of we do not use laxatives and enemas together at the exact same time. That doesn't mean we don't use them in the same patient for the same reason. So we'll use enemas to clean the patient out. Like I said, the most important concept is start with a clean patient, and often that requires enemas to get to that clean patient, and then we start laxatives as our maintenance therapy. I also have patients. That I sometimes treat laxatives get them through the week, but long term, they, they build up a little bit of stool, and over a long period of time. It causes problems. So in those patients, sometimes they use laxatives throughout the week, and then on every Saturday or every other Saturday, they might do an enema, just to sort of have a reset. And families are usually good with that because they've been on enemas maybe in the past, and now I've got them, instead of doing it every day, and it's about an hour-long process, I'm having them do it every other Saturday. Clearly gives time back to the patient and their families, gives them a better quality of life. And so, I don't say absolute do not use laxatives and enemas in the same patient. It's sort of at the same exact time. We don't do that. So let's talk a little bit about bowel management troubleshooting. I love this slide. Um, I think it, it's just brilliant. So here's an example of a patient, an 11 year old with a rectal prostatic urethral fistula, who's undergone a pussior sagylo or rectoplasty. So, this is in the middle, right? First step is, are they going to be true fecal incontinence versus pseudo incontinence? And I mentioned earlier. The patients with prostatic fistulas are about 60% chance of having Fecal continence, but you also need to, uh, unfortunately, not in the live audience, but I would ask you, what are the things would you wanna know? I'd wanna know if this patient has a tethered cord. I'd wanna know what their sacral ratio or sacral development was to help guide me in counseling this family on what might be the best treatment um for this child. So, the other thing is, right, we took this, uh, I look at the caliber of this colon. It looks a little small to me. I don't see that big dilated part on the left. I do see a little bit larger colon and more of the stool hanging out on the right side. So that's one thing. I told you I'd like to know colonic transit time. And a good cheap way is get an X-ray the day after. So here we are with an x-ray the day after in this child, um, and it's obviously clean. All the contrast has been evacuated. So I'm a little worried that this patient might have a hyperactive or fast-moving colon. The other thing I'm looking at that concerns me a little bit is, and this is, these are not great X-rays, but I do not, I'm not sure that this child has had great sacral development. It's hard to tell because sometimes without a lateral, but, cause sometimes that sacrum sort of fans out in the AP plane and you don't see it so well. But to me, I'm hinting towards this might not be great sacral development. And I would get a lateral to help me on this. So like I mentioned before that I'm worried that this patient might be a hypermodal patient, non-ilated colon. And with the possibility that the sacrum didn't develop well. Along with that, it's a prostatic fistula. I'm uncertain if this is. True versus pseudo-incontent, but remember this is also an 11 year old. This child has suffered with this for quite some time. This is a patient that I likely would recommend doing enemas on first. More predictability in treating this patient and maybe a better outcome, and long term, we might be able to transition to laxatives. We went over this already for um about The chance of continence and for sacral development. Sorry, it's getting texts. Um, so, for me, I would probably treat this patient as a hypermodal patient, give loperamide, and then use enemas to evacuate the patient in a timed and coordinated fashion. Might also include diet and pectin. Well, I would not use laxatives initially in this patient. I think that would go against it. But again, this is trial and error and there's nothing in stone, so I could be wrong, but that's what I would start with is I would do that algorithm of trying to clog the patient and then use an enema to empty them, and you could clog or constipate the patient with a number of different agents and manipulations. So let's talk about laxatives for a moment. When we talk about laxatives. It's a very broad term. MiraLax, for those in America or PEG 3350 or um uh Movicol, I think they call it in, in Europe, um, is an agent that has the word laxative or laxative, but it's not, we, when we talk about laxatives, we talk about stimulant laxatives, laxative agents that actually help the colon contract and move things forward. There are stool softeners. That work in a number of ways, but most of them work by bringing water into the colon. MiraLax being the most popular one in the United States and I think around the world, um, using peg, um, in our patients. MiraLax or PG works really well in patients with totally normal anal canals and motility and those that just need maybe a little bit of softening of the stool. In patients with anatomic and congenital issues, it often does not work well at all. You're on the brink of a patient that has the nerve and musculature of their anal canal and functioning of their Of their uh colon motility, that if you give this liquid stool, you're worsening the level of pseudoincontinence by just making liquid stool. Leak around the hard stool. So we often use Senna, which comes in, especially in pediatrics, we like Senna, it's a stimulant laxative. It's called the Ex-lax, uh, over the counter. Often, you'll see, those are those little chocolate squares that people buy that you could stimulate the colon and work really well. Kids like taking chocolate squares. It comes in a liquid form, and it also comes in a pill form. So we really like this because one, we use it a lot and we've gotten comfortable in its dosing, but we also, it comes in multiple forms that in our pediatric population, different patients have different needs. The other stimulant laxative that's out there, at least in the United States, that's available is bisocoy or Dulcolax. Another stimulating agent that actually makes the colon move. And when I talked to the family, those agents do two things. One, it obviously propels the stool forward by stimulating the colon's movement. But if stool moves quicker through the colon, it has less time to absorb water. So it also softens the stool because the transit time is decreased. And so, we are very big proponents of using these two agents. We use X-lex as, for the reasons I mentioned before, um, to help move things through. There are other agents out there, and I'm not going to go into all of them because it's its own science and its own world of the neuroenteric system. Um, there are other agents that stimulate the colon. Uh, in different ways, but these are the two sort of over the counter, simplest ones that I know are available, somewhat, you know, with maybe a little work throughout the world. Here's some examples of the chocolate squares, and I, when I tell families, sometimes these are Hershey bars, these are the Senna tabs, but so I've had families where I say, oh, take 2 squares of the Exlax, and they take these two big bricks of the X-lax instead of each square is these little ones, and those kids had a lot of diarrhea for a day or two, till it left their system. So the patients that we use laxatives on are those that have a good prognosis, and like I mentioned before, patients with interectal malformations that have perineal fistulas, vestibular fistulas, bulbars, um, cloacas, um, idiopathic constipation, those are the patients that we use, um, the patients on. Remember, if doing a laxative trial, and again, trial and error, you go up or down on the laxative a little bit, our basic rule of thumb is We start with whatever number you want to start with. Let's say 2 squares of X lax. If the patient is doing really well, We leave them the same, and we get an X-ray to make sure they're actually emptying. If the patient is going to the bathroom multiple times a day, we decrease by 0.5 square. If a patient doesn't have a bowel movement in 24 hours, we give an enema, because we want them to evacuate every 24 hours, and we go up a square. And that's sort of the basic algorithm for adjusting for the patients until you find that right dosage. To, um, the laxative dose is adapted for each patient. It's really just a trial and error process. Again, a few basic tenets. Start with an empty colon, check every day to see how they're doing, and just adjust with a trial and error process to the right dose. We talked about that. Again, disimpact the patient before starting the laxatives, it won't work. Sometimes, so this is an important information. Sometimes when using laxatives, like I mentioned before, it might loosen the stool, maybe too much because the transit time is now decreased. But you need that stimulation to evacuate the stool. So then sometimes we add a bulking agent. With the use of the stimulant laxative to get the right consistency of the stool, so that they're not having too loose of a stool, that they're having issues detecting stool in their rectum and anal canal, having accidents. So we use things like pectin, which is what makes Jell-O or Citrucel to thicken or bulk the stool, yet we're using the stimulant laxative to push the stool through. So, it's a little counterintuitive that we're bulking the stool in a patient that's having constipation issues, but you have to get that right consistency of stool that the child uses their sensory, the, the, the nerves and the sensory of their anal canal to be able to have continence. So what are our outcomes? I'll talk about this for a couple of minutes and then we'll be done. So we studied a few years ago, 222 consecutive patients that enrolled in our bowel management program. About half, 120 were analectal malformations and then half were, had other issues. We used a validated quality of life score and matched it with um a severity score, meaning how many accidents they had. So here's our quality of life. The lower the number, the lower the quality of life, and the blue line is our um overall outcome. And so you could see it was uh, a little bit above 70, uh, was the score and the quality of life when they started our program at 1 year. So sustainability of the program went up to nearly 85, uh, which had statistical significance. This is a really interesting graph. This is a bubble plot with population, so the size of the circle is the number of the patients, and overall patients going through our bowel management program started with having 3 to 4 accidents or involuntary bowel movements per um Per week. And then at the one year, it was less than one, the blue line is the average of all the numbers, less than one involuntary bowel movement per week. Then we divided it and looked at enemas versus laxatives, and again, the enemas, it's interesting, there's a bias, right, to if we prescribe the enemas or laxatives. Patients who are having more accidents and likely more true fecal incontinence have more accidents every day. And then at the course of one year on enemas, less than one accident per week. Patients who were in our um Laxative trial, this was our enema trial, I might have misspoken. This was our enema trial. Our laxative trial was having 1 to 2 accidents per week, and then ended with less than 1 accident per week, 1 year showing sustainability of the program. Other options that are out there are sacral nerve stimulators, uh, Celesta, which is a bulking agent. Uh, I do wanna talk about Malone's for a second, then I'm gonna end my talk and allow a few minutes for questions. But many neurologists Perform the Malone or MACE procedure or AceCE procedure, and I'm not here to teach you how to do it. But I am here, again, probably tying the whole talk full circle, is that do not do this in isolation. Do not make a malone or metrofenoff in your patient without considering all systems involved. And so, we have a very Programmatic way within our group of any patient getting a Malone or Metrofanov is brought to our combined conference to make sure that the other team thinks it's appropriate. The appendix won't be needed cause we could split the appendix or do the procedure together to make sure that we're offering the right treatments for our families and a, and a better quality of life. So, um, That I think is important to discuss, and those are pictures of Malone's and you can do Malone's and Neil Malone's. I'm going to end my talk now. Um, I'm gonna skip, unfortunately, the sacral nerve talk for another time. Um, but again, it's a teamwork effort. Here's some members of our teams from a few years ago. Uh, if Debbie's on here, Debbie, the backbone of the urology program, unfortunately, just, uh, retired and is probably enjoying a much more happy life, uh, for all the hours she put in, but an incredible member of our team. Uh, so, again, I thank you. I thank Pramode and the entire urology team for allowing me this opportunity and hopefully we have uh 56 minutes for questions. Thank you, Jason, for a phenomenal lecture and uh for flushing out any concerns we have about uh bowel management. Uh, and I just wanted to echo Doctor Fisher's, uh, comments, you know, as a director of the colorectal team, uh, he has been a phenomenal partner for us and, uh, leads by example. We truly have a phenomenal collaborative program here and, uh, yesterday, during, uh, one of the chat rooms, they were asking us how do we manage our, uh, patients with chronic constipation or idiopathic constipation. I say, you know, we're so lucky that we have our colorectal colleagues in the bowel management program and you just heard about that. So, um, thank you. This lecture will be made available for. Uh, later viewing because I know Jason covered a lot of ground. And so, uh, please view it because this goes hand in hand with a lot of, um, bladder dysfunction, which is bowel dysfunction. And so when you manage to bowel dysfunction, a lot of times you reduce the risk of infections and, um, incontinence. So, uh, Jason, a couple of questions while you're, uh, rehydrating there. One was, uh, do you have a specific, uh, home cleanout regimen that you have families do before they start their bowel management program? Great question. So, I like to attack from below and above, so getting imaging to see where that constipation burden is, if it's very distal, then I attack from the bottom, and you can use whatever enema program works for you. Um, we use this saline combined with glycerin, but if you use, uh, just glycerin, you can use suppositories. You, whatever you want to do. To evacuate the bottom, but what I urge you to do is to make sure that it's empty, just. The parent might say, oh, we had a tremendous output, but make sure it's really empty before you start using a laxative, whatever your, your treatment might be. Um, so, we use that for below is any enema you want. From above, I think the best is you can use MiraLax or, or a peg, um, combined with water, and, and, uh, for us, it's usually somewhere in the order of like 8 caps to 16 caps, depending on The size of the patient, uh, to sort of loosen things up from above, and give them a clean out, but make sure the bottom's empty, cause if you start giving all this fluid and Uh, um, la, uh, not laxative, but, uh, stool softener, and a huge volume, and you're putting it above, from above, and you have an obstruction distally, that patient's gonna be extremely uncomfortable, and you could even get into some problems. So, make sure the patient's emptying from below, and you can give some uh Uh, stool softeners, we use MiraLax, uh, sort of 8 caps as sort of the starting point in, in, in. 16 ounces of water and sort of try to get them to sort of loosen the stool that way. So that's our starting point for that. Thank you, Jason. Um, there was one question looking at the terminology that you use and for just clarification, so, you know, when do you use enema, when do you call it a flush, and when do you call it irrigation? Ah, yes, that's institution dependent and sort of the lingo. So enema, we use the term enema when it's a rectal infusion of a volume of fluid to stimulate the rectum and colon to evacuate. That's how we use the word enema. The flush, when we use the term flush, we use that when we have a mace or an ace or sycostomy, a, when using an anti-grade solution to help evacuate the colon. So, flush is anti-grade, enema is retrograde. Trying to accomplish the same thing. Irrigation is very different. So the term irrigation we use specifically, uh, often in patients with Hirschprung's disease, but can be used for others, where you use a low volume, and you're, you're sort of washing out the colon with low volume. You use 20 to 50 mLs. we instill that, and we suck it out through the catheter, and you could do that for hundreds to thousands of milliliters of fluid. But we, it's in small volumes. And so in irrigation, we use that term, typically in Hirschberg's patients with enterocolitis, but could be for others, in where we instill a small volume and remove that same volume. At the same time, versus an enema or flush we're instilling a larger volume, usually with an irritant, to help evacuate the colon. So I hope that clears that up. It is a, an important nuance, and every institution might use those terms, that lingo a little differently, but they're different terms, and so make sure you, everyone's on the same page. Thank you, Jason. Um, one question is that if you have a child with an obvious poor prognosis based on their, uh, presenting diagnosis, would you consider doing a MAC at the time of the pull-through? Uh, great question. So, we typically do not perform. A MAC procedure, um, at the time of pull-through. You never know what their outcome is going to be. There's anatomic issues, the appendix is quite small when we're doing their pull-through. And I would say in patients that we do a MAC and a metrofenoff, the urologic issues sort of dictate the timing of the procedure more. Much more often than the colon issues. Meaning, our urodynamics changing? Do you need to do uh leakage from urine? Are you going to need to augment the bladder, and so, and we try to do these procedures together. So, usually the urologic procedure dictates that, but we have not done pull-through or PR procedures in 6 month olds or 1-year-olds and done uh MCce procedure at that time. One, the appendix is so small, but two, you really don't know what the functional outcome is at that time, and you have to let the patient. Determine their functional outcome before you commit them to a procedure that they might need. I have bladder neck fistulas that are continent of stool and don't need them alone. You have to let, these are prognostic tools, but the real answer that I tell families is, I could give the, at lectures, I could give you 80%, 60%, but for your child, it's either 100%, you know, your child's either continent or not, and we have to determine that when they're going through their potty training years. Thank you, Jason. Last question, and that is, I know you already mentioned the issue of, uh, you know, use of radio, uh, radiology, X-rays and, uh, radiation exposure and how we are such big proponents of image gently, but, uh, even that, uh, you know, X-rays are still the best modality. Any thoughts on using ultrasounds for measuring, um, the fecal it's, it's, I, I, in our institution, Brian Colley and I have been meeting to to try, it's, it's more about. Ultrasound would be a, is a great modality to look at stool burden. The question is training, the availability of that tool, um. I could get an X-ray on a patient anywhere and look at that X-ray minutes later, whereas the ultrasound, it's a little bit harder. It, I think that is the wave of the future is getting that. Whether you could teach, families could have handheld ones at home and just scan you, scan their abdomen. I think it's absolute, and I, your point of gentle radiation, we all have to be conscious of what we're, the radiation exposures we're giving to our, prescribing to our patients. Uh, when you, I always tell my trainees, don't order a test if you don't want the results. You need to be able to react to the, if you're ordering a test that you should be reacting to it, and it helping you make clinical decisions for your patients, but it's always up in the mind and it's a great question that we just have to keep challenging ourselves, how can we lessen this, and we're always working on that. Thank you, Jason. Uh, again, it's always a pleasure to have you speak at our conference, and, uh, just want you and your family to know that the global urology community is keeping your dad in our prayers and thoughts, and we're wishing him a speedy, uneventful recovery. I wish I was staying on, but I'm gonna head up to the unit, ICU now, um, but I appreciate it. Uh, I appreciate working with all of you and, and, and, and, uh, you're, you're great partners, great friends. I mean, Brian personally treated me about two weeks ago and HIPAA, HIPAA. I, it's just wonderful, and, and of course I've watched the development of this course and this year obviously has blown it to a different Uh, way, but I think it's great you're reaching more people, and we're helping educate and, and if anyone has questions, ever wants to show me an X-ray, my email, my cell phone is on there. Call me anytime. I'm on WhatsApp. I'm happy to help, uh, work with you and help patients any way possible, and I really truly appreciate this opportunity. I do. Have a great rest of the course and thank you formo in urology department. Can you go ahead and stop sharing? I'm gonna unshare. Yes, yeah, thank you. Thank you.