Spinal Constipation

Fecal incontinence and constipation are a major cause of morbidity in children. Children diagnosed with an anorectal malformation, Hirschsprung disease, idiopathic or functional constipation with or without pseudo incontinence, and those with spinal abnormalities can have significant and underestimated problems. Children may require psychological support to deal with the negative effects that persistent soiling has had on their ability to form friendships and to cope with bullying. The persistently soiling child can place enormous strain on a family in terms of extra financial burden, reduced social interactions, and difficulties in planning vacations due to soiling concerns, amongst many other examples. It is important to note, however, that this is first and foremost a physiological problem that can become a psychologic problem secondarily, not vice versa. No child wants to be dirty. To handle the physiological problems, all of these children will need appropriate bowel management. Meaning the methods in which the bowel can be controlled in order to be socially continent. These methods include dietary modification, fiber, stool softeners, stimulant laxatives, anti-diarrheals, electrolyte balance, bile acid sequestrant, and enema constituents. These will be discussed in a separate video. The exact bowel management regimen a child receives depends mainly on three physiological factors the age of the child, the underlying diagnosis, and the child's potential for bowel control, i.e., their inherent ability to have voluntary bowel movements. A good potential suggests that the child will be clean for stool with or without the need for medication such as laxatives. A poor potential for bowel control means that the child is very unlikely to be continent of stool, but will have to be kept clean with the use of enemas via a sycostomy, appendicostomy, or via the rectum. These are examples of mechanical techniques that ensure that the colon empties at a specific time each day. Now we will look at patients with spinal abnormality in more detail. Good potential for bowel control requires 1, maturity and commitment to potty training, 2, normal dentate line and anal canal. 3, intact anal sphincters, 4, normal sacral and spinal anatomy, and 5, where clinically indicated, surgical correction for an anatomic problem. The age of potty training varies from country to country. Certain areas will require the child be potty trained before the child can attend preschool or nursery school. There are therefore increasing social pressures for a child to be continent at a young age. Children with developmental delay from a variety of conditions, such as Down syndrome may not potty train, but they can still be socially clean with the appropriate bowel management regimen. The dentate line, part of the anatomy of the anal canal, is required in order for the patient to have anal canal sensation. The dentate line enables the patient to recognize the difference between solid stool, liquid stool, and gas. In those with normal anatomy, it is easy to recognize the difference between stool and gas, and there is controlled passage of gas or stool at an appropriate time without inadvertent leakage of stool. An additional factor is the inability to sense when the rectum is full, leading to incontinence and smearing. Children with spinal abnormalities have a normal dentate line and anal canal. However, the innervation to these areas may be reduced. The ability to squeeze the anus relies on the presence of intact anal sphincters, both voluntary, skeletal muscle, and involuntary, smooth muscle. The innervation of the anal sphincters can also be impaired in children with spinal abnormalities. Patients with spinal abnormalities may also have abnormal development of the sacrum. Depending on the underlying diagnosis. Children with spinal abnormalities may require surgical intervention, and this will be discussed at the time of your office visit. Spinal abnormalities are seen in patients with anorectal malformations, spina bifida patients, those with a tethered spinal cord, occult spinal dysraphism, myelomeningocele, and in those with a sacrococcygeal teratoma. The sacral development is thought to correlate with the development of the pelvic muscles and nerves. When foreshortened and hypodeveloped, so too are sphincter muscles and nerves. A sacral ratio is a valuable piece of information, as it correlates with the development of the sphincter muscle and nerves. Children can have alteration in the anatomy of the anal canal for a variety of other reasons, and each child needs to be assessed on an individual basis with the same considerations as previously described. In conclusion, there are many factors that can affect a child's ability to be continent of stool, and we hope this video helps to explain the most important concepts. Together as a team, we will work to maximize the chance of your child being independent and continent of stool. Our priority is to ensure that they are happy and reaching their full potential. We believe that every child should be clean for stool. For more information, please contact the Center for Colorectal and Pelvic Reconstruction at Nationwide Children's Hospital.