Idiopathic 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 idiopathic constipation 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, well performed surgical correction. 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. The ability to squeeze the anus relies on the presence of intact anal sphincters, both voluntary skeletal muscle and involuntary smooth muscle. The anal sphincters are normal in patients with idiopathic or functional constipation. However, sometimes children can hold on to the stool and fail to relax the sphincters at the correct time. The sacrum, spine, and spinal cord are usually normal in children with idiopathic or functional constipation. If there are specific concerns regarding the spine in your child, this will be discussed in more detail at the time of your visit. In some instances, children with functional constipation require surgery, and this will be discussed in more detail later in the video. Now, we'll look at functional constipation in more detail. Children with idiopathic or functional constipation have the ability to be continent of stool as they have an intact dentate line and anal sphincters. Problems arise, however, when the constipation is poorly or ineffectively managed. Chronic constipation and retention of stool can lead to severe dilatation of the rectum and colon, which in turn can lead to ineffective peristalsis and contraction, leading to further accumulation of stool, and the patient ends up in a vicious cycle of failure to empty and stool accumulation. There reaches a critical point where the child will be unable to evacuate without assistance. A large fecalloma may develop in the rectum, which cannot be passed spontaneously. However, more proximal liquid stool is able to bypass the fecalloma, often resulting in the constant leakage of stool. This is termed pseudo incontinence or opresis. The management strategy for these children is therefore to empty the colon and rectum of stool on a regular daily basis to prevent the accumulation of stool. A small percentage of patients have motility disorder and need manometry testing and more sophisticated interventions. Some are found to have dysfunctional segments of colon which in certain circumstances may need to be surgically removed in order to improve their ability to empty the colon of stool. But this is extremely rare, and will be discussed with you and your child in more detail, if appropriate. 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.