Bowel Management Updates & Innovations with Live Q&A: April 2018
With Dr. Jason Fisher & Dr. Monica Holder · StayCurrentMD
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
The Colorectal Center patient population includes anorectal malformations (imperforate anus), Hirschsprung's disease, spina bifida, sacrococcygeal teratomas, trauma patients, and refractory constipation.
Appendicostomy (Malone/MAC/ACE procedure) involves bringing the appendix to the belly button with a valve mechanism to prevent reflux, allowing patients to independently administer flushes through the colon over 10–15 minutes, then sit on toilet for approximately 45 minutes to empty.
Sacral nerve stimulator is not FDA approved for children under 18, but is performed off-label; it acts like a heart pacemaker, stimulating the third sacral nerve to improve bowel and urinary continence outcomes.
Sacral nerve stimulator is a two-stage procedure (test phase and permanent phase) and has been performed at Cincinnati Children's for almost 3 years.
Solesta is an injection of hyaluronic acid polymer that fills space in the anal canal, used in patients with patulous (more open) anuses to help gain control.
Patients with deformed sacrums have lower likelihood of success with bowel management using medication alone (not on enema program).
Malone procedure requires prior success with enemas because it only changes the route of administration; surgical procedure should not be performed on patients unsuccessful with enema program.
Malone procedure is typically performed starting at age 5 years and older, most commonly between ages 5 and 10–12 years.
Vomiting after enema can be caused by high-volume enema with irritant causing colon distention and discomfort.
To reduce enema-related nausea, give enema prior to meals or about an hour after a meal to allow digestion, avoiding administration right after a full meal when stomach distention plus bowel filling causes nausea.
In cecostomy patients, if enema solution flows too fast or goes into small bowel instead of colon, it can cause vomiting; a study can track solution flow to diagnose this.
Warming enema solution and ensuring irritant is not too strong for the child helps reduce vomiting; additive and volume must be adjusted to treat symptoms.
Enema solution should be given over at least 5 minutes, sometimes 10–15 minutes, to avoid rapid distention and vomiting.
Sacral nerve stimulator indication per manufacturer requires 50% improvement on symptoms; patient must have tried non-surgical bowel management first.
Sacral nerve stimulator requires normal sacrum; it is the least invasive option compared to Malone or Solesta when bowel management is working or needs improvement.
Using hybrid OR with 3D imaging, sacral nerve stimulator can be placed in patients with very abnormal sacrums by identifying anatomy in real-time.
Maximum enema volume is tailored to colon size based on contrast enema study; typically upper limit is around 500 mL for rectal and cecostomy/Malone enemas, occasionally slightly higher but rarely.
For failed redo Hirschsprung's pull-through, redo surgery can almost always create a channel for stool evacuation via rectum/anus, even after 1–3 prior redos; very few patients end up with ileostomy if goal is rectal evacuation.
Patients with almost all large bowel removed may achieve cleanliness on enemas but require very regimented diet (avoiding laxative foods, high-sugar drinks) and multiple daily Imodium doses; some choose stoma over this quality-of-life burden.
The large intestine (colon) primarily absorbs water; in adults it can absorb up to 1 liter of water per day. When colon is removed, stool becomes softer/looser because less water is absorbed.
Bowel management sometimes requires using Imodium to constipate/harden stool, then using enema to empty it—thickening stool first, then mechanically emptying.
There is no perfect surgery for constipation; if there were, all surgeons would recommend and perform it.
Transanal colon/rectum resection is minimally invasive but carries risk of post-surgical incontinence in some patients.
Colon resection for constipation may lessen treatment burden (e.g., reduce laxative dose from 10 to 5 squares of Ex-Lax) but this outcome is not guaranteed.
Before colon resection, offer sacral nerve stimulator and perform manometry (colonic and anorectal) to identify non-functioning colon segments or outlet problems (sphincter dysfunction).
Anorectal manometry can reveal paradoxical sphincter function where child squeezes when trying to relax and vice versa; Botox works in younger children, physical therapy and biofeedback in older children for this.
Colon resection is a big surgery requiring bowel anastomosis with associated risks; once colon is resected, it cannot be replaced. All other treatments (sacral nerve, enemas, laxatives) are reversible.
Many patients referred for bowel resection have tried enemas/laxatives at doses based on age, weight, or manufacturer recommendations, but severe constipation often requires much higher doses than outlined; additional treatment may still achieve success.
There is no research showing scary outcomes from long-term Senna (Ex-Lax) use; patients may need dose increases or decreases over time based on diet, exercise, and hormonal changes.
Long-term Senna use causes melanosis coli (freckling appearance on colonoscopy) but no other long-term side effects beyond this visual finding.
Senna laxative is like insulin for a diabetic—a necessary medication to help move bowels in severe constipation; dose may change over time but patients are not 'addicted' to it.
Excessive laxative dose causes diarrhea; laxative use must be adjusted and monitored by healthcare provider.
Stimulant laxatives (Senna, Dulcolax) make the colon squeeze/push stool forward and reduce water absorption time, resulting in softer stool—two mechanisms that benefit the patient population.
Only two stimulant laxatives are available in the United States: Senna (Ex-Lax chocolate squares, tablet, liquid forms) and Dulcolax.
MiraLax is not a stimulant laxative; it prevents colon from absorbing water, keeping water in colon and making stool softer.
MiraLax is avoided in patients without full continence mechanisms because very loose stool is hard to control when nerves and muscle are partially impaired.
In spinal cord patients (tethered cord, spina bifida), stool is often so formed that MiraLax-type agent is needed to soften stool along with motility agents.
Patients with colostomy can still suffer from constipation and may require stool softener or laxative for daily colostomy output.
When colonic manometry proves lower bowel has poor contraction, colostomy on upper colon allows lower colon to rest; after 6 months to 1 year (sometimes 2 years), repeat manometry checks if bowel has recovered motility, then colostomy can be closed.
Bowel rest with colostomy is typically used in patients with anorectal malformation or Hirschsprung's pull-through complications (narrowing, stenosis, tightness) causing dilated colon/rectum upstream.
If colostomy is not working due to constipation, consider ileostomy to totally exclude colon and divert stool before it reaches colon.
Cone enemas are not routinely used in the Cincinnati program, but if patients are already using them successfully, the team will adjust enema ingredients within that delivery system.
Enema-related pain requires evaluation for injury from enema device (fissures, cuts, ulcers in anal region) and also consideration of other abdominal organ causes (appendix, gallbladder) to avoid missing non-constipation diagnoses.
Peristeen device was originally designed for spina bifida patients, with features for those with limited finger dexterity or arm use; requires physician order and education for independent use.
Peristeen has better success in patients age 8 or older; younger patients (under 8) had difficulty keeping the balloon device in the rectum.
Peristeen insurance coverage is challenging; insurance companies typically deny initially because product is not widely used in US, requiring appeal letters and significant paperwork from healthcare provider.
Michael Helmrath at Cincinnati Children's is growing colons in the lab from single cells, able to lengthen colon in mice and expanding to larger primates.
Anal sphincter tissue regeneration has been attempted by many researchers (using muscles from other areas, other sphincters from esophagus/stomach) but none have been proven to work; no successful procedure is currently offered.
Cincinnati Children's has nearly 3 years of experience with sacral nerve stimulators in children; it works in refractory constipation and combined urinary/stool issues, but pediatric patient heterogeneity makes outcome prediction difficult.
Sacral nerve stimulator was initially designed for urinary incontinence in postpartum women; during testing it was found to also help fecal constipation and incontinence, leading to later FDA approval for fecal symptoms.
Sacral nerve stimulator in adults is used in patients with normal anatomy/development, but in pediatrics it is used in patients with prior pelvic operations, malformations, or disease processes, making study difficult because every patient is different.
Sacral nerve stimulator has a temporary trial stage (1–2 weeks); if it doesn't work, the device is removed without implanting permanent battery.
Urinary symptom improvement with sacral nerve stimulator often exceeds the manufacturer's 50% improvement threshold.
Sacral nerve stimulator has approximately 4 different programs; if symptoms return over time, the program can be changed within the implant to regain success.
Constipation or fecal impaction puts pressure on urinary tract, causing urinary infections, improper emptying, urgency, and other symptoms; treating stool issues is often first step before urologic investigation.
New bedtime wetting in a patient previously clean on bowel management is suspected to be constipation; this is checked first before other evaluation.
All anorectal malformation patients should be followed by urology long-term; more complex malformations have more associated urinary tract malformations, but even minor malformations require periodic follow-up to ensure kidney function and proper urinary tract emptying.
Urinary tract problems in anorectal malformation patients can cause diminished health with late-appearing signs/symptoms; regular urology checkups (exam, renal ultrasound, possibly further testing) are important even without visible problems.
Female anorectal malformation patients should see a gynecologist for reproductive health evaluation and examination.
Cincinnati Children's has weekly meeting with colorectal, urology, and gynecology teams reviewing all patients to ensure comprehensive (not just focused) evaluation.