Predictors of medical adherence following a bowel management program for youth and young adults with Spina Bifida.

PURPOSE: To evaluate individual and community sociodemographic factors that predict bowel regimen adherence in youth and young adults with Spina Bifida (SB) following participation in a bowel management program (BMP). METHODS: Participants were drawn from clinical cases seen through an International Center for Colorectal and Urogenital Care. Area deprivation index (ADI) scores were extracted from participant addresses and bowel regimen adherence data were collected from the electronic medical record (EMR). RESULTS: Participants' mean age was 8.06 years old, 51.7% were male, 72.4% white, 37.9% Hispanic, 56.9% government insurance, 89.7% myelomeningocele, 15.5% non-adherent. Average neighborhood disadvantage was 5.19 (SD:2.83, range:1-10). After controlling for variables correlated with adherence (p < .20), every one decile higher neighborhood disadvantage score was associated with a 48% decrease in the odds of being adherent (OR = 0.52, p = .005, 95% CI: - 101.90, - 0.21). CONCLUSION: Our results suggest that neighborhood disadvantage is a strong predictor of medical adherence following a BMP, more so than other sociodemographic and health-related variables. These results may assist with identifying which individuals may be at higher risk for poor health outcomes due to neighborhood socioeconomic disadvantage and help health care systems intervene proactively.

Pilot bowel management program at Mbarara Hospital, Uganda.

PURPOSE: Children with Hirschsprung's disease (HD) and anorectal malformations (ARM) may benefit from a bowel management program (BMP) to treat constipation and fecal incontinence. This study describes a pilot BMP in Uganda. METHODS: Patients treated for HD or ARM were recruited for the BMP. Local staff underwent training and progressively took over decision-making. The rates of patient involuntary bowel movements (IBMs) and provider confidence were evaluated pre- and post-BMP with questionnaires. The results were compared with Fischer's exact test. RESULTS: Ten staff-2 surgeons, 6 nurses and 2 physiotherapists-and 12 patients participated. Patient median age was 4.5 years (IQR 3-6.6) and ten were male. Ten reported at least daily IBMs prior to the BMP. All patients underwent a clean-out. The parents were then taught to perform daily enemas or irrigations. Specific regimens were determined by patient history and imaging and titrated throughout the BMP. There were differences in the rates of both daytime and nighttime IBMs before and after the BMP (p = 0.0001 and 0.002, respectively). All staff reported increased confidence. CONCLUSIONS: We describe the first BMP in Uganda. BMPs can successfully treat constipation and fecal incontinence in low-income countries, although there are challenges with resources and follow-up.

Identifying predictive factors for bowel control in patients with spina bifida and spinal cord injuries.

PURPOSE: This study aimed to assess our bowel management program (BMP) and identify predictive factors for bowel control in patients with Spina Bifida (SB) and Spinal Cord Injuries (SCI). Additionally, in patients with SB, we examined the impact of fetal repair (FRG) on bowel control. METHODS: We included all patients with SB and SCI seen in the Multidisciplinary Spinal Defects Clinic at Children's Hospital Colorado from 2020 to 2023. RESULTS: 336 patients included. Fecal incontinence was present in 70% and bowel control in 30%. All patients with urinary control also had bowel control. Fecal incontinence prevalence was higher in patients with ventriculoperitoneal (VP) shunt (84%), urinary incontinence (82%), and wheelchair users (79%) compared to those who did not need a VP shunt (56%), had urinary continence (0%) and non-wheelchair users (52%), respectively (p = < 0.001 in all three scenarios). After completing BMP, 90% remained clean for stool. There was no statistical significance when comparing bowel control in FRG with non-fetal repair group. CONCLUSIONS: Urinary continence predicts bowel control in patients with SB and SCI. Risk factors for fecal incontinence were the need for a VP shunt, urinary incontinence, and wheelchair usage. We did not find any positive impact of fetal repair on bowel and urinary control.

Bowel management in spinal cord injury patients.

Spinal cord injuries are common in the United States, affecting approximately 12,000 people per year. Most of these patients lack normal bowel function. The pattern of dysfunction varies with the spinal level involved. Most patients use a bowel management program, and elements of successful programs are discussed. Surgical treatment, when indicated, could include sacral nerve stimulation, Malone antegrade continence enema, and colostomy.

Laxative Weaning Protocol for Patients With Functional Constipation: A Pilot Study.

BACKGROUND: Children with functional constipation require prolonged laxative administration for proper emptying. Whether these laxatives can be weaned after better functioning is achieved is unknown. We aim to describe a standardized protocol for stimulant laxative weaning and its early outcomes. METHODS: Patients were candidates for weaning if they had been on a stable laxative dose for six months, defined as one bowel movement per day with no soiling, impaction, or enemas. Laxative dose was decreased by 10-25% with re-evaluation every two weeks. If patients remained well without constipation, dose was weaned further by 10-25%. If there were worsening of symptoms, lower dose was maintained for 3-6 months until re-evaluation. RESULTS: There were a total of sixteen patients evaluated. Median age was 12.7 years [IQR: 11.7-15.3] with laxative duration of 8.0 years [IQR: 5.4-10.7]. All patients were on senna; some were on fiber. Median starting senna dose was 71.3 mg [IQR: 54.3-75.0] and median fiber dose was 5.5 g [IQR: 4.0-6.0]. As of most recent follow up, nine patients (56.3%) had weaned off laxatives in 3.7 months [IQR: 1.3-11.6]. For those still on laxatives, median reduction in dose was 41.4 mg [30.0-75.0], and over half weaned their dose by >50%. Almost all (90.9%) of those on high doses were able to wean. CONCLUSION: A standardized laxative weaning process can be successful in patients with functional constipation, especially on high doses. Further prospective studies will be necessary to confirm the success of this protocol. LEVEL OF EVIDENCE: III.

Evaluation of Bowel Management Program on Quality of Life in Children with Fecal Incontinence.

Background: Fecal incontinence (FI) is a common disorder that affects the psychological, social, and mental aspects in children. It was showed that the quality of life (QoL) in children with FI was in low level. Bowel management program (BMP) is one of the most effective and low-cost therapies in selected children with FI, but it has also significant effects on mental functions. This study was conducted to evaluate the impact of BMP on the QoL of children with FI. Materials and Methods: In a case series study, we prospectively included all school-age children suffering from FI who had visited in colorectal follow-up center of Isfahan University of Medical Sciences. Patient eligibility included children with FI between 8 and 12 years who were candidate of BMP. The QoL was assessed by Persian version of pediatric QoL (PedsQL) 4.0. Results: In this study, 24 children with FI were studied. Our results showed that total QoL score is significantly different after BMP. The mean score of physical performance before and after BMP was significantly different (P = 0.02). In terms of emotional performance, the mean score of this dimension before and after starting of BMP was significantly different (P = 0.06). In terms of social performance, the mean score of this dimension before and after starting of BMP was significantly different (P = 0.008). Conclusion:: BMP is a low-cost and affordable treatment that can have a significant impact on improving the QoL of the child by improving intestinal function.

Functional fecal and urinary outcomes after sacrococcygeal mass resection in pediatric patients.

BACKGROUND: Sacrococcygeal masses (SCM) are uncommon in children. The purpose of this study is to review the functional fecal and urinary outcomes following resection of SCM and to determine the impact of a multidisciplinary clinic (MDC) on these outcomes. METHODS: A retrospective review was performed of patients who underwent SCM resection between 1979 and 2019. Baylor Social Continence Scale (BCS), Vancouver Symptom Score (VSS) and Cleveland constipation score (CSS) surveys were used to assess fecal and urinary continence at time of most recent follow up. Age, tumor characteristics, histopathology, and type of anorectal malformations (ARM), if present, were also recorded. RESULTS: 75 patients were included. 51 (69%) patients were females and 23 (31%) had an associated ARM. The median age at resection was 8.5 months (IQR 0-26.8). 41 (56%) patients were followed in the MDC. 27 (82%) of patients seen in the MDC were clean for stool and 26 (87%) were dry for urine, while only 17 (59%) of patients not seen in the MDC were clean for stool and dry for urine (p<0.05). There was improvement in Baylor, Vancouver and Cleveland scores. CONCLUSIONS: A multidisciplinary approach to the care of patients following SCM resection may improve bowel and bladder outcomes.

Commentary on "One-year impact of a bowel management program in treating fecal incontinence in patients with Anorectal Malformations".

This is a commentary on the manuscript entitled "One-Year Impact of a Bowel Management Program in Treating Fecal Incontinence in Patients with Anorectal Malformations" by Richard Wood and colleagues.

One-year impact of a bowel management program in treating fecal incontinence in patients with anorectal malformations.

BACKGROUND: Many patients with anorectal malformations (ARM) need a bowel management program (BMP) to manage lifelong problems of fecal incontinence or severe constipation. We aimed to evaluate the sustainability of the results in such a program. METHODS: A single-institution retrospective review was performed in children with ARM who attended our BMP (2015-2019). Standardized definitions and validated tools were used to assess fecal continence (Baylor Continence Scale), constipation (Cleveland Constipation Scoring System), urinary symptoms (Vancouver Symptoms Score), and the Pediatric Quality of Life (PedsQL) and health-related quality of life (HRQOL) at the start of BMP and 1-year after completion of the program. RESULTS: 222 patients with ARM at a median age of 6.7 (IQR, 4.9-10.1) years were identified. All (100%) soiled at intake with 149 (67.1%) patients being treated with rectal or antegrade enemas and 73 (32.9%) with oral laxatives. At 1 year 150 (70.4%) were clean, 72.7% were on enemas and 27.3% were on laxatives (p = 0.08). 109 out of 148 (73.6%) patients were clean on enemas. A further 41 out of 66 (62.1%) patients were continent on laxatives with voluntary bowel movements and clean. In the group that was clean, there was improvement in Baylor Continence Scale (25 vs. 13.0, p < 0.000000002), Vancouver (11 vs. 6, p = 0.0110) scores, and clinically relevant improvement in the total PedsQL HRQL (78-85) and the PedsQL HRQL physical function (86-92) and psychosocial domain (77-82). There was no improvement in Cleveland (10 vs. 9, p = 0.31) score. CONCLUSION: An intensive BMP offers significant benefits in the treatment of fecal incontinence in ARM. It appears to also improve urinary incontinence and urinary voiding as well as the patient's quality of life. These changes are sustainable over at least one year.

Multi-institutional review of bowel management strategies in children with anorectal malformations.

BACKGROUND/RATIONALE: To describe current bowel management program (BMP) strategies in anorectal malformation (ARM) patients based on patient-level predictors using data from a multi-institutional consortium. MATERIALS/METHODS: Patient bowel function and BMP were reviewed from Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) data. The PCPLC is comprised of multidisciplinary specialists researching colorectal and pelvic disorders. Seven US institutions submitted de-identified clinical data on ARM patients into a centralized patient registry. RESULTS: The primary ARM of 624 patients was categorized into Mild (45.2%), Moderate (40.4%) or Complex (14.2%) anomaly classifications. Patient-specific BMP were examined based on age and on the presence of spinal cord/sacral anomalies. 418 (67%) enrolled patients were prescribed BMP (<5 yo 56.4%; ≥5-<12 yo 86.7%; ≥12 81.5%). Constipation was the primary chief complaint (80.2%). Forty percent of patients on a BMP were toilet trained and approximately one-half (48.5%) reported daytime stool accidents. Secondary surgical interventions for antegrade continence enemas (ACE) were examined; 14.5% of patients employed ACE strategies and utilization increased with age and varied based on anatomic anomalies. CONCLUSIONS: This is the first report on BMP strategies for patients with ARM from the Pediatric Colorectal and Pelvic Learning Consortium. Individual patient characteristics are explored for their impact on bowel management strategy utilization. LEVEL OF EVIDENCE: IV.

A structured bowel management program for patients with severe functional constipation can help decrease emergency department visits, hospital admissions, and healthcare costs.

BACKGROUND: Published health-care costs related to constipation in children in the USA are estimated at $3.9 billion/year. We sought to assess the effect of a bowel management program (BMP) on health-care utilization and costs. METHODS: At two collaborating centers, BMP involves an outpatient week during which a treatment plan is implemented and objective assessment of stool burden is performed with daily radiography. We reviewed all patients with severe functional constipation who participated in the program from March 2011 to June 2015 in center 1 and from April 2014 to April 2016 in center 2. ED visits, hospital admissions, and constipation-related morbidities (abdominal pain, fecal impaction, urinary retention, urinary tract infections) 12 months before and 12 months after completion of the BMP were recorded. RESULTS: One hundred eighty-four patients were included (center 1 = 96, center 2 = 88). Sixty-three (34.2%) patients had at least one unplanned visit to the ED before treatment. ED visits decreased to 23 (12.5%) or by 64% (p < 0.0005). Unplanned hospital admissions decreased from 65 to 28, i.e., a 56.9% reduction (p < 0.0005). CONCLUSION: In children with severe functional constipation, a structured BMP decreases unplanned visits to the ED, hospital admissions, and costs for constipation-related health care. LEVEL OF EVIDENCE: 3.