Comparing quality of life improvement after antegrade continence enema (ACE) therapy for patients with organic and functional constipation / encopresis.

BACKGROUND: We compared patient- and family-reported overall and stool-related quality of life (QoL) before and after an antegrade continence enema (ACE) procedure (cecostomy tube insertion) for refractory chronic constipation or fecal incontinence (CCFI). We hypothesized that patients with functional diagnoses experience similar improvements in QoL compared to those with organic diagnoses. METHODS: This is a cross-sectional study of patients undergoing cecostomy tube insertion for CCFI at a tertiary pediatric hospital from 2012 to 2019. Patients and/or primary caregivers completed validated stooling and overall QoL surveys based on three time points: before surgery, three months after surgery, and at the time of survey / date of last follow-up. Repeated measures analyses compared scores over time between subjects and within the diagnostic groups. RESULTS: The response rate was 65% (22/34 patients, 12 organic and 10 functional diagnoses). Mean age was 8.3 years and 32% of the participants were female. Organic diagnoses were: spina bifida (6), anorectal malformation (5), and Hirschsprung Disease (1). There was substantial improvement in stool-related and overall QoL at three months post-ACE procedure (both p<0.001) for all patients; both scores continued to improve significantly until the date of last follow-up (median 4.1 years, IQR 2.3-5.6, p<0.001). There was no statistically significant difference in scores between patients with organic and functional diagnoses. CONCLUSIONS: Caregivers perceive a significant, sustainable improvement in stooling habits and QoL following ACE therapy. The improvement is comparable between patients with a functional diagnosis and those with an underlying organic reason for their CCFI.

Long-term outcomes of antegrade continence enema in children with chronic encopresis and incontinence: what is the optimal flush to use?

PURPOSE: Severe constipation and encopresis are significant problems in the pediatric population. Medical management succeeds in 50-70%; however, surgical considerations are necessary for the remainder such as the antegrade continence enema (ACE). The purpose of this study is to assess the long-term outcomes following the ACE procedure. METHODS: All patients undergoing an ACE over a 14-year period were included. Data on clinical conditions, treatments, and outcomes were collected. A successful outcome was defined as remaining clean with ≤ 1 accident per week. Comparative data were analyzed using the Fisher's exact test, Mann-Whitney U test, or Student's t test. RESULTS: There were 42 ACE patients, and overall, 79% had improvement in their bowel regimens. Encopresis rates decreased from 79 to 5% (P < 0.001). Admissions for cleanouts decreased from 52 to 19% (P = 0.003). All cases of Hirschsprung's, functional constipation and spina bifida were successful. Rates of success varied for other diseases such as slow-transit constipation (60%) and cerebral palsy (33%). A majority (85%) required a change in the enema composition for improvement. CONCLUSION: In our study, ACE reduced soiling, constipation, and need for fecal disimpaction. Higher volume saline flushes used once a day was the optimal solution and most preferred option. LEVEL OF EVIDENCE: Level 4 (retrospective case series or cohort).

[Home training as a treatment of faecal incontinence and sphincter dyssynergia]. / Entrenamiento anorrectal domiciliario como tratamiento de la encopresis y disinergia esfinteriana.

OBJECTIVE: The defecation disorders represents the 3% of consultations in pediatrics patients. Our goal was to demonstrate the effectiveness and efficiency of the reeducation of the defecation maneuver through home training in patients with encopresis and sphincter dyssynergia. MATERIAL AND METHODS: Study of patients with fecal incontinence treated with home training at our center between 2014-2015. Anorectal manometry was performed and was valued defecation maneuver by expulsion of rectal probe with or without the ball. Daily sessions were performed using a Foley catheter (18-20Fr.) with progressive filling of the balloon, maximum 20cc. The response to the treatment was assessed in terms of episodes of soiling. RESULTS: Seven patients (6 males and 1 female) with a mean age of 9.7 years (range, 5-15) were included; two patients with anorectal malformation history, 1 Hirschsprung disease, 1 sacrococcygeal teratoma and 3 functional encopresis. Three patients had soiling episodes daily and 4 patients frequently. The mean basal pressure of anal channel was 32.34mmHg (range, 11.74-50.75) with negative defecation maneuver in 2 cases, deficient in 3 and dyssynergic in 2 patients. The mean time of biofeedback therapy to be asymptomatic was 5.14 months (range, 2-11), with a mean of 16.14 months (range, 3-24), with the 7 patients currently maintained clean. CONCLUSIONS: The present study suggests that re-education of defecation maneuver through home training, seems to be an effective and efficient therapy, achieving excellent results in medium term.

OBJETIVO: Los trastornos de la defecación representan el 3% de las consultas en pediatría. Nuestro objetivo fue demostrar la eficacia y eficiencia de la reeducación en la maniobra defecatoria mediante el entrenamiento domiciliario en los pacientes con encopresis y disinergia esfinteriana. MATERIAL Y METODOS: Estudio de los pacientes con encopresis tratados mediante entrenamiento domiciliario en nuestro centro entre 2014-2015. Se realizó manometría anorrectal y fue valorada la maniobra defecatoria mediante la expulsión o no de la sonda rectal con o sin balón. Se realizaron sesiones diarias de forma domiciliaria empleando una sonda de Foley (18-20 Fr.) con llenado progresivo del balón, máximo 20 cc. Se evaluó la respuesta al tratamiento en función de la presencia de manchado. RESULTADOS: Se incluyeron 7 pacientes (6 varones y 1 mujer) con edad media de 9.7 años (rango, 5-15); dos con antecedente de malformación anorrectal, una enfermedad de Hirschsprung, 1 teratoma sacrococcígeo y 3 encopresis funcionales. Tres pacientes presentaban manchado diario y 4 de forma frecuente. La media de presión basal del canal fue de 32,34 mmHg (rango, 11,74-50,75) con maniobra defecatoria negativa en 2 casos, deficiente en 3 y disinérgica en 2. La media de tiempo realizando el entrenamiento intestinal hasta lograr estar asintomáticos fue 5.14 meses (rango, 2-11), con un seguimiento medio de 16,14 meses (rango, 3-24), manteniéndose limpios actualmente los 7 pacientes. CONCLUSIONES: El presente estudio sugiere que la reeducación de la maniobra defecatoria mediante entrenamiento domiciliario parece ser una terapia eficaz y eficiente, logrando excelentes resultados a medio plazo.

An 8-Year-Old Boy With Treatment-Resistant Encopresis.

CASE: Paul is an 8-year-old boy with a long-standing history of encopresis and enuresis. Potty training was initiated when he was 2 years old. At this time, his mother was absent from the home for 6 weeks when she cared for her ill father in a different city. The process of teaching Paul to use the bathroom was described as "inconsistent" due to multiple caretakers.Paul never successfully mastered bowel and bladder control. He continues to wet and soil his clothes on a daily basis at home and school. According to his parents, he does not accept responsibility and comments about his soiling such as, "I didn't do it; someone else must have put it there." One of Paul's teachers commented that she could tell at the beginning of the school day whether he would maintain bowel and bladder control. If he was "agitated and talkative" in the early morning, he would often soil that day.He had a pediatric gastroenterological evaluation at the age of 5 years when he was having daily episodes of stool soiling. Physical examination revealed normal anal tone, normal placement of the anus, and moderate stool in the rectal vault. An abdominal radiograph revealed moderate stool throughout the colon. He was treated with Miralax and instructed to sit on the toilet twice daily. Paul did not respond to these interventions and was diagnosed with "overflow incontinence secondary to stool withholding." When he was taking Miralax, he had a normal barium enema radiograph. He was admitted to the hospital for a cleanout with a polyethylene glycol/electrolyte solution.Although abdominal radiographs demonstrated absence of colonic stool for the following 5 months, he continued to soil his clothing. Play therapy and biofeedback did not change the chronic soiling and wetting pattern. An evaluation at the Continence Clinic resulted in a rigorous program including stooling after each meal, wearing a vibrating watch reminding him to void every 2 hours, drinking 60 ounces of water per day, tracking elimination patterns on a calendar, and a daily laxative (polyethylene glycol). A neuropsychological evaluation revealed a superior aptitude associated with unresolved early childhood issues of self-control, self-care, and frustration tolerance. Family therapy was initiated. However, daily fecal soiling and wetting persisted.Paul was born full-term without prenatal or perinatal complications. He was breast fed for 1 year and described as an easy baby. He achieved motor, social, and language milestone on time. Paul had difficulty with separation and aggression in preschool (e.g., biting). In school, teachers report inattention, fidgetiness, and difficulty following directions. He has been obese since age 3 years; his current body mass index is 29.

Antegrade continence enemas improve quality of life in patients with medically-refractory encopresis.

PURPOSE: Fecal incontinence is a socially debilitating problem for many children. We hypothesized that in selected patients with medically-refractory encopresis, placement of an appendicostomy or cecostomy tube for administration of antegrade continence enemas (ACE) would improve quality of life (QOL). METHODS: We reviewed all patients with encopresis who underwent appendicostomy or cecostomy placement from 2003 to 2014 at our institution. We contacted subjects' parents by phone and administered 3 surveys: a survey reflecting current stooling habits, a disease-specific QOL survey, and the PedsQL™ QOL survey. QOL surveys were completed twice by parents, once reflecting pre-operative QOL, then again reflecting current QOL. Pre-procedure and post-procedure scores were compared by paired t-test. RESULTS: Ten patients underwent appendicostomy/cecostomy for encopresis. Eight completed phone surveys. All procedures were performed laparoscopically. All patients experienced fecal soiling pre-operatively, whereas 5/8 surveyed patients (63%) noted complete resolution of soiling post-procedure (p<0.01). General and disease-specific QOL improved from pre-procedure to post-procedure in the following domains: social habits, physical activity, ability to spend the night elsewhere, feeling, and overall QOL (p<0.05). PedsQL™ scores improved significantly in physical functioning, social functioning, and overall functioning (p<0.05). CONCLUSIONS: Antegrade continence enemas significantly improve quality of life in patients with medically-refractory encopresis, likely related to resolution of soiling. LEVEL OF EVIDENCE: 4.

Identifying Underlying Emotional Instability and Utilizing a Combined Intervention in the Treatment of Childhood Constipation and Encopresis-A Case Report.

BACKGROUND: Childhood constipation is a common ailment that in certain cases can lead to encopresis or fecal incontinence. The literature suggests that standard care varies in effectiveness, especially in the long term. Fecal incontinence can lead to frustration, guilt, and shame for both the child and family and has untold long-term psychological and physical consequences. OBJECTIVE: To address alternative treatment options for pediatric constipation and encopresis by using acupuncture and Chinese medicine. Patient and Setting: This is a case study of a 6-year-old girl seen in a private practice acupuncture clinic in the northwestern United States. INTERVENTION: Treatment involved acupuncture, massage, and Chinese herbal medicine. RESULTS: The patient in this study began to have regular bowel movements on her own, from a type 5 on the modified Bristol Stool Form Scale for Children to a type 3, with no laxative use and few to no fecal accidents. CONCLUSIONS: Emotional stability and support seem to play an important role in pediatric constipation and encopresis. Acupuncture may be an effective treatment option in the integrative care model to address both the emotional and physical components of childhood constipation.

Quality of life in pediatric patients with unremitting constipation pre and post Malone Antegrade Continence Enema (MACE) procedure.

OBJECTIVE: The primary aim of this study was to determine if there is a change in the quality of life in pediatric patients with unremitting functional constipation and/or encopresis after undergoing a MACE procedure. METHODS: Patients, ages 5 to 18 years with unremitting constipation and a normal evaluation, including anorectal manometry and colonic manometry, who opted to undergo a MACE procedure were contacted to participate in the study. Patients with congenital anorectal malformations as well as spinal cord disorders were excluded from the study. The patient's parent/guardian completed the PedsQL(TM) Generic Core Scales QOL survey prior to the operation, 6 months, and 12 months after the procedure. RESULTS: A total of 15 consecutive patients meeting protocol criteria were recruited within a period of 20 months. The mean age at the MACE procedure was 9.8 years (range 7.0-11.1). 5 patients were female. The mean QOL score pre-MACE was 64.1. At 6 months post-MACE the mean overall QOL score was 90.2, and it was 92.0 at 12 months. All 15 patients at the 6 month follow up had significant improvement in their QOL (p=1.9 × 10(-7)) and all subcategories of QOL were significantly improved as well. CONCLUSIONS: A MACE procedure is of benefit to otherwise normal pediatric patients who have unremitting functional constipation with failure of medical treatment. Our patients had a significant improvement in all QOL categories and overall QOL.

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children.

BACKGROUND: Faecal incontinence is a common and potentially distressing disorder of childhood. OBJECTIVES: To assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 October 2011), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings, and the reference lists of relevant articles. We contacted authors in the field to identify any additional or unpublished studies. SELECTION CRITERIA: Randomised and quasi-randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children. DATA COLLECTION AND ANALYSIS: Reviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta-analysis when appropriate. MAIN RESULTS: Twenty one randomised trials with a total of 1371 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by trials addressing the same comparisons.Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow-up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children (OR 1.40 95% CI 0.72 to 2.73 at 24 months).In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65). AUTHORS' CONCLUSIONS: There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence in children with functional faecal incontinence associated with constipation.

An 8-year-old boy with treatment-resistant encopresis.

CASE: Paul is an 8-year-old boy with a long-standing history of encopresis and enuresis. Potty training was initiated when he was 2(1/2) years old. At this time, his mother was absent from the home for 6 weeks when she cared for her ill father in a different city. The process of teaching Paul to use the bathroom was described as "inconsistent" due to multiple caretakers.Paul never successfully mastered bowel and bladder control. He continues to wet and soil his clothes on a daily basis at home and school. According to his parents, he does not accept responsibility and comments about his soiling such as, "I didn't do it; someone else must have put it there." One of Paul's teachers commented that she could tell at the beginning of the school day whether he would maintain bowel and bladder control. If he was "agitated and talkative" in the early morning, he would often soil that day.He had a pediatric gastroenterological evaluation at the age of 5 years when he was having daily episodes of stool soiling. Physical examination revealed normal anal tone, normal placement of the anus, and moderate stool in the rectal vault. An abdominal radiograph revealed moderate stool throughout the colon. He was treated with Miralax and instructed to sit on the toilet twice daily. Paul did not respond to these interventions and was diagnosed with "overflow incontinence secondary to stool withholding." When he was taking Miralax, he had a normal barium enema radiograph. He was admitted to the hospital for a clean out with a polyethylene glycol/electrolyte solution. Although abdominal radiographs demonstrated absence of colonic stool for the following 5 months, he continued to soil his clothing. Play therapy and biofeedback did not change the chronic soiling and wetting pattern. An evaluation at the Continence Clinic resulted in a rigorous program including stooling after each meal, wearing a vibrating watch reminding him to void every 2 hours, drinking 60 ounces of water per day, tracking elimination patterns on a calendar, and a daily laxative (polyethylene glycol). A neuropsychological evaluation revealed a superior aptitude associated with unresolved early childhood issues of self-control, self-care, and frustration tolerance. Family therapy was initiated. However, daily fecal soiling and wetting persisted.Paul was born full-term without prenatal or perinatal complications. He was breast fed for 1 year and described as an easy baby. He achieved motor, social, and language milestone on time. Paul had difficulty with separation and aggression in preschool (e.g., biting). In school, teachers report inattention, fidgetiness, and difficulty following directions. He has been obese since age 3 years; his current body mass index is 29.

Update on pediatric faecal incontinence.

PURPOSE: Faecal incontinence represents a devastating problem; it is often a barrier to social acceptance. It can affect many children including those with prior surgery (for anorectal malformations and Hirschsprung's disease) as well as those with spinal problems or injuries. Management involves distinguishing between true and pseudo-incontinence, and then determining the proper protocol of treatment. METHODS: An extensive review of the authors' series of over 500 patients who presented with soiling was undertaken with the goal of determining helpful algorithms of treatment. RESULTS: Treatment begins first with proper categorisation of patients. Pseudo-incontinence (encopresis) can be treated with disimpaction followed by laxative therapy. True incontinence requires an enema programme, with treatment tailored to either hypo or hyper-motile colons. Surgery for pseudo-incontinence, rarely required, takes the form of colonic resection but only for patients with a demonstrated ability to have voluntary bowel movements, albeit with enormous laxative requirements. Removal of the rectosigmoid in this situation can reduce or eliminate the need for laxatives. Surgery for true faecal incontinence involves changing the route for a successfully demonstrated enema programme to an antegrade, i.e., a Malone appendicectomy. CONCLUSION: The keys to success in helping a fecally incontinent child are dedication and sensitivity on the part of the medical team. The basis of the bowel management programme is to clean the colon (either with medical treatment for patients with the potential for bowel control, or artificially with enemas for patients with true faecal incontinence), and then keep the colon quiet for 24 hours until the next treatment, thereby ensuring that the patient is clean and no longer soiling. The programme is an ongoing process of trial and error that responds to the individual patient and differs for each child. We carry out this programme over the course of one week with daily abdominal radiographs as we tailor the regimen. More than 95 % of the children who follow this programme are clean and dry. The clinician must embrace the philosophy that it is unacceptable to send a child with faecal incontinence to school in diapers when their classmates are already toilet trained. Proper treatment to prevent this is perhaps more important than any surgical procedure.

When the going gets tough: pediatric constipation and encopresis.

Constipation and encopresis are two common conditions seen in the pediatric gastroenterology setting. Organic causes cannot be excluded although they are rarely diagnosed in infants and children with defecation disorders. To successfully treat these disorders, a combination of family education, disimpaction and maintenance medications, a well-balanced diet, and behavior management is essential.

Integrative approaches to childhood constipation and encopresis.

Constipation and encopresis (fecal soiling) are common childhood disorders that may lead to significant functional impairment. The etiology and course of constipation and encopresis are increasingly conceptualized from a broad biopsychosocial perspective, and therefore a holistic approach to assessment and treatment is indicated. Many children experience symptoms of chronic constipation and/or encopresis that are only partially responsive to conventional medical therapy. Complementary/alternative therapies can often help in the treatment of constipation/encopresis and are well accepted by patients and families.

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children.

BACKGROUND: Faecal incontinence is a common and potentially distressing disorder of childhood. OBJECTIVES: To assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 1 February 2006). SELECTION CRITERIA: Randomised and quasi-randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children. DATA COLLECTION AND ANALYSIS: Reviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta-analysis when appropriate. MAIN RESULTS: Eighteen randomised trials with a total of 1168 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by trials addressing the same comparisons. Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow-up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children (OR 1.40 95% CI 0.72 to 2.73 at 24 months). In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65). AUTHORS' CONCLUSIONS: There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence in children with functional faecal incontinence associated with constipation.

Assessment of the effectiveness of biofeedback in children with dyssynergic defecation and recalcitrant constipation/encopresis: does home biofeedback improve long-term outcomes.

The purpose of this study was to determine whether biofeedback benefits children with dyssynergic defecation and constipation/encopresis, and whether home biofeedback improves long-term outcomes. Thirty-six patients with chronic constipation who had failed at least 6 months of conventional treatment and demonstrated dyssynergic defecation at anorectal manometry were randomized to biofeedback in the laboratory alone (group 1, n=24) or in the laboratory and at home (group 2, n=12) and followed up at 2, 4, and a mean of 44 months. Thirty patients were available for long-term follow-up. Bowel movements increased in all from a mean of 1.4/week to 5.1, 5.8, and 5.1 per week at 2 months, 4 months, and long-term, respectively (p < or = 0.001). Soiling decreased in all from a mean of 5.5/week to 0.6, 0.1, and 1 per week at 2 months, 4 months, and long-term, respectively (p < or = 0.001). Laxative use decreased from a mean of 4.1 days/week to 0.6, 0.3, and 0.7 per week at 2 months, 4 months, and long-term, respectively (p < or = 0.001). Twenty-seven of 30 parents ranked their satisfaction a mean of 2.2 (range 1-excellent to 3-good). There were no significant differences in outcomes between the laboratory alone group and the laboratory plus home group. Biofeedback is beneficial for some children with chronic constipation and dyssynergic defecation. Supplemental home biofeedback does not improve long-term outcomes.

[Utility of anorectal manometry in the diagnosis and treatment of encopresis]. / Utilidad de la manometría anorrectal para el diagnóstico y tratamiento de la encopresis.

BACKGROUND: Biofeedback based on anomanometric techniques has been shown to be effective in the treatment of children with encopresis. The long-term efficacy of biofeedback and which variables of anorectal manometry (anorectal manometry) could help to establish biofeedback indications are currently the subject of debate. OBJECTIVES: To identify which variables of anorectal manometry, in addition to symptoms, could be useful in deciding which patients could benefit from biofeedback therapy and to assess the outcome of this treatment. PATIENTS AND METHODS: Anorectal manometry was performed in 88 patients, who were referred to our service complaining of soiling at least once a month for a minimum of 6 months after a period of normal continence of 1 year or more. The chronological and mental age of the patients was 4 years. All patients were otherwise in good health and had shown no response to medical treatment. The following variables were studied: anal canal profile, rectoanal inhibitory reflex (RAIR), continence reflex, rectal sensitivity, external anal sphincter (EAS) activity and defecatory maneuver. The patients were divided into two groups, according to clinical and anomanometric impairment, and the most affected patients (n = 41) underwent biofeedback therapy. The indications and outcome of biofeedback were assessed through clinical course and anorectal manometry. In the statistical analysis, the mean and standard deviation were calculated. The chi-squared test with Yates' correction was used to compare clinical and manometric qualitative parameters; Student's t-test was used to compare quantitative parameters; nonparametric tests consisted of the Mann-Whitney test and the Wilcoxon test was used for paired data. RESULTS: Patients treated with biofeedback therapy presented shorter anal canal, greater pressure in the rectal ampulla (P < 0.001), decreased pressure in the anal canal (P < 0.05), lesser distension of the EAS on provoking RAIR, lower presence of the continence reflex (P < 0.01), lower rectal sensitivity, and a worse response of the striated sphincteric muscle and of the defecatory maneuver (P < 0.001). Seventy-eight percent of the patients had a good response to biofeedback therapy. Pressure in the anal canal and rectal sensitivity improved (P < 0.001) with normality on straining in 11 out of 15 patients. These good results persisted in a long-term follow-up of 10 patients. Eight of 10 patients who did not undergo biofeedback therapy showed persistent encopresis (P < 0.001). CONCLUSIONS: Anorectal manometry detected disturbances, chiefly in the activity of the EAS, which are useful in indicating biofeedback therapy in children with secondary encopresis. Biofeedback therapy seems to produce favorable long-term results in the majority of the most severely affected patients.

Management of functional constipation in childhood.

Functional constipation is a common condition. In the majority of cases the constipation develops as a result of a complex weave of factors including specific triggers, e.g. reduced fluid intake following a viral infection or periods of restricted access to the toilet. The passage of large painful stools perpetuates the problem when the child begins to associate pain with defecation. The management of constipation can often be a challenge in children, who initially may be reluctant to sit on the toilet. This article will discuss the contributory factors to the cause of constipation and identify the keys to successful treatment, including ensuring a holistic child-focused approach with effective initial evacuation and appropriate maintenance therapy.

Trends in referral to a single encopresis clinic over 20 years.

OBJECTIVE: To compare the characteristics of children with encopresis referred to a single encopresis clinic over the course of 20 years, including symptoms, previous diagnostic and therapeutic interventions, and parental attitudes. METHODS: A retrospective study was conducted of an encopresis clinic at a tertiary care pediatric hospital. Questionnaires at initial evaluation elicited information about bowel habits, soiling, previous evaluations, previous treatments, and parental attitudes. RESULTS: In 503 children with encopresis, the average age of referral dropped from 115 months during the earliest 5 years to 77 months during the most recent 5 years. Children who had soiling for >3 years before referral decreased from 63% to 12%. The use of barium enema before referral decreased from 14% to 5%, as did psychological evaluation, from 25% to 14%. Previous therapy with enemas decreased from 45% to 27%. Mineral oil use remained at approximately 50%, and 20% of children had no previous treatment. Symptoms at referral and parental attitudes did not change across the years. CONCLUSIONS: Children are now referred at an earlier age to our tertiary encopresis clinic. The number of invasive and psychological evaluations has decreased before referral. However, treatment by many primary care providers before the referral has not changed. These data may suggest that pediatricians have increased awareness of encopresis and greater appreciation of its primarily physical rather than psychological nature. Additional studies will be needed to determine how these factors affect outcome.

Playful metaphors.

The inner world of the child is a community of archetypes potentially available for the child's healthy ego development. Many forces limit and prohibit their utility. Play therapy in the context of a hypnotic relationship can potentiate these archetypes into becoming "playful metaphors" for healing and strengthening ego development. In this article, the author describes her use of playful metaphors in her therapeutic work with two children and explores how metaphor in play therapy is able to connect the child with healing archetypal imagery.

The physiology of continence: idiopathic fecal constipation and soiling.

The anatomic and functional elements contributing to fecal continence and defecation are explored. The high incidence and importance of chronic idiopathic constipation as an entity in itself and a contributing factor to fecal incontinence are emphasized, and its management is discussed. The importance of a proper clinical history and examination is highlighted, and investigative modalities including radiology, transit studies, and anorectal manometry are described and placed in the context of practical clinical management.

Treatment of childhood encopresis: a randomized trial comparing three treatment protocols.

OBJECTIVES: To compare short- and long-term effectiveness of three additive treatment protocols in children experiencing chronic encopresis. METHODS: Children, 6 to 15 years of age, who experienced at least weekly fecal soiling for 6 months or longer were eligible for the study. Children were randomly assigned to a group that received intensive medical therapy (IMT), a group that received intensive medical therapy plus a behavior management program called enhanced toilet training (ETT), or a group that received intensive medical therapy with enhanced toilet training and external anal sphincter electromyographic biofeedback (BF). Data concerning toileting habits were collected for 14 consecutive days before an initial visit, and at 3, 6, and 12 months after initiation of therapy. All data were collected using a computerized voice-mail system that telephoned the families each day. At 12 months, children were classified as significantly improved (reduction in soiling, P < 0.001) or cured ( 0.90, P < 0.001 in each case). Response to treatment during the first 2 weeks of therapy was highly predictive of outcome at 3, 6, and 12 months (P < 0.0001). Children in the ETT group used less laxative medication (P < 0.04) and required fewer treatment contacts (P = 0.08) than children in the IMM group. All three treatments resulted in significant increases in daily bowel movements passed in the toilet and self-initiated toileting, and resulted in decreases in average daily soiling at 3, 6, and 12 months (P < 0.05). CONCLUSIONS: Enhanced toilet training is somewhat more effective in treating childhood encopresis than either intensive medical therapy or anal sphincter biofeedback therapy. Although similar total cure rates at 1 year can be expected with these three forms of therapy, enhanced toilet training results in statistically significant decreases in the daily frequency of soiling for the greatest number of children.