Terminology for children with bowel and bladder dysfunction is confusing, and only in the last decade has there been consensus regarding these terms. This is divided into:
- Lower urinary tract dysfunction
- Daytime urinary incontinence (DUI) - see Enuresis - day wetting pre-referral guideline.
- Enuresis or nocturnal enuresis - see Enuresis - night wetting pre-referral guideline.
- Bowel dysfunction (encopresis) - note that the term encopresis has now largely been superseded with 'faecal incontinence' in international terminology.
Fecal incontinence (previously known as encopresis) is defined as involuntary leaking of feces. This is often associated with constipation.
Encopresis is often the result of an inciting painful stool in toddler years that leads to retention behaviours (child not wanting to poo and holding on) and resultant rectal distention. Over time, with increased rectal distension, the message of rectal fullness is 'lost' to the brain, so that children no longer feel the need to defecate. Then, not until they sense stool on their perianal region will the child go to the toilet. These 'skidmarks' lead a parent to believe their child is “being lazy” and putting off stooling, when reality is they have lost their warning.
Always ask about associated daytime urinary incontinence or nocturnal enuresis symptoms, as they will also require management.
Differentials
Celiac disease - celiac disease can cause constipation or diarrhoea, and can present as encopresis.
Electrolyte disturbance - constipation can be caused by electrolyte disturbance; consider baseline electrolytes if concerned about constipation. Hypercalcemia causes polyuria, which leads to dehydration which in turn can lead to constipation. Hypocalcemia can lead to constipation from decreased muscle contractility.
Cow’s milk protein intolerance - ask about the volume of dairy intake. Cow's milk protein intolerance is a common precipitant of constipation and resultant encopresis.
- Daytime continence is a developmental milestone, and there is variation in when continence is achieved. About 3% of 4 year olds, 2% of 6 year olds, and 1.5% of 10 year olds continue to have faecal incontinence.
- Always ask about associated daytime urinary incontinence or nocturnal enuresis symptoms, as they will also require management.
- The effect of dietary changes on constipation and encopresis in children remains controversial.
- Management centres around removal of faecal retention then reconditioning the bowel.
- Bowel washout failures generally occur when softener is ceased too soon and the empty but distended rectum refills again.
- Enemas are rarely advisable in children.
Investigations
- A baseline AXR should be considered only if initial attempts at washout in the home setting are unsuccessful - constipation is often over-diagnosed on AXR.
Management
Simple management steps should include:
- Demystify and educate - daytime continence is a developmental milestone, and as with all milestones, there is variation in when continence is achieved. About 3% of 4 year olds, 2% of 6 year olds, and 1.5% of 10 year olds continue to have faecal incontinence.
- Remove blame - most parents believe that their child waits too long to go to the toilet, or is being lazy. Explain that because of rectal hyposensitivity from stretching the child often has no warning of need to stool, or even intermittent warning. There can be confusion, frustration and anger about why the child can “get it right” some of the time, but not others.
- The effect of dietary changes on constipation and encopresis in children remains controversial. Concentrating effort on a sitting regime and taking stool softeners is a far better use of energy than change in diet.
1. Remove faecal retention:
- First manage constipation - home washout preferable; Macrogol is the first choice for children over the age of 2, either an osmolax washout or movicol washout.
- Continued softener is essential - washout failures generally occur when softener is ceased too soon and the empty but distended rectum refills again. A rule of thumb is that softener needs to continue for half as long as the issue has been occurring, which may mean months, if not years of ongoing softener. Doses are available at the bottom of the Osmolax or Movicol washout guidelines (see Other Resources below).
- Enemas are rarely advisable in children - given that passage of painful stool often starts the cycle of retention, the noxious stimuli of enemas in the anal region can often propagate the problem.
2. Recondition the bowel:
- Stool diary and sitting diary - children should sit three times daily, for five minutes. Ideally, 20 minutes after eating.
- Encourage stooling:
- position correctly with legs at 90 degrees, practice blowing out tummy, or even blowing up balloons.
- make the toilet environment a happy place - books, posters, iPad.
- reward system to encourage sitting
- Exploring reasons for refusal of sitting - often it is to do with the height of the toilet, the fear of the water splash, that the bathroom is too cold, etc.
- Paediatrician
- generally a non-urgent referral to paediatric outpatient services to i) confirm diagnosis, ii) discuss management strategies and iii) consider appropriateness of medication.
- Information to bring to any
appointments:
- Stool diary - at least 7 days recording is needed, but the more the better
- Sitting diary
- Paediatric
Continence Service
- referrals to Dr Mark Nethercote, Queen Elizabeth Centre, 102 Ascot Street South, Ballarat 3350, fax 53203737
- All patients are seen by a Continence Nurse initially, who performs and intake assessment and management plan.
- If deemed necessary, the Continence Nurse will on-refer to Dr Mark Nethercote, the Paediatrician attached to the Continence Service.
- Other resources
- Osmolax washout guidelines
- Movicol washout guidelines
- Stool diary
- Sitting diary