The effects of transanal irrigation as a stepwise bowel management program on the quality of life of children with spina bifida and their caregivers

A Structured Training for Trans Anal Irrigation in Pediatric Patients Improves Outcomes and Reduce Failures: Results of an Interventional Multicenter Prospective Study

BACKGROUND

Continence issues due to organic causes including previous colorectal surgery or neurological issues might benefit from Transanal irrigation (TAI) that proved to be highly effective but with a number of limitations including a relatively high discontinuation rates. Our study was aimed at evaluating the efficacy of an advanced protocol tailored to each patient to prevent dropout and increase satisfaction, independence, and quality of life.

MATERIALS AND METHODS

This was a prospective, interventional, multicenter, nonrandomized study involving children aged 4-18 years with bowel dysfunction unresponsive to conventional treatments who required TAI. TAI was performed in accordance to the best standards of care with a total irrigation volume that was determined based on low emission X-Ray barium enemas performed at the very beginning of the study. All patients underwent training and assessments of continence, patients' perspectives and quality of life were performed at different timepoints from enrollment (T0) up to 6 months since TAI was introduced (T3).

RESULTS

A total of 78 patients were enrolled. Male to female ratio was 1.4:1. Mean age at enrollment was 106.1 ± 42.8 months. Discontinuation was reported by 3 patients (3.8 %). Continence, satisfaction and a number of other outcome measures increased from baseline (T0) to the last visit (T3). In particular, mean Rintala total score increased linearly from 7.8 to 14.8 during the study period (T0 to T3 timepoints). On a multivariate analysis, the only parameter that proved to be inversely associated with continence as well as with other outcome measures was the use of laxatives at enrollment and during the study.

CONCLUSIONS

This study has demonstrated the high efficacy of this innovative patient-tailored TAI protocol across all assessed scores. Of note, given the negative impact of laxatives, our findings suggest limiting their use in this patient population to further increase the efficacy of the procedure.

Association Between Quality of Life and Neurogenic Bowel Symptoms by Bowel Management Program in Spina Bifida

OBJECTIVE

To compare differences in bowel-specific quality of life (QOL), overall qQOL, and neurogenic bowel dysfunction (NBD) severity by bowel management program in patients with spina bifida (SB).

METHODS

We performed a retrospective cross-sectional study of patients ≥12 years old at our multidisciplinary SB center who completed both a modified Peristeen NBD questionnaire (assessing bowel symptom severity and bowel-specific QOL) and the Patient-Reported Outcomes Measurement Information System Pediatric Global Health questionnaire (assessing overall QOL). Nested, multivariable models were fit for associations between outcomes and bowel management program (enemas, conservative management, and none).

RESULTS

A total of 173 patients, 56.1% female and 64.6% with myelomeningocele, were included in our analysis. Median age was 18.2 years old. Patients reported using enemas (n = 42), conservative management (n = 63), and no bowel program (n = 68). When adjusting for covariates, there was no significant association between bowel-specific QOL nor overall QOL across bowel management programs. However, the use of conservative management compared to enemas was associated with worse bowel symptoms severity (adjusted beta=2.58, 95%CI=[0.09,5.06]). Additionally, greater bowel symptom severity was significantly associated with lower overall QOL (adjusted beta=-0.33, 95%CI=[-0.57,-0.10]).

CONCLUSION

NBD symptom severity in SB is more strongly associated with QOL than the individual bowel program being utilized. Our findings suggest that different degrees of NBD require different invasiveness of bowel programs, but it is the outcome of the bowel management program and not the specific program itself that is most associated with QOL.

State of the Art Bowel Management for Pediatric Colorectal Problems: Spinal Anomalies

BACKGROUND

Patients with spinal abnormalities often struggle with fecal and/or urinary incontinence (up to 87 and 92%, respectively) and require a collaborative approach to bowel management in conjunction.

METHODS

To define existing approaches and propose state-of-the-art bowel management, a literature search was performed using Medline/PubMed, Google Scholar, Cochrane, and EMBASE databases and focusing on the manuscripts published July 2013 and July 2023.

RESULTS

Patients with spinal anomalies have impaired innervation of the rectum and anal canal, decreasing the success rate from laxatives and rectal enemas. Thus, transanal irrigations and antegrade flushes are widely utilized in this group of patients. Based on spinal MRI, the potential for bowel control in these children depends on age, type, and lesion level. On referral for bowel management, a contrast study is performed to assess colonic motility and evacuation of stool, followed by a series of abdominal X-rays to define colonic emptying and adjust the regimen. The options for management include laxatives, rectal enemas, transanal irrigations, antegrade flushes, and the creation of a stoma. Approximately 22-71% of patients achieve social continence dependent on the type and level of the lesion.

CONCLUSION

Patients with spinal anomalies require a thorough assessment for continence potential and stool burden prior to initiation of bowel management. The optimal treatment option is defined according to the patient's age, anatomy, and mobility. The likelihood of independent bowel regimen administration should be discussed with the patients and their caregivers.

Transanal irrigation to manage neurogenic bowel in the pediatric population with spina bifida: a scoping review

OBJECTIVE

To map available scientific evidence about the pediatric population with spina bifida submitted to transanal irrigation to manage signs and symptoms of neurogenic bowel.

SOURCE OF DATA

This research was developed according to recommendations from the Joanna Briggs Institute Reviewers' Manual and the PRISMA Extension for Scoping Reviews. Searches were carried out in the databases: CINAHL, Medline/Pubmed, Scielo, Scopus, Web of Science, Embase, LILACS, Proquest, and the CAPES catalog of theses and dissertations. Quantitative and qualitative studies on the topic were included, as long as they dealt with this population. There was no predetermined time frame.

SUMMARY OF THE FINDINGS

The authors found 1.020 studies, selected 130 for close reading, and included 23 in the review, all of which had been published from 1989 to 2021. The authors mapped the characteristics of the studies, including their definitions of concepts and use of scales, criteria for the indication of transanal irrigation, training to carry out the procedure, devices and solutions used, number and frequency of transanal irrigations, health care actions, time spent, associated complications, complementary exams, adherence rate, follow-up, and outcomes, focusing on the benefits for bowel management.

CONCLUSIONS

Despite the variability of evaluation parameters and term definitions, evidence suggests that transanal irrigation is a safe and effective method to manage fecal incontinence. Studies in the field are likely to grow, using standardized scales and longitudinal follow-ups. The authors suggest further research on transanal irrigation in the pediatric population with spina bifida in the Latin American context.

Pilot study of an adult bowel management program for fecal incontinence

OBJECTIVE

Bowel management programs are efficacious in pediatric patients with fecal incontinence or intractable constipation unresponsive to standard treatment. No studies have been done examining outcomes in adults. The objective of this study was to assess continence and quality of life outcomes in adults who have underwent bowel management program.

METHODS

A retrospective review of patients 16 or older at the time they underwent a bowel management program for fecal incontinence or constipation was performed. Data collected included intake and follow-up stool and urinary continence, patient-reported outcomes measures (Cleveland Clinic Constipation Score, Baylor Continence Scale, Vancouver Symptom Score for Dysfunctional Elimination), and an age-adjusted health-related quality of life measure.

RESULTS

The cohort included 38 patients with a median age of 19 years (range: 16-55) when they underwent our program. 50% of patients were female and the majority (33, 87%) were White. The most common diagnosis was anorectal malformation (16, 42%) followed by functional constipation (10, 27%). Stool continence rates improved after undergoing the program (52.7% prior to 87.6% at follow-up, p<0.01). There was significant improvement in the Baylor Continence Scale, Cleveland Clinic Constipation Score, and PedsQL (p<0.05).

CONCLUSIONS

Adult patients who underwent a bowel management program for severe fecal incontinence or constipation show significant improvement in stool continence rates, patient-reported outcomes measures, and quality of life. A bowel management program (in-person or via telemedicine) is a feasible treatment strategy for adult patients who fail standard management of fecal incontinence or constipation and should be offered when appropriate.

LEVEL OF EVIDENCE

III.

Investigating the landscape and trajectory of spina bifida research in Asia: a bibliometric analysis

BACKGROUND

Spina bifida is a type of a neural tube defect which affects 243.14 per 100,000 babies in Asia. Research articles on spina bifida have increased in the recent years. However, no study has focused on the research trends in this field in Asia.

METHODS

A systematic review of literature on spina bifida in Asia was performed using the Scopus database from inception to 2020. All published studies on spina bifida conducted in or published by authors from Asia were included in our analysis. Bibliometric information was obtained from Scopus and bibliometrics diagrams were created using VOSviewer software.

RESULTS

A total of 652 articles were obtained in this study. The number of publications showed an upward trend starting 2000s. The country with the greatest number of publications was Japan while All India Institute of Medical Sciences was the most productive institution in spina bifida research in Asia. The current focus of this field in Asia was prevalence of spina bifida, prenatal diagnosis, folic acid supplementation, and complications of spina bifida. Future areas of research in spina bifida include the genetic basis of neural tube defects and the use of stem cell technology as therapies for spina bifida.

CONCLUSION

This is the first bibliometric analysis on spina bifida in Asia. It showed the trend and future areas of research on spina bifida in Asia. Despite the increase in scientific literature on spina bifida research, more research outputs and collaborations are needed especially in developing countries in Asia.

Prospective Evaluation of Transanal Irrigation With a Validated Pediatric Neurogenic Bowel Dysfunction Scoring System

OBJECTIVES

To evaluate the efficacy of transanal irrigation (TAI) in pediatric patients with neurogenic bowel dysfunction (NBD) who were treatment naïve to catheter-based TAI using Peristeen device (Coloplast).

METHODS

Prospective recruitment of patients with NBD who were unsatisfied with their bowel regimen or had no bowel regimen in place, were assessed using the neurogenic bowel dysfunction score (NBDS) before initiating treatment (Time 0) with Peristeen. NBDS scores were reassessed twice: within the first 6 months (Time 1) of initiation of Peristeen and again after greater than 6 months of usage with Peristeen (Time 2).

RESULTS

Over a 26-month period, 104 patients with NBD were enrolled. Mean age was 10.6 years ± 4.7 (range 3-18 years). The NBDS at Time 1 had an average reduction of 14 points from the original score. A similar trajectory was seen at Time 2, with an average reduction of 13 points from original score. There was a statistically significant decrease of 14 points, P < 0.001 at Time 1 and this response was sustained at Time 2 with a statistically significant decrease in scores from initiation by 13 points, P < 0.001. Improved patient satisfaction and quality of life with Peristeen was seen at Time 1 and Time 2.

CONCLUSION

Our results suggest that Peristeen can improve quality of life in pediatric patients with NBD. Significant improvement in NBDS occurred in our pediatric patients with NBD when initiated on Peristeen. Lower scores were seen at both Time 1 and Time 2, which indicated an improvement in their overall NBD.

The importance of dedicated colorectal team participation in the management of spina bifida and spinal cord injury patients

PURPOSE

In September 2020, the colorectal team of the International Center for Colorectal and Urogenital Care joined the spina bifida and spinal cord injury multidisciplinary clinic at Children's Hospital Colorado. Many important lessons were learned.

METHODS

A retrospective review of patients seen in the spina bifida and spinal cord injury multidisciplinary clinic from September 2020 to May 2021 was conducted. Data collected included demographics, diagnosis, pre or post-natal repair for those with myelomeningocele, whether the patient was previously seen by the colorectal team, wheelchair usage, voluntary bowel control vs. fecal incontinence, urinary control vs. clean intermittent catheterization, characteristics of contrast enema, and our proposed intervention.

RESULTS

Overall, 189 children were seen during the study period, ranging from 3 months to 20 years of age (average = 9.5 years). One hundred and two were males and 87 were females. Diagnosis included myelomeningocele (n = 153), spinal cord injury (n = 18), transverse myelitis (n = 7), sacral agenesis (n = 5), diastematomyelia (n = 2), spinal stenosis (n = 2), and tethered cord with lipoma (n = 2). Fifteen patients with myelomeningocele were repaired in-utero. One hundred and sixty patients were new to the colorectal team. Eighty-one patients were wheelchair users. One hundred and twenty-three patients suffered from fecal incontinence and needed enemas to be artificially clean for stool and thirty-eight patients had voluntary bowel movements and were clean with laxatives, suppository, or rectal stimulations. Twenty-eight patients were younger than three years of age and still in diapers. Despite a non-dilated colon on contrast enema, this population has a hypomotile colon. One hundred and twenty-eight patients required clean intermittent catheterization.

CONCLUSION

Joining the spina bifida and spinal cord injury multidisciplinary clinic allowed us to better serve this population and gave us enormous satisfaction to contribute to improve the quality of life of the patients and their parents.

LEVEL OF EVIDENCE

III.

Outcomes of a telemedicine bowel management program during COVID-19

PURPOSE

Due to the COVID-19 pandemic, we transitioned from an in-person bowel management program (BMP) to a telemedicine BMP. The telemedicine BMP consisted of video and/or phone call visits (remote) or a single initial in-person visit followed by remote visits (hybrid). We hypothesized that patient/family satisfaction of a telemedicine BMP would be comparable to an in-person BMP and that there would be improvement in quality of life and functional outcomes after the telemedicine BMP.

METHODS

After IRB approval, demographic and outcomes data were obtained for patients who underwent the telemedicine BMP from May-October 2020. Outcomes included a parent/patient satisfaction survey, Pediatric Quality of Life Inventory (PedsQL), and parent/patient-reported outcome measures (Vancouver, Baylor, and Cleveland scores) at baseline, 1 and 3 month follow-up. Variables were compared using Chi-square or Wilcoxon-Mann-Whitney tests and a generalized mixed model was used to evaluate outcomes scores at follow-up compared to baseline.

RESULTS

Sixty-seven patients were included in our analysis with an average age of 8.6 years (SD: 3.9). Patients had the following diagnoses anorectal malformation (52.2%), Hirschsprung's disease (20.9%), functional constipation (19.4%), myelomeningocele (6.0%), and spinal injury (1.5%). Forty-eight patients (72%) underwent the remote BMP and 19 (28%) underwent the hybrid BMP. Sixty-two percent of parents completed the satisfaction survey, with a median score of 5 (very satisfied) for all questions. Over 75% of parents said they would prefer a telemedicine program over an in-person program. There was significant improvement in the Baylor and Vancouver scores after the BMP (p < 0.01), but no difference in the PedsQL or Cleveland scores (p > 0.05). There was a significant improvement in stool continence after the BMP (p < 0.01).

CONCLUSION

A telemedicine BMP can be an acceptable alternative to a traditional in-person program. There was high parental/patient satisfaction and significant improvement in outcomes. Further research is needed to assess long-term outcomes.

LEVEL OF EVIDENCE

III.

Advanced Management Protocol of Transanal Irrigation in Order to Improve the Outcome of Pediatric Patients with Fecal Incontinence

Background: Transanal irrigation (TAI) is employed for children with fecal incontinence, but it can present several problems which require a study of their outcomes among different pathologies and without a tailored work up. The aim of our study was to evaluate the effectiveness of an advanced protocol in order to tailor TAI, prevent complications, and evaluate outcomes. Methods: We included 70 patients (14 anorectal malformation, 12 Hirschsprung’s disease, 24 neurological impairment, 20 functional incontinence) submitted to a comprehensive protocol with Peristeen^®: fecal score, volumetric enema, rectal ultrasound, anorectal 3D manometry, and diary for testing and parameter adjustment. Results: Among the patients, 62.9% needed adaptations to the parameters, mainly volume of irrigated water and number of puffs of balloon. These adaptations were positively correlated with pre-treatment manometric and enema data. In each group, the improvement of score was statistically significant in all cases (p 0.000); the main factor influencing the efficacy was the rate of sphincter anomalies. The ARM group had slower improvement than other groups, whereas functional patients had the best response. Conclusions: Our results showed that TAI should not be standardized for all patients, because each one has different peculiarities; evaluation of patients before TAI with rectal ultrasound, enema, and manometry allowed us to tailor the treatment, highlighting different outcomes among various pathologies, thus improving the efficacy.

Improving continence in children and young people with neurodisability: a systematic review and survey

BACKGROUND

Children and young people with neurodisability often need help to achieve socially acceptable bladder and bowel control. Approaches vary depending on whether or not the impairment results from spinal cord pathology that impairs motor control and sensation of the bladder and bowel. Currently, there is uncertainty about which interventions are effective.

OBJECTIVE

The objective was to summarise the available evidence on and current practice for improving continence in children and young people with neurodisability.

DESIGN

A systematic review of the effectiveness, cost-effectiveness and factors that modify intervention implementation, alongside a cross-sectional, online survey of current practice with health professionals, parent carers, school and care staff and young people with neurodisability.

RESULTS

Twelve databases were searched in the review, resulting in 5756 references; 71 studies (72 papers) were included in the analyses. Most of the evidence was for children with spinal cord pathology, which involved evaluations of pharmacological approaches and surgical techniques, whereas the evidence pertaining to those with non-spinal-cord-related pathology tended to be for behavioural interventions. The methodological quality of studies was rated as being moderate to poor. There were three robust qualitative studies about the experience of continence among children with spinal cord pathology. We found substantial heterogeneity across the interventions that we evaluated in terms of quality, study design and outcomes measured. No economic studies were found. The results were synthesised narratively and reported in text and tables. We did not find any eligible studies evaluating interventions using toilet and clothing adaptations in the review, although the survey highlighted that these types of interventions are frequently used and considered. In total, 949 people responded to the survey: 202 health professionals, 605 parent carers, 122 school and social care staff, and 20 young people. The survey results illustrated the different roles that professionals have in improving continence, highlighting the importance of a multidisciplinary approach to supporting children and young people and their families. Clinicians employ a range of assessments and interventions to improve continence or independent toileting, depending on the needs of the child.

LIMITATIONS

Quantitative studies in the review were not methodologically robust. The survey had a risk of response bias.

CONCLUSIONS

Our research found a dearth of good-quality evidence for many of the interventions currently in use, and no evidence of experiences of implementing interventions for children with non-spinal-cord-related pathology. There was also no evidence of cost-effectiveness of any of the interventions.

FUTURE WORK

There is a need to involve young people and families in the design of high-quality evaluative research for interventions that aim to improve continence. This is especially the case for children with autism and learning disability, who have been neglected in previous evaluative and qualitative research. We recommend better training for health, education and care professionals about toileting, informed by evidence and the lived experiences of children and their families. We recommend a joined-up multidisciplinary and holistic approach to improving continence to maximise independence, dignity and comfort. It is vital that children and young people with neurodisability have early access to regular, integrated assessment of their bladder and bowel health, and are fully supported with appropriate personalised treatment.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018100572.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 73. See the NIHR Journals Library website for further project information.

Quality of life: Guidelines for the care of people with spina bifida

Quality of Life (QOL) and Health-Related Quality of Life (HRQOL) are important concepts across the life span for those with spina bifida (SB). This article discusses the SB Quality of Life Healthcare Guidelines from the 2018 Spina Bifida Association's Fourth Edition of the Guidelines for the Care of People with Spina Bifida. The focus of these QOL Guidelines was to summarize the evidence and expert opinions on how to mitigate factors that negatively impact QOL/HRQOL or enhance the factors positively related to QOL/HRQOL, the measurement of QOL/HRQOL and the gaps that need to be addressed in future research.

Neurogenic bowel treatments and continence outcomes in children and adults with myelomeningocele

PURPOSE

Neurogenic bowel dysfunction (NBD) is a common comorbidity of myelomeningocele (MMC), the most common and severe form of spina bifida. The National Spina Bifida Patient Registry (NSBPR) is a research collaboration between the CDC and Spina Bifida Clinics. Fecal continence (continence) outcomes for common treatment modalities for NBD have not been described in a large sample of individuals with MMC. NSBPR patients with MMC and NBD were studied to determine variation in continence status and their ability to perform their treatment independently according to treatment modality and individual characteristics.

METHODS

Continence was defined as < 1 episode of incontinence per month. Eleven common treatments were evaluated. Inclusion criteria were established diagnoses of both MMC and NBD, as well as age ⩾ 5 years (n= 3670). Chi-square or exact statistical tests were used for bivariate analyses. Logistic regression models were used to estimate the odds of continence outcomes by age, sex, race/ethnicity, level of motor function, and insurance status.

RESULTS

At total of 3670 members of the NSBPR met inclusion criteria between November 2013 and December 2017. Overall prevalence of continence was 45%. Prevalence ranged from 40-69% across different treatments. Among continent individuals, 60% achieved continence without surgery. Antegrade enemas were the most commonly used treatment and had the highest associated continence rate. Ability to carry out a treatment independently increased with age. Multivariable logistic regression showed significantly higher odds of continence among individuals aged ⩾ 12 years, female, non-Hispanic white, and with private insurance.

Parents' Perception of Self-Management Behaviors for Their Children With Spina Bifida in South Korea: A Qualitative Study

PURPOSE

This study aimed to explore parents' perceptions of self-management behaviors for their children with spina bifida (SB).

DESIGN

Qualitative method.

METHODS

In-depth interviews were conducted with nine Korean parents of children with SB. The data were analyzed using the content analysis method.

FINDINGS

Parental perceptions of the experiences of self-management behaviors in children with SB were classified into risk factors that hinder self-management behaviors and protective factors that accelerate them. Each category of factors was then further classified into child-, parent-, and school-related factors.

CONCLUSIONS

To promote self-management behaviors in children with SB, reducing risk factors and promoting protective factors considering child, family, and school dimensions based on cultural differences are necessary.

CLINICAL RELEVANCE

Rehabilitation nurses should be considered essential healthcare providers who can offer stepwise guidance to achieve self-management behaviors in children with SB according to their stage of development.

Transanal irrigation (TAI) in the paediatric population: Literature review and consensus of an Italian multicentre working group

Constipation and fecal incontinence in pediatric patients are conditions due to either functional or organic bowel dysfunction and may represent a challenging situation both for parents, pediatricians, and pediatric surgeons. Different treatments have been proposed throughout the past decades with partial and alternant results and, among all proposed techniques, in the adult population the Transanal Irrigation (TAI) has become popular. However, little is known about its efficacy in children. Therefore, a group of Italian pediatric surgeons from different centers, all experts in bowel management, performed a literature review and discussed the best-practice for the use of TAI in the pediatric population. This article suggests some tips, such as the careful patients' selection, a structured training with expert in pediatric colorectal diseases, and a continuous follow-up, that are considered crucial for the full success of treatment.

Neurogenic Bowel Dysfunction in Children and Adolescents

Neurogenic/neuropathic bowel dysfunction (NBD) is common in children who are affected by congenital and acquired neurological disease, and negatively impacts quality of life. In the past, NBD received less attention than neurogenic bladder, generally being considered only in spina bifida (the most common cause of pediatric NBD). Many methods of conservative and medical management of NBD are reported, including relatively recently Transanal Irrigation (TAI). Based on the literature and personal experience, an expert group (pediatric urologists/surgeons/gastroenterologists with specific experience in NBD) focused on NBD in children and adolescents. A statement document was created using a modified Delphi method. The range of causes of pediatric NBD are discussed in this paper. The various therapeutic approaches are presented to improve clinical management. The population of children and adolescents with NBD is increasing, due both to the higher survival rate and better diagnosis. While NBD is relatively predictable in producing either constipation or fecal incontinence, or both, its various effects on each patient will depend on a wide range of underlying causes and accompanying comorbidities. For this reason, management of NBD should be tailored individually with a combined multidisciplinary therapy appropriate for the status of the affected child and caregivers.

Prospective switch study comparing two irrigation systems for transanal irrigation in children

BACKGROUND AND STUDY AIMS

Transanal irrigation (TAI) is used in children to treat constipation and incontinence. Belgium has 2 systems available: Colotip® (cheaper, however not designed for TAI) or Peristeen®.

PATIENTS AND METHODS

This patient-control switch study is the first to compare 2 TAI systems. Children regularly using Colotip® for TAI were asked to participate, after consent, a visual analogue scale (VAS) rating the system and a 2-week diary (fecal continence, self-reliance, time spent on the toilet, pain, Bristol stool scale, irrigation volume and frequency of enema) were completed. Non-parametric statistics were used.

RESULTS

Out of 26 children using Colotip®, 18 (69%) children participated and 5 refused (fear n=1, satisfaction Colotip® system n=7). Of these 18 children (interquartile range: 3-18 years, median 12.5 years, 9 girls) 5 patients stopped Peristeen® (pain n=1, fear n=1 and balloon loss n=3) and 2 were lost from follow up. Dropouts and included patients showed no statistical difference. In the 11 remaining patients, pseudo-continence (p 0.015), independence (p 0.01) and VAS score (p 0.007) were significantly better with Peristeen®, no difference was found in time spent on the toilet (p 0.288) and presence of pain (p 0.785).

CONCLUSIONS

In children Peristeen® offered significantly higher pseudo-continence and independency. 30% refused participation because of satisfaction with the Colotip® and 30% spina bifida patients reported rectal balloon loss due to sphincter hypotony. To diminish Peristeen® failure, a test-catheter could be of value. Considering Colotip® satisfaction, both systems should be available. Patient selection for Peristeen® needs further research.

Illness Experiences of Adults with Spina Bifida: Protecting the Whole Self

PURPOSE

To understand and describe the illness experiences of adults with spina bifida (SB) which is an incurable birth defect and chronic condition that must be managed throughout life.

METHODS

A qualitative study using grounded theory was adopted. Data were collected through individual interviews with 16 adults with SB between 2016 and 2017 in South Korea. All interviews were audiotaped, and the transcribed data were analyzed using constant comparative analysis.

RESULTS

The basic socio-psychological process that underlies the illness experiences of adults with SB was identified as protecting the whole self. This consists of three stages: strict self-concealment, attempting self-disclosure, and balancing between self-concealment and self-disclosure. These stages reveal a process of establishing a firm sense of self by freeing oneself from the shame and stigma of society. Three different patterns of living emerged as a result: living as a non-disabled person, living as a marginal person between non-disabled and disabled, and living as a disabled person.

CONCLUSION

Adults with SB struggle to protect their whole self while managing their chronic conditions by having to constantly balance between self-concealment and self-disclosure. Intervention for adults with SB needs to be based on the stage of sociopsychological maturation. In the early stage, intervention needs to be focused on self-concealment to help establish a firm sense of self. On the other hand, in the later stage when psychological maturity occurs, an intervention that focuses on self-disclosure would be helpful so as not to be isolated from society.

Impact of Transanal Irrigation Device in the Management of Children With Fecal Incontinence and Constipation

OBJECTIVES

Children with fecal incontinence and constipation can be classified into 3 groups: neurogenic bowel dysfunction (NBD) related to spinal cord defects (NBD), refractory constipation (RC), or anorectal malformations (ARMs). The transanal irrigation (TAI) device (Peristeen) was approved in 2012 by the Food and Drug Administration. This system uses a pump rather than gravity to instill water as a colonic irrigant and uses balloon occlusion of the rectum. Our aim was to evaluate the effectiveness of TAI (Peristeen) in children who failed to respond to conservative measures for stool incontinence and constipation.

METHODS

Retrospective study of 147 patients prescribed TAI between January 2014 and January 2020. Data collected included demographics, prior bowel regimen, symptoms before and after, patient satisfaction scores, and NBD scores.

RESULTS

Of the 147 patients initiated, 114 remain active users (13 lost to follow-up and 20 discontinued use). Multiple bowel regimens including laxatives (n = 139), cone enema (n = 40), and cecostomy (n = 7) were tried previously. The majority of our patients (n = 85) have NBD, primarily spina bifida, followed by RC (n = 43), and ARM (n = 19). For all patient groups, there was significant improvement in symptoms of fecal incontinence and constipation (P ≤ 0.001). Abdominal pain was improved in the NBD and RC group, but not significantly in the ARM group.

CONCLUSIONS

We provide a single-center review of a large pediatric cohort using TAI (Peristeen) for management of fecal incontinence and constipation. Peristeen offered significant improvement in patients with NBD, RC, and ARM.

Assessment of neurogenic bowel symptoms with the bowel dysfunction score in children with spina bifida: a prospective case-control study

AIM

To compare the quality of life (QoL) in children with spina bifida with a control group of their peers using a validated questionnaire, the Neurogenic Bowel Dysfunction Score (NBDS).

METHODS

The NBDS questionnaire was prospectively distributed to children attending a multi-disciplinary Spina Bifida clinic and healthy controls attending pediatric urology clinics. A score (out of 41) was assigned to each child based on their responses to the validated questionnaire. A lower score indicates better bowel function-related quality of life. SPSS software (v.25) was used for all statistical analysis.

RESULTS

There were 98 respondents to the questionnaire, 48 children with spina bifida and 50 controls. The average age of respondents was 7.88 years (3-16 years). Of those with Spina Bifida, 33 (69%) were on retrograde rectal irrigations, [19 (58%) Peristeen® system, 11 (33%) tube rectal irrigations, and 3 (9%) Willis system], 6 (12%) were on laxatives, and 9 (19%) were on no treatment. The median NBDS for Spina Bifida patients was significantly higher 13.5 (2-32) compared to the control group 2 (0-26, p < 0.001). Amongst Spina Bifida patients, there was no difference in quality of life between the modalities of bowel management (p = 0.203).

CONCLUSIONS

Despite active bowel management, children with spina bifida report a worse quality of life compared to the control group. In those with spina bifida, the lack of a difference between various bowel management strategies, including no treatment, indicates the need for a longitudinal study to evaluate the basis for this unexpected finding.

Pediatric Neurogenic Bladder and Bowel Dysfunction: Will My Child Ever Be out of Diapers?

CONTEXT

Managing patient and parent expectations regarding urinary and fecal continence is important with congenital conditions that produce neurogenic bladder and bowel dysfunction. Physicians need to be aware of common treatment algorithms and expected outcomes to best counsel these families.

OBJECTIVE

To systematically evaluate evidence regarding the utilization and success of various modalities in achieving continence, as well as related outcomes, in children with neurogenic bladder and bowel dysfunction.

EVIDENCE ACQUISITION

We performed a systematic review of the literature in PubMed/Medline in August 2019. A total of 114 publications were included in the analysis, including 49 for bladder management and 65 for bowel management.

EVIDENCE SYNTHESIS

Children with neurogenic bladder conditions achieved urinary continence 50% of the time, including 44% of children treated with nonsurgical methods and 64% with surgical interventions. Patients with neurogenic bowel problems achieved fecal continence 75% of the time, including 78% of patients treated with nonsurgical methods and 73% with surgical treatment. Surgical complications and need for revisions were high in both categories.

CONCLUSIONS

Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Surgical intervention can be successful in patients refractory to nonsurgical management, but the high complication and revision rates support their use as second-line therapy. This is consistent with guidelines issued by the International Children's Continence Society.

PATIENT SUMMARY

Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence, and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Most children can be managed without surgery. Patients who do not achieve continence with nonsurgical methods frequently have success with operative procedures, but complications and requirements for additional procedures must be expected.

A 2-Step Integrative Education Program and mHealth for Self-Management in Korean Children with Spina Bifida: Feasibility Study

PURPOSE

The aim of this study was to develop and test the feasibility of a 2-step self-management program, including onsite integrative education and a mobile health (mHealth) intervention, for children with spina bifida (SB).

DESIGN AND METHODS

This feasibility study used a quasi-experimental single group pre-and post-test design. The onsite integrative education and the mHealth program, "Glowing Stars™," were developed and then tested for content validity by a panel of experts. The feasibility and user satisfaction were evaluated using factors such as school adjustment, self-management knowledge, self-efficacy, self-management behavior, and quality of life measurement by children aged 10 to 12 years with SB and their parents, from March 2018 to April 2018.

RESULTS

A total of five children with SB completed this intervention. All children perceived that this program was usable and feasible to maintain self-management behavior. A statistically significant difference was observed in the children's self-management behavior domain between the first and second post-test (p = .043).

CONCLUSION

This innovative 2-step self-management intervention program complements existing single interventions and confirms the possibility of mHealth technology as an intervention for children with SB.

PRACTICE IMPLICATIONS

In pediatric nursing, this innovative intervention could be adapted for children with chronic conditions, with a positive effect on self-management.

Using a Decision Tree to Guide Bowel Management in Spina Bifida

BACKGROUND

When born with spina bifida, there are numerous neurologic disorders that accompany this birth defect, including neurogenic bowel. Proactive, systematic, and rational approaches can lead to continence and a more functional lifestyle [1].

METHODS

Based on the evidence in the literature and expert experience, our approach to bowel management was developed as a step by step, individualized approach. This was converted to a decision tree for easy guidance of treatment decisions. The approach includes teaching patients and families normal bowel function, changes resulting from neurogenic bowel, common pitfalls in bowel management, and techniques that may improve outcomes. The decision tree, starting with dietary management, breaks into a two-fold attack, oral and rectal. Our data as part of the National Spina Bifida Patient Registry (NSBPR) database was compared to public data from the NSBPR.

RESULTS

Preliminary data from the NSBPR in 2011 reported bowel continence in 42.1% (n = 898) compared to our clinical outcomes of 72.1% (n = 43). As the variable of bowel continence was further defined and more patients were enrolled, the clinic results were comparable to the national reports.

CONCLUSION

Consistency among providers and caregivers is critical to evaluating the management of continence in spina bifida. While this protocol warrants further evaluation, it is offered as an evidence-based, step by step, approach to bowel management in spina bifida with good outcomes for patient management.

Long-term results using a transanal irrigation system (Peristeen®) for treatment of stool incontinence in children with myelomeningocele

INTRODUCTION

Faecal incontinence due to constipation associated with myelomeningocele (MMC) is a frustrating problem. It could have a bad impact on patients and their families' quality of life. Conservative measures could be a starting point. In case of failure, Malone antegrade continence enema (MACE) is commonly considered. However, it is associated with higher complications. Peristeen transanal irrigation (TAI) depends on the injection of water into the colon through a rectal catheter with an inflatable balloon to promote a controlled evacuation of large quantities of faecal contents. Transanal irrigation could be an alternative in these patients to avoid surgery.

OBJECTIVE

The objective of this study was to evaluate the long-term effectiveness and satisfaction of TAI management (Peristeen^®, Coloplast, Denmark) in children with MMC who failed to respond to conservative measures for stool incontinence.

STUDY DESIGN

All patients with MMC who did not respond to conservative measures for stool incontinence and were using TAI with the last follow-up 6 months before the end date were included. Data were collected retrospectively from January 2008 till January 2016. The data collected included the age of starting Peristeen, duration of using the Peristeen, acceptance and compliance of the patient's family with the TAI. Success was defined as stool continence.

RESULTS

A total of 109 patients (55 males and 54 females) diagnosed as having MMC were started on TAI Peristeen. With a mean follow-up of 48 months (24-108), 101 patients (90.4%) achieved complete stool continence and 8 patients were considered failures.

DISCUSSION

The study results are comparable with those of previously reported publications. The main limitation of Peristeen TAI is that it cannot be performed by the patient himself/herself. This may present a problem with later independence.

CONCLUSION

Transanal irrigation with Peristeen^® system is a safe and good alternative option for stool incontinence when other conservative measures fail.

Bowel management program in patients with spina bifida

PURPOSE

Our center has been successfully implementing a bowel management program (BMP) for fecal incontinence consecutive to anorectal malformation and Hirschsprung disease. Recently, the number of patients with spina bifida requiring management for fecal incontinence has increased. The purpose of this study was to review the results of bowel management in patients with spina bifida and the challenges unique to this population.

METHODS

A retrospective chart review was performed including all patients with spina bifida who attended our BMP from February 2016 until April 2018. Data collection included: prenatal intervention, gender, age, characteristics of contrast enema, success rateand challenges faced.

RESULTS

Twenty-two patients met inclusion criteria 13 of which were females. Three patients had their myelomeningocele repaired prenatally, the remaining were repaired postnatally. Patient ages ranged from 2 to 24 years. Only nine patients were referred to BMP at proper toilet training age. Three patients came to BMP status post an antegrade enema procedure with reported "accidents" on their current regimen. The colon in the contrast enema was non-dilated in all patients and two behaved as hypermotile requiring loperamide. Seventeen patients (77%) were clean of stool and considered successful. Solution leakage during enema administration was the most common challenge and was corrected by increasing the Foley balloon fill volume.

CONCLUSIONS

Our bowel management program with enemas is effective for patients with a history of spina bifida. The data support specific considerations for this population including frequent adjustments, close follow-up and specific administration techniques.

Short versus mid-long-term outcome of transanal irrigation in children with spina bifida and anorectal malformations

PURPOSE

We assessed short- and mid-long-term clinical efficacy of transanal irrigation (TAI) and its effect on the quality of life of children with spina bifida (SB) and anorectal malformations (ARM).

METHODS

Seventy-four pediatric patients (age 6-17 years) with SB and ARM with neurogenic bowel dysfunction were enrolled for a prospective and multicentric study. Patients were evaluated before the beginning of TAI (T0), after 3 months (T1) and after at least 2 years (range 24-32 months) (T2) using a questionnaire assessing bowel function, the Bristol scale, and two validated questionnaires on quality of life: the CHQ-PF50 questionnaire for the parents of patients aged 6-11 years and the SF36 questionnaires for patients aged between 12 and 18 years.

RESULTS

Seventy-two patients completed TAI program in T1, and 67 continued into T2. Bowel outcomes (constipation and fecal incontinence) improved in both the SB and the ARM groups in the short and mid-long term. In both groups at T1 and T2, parents and children reported an improvement in quality of life and there was a significant increase of stool form types 4 and 5 as described by the Bristol scale. Common adverse effects during the study were similar at T1 and T2 without serious complications.

CONCLUSIONS

We observed a sustained improvement in bowel management and quality of life in SB and ARM children during the study, more significant in the short term than in mid-long term. To maintain success rates in the mid-long term and to reduce the dropout rate, we propose patient training and careful follow-ups.

Bowel management in children with spina bifida

Spina bifida is a birth defect that commonly causes bowel and bladder dysfunction in children with a significant negative impact on quality of life and emotional wellbeing. Fecal continence improves satisfaction and the quality of life of both children and their caretakers. Bowel management in children with spina bifida is hampered by limited controlled studies and variable practice within different institutions and subspecialists. The goals of a successful bowel management program in children with spina bifida consist of predictable bowel movements, social continence, and eventual independence. Treatment options range from conservative interventions such as diets and oral laxatives that modify stool consistency and transit, to trans-anal irrigations and antegrade continence enemas that facilitate predictable recto-sigmoid emptying and provide a greater degree of independence. In children, the treatment approach should be implemented in the context of the child's developmental age in order to allow for optimum social integration with their age-appropriate peers. We present a review of a stepwise approach to bowel management in children with spina bifida and the challenges related to the proposed treatment options.

Bowel Management and Quality of Life in Children With Spina Bifida in South Korea

Bowel management is a concern in patients with spina bifida. We evaluated the status of bowel management in children with spina bifida (SB) and the effects on quality of life (QoL) of children and their caregivers. Data were collected from 173 children with SB between January and June 2011, whose bowel management status and QoL were assessed using a self-administered questionnaire. Of the 173 children, 38 (22.0%) reported normal defecation, 73 (42.2%) reported constipation only, and 62 (35.8%) reported fecal incontinence with/without constipation. For defecation, 59 children (34.1%) used digital stimulation or manual extraction, 28 (16.2%) used suppositories or enemas, 35 (20.3%) used laxatives, 4 (2.3%) used an antegrade continence enema, and 3 (1.7%) used transanal irrigation. There were significant differences in QoL, depending on defecation symptoms. Children with fecal incontinence and their caregivers had difficulties in travel and socialization (p < .0001), caregivers' emotions (p < .0001), family relationships (p < .0001), and finances (p < .0001). Constipation and fecal incontinence affect QoL of children with SB and their caregivers. Therefore, more attention should be paid to bowel problems and help should be provided to children and their caregivers to improve QoL.

Medical and surgical management of neurogenic bowel

PURPOSE OF REVIEW

Neurogenic bowel dysfunction (NBoD) commonly affects patients with spina bifida, cerebral palsy, and spinal cord injury among other neurologic insults. NBoD is a significant source of physical and psychosocial morbidity. Treating NBoD requires a diligent relationship between patient, caretaker, and provider in establishing and maintaining a successful bowel program. A well designed bowel program allows for regular, predictable bowel movements and prevents episodes of fecal incontinence.

RECENT FINDINGS

Treatment options for NBoD span conservative lifestyle changes to fecal diversion depending on the nature of the dysfunction. Lifestyle changes and oral laxatives are effective for many patients. Patients requiring more advanced therapy progress to transanal irrigation devices and retrograde enemas. Those receiving enemas may opt for antegrade enema administration via a Malone antegrade continence enema or Chait cecostomy button, which are increasingly performed in a minimally invasive fashion. Select patients benefit from fecal diversion, which simplifies care in more severe cases.

SUMMARY

Many medical and surgical options are available for patients with NBoD. Selecting the appropriate medical or surgical treatment involves a careful evaluation of each patient's physical, psychosocial, financial, and geographic variables in an effort to optimize bowel function.

Bowel management in children with spina bifida

Spina bifida is a birth defect that commonly causes bowel and bladder dysfunction in children with a significant negative impact on quality of life and emotional wellbeing. Fecal continence improves satisfaction and the quality of life of both children and their caretakers. Bowel management in children with spina bifida is hampered by limited controlled studies and variable practice within different institutions and subspecialists. The goals of a successful bowel management program in children with spina bifida consist of predictable bowel movements, social continence, and eventual independence. Treatment options range from conservative interventions such as diets and oral laxatives that modify stool consistency and transit, to trans-anal irrigations and antegrade continence enemas that facilitate predictable recto-sigmoid emptying and provide a greater degree of independence. In children, the treatment approach should be implemented in the context of the child's developmental age in order to allow for optimum social integration with their age-appropriate peers. We present a review of a stepwise approach to bowel management in children with spina bifida and the challenges related to the proposed treatment options.

Consensus Review of Best Practice of Transanal Irrigation in Children

Pediatric patients with either functional or organic bowel dysfunction may suffer from constipation and fecal incontinence and represent a complex group in whom management is often difficult. Many noninvasive and invasive treatments have been proposed, with variable efficacy and adverse effects. Transanal irrigation (TAI) is now an accepted alternative, in both children and adults, for bowel dysfunction that has not responded to conservative and medical therapies. There is, however, still some uncertainty about the use of TAI in pediatric populations. Hence, a group of specialists from different nations and pediatric disciplines, all with long-standing experience of bowel management in children, performed a literature search and had round table discussions to determine the best-practice use of TAI in the pediatric patient population. Based on these findings, this article provides best-practice recommendations on indications, patient selection, important considerations before treatment, patient and family training, treatment regimens, troubleshooting, and practical aspects of TAI. We conclude that careful patient selection, a tailored approach, directly supervised training, and sustained follow-up are key to optimize outcomes with TAI in children with functional or organic bowel dysfunction.

Transanal Irrigation in the Treatment of Children With Intractable Functional Constipation

OBJECTIVES

The aim of the study was to assess the treatment efficacy of transanal irrigation and parental satisfaction in children with intractable functional constipation (FC) treated with Peristeen.

METHODS

Cross-sectional survey study among parents of children (age 0-18 years) treated with Peristeen for FC (based on the Rome III criteria). Anonymous questionnaires were sent out to parents via mail, these consisted of 25 self-developed, multiple-choice questions regarding the use of Peristeen, current gastrointestinal symptoms, adverse effects of Peristeen, concomitant medication use, and parental satisfaction.

RESULTS

Out of 91 invited families, 67 (74%) returned the questionnaire. In total, 84% of patients experienced fecal incontinence prior to treatment. Out of all children who still used Peristeen at the time of survey (n = 49), fecal incontinence had resolved completely in 41%, 12% experienced occasional episodes of fecal incontinence (<1 episode per week) and the remaining 47% still experienced episodes of fecal incontinence regularly (≥1 time per week). A total of 28 children (42%) experienced pain during rectal irrigation, especially during insertion of the catheter, inflating the balloon, or during irrigation. Overall, 86% of the parents were satisfied with the result of transanal irrigation and 67% reported that they would continue using transanal irrigation for the treatment of their child's symptoms.

CONCLUSIONS

Transanal irrigation may be effective in the treatment of children with FC and renders a high parental satisfaction. Future prospective studies, preferably RCTs, are necessary to further evaluate this treatment option.

Neurogenic Bowel Dysfunction in Patients with Neurogenic Bladder

Patients with primary neurologic conditions often experience urinary and bowel dysfunction due to loss of sensory and/or motor control. Neurogenic bowel dysfunction is frequently characterized by both constipation and fecal incontinence. In general, the management of neurogenic bowel dysfunction has been less well studied than bladder dysfunction despite their close association.. It is widely accepted that establishment of a multifaceted bowel regimen is the cornerstone of conservative management. Continuing assessment is necessary to determine need for more invasive interventions. In the clinical setting, the Urologist may be the principle provider addressing bowel concerns in addition to bladder dysfunction, and furthermore, treatment of one often impacts the other. Future directions should include development of follow up and management guidelines that address the comprehensive care of this patient population.

Childhood constipation: finally something is moving!

Recent developments in the evaluation and treatment of childhood constipation are likely to influence the way we deal with pediatric defecation disorders in the near future. Innovations in both colonic and anorectal manometry are leading to novel insights into functional defecation disorders in children. Promising results have been achieved with innovative therapies such as electrical stimulation and new drugs with targets that differ from conventional pharmacological treatments. Also, new surgical approaches, guided by manometric findings, have led to improvement in patient outcome. Finally, utilization of non-pharmacological interventions such as fiber and probiotics has been a field of particular interest in recent years. The aim of this article is to provide an update on these and other novel diagnostic and therapeutic tools related to childhood constipation.

Prospective evaluation of Peristeen® transanal irrigation system with the validated neurogenic bowel dysfunction score sheet in the pediatric population

AIMS

To determine the ability of Peristeen® transanal irrigation system to reduce symptoms of neurogenic bowel dysfunction (NBD) in patients using the validated neurogenic bowel dysfunction scoring system for the pediatric population.

METHODS

Patients 3-21 years with NBD whose current bowel program was unsuccessful were given the Neurogenic Bowel Dysfunction (NBoDS) score sheet before initiating Peristeen®, and at 2 weeks, 2 months, and 6 months after. All patients were started on Peristeen® with tap water (20 ml/kg) per daily irrigation. Mean and paired t-tests were completed.

RESULTS

24 patients were enrolled and had follow-up. Mean age was 10.5 years (range 3-21 years), 25%, 50%, 25% had thoracic, lumbar and sacral level lesions respectively. Mean NBoDS score at initiation of Peristeen® was 20.21 (±5.56), n = 24. The mean score after two weeks of use was 12.75 (±4.40), n = 24. There was a statistically significant decrease of 7.46 (95%CI, 5.07-9.84) points, t(23) = 6.47, P < 0.0005 after two weeks. There was a statistically significant decrease in their scores from initiation to the 2 month time period of 7.00 (95%CI, 2.18-11.82) points, t(9) = 3.29, P = 0.009. By the sixth month of daily use the mean NBoDS score was 9.67 (n = 12). This was an average decrease of 8.83 (95%CI, 5.39-12.28) points from initiation score, t(11) = 5.641, P < 0.005.

CONCLUSION

The Peristeen® transanal irrigation system provides a significant reduction in NBoDS scores in pediatric patients with NBD. Peristeen® should be considered when other conservative bowel management options have been unsuccessful. Neurourol. Urodynam. 36:632-635, 2017. © 2016 Wiley Periodicals, Inc.

Management of Functional Constipation in Children: Therapy in Practice

Functional constipation is a common healthcare problem among children worldwide and accounts for high healthcare usage and costs. Functional constipation is a clinical diagnosis; the evaluation primarily consists of a thorough medical history and a complete physical examination. Additional investigations are not necessary in most cases. Treatment consists of non-pharmacological and pharmacological interventions. Non-pharmacological interventions involve education and demystification, toilet training (with a reward system), and a defecation diary. Pharmacological treatment comprises three steps: disimpaction, maintenance treatment, and weaning. The treatment of first choice is oral laxatives, preferably polyethylene glycol. When this is insufficient, other therapeutic agents are available. This review discusses the evaluation and management of functional constipation in the pediatric population and provides a summary of drug treatment options.

Transanal irrigation for intractable faecal incontinence and constipation: outcomes, quality of life and predicting non-adopters

PURPOSE

Intractable faecal incontinence (FI) and constipation is a challenging condition to manage in children. Transanal irrigation (TAI) is a non-operative treatment option. This study presents our experience with TAI with the aim of finding predictive factors of non-compliance.

METHODS

This is an outcome and quality of life (QoL) study of a prospectively maintained database of patients < 17 years old commenced on TAI for intractable FI/constipation between 2008 and 2014. Outcome measures were: (1) compliance-classified as non-adopter (use of TAI stopped within 1 month after commencement) or adopter; (2) functional outcome-classified as responder (totally continent or occasional soiling) or non-responder; (3) Rintala score; and (4) QoL score (PedsQL™ 4.0 Generic Core Scale). Analysis to determine predictive factors was also performed.

RESULTS

42 patients were started on TAI [74% male, median age of commencement was 7 (3-16) years]. Underlying diagnoses were: idiopathic constipation (62%), anorectal malformation (26%), Hirschsprung disease (5%), spina bifida (5%) and gastroschisis (2%). Median follow-up period was 14 (3-78) months. 24% were non-adopters. 84% of the adopters responded to treatment. Rintala scores (mean ± SD) pre- and post-TAI were 6.7 ± 3.5 and 11.2 ± 4.8, respectively (P < 0.001). QoL scores pre- and post-TAI were 55.6 ± 24.1 and 65.5 ± 23.7, respectively (P < 0.001). Median age at which TAI was commenced in the non-adopter and adopter group were 6 (IQR 4.5-8.25) and 8 (IQR 7-12), respectively (P = 0.008).

CONCLUSION

TAI is a safe and effective treatment for intractable constipation/FI in children. If tolerated, it can significantly improve quality of life. Age and underlying diagnosis are important factors when recommending TAI to children with intractable FI/constipation.

Patient reported outcomes measures in neurogenic bladder and bowel: A systematic review of the current literature

AIM

To describe existing bladder and bowel specific quality of life (QoL) measurement tools, QoL in patients with multiple sclerosis (MS), spinal cord injury (SCI), Parkinson's Disease (PD), stroke, or spina bifida (SB) affected by bladder or bowel dysfunction, and the impact of specific bladder and bowel management on QoL.

METHODS

We performed a systematic review in PubMed/Medline databases in accordance with the PRISMA statement for English publications between January 1, 2000 and January 1, 2014. Articles were first screened based on their abstract and select full-text articles were then reviewed for eligibility. Articles with no QoL or PROM assessing urinary or bowel dysfunction were excluded. Risk of bias assessment included randomization, incomplete outcomes data, selective outcomes reporting, and other biases. All articles were graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system as per the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

The most common QoL measurement tool for urinary and bowel dysfunction was the Medical Outcomes Study SF-36. Twelve (24%) studies used only non-validated QoL questionnaires. Only three urinary or bowel specific QoL measures were found: the Qualiveen questionnaire, the FICQoL, and the QoL-BM. Several studies identified instances were clinical and patient-reported outcomes were inconsistent particularly with indwelling urinary catheter usage and reconstructive surgery. Additionally, certain clinical outcomes surrogates commonly used as primary outcomes measures may not correlate with the patient reported outcomes (PRO).

CONCLUSIONS

Current PRO measures (PROM) and QoL assessments are heterogeneous and several inconsistencies in clinical and PRO for various management options exist. Standardized PROM will help identify optimal bladder and bowel management for patients with neurologic conditions.

Satisfaction after the Malone antegrade continence enema procedure in patients with spina bifida

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To evaluate the clinical outcomes and factors influencing patient satisfaction with Malone antegrade continence enema (MACE) in patients with spina bifida.

SETTING

Japan.

METHODS

We performed retrospective analysis of 21 patients with spina bifida who underwent surgical creation of an MACE stoma. Clinical outcomes were evaluated by medical records, operative notes and mailed questionnaires. Patient satisfaction scores (SSs) were measured on a modified visual analog scale (VAS) from 1 to 10, and the factors influencing the SS were analyzed.

RESULTS

A 100% return rate for the mailed questionnaires was achieved. All patients underwent in situ appendicocecostomy with cecal plication. There was only one complication that required surgical revision. Regarding fecal continence, the overall success rate was 90%. Although 4 patients (19%) had severe irrigation pain and 4 patients (19%) found the washout time intolerably long, 18 (85%) of them were satisfied with the MACE procedure. Age at operation, experience of retrograde colonic enema (RCE), experience of stomal leakage, increased comfort at school or workplace and increased comfort at sleepovers significantly influenced SSs.

CONCLUSION

MACE is a valuable option in achieving fecal continence in patients with spina bifida, with most patients being satisfied with the procedure. In our analysis, younger age at operation, previous experience of RCE, no stomal leakage and improvement of quality of life (enhanced comfort at school, workplace and sleepovers) significantly influenced the high satisfaction after MACE.