Functional urinary and fecal incontinence in neurologically normal children: symptoms of one 'functional elimination disorder'?

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.

Genitourinary and gastrointestinal co-morbidities in children: The role of neural circuits in regulation of visceral function

OBJECTIVE

Pediatric lower urinary tract dysfunction (LUTD) is a common problem in childhood. Lower urinary tract symptoms in children include overactive bladder, voiding postponement, stress incontinence, giggle incontinence, and dysfunctional voiding. Gastrointestinal co-morbidities, including constipation or fecal incontinence, are commonly associated with lower urinary tract (LUT) symptoms in children, often reaching 22-34%. This review summarized the potential mechanisms underlying functional lower urinary and gastrointestinal co-morbidities in children. It also covered the current understanding of clinical pathophysiology in the pediatric population, anatomy and embryological development of the pelvic organs, role of developing neural circuits in regulation of functional co-morbidities, and relevant translational animal models.

MATERIALS AND METHODS

This was a non-systematic review of the published literature, which summarized the available clinical and translational studies on functional urologic and gastrointestinal co-morbidities in children, as well as neural mechanisms underlying pelvic organ 'cross-talk' and 'cross-sensitization'.

RESULTS

Co-morbidity of pediatric lower urinary and gastrointestinal dysfunctions could be explained by multiple factors, including a shared developmental origin, close anatomical proximity, and pelvic organ 'cross-talk'. Daily physiological activity and viscero-visceral reflexes between the lower gastrointestinal and urinary tracts are controlled by both autonomic and central nervous systems, suggesting the dominant modulatory role of the neural pathways. Recent studies have provided evidence that altered sensation in the bladder and dysfunctional voiding can be triggered by pathological changes in neighboring pelvic organs due to a phenomenon known as pelvic organ 'cross-sensitization'. Cross-sensitization between pelvic organs is thought to be mainly coordinated by convergent neurons that receive dual afferent inputs from discrete pelvic organs. Investigation of functional changes in nerve fibers and neurons sets certain limits in conducting appropriate research in humans, making the use of animal models necessary to uncover the underlying mechanisms and for the development of novel therapeutic approaches for long-term symptomatic treatment of LUTD in the pediatric population.

CONCLUSION

Pediatric LUTD is often complicated by gastrointestinal co-morbidities; however, the mechanisms linking bladder and bowel dysfunctions are not well understood. Clinical studies have suggested that therapeutic modulation of one system may improve the other system's function. To better manage children with LUTD, the interplay between the two systems, and how co-morbid GI and voiding dysfunctions can be more specifically targeted in pediatric clinics need to be understood.

Management of functional nonretentive fecal incontinence in children: Recommendations from the International Children's Continence Society

BACKGROUND

Fecal incontinence (FI) in children is frequently encountered in pediatric practice, and often occurs in combination with urinary incontinence. In most cases, FI is constipation-associated, but in 20% of children presenting with FI, no constipation or other underlying cause can be found - these children suffer from functional nonretentive fecal incontinence (FNRFI).

OBJECTIVE

To summarize the evidence-based recommendations of the International Children's Continence Society for the evaluation and management of children with FNRFI.

RECOMMENDATIONS

Functional nonretentive fecal incontinence is a clinical diagnosis based on medical history and physical examination. Except for determining colonic transit time, additional investigations are seldom indicated in the workup of FNRFI. Treatment should consist of education, a nonaccusatory approach, and a toileting program encompassing a daily bowel diary and a reward system. Special attention should be paid to psychosocial or behavioral problems, since these frequently occur in affected children. Functional nonretentive fecal incontinence is often difficult to treat, requiring prolonged therapies with incremental improvement on treatment and frequent relapses.

Peristeen(®) transanal irrigation in paediatric patients with anorectal malformations and spinal cord lesions: a multicentre Italian study

AIM

In paediatric and adult patients with neurogenic bowel, transanal irrigation (TAI) of the colon has gained popularity due to the introduction of a specifically designed device. The aim of this pilot study was to present the results of TAI using the Peristeen(®) TAI system in a group of paediatric patients with anorectal malformation (ARM) and congenital or acquired spinal cord lesions (SCLs).

METHOD

Eight Italian paediatric surgery and spina bifida centres participated in the study. The inclusion criteria were age between 6 and 17 years, weight above 20 kg and unsatisfactory bowel management. Patients with chronic inflammatory bowel disease, mental disability and surgery within the previous 3 months were excluded. At the beginning of treatment (T0) and after 3 months (T1) the Bristol scale, a questionnaire assessing bowel function, and two questionnaires on quality of life (QoL) for patients aged 6-11 years (CHQ-pf50) and 12-17 years (SF36) were administered.

RESULTS

Eighty-three patients were enrolled, and seventy-eight completed the study (41 ARMs, 37 SCLs). At T1, constipation was reduced in ARMs from 69% to 25.6% and in SCLs from 92.7% to 41.5%, faecal incontinence in ARMs from 50% to 18.6% and in SCLs from 39% to 9.8% and flatus incontinence in ARMs from 20.9% to 9.8% and in SCLs from 31.7% to 10%. At T0, the Bristol Stool Scale types were 1-2 in 45% of ARMs and 77.5% of SCL patients, whereas at T1 types 1-2 were recorded in only 2.5% of SCL patients. QoL improved in both groups. In the younger group, a significant improvement in QoL was recorded in ARM patients for eight of nine variables and in SCL patients for seven of nine variables.

CONCLUSION

This study showed that Peristeen TAI resulted in a significant time reduction in colonic cleansing, increased independence from the carer and improved QoL in paediatric patients with ARMs and SCLs.

Randomized, double-blind, placebo-controlled trial of polyethylene glycol (MiraLAX®) for urinary urge symptoms

OBJECTIVE

Polyethylene glycol (PEG) is common first-line therapy for urinary symptoms despite minimal evidence-based support. We performed a randomized, double-blind, placebo-controlled study of PEG for initial treatment of overactive bladder (OAB) symptoms in children.

PATIENTS AND METHODS

Patients aged >3 years underwent baseline urinary symptom questionnaire (USQ, scored 0-16), bowel symptom questionnaire (scored 0-20) and abdominal X-ray (KUB). Patients were randomized to placebo/PEG regardless of parent's perception of constipation. After 1 month, patients completed follow-up questionnaires and KUB. Improvement was defined as decrease in USQ (ΔUSQ) ≥ 3 points. Secondary analyses compared urinary and bowel symptoms to KUB.

RESULTS

Of 138 enrolled patients, 71 (51.4%) completed 1 month of therapy. Analyses of those randomized to placebo vs. PEG and non-completers demonstrated similar demographics, baseline symptoms, and KUB. Patients treated with placebo and PEG both had significant improvement in USQ scores (p < 0.0001). Patients treated with placebo and PEG responded similarly to placebo (ΔUSQ 3.7 vs. 3.4, p = 0.773), with improvement in nearly half (48.5% PEG vs. 44.7% placebo). There was no correlation between KUB and urinary or bowel symptoms.

CONCLUSIONS

Nearly 50% of patients with urinary urge symptoms treated with either placebo or PEG for 1 month had improvement in urinary symptoms. KUB did not correlate with baseline or follow-up urinary or bowel symptoms.

The effect of pelvic physiotherapy on reduction of functional constipation in children: design of a multicentre randomised controlled trial

Background

Functional constipation is a common disorder worldwide and is found in all paediatric age groups. Functional constipation can be caused by delayed colonic transit or dysfunction of the pelvic floor muscles. Standard medical care in paediatric practice is often based on clinical experience and mainly consists of a behavioural approach and toilet training, along with the prescription of laxatives. Evidence to evaluate the effectiveness of pelvic physiotherapy for this complaint is lacking.

Methods/design

A two-armed multicentre randomised controlled trial has been designed. We hypothesise that the combination of pelvic physiotherapy and standard medical care will be more effective than standard medical care alone for constipated children, aged 5 to 17 years. Children with functional constipation according to the Rome III will be included. Web-based baseline and follow-up measurements, scheduled at 3 and 6 months after inclusion, consist of the numeric rating scale in relation to the perceived severity of the problem, the Strength and Difficulties Questionnaire and subjective improvement post-intervention (global perceived effect). Examination of the pelvic floor muscle functions, including digital testing and biofeedback, will take place during baseline and follow-up measurements at the physiotherapist. The control group will only receive standard medical care, involving at least three contacts during five months, whereas the experimental group will receive standard medical care plus pelvic physiotherapy, with a maximum of six contacts. The physiotherapy intervention will include standard medical care, pelvic floor muscle training, attention to breathing, relaxation and awareness of body and posture. The study duration will be six months from randomisation, with a three-year recruitment period. The primary outcome is the absence of functional constipation according to the Rome III criteria.

Discussion

This section discusses the relevance of publishing the study design and the development of the presented physiotherapy protocol. It also addresses difficulties when interpreting the literature with regard to the effectiveness of biofeedback, potential confounding, and future research indications. To our knowledge, this article is the first to describe the design of a randomised controlled trial among children with constipation to assess the effect of pelvic physiotherapy as an add-on to standard medical care.

Trial registration

Current Controlled Trials NL30551.068.09

Multi-center randomized controlled trial of cognitive treatment, placebo, oxybutynin, bladder training, and pelvic floor training in children with functional urinary incontinence

OBJECTIVE

Functional urinary incontinence causes considerable morbidity in 8.4% of school-age children, mainly girls. To compare oxybutynin, placebo, and bladder training in overactive bladder (OAB), and cognitive treatment and pelvic floor training in dysfunctional voiding (DV), a multi-center controlled trial was designed, the European Bladder Dysfunction Study.

METHODS

Seventy girls and 27 boys with clinically diagnosed OAB and urge incontinence were randomly allocated to placebo, oxybutynin, or bladder training (branch I), and 89 girls and 16 boys with clinically diagnosed DV to either cognitive treatment or pelvic floor training (branch II). All children received standardized cognitive treatment, to which these interventions were added. The main outcome variable was daytime incontinence with/without urinary tract infections. Urodynamic studies were performed before and after treatment.

RESULTS

In branch I, the 15% full response evolved to cure rates of 39% for placebo, 43% for oxybutynin, and 44% for bladder training. In branch II, the 25% full response evolved to cure rates of 52% for controls and 49% for pelvic floor training. Before treatment, detrusor overactivity (OAB) or pelvic floor overactivity (DV) did not correlate with the clinical diagnosis. After treatment these urodynamic patterns occurred de novo in at least 20%.

CONCLUSION

The mismatch between urodynamic patterns and clinical symptoms explains why cognitive treatment was the key to success, not the added interventions. Unpredictable changes in urodynamic patterns over time, the response to cognitive treatment, and the gender-specific prevalence suggest social stress might be a cause for the symptoms, mediated by corticotropin-releasing factor signaling pathways.

[Primary vesicoureteral reflux]

The never ending discussion about the diagnostics and treatment of vesicoureteral reflux (VUR) now includes arguments for diagnostic nihilism as well as invasive diagnostics and therapy, which is reminiscent of the debate on prostate cancer in adulthood. The common goal of all currently competing diagnostic strategies and approaches is the prevention of renal scars by the most effective and least burdensome approach. There is a difference between acquired pyelonephritic scars with VUR (acquired reflux nephropathy) and congenital reflux nephropathy (primary dysplasia) which cannot be influenced by any therapy.The VUR can be verified by conventional radiological voiding cystourethrography (VCUG), by urosonography, radionuclide cystography or even by magnetic resonance imaging (MRI). The guidelines of the European Association of Urology/European Society for Paediatric Urology (EAU/ESPU) recommend radiological screening for VUR after the first febrile urinary tract infection. Significant risk factors in patients with VUR are recurrent urinary tract infections (UTI) and parenchymal scarring and the patients should undergo patient and risk-adapted therapy. Infants with dilating reflux have a higher risk of renal scarring than those without dilatation of the renal pelvis. Bladder dysfunction or dysfunctional elimination syndrome represents a well-known but previously neglected risk factor in combination with VUR and should be treated prior to any surgical intervention as far as is possible.Certainly not every patient with VUR needs therapy. The current treatment strategies take into account age and gender, the presence of dysplastic or pyelonephritic renal scars, the clinical symptoms, bladder dysfunction and frequency and severity of recurrent UTI as criteria for the therapy decision. The use of an antibacterial prophylaxis as well as the duration is controversially discussed. Endoscopic therapy can be a good alternative to antibacterial prophylaxis or a surveillance strategy in patients with low grade VUR. In patients with dilating VUR and given indications for surgery, endoscopic treatment can be offered. However, parents should be completely informed about the significantly lower success rate of endoscopic therapy compared to open surgical procedures. The open surgical techniques guarantee the highest success rates and should be used in patients with a dilating VUR and high risk of renal damage.

[Voiding disorders in childhood: from symptoms to diagnosis]

The new definitions of voiding disorders in children should be used in clinical practice. Two major kinds of voiding disorders are identified: 1) isolated primary enuresis as a disorder occurring exclusively during sleep with no daytime leakage; 2) urinary dysfunctions that include uninhibited detrusor contraction, sphincter hypertonicity, and urethral instability. These dysfunctions may be primary or secondary. Constipation as an underlying cause is frequent and usually underestimated. The diagnostic process requires one (or more) long consultations. After ruling out a urine leak without a voiding disorder and secondary causes (constipation, inadequate hydration, poor voiding hygiene, crystalluria, etc.), the aim is to distinguish isolated sleep-time disorders (primary enuresis) from daytime ± sleep-time symptoms (primary urinary dysfunctions). Anamnesis, long and accurate, can be sensitized by a questionnaire completed at home. The physical examination focuses on the exclusion of anatomic abnormalities and local inflammation (vulvitis, balanitis, etc.). Diagnostic tests are rarely required at the beginning. Urodynamic exploration may be indicated, never at the first consultation, in case of primary urinary dysfunction. This diagnostic approach provides an appropriate therapeutic decision.

Constipation and LUTS - how do they affect each other?

CONTEXT

Urinary bladder and rectum share a common embryological origin. Their autonomic and somatic innervations have close similarities. Moreover, the close proximity of these two organ systems could suggest that dysfunction in one may influence, also mechanically, the function of the other. Therefore, it is not surprising that defecation problems and lower urinary tract symptoms (LUTS) occur together, as reported in the literature.

OBJECTIVE

To study the relationship between constipation and LUTS focusing on what is evidence-based.

EVIDENCE ACQUISITION

We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE) database in February 2010 to retrieve English language studies (from 1997 to 2009) and the 2005, 2006 and 2007 abstract volumes of the European Association of Urology (EAU), American Urological Association (AUA) and International Continence Society (ICS).

EVIDENCE SYNTHESIS

We present the findings according to the studied population in four groups: (a) children, (b) middle-aged women, (c) elderly and (d) neuropathic patients. Most published studies that correlated rectal and bladder dysfunction were carried out in children or in young women. On the other hand, there are few studies regarding the association between constipation and LUTS in the elderly and in neuropathic patients.

CONCLUSIONS

Several studies in children documented that constipation is linked to urinary tract problems, including infections, enuresis, vesicoureteral reflux and upper renal tract dilatation. The underlying pathophysiology of these findings has not yet been clearly defined. Studies in middle-aged women also support a high prevalence of constipation among patients suffering from urinary tract dysfunction. Furthermore, an association between constipation and urinary incontinence, as well as between constipation and pelvic organ prolapse, has been suggested. The only prospective study in constipated elderly with concomitant LUTS demonstrates that the medical relief of constipation also significantly improves LUTS. Finally, the available data on neuropathic patients suggest that stool impaction in the rectum may mechanically impede bladder emptying. However, most of the studies only include a small number of patients, are not prospective and are uncontrolled. Therefore, there is a need for large-scale, controlled studies to further improve evidence and to provide a valid recommendation for all groups, especially for the elderly and neuropathic patients.

Urinary incontinence in children

BACKGROUND

Urinary incontinence (bedwetting, enuresis) is the commonest urinary symptom in children and adolescents and can lead to major distress for the affected children and their parents. Physiological and non-physiological types of urinary incontinence are sometimes hard to tell apart in this age group.

METHODS

This article is based on selected literature retrieved by a PubMed search and on an interdisciplinary expert consensus.

RESULTS AND CONCLUSION

Nocturnal enuresis has a variety of causes. The main causative factors in monosymptomatic enuresis nocturna (MEN) are an impaired ability to wake up when the bladder is full, due to impaired or absent perception of fullness during sleep, and an imbalance between bladder capacity and nocturnal urine production. On the other hand, non-monosymptomatic enuresis nocturna (non-MEN) is usually traceable to bladder dysfunction, which is also the main cause of diurnal incontinence. A basic battery of non-invasive diagnostic tests usually suffices to determine which type of incontinence is present. Further and more specific testing is indicated if an organic cause is suspected or if the treatment fails. The mainstay of treatment is urotherapy (all non-surgical and non-pharmacological therapeutic modalities). Some patients, however, will need supportive medication in addition. Urinary incontinence has different causes in children and adults and must therefore be diagnosed and treated differently as well. All physicians who treat the affected children (not just pediatricians and family doctors, but also pediatric nephrologists, urologists, pediatric surgeons, and child psychiatrists) must be aware of the specific features of urinary incontinence in childhood.

The natural history of daytime urinary incontinence in children: a large British cohort

AIM

Few studies have looked at the prevalence of daytime incontinence in a longitudinal cohort of children. This study set out to determine the prevalence of daytime incontinence and relationships between daytime incontinence and bedwetting, faecal incontinence and urgency in a large cohort of British children.

METHODS

Parents of children taking part in the Avon Longitudinal Study of Parents and Children (ALSPAC) were asked questions concerning the child's daytime wetting, bedwetting and faecal incontinence at different time points, 4.5, 5.5, 6.5, 7.5 and 9.5 years. The difference between the sexes for these different conditions was compared.

RESULTS AND LIMITATIONS

Data were available for 10 819 of the 13 973 children who entered the study. The prevalence of any daytime incontinence declined from 15.5% at 4.5 years to 4.9% at 9.5 years, and was mainly described as infrequent. Daytime incontinence was more common in girls than boys and frequent (DSM-IV) incontinence was more commonly related to urgency, bedwetting and faecal incontinence than infrequent incontinence.

CONCLUSIONS

Daytime incontinence is relatively common among children of primary school age and frequent incontinence more commonly coexists with other conditions, such as bedwetting and urgency. This study suggests the need for treatment to focus on children with frequent incontinence.

Bowel management for paediatric patients with faecal incontinence

This review assesses the incidence and aetiology of faecal incontinence in childhood. We then systematically address the presentation, clinical assessment, investigation and management of these children. Under management, both medical and surgical approaches and their complications are discussed.

Quantifying demographic, urological and behavioral characteristics of children with lower urinary tract symptoms

OBJECTIVE

This project examines the voiding and behavioral characteristics of children referred to a specialty voiding clinic, including the impact of incontinence on the child and family.

PATIENTS AND METHODS

A total of 351 new patients (aged 5-17 years) referred to our specialty voiding clinic completed background information, including demographics and medical history, a standardized voiding questionnaire, school history, and questions about child and family quality of life, prior to their first appointment.

RESULTS

Patients are primarily female (53%) and Caucasian (70%) with a mean age of 9.5 years (range 5-17; SD=3.5). Of the patients, 25% were diagnosed with a mental or behavioral health problem. Mean urological symptom score was 12 (range 0-29). Higher symptom scores are associated with younger age, ethnic minority status, a mental health diagnosis, being on psychotropic medications, and a poor child and family quality of life. Families of children who are wet day and night reported a poorer quality of life as compared to the families of children who were daytime wetters or bedwetters only.

CONCLUSION

Symptom scores are associated with type of incontinence, social and quality of life variables. Collecting this baseline data will enable ongoing monitoring of progress for these complex patients.

Constipation and incontinence in childhood: two sides of the same coin?

Perspective on the paper by Loening‐Baucke (see page 486)

Darmentleerung, Sauberkeitsentwicklung bei Kindern und ihre Störungen (Obstipation und Enkopresis)

Zusammenfassung. Verstopfung und Stuhlinkontinenz bei Kindern stellen für die Betroffenen und deren Familien eine schwere Belastung dar. In den meisten Fällen liegen funktionelle Störungen ohne organische Erkrankungen zugrunde. Trotzdem muss bei jedem Kind eine zielgerichtete somatische Diagnostik erfolgen. Rein psychische Ursachen für Obstipation und Inkontinenz sind eher selten. Nach Eingrenzen der Diagnose kann durch verschiedene Therapieansätze eine Besserung der Symptomatik erfolgen. Neben medikamentösen und diätetischen Maßnahmen stehen verhaltenstherapeutische Ansätze im Vordergrund. Der vorliegende Text gibt einen Überblick über den aktuellen Stand der wissenschaftlichen Erkenntnisse zu Kontinenzentwicklung, Physiologie und Pathophysiologie der Darmentleerung sowie Diagnostik und Behandlung von Obstipation und Enkopresis aus pädiatrisch-gastroenterologischer Sicht.