Use of Rome II versus Rome III criteria for diagnosis of functional constipation in young children

Prevalence and determinants of constipation in children in Asia: a systematic review and meta-analysis

Background

Constipation is prevalent worldwide, significantly increasing healthcare costs and diminishing the quality of life in children affected. Current studies have yielded mixed results regarding the factors associated with constipation, and mainly focusing on patients outside of Asia. Moreover, most of these studies lack focus on the paediatric population. This study aimed to identify the prevalence and associated factors of constipation among children in Asia.

Methods

In this systematic review and meta-analysis, we systematically searched PubMed, Scopus, and Cochrane for cohort and cross-sectional studies published from database inception up to October 12, 2022, and continued with manual searching until September 2, 2023. Eligible studies were those that included children in Asia aged 0-18 years old suffering from idiopathic constipation, with prevalence value provided in the English abstract. The analysis included clinical and general population. Children with organic constipation, who had undergone gastrointestinal surgery, or with congenital defects were excluded, as these factors affect the incidence of constipation. Data included in the analysis were extracted from published reports only. The extracted data were pooled using random-effects model to analyse the prevalence of constipation in children in Asia. This study is registered with PROSPERO, CRD42022367122.

Findings

Out of 4410 systematically searched studies and 36 manually searched ones, a total of 50 studies were included in the final analysis, encompassing data from 311,660 children residing in Asia. The pooled prevalence of constipation was 12.0% (95% CI 9.3-14.6%, I2 = 99.8%). There was no significant difference in constipation prevalence observed by sex and geographical location. Nonetheless, adolescents and children aged 1-9 years exhibited a significantly higher prevalence constipation compared to infants (p < 0.0001) Additionally, significant differences in constipation rates were observed across various diagnostic methods, population sources, and mental health conditions.

Interpretation

Despite the high heterogeneity resulting from varying diagnostic tools or definitions used among studies, our review adds to the literature on constipation among children in Asia. It reveals a notably high prevalence of constipation in this demographic. Diagnostic methods, age, and compromised mental health emerged as significant influencers of constipation among children in Asia, highlighting potential strategies to mitigate constipation prevalence in children in Asia.

Funding

The National Science and Technology Council, Taiwan.

Establishment of a nomogram for predicting functional constipation among children in China: Using the Rome IV criteria

BACKGROUND AND STUDY AIMS

Childhood functional constipation (FC) is gradually becoming an emerging public health problem. This study aimed to develop a personalized nomogram for the prediction of incident FC among Chinese children, and the diagnosis of FC was based on the Rome IV criteria.

PATIENTS AND METHODS

This cross-sectional study was conducted from Nov. 2020 to Jan. 2021 among children residing in Anhui province, China. An electronic questionnaire regarding the general demographic and clinical characteristics of all children was completed by their primary caregivers. The multivariate logistic regression analysis was applied to identify risk factors for FC. Moreover, a nomogram was constructed for FC based on the risk factors identified from the multivariate analysis.

RESULTS

In this study, a total of 901 electronic questionnaires were collected, of which 832 (92.3%) questionnaires were properly completed and included in the final analysis. The prevalence of FC among Chinese children was 11.3% based on the Rome IV criteria. After controlling for potential confounding factors, the multivariate logistic regression analysis showed that inadequate sleep, picky eating, and positive family history of FC were identified as key risk factors of FC. The area under the receiver operating characteristic curve of the nomogram was 0.694 (95 %CI: 0.6412-0.7459). Further, a calibration curve drawn illustrated that the predicted probabilities reasonably approximately the actual prevalence of FC in this population.

CONCLUSION

Inadequate sleep, picky eating, and positive family history of FC were identified as risk factors of FC. An easy-to-use nomogram was constructed based on these three significant factors. Besides, this nomogram was validated to have acceptable discrimination and calibration capabilities. Hence, this nomogram may enable clinical professionals to predict the risk of FC among Chinese children and further provide optimized disease prevention and intervention for this population.

Prevalence and risk factors of functional gastrointestinal disorders in Vietnamese infants and young children

BACKGROUND

Functional gastrointestinal disorders (FGIDs) are common early in life. The prevalence of FGIDs varies among countries but is unknown in Vietnam. The aim of this study is to assess the prevalence of FGIDs in healthy Vietnamese infants and young children.

METHODS

This was a cross-sectional, observational study involving healthy infants and young children between 0 - 48 months old in Hanoi, Vietnam. A representative total of 1511 subjects completed the validated questionnaire on paediatric FGIDs. Rome IV criteria were used to define FGIDs.

RESULTS

For Vietnamese infants (0-6 months) and young children (7-48 months), the prevalence of having at least one FGID was 10.0% and only 0.6% was having more than one FGID. Infantile regurgitation (9.3%) was the most prevalent FGID among infants 0-6 months of age while all other FGIDs had a low prevalence between 0-2.5%. For young children between 7 - 48 months old, functional constipation was the most common disorder at the rate of 5.6%. Association analysis revealed that the risk of infant regurgitation was significantly lower among infants with exclusively breastfeeding at 2 - 3 months and 3 - 4 months, formula initiation at 0 - 1 months, and higher paternal education level. The prevalence of functional constipation was significantly higher in male subjects, children in families with annual household income between 273,000,000 - 546,999,999 VND (or estimate around 11,800 - 23,800 USD), families with one child only, and formula feeding initiation at 1 - 2 months.

CONCLUSIONS

The prevalence of FGIDs in Vietnamese infants and young children is relatively low compared to the published literature using Rome IV diagnostic criteria. Infantile regurgitation was the most common FGID in Vietnamese infants while functional constipation was most prevalent among Vietnamese young children.

TRIAL REGISTRATION

Netherlands Trial Registry Identifier: NL7286/NTR7495 .

Low prevalence of infantile functional gastrointestinal disorders (FGIDs) in a multi-ethnic Asian population

BACKGROUND

Functional gastrointestinal disorders (FGIDs) are common in children. The prevalence of FGIDs varies across the world but is unknown in Malaysia. We aimed to investigate the prevalence of FGIDs in healthy Malaysian infants.

METHODS

This was a cross-sectional study involving healthy infants younger than 12 months of age who attended a well-baby clinic. A universal sampling method was adopted. Children with congenital disorders potentially affecting gastrointestinal functions, chronic debilitating diseases and hypothyroidism were excluded. Rome IV criteria were used to define FGIDs.

RESULTS

Of the total 534 infants recruited (54% males), 92% were born at term; 85% had normal birth weight [range 2.5-4.0 kg], and the mean (±S.D.) age at interview was 6.8 (±3.4) months. Thirty-six percent were breastfed, 29% were formula-fed, and 35% had mixed feeding. Prevalence of infant regurgitation and rumination syndrome was 10.5% and 1.7%, respectively. Prevalence of infant colic was 1.9% (3/160) (infant < 5 months old) while infant dyschezia, functional constipation and diarrhoea were 1.3%, 1.1% and 0.3%, respectively. No subjects fulfilled diagnostic criteria for cyclic vomiting syndrome. Breastfed infants were less likely to regurgitate, after adjustment for age, gender, ethnicity, birth weight and gestation (adjusted OR 0.25 [95% CI 0.12-0.54]; p < 0.001). No significant differences among other factors (gender, Malays vs. non-Malays, premature vs. term, and birthweight) were noted for other FGIDs.

CONCLUSION

With the exception of the lower prevalence of infant colic and functional constipation, the prevalence rates of other FGIDs observed in the present study were similar to those published in the literature. Breastfeeding protects against infant regurgitation.

Functional constipation in infancy and early childhood: epidemiology, risk factors, and healthcare consultation

Background

Functional constipation (FC) is a pediatric problem that is seen frequently. However, its prevalence in Asia remains undetermined. In this study we attempted to determine the prevalence, risk factors and therapeutic modalities of FC in infants and toddlers in Sri Lanka.

Methods

Children aged 6.5 months to 4 years were selected from 14 well-baby and vaccination clinics in the Gampaha District of Sri Lanka. A questionnaire with questions regarding the socio-demographic characteristics, child’s bowel habits, psycho-social risk factors and treatment modalities were filled by the mothers. FC was diagnosed according to ROME III criteria.

Results

A total of 1113 children were analyzed [(female n = 560 (50.3%) with a mean age of 20.7 months, standard deviation [SD] 11.2 months. FC was found in 89 (8.0%). FC was significantly and independently associated with underweight (14.3% vs 7.2%, p = 0.008. [OR and 95% CI: 2,3 (CI; 1.3–4.2)] and residence in an urban area (9.6% vs 5.6%, p = 0.013). [OR and 95% CI: 0.592 (CI; 0.396–0.95)]. Children subjected to violence showed a significantly higher prevalence of FC (20.0 vs 7.8%, p = 0.046). Children being overweight and children living with mothers subjected to violence showed a higher, though not statistically significant, tendency to develop FC. Children with FC visited healthcare clinics more frequently when compared to controls (19.6% vs 6.0%, p < 0.0001). However, only 24% of infants and toddlers with FC were treated specifically for the condition by a doctor.

Conclusions

FC occurred in 8% of this cohort of Sri Lankan infants and toddlers. It is significantly associated with underweight and living in an urban area. Only a quarter of them received medical attention for their constipation.

Trial registration

SLCP/ERC/2014/12, December 2014.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1652-y) contains supplementary material, which is available to authorized users.

Association between cesarean section and constipation in infants: the Japan Environment and Children's Study (JECS)

Objective

There have been increasing reports on the association between cesarean section (C-section) and the subsequent development of diseases in infants. C-section affects the diversity of microbiota in the infant’s gut. In the present study, we investigated the association between infants delivered by C-section and the development of constipation at 1 year old due to altered gut microbiota using data from the Japan Environment and Children’s Study (JECS).

Results

This cohort study (n = 83,019) used data from JECS, an ongoing cohort study which began in January 2011. Data on bowel movement and potential confounding factors were recorded. A log-binomial regression model was used to estimate the risk of C-section, and the results were expressed as risk ratios and their respective 95% confidence intervals. Although infants delivered by C-section were of significantly younger gestational age and lesser birth weight than vaginally delivered infants, the frequency of bowel movements was almost similar between the two, independent of the mode of delivery. The prevalence of constipation in the entire infant was 1.37%. No significant differences were observed for C-section in crude and adjusted risk ratios for constipation.

Prevalence of Functional Defecation Disorders in Children: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically review the literature regarding the epidemiology of functional constipation and functional nonretentive fecal incontinence (FNRFI) in children. Secondary objectives were to assess the geographical, age, and sex distribution of functional constipation and FNRFI and to evaluate associated factors.

STUDY DESIGN

The Cochrane Library, PubMed, and Embase databases were searched from 2006 until September 2017. The following inclusion criteria were applied: (1) prospective studies of population-based samples; (2) reporting on the prevalence of functional constipation or FNRFI according to the Rome III/IV criteria; (3) in children aged 0-18 years; and (4) published in full manuscript form. A quality assessment of included studies was conducted. Random effect meta-analyses with meta-regression analyses of study characteristics were performed.

RESULTS

Thirty-seven studies were included, of which 35 reported on the prevalence of functional constipation and 15 of FNRFI. The reported prevalence of functional constipation ranged from 0.5% to 32.2%, with a pooled prevalence of 9.5% (95% CI 7.5-12.1). The prevalence of FRNFI ranged from 0.0% to 1.8%, with a pooled prevalence of 0.4% (95% CI 0.2-0.7). The prevalence of functional constipation was 8.6% in boys compared with 8.9% in girls (OR 0.99, 95% CI 0.9-1.4). Geographical location, dietary habits, and exposure to stressful life events were reported to be associated with the prevalence of functional constipation. Data on FNRFI were scarce and no associated factors were identified.

CONCLUSION

Functional constipation is common in childhood and is associated with geographical location, lifestyle factors, and stressful life events. FNRFI is rare, and no associated factors were identified.

Constipation and paediatric emergency department utilization

Background

Constipation is a common condition in children. Little is known about the acute health care utilization of constipated children, including how many present to the paediatric emergency department (ED), the spectrum of presenting complaints, investigations and treatments used.

Methods

We conducted a cross-sectional chart review of all 42,875 visits to British Columbia Children's Hospital ED between August 31, 2012 and September 1, 2013. All visits were assessed for a potential diagnosis of constipation and a total of 913 patients were included. We recorded the chief complaints, tests performed and therapies administered in the ED and measures of flow/efficiency including waiting time (WT), length of stay (LOS) and disposition.

Results

Constipation-related visits comprised 2.1% of overall visits. Abdominal pain was found to be the most common presenting complaint in 65.6% of patients; however, 11.9% of patients presented with complaints unrelated to the gastrointestinal tract. Abdominal radiographs were obtained in nearly one-third of patients and almost half of the patients received a fleet enema in the ED. Only a quarter of patients were discharged home on longer-term management. Measures of ED flow were similar between groups, with no meaningful difference in WT or LOS. The vast majority of children (99.7%) were discharged home.

Conclusions

Constipation can be treated as an out-patient, rather than burdening the paediatric ED unnecessarily. This study demonstrates over utilization of radiologic tests and invasive ED treatments and an under utilization of outpatient medication and dietary counselling that may contribute to unnecessary return ED visits.

Functional constipation in children: challenges and solutions

This review intends to update what is known about and what is still a challenge in functional constipation (FC) in children regarding epidemiology, pathophysiology, diagnosis, and management. Although FC is a common childhood problem, its global burden remains unknown as data from parts of the world are missing. Another problem is that there is a large variation in prevalence due to differences in study methods and defining age groups. The pathophysiology of FC remains unclear to date but is probably multifactorial. Withholding behavior is likely to be the most important factor in toddlers and young children. Genetics may also play a role since many patients have positive family history, but mutations in genes associated with FC have not been found. Over the past years, different diagnostic criteria for FC in infants and children have been proposed. This year, Rome IV criteria have been released. Compared to Rome III, it eliminates two diagnostic criteria in children under the age of 4 who still wear diapers. Physical examination and taking a thorough medical history are recommended, but other investigations such as abdominal radiography, transabdominal recto-ultrasonography, colonic transit time, rectal biopsies, and colon manometry are not routinely recommended. Regarding treatment, guidelines recommend disimpaction and maintenance therapy with polyethylene glycol (PEG) with or without electrolytes. But experience shows that acceptability, adherence, and tolerance to PEG are still a challenge. Counseling of parents and children about causes of FC is often neglected. Recent studies suggest that behavior therapy added to laxative therapy improves the relief of symptoms. Further homogeneous studies, better-defined outcomes, and studies conducted in primary care are needed.

Pediatrician's knowledge on the approach of functional constipation

OBJECTIVE

To evaluate the pediatrician's knowledge regarding the diagnostic and therapeutic approach of childhood functional constipation.

METHODS

A descriptive cross-sectional study was performed with the application of a self-administered questionnaire concerning a hypothetical clinical case of childhood functional constipation with fecal incontinence to physicians (n=297) randomly interviewed at the 36th Brazilian Congress of Pediatrics in 2013.

RESULTS

The majority of the participants were females, the mean age was 44.1 years, the mean time of professional practice was 18.8 years; 56.9% were Board Certified by the Brazilian Society of Pediatrics. Additional tests were ordered by 40.4%; including abdominal radiography (19.5%), barium enema (10.4%), laboratory tests (9.8%), abdominal ultrasound (6.7%), colonoscopy (2.4%), manometry and rectal biopsy (both 1.7%). The most common interventions included lactulose (26.6%), mineral oil (17.5%), polyethylene glycol (14.5%), fiber supplement (9.1%) and milk of magnesia (5.4%). Nutritional guidance (84.8%), fecal disimpaction (17.2%) and toilet training (19.5%) were also indicated.

CONCLUSIONS

Our results show that pediatricians do not adhere to current recommendations for the management of childhood functional constipation, as unnecessary tests were ordered and the first-line treatment was not prescribed.

Pediatrician's knowledge on the approach of functional constipation

Objective:

To evaluate the pediatrician's knowledge regarding the diagnostic and therapeutic approach of childhood functional constipation.

Methods:

A descriptive cross-sectional study was performed with the application of a self-administered questionnaire concerning a hypothetical clinical case of childhood functional constipation with fecal incontinence to physicians (n=297) randomly interviewed at the 36th Brazilian Congress of Pediatrics in 2013.

Results:

The majority of the participants were females, the mean age was 44.1 years, the mean time of professional practice was 18.8 years; 56.9% were Board Certified by the Brazilian Society of Pediatrics. Additional tests were ordered by 40.4%; including abdominal radiography (19.5%), barium enema (10.4%), laboratory tests (9.8%), abdominal ultrasound (6.7%), colonoscopy (2.4%), manometry and rectal biopsy (both 1.7%). The most common interventions included lactulose (26.6%), mineral oil (17.5%), polyethylene glycol (14.5%), fiber supplement (9.1%) and milk of magnesia (5.4%). Nutritional guidance (84.8%), fecal disimpaction (17.2%) and toilet training (19.5%) were also indicated.

Conclusions:

Our results show that pediatricians do not adhere to current recommendations for the management of childhood functional constipation, as unnecessary tests were ordered and the first-line treatment was not prescribed.

Childhood constipation as an emerging public health problem

Functional constipation (FC) is a significant health problem in children and contrary to common belief, has serious ramifications on the lives of children and their families. It is defined by the Rome criteria which encourage the use of multiple clinical features for diagnosis. FC in children has a high prevalence (0.7%-29%) worldwide, both in developed and developing countries. Biopsychosocial risk factors such as psychological stress, poor dietary habits, obesity and child maltreatment are commonly identified predisposing factors for FC. FC poses a significant healthcare burden on the already overstretched health budgets of many countries in terms of out-patient care, in-patient care, expenditure for investigations and prescriptions. Complications are common and range from minor psychological disturbances, to lower health-related quality of life. FC in children also has a significant impact on families. Many paediatric clinical trials have poor methodological quality, and drugs proved to be useful in adults, are not effective in relieving symptoms in children. A significant proportion of inadequately treated children have similar symptoms as adults. These factors show that constipation is an increasing public health problem across the world with a significant medical, social and economic impact. This article highlights the potential public health impact of FC and the possibility of overcoming this problem by concentrating on modifiable risk factors rather than expending resources on high cost investigations and therapeutic modalities.

Epidemiology of functional gastrointestinal disorders in infants and toddlers: A systematic review

AIM: To assess the functional gastrointestinal disorders (FGID) prevalence in infants and toddlers.

METHODS: PubMed, EMBASE, and Scopus were searched for original articles from inception to February 2016. The literature search was made in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). For inclusion, each study had to report epidemiological data of FGID on children up to 4 years old and contain standardized outcome Rome II or III criteria. The overall quality of included epidemiological studies was evaluated in accordance to Loney’s proposal for prevalence studies of health literature. Two reviewers assessed each study for inclusion and extracted data. Discrepancies were reconciled through discussion.

RESULTS: It was identified a total of 101 articles through the databases and two through the manual search. A total of 28 articles fulfilled the eligibility criteria. After reading the full articles, 13 of them were included in the present review. Twelve studies were written in English and one in Chinese, and published between 2004 and 2015. Eight articles (61.5%) were performed in Europe, three (23.1%) in America and two (15.4%) in Asia. Sample size varied between 45 and 9660 subjects. Cross-sectional frequency was reported in majority of studies (k = 9) and four studies prospectively followed the subjects. 27.1% to 38% of participants have met any of Rome’s criteria for gastrointestinal syndromes, of those 20.8% presented two or more FGID. Infant regurgitation and functional constipation were the most common FGID, ranging from less than 1% to 25.9% and less than 1% to 31%, respectively. Most included studies were of moderate to poor data quality with respect to absence of confidential interval for prevalence rate and inadequate sampling methods.

CONCLUSION: The scarcity and heterogeneity of FGID data call for the necessity of well-designed epidemiological research in different levels of pediatric practice and refinement of diagnostic.

Genetics of enteric neuropathies

Abnormal development or disturbed functioning of the enteric nervous system (ENS), the intrinsic innervation of the gastrointestinal tract, is associated with the development of neuropathic gastrointestinal motility disorders. Here, we review the underlying molecular basis of these disorders and hypothesize that many of them have a common defective biological mechanism. Genetic burden and environmental components affecting this common mechanism are ultimately responsible for disease severity and symptom heterogeneity. We believe that they act together as the fulcrum in a seesaw balanced with harmful and protective factors, and are responsible for a continuum of symptoms ranging from neuronal hyperplasia to absence of neurons.

Prevalence and Health Outcomes of Functional Gastrointestinal Symptoms in Infants From Birth to 12 Months of Age

OBJECTIVES

The aim of the study was to review published evidence and the opinion of practising clinicians on the prevalence and long-term health consequences of functional gastrointestinal symptoms in infants younger than 12 months.

METHODS

PubMed was searched from inception to November 2014 to find articles reporting the prevalence and long-term health outcomes of infantile colic, regurgitation, functional constipation, functional diarrhoea, and dyschezia in infants younger than <12 months. A questionnaire was sent to practising clinicians worldwide, and a group of 15 international experts met to discuss the likely frequency and longer-term consequences of these symptoms.

RESULTS

The literature search identified 30 studies reporting the prevalence of infantile colic (2%-73%), 13 that of regurgitation (3%-87%), 8 that of functional constipation (0.05%-39.3%), 2 that of functional diarrhoea (2%-4.1%), and 3 that of dyschezia (0.9%-5.6%). The studies varied in design, populations investigated, and definition of the symptoms. Questionnaires were received from 369 respondents. The experts agreed that the likely prevalences for colic, regurgitation, and functional constipation were 20%, 30%, and 15%, respectively. The limited data in the literature for functional diarrhoea and dyschezia suggest prevalences <10%. Infantile colic may be associated with future health problems in a subset of infants.

CONCLUSIONS

Functional gastrointestinal symptoms appear to occur in a significant proportion of infants younger than 12 months and may have an impact on future health outcomes. Prospective collection of data according to agreed criteria is needed to obtain more accurate estimates of the prevalence and consequences of these symptoms.

Transabdominal electrical stimulation (TES) for the treatment of slow-transit constipation (STC)

Slow-transit constipation (STC) is a newly described subtype of intractable constipation in children which we originally identified with deficiency of substance P in axons supplying the proximal colonic muscle. When nuclear transit studies became available, the patients were found to have slow proximal colonic transit, and responded to antegrade enemas. Using the appendicostomy, we found that there was reduced frequency in propagating sequences throughout the colon. We began testing whether transcutaneous electrical stimulation (TES) could improve motility and symptoms, and over several trials have now shown that TES is remarkably effective in treating children with STC, with long-lasting effects. TES holds promise for treating STC, as well as a range of gastrointestinal motility disorders.

Predictors of slow colonic transit in children

PURPOSE

Slow transit constipation (STC) and functional fecal retention (FFR) are two forms of severe intractable constipation in childhood diagnosed by nuclear transit studies (NTS). This retrospective study aims to identify the predicting factors for STC and FFR by looking at the association with neuropsychiatric disorders (NPD), obesity, family history of constipation and atopic disease.

PATIENTS AND METHODS

A retrospective chart review was conducted on children with intractable constipation referred for NTS between 1st April 2003 and 1st April 2014. Comparisons were made between STC, FFR and normal transit patients with regards to NPD, obesity (BMI z score >95th percentile), family history of constipation in first and second-degree relatives and atopic disease which included food allergy, asthma and eczema.

RESULTS

Between 2003 and 2014, 97 patients were referred for a NTS. Out of 36 patients with NPD, 21 (58.3 %) had STC and 13 (36.1 %) had FFR (p < 0.05). 15.8 % of patients with constipation were obese, compared to 6.4 % in the general Australian paediatric population (p < 0.05). There was no significant association between constipation and atopic disease or family history.

CONCLUSION

Neuropsychiatric disorders, in particular autism, are useful predictors of STC and FFR in children. Obesity may be associated with a higher risk of developing chronic constipation.

Vesicoureteral reflux--the role of bladder and bowel dysfunction

Vesicoureteral reflux (VUR) is a significant risk factor for clinical pyelonephritis and renal scarring. In 2010, the American Urological Association (AUA) reported that bladder and bowel dysfunction (BBD), which is common in patients with VUR, increases the risk of breakthrough UTI in children receiving antibiotic prophylaxis, reduces the success rate for endoscopic injection therapy, and increases the risk of postoperative UTI, irrespective of the surgical success rate for VUR. Accordingly, physicians are strongly recommended to investigate BBD in their patients with VUR. Symptoms and signs of BBD include urinary frequency and urgency, prolonged voiding intervals, daytime wetting, perineal and penile pain, holding manoeuvres (posturing to prevent wetting), constipation, and encopresis. Primary assessment tools include the Pediatric Symptom Checklist, urinalysis, urine culture, bladder diary, measurement of the postvoid residual urine volume, Dysfunctional Voiding Symptom Score, uroflow with electromyography, and Bristol Stool Form Score. The Rome III criteria can also be used for diagnostic assessment of bowel function. Treatment of BBD should be individualized, directed at symptomatic and objective improvement, and can include behavioural modification, biofeedback, selective use of anticholinergics and α-blockers, and bowel management.