Childhood constipation: Current status, challenges, and future perspectives

Breaking the cycle: Psychological and social dimensions of pediatric functional gastrointestinal disorders

BACKGROUND

Functional gastrointestinal disorders (FGIDs) in children present with chronic symptoms like abdominal pain, diarrhea, and constipation without identifiable structural abnormalities. These disorders are closely linked to gut-brain axis dysfunction, altered gut microbiota, and psychosocial stress, leading to psychiatric comorbidities such as anxiety, depression, and behavioral issues. Understanding this bidirectional relationship is crucial for developing effective, holistic management strategies that address physical and mental health.

AIM

To examine the psychiatric impacts of FGIDs in children, focusing on anxiety and depression and their association with other neurodevelopmental disorders of childhood, such as attention-deficit/hyperactivity disorder, emphasizing the role of the gut-brain axis, emotional dysregulation, and psychosocial stress. Key mechanisms explored include neurotransmitter dysregulation, microbiota imbalance, central sensitization, heightening stress reactivity, emotional dysregulation, and symptom perception. The review also evaluates the role of family dynamics and coping strategies in exacerbating FGID symptoms and contributing to psychiatric conditions.

METHODS

A narrative review was conducted using 328 studies sourced from PubMed, Scopus, and Google Scholar, covering research published over the past 20 years. Inclusion criteria focused on studies examining FGID diagnosis, gut-brain mechanisms, psychiatric comorbidities, and psychosocial factors in pediatric populations. FGIDs commonly affecting children, including functional constipation, abdominal pain, irritable bowel syndrome, gastroesophageal reflux, and cyclic vomiting syndrome, were analyzed concerning their psychological impacts.

RESULTS

The review highlights a strong connection between FGIDs and psychiatric symptoms, mediated by gut-brain axis dysfunction, dysregulated microbiota, and central sensitization. These physiological disruptions increase children's vulnerability to anxiety and depression, while psychosocial factors - such as chronic stress, early-life trauma, maladaptive family dynamics, and ineffective coping strategies - intensify the cycle of gastrointestinal and emotional distress.

CONCLUSION

Effective management of FGIDs requires a biopsychosocial approach integrating medical, psychological, and dietary interventions. Parental education, early intervention, and multidisciplinary care coordination are critical in mitigating long-term psychological impacts and improving both gastrointestinal and mental health outcomes in children with FGIDs.

Utility of Monitoring Fasting Phase During Pediatric Colonic Manometry Studies

INTRODUCTION

Colonic manometry (CM) is a diagnostic procedure used to evaluate pediatric patients with refractory constipation, fecal incontinence, Hirschsprung disease, and pediatric intestinal pseudo-obstruction. Pan-colonic high-amplitude propagated contractions (HAPCs), measured by CM, reflect an intact neuromuscular function of the colon. Current guidelines recommend starting CM with fasting recording for 1-2 h, but no prior evaluation has determined the diagnostic yield of the fasting phase. We aimed to determine the utility of the fasting phase during CM studies.

METHODS

We evaluated CM studies conducted at a tertiary pediatric center (2018-2022). Fasting phases of normal CM studies were evaluated.

KEY RESULTS

In 433 included studies 241 (55.7%) females, median age (9.7 years), the average fasting recording lasted 126 min. A total of 193 (44.6%) studies exhibited fasting HAPCs, with 123 (28.4%) being pan-colonic. The presence of pan-colonic HAPCs was based solely on the fasting phase in 11 (2.5%) studies. Patients with fasting pan-colonic HAPCs were younger (median age of 6.9 vs. 9.8 years, p = 0.0001) and had a higher rate of postprandial HAPCs (69.1% vs. 25.2%, p < 0.0001). Most fasting pan-colonic HAPCs presented during the first 60 min (94/123, 76.4%). All studies demonstrated HAPCs after stimulation with bisacodyl. In analyzing just the initial 30 min of fasting on CM, only 2 (0.5%) studies would have been misclassified as abnormal, with no bisacodyl administration in these studies.

CONCLUSIONS & INFERENCES

Shortening the fasting phase minimally affects next-day CM results and could reduce patient inconvenience, hospital-related costs, and potential side effects.

Efficacy of anal botulinum toxin injection in children with functional constipation

OBJECTIVES

Functional constipation (FC) is a common diagnosis in the pediatric age group. In addition to laxative regimens and behavioral interventions, some have reported the use of anal botulinum toxin (BTX) injections to treat FC, with limited data regarding its efficacy.

METHODS

This is a retrospective, multicenter study including patients who received BTX for FC refractory to medical therapy. Demographic data, results of anorectal manometry, and BTX data (number of sessions, dose, and side effects) were collected. Patients were divided into three groups based on the indication for BTX: group 1 (FC with FI [fecal incontinence]), group 2 (FC without FI), and group 3 (FI alone). Response to therapy was assessed for whole cohort and for each group based on improvement in weekly frequency of BM (bowel movements) to 3 or more per week and/or resolution of FI. We also compared the response to therapy to the parental and provider report.

RESULTS

A total of 63 patients were included in the study. Median age was 6.4 years and 32 (51%) were female. The median dose of BTX was 100 units, and most patients (55/63) received a single BTX injection. Medical therapy was continued after BTX injections in most patients (60/63 or 95%). After BTX, the frequency of BM increased to >3/week in 29/56 (52%) and FI improved in 8/47 (17%) for the whole cohort. We observed a response rate of 10% in group 1, 50% in group 2 and 14% in group 3. No factors (age, gender, anal resting pressure) were associated with BTX response except for prolonged time of therapy before BTX and shorter median follow up after BTX. Parents/primary provider reported improvement in 44/63 (70%) after BTX, which was significantly higher than the actual observed response to therapy (70% vs. 21%, p = 0.003, kappa = 0.202). We found no association between response to BTX and presence of developmental delay and/or behavioral disorders (p = 0.531). Side effects were minimal and noted in seven (11%) patients, mainly FI. No factors were associated with the development of side effects.

CONCLUSIONS

Anal BTX injections improved BM frequency with minimal effect on FI with an overall symptom resolution in 21% of patients. BTX does not seem to have a notable effect in patients with FC and developmental delay and/or behavioral disorders. Provider and parental reported success were significantly higher than the actual observed response.

Association between constipation and insufficient dietary intake to achieve satiety in preschool age

Background: Few studies have explored the relationship between constipation and not eating enough to feel satiety. Aim: The study aims to examine the association between constipation and not eating enough to feel satiety. Methods: This cross-sectional study included 189 children 3 to 6 years of age. Constipation was defined as two or fewer defecations per week. To assess the satiety of children, mothers were asked, "Does your child eat until he/she is full every day?" The response options were as follows: "eats every day," "eats occasionally," "neither eats every day nor eats occasionally," "does not eat much," or "does not eat at all." "Eats every day" was defined as eating enough to feel satiety. The other four responses were defined as not eating enough to feel satiety. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a logistic regression analysis. Results: Thirty-nine (20.6%) children had constipation and 112 (59.3%) children did not eat enough to feel satiety. The association between constipation and not eating enough to feel satiety was significant. The crude OR of constipation for children who did not eat enough to feel satiety was 2.25 (95% CI 1.02-4.96). After adjusting for sex and age, the OR was 2.15 (95% CI 1.01-4.98). After further adjustment for underweight and overweight, the OR was 2.11 (95% CI 0.94-4.76). Conclusion: Not eating enough to feel satiety was associated with constipation independent of sex and age.

Evaluation and management of pediatric refractory constipation: Recommendations from the NASPGHAN neurogastroenterology and motility committee

Refractory constipation (RC) in pediatric patients should be recognized as a distinct condition with long-term impacts on patient and family quality of life. RC requires a more targeted diagnostic evaluation and complex management strategy that may involve management by pediatric neurogastroenterology and motility specialists and multidisciplinary teams including surgeons. Currently, there is a lack of a clear definition, evaluation, and management strategies for RC. This is the first North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition position paper to address pediatric RC regarding its definition, evaluation, and management.

Hospitalization Trends and Healthcare Resource Utilization for Fecal Impactions in Pediatric Patients with Functional Constipation

Objectives: To analyze the clinical characteristics, trends in hospitalization, and healthcare resource utilization of pediatric patients with fecal impaction. Methods: We utilized the Healthcare Cost and Utilization Project (HCUP) databases, including the National Inpatient Sample (NIS) and the Kids Inpatient Database (KID) datasets from 2011 to 2019, to include all hospitalizations of patients up to 18 years of age with a primary diagnosis of (1) fecal impaction or (2) a primary diagnosis of abdominal pain or constipation with a secondary diagnosis of fecal impaction. The study analyzed various comorbid factors and clinical characteristics of these patients. For healthcare resource utilization, we analyzed the length of hospital stays and total hospital charges, adjusted for inflation. Results: A total of 23,570 admissions due to fecal impactions in children between the years 2011 and 2019 were analyzed, contributing to 0.18% of the total pediatric admissions. Hospitalization rates nearly doubled from 2011 (0.15%) to 2019 (0.29%). The mean hospitalization charges also trended upwards from 15,234 USD in 2011 to 22,487 USD in 2019. The inflation-adjusted annual rate of increase in hospital charges during this period was 5.9% per year. Aggressive fecal disimpaction procedures (either manual or surgical) were performed in approximately 3% of these admissions. Multivariate regression showed that older children (13-18 years of age) were more likely to require aggressive disimpaction. Female children, those with Hispanic ethnicity, and those with obesity were less likely to be associated with the need for disimpaction. Conclusions: Hospitalizations for fecal impaction have increased significantly over the past decade, creating a substantial burden on healthcare resources. Our study highlights the importance of aggressive outpatient management strategies with close follow-up for fecal impactions, which will potentially minimize these hospitalizations.

The Association of Short-Chain Fatty Acids with the Occurrence of Gastrointestinal Symptoms in Infants

Short-chain fatty acids (SCFAs) are produced by the fermentation of undigested polysaccharides; they are a group of metabolites resulting from the activity of intestinal bacteria. The main SCFAs are acetic, butyric, propionic, valeric, and caproic acid, and their levels and proportions depend on various factors. The aim of this study was to investigate the relationship between the concentration of SCFAs and the occurrence of specific gastrointestinal symptoms in infants. This study was conducted using faecal samples obtained at 1, 3, 6, and 12 months of age. The SCFA content was measured using gas chromatography. At 1 month, an association was found between butyric acid and flatulence. At 3 months, an association was found between butyric acid and flatulence/gas and between 3,4-methylovaleric acid and mucus in the stool. At 6 months, an association was found between butyric and valeric acids and flatulence. By 12 months, the gastrointestinal symptoms had decreased significantly. This study confirms that there is an association between SCFA levels and the presence of bloating, gas, mucus in the stool, and constipation in the gastrointestinal tract. Higher levels of butyric and valeric acids may lead to an increase in troublesome symptoms, such as flatulence and gas, in the first few months of life but are not associated with the occurrence of intestinal colic. The level of 3,4-methylovaleric acid is associated with the presence of allergies, whereas a decrease in acetic acid and an increase in isovaleric acid may exacerbate defecation problems in infants.

Facilitators and barriers of adherence to rectal interventions by parents of young children with functional constipation: a qualitative study

Background

Functional constipation in children is a worldwide problem that impacts both children's gastrointestinal function and the quality of family life. The treatment of this condition often depends on parental involvement to administer rectal interventions to their children to stimulate defecation. However, adherence to rectal interventions is currently suboptimal. We sought to explore the factors that facilitate and hinder parents from adherence to rectal interventions.

Methods

A descriptive qualitative study was conducted involving semi-structured interviews with parents of infants and young children with functional constipation requiring rectal interventions from March to May 2023. The data were analyzed using content analysis.

Results

Fourteen parents participated in the study. Parents reported the main facilitators of adherence to prescribed rectal interventions as recognition of illness severity, support from family and friends, and medical resource support and e-health literacy. Parents reported the primary barriers as information barriers, family conflict, cognitive misalignment, and difficulties in accessing healthcare services.

Conclusion

Rectal interventions are often essential in managing constipation in young children, with parental compliance being crucial for effective treatment. Healthcare providers must consider the psychosocial aspects of parents' perceptions, adhere to guidelines to standardize communication, and ensure comprehensive education to improve medication literacy.

Functional Constipation: Pathophysiology, evaluation, and management

BACKGROUND

Functional constipation (FC), a disorder of the gut-brain interaction of multifactorial pathophysiology that is prevalent in paediatrics. It is associated with bothersome symptoms, increased healthcare costs, disgruntled caregivers and impaired health-related quality of life. Paediatric FC is a clinical diagnosis based on the Rome IV criteria and is characterised by decreased bowel movement frequency and/or hard, painful stools and can be complicated by retentive faecal incontinence. Stressful life events, difficult temperaments and emotional and behavioural challenges have been implicated in increasing risk of developing paediatric FC.

AIMS

To provide current concepts in pathophysiology, evaluation and management of paediatric FC.

METHODS

We reviewed pertinent literature after a comprehensive search utilising PubMed with keywords FC, chronic childhood constipation and paediatric FC.

RESULTS

In the last decade, advances in our understanding of paediatric FC have changed the landscape of diagnosing and treating this disorder. Although polyethylene glycol is the first-line treatment for maintenance of FC, the armamentarium of therapeutics has expanded including the first Food and Drug Administration- agent, linaclotide, for children 6-17 years of age in conjunction with more emphasis on behavioural and physical therapy interventions.

CONCLUSIONS

Treatment approach to paediatric FC should be individualised and integrated focusing on parental education, lifestyle and behavioural modifications, and pharmacological therapy to maximise therapeutic success. This review highlights advances in pathophysiology, diagnosis and treatment of FC in children.

Exploring Diagnostic Priorities: The Role of Colonic Manometry in Evaluating Pediatric Patients with Intractable Idiopathic Constipation Prior to Sacral Nerve Stimulation

BACKGROUND

Despite the limited understanding of its precise mechanism of action, sacral nerve stimulation (SNS) has proven to be helpful for pediatric patients with constipation, particularly those with fecal incontinence. It is unclear whether the outcome of SNS is impacted by normal or abnormal colonic motility. Our study aimed to determine whether colonic manometry results had an impact on the outcome of SNS as a treatment in pediatric patients with refractory idiopathic constipation.

METHODS

Electronic medical records of patients with idiopathic constipation who underwent colonic manometry and SNS placement at our center over 6 years were reviewed. A comparison of post-SNS outcomes was performed between patients with normal and abnormal colonic manometry studies.

RESULTS

Twenty patients [12 (60%) females, median age of 10.2 years] met inclusion criteria, with fecal incontinence in 12 (60%) and abnormal colonic manometry in 6 (30%). Significantly more patients had an improvement in fecal incontinence following SNS placement (p = 0.045). There were no significant differences in post-SNS constipation outcome measures between patients with normal versus abnormal colonic manometry.

CONCLUSIONS

Colonic manometry did not help with patient selection for those being considered for SNS therapy. Our findings do not support performing colonic manometry as a screening prior to SNS placement.

Diagnostic yield of left-sided colonic manometry in identifying colonic dysmotility in pediatric patients

BACKGROUND

Colonic manometry (CM) is a diagnostic procedure utilized in the evaluation of intractable constipation and involves endoscopic insertion of a manometry catheter with the tip placed in the cecum. Difficulty in advancing the colonic manometry catheter to the right colon and/or distal displacement of the catheter after appropriate placement can result in partial evaluation of the colon. Our study aimed to assess the value of limited left CM in identifying motility disorders.

METHODS

We evaluated CM studies conducted at a tertiary pediatric center (2019-2022). Abnormal CM studies with catheter tips located in the cecum or ascending colon were included.

KEY RESULTS

Of 161 CM studied, 68 with abnormal CM studies met inclusion criteria (29 [42.7%] females, median age 10.3 years). Pan-colonic dysmotility was noted in 29 (42.7%) studies and segmental dysmotility in 39 (57.4%) studies. Dysmotility of the descending and/or sigmoid colon was the most common segmental dysmotility (30, 76.9%). Isolated dysmotility of the ascending colon was noted only in patients with a cecostomy (6/13, 46.2%). The diagnostic sensitivity for dysmotility by left CM was 91.2%, which increased to 100% when excluding patients with cecostomy.

CONCLUSIONS AND INFERENCES

Left CM is a valuable and sensitive diagnostic tool for identifying abnormal colonic motility in most pediatric patients with constipation without cecostomy. Our study results provide reassurance when the manometry catheter becomes dislodged from the cecum and moves distally. Those with cecostomy have a high prevalence of dysmotility in the ascending colon and need a complete CM to identify it.

Position paper on transanal irrigation in chronic non-organic constipation

The practice of recto-colonic water irrigation to treat constipation has been used since ancient times with different, uncontrolled, and variably performing methods which have been considered interchangeably all alike. The use of better-performing devices with a standardized methodology is relatively recent, and the term Trans Anal Irrigation (TAI) defines a methodology performed with devices able to control the timing, volume, and pressure of the water introduced into the rectum and colon utilizing a catheter or a cone through the anus. Such practice has been implemented with favorable responses in patients with refractory chronic constipation secondary to neurological diseases. However, since the role of Trans Anal Irrigation as a therapeutic aid in chronic functional constipation and functional evacuation disorders is not yet fully clarified and standardized, a group of clinical investigators with recognized expertise in these clinical conditions intends to clarify the elements that characterize a TAI procedure that can benefit patients with functional constipation and functional defecation disorders defined according to the lastly updated Rome Diagnostic Criteria. Finally, the paper deals with adherence and practical implementation of TAI.

Efficacy of lubiprostone for functional constipation treatment in adolescents and children: Randomized controlled trial

OBJECTIVES

Adolescent and pediatric functional constipation (FC) is a common clinical problem. Currently, data on lubiprostone for the treatment of pediatric FC are scarce. This study investigated the efficacy and safety of lubiprostone in the treatment of pediatric FC.

METHODS

In a single-blinded, randomized controlled study, we included 280 patients aged 8-18 years with FC. Patients were randomized either to a weight-based lubiprostone dose (n = 140) or conventional laxatives (n = 140), including lactulose, bisacodyl, or sodium picosulfate, for 12 weeks, followed by 4 weeks posttreatment follow-up.

RESULTS

Improvement in constipation was achieved in 128 (91.4%) patients in the lubiprostone group, and in 48 (34.3%) patients of the conventional therapy group (p < 0.001) and was sustained after treatment discontinuation. One quarter of the lubiprostone group experienced the first spontaneous bowel motion within 48 h after dose initiation. A total of 75.7% of the lubiprostone group could achieve and sustain Bristol stool form of 3 or 4 during the last 4 weeks of therapy and through the 4 weeks of follow-up versus 50 (35.7%) patients in the conventional therapy group (p < 0.001). No life-threatening adverse drug reactions were encountered, and no treatment-related discontinuation. Mild self-limited colicky abdominal pain and headache were the most prevalent side effects in the lubiprostone group.

CONCLUSIONS

Lubiprostone is an effective and well-tolerated pharmacotherapy for youthful age and pediatric age groups, which may alter the paradigm of pediatric FC treatment.

Constipation: A Pristine Universal Pediatric Health Delinquent

Constipation suffered by children is a global public health problem. Functional constipation (FC) brings about deteriorating effects in the children's lives who suffer from it. The risk factors for the development of constipation include the consumption of a diet low in fiber and high in calories (such as the consumption of fast food), a sedentary lifestyle with a lack of exercise, a family history of constipation, and emotional and psychological stress endured by children in their families. It is one of the most common causes of stomachaches in children. FC may lead to fecal incontinence (FI), anal fissures, recurrent urinary tract infections (RUTI), and enuresis in children. Severe constipation may result in stool becoming rock-hard and inflexible in the rectum, which is clinically identified as fecal impaction. It is imperative to perform clinical evaluation and treatment, including pharmacological (the use of stimulant and osmotic laxatives) and non-pharmacological (education, changes in diet, intervention to promote positive behavior and address any emotional issues, toilet training, and physiotherapy for the pelvic floor) interventions. In the case of refractory patients, neuromodulation, the irrigation of the anal canal, and surgical management may be needed. It is essential to lead a healthy, stress-free lifestyle with plenty of exercise and a balanced diet rich in fiber (such as fruits and vegetables) so children can have regular bowel habits and thrive.

The Effect of the Flint Water Crisis Secondary to Increased Lead Levels in Drinking Water on Constipation in Children in the City of Flint, Michigan, USA

Introduction  Constipation is a common condition in children, affecting almost one-third of the population at some point in childhood across the world. Functional constipation is the most common cause, with no clear etiology. From April 25, 2014, through October 16, 2015, the water source for the city of Flint residents was untreated Flint River water, which resulted in lead-contaminated drinking water. Lead poisoning has been associated with constipation and has multisystem sequelae, including neurological, muscular, and hematological impacts. Children may be especially vulnerable to this with their higher water intake-to-body weight ratio. There has been no previous study examining the possible relationship between the Flint water crisis and constipation in children. In our study, we aimed to see if the increased lead level in the water had any effect on constipation in children in Flint. Methods We included all children seen and diagnosed with constipation at Hurley Medical Center's Pediatric Gastrointestinal (GI) Clinic. We included only children seen in 2013 (pre-water crisis) and 2017 (post-water crisis). Children with chronic neurologic disorders, celiac disease, hypothyroidism, diabetes, Hirschsprung's disease, short bowel syndrome, and gastrointestinal surgeries were excluded. We looked at the age of presentation, associated symptoms, medications used, need for hospital admission or emergency department (ED) visits, and improvements at follow-up. Results  A total of 79 patients were included in the study. There were 29 patients from 2013 and 50 patients from 2017 (post-lead exposure period). The rate of constipation referrals to the GI clinic for the Flint population of children was significantly higher in 2017 (p=0.001). The most common associated symptom was abdominal pain in both groups. Straining was more prominent in the 2017 group (60%) compared to the 2013 group (34.5%, p=0.029). There was no clinical or statistically significant difference between the groups noted in abdominal pain, blood in the stool, fecal incontinence, vomiting, history of urinary tract infection (UTI), abdominal distention, or stool impaction. Conclusions The number of patients referred to Hurley's Pediatric GI Clinic for constipation increased after the lead water crisis in Flint. Moreover, straining has significantly increased in post-lead exposure compared to pre-lead exposure. There was no clinical or statistically significant difference noted in abdominal pain, blood in the stool, fecal incontinence, vomiting, history of UTI, abdominal distention, or stool impaction between both groups. A larger study would need to be done to confirm these findings, rule out other cofactors, and look into minerals in water and their effect on intestine innervations.

A narrative review on the diagnosis and management of constipation in infants

INTRODUCTION

Functional constipation is one of the common disorders of gut-brain interaction in infancy, and decreases the quality of life of infants and parents.

AREAS COVERED

Relevant articles up to November 2022 were reviewed. We searched in PubMed, Google Scholar, and MEDLINE for guidelines, position papers, reviews, and randomized controlled trials on infant constipation.

EXPERT OPINION

Randomized controlled trials in this specific age group are mostly limited to trials with infant formula. The prevalence of infant constipation in formula-fed infants is decreasing, and can be associated with adaptations in formula composition. While the supplementation of infant formula with pro-, pre- and/or synbiotics decreases the prevalence of constipation, their efficacy in constipated infants is disappointing. There is limited evidence to support the addition of magnesium to infant formula to treat constipation. The evidence for the efficacy and safety of polyethylene glycol in children < 2 years has expanded over the past years. The administration of lactulose or polyethylene glycol is the preferred medical management, in case nutritional management does result in insufficient improvement.

Dietary Fibers in Healthy Children and in Pediatric Gastrointestinal Disorders: A Practical Guide

Dietary fibers include non-digestible plant carbohydrates, lignin and resistant starch. Dietary fibers provide immune, cardiovascular, metabolic and intestinal beneficial effects in humans. Fibers naturally present in foods (fruits, vegetables, legumes, cereals) or used as supplements have different physical, chemical and functional profiles. This narrative review provides an update to the knowledge on the effects of dietary fibers in healthy subjects and in children with gastrointestinal disorders. Soluble fibers are digested by gut bacteria, producing short-chain fatty acids and energy for colonocytes, and may exert prebiotic effects that promote the growth of bifidobacteria and lactobacilli. Non-soluble fibers are bulking agents and may improve intestinal transit. The exact amount and characteristics of the fiber requirement in infants and children need to be further established. There are limited data evaluating fibers in children with gastrointestinal disorders. The low intake of fibers has been associated with constipation, but the intake of excessive fibers is not recommended as it may cause flatulence and abdominal discomfort. Certain fibers (particularly psyllium in irritable bowel syndrome) have shown beneficial effects in children with gastrointestinal disorders, but the limited and heterogenous data do not currently allow a specific recommendation.

Sacral Nerve Stimulation in Children with Medically Refractory Fecal Incontinence or Severe Constipation

INTRODUCTION

The goal of this study was to evaluate outcomes in patients treated with sacral nerve stimulation (SNS) for medically refractory fecal incontinence or severe constipation.

METHODS

We performed a retrospective cohort study of all patients treated with SNS after failed medical management at a single center between 9/1/2015 and 6/30/2022. Demographic and clinical data was extracted from the electronic medical record. Rates of involuntary bowel movements were evaluated using a bowel severity score questionnaire and compared pre- and post-SNS using McNemar and McNemar-Bowker tests.

RESULTS

70 patients underwent SNS placement. The median age was 12.8 years (IQR 8.6-16.0) and 61.4% were male. The most common diagnosis was idiopathic constipation (67.1%), followed by anorectal malformation (15.7%), and others. 43 patients had severity scores recorded both pre- and at least 90 days post-SNS insertion. The rates of daytime and nighttime involuntary bowel movements were significantly different pre-compared to post-SNS placement (p = 0.038 and p = 0.049, respectively). The rate of daytime and nighttime fecal continence increased from 44% to 58.1% and 53.5%-83.7%, respectively. The rate of at least weekly daytime and nighttime fecal incontinence decreased from 48.8% to 18.7% and 34.9%-7.0%, respectively. Minor pain/neurological symptoms occurred in 40% of patients, while 5.7% developed a wound infection. Further surgery for the SNS was required in 40% of patients.

CONCLUSIONS

SNS placement can be an effective treatment for medically refractory fecal incontinence. Minor complications and the need for further procedures are common, while more serious complications like wound infections are rare.

TYPE OF STUDY

Retrospective Cohort Study.

LEVEL OF EVIDENCE

Level 3.