Abstract
Purpose: Faecal incontinence represents a devastating problem; it is often a barrier to social
acceptance. It can affect many children including those with prior surgery (for anorectal
malformations and Hirschsprung's disease) as well as those with spinal problems or
injuries. Management involves distinguishing between true and pseudoincontinence,
and then determining the proper protocol of treatment. Methods: An extensive review of the authors' series of over 500 patients who presented with
soiling was undertaken with the goal of determining helpful algorithms of treatment.
Results: Treatment begins first with proper categorisation of patients. Pseudoincontinence
(encopresis) can be treated with disimpaction followed by laxative therapy. True incontinence
requires an enema programme, with treatment tailored to either hypo or hypermotile
colons. Surgery for pseudoincontinence, rarely required, takes the form of colonic
resection but only for patients with a demonstrated ability to have voluntary bowel
movements, albeit with enormous laxative requirements. Removal of the rectosigmoid
in this situation can reduce or eliminate the need for laxatives. Surgery for true
faecal incontinence involves changing the route for a successfully demonstrated enema
programme to an antegrade, i.e., a Malone appendicostomy. Conclusion: The keys to success in helping a faecally incontinent child are dedication and sensitivity
on the part of the medical team. The basis of the bowel management programme is to
clean the colon (either with medical treatment for patients with the potential for
bowel control, or artificially with enemas for patients with true faecal incontinence),
and then keep the colon quiet for 24 hours until the next treatment, thereby ensuring
that the patient is clean and no longer soiling. The programme is an ongoing process
of trial and error that responds to the individual patient and differs for each child.
We carry out this programme over the course of one week with daily abdominal radiographs
as we tailor the regimen. More than 95 % of the children who follow this programme
are clean and dry. The clinician must embrace the philosophy that it is unacceptable
to send a child with faecal incontinence to school in diapers when their classmates
are already toilet trained. Proper treatment to prevent this is perhaps more important
than any surgical procedure.
Key words
faecal incontinence - anorectal malformations - Hirschsprung's disease - bowel management
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Dr. Marc Levitt
Department of Pediatric Surgery
CCHMC
3333 Burnet Ave
Cincinnati, OH 45229
USA
Email: marc.levitt@cchmc.org
