Constipation is the infrequent passage of hard stools with pain and difficulty. It is one of the most common pediatric problems parents and healthcare providers face. A significant number of children, especially of the younger age group, are referred to specialists because of constipation. Fecal incontinence is almost always associated with constipation, which leads to marked loss of self esteem among children. The majority of cases of constipation and fecal incontinence are secondary to functional disorders, rather than organic causes and result in behavioral problems, which affect the social life of the child, as well as the family. Previously, it was believed that constipation and fecal incontinence were actually secondary to underlying psychological problems. Studies have failed to prove that psychological abnormalities are etiological factors for constipation among children; chronic constipation probably leads to behavioral abnormalities and also affects the family dynamics. The important causes of constipation and fecal incontinence, their impact on the child and the family, as well as various treatment modalities available are discussed in this article, which also emphasizes the importance of history and physical examination. Fecal incontinence is a common problem among children. The significance of the problem is often underestimated by medical practitioners. Chronic constipation with fecal incontinence is reported to account for 3% of referrals to pediatric clinics in teaching hospitals. In reality, constipation and fecal incontinence in a child are major problems for parents. Fecal incontinence results in marked loss of self esteem in children. Parents who assume that fecal incontinence is an intentional behavior may become angry and aggressive, often resulting in disruption of the relationship between parents, as well as between parents and their children.1 These children often become very frightened as they are punished for something which the majority of them have no control over. In the past, there was a tendency to attribute fecal incontinence in childhood to an underlying psychological disorder. However, studies have failed to identify the presence of underlying psychological abnormalities as the cause of fecal incontinence. On the contrary, there is evidence to suggest that many of the associated behavioral abnormalities are the result and not the cause of fecal incontinence. Resolution of behavioral problems has been demonstrated when fecal incontinence was successfully treated.2 Fecal incontinence is almost always associated with constipation.3 Constipation is associated with hard, large stools in the rectum which become difficult and painful to evacuate, often leading to withholding of stools. The lower colonic segment becomes gradually distended with accumulated stool. The urge to defecate becomes irregular because of a decrease in rectal sensation. A vicious cycle ensues. When the rectum becomes sufficiently distended, softer stool arriving from the more proximal colon cannot be accommodated and leaks around the bolus of hard stool. Because of the lack of sensation in the distended distal colon, this passage of soft stool (overflow) is not sensed by the child until incontinence has actually transpired. The parents of these children will often insist that there is no history of constipation and that the child passes several soft stools daily. Hence, it is often difficult to convince the parents that the child should be treated for constipation. Care has to be taken in obtaining accurate history from children with fecal incontinence.3 Parents of children who are toilet trained for a few years generally have little idea concerning the regularity of their child’s bowel movement. The child (if old enough) and the parents should be asked specifically about the presence of very large stools, painful defecation, blood in the stools and stool withholding behavior. Children with severe constipation are usually found to be tired, irritable and pale. The parents often remember marked changes in the child’s behavior after previous successful courses of laxatives. Stool withholding behavior may begin as early as one year of age, but is more common in the latter part of the second year of life. Parents often notice the child spending long periods of time standing in a corner prior to passing stool in the nappy or undergarment. They often mistake stool withholding behavior for exaggerated attempts at defecation. All cases of fecal incontinence should in the first instance be treated as being secondary to constipation, unless there is also a history of daytime wetting or major psychological and/or behavioral abnormalities.4 If however, fecal incontinence persists after successful treatment of constipation; psychological assessment should be undertaken. Investigations related to possible organic causes of constipation should be undertaken if initial treatment efforts fail, or in the minority of cases where there is a history suggestive of Hirschsprung disease or other organic causes. Hirschsprung disease is usually not associated with fecal incontinence.
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Sep 1, 2012
Miranda A.L Van Tilburg + 6
Open Access
