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Fecal Incontinence and Bowel Dysfunction Assessment in Both Adult and Pediatric Patients

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Spina bifida (SB) or meningomyelocele is a complex neuroembryological disorder resulting from a variable degree of incomplete closure of the posterior neural tube. Clinical presentation is highly variable and depends on the localization of the defect along the spinal cord and the degree of incomplete closure. These patients present with a spectrum of impairments but the primary functional deficits are lower-limb paralysis and sensory loss, bladder and bowel dysfunction and cognitive dysfunction. In the majority of patients the lower regions of the spine are affected, resulting in dysfunction of the distal gastrointestinal tract: rectum, anus and anal sphincter

Voluntary control of defecation requires normal rectal sensation, peristalsis and normal anal sphincter function. Two primary involuntary reflexes, the intrinsic and parasympathic reflex, located at sacral level 2–4, initiate defecation.

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Fecal incontinence is a devastating underestimated problem, affecting a large number of individuals all over the world. Most of the available literature relates to the management of adults. The treatments proposed are not uniformly successful and have little application in the pediatric population. This paper presents the experience of 30 years, implementing a bowel management program, for the treatment of fecal incontinence in over 700 pediatric patients, with a success rate of 95%. The main characteristics of the program include the identification of the characteristics of the colon of each patient; finding the specific type of enema that will clean that colon and the radiological monitoring of the process. It is easy to understand that if an extremely constipating diet is prescribed to a patient with incontinence, he/she, the doctor and the nurse may get the impression of improvement, simply because the patient stops passing stool. That, however, will eventually produce more serious consequences without alleviating the real problem. Occasionally, a bulking forming diet may improve a patient with borderline fecal incontinence because it is more likely for him/her to feel a formed stool than a liquid one. All these dietary changes we have seen prescribed in a rather indiscriminate manner with variable, rather poor results. In addition, a concept that is usually missed when diet is prescribed as an adjuvant therapy or main therapy is the need to individualize the treatment. For example, in our experience, a constipating diet is extremely important in patients with fecal incontinence and tendency to diarrhea (hypermotile colon)

They are the ones that benefit having a constipating diet, as it will be explained later. There are two types of fibers: soluble (psyllium, gum, arabic and pectin) that binds water and forms a gel-like substance with it, and insoluble (methyl cellulose, calcium polycarbophil, lignins and hemicelluloses) that does not absorb or dissolve in water, but has a high capacity to bind with bile acid. Soluble fibers tend to bulk the stool, whereas the insoluble fibers tend to make the stool looser. In general, through the years, doctors prescribe medications to decrease the colonic peristalsis as a simple, frequently unsuccessful attempt to treat fecal incontinence. As expected, these drugs may produce an immediate, but temporary relief of the fecal incontinence giving a false good result. The patient may stop passing stool. However, they keep producing stool, and if this is not completely eliminated, accumulation and impaction will occur and eventually the fecal incontinence will be even worse.

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Bladder and bowel dysfunction (BBD) describes a spectrum of lower urinary symptoms (LUTS) accompanied by fecal elimination issues that manifest primarily by constipation and/or encopresis. This increasingly common entity is a potential cause of significant physical and psychosocial burden for children and families. BBD is commonly associated with vesicoureteral reflux (VUR) and recurrent urinary tract infections (UTIs), which at its extreme may lead to renal scarring and kidney failure. Additionally, BBD is frequently seen in children diagnosed with behavioural and neuropsychiatric disorders such as attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Patients with concomitant BBD and neuropsychiatric disorders have less favourable treatment outcomes. Early diagnosis and treatment of BBD are critical to avoid secondary comorbidities that can adversely impact children’s kidney and bladder function, and psychosocial well-being. The majority of patients will improve with urotherapy, adequate fluid intake, and constipation treatment. Pharmacological treatment must only be considered if no improvement occurs after intensive adherence to at least six months of urotherapy ± biofeedback and constipation treatment. Anticholinergics remain the mainstay of medical treatment. Selective alpha-blockers appear to be effective for improving bladder emptying in children with non-neurogenic detrusor overactivity (DO), incontinence, recurrent UTIs, and increased post-void residual (PVR) urine volumes. Alpha-1 blockers can also be used in combination with anticholinergics when overactive bladder (OAB) coexists with functional bladder outlet obstruction (Cohen H, Nussinovitch M, 1993)

Minimally invasive treatment with onabotulinumtoxinA bladder injections, and recently neurostimulation, are promising alternatives for the management of BBD refractory to behavioural and pharmacological treatment. Particularly at toilet-training phase, children tend to delay urination while distracted playing, using electronic toys, or watching television. This behaviour often results in holding maneuvers, low voiding frequency, urgency, and daytime incontinence. Frequency of wetting significantly improves in 45% of children with daytime incontinence after a trial of timed voiding.7 Constipation is frequently associated with voiding postponement, as the mechanism to delay defecation is similar (Feldman AS, Bauer SB., 2006).

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As has been noted, bladder dysfunction and bowel dysfunction refer to problems with urinating and passing stools. These may lead to the unwanted passage of urine or stool, called urinary or fecal incontinence. If you have these types of bladder and bowel problems, you may feel embarrassed at the thought of bringing them up with your doctor or other health care provider

The conditions can be physically and emotionally difficult to deal with, but you shouldn't feel uncomfortable about talking to your health care provider. Health care providers are used to dealing with these issues and can help you manage the problem.

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Allen H, Austin J, Cooper C. Initial trial of timed voiding is warranted for all children with daytime incontinence. Urology. 2007;69:962–5.

Cohen H, Nussinovitch M, Frydman M. Extraordinary daytime urinary frequency in children. J Fam Pract. 1993;37:28–9.

Bergmann M, Corigliano T, von Vigier R. Childhood extraordinary daytime urinary frequency — a case series and a systematic literature review. Pediatr Nephrol. 2009;

Feldman AS, Bauer SB. Diagnosis and management of dysfunctional voiding. Curr Opin Pediatr. 2006

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