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This study was designed to investigate the prevalence of attention-deficit/hyperactivity disorder (ADHD) and its association with functional urination and defecation disorders among children in rural China.A cross-sectional study was conducted with children aged 6-18 in rural schools in southwest China using a survey questionnaire. The Swanson, Nolan, and Pelham Questionnaire-IV (SNAP-IV) was used to measure ADHD symptoms, and standardized questions about urination and defecation were used to measure lower urinary tract symptoms (LUTS) and functional defecation disorders (FDDs). The association of ADHD with LUTS and FDDs was analyzed by matched logistic regression after propensity score matching was performed to minimize the influence of potential confounders, including demographic characteristics.A total of 17,279 participants were included in the analyses. The prevalence of ADHD was 2 % mainly among boys before age 12, after which it showed a decreasing trend with age, resulting in a concomitant reduction in gender differences. The risk of ADHD was positively associated with the presence of enuresis, holding maneuvers, intermittency, and encopresis, with encopresis having the strongest association (P = 0.001). The presence of holding maneuvers, intermittency, excessive volitional stool retention, and encopresis were associated with a higher risk of ADHD at 6-15 years-old, with intermittency exhibiting an increasingly positive association with ADHD risk across ages 6-15.ADHD was associated with LUTS and FDDs, which highlights that functional urination and/or defecation disorders could serve as warning signs for ADHD that should trigger screening, especially in relatively backward regions with little ADHD awareness.

We compared patient- and family-reported overall and stool-related quality of life (QoL) before and after an antegrade continence enema (ACE) procedure (cecostomy tube insertion) for refractory chronic constipation or fecal incontinence (CCFI). We hypothesized that patients with functional diagnoses experience similar improvements in QoL compared to those with organic diagnoses.This is a cross-sectional study of patients undergoing cecostomy tube insertion for CCFI at a tertiary pediatric hospital from 2012 to 2019. Patients and/or primary caregivers completed validated stooling and overall QoL surveys based on three time points: before surgery, three months after surgery, and at the time of survey / date of last follow-up. Repeated measures analyses compared scores over time between subjects and within the diagnostic groups.The response rate was 65% (22/34 patients, 12 organic and 10 functional diagnoses). Mean age was 8.3 years and 32% of the participants were female. Organic diagnoses were: spina bifida (6), anorectal malformation (5), and Hirschsprung Disease (1). There was substantial improvement in stool-related and overall QoL at three months post-ACE procedure (both p0.001) for all patients; both scores continued to improve significantly until the date of last follow-up (median 4.1 years, IQR 2.3-5.6, p0.001). There was no statistically significant difference in scores between patients with organic and functional diagnoses.Caregivers perceive a significant, sustainable improvement in stooling habits and QoL following ACE therapy. The improvement is comparable between patients with a functional diagnosis and those with an underlying organic reason for their CCFI.

Background An appendicostomy (ACE) is a surgical option for antegrade enemas in children with severe constipation and/or fecal incontinence who have failed medical management. In 2019, we initiated an expedited post-operative protocol and sought to examine our short-term outcomes compared with our historical cohort. Methods A retrospective review was performed of all children undergoing ACE between 2017 and 2020. Children were excluded if they underwent an associated procedure (e.g. colon resection). Patients were divided into two cohorts: historical cohort (2017–2018, Group A) and the expedited protocol (2019 to present, Group B). The primary outcome was length of stay. Results 30 patients met inclusion (Group A = 16, Group B = 14). The most common indications for ACE were constipation (50%) and constipation or fecal incontinence associated with anorectal malformation (43%). Group B experienced a decreased length of stay (1 vs 3 days, P = 0.001) without differences in 30-day surgical site infection (7.1% vs 18.8%, p = 0.61) or unplanned visit (15.4% vs 18.8%, p = 1.0). Group B had a higher prevalence of MiniACE® button placed through the appendix vs. Malone (42.8% vs 12.5%, p = 0.10). Conclusions Our expedited post-op protocol decreased length of stay without other significant adverse clinical sequelae. Level of evidence Retrospective Comparative Study, Level III.

Objective: To identify and describe the protocols and clinical outcomes of urotherapy interventions in children and adolescents with bladder bowel dysfunction. Method: Systematic review carried out in June 2018 on Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica dataBASE (EMBASE), Scientific Electronic Library Online (SciELO), Cochrane Library, and PsycInfo databases. Clinical trials and quasi‐experimental studies carried out in the last ten years in children and/or adolescents with bladder and bowel symptoms and application of at least one component of urotherapy were included. Results: Thirteen clinical trials and one quasi‐experimental study were included, with moderate methodological quality. The heterogeneity of the samples and of the methodological design of the articles prevented the performance of a meta‐analysis. The descriptive analysis through simple percentages showed symptom reduction and improvement of uroflowmetry parameters. The identified urotherapy components were: educational guidance, water intake, caffeine reduction, adequate voiding position, pelvic floor training, programmed urination, and constipation control/management. Conclusion: This review indicates positive results in terms of symptom reduction and uroflowmetry parameter improvement with standard urotherapy as the first line of treatment for children and adolescents with bladder bowel dysfunction. It is recommended that future studies bring contributions regarding the frequency, number, and time of urotherapy consultations. Resumo: Objetivo: Identificar e descrever os protocolos e desfechos clínicos das intervenções de uroterapia em crianças e adolescentes com disfunção vesical e intestinal. Método: Revisão sistemática realizada em junho de 2018 nas bases Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica dataBASE (EMBASE), Scientific Electronic Library Online (SciELO), Cochrane Library e PsycInfo. Foram incluídos ensaios clínicos e estudos quase‐experimentais dos últimos 10 anos, em crianças e/ou adolescentes com sintoma urinário e intestinal e aplicação de no mínimo um componente de uroterapia. Resultados: 13 ensaios clínicos e 1 estudo quase‐experimental foram incluídos, sendo a qualidade metodológica moderada. A heterogeneidade da amostra e de delineamento metodológico dos artigos impediu a realização de meta‐análise. A análise descritiva por meio de percentual simples demonstrou redução dos sintomas e melhora dos parâmetros de urofluxometria. Os componentes de uroterapia identificados foram: orientação educacional, ingestão hídrica, redução de cafeína, posicionamento adequado para eliminação, treinamento do assoalho pélvico, micção programada e controle/manejo da constipação. Conclusão: Esta revisão sinaliza resultados positivos em termos de redução de sintomas e melhora nos parâmetros de urofluxometria com aplicação de uroterapia padrão como primeira linha de tratamento nos casos de crianças e adolescentes com disfunção vesical e intestinal. Recomenda‐se que estudos futuros tragam contribuições no que tange a frequência, número e tempo para as consultas de uroterapia. Keywords: Bladder bowel dysfunction, Urotherapy, Behavior therapy, Dysfunctional elimination syndrome, Dysfunctional voiding, Child, Palavras‐chave: Disfunção vesical e intestinal, Uroterapia, Terapia comportamental, Síndrome de eliminação disfuncional, Micção disfuncional, Criança

The aim of the study was to assess the impact of bowel management on the quality of life in children with spina bifida with overactive bladder and detrusor sphincter dyssynergia.The research was carried out over the 2014-2017 period, during which 70 patients with spina bifida with overactive bladder and detrusor sphincter dyssynergia were observed. The first group (group 1) consisted of 35 patients who were administered bowel management combined with anticholinergic medication therapy and CIC. The second group (group 2) consisted of 35 patients who were treated only with anticholinergic medication therapy and CIC. Bowel management included daily enema, laxative application, and a special diet, with a view of treating constipation and fecal incontinence that was estimated on the basis of Roma III criteria, the echosonographically determined transversal rectal diameter, and encopresis frequency. The effects of the administered bowel management on urinary incontinence were estimated on the basis of the average dry interval between two CICs. Regarding the quality of life, a KINDL questionnaire was used for children and parents to determine the overall quality of life, but also the various aspects of the quality of children's life (physical well-being, emotional well-being, self-confidence, family, friends, school, disease). The test score ranges from 0 to 100, where 0 is the lowest and 100 denotes the highest quality of life. The follow-up period of every patient was one year.At baseline, there was no significant difference between the groups regarding demographic and clinical features (p 0.05). After one year, treatment by bowel management demonstrated significant improvement for both fecal constipation/incontinence and urinary incontinence (p 0.001). The bowel management group showed improved overall quality of life in contrast to the group without bowel management 88.9 ± 7.1 vs. 55.4 ± 11.4 (p 0.001, assessed by parents) and 84.5 ± 8.9 vs. 53.4 ± 12.5 (p 0.001, assessed by children), respectively. Moreover, the positive impact of bowel management on quality of life was confirmed for all domains of the quality of life (physical well-being, emotional well-being, self-confidence, family, friends, school, disease), (p 0.001 for all), both by the parents' and the children's assessment.Administering bowel management considerably alleviates the symptoms of fecal and urinary incontinence and considerably improves the quality of life. Bowel management should be considered as an integral part of treatment of children with spina bifida.

Constipation is a common problem in children. Although most children respond to conventional treatment, symptoms persist in a minority. For children with refractory constipation, anorectal and colonic manometry testing can identify a rectal evacuation disorder or colonic motility disorder and guide subsequent management. Novel medications used in adults with constipation are beginning to be used in children, with promising results. Biofeedback therapy and anal sphincter botulinum toxin injection can be considered for children with a rectal evacuation disorder. Surgical management of constipation includes the use of antegrade continence enemas, sacral nerve stimulation, and colonic resection.

Purpose A protocol to treat idiopathic constipation is presented. Methods A contrast enema is performed in every patient and, when indicated, patients are initially submitted to a "clean out" protocol. All patients are started on a Senna-based laxative. The initial dosage is empirically determined and adjusted daily, during a one week period, based on history and abdominal radiographs, until the amount of Senna that empties the colon is reached. The management is considered successful when patients empty their colon daily and stop soiling. If the laxatives dose provokes abdominal cramping, distension, and vomiting, without producing bowel movements, patients are considered nonmanageable. Results From 2005 to 2012, 215 patients were treated. 121 (56%) were males. The average age was 8.2years (range: 1–20). 160 patients (74%) presented encopresis. 67 patients (32%) needed a clean out. After one week, 181 patients (84%) achieved successful management, with an average Senna dose of 67mg (range: 5–175mg). In 34 patients (16%) the treatment was unsuccessful: 19 were nonmanageable, 3 noncompliant, and 12 continued soiling. At a later follow-up (median: 329days) the success rate for 174 patients was 81%. Conclusion We designed a successful protocol to manage idiopathic constipation. The key points are clean out before starting laxatives, individual adjustments of laxative, and radiological monitoring of colonic emptying. Treatment study Level IV.

Introduction Evidence suggests that urinary and fecal incontinence and abnormal voiding and defecation dynamics are different manifestations of the same syndrome. This article reports the success of an innovative program for care of children with incontinence and dysfunctional elimination. This program is innovative because it is the first to combine subspecialty services (urology, gastroenterology, and psychiatry) in a single point of care for this population and the first reported independent nurse practitioner–run specialty referral practice in a free-standing pediatric ambulatory subspecialty setting. Currently, services for affected children are siloed in the aforementioned subspecialties, fragmenting care. Methods Retrospective data on financial, patient satisfaction, and patient referral base were compiled to assess this program. Results Analysis indicates that this model is fiscally sound, has similar or higher patient satisfaction scores when measured against physician-run subspecialty clinics, and has an extensive geographic referral base in the absence of marketing. Discussion This model has potential transformative significance: (a) the impact of children achieving continence cannot be underestimated, (b) configuration of services that cross traditional subspecialty boundaries may have broader application to other populations, and (c) demonstration of effectiveness of non-physician provider reconfiguration of health care delivery in subspecialty practice may extend to the care of other populations.

Summary Background Bladder and bowel dysfunction (BBD) is a common pediatric problem that describes a constellation of lower urinary tract symptoms associated with constipation and/or encopresis. Its association with neurodevelopmental and psychiatric (NDP) problems is not well understood. Objectives Our primary aim was to identify pre-existing NDP disorders in children with BBD. Secondarily, we aimed to screen for new behavioral problems and evaluate the association between bladder or bowel symptoms and behaviors symptoms. Methods A cross sectional study was conducted in urology clinics. New patients referred for BBD between 4 and 17 years old were recruited and completed: a demographics survey, Dysfunctional Voiding Score System questionnaire, assessment of bowel movements with the Bristol Stool Scale, and Strength and Difficulties questionnaire (SDQ). Those with known spinal dysraphism were excluded. SDQ scores were evaluated for abnormal screens in different subscales and total difficulties scores. Pearson correlation analyses were conducted for association. Results We included 61 participants (age 9.5 ± 4.1 years), including 33 females and 28 males. One or more pre-existing NDP disorder(s) was reported in 14 (23%) children; most commonly being learning disability (43%) and attention deficit hyperactivity disorder (29%). This cohort had more severe BBD symptoms as reflected in DVSS scores. SDQ scores demonstrated that 12 patients without pre-existing NDP diagnoses scored in the clinical range, with hyperactivity as the most common difficulty (6/12; 50%). Conclusions A significant proportion of children with BBD have a comorbid NDP disorder and present with more severe symptomatology. The SDQ can be used as a behavioral screening tool this population for the identification of children who may benefit from formal developmental pediatrics assessment. Summary Table 1 . Comparison between those with and without neuropsychiatric disorder. Prior Neuropsychiatric Disorder No Prior Neuropsychiatric Disorder P value (95% Confidence Interval) Patients 14 (23) 47 (77) – Age 10 (SD = 3.5) 9 (SD = 4) 0.403 (−1.45 to 3.55) Gender Female 6 (43) 27 (43) – Male 8 (57) 20 (57) – DVSS (Mean Total Score) 13 (SD = 6) 9 (SD = 4) 0.018∗ (0.59–6.15) Bristol Stool Scale (Median Score) 3 3 0.791 (−0.50 to 0.66) SDQ (Mean Total Score) 19 (SD = 5.5) 9.6 (SD = 4.7) 0.0001∗ (6.72–12.72)

Fecal incontinence is a socially debilitating problem for many children. We hypothesized that in selected patients with medically-refractory encopresis, placement of an appendicostomy or cecostomy tube for administration of antegrade continence enemas (ACE) would improve quality of life (QOL).We reviewed all patients with encopresis who underwent appendicostomy or cecostomy placement from 2003 to 2014 at our institution. We contacted subjects' parents by phone and administered 3 surveys: a survey reflecting current stooling habits, a disease-specific QOL survey, and the PedsQL™ QOL survey. QOL surveys were completed twice by parents, once reflecting pre-operative QOL, then again reflecting current QOL. Pre-procedure and post-procedure scores were compared by paired t-test.Ten patients underwent appendicostomy/cecostomy for encopresis. Eight completed phone surveys. All procedures were performed laparoscopically. All patients experienced fecal soiling pre-operatively, whereas 5/8 surveyed patients (63%) noted complete resolution of soiling post-procedure (p0.01). General and disease-specific QOL improved from pre-procedure to post-procedure in the following domains: social habits, physical activity, ability to spend the night elsewhere, feeling, and overall QOL (p0.05). PedsQL™ scores improved significantly in physical functioning, social functioning, and overall functioning (p0.05).Antegrade continence enemas significantly improve quality of life in patients with medically-refractory encopresis, likely related to resolution of soiling.4.

OBJECTIVE: Enuresis and encopresis, both conditions are very distressful to children and their family members and it is responsible for significant social and psychological consequences in children and adolescents. The present study aims to determine the rate of abusive maternal attitudes towards children and adolescents with elimination disorders (EDs) and to investigate the maternal psychological and socio-cultural factors associated with abusive parenting attitudes. METHOD: N = 180 children with ED were included in the study. Family Assessment Device (FAD), and Symptom Check List (SCL-90-R) were administered to mothers. RESULTS: Our results indicated that prevalence of abusive maternal attitudes in our sample was 73.8%. Children and adolescents with ED who live with low-educated parents (p = 0.008), low socio economic status (p = 0.014), and in cases with living in a large or divorced family (p = 0.014), disorganized or chaotic families can be considered a population at risk (p CONCLUSION: Present study showed high rates of abusive parenting attitudes in cases of EDs in a sample of Turkish children and adolescents. Further research on the etiological and therapeutic importance of the family in the case of ED referred to a psychiatry clinic should be carried out.Copyright © 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved. Language: en

BACKGROUND: Fecal incontinence (FI) in children is frequently encountered in pediatric practice, and often occurs in combination with urinary incontinence. In most cases, FI is constipation-associated, but in 20% of children presenting with FI, no constipation or other underlying cause can be found - these children suffer from functional nonretentive fecal incontinence (FNRFI).OBJECTIVE: To summarize the evidence-based recommendations of the International Children's Continence Society for the evaluation and management of children with FNRFI.RECOMMENDATIONS: Functional nonretentive fecal incontinence is a clinical diagnosis based on medical history and physical examination. Except for determining colonic transit time, additional investigations are seldom indicated in the workup of FNRFI. Treatment should consist of education, a nonaccusatory approach, and a toileting program encompassing a daily bowel diary and a reward system. Special attention should be paid to psychosocial or behavioral problems, since these frequently occur in affected children. Functional nonretentive fecal incontinence is often difficult to treat, requiring prolonged therapies with incremental improvement on treatment and frequent relapses.

Objective To assess the prevalence of vulvovaginitis, enuresis and encopresis in children who were referred for allegations of sexual abuse. Subjects A retrospective chart review of 1280 children presenting for non-acute examination after allegations of sexual abuse during a 15-year time span. Interview documentation, physical examination documentation, urinalysis, urine and vaginal cultures were reviewed. Results Of the 1280 children, 73.3% were female and 26.7% male. The ages of the children ranged from 6 months to 18 years (median age was 6 years). Interviews revealed that fondling contact was the most common allegation, followed by oral, vaginal, and anal penetration. Interviews also disclosed lower urinary tract symptoms, UTI, constipation, encopresis and enuresis. Physical examination revealed no abnormal genital findings in 44.7% of cases. Examinations of the vagina noted: erythema (18.1%); hymenal notching (posterior 16.8%, anterior 4.4%); vuvlovaginitis (14.0%); laceration or transection (0.6%); and bruising (0.4%). Examination of the anus noted: anal fissure/tear (14.9%); loss of anal tone (10.6%); reflex anal dilatation (9.2%); venous congestion (3.8%); and proctitis (0.9%). Vulvovaginitis was noted in 14% (131/936) and encopresis in 2.3% (21/936). Enuresis according to age was reported in 13% of 5–9 year olds, 14.7% of 10–16 year olds and 18.2% of 17–18 year olds suspected of being abused. Conclusion Prevalence of vulvovaginitis and enuresis were increased, and encopresis was decreased in children with allegations of sexual abuse when compared to the general pediatric population. Physicians should continue to be aware of the possibility of the presence of these conditions in children who have been sexually abused, and offer appropriate treatment.

Objective The primary aim of this study was to determine if there is a change in the quality of life in pediatric patients with unremitting functional constipation and/or encopresis after undergoing a MACE procedure. Methods Patients, ages 5 to 18years with unremitting constipation and a normal evaluation, including anorectal manometry and colonic manometry, who opted to undergo a MACE procedure were contacted to participate in the study. Patients with congenital anorectal malformations as well as spinal cord disorders were excluded from the study. The patient's parent/guardian completed the PedsQL TM Generic Core Scales QOL survey prior to the operation, 6months, and 12months after the procedure. Results A total of 15 consecutive patients meeting protocol criteria were recruited within a period of 20months. The mean age at the MACE procedure was 9.8years (range 7.0–11.1). 5 patients were female. The mean QOL score pre-MACE was 64.1. At 6months post-MACE the mean overall QOL score was 90.2, and it was 92.0 at 12months. All 15 patients at the 6month follow up had significant improvement in their QOL (p=1.9×10 −7 ) and all subcategories of QOL were significantly improved as well. Conclusions A MACE procedure is of benefit to otherwise normal pediatric patients who have unremitting functional constipation with failure of medical treatment. Our patients had a significant improvement in all QOL categories and overall QOL.

Objective This study reports the incidence of enuresis and encopresis among children with attention-deficit/hyperactivity disorder (ADHD) versus those without ADHD. Methods Subjects included 358 children (74.5% boys) with research-identified ADHD from a 1976 to 1982 population-based birth cohort (n = 5718) and 729 (75.2% boys) non-ADHD control subjects from the same birth cohort, matched by gender and age. All subjects were retrospectively followed from birth until a diagnosis of enuresis or encopresis was made or last follow-up before 18 years of age. The complete medical record for each subject was reviewed to obtain information on age of initial diagnosis of an elimination disorder, frequency and duration of symptoms, and identification of exclusionary criteria specified by DSM-IV, with confirmation of the diagnosis by expert consensus. Results Children with ADHD were 2.1 (95% confidence interval [CI], 1.3–3.4; P = .002) times more likely to meet DSM-IV criteria for enuresis than non-ADHD controls; they were 1.8 (95% CI, 1.2–2.7; P = .006) times more likely to do so than non-ADHD controls when less stringent criteria for a diagnosis of enuresis were employed. Though not significant, children with ADHD were 1.8 (95% CI, 0.7–4.6; P = .23) times more likely to meet criteria for encopresis than non-ADHD controls. The relative risk was 2.0 (95% CI, 1.0–4.1; P = .05) when a less stringent definition for encopresis was utilized. Conclusions Children with ADHD are more likely than their peers without ADHD to develop enuresis with a similar trend for encopresis.

Objective To evaluate the response to rectal distension in children with chronic constipation and children with chronic constipation and encopresis. Study design We studied 27 children, aged 3 to 16 years, with chronic constipation; 12 had encopresis. Anorectal motility was measured with a solid state catheter. When the catheter was located in the internal sphincter, the balloon was inflated to 60 mL with air. Results There were no differences in age, sex distribution, and duration of constipation in the two groups. Comparing groups, anorectal manometry showed no differences in the resting sphincter pressure, recovery pressure, the lowest relaxation pressure, and percent relaxation. However, time to maximum relaxation, time to recovery to baseline pressure, and duration of relaxation were significantly higher in patients with constipation and encopresis, compared with patients who had constipation alone. Conclusions There may be an imbalance in neuromuscular control of defecation in constipated patients with encopresis that results in incontinence as a consequence of the increased time to recovery and duration of relaxation of the internal anal sphincter.

A lack of toileting skills is one of many impairments that individuals with intellectual and developmental disabilities experience. Unfortunately, little research has focused on problems in this area including assessment, function, and treatment. A newly developed checklist, the Profile of Toileting Issues (POTI), is being considered for use to screen for toileting issues in this population, and to identify potential functions to target in treatment. The purpose of the current study was to examine the reliability of the POTI. Internal consistency was sound (α = .83) and interrater reliability was significant. The implications of these findings are included.

Introduction Defecation and urination disorders are well known problems in children which leads their parents to consult a specialist. The solving of these problems usually needs a multidisciplinary approach and cooperation of different specialists to find a diagnosis and determine the correct treatment. Methods Abnormal pudendal nerve function was investigated with the St. Mark EMG electrode in six children between the ages of 8 and 13 years with pelvic organ disorders and preliminary diagnosis of neurogenic bladder (NB). The pudendal nerve terminal motor latency (PTL) was measured after the stimulation on both sides. Results In comparison with the literature normal values of 1.58 ± 0.33 ms (Sentovich, Stephen M., 1998) the PTL was increased in all patients to the mean value of 1.92 ± 0.33 ms. The increased PTL on one side (OS) was found in one patient and on both sides (BS) in five patients. In BS patients the increased PTL was accompanied by the ureteral hypoplasia and/or reduction of muscle tone tested by ultrasound investigation. In a one patient with OS, an increase in PTL was accompanied by clinical symptoms, there was no organic pathology. The increase in PTL exceeded the normal range by 0.9 ms. Conclusion The EMG study of the abnormal pudendal nerve function is important in diagnostics of urination disorders and possible pathogenesis in children. The preliminary data needs to be confirmed on a bigger cohort of patients.

Purpose: Erythromycin is successfully used as a gastroduodenal prokinetic agent. Given the limited available treatments for colonic dysmotility, further investigation into erythromycin's effect on colonic motility is warranted. We aimed to study the effect of erythromycin on colonic motility in pediatric patients with recalcitrant chronic constipation/encopresis and other suspected colonic motility disorders. Methods: Patients referred for colonic manometry were eligible for enrollment. Fasting motility was recorded for 1 to 2 hours, then erythromycin lactobionate (EL), 3 mg/kg, was administered intravenously, and colonic motility was monitored for 1 to 2 hours after erythromycin. Manometry was then continued per routine. The motility index (MI) of pressure tracings at each pressure transducer was calculated for each patient for a period of 15 and 60 minutes before and after EL infusion. Change in MI was compared by Wilcoxon signed rank test. Results: Twenty patients were enrolled. The most common indication was constipation with encopresis. Seventy percent of patients had normal colonic manometry, and 30% of patients demonstrated a neuropathy. Average MI for the 60-minute period before and after EL infusion were 254 ± 74 mm Hg/h and 253 ± 94 mm Hg/h, respectively (P = .55). Average MI for the 15-minute period before and after EL infusion were 64 ± 23 mm Hg/15 min and 69 ± 32 mm Hg/15 min, respectively (P = .45). Conclusions: Administration of intravenous EL resulted in no changes in colonic MI in pediatric patients referred for colonic manometry. Further studies on potential colokinetic agents are warranted in this population of patients.

Gastrointestinal symptoms are very frequent in myotonic dystrophy but largely unrecognized. They can be the revealing factors of the disease. We report 2 cases of 10 and 17-year-old children with persistent encopresis starting at the age of 3 and 5 years in spite of laxative treatment. Neurological examination and anorectal manometry provided the diagnosis of myotonic dystrophy. Procainamide treatment was introduced and the digestive symptoms improved. Any child with encopresis should have complete evaluation to rule out the diagnosis of myotonic dystrophy and physicians should look for upper and/or lower gastrointestinal symptoms in every patient with myotonic dystrophy.

We report two new patients with the 1.4 Mb recurrent 22q11.2 distal deletion syndrome. Features common to both children, as well as to several of the previously reported cases, include normal palate, smooth philtrum, hypoplastic alae nasi and delayed development. Both children are small but not growth retarded, and are microcephalic. Their developmental delay is global and most pronounced for language acquisition. One child has unilateral sensorineural hearing loss and encopresis, and the other child has treatment-responsive nocturnal epileptogenic activity. These two new cases confirm the recurrent nature of the deletion and help to further delineate the phenotype.

Objective This study evaluated the Trap-door button use (Cook Medical, Bloomington, IL) for antegrade enemas in children. Methods Since 2002, patients with fecal incontinence or encopresis and constipation underwent percutaneous cecostomy under laparoscopy using a button. Technical details are described. Age at surgery, operative time, hospital stay, diagnosis, indications for cecostomy, and duration of follow-up were recorded. A survey was proposed via a questionnaire that was sent to the patients. Patients wearing the button for less than 1 month were excluded from this evaluation. The survey concerned volume and frequency of enemas, difficulties encountered, benefits and disadvantages of this method, and assessment of the antegrade enemas in continence. Results Twenty-nine patients, 18 males and 11 females, aged 3 to 21 years (mean, 8.5 years) underwent laparoscopic Trap-door button placement. The indications for all the patients were intractable fecal incontinence in 24 cases and constipation with encopresis in 5 cases. Incontinence was because of myelomeningocele (n = 10), anorectal malformations (n = 11), caudal regression syndrome (n = 1), 22q11 syndrome (n= 1), and Hirschsprung disease with encephalopathy with convulsions (n = 1). Constipation with encopresis was because of sacrococcygeal teratoma (n = 1), cerebral palsy (n = 1), and acquired megarectum with psychiatric and social disorders (n = 3). A total of 26 cecostomy button placements and 3 sigmoidostomy button placements were successful with no intraoperative complication. The mean operative time was 25 minutes (10-40 minutes), and the hospital stay was 2.5 days (1-4 days). Twenty-two parents or patients answered the questionnaire. At the time of this survey, 2 patients had improved their fecal continence and had had the button removed. A mean of 4 weekly enemas was enough to improve fecal continence troubles (range, 1 daily to 1 for 2 weeks). The volume for enemas was 250 to 1000 mL (mean, 700 mL). The time required for the irrigation of the bowel by gravity took from 5 to 60 minutes (mean, 25 minutes) for 20 patients. Before surgery, 14 patients needed a diaper, day and night, and 6 needed sanitary protection. Soiling was a very significant inconvenience for all the patients. After surgery, only 5 patients needed a diaper (cerebral palsy, 22q11, cloacal malformation, myelomeningocele, bladder exstrophy) because of moderate results or urinary incontinence and continued soiling. Patients were asked to give an assessment (null = 0, bad=1, fair=2, good=3, very good=4). None of the patients felt there had been no changes or a bad result. There were 5 patients who felt they had an average result, 5 a good result, and 12 a very good result. The mean grade was 3.44 (17.2/20). A total of 3 patients had hypertrophic granulation tissue formation around the cecostomy button, and 12 had tiny leakage. Conclusion Percutaneous placement of a cecostomy button under laparoscopic control is an easy and major complication-free procedure. The use of the Trap-door device by the patients or with the help of the parents for antegrade enemas is effective and satisfactory. It improves the quality of life and is reversible.

Objective Autism spectrum disorders are now recognized to occur in up to 1% of the population and to be a major public health concern because of their early onset, lifelong persistence, and high levels of associated impairment. Little is known about the associated psychiatric disorders that may contribute to impairment. We identify the rates and type of psychiatric comorbidity associated with ASDs and explore the associations with variables identified as risk factors for child psychiatric disorders. Method A subgroup of 112 ten- to 14-year old children from a population-derived cohort was assessed for other child psychiatric disorders (3 months' prevalence) through parent interview using the Child and Adolescent Psychiatric Assessment. DSM-IV diagnoses for childhood anxiety disorders, depressive disorders, oppositional defiant and conduct disorders, attention-deficit/hyperactivity disorder, tic disorders, trichotillomania, enuresis, and encopresis were identified. Results Seventy percent of participants had at least one comorbid disorder and 41% had two or more. The most common diagnoses were social anxiety disorder (29.2%, 95% confidence interval [Cl)] 13.2-45.1), attention-deficit/hyperactivity disorder (28.2%, 95% Cl 13.3-43.0), and oppositional defiant disorder (28.1 %, 95% Cl 13.9-42.2). Of those with attention-deficit/hyperactivity disorder, 84% received a second comorbid diagnosis. There were few associations between putative risk factors and psychiatric disorder. Conclusions Psychiatric disorders are common and frequently multiple in children with autism spectrum disorders. They may provide targets for intervention and should be routinely evaluated in the clinical assessment of this group. J. Am. Acad. Child Adolesc. Psychiatry , 2008;47(8):921-929.

Constipation is a common problem in primary care. Nurse practitioners should be able to diagnose and treat constipation appropriately and to recognize which children require referral to a gastroenterologist. Referral to a gastroenterologist is necessary for the child with simple constipation or encopresis fails to respond to treatment, an organic etiology is suspected, or complex management is required.

Objetivo: Analizar la prevalencia del estreñimiento funcional asociado o no a encopresis, los factores implicados en su desarrollo y la respuesta al tratamiento. Pacientes y métodos: Estudio prospectivo de 62 niños en el que se incluyó cuestionario estándar (edad de comienzo, hábito higiénico, encopresis, complicaciones, encuesta dietética y factores psicológico-ambientales) y exploraciones clínica y antropométrica. Se definió estreñimiento funcional a la frecuencia de defecación inferior a 3 veces/semana con heces voluminosas o escíbalos, acompañado o no de 2 manchados/semana, sin causa orgánica. El tratamiento incluyó desmitificación, corrección de hábitos y fármacos (lubricantes y senósidos). Se reevaluaron periódicamente considerándose respuesta positiva si la defecación fue igual a 3 veces/semana, sin molestias y menos de 2 manchados/mes. Resultados y conclusiones: El estreñimiento funcional supuso el 13 % de las primeras consultas, siendo el 60% niños y el 40% niñas, con edad promedio de 6,1 años. Las principales manifestaciones fueron dolor a la defecación (60 %), rectorragia (42 %), episodios obstructivos (32 %) y fisuras y/o hemorroides (18 %); en 19 casos (31 %) se asoció encopresis. El 84 % estaba normonutrido y el 16% tenían sobrepeso, siendo la alimentación deficitaria en fibra en más del 60 %. Requirieron desimpactación 16 niños con la combinación de senósidos (20-30 mg/dosis) y aceite de parafina, con total eficacia. El tratamiento de mantenimiento incluyó lubricantes (15-30 ml/día) y senósidos en la dosis mínima eficaz (media: 5-15 mg/día). La respuesta al mes fue positiva en el 32 %, a los 3-6 meses en el 71% y a los 6-12 meses en el 85% y se relacionó de forma estrecha con la modificación de los hábitos higiénico-dietéticos y el cambio en la actitud familiar. : Objective: To assess the prevalence of functional constipation (FC) with and without encopresis, the factors involved in its onset, and treatment response. Patients and methods: A prospective study of 62 children was performed using a standard questionnaire (onset-age, regular toilet use, encopresis, complications, dietary habits and environmental and psychological factors) and physical and anthropometric assessment. FC was defined as a stool frequency of less than 3 bowel movements/week, with passage of large or scybalous stools, with or without 2 or more soiling episodes per week, without underlying disease. Treatment included demystification, behavioral modification and drugs (mineral oil and senna). Each child was periodically re-evaluated, and treatment was considered successful when the defecation rate was 3 or more bowel movements/week, discomfort was absent, and fecal soiling frequency was 2 or fewer episodes/ month. Results and conclusions: FC accounted for 13 % of all first consultations (60% boys, 40 % girls; mean age at diagnosis 6.1 years). The most frequent manifestations were painful defecation (60 %), rectorrhagia (42 %), obstructive episodes (34 %) and anal fissure or hemorrhoids (17 %); 19 patients (31 %) had encopresis. Nutritional assessment revealed that 84 % of the patients was well nourished and 16 % was overweight. Fiber intake was deficient in more than 60 %. Sixteen (26 %) patients underwent successful relief of impaction with senna (20-30 mg/dose) combined with mineral oil. Maintenance treatment included mineral oil (15-30 ml/day) and senna at the minimum effective dose (5-15 mg/day). Satisfactory results were achieved 1 month later in 32 % of the children, 3-6 months later in 71 %, and 6-12 months later in 85 %; successful response was closely related to regular toilet habits, dietary modification and a shift in the family’s attitude.

Purpose Chronic idiopathic constipation (CIC) with soiling in children may result from slow colonic transit (SCT) or anorectal dysfunction and/or psychological problems known as functional fecal retention (FFR). Evidence is accumulating that SCT and FFR need different treatments, but they are poorly distinguished by solid marker studies. The authors used radionuclear transit scintigraphy to categorize children with CIC as having either FFR or SCT. Methods Children (N = 101) with CIC (and soiling) who were referred for further investigation after failure of standard treatments (diet, laxatives) received radiolabeled colloid orally, and scintillation images were collected at 0 to 2, 6, 24, 30 and 48 hours (total radiation dosage=2 standard x-rays). Radioactivity in 6 regions (precolonic, ascending, transverse, descending, rectosigmoid, and evacuated feces) was measured, and the median position (geometric center) of radioactivity at each time was determined. Results In children, meals normally reach the cecum at 6 hours and are evacuated in 30 to 58 hours. Fifty patients had retention of radioactivity in the proximal colon at 48 hours, indicating SCT. Analysis of the images and the geometric center showed that passage through the ascending colon and transverse colon was delayed in SCT. In 24 patients, radioactivity was passed by 30 hours, indicating normal transit or possible FFR. Twenty-two patients had retention in the rectum, indicating definite FFR. Five studies were borderline. Conclusions Radionuclear transit scintigraphy is useful for categorizing patients with CIC as having either FFR or SCT, allowing for different treatments. Radionuclear transit scintigraphy provides more detail and greater sensitivity than solid marker studies in diagnosing CIC. Radionuclear transit scintigraphy showed that half of our patients had SCT.

Background Hirschsprung's disease (HD) patients after pull-through (PT) may have recalcitrant constipation or recurrent enterocolitis (EC). Posterior myotomy/myectomy (POMM) are possible options for these problems. This study analyzed the outcome of POMM in HD patients post-PT. Methods Records of 348 HD patients were reviewed, and 32 were found to have undergone a POMM post-PT (1981 to 2002). Outcomes after this procedure were assessed. Statistics used linear and logistic regression. Results Of the 32 patients, 29 had complete records for analysis. Of those with pure constipation (12), 6 had aganglionosis post-PT. Of those with recurrent EC (17) only 1 had aganglionosis post-PT. POMM was performed at a mean of 3.1 years post-PT (11 myotomy, 18 myectomy). Average follow-up was 8.6 years (range, 0.7 to 21). Type of POMM had no correlation with overall functional outcome ( P = .44). Of those with chronic constipation, 60% had good results after POMM; the remainder required a redo-PT or colostomy. Interestingly, most patients with retained aganglionosis and chronic constipation did not respond after POMM (83%). Of those with recurrent EC, 75% became free of symptoms; none of the patients not responding have required redo-PT. Conclusions POMM to treat chronic constipation or recurrent EC in patients with HD post-PT is moderately successful. Because of the unsuccessful outcome with POMM in patients with a combination of constipation and aganglionosis, one should defer to a redo-PT in this group.

Background/Purpose: The authors' 15-year experience with children shows a high percentage of recurrence of functional constipation (FC) with conventional treatment. These data, confirmed in the international literature, led them to develop a new therapeutic approach. The aim of this study was to achieve intestinal control and avoid recurrence of FC in children through use of medical-psychological treatment. Methods: The authors studied 25 children (18 boys; mean age, 4.7 years; range, 2.10 to 7), 20% of whom had anal fissure, 30% retentive soiling, 52% pain on defecation, and 88% fecal retention owing to FC. Children and parents were questioned about eating and sleeping habits, school, toilet training, and daily routine. Treatment included increasing water and fiber intake, laxatives, and family therapy including making rules and working on autonomy and paternal role. Results: Mean onset of FC was 3.5 years, after "stressful events" in 88%. The questionnaire shows that 68% lacked parental autonomy and authority; 84% of children decided on their own about eating habits and sleeping; 68% had a "peripheral" father with a mother-child symbiotic relationship. After one month of therapy, 92% of children showed a modification of at least 2 behavioral patterns; after 3 months, 88% had regular bowel movements. During follow-up (range, 6 to 28 months), 48% had 2 or 3 recurrent episodes. After one year, 68% had reinforced the new behavioral patterns with resolution of the pathologic aspects. Conclusions: A multidisciplinary approach in the treatment of childhood functional constipation showed consistent therapeutic results by making rules and by equalizing family roles. J Pediatr Surg 38:819-823. © 2003 Elsevier Inc. All rights reserved.

Chronic constipation in childhood, with attendant symptoms of soiling, mood changes, anorexia and painful defaecation, has a devastating effect on the quality of life. Guidelines are based largely on personal practice rather than evidence. One of the most common causes is ineffective defaecation whereby the child contracts rather than relaxes the internal sphincter and perineal muscles during defaecation. Those who pass meconium beyond 48 h after birth should be investigated further. Measurement of radio-opaque marker intestinal transit time and use of the Heaton stool form chart are useful aids to diagnosis and management. The majority of children can be successfully treated with polyethylene glycol (macrogol) plus electrolyte laxatives and behavioural techniques.

Necessity of research of teenagers after violent actions of sexual character is connected basically with anogenital sexual contacts. Survey of victims by the medicolegal (forensics medicines) expert assumes knowledge of illnesses like anorectal complex, causing anorectal dysfunctions (perianal itch, proctalgia, a crack of anal tract, encopresis). All specified diseases concerned with anorectal rings can be idiopatic (without the established reason) and secondary (locks, violent actions of sexual character, medical manipulations, traumas). On suspicion of anal penetration in children, survey should be carried out after obligatory conversation with the psychologist and with special feeling of a step, taking into account age factors and diseases of mental sphere. Such survey demands a certain algorithm of inspection, whose basic stages consist of the following: 1.Survey of anal areas will be carried out after preliminary conversation and examinations of other sites of a body in knee–elbow position. Whenever possible, the expert should be on floor with surveyed. 2.Hands of the expert should be warm so as not to provoke a pressure of muscles in the anus. 3.The anal reflex is checked by an easy touch, without painful variant, to a superficial part anal apertures (external sphincter is tunicae reduced, back pass is involved). 4.Children, as a rule, do not keep sphincter, a strong-willed pressure and therefore, reduction of a reflex is accompanied by reduction of force as a result of reduction of sphincter and its tone.

We describe a pediatric patient with an atypical teratoid rhabdoid tumor (AT/RT) exclusively of the lumbar spine, with a different presentation from the two previously reported pediatric lumbar AT/RT. AT/RT are rare pediatric tumors of the central nervous system, with a dismal prognosis. Although there is sufficient literature on brain AT/RT, spinal AT/RT continues to be a rare entity, with a lumbar location even less frequently reported. A 30-month-old African American boy with multiple comorbidities presented with the inability to ambulate, encopresis and urinary dribbling. The MRI showed an intradural extramedullary mass extending downwards from the L3-4 level. He underwent an L3-S2 laminoplasty. The surgically resected mass was marked by sheets of cells with large nuclei and prominent nucleoli. The tumor cells stained with antibodies to synaptophysin and CAM5.2, and showed no immunoreactivity to INI-1 antibody. He was diagnosed with a World Health Organization Grade IV AT/RT. There was no mutation detected in the SMARCB1 gene on a comprehensive analysis of his blood. The boy is currently being treated according to the Medical University of Vienna AT/RT protocol, with no evidence of tumor recurrence 8 months after surgery. To our knowledge, this is the only report of a lumbar AT/RT in an African American child.

Chronic constipation and encopresis are common problems in children with spina bifida and anorectal anomalies. Commonly used therapies include complicated bowel regimens and antegrade continence enemas delivered via surgically placed appendicostomies and radiologically placed cecostomies. We have described a technique for percutaneous placement of cecostomies for the delivery of continence enemas or venting. Percutaneous cecostomies were placed in 22 patients. Improvement in bowel management occurred in all patients.

The anatomic and functional elements contributing to fecal continence and defecation are explored. The high incidence and importance of chronic idiopathic constipation as an entity in itself and a contributing factor to fecal incontinence are emphasized, and its management is discussed. The importance of a proper clinical history and examination is highlighted, and investigative modalities including radiology, transit studies, and anorectal manometry are described and placed in the context of practical clinical management.

Objective To review the progress made over the past decade with regard to the treatment of enuresis and encopresis, as well as advances in the understanding of etiological mechanisms. Method Separate computerized literature (English language only) searches of Medline and PsycINFO databases were conducted under the parameter of enuresis and children-adolescents, as well as encopresis and children-adolescents. Results There has been a substantial decrease in published research concerning the use of imipramine to treat enuresis compared with the prior two decades, accompanied by a corresponding increase in the number of papers concerning desmopressin acetate (DDAVP), which has become the primary pharmacological treatment. Genetic studies of large pedigrees have further confirmed the importance of heritable factors. With regard to encopresis, the research has focused primarily on pathophysiological factors related to the colon and anal sphincter. Conclusions The widespread use of DDAVP has been the primary addition to treatment strategies over the past decade. The bell-and-pad method of conditioning, the only major treatment that has enduring benefit after being withdrawn, is the most cost-effective and appears to be underutilized. Research into etiological mechanisms has focused primarily on the mechanism of action of DDAVP and advances in the understanding of genetic factors. Advances in the treatment and etiological understanding of encopresis have been less impressive.

Soiling can best be understood in childhood with reference to normal anorectal function, and the development of the awareness of the social value of continence. The pathophysiology as well as the disturbed behaviour associated with faecal incontinence is described. An illustrative case history is given to emphasize the evolution of the problems with age. The range of associated problems from neuropathic rectum, megarectum with overflow soiling, and through to the more psychological encopresis is described with some suggested treatments. Although there is little hard evidence about effectiveness of different treatment regimes, there is a strong consensus that early multidisciplinary help for these common problems is likely to prevent major social and psychological consequences of coping with faecal incontinence in late childhood and adolescence.

Objectives To assess the comorbidity of developmental disorder/delay in children with selective mutism (SM) and to assess other comorbid symptoms such as anxiety, enuresis, and encopresis. Method Subjects with SM and their matched controls were evaluated by a comprehensive assessment of the child and by means of a parental structured diagnostic interview with focus on developmental history. Diagnoses were made according to DSM-IV. Results A total of 54 children with SM and 108 control children were evaluated. Of the children with SM, 68.5% met the criteria for a diagnosis reflecting developmental disorder/delay compared with 13.0% in the control group. The criteria for any anxiety diagnosis were met by 74.1% in the SM group and for an elimination disorder by 31.5% versus 7.4% and 9.3%, respectively, in the control group. In the SM group, 46.3% of the children met the criteria for both an anxiety diagnosis and a diagnosis reflecting developmental disorder/delay versus 0.9% in the controls. Conclusions SM is associated with developmental disorder/delay nearly as frequently as with anxiety disorders. The mutism may conceal developmental problems in children with SM. Children with SM often meet diagnostic criteria for both a developmental and an anxiety disorder.

Analysis of the body mass index of pediatric patients with gastrointestinal complaints as a whole and by disease subgroup revealed a greater percentage of obese patients with constipation, gastroesophageal reflux, irritable bowel syndrome, encopresis, and functional abdominal pain compared with local and New Jersey control populations.

Encopresis most often results from functional constipation and a behaviour disorder characterised by retention of faeces. Rarely it is a passive or active expulsion of normal faeces. It indicates a failure in the education of sphincter control, often with a preferential development of autoerotic versus relational investments. A depressive component is frequent. We propose a bidisciplinary approach with a somatic and psychological evaluation of the encopretic child from the first visit. The physical examination assesses constipation and stercoral stasis. Associated psychopathological symptoms or a pathogenic psychosocial situation must be sought. The therapeutic means must be directed towards the different etiologic features. Explanations of the physiopathology of the symptom and discussion with the child and the parents on the origin of the dysfunction must be accomplished first. A medical treatment of the constipation is generally indicated. Psychotherapy is initiated according to the background and associated psychopathological symptoms.

Defecation difficulties in children present as stool toileting refusal, encopresis (caused by idiopathic or functional constipation), or fecal incontinence (caused by anatomic or neurologic disorders). The appropriate evaluation, treatment, and expected treatment results for children with stool soiling are presented.

This paper addresses pediatric elimination disorders including nocturnal enuresis from the perspectives of terminology (the Whorf hypothesis), the elimination interview, and the guarding reflex.The elimination interview and a modern model of normal voiding function, including the guarding reflex, are explained.The language of voiding dysfunction influences our perception of it. Nocturnal enuresis, and all other voiding dysfunctions, should be evaluated by a careful elimination interview. The guarding reflex may fit into an evolving etiologic paradigm for nocturnal enuresis.(1) Words and phrases of eliminology should aim for simplicity, clarity and accuracy. (2) Urologists need to perfect their eliminology skills vis-à-vis the elimination interview. (3) The role of the guarding reflex in nocturnal enuresis and all other voiding dysfunctions should be critically examined.

We determined the incidence of stool toileting refusal in 53 children with overflow encopresis ; 24 (45%) experienced difficulty toilet training for bowel movements. One-year follow-up data were obtained for 43 children, 31 with secondary encopresis and 12 with primary encopresis. Among the children with secondary encopresis, no difference was observed in response to treatment between children with and without difficulty toilet training. Ninety-one percent (11 of 12) of the children who had been soiling for less than 1 year at the time of presentation were free of soiling and no longer required therapeutic medication, compared with 55% (10 of 18) of the children who had been soiling for a longer period. Only 1 of 12 children with primary encopresis was free of soiling and no longer receiving therapeutic medication at 1 year, compared with 21 of 37 with secondary encopresis (p = 0.003). We concluded that children with primary encopresis who demonstrated stool toileting refusal during toilet training were resistant to medical treatment. (J Pediatr 1997;131:768-71)

Purpose: The authors devised computerized equipment for use in the biofeedback therapy in the management of fecal continence after surgery for anorectal malformations. Methods: The therapy was used for two to eight sessions in 14 children (11 who had high-type anomalies and three who had intermediate-type anomalies). The ages ranged 5 to 14 years. A control group of 17 children, aged 5 to 11 years, who had encopresis, was also treated with the same biofeedback therapy. Results: Clinical improvement was noted in 5 of the 14 (36%) children who had fecal incontinence, and in 15 of the 17 children (88%) who had encopresis. Both in patients who had fecal incontinence and in those who had encopresis, anal resting pressures were not affected by biofeedback therapy. Furthermore, the anal resting pressure in children who had fecal incontinence was significantly lower than that in children who had encopresis. However, anorectal manometry showed that the biofeedback therapy improved voluntary sphincter function and rectal sensation in both groups. Conclusion: Biofeedback therapy appears to be effective in most children who have encopresis whose sphincter function is intact, and in some children who have fecal incontinence after surgery for anorectal malformations.

The multifactorial nature of functional constipation in children suggests that a multidisciplinary management approach may be effective. The authors tested this hypothesis in a newly created pediatric Bowel Management Clinic (BMC). Detailed data were collected prospectively on all patients seen in the clinic over the first 16 months. Both quantitative and qualitative analyses were performed to describe the index population and to demonstrate the impact of the intervention. Satisfaction with care in the clinic was measured using the Measure of Processes of Care tool, then compared with a normative sample. One hundred fourteen patients, all previously treated unsuccessfully for constipation, were referred to a team comprised of a physician, nurse practitioner, nurse educator, dietitian, and psychosocial nurse specialist. The mean age was 5.4 years with equal gender distribution. Between the first and last visits recorded, several variables including stool consistency and frequency, soiling frequency, abdominal pain, rectal pain, and rectal bleeding all showed statistically significant (P.05) improvement. Qualitative data analysis showed the significant psychosocial impact of constipation on patients and their families. In the Measures of Processes of Care questionnaire, scores for the BMC were higher than normal on all scales except in provision of information. A multidisciplinary approach to functional constipation leads to both patient and parent satisfaction and significant short-term improvement. Further studies will examine the long-term impact of the clinic.

The purpose of this paper is threefold: (a) to report an unusually high prevalence of encopresis in a sample of boys in psychiatric residential treatment; (b) to explore the possible relationship of sexual abuse to the development of encopresis in these cases; and (c) to discuss the diagnostic and treatment implications of our findings.

Children with mental retardation often present urinary incontinence because they are unable to control micturition. Constipation and/or encopresis are often associated. Careful assessment of the upper urinary tract and renal function is indicated. Urinary infections are frequent, however, bladder dysfunction complications of the upper urinary tract are uncommon. The cause of wetting could be explained by urodynamic findings: small capacity bladder with uninhibited contractions, hypertonic sphincter, or incomplete emptying secondary to detrusor-sphincter dyssynergia. Treatment of urinary incontinence should be adapted to the type of incontinence and be apart of the global training.

Constipation in childhood is common, accounting for 3% of general paediatric referrals and up to 25% of referrals to paediatric gastroenterology centres. Although common, it is a poorly understood condition and often responds poorly to treatment. Unfortunately there is no standard definition of constipation which is generally taken to mean a decreased frequency, harder consistency, and subjective difficulty in passing a bowel movement. The term soiling refers to involuntary seepage of faeces and implies overflow incontinence associated with faecal impaction. Encopresis implies the voluntary or involuntary passage of an ordinary bowel movement into the clothing or other abnormal place after the age of 4 years and occurring on a regular basis without any organic cause. In the great majority of cases of constipation no organic cause can be demonstrated (see Table 1). It is important to realise that primary psychological problems are not more common in children with constipation than in the general population; in one large study only 20% of patients had any identifiable psychological problems whatsoever. 1 Similarly, most recent studies indicate that there is no evidence to suggest a primary psychological problem even in encopretic children. 1-3

Background & Aims: Rectal sensations to balloon distention are impaired in children with chronic constipation and encopresis. The impairment of rectal sensation, which is often persistent and is related to nonrecovery, could be caused by a defect in the visceral afferent pathways. The aim of this study was to test whether the afferent pathway from the rectum is impaired in children with constipation and encopresis. Methods: Fifteen healthy children and 15 children with constipation and encopresis were studied. Cerebral evoked potentials (EPs) were studied by averaging results of 100 rectal distentions, which used 10, 20, and 30 mL air. EPs were recorded from Cz′ to Fz. Results: Two different types of EPs were recorded in each control subject and each child with constipation and encopresis. One EP had an early onset and showed multiple positive and negative peaks. The other EP had a much later onset and was triphasic. Early-onset EPs were recorded with significantly smaller distention volumes than the late-onset EPs. N1 and P2 latencies of the early-onset EPs and NI, PI, and NII latencies of the late-onset EPs were significantly prolonged in children with constipation and encopresis compared with controls. Conclusions: The prolonged latencies suggest a defect in the afferent pathway from the rectum in children with chronic constipation and encopresis.

Chronic functional constipation is common in childhood. Basic understanding of the defecation process is essential to formulate a rational diagnostic and therapeutic approach to pediatric patients with chronic constipation, with or without encopresis. Primary care physicians can perform a major preventive function by anticipatory guidance and early dietary intervention. Most patients referred to pediatric gastroenterologists can be effectively treated as outpatients with use of an approach consisting of colonic evacuation, stool softeners, dietary manipulations, bowel training, and behavioral management. Avoidance of painful (laxatives) and invasive (suppositories, enemas) modalities is an important part of successful management. Further evaluation, including manometric tests, are reserved for patients with a history or physical findings suggesting an underlying disorder predisposing the patient to difficulty with defecation. Biofeedback therapy is likely destined to play a role in the subgroup who respond poorly to traditional therapeutic methods.