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Purpose Malone antegrade continence enema has been a successful and widely used procedure for achieving fecal continence in children. We present data on the previously uninvestigated issue of patient and caregiver regret following surgery for intractable constipation and fecal incontinence. Materials and Methods We reviewed all patients undergoing antegrade continence enema or cecostomy creation at a single institution between 2006 and 2016. Patients and caregivers were assessed for decisional regret using the Decisional Regret Scale. Results were correlated with demographics, surgical outcomes and complications. Results A total of 81 responses (49 caregivers and 32 patients) were obtained. Mean followup was 49 months. Decisional regret was noted in 43 subjects (53%), including mild regret in 38 (47%) and moderate to severe regret in 5 (6%). No statistical difference in regret was noted based on gender, complications or performance of concomitant procedures. On regression analysis incontinence was strongly associated with decisional regret (OR 4.4, 95% CI 1.1–18.1, p <0.001) and regret increased as age at surgery increased, particularly when patients were operated on at age 13 to 15 years (OR 2.6, 95% CI 1.0–6.4 for age 13 years; OR 2.9, 95% CI 1.1–7.8 for age 14 years; OR 3.1, 95% CI 1.1–8.8 for age 15 years). Conclusions This is the first known study describing decisional regret following surgery for fecal incontinence. Surgical factors aimed at achieving continence may be effective in decreasing postoperative regret. The finding of increased regret in teenage patients compared to younger children should be shared with families since it may impact the age at which surgery is pursued. [ABSTRACT FROM AUTHOR]

Purpose: We assessed the prevalence of functional defecation disorders, such as functional constipation and functional nonretentive fecal incontinence, in children referred to a tertiary pediatric urology outpatient clinic for lower urinary tract symptoms. Materials and Methods: We reviewed the charts of 4 to 17-year-old patients evaluated due to lower urinary tract symptoms. All patients received a standardized bowel questionnaire and physical examination. We assessed the prevalence of pediatric functional defecation disorders according to Rome III criteria. Transabdominal ultrasound was performed to measure rectal diameter with a diameter of greater than 3 cm considered to indicate a rectal fecal mass. Results: We analyzed the records of 113 patients, including 50 boys, with a median age of 8 years (IQR 6–10) who had lower urinary tract symptoms. Of the patients 46 had dysfunctional voiding and 38 had urge incontinence/overactive bladder. Rome III criteria for functional constipation and functional nonretentive fecal incontinence were fulfilled by 47% and 11% of patients with lower urinary tract symptoms, respectively. Children with dysfunctional voiding were more likely to fulfill the criteria for functional constipation than those with urge incontinence and other urological disorders (63% vs 42% and 28%, respectively, p = 0.009). Children with urge incontinence more likely fulfilled the criteria for functional nonretentive fecal incontinence than those with dysfunctional voiding and other urological disorders (21% vs 2.2% and 10%, respectively, p = 0.02). Conclusions: More than 50% of children with lower urinary tract symptoms evaluated at a tertiary referral center fulfilled the diagnostic criteria for functional defecation disorders. We recommend evaluating bowel habits as part of the initial assessment of a child who presents with urological symptoms. Future studies of the effect on urological symptoms of treating functional defecation disorders are justified. [Copyright &y& Elsevier]

Purpose: Attention deficit/hyperactivity disorder is a common comorbid disorder in children with nocturnal enuresis, daytime urinary incontinence and fecal incontinence. We assessed the specific association of these conditions in a population based sample. We hypothesized that children with elimination disorders have a higher rate of attention deficit/hyperactivity disorder, and that children with daytime urinary incontinence are more strongly affected than those with nocturnal enuresis. Materials and Methods: All children in a defined geographic area (Saarpfalz Kreis) were examined at school entry. Mean age was 6.22 years in 734 boys and 6.18 years in 645 girls. A questionnaire regarding elimination problems and the attention problems scale of the Child Behavior Checklist were administered as an interview to parents. Participation rate was 99.1% (1,379 parents). Results: Of the children 71 (5.1%) had attention deficit/hyperactivity disorder problems of clinical relevance (7.1% of boys and 2.9% of girls). A total of 185 children (13.4%) were wet (nocturnal enuresis in 9.1% and daytime urinary incontinence in 4.4%) and 19 (1.4%) had fecal incontinence. Attention deficit/hyperactivity disorder symptoms were more common in children with urinary incontinence than nonwetting children (16.8% vs 3.4%). When controlled for confounding variables, only children with daytime urinary incontinence (but not nocturnal enuresis) had a significantly higher risk of attention deficit/hyperactivity disorder symptoms (OR 4.4). Conclusions: Attention deficit/hyperactivity disorder symptoms were increased in children with urinary incontinence in this population based sample. Children with daytime urinary incontinence were at greater risk for attention deficit/hyperactivity disorder than those with nocturnal enuresis. Screening and referral for specialized treatment of both disorders are recommended. [ABSTRACT FROM AUTHOR]

Purpose: The clinical benefit of sacral neuromodulation is unclear due to the paucity of randomized trial data. The purpose of this study was to evaluate sacral neuromodulation for management of urinary and fecal incontinence in a pediatric population. Materials and Methods: This multicenter, open label, randomized, crossover study included children older than 5 years. After trial stimulation of the S3 root a neuromodulator (InterStim®) was implanted on the S3 foramen. Clinical examinations, voiding and bowel diaries, and urodynamic and manometric evaluations were performed at the beginning (t1) and end (t2) of the first period, and at the beginning (t3) and end (t4) of the second period. Results: A total of 33 patients (24 boys) with a mean ± SD age of 12.22 ± 5.09 years were randomized. Etiologies were mainly of neurological origin. Incontinence was mixed urinary and fecal in 19 cases, urinary only in 9 and fecal only in 5. Cystometric bladder capacity increased during sacral neuromodulation (delta +24.27 ml vs −37.45 ml, p = 0.01). There was no significant change in other urodynamic or manometric parameters. Overall positive response rate was more than 75% for urinary (81%) and bowel (78%) function. Crossover analysis indicated that sacral neuromodulation is more effective than conservative treatment for both types of incontinence (p = 0.001). Conclusions: In a pediatric population sacral neuromodulation is effective for bladder and bowel dysfunction and should be considered before irreversible surgery. [Copyright &y& Elsevier]

Purpose: Dysfunctional elimination syndrome is a heterogeneous syndrome with no widely accepted diagnostic criteria. Previously developed questionnaires provide incomplete psychometric assessment. We developed a discriminative questionnaire for diagnosing dysfunctional elimination syndrome and assessed its validity and reliability. Materials and Methods: A 14-item 5-point Likert scale questionnaire was devised using literature review, expert opinions and patient input. The questionnaire was administered to 62 children 4 to 16 years old (median age 8) clinically diagnosed with dysfunctional elimination syndrome by a pediatric urologist, of whom 71% were female. It was also administered to 50 healthy controls 4 to 16 years old (median age 7), of whom 66% were female. Children with structural abnormalities were excluded from study. To assess reliability 50 participants were asked to complete the questionnaire again 1 week later. Results: Median total score in cases and controls was 14 of 52 (range 4 to 30) and 6 of 52 (range 1 to 13), respectively. The difference was statistically significant (p = 0.001). Discriminant function analysis showed 80% accuracy. ROC curve showed a score of 11 as the optimum threshold with an AUC of 0.903 (95% CI 0.814–0.948). Test-retest reliability was 84.5% (p = 0.001). Factor analysis showed unloading on 4 factors, corresponding to urinary incontinence, urgency, obstructive symptoms and constipation/fecal soiling. Of participants 85% classified the questionnaire as very easy or easy to complete. Conclusions: This new questionnaire is valid and reliable for diagnosing dysfunctional elimination syndrome. It can be used as a clinical or research instrument. [Copyright &y& Elsevier]

Purpose: We report the long-term outcome of the Malone antegrade continence enema procedure in the treatment of chronic constipation and fecal incontinence in children with neuropathic bowel. Materials and Methods: We performed a retrospective chart review of 256 Malone antegrade continence enema procedures. Patient age at surgery, bowel segment used, location of stoma, number and type of revisions required, and fecal continence were documented and a database was created. Results: A total of 236 patients with at least 6 months of followup are included in this report. There were 172 in situ appendicocecostomies, 23 split appendix channels, 9 appendicocecostomies with cecal extension, 22 Yang-Monti ileocecostomies and 10 colon flap channels performed. A total of 112 males (47%) and 124 females (53%) were included in the study. Median patient age at surgery was 9 years (range 2 to 36) and median followup for the entire cohort was 50 months (6 to 115). A total of 56 surgical revisions were performed in 39 patients (17%). Median time to first revision was 9.5 months (range 1 to 105). Stomal stenosis occurred in 32 patients (14%). Overall, surgical revisions were required in 14% of in situ appendix channels (24 of 172), 22% of split appendix channels (5 of 23), 33% of appendix channels with cecal extension (3 of 9), 18% of Yang-Monti Malone antegrade continence enema channels (4 of 22) and 30% of colon flap channels (3 of 10). Independent of channel technique, surgical revisions were required in 15% of umbilical stomas and 18% of lower quadrant stomas (p = 0.516). Two patients had minimal stomal leakage, and 94% (221 of 236) achieved fecal continence with irrigations. Conclusions: The long-term results of the Malone antegrade continence enema channel in a large cohort of patients with neuropathic bowel and chronic constipation are encouraging. Of the patients 17% will require revision surgery, and patients/parents should be counseled accordingly. In our series in situ appendicocecostomy had the lowest revision rate on long-term followup, although the difference was not statistically significant (p = 0.226). [Copyright &y& Elsevier]