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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.

Avoidant restrictive food intake disorder (ARFID) was recently characterized, according to the DSM-5 classification, as a feeding and eating disorder (FED). However, ARFID remains poorly known by most pediatricians, but also by psychiatrists and primary care professionals. Despite the fact that patients with ARFID generally have a higher BMI than patients with anorexia nervosa, our purpose was to highlight the fact that they may present severe nutritional deficiencies and major somatic complications when the diagnosis is delayed. We describe here a case of a 16-year-old boy who presented with severe undernutrition (BMI = 11.5) leading to Ogilvie’s syndrome, which resolved with enteral refeeding. Because of undernutrition, very bad dental condition, and encopresis, some physicians wrongly suspected child neglect, but retrospective analysis of his personal history revealed a long-term FED and sensory specificities that led to the final diagnosis of an ARFID–autism spectrum disorder (ASD) association. A literature review was conducted on the ARFID somatic complications. The training of health professionals in the clinical forms of pediatric FED, including ARFID, is necessary, to promote early diagnosis and prevent poor nutritional outcomes. In this case the association of ARFID–ASD and the delay in access to specialized care favored by the disadvantaged social environment led to severe gastrointestinal complications. V, descriptive study.

Several reports suggest a possible link between child abuse and enuresis or encopresis but concern small series of children and present therefore methodological biases. The objective of the present study was to clarify this issue by examining the relationships between child abuse and enuresis or encopresis in a large sample of children.A multicenter cross-sectional study was conducted on a sample of 428 children in social residential centers in France. Four types of child abuse were considered: sexual abuse, physical abuse, psychological abuse and neglect. The accuracy and reliability of the characterization of the type of abuse as well as that of the sphincter disorder was particularly high. In fact, all the cases benefited from both a social and a psychological investigation and from an observation in a residential center.More than 60% of the children were victims of at least one type of abuse. Encopresis was reported in 15 children (3.5% [95% CI: 2.0%-5.7%]), mostly among boys (13 cases). Enuresis affected 54 of the 390 children aged five years or more (13.8% [95% CI: 10.6%-17.7%]). Most of the cases also appeared in boys (38 cases). Rates of encopresis were found to be seven-fold higher in both psychologically abused and neglect children compared to non-abused children (P=0.01). Concerning enuresis, a weaker but still significant association was found with sexual (OR= 3.3, P=0.025) and physical abuse (OR=2.3, P=0.035).Our findings support the hypothesis that enuresis and encopresis are associated with specific types of child abuse.

Bladder and bowel dysfunction (BBD) is a common yet underdiagnosed paediatric entity that describes lower urinary tract symptoms (LUTS) accompanied by abnormal bowel patterns manifested as constipation and/or encopresis. LUTS usually manifest as urgency, urinary frequency, incontinence, and urinary tract infections (UTI). Despite increasing recognition of BBD as a risk factor for long-term urinary tract problems including recurrent UTI, vesicoureteral reflux, and renal scarring, the mechanisms underlying BBD have been unclear, and treatment remains empirical. We investigated how constipation affects the lower urinary tract function using a juvenile murine model of functional constipation. Following four days of functional constipation, animals developed LUTS including urinary frequency and detrusor overactivity evaluated by awake cystometry. Physiological examination of detrusor function in vitro using isolated bladder strips, demonstrated a significant increase in spontaneous contractions without affecting contractile force in response to electrical field stimulation, carbachol, and KCl. A significant upregulation of serotonin receptors, Htr2a and Htr2c, was observed in the bladders from mice with constipation, paralleled with augmented spontaneous contractions after pre-incubation of the bladder strips with 0.5 µM of serotonin. These results suggest that constipation induced detrusor overactivity and increased excitatory serotonin receptor activation in the urinary bladder, which contributes to the development of BBD.

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.

Purpose To describe the implementation and effectiveness of a multimodal therapeutic approach used to successfully treat a child with encopresis. Summary of key points The child demonstrated chronic constipation, poor pelvic floor muscle awareness, weakness, and incoordination during voiding. He participated in 8 sessions of physical therapy intervention including pelvic floor muscle awareness, strengthening and coordination exercises, behavioral adaptations, diet modification, and use of media, art, and interactive visualization activities. Conclusions The child improved pelvic floor muscle strength and coordination and became fully continent of bowel in home and community settings. What this case adds to evidence-based practice This case report demonstrates that pediatric age-appropriate educational and motivational tools (media, art, and interactive visualization activities) are readily available, economical, and effective when used in conjunction with current practice to decrease impairments and improve active participation and compliance during treatment of retentive encopresis in the pediatric population.

Autism spectrum disorders (ASD) are defined by persistent deficits in reciprocal social interaction, communication, and language, as well as stereotyped and repetitive behavior. Functional incontinence, as well as ASD are common disorders in childhood. The aim of this systematic review was to give an overview of the co-occurrence of nocturnal enuresis (NE), daytime urinary incontinence (DUI), and fecal incontinence (FI) in ASD, and vice versa, of ASD in children with incontinence. A systematic literature search of the terms “incontinence”, “enuresis”, and “encopresis” in combination with “autism” or “Asperger” in four databases (Scopus, PubMed, PsycInfo and Web of science) was conducted. All studies that examined incontinence frequencies in samples with ASD, and studies that measured frequencies of ASD diagnoses or symptoms in samples with incontinence were included. Risk of bias and limitations of each study were described. After eligibility assessment, 33 publications were included in the review. The published literature implies a higher prevalence of incontinence in children with ASD compared to typically developing children. Limitations and biases as inappropriate diagnostic criteria for ASD and incontinence, selected samples, or lack of control groups are reported. Associations of incontinence in ASD with psychopathological symptoms were found. Vice versa, ASD symptoms are found in incontinent children, but no study included a non-ASD control sample. Incontinence symptoms are also reported as an adverse effect of medication in ASD. Due to methodological problems and definitional discrepancies in some publications, results have to be interpreted cautiously. Research in ASD and incontinence is scarce. More systematic research including state-of-the-art assessments is needed.

Aims Tuberous sclerosis complex (TSC) is a multisystem genetic disorder caused by a mutation in the TSC1 or TSC2 gene with a broad spectrum of physical and psychological manifestations. The aim of the study was to examine incontinence, psychological problems, and adaptive behavior skills in patients with TSC. Methods Through a worldwide TSC support group, 26 children (4-17 years) and 15 adults (18-50 years) with TSC were recruited (38.1% male, mean age 16.4 years). Parents or care-givers completed the Developmental Behavior Checklist (DBC), the Parental Questionnaire: Enuresis/urinary Incontinence, and the Vineland Adaptive Behavior Scales (3rd edition). Results A total of 60.0% of the participants had nocturnal enuresis (NE), 51.3% daytime urinary incontinence (DUI) and 52.4% fecal incontinence (FI). 65.4% of children and 50.0% of adults had a clinically relevant DBC score. Psychological symptoms were associated with at least one subtype of incontinence. The mean adaptive behavior composite (ABC) score of the patients was 57.2 (SD = 26.1), with 38.1% in the average or below-average range (IQ >70), 26.2% with a mild, 11.9% with a moderate and 23.8% with a severe/profound intellectual disability. The incontinence rate was significantly higher in the groups with a lower ABC score. Conclusion A substantial proportion of patients with TSC are affected by incontinence and psychological symptoms. Incontinence was higher in persons with lower adaptive skills and those with at least one type of incontinence showed a significantly higher DBC score. As incontinence and psychological problems affect daily functioning and well-being, assessment, and treatment are recommended.

Enuresis and encopresis can be stressful for children and parents. We investigated the comorbid psychiatric disorders and the emotional and behavioral symptoms associated with elimination disorders. A total of 97 children and adolescents (aged 4-17 years) with an elimination disorder participated in this study. The elimination disorder group consisted of three subgroups: 50 subjects with enuresis nocturna, 26 with encopresis, and 21 subjects with enuresis+encopresis. The control group with no elimination disorder comprised 50 healthy subjects. All children were interviewed by a child and adolescent psychiatrist. Comorbid psychiatric disorders were assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL). Parents completed the Strengths and Difficulties Questionnaire. The most common diagnosis was attention-deficit/hyperactivity disorder, followed by oppositional defiant disorder. The highest rate of psychiatric comorbidity was observed in the enuresis+encopresis subgroup, followed by the enuresis nocturna and encopresis subgroups. All the subgroups had higher total difficulties scores than the control group. Screening for psychiatric disorders should be performed for all children with incontinence.

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.

With increasing numbers of children being diagnosed with neurodevelopmental disorders (NDDs) attention has been drawn to these children’s physical health. We aimed to identify the prevalence of defined physical problems (epilepsy, migraine, asthma, cancer, diabetes, psoriasis, lactose intolerance, celiac disease, diarrhea, constipation, daytime enuresis, encopresis) in a nationwide population of 9- and 12-year-old twins subdivided into those with and without indications of NDDs. Parents of 28,058 twins participated in a well-validated telephone interview regarding their children’s mental health and answered questions about their physical problems. The results indicate a high rate of physical problems in children with NDDs, particularly in those with indications of the presence of combinations of several NDDs. Electronic supplementary material The online version of this article (10.1007/s10803-018-3697-4) contains supplementary material, which is available to authorized users.

Background The role of endoscopic ultrasound (EUS) in the management of pancreatobiliary and digestive diseases is well established in adults, but it remains limited in children. The aim of this study was to evaluate the feasibility, safety, and clinical impact of EUS use in children. Methods This is a retrospective analysis of a prospectively acquired database of consecutive pediatric (< 18 years) patients presenting an indication for EUS for pancreatobiliary and gastrointestinal disorders. Results Between January 2010 and January 2016, 47 procedures were performed in 40 children (mean age of 15.1 ± 4.7 years; range 3–18). The majority of EUS (n = 32; 68.1%) were performed for pancreatobiliary and upper gastrointestinal pathologies, including suspected common bile duct stones (CBDs), acute biliary pancreatitis, recurrent/chronic pancreatitis, cystic pancreatic mass, recurrent hypoglycemia, duodenal polyp, gastric submucosal lesion, and perigastric abscess. In only 2 out of 18 children with suspected CBDs or acute biliary pancreatitis, EUS confirmed CBDs. EUS-guided fine needle aspiration was performed in 3 (6.4%) patients. Fifteen (31.9%) procedures were performed for lower gastrointestinal tract disorders, including suspected anal Crohn’s disease, fecal incontinence, and encopresis. Overall, EUS had a significant impact on the subsequent clinical management in 87.2% of patients. Conclusion The present findings were consistent with results observed in the current relevant literature and support EUS as a safe and feasible diagnostic and therapeutic tool, which yields a significant clinical impact in children with pancreatobiliary and gastrointestinal disorders.

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.

We evaluated whether an animated bladder training video was as effective as standard individual urotherapy in improving bladder/bowel symptoms.Patients 5 to 10 years old who scored greater than 11 on the bladder/bowel Vancouver questionnaire were included in a noninferiority randomized, controlled trial. Children with vesicoureteral reflux, neuropathic bladder, learning disabilities, recent urotherapy or primary nocturnal enuresis were excluded from analysis. Patients were randomly assigned to receive standard urotherapy or watch a bladder training video in clinic using centralized blocked randomization schemes. Bladder/bowel symptoms were evaluated at baseline and 3-month followup by intent to treat analysis. A sample size of 150 patients ensured a 3.5 difference in mean symptomology scores between the groups, which was accepted as the noninferiority margin.Of 539 screened patients 173 (37%) were eligible for study and 150 enrolled. A total of 143 patients (95%) completed the trial, 5 (4%) were lost to followup and 2 (1%) withdrew. Baseline characteristics were similar between the groups. Baseline mean ± SD symptomology scores were 19.9 ± 5.5 for the bladder training video and 19.7 ± 6.0 for standard urotherapy. At 3 months the mean symptomology scores for the bladder training video and standard urotherapy were reduced to 14.4 ± 6.5 and 13.8 ± 6.0, respectively (p = 0.54). The mean difference was 0.6 (95% CI -1.4-2.6). The upper 95% CI limit of 2.6 did not exceed the preset 3.5 noninferiority margin.The bladder training video was not inferior to standard urotherapy in reducing bladder/bowel symptoms in children 5 to 10 years old. The video allows families to have free access to independently review bladder training concepts as often as necessary.

CASE: Paul is an 8-year-old boy with a long-standing history of encopresis and enuresis. Potty training was initiated when he was 21/2 years old. At this time, his mother was absent from the home for 6 weeks when she cared for her ill father in a different city. The process of teaching Paul to use the bathroom was described as "inconsistent" due to multiple caretakers. Paul never successfully mastered bowel and bladder control. He continues to wet and soil his clothes on a daily basis at home and school. According to his parents, he does not accept responsibility and comments about his soiling such as, "I didn't do it; someone else must have put it there." One of Paul's teachers commented that she could tell at the beginning of the school day whether he would maintain bowel and bladder control. If he was "agitated and talkative" in the early morning, he would often soil that day. He had a pediatric gastroenterological evaluation at the age of 5 years when he was having daily episodes of stool soiling. Physical examination revealed normal anal tone, normal placement of the anus, and moderate stool in the rectal vault. An abdominal radiograph revealed moderate stool throughout the colon. He was treated with Miralax and instructed to sit on the toilet twice daily. Paul did not respond to these interventions and was diagnosed with "overflow incontinence secondary to stool withholding." When he was taking Miralax, he had a normal barium enema radiograph. He was admitted to the hospital for a cleanout with a polyethylene glycol/electrolyte solution. Although abdominal radiographs demonstrated absence of colonic stool for the following 5 months, he continued to soil his clothing. Play therapy and biofeedback did not change the chronic soiling and wetting pattern. An evaluation at the Continence Clinic resulted in a rigorous program including stooling after each meal, wearing a vibrating watch reminding him to void every 2 hours, drinking 60 ounces of water per day, tracking elimination patterns on a calendar, and a daily laxative (polyethylene glycol). A neuropsychological evaluation revealed a superior aptitude associated with unresolved early childhood issues of self-control, self-care, and frustration tolerance. Family therapy was initiated. However, daily fecal soiling and wetting persisted. Paul was born full-term without prenatal or perinatal complications. He was breast fed for 1 year and described as an easy baby. He achieved motor, social, and language milestone on time. Paul had difficulty with separation and aggression in preschool (e. g., biting). In school, teachers report inattention, fidgetiness, and difficulty following directions. He has been obese since age 3 years; his current body mass index is 29

Objectives The aim of the study was to examine the prevalence of diagnosis and treatment for constipation among children receiving Medicaid and to compare healthcare utilization and spending for constipation among children based on number of complex chronic conditions (CCCs). Methods Retrospective cohort study of 4.9 million children ages 1 to 17 years enrolled in Medicaid from 2009 to 2011 in 10 states in the Truven Marketscan Database. Constipation was identified using International Classification of Disease, 9th revision codes for constipation (564.0x), intestinal impaction (560.3x), or encopresis (307.7). Outpatient and inpatient utilization and spending for constipation were assessed. CCC status was identified using validated methodology. Results A total of 267,188 children (5.4%) were diagnosed with constipation. Total constipation spending was $79.5 million. Outpatient constipation spending was $66.8 million (84.1%) during 406,814 visits, mean spending $120/visit. Among children with constipation, 1363 (0.5%) received inpatient treatment, accounting for $12.2 million (15.4%) of constipation spending, mean spending $7815/hospitalization. Of children hospitalized for constipation, 552 (40.5%) did not have an outpatient visit for constipation before admission. Approximately 6.8% of children in the study had ≥1 CCC; these children accounted for 33.5% of total constipation spending, 70.3% of inpatient constipation spending, and 19.8% of emergency department constipation spending. Constipation prevalence was 11.0% for children with 1 CCC, 16.6% with 2 CCCs, and 27.1% with ≥3 CCCs. Conclusions Although the majority of pediatric constipation treatment occurs in the outpatient setting, inpatient care accounts for a sizable percentage of spending. Children with CCCs have a higher prevalence of constipation and account for a disproportionate amount of constipation healthcare utilization and spending.

Children with autism spectrum disorder (ASD) are often delayed in achieving bowel continence, resulting in negative outcomes. In this pilot trial, 20 children with ASD and encopresis were randomly assigned to multidisciplinary intervention for encopresis (MIE; n = 10) or a waitlist control group (n = 10). The MIE group was treated for constipation and received a 10-day behavioral intervention that utilized suppositories to produce predictable bowel movements that were reinforced. Caregivers were trained to implement the intervention. Results support the feasibility of clinical trials of MIE, with high enrolment, competition, attendance, and caregiver acceptability. Preliminary outcomes were positive, with six of 10 in the MIE group achieving continence by the end of treatment compared to 0 in the control group (p = 0.005).Registered at clinicaltrials.gov (https://clinicaltrials.gov); ID: NCT02383732.

Background Opioid use is a significant national crisis impacting individuals struggling with addiction and their families. The majority of individuals who abuse opioids are of child-rearing age, and critical knowledge gaps remain regarding how this abuse impacts their offspring. Fortunately, treatment for opioid use disorders is available. The primary goal of this study was to evaluate both physical and psychiatric diagnoses of children who have at least 1 parent participating in a buprenorphine-assisted treatment program. Methods This retrospective study is based on chart review (January 1, 2010, through June 30, 2018). Children with parents receiving care in a buprenorphine clinic were identified and matched on sex, race, and age in a ratio of 1:5 with controls from the general pediatric clinic population. Data related to health outcomes were extracted from the medical records. Results Compared to controls (n = 120), children of parents receiving buprenorphine-assisted treatment (n = 24) were more likely to have been born premature (odds ratio [OR] = 3.3, P = .035), had jaundice after birth (OR = 2.7, P = .034), had enuresis/encopresis (P < .001), and had been the victims of abuse or neglect (OR = 19.7, P = .0005). Children of parents with opioid use disorders were also more likely to utilize emergency services (ie, being seen in the emergency department for fussiness; OR = 4.0, P = .046) and were less likely to be covered by private insurance compared to state-funded insurance (OR = 0.2, P = .0013). Conclusions Parental opioid use disorder impacts children. More research is needed to better describe long-term effects of treatment of parental opioid use on their offspring and to help design addiction treatment programs to support whole family units.

Objective: Evaluate clinical aspects associated with the presence of nocturnal enuresis (NE) in children with a diagnosis of overactive bladder (OAB). Material and Methods: A data base of 200 children who were evaluated by a structured questionnaire was analysed retrospectively . OAB was defined as the presence of urinary urgency (n=183 cases) and/or daytime urinary incontinence associated with holding maneuvers (n=168 cases). Inclusion criteria were a confirmed diagnosis of OAB, age 5-16 years, and no anatomical or neurological alterations of the urinary tract. Patients were divided into enuretics and non-enuretics. The two groups were compared with respect to sex, age, skin color, presence urinary infection, urgency, urge incontinence, non-urge incontinence, pollakiuria, urinary dysfunction, nocturia, holding maneuvers, number of episodes of enuresis and bowel alterations. In a univariate analysis, the chi-square test was used to compare proportions, with p-values

The aim of the present study was to study the effect of octreotide on colonic motility in pediatric patients with recalcitrant chronic constipation/encopresis and other suspected colonic motility disorders.This was a nonrandomized, single-center, open-label, prospective study evaluating the effect of a single subcutaneous dose of octreotide on colonic motility.Thirteen patients (5 boys) were enrolled in the study. The age range was 4.6 to 16.2 years. Eleven patients (84%) had normal colonic manometry and 2 patients (16%) had colonic neuropathy. Motility Index (MI) (mmHg) for the 15 minutes before and after octreotide infusion was 6.03 ± 1.26 (95% confidence interval [CI] 5.35-6.72) and 5.32 ± 1.66 (95% CI 4.42-6.23), respectively, with P value of 0.08. MI for the 30 minutes before and after octreotide infusion was 6.89 ± 1.37 (95% CI 6.14-7.64) and 6.71 ± 1.47 (95% CI 5.91-7.52), respectively, with P value of 0.55. MI for the 45 minutes before and after octreotide infusion was 7.73 ± 1.32 (95% CI 7.01-8.45) and 7.53 ± 1.38 (95% CI 6.78-8.28), respectively, with P value of 0.8.Our study showed that the administration of octreotide resulted in no significant changes in colonic MI in pediatric patients with chronic recalcitrant constipation.

Severe constipation and encopresis are significant problems in the pediatric population. Medical management succeeds in 50–70%; however, surgical considerations are necessary for the remainder such as the antegrade continence enema (ACE). The purpose of this study is to assess the long-term outcomes following the ACE procedure. All patients undergoing an ACE over a 14-year period were included. Data on clinical conditions, treatments, and outcomes were collected. A successful outcome was defined as remaining clean with ≤ 1 accident per week. Comparative data were analyzed using the Fisher’s exact test, Mann–Whitney U test, or Student’s t test. There were 42 ACE patients, and overall, 79% had improvement in their bowel regimens. Encopresis rates decreased from 79 to 5% (P

Results of examination and treatment of 12 children, operated on in various clinics for Hirschprung’s disease, in whom chronic constipation and other signs of anorectal dysfunction have occurred, were analyzed. In 8 patients Duhamel-Bairov operation was conducted, in 2 – Soave-Lenyushkin operation, and in 2 – Soave-Boley operation. The main cause of postoperative chronic constipation occurrence after Duhamel operation is the colorectal septum preservation. The only one radical method of treatment of this complication is a transanal removal of colorectal septum. The cause of anastomotic narrowing after Soave-Boley operation was absence of myotomy intraoperatively and of bougienage – after it. Elimination of chronic constipation in such patients, using long-standing bougienage and complex conservative treatment. The main cause of chronic constipation and nocturnal encopresis after Soave-Lenyushkin operation was preservation of the tissue excess while doing resection of a large bowel stump and creation of the narrowed ring, looking like a pendent plica. Complete reconvalescence of such patients is possible in transanal method of excision of stenosing ring and conduction of complex treatment.

Background The aim of this study was to determine the prevalence of neurological disorders and their associated correlates and relations with clinical and behavioural problems among children and adolescents with HIV/AIDS (CA-HIV). Methods This study involved a sample of 1070 CA-HIV/caregiver dyads who were evaluated at their 6-month follow-up visit as part of their participation in the longitudinal study, ‘Mental health among HIV infected CHildren and Adolescents in KAmpala and Masaka, Uganda (the CHAKA study)’. Participants completed an extensive battery of measures that included a standardized DSM-5- referenced rating scale, the parent version (5–18 years) of the Child and Adolescent Symptom Inventory-5 (CASI-5). Using logistic regression, we estimated the prevalence of neurological disorders and characterised their associations with negative clinical and behavioural factors. Results The overall prevalence of at least one neurological disorders was 18.5% (n = 198; 95% CI, 16.2–20.8). Enuresis / encopresis was the most common (10%), followed by motor/vocal tics (5.3%); probable epilepsy was the least prevalent (4%). Correlates associated with neurological disorders were in two domains: socio-demographic factors (age, ethnicity and staying in rural areas) and HIV-related factors (baseline viral load suppression). Enuresis/encopresis was associated with psychiatric comorbidity. Neurological disorders were associated with earlier onset of sexual intercourse (adjusted OR 4.06, 95% CI 1.26–13.1, P = 0.02). Conclusions Neurological disorders impact lives of many children and adolescents with HIV/AIDS. There is an urgent need to integrate the delivery of mental and neurological health services into routine clinical care for children and adolescents with HIV/AIDS in sub-Saharan Africa. Electronic supplementary material The online version of this article (10.1186/s12888-019-2023-9) contains supplementary material, which is available to authorized users.

Sexual victimisation is an important problem that affects millions of people around the world, especially those with some kind of disability. The aim of this study was to determine the prevalence of self-reported and documented sexual abuse in people with mild or moderate intellectual disability and to analyse the sequelae that such experiences can have on their psychosocial health.The sample consisted of 360 adults (50% men and 50% women) between 18 and 55 years of age (M = 39.87; standard deviation = 10.55).The prevalence of sexual abuse is 6.10% when it is self-reported (9.4% in women and 2.8% in men) and 28.6% when it is reported by professionals (27.8% in women and 29.4% in men). People who self-report cases of abuse present poorer quality of life, more negative attitudes towards sex and a lower capacity to identify situations that entail a risk of sexual abuse. Individuals who have suffered documented cases of abuse are more likely to present encopresis, social isolation, self-harm and a higher number of suicide attempts.Our results evidence the need to have access to all sources of information so as to be able to obtain prevalence figures that match the real situation and to perform a proper analysis of the sequelae.

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.

Background There are various language adaptations of the Schedule for Affective Disorders and Schizophrenia for School Age Children Present and Lifetime Version (K-SADS-PL). In order to comply with the changes in DSM classification, the Spanish edition of the interview was in need of update and evaluation. Methods K-SADS-PL was adapted to correspond to DSM-5 categories. All clinicians received training, and a 90% agreement was reached. Patients and their parents or guardians were interviewed and videotaped, and the videos were exchanged between raters. Factor analysis was performed and inter-rater reliability was calculated only in the case of diagnoses in which there were more than five patients. Results A total of 74 subjects were included. The Factor Analysis yielded six factors (Depressive, Stress Hyperarousal, Disruptive Behavioral, Irritable Explosive, Obsessive Repetitive and Encopresis), representing 72% of the variance. Kappa values for inter-rater agreement were larger than 0.7 for over half of the disorders. Conclusions The factor structure of diagnoses, made with the instrument was found to correspond to the DSM-5 disorder organization. The instrument showed good construct validity and inter-rater reliability, which makes it a useful tool for clinical research studies in children and adolescents. Electronic supplementary material The online version of this article (10.1186/s12888-018-1773-0) contains supplementary material, which is available to authorized users.

Dexter is a 12-year-old boy who presents with his maternal grandmother for follow-up to primary care for secondary encopresis. Dexter presented, 18 months ago, with a 3-month history of secondary encopresis. At that time, a comprehensive assessment revealed functional constipation resulting in encopresis. Dexter's symptoms resolved with a combination of medication management and behavioral strategies; laxatives were discontinued 12 months ago.Dexter's grandmother reports that for the past 6 months, her grandson developed encopresis once again. However, she notes that, although Dexter had small-volume episodes of soiling in the past, he is now passing fully formed stools into his underwear. These episodes usually occur once a day, either at home or at school. Frustrated, Dexter's grandmother has transitioned him to adult diapers.Dexter denies hematochezia, pain, dysuria, hematuria, urinary incontinence, dietary changes, or weight loss. He passes soft stool in his underwear once daily without blood or pain. When interviewed alone, Dexter denies drug use, depression, or significant social stressors. Surprisingly, he seems unconcerned about depression, drugs and social stress, and frequently laughs when discussing them. His physical examination, including a rectal examination, is normal.Dexter's medical history is notable for attention-deficit hyperactivity disorder, treated with stimulant medication. He was toilet trained at 3 years without any difficulty. He lives with his grandmother, who is his legal guardian; his mother has chronic mental health problems and substance abuse. Dexter maintains regular contact with his mother and reports that their relationship is positive.Dexter's grandmother is extremely distressed by his current presentation and notably, Dexter is not. What would you do next?

The defecation disorders represents the 3% of consultations in pediatrics patients. Our goal was to demonstrate the effectiveness and efficiency of the reeducation of the defecation maneuver through home training in patients with encopresis and sphincter dyssynergia.Study of patients with fecal incontinence treated with home training at our center between 2014-2015. Anorectal manometry was performed and was valued defecation maneuver by expulsion of rectal probe with or without the ball. Daily sessions were performed using a Foley catheter (18-20Fr.) with progressive filling of the balloon, maximum 20cc. The response to the treatment was assessed in terms of episodes of soiling.Seven patients (6 males and 1 female) with a mean age of 9.7 years (range, 5-15) were included; two patients with anorectal malformation history, 1 Hirschsprung disease, 1 sacrococcygeal teratoma and 3 functional encopresis. Three patients had soiling episodes daily and 4 patients frequently. The mean basal pressure of anal channel was 32.34mmHg (range, 11.74-50.75) with negative defecation maneuver in 2 cases, deficient in 3 and dyssynergic in 2 patients. The mean time of biofeedback therapy to be asymptomatic was 5.14 months (range, 2-11), with a mean of 16.14 months (range, 3-24), with the 7 patients currently maintained clean.The present study suggests that re-education of defecation maneuver through home training, seems to be an effective and efficient therapy, achieving excellent results in medium term.Los trastornos de la defecación representan el 3% de las consultas en pediatría. Nuestro objetivo fue demostrar la eficacia y eficiencia de la reeducación en la maniobra defecatoria mediante el entrenamiento domiciliario en los pacientes con encopresis y disinergia esfinteriana.Estudio de los pacientes con encopresis tratados mediante entrenamiento domiciliario en nuestro centro entre 2014-2015. Se realizó manometría anorrectal y fue valorada la maniobra defecatoria mediante la expulsión o no de la sonda rectal con o sin balón. Se realizaron sesiones diarias de forma domiciliaria empleando una sonda de Foley (18-20 Fr.) con llenado progresivo del balón, máximo 20 cc. Se evaluó la respuesta al tratamiento en función de la presencia de manchado.Se incluyeron 7 pacientes (6 varones y 1 mujer) con edad media de 9.7 años (rango, 5-15); dos con antecedente de malformación anorrectal, una enfermedad de Hirschsprung, 1 teratoma sacrococcígeo y 3 encopresis funcionales. Tres pacientes presentaban manchado diario y 4 de forma frecuente. La media de presión basal del canal fue de 32,34 mmHg (rango, 11,74-50,75) con maniobra defecatoria negativa en 2 casos, deficiente en 3 y disinérgica en 2. La media de tiempo realizando el entrenamiento intestinal hasta lograr estar asintomáticos fue 5.14 meses (rango, 2-11), con un seguimiento medio de 16,14 meses (rango, 3-24), manteniéndose limpios actualmente los 7 pacientes.El presente estudio sugiere que la reeducación de la maniobra defecatoria mediante entrenamiento domiciliario parece ser una terapia eficaz y eficiente, logrando excelentes resultados a medio plazo.

Objective To identify the reasons why pediatric gastroenterologists obtain abdominal radiographs in the management of pediatric constipation. Study design This was a prospective study surveying providers regarding their rationale, interpretation, resultant change, and confidence in their management before and after obtaining KUBs in patients seen for suspected constipation. Demographics and clinical findings were obtained from medical records. Results A total of 24 providers were surveyed after 72 patient encounters. Reasons for obtaining an abdominal radiograph included evaluation of stool burden (70%), need for a clean out (35%), fecal impaction (27%), cause of abdominal pain (24%), demonstration of stool burden to families (14%), assessment of response to therapy (13%), or encopresis (10%). The plan was changed in 47.6% of cases based on radiographic findings. In cases in which a plan was outlined before obtaining the radiograph (69%), the initial plan was implemented on average in 52.5%. In cases with no plans before obtaining the radiograph, previously unconsidered plans were implemented in 8.7%. Provider confidence in the management plan increased from 2.4 ± 2.7 to 4.1 ± 1.8 (P Conclusion Abdominal radiographs commonly are obtained by pediatric gastroenterologists in the evaluation and management of constipation. The majority used it to make a diagnosis, and nearly one-half changed their management based on the imaging findings. Overall, they reported an improved confidence in their management plan, despite evidence that radiographic findings poorly correlate with clinical severity. This study highlights the need for further provider education regarding the recommendations delineated in existing constipation guidelines.

To determine the efficacy of physical therapy (PT) for fecal incontinence in children with pelvic floor dyssynergia (PFD).Retrospective chart review of children with PFD completing1 PT session for fecal incontinence at a quaternary children's hospital. The frequency of fecal incontinence (primary outcome), constipation-related medication use, number of bowel movements (in those with3 per week at baseline) and pelvic floor muscle (PFM) function were captured at baseline and at the final PT visit. Outcomes were categorized as excellent (complete continence), good (50% decrease in fecal incontinence frequency), fair (not worsening but50% fecal incontinence frequency decrease), and poor (more frequent fecal incontinence). Compliance with PT was determined by the percentage of attended PT appointments.Children included met the following primary outcomes: 27 (42.2%) excellent, 24 (37.5%) good, 11 (17.1%) fair, and 2 (3.1%) poor. Factors associated with an excellent or good outcome included improved PFM functioning and good (≥70% PT attendance) compliance. Children with a history of surgically corrected tethered spinal cord were more likely to have a fair outcome (P = .015). Use of constipation-related medications decreased (1.9 ± 0.7 vs 1.5 ± 0.9, P = .005). Weekly bowel movement frequency increased (1.6 ± 0.6 vs 6.4 ± 4.8, P .001) in those with infrequent bowel movements (n = 26) at baseline.Pelvic floor PT is effective in the majority of children with fecal incontinence related to PFD. Factors associated with PT efficacy include improved PFM functioning, good compliance with PT, and history of tethered cord.

The aim of our study was to find the reason of various forms of somatoform disorders (phobias, behavioral disorders, insomnia, tics, stuttering, enuresis, encopresis) in children and adolescents of various social status for diagnosis and treatment. We have examined 202 patients who referred to our clinic from 2012-2016. The age range was 2-18 years. After examination we have concluded the following recommendations: - to implement neuropsychological rehabilitation in order to stimulate mental development; - to work with speech therapist to improvement the speech; - to work individually with psychotherapist to improve the behavior; - to train the parent to manage the behavior at home; - to give the personal card containing information about exercises, games and puzzles to stimulate the development and in some cases to give individual educational program; - to give separate information to parents and in some cases to teachers of kindergartens and schools.

Chronic functional constipation with or without encopresis is a common problem in the pediatric population, and the prevalence of encopresis may be underestimated. The aim of this study was to assess the prevalence and risk factors for overflow incontinence in patients with chronic constipation seen at a pediatric gastroenterology consultation. A retrospective study of 270 files of patients seen between 1997 and 2012 was conducted, and a classification according to Rome III criteria was done. Among 145 (53.7%) boys and 125 (46.2%) girls, 117 had overflow incontinence (43.3%) - 41 (35%) girls and 76 (65%) boys. The first symptoms of chronic constipation appeared at a median age of 30 and 33 months in encopretic and 16 and 12 months in nonencopretic girls and boys, respectively. The first specialized consultation took place after a median disease duration of 26.5 and 24 months in encopretic and 16 and 9 months in nonencopretic girls and boys, respectively. A history of stool retention and the presence of scybala at examination, but not of pain at defecation or anal fissure, were associated with encopresis. The onset of chronic constipation after the age of 2 years, a longer disease duration, male gender, and a history of stool retention were seen as risk factors for the development of encopresis in patients with chronic functional constipation.

The aim of this prospective study was to evaluate the functional outcome of transanal surgery in male patients suffering from fecal incontinence, soiling, and obstructed defecation associated with rectal mucosal prolapse.All male patients who underwent transanal surgery (either stapled or Delorme mucosectomy) for rectal mucosal prolapse associated with fecal incontinence and obstructed defecation were prospectively enrolled in the study. The recruitment phase was 17 months (April 2011 to August 2012). Symptom evaluation was based on the validated scores preoperatively and 12 months after surgery (Wexner incontinence score and Wexner constipation score). The primary end point was "success," which was defined as a 50 % reduction in symptoms. Using a decision-tree algorithm, patient groups with the highest and lowest chance of success were identified.Thirty-eight male patients (mean age 51 years) underwent transanal surgery for rectal mucosal prolapse. The predominant symptoms were fecal incontinence in 31 patients (82 %) and obstructed defecation in 7 (18 %). Stapled mucosectomy was performed in 34 patients and Delorme mucosectomy in 4 patients. No major morbidity occurred. Symptom resolution for soiling was 77 %, itching and mucus secretion were improved in 47 and 50 %, and bleeding resolved in 89 % of patients affected. Functional outcome was good in 90 % (28/31) of the patients with fecal incontinence but in only 28 % (2/7) for obstructed defecation. The Wexner incontinence score decreased significantly (11.1 vs. 3.9, p0.01), whereas the Wexner constipation score was not influenced (18.4 vs. 15.6, p0.05). Using a decision-tree algorithm, a success rate of 96 % was observed in patients with fecal incontinence associated with younger age (age45 years) and no presence of fecal urgency prior to surgery.Transanal stapled mucosectomy for rectal mucosal prolapse in males is effective for fecal incontinence, but not for obstructed defecation.

It is recognized that there is a strong association between bladder and bowel dysfunction. We determined the association of constipation and/or encopresis with specific lower urinary tract conditions.We reviewed our database of children with lower urinary tract dysfunction and divided cases into 3 categories of bowel dysfunction (constipation, encopresis and constipation plus encopresis) and 4 lower urinary tract conditions (dysfunctional voiding, idiopathic detrusor overactivity disorder, detrusor underutilization disorder and primary bladder neck dysfunction). Associations between bowel dysfunction types and each lower urinary tract condition were determined.Of 163 males and 205 females with a mean age of 8.5 years constipation was the most common bowel dysfunction (27%). Although encopresis is generally thought to reflect underlying constipation, only half of children with encopresis in this series had constipation. Dysfunctional voiding was associated with the highest incidence of bowel dysfunction. All but 1 patient with encopresis had associated urgency and detrusor overactivity, and the encopresis resolved in 75% of patients after initiation of anticholinergic therapy. Constipation was significantly more common in girls (27%) than in boys (11%, p0.01), while encopresis was more common in boys (9%) than in girls (3%, p = 0.02), likely reflecting the higher incidence of dysfunctional voiding in girls and idiopathic detrusor overactivity disorder in boys.Active bowel dysfunction was seen in half of the children with a lower urinary tract condition. Constipation was more common in patients with dysfunctional voiding, while encopresis was significantly increased in those with idiopathic detrusor overactivity disorder and in those with dysfunctional voiding, severe urgency and detrusor overactivity. Anticholinergics, despite their constipating effect, given for treatment of detrusor overactivity resolved encopresis in most children with this bowel dysfunction.

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.

Background: Behavioral aberrations such as nail biting, finger sucking, and pica have been postulated as risk factors that enhance helminths ova transmission. These aberrations may present commonly in children with chronic neurological disorders and predispose them to heavy intensity of intestinal helminthiasis. This comparative cross-sectional study was to determine the prevalence, intensity, and behavioral risk factors for intestinal helminthiasis in children with chronic neurological disorders and apparently healthy controls. Methods: Fresh stool samples from 155 children (217 years) with chronic neurological disorders seen at the child neurology clinic and 155 age and sex matched controls from nursery and primary schools in Benin City were analyzed using the Kato-Katz technique for detection of ova of helminths from November 2008 to April 2009. Results: The prevalence of intestinal helminthiasis (31.0%) was significantly higher in children with chronic neurological disorders compared with the controls (19.4%) (P=0.03). The intensity of infections in both groups was light ranging 24-144 eggs per gram. Ascaris lumbricoides, Trichuris trichiura and hookworm were the intestinal helminths isolated in both groups. Behavioral aberrations were significantly more represented in the subjects than in the controls (P

IntroductionFetal alcohol spectrum disorders (FASD) are one of the leading preventable causes of intellectual disabilities (ID). Not much is known about the topic of pediatric incontinence related to FASD, for example nocturnal enuresis (NE), daytime urinary incontinence (DUI), and fecal incontinence (FI). So far, incontinence problems have been examined among children with other specific syndromes.ObjectiveThe aim of the present study is to investigate the possible presence of incontinence among children with FASD in a South African cohort.Study designThe South African version of the combined questionnaire including the "Parental Questionnaire: Enuresis/Urinary Incontinence" and "Encopresis Questionnaire - Screening Version"; and lower urinary tract symptoms (LUTS) were assessed by the "International-Consultation-on-Incontinence-Questionnaire - Pediatric Lower Urinary Tract Symptom" (ICIQ-CLUTS) among 99 interviewees (e.g. mothers, grandparents) of children with FASD. Moreover, scores on the "Griffiths Mental Development Scales - Extended Revised" (GMDS-ER) were obtained of all included children for further statistical analysis.ResultsThe overall incontinence rate was 20% (n = 20), in children diagnosed within the FASD spectrum (fetal alcohol syndrome or FAS n = 17, partial fetal alcohol syndrome or pFAS, n = 1, alcohol related neuro-developmental disorder or ARND n = 2). NE affected 16% (n = 16) of children with a FASD (FAS n = 13, pFAS n = 1, and ARND n = 2). DUI was reported in one child (FAS), and FI in 4% (n = 4) of children (again, only FAS). No indication of lower urinary tract symptoms (LUTS) in the clinical range was reported (sample mean score = 5.17). Based on the GMDS-ER, 88% of the children scored lower than 10th percentile.DiscussionThis is a first study to examine the problems of incontinence among children diagnosed within the spectrum of FASD. The rates for children with a FASD are lower than the rates for many children with special needs, but much higher than for typically developing children. Children with a FASD are mainly affected by NE.ConclusionThe problem of incontinence among children with a FASD in South Africa needs to be assessed and considered for clinical management. Future research is necessary to examine problems of incontinence in relation to cognitive and behavioral functioning among children with a FASD, as well as identifying possible causes.

Attention deficit hyperactivity disorder (ADHD) is among the most frequently reported coexisting psychiatric conditions in children with encopresis. Some case reports state that atomoxetine-a selective presynaptic norepinephrine reuptake inhibitor-approved for treatment of ADHD is also effective in the treatment of coexisting encopresis. Contrasting those reports, here we present a case diagnosed with ADHD and secondary encopresis without constipation whose encopretic symptoms increased after atomoxetine treatment and discuss possible mechanisms.

Summary Background Faecal incontinence (FI) in children is a significant gastrointestinal problem, with great personal and social impacts. It is characterised by recurrent loss of faecal matter into the underwear. Both functional and organic causes contribute to its aetiology with the former predominating. Aim To review the epidemiology, pathophysiology, clinical evaluation and management of functional faecal incontinence in children. Methods A PubMed search was conducted using search terms f(a)ecal incontinence, and encopresis. Articles on epidemiology, pathophysiology, clinical evaluation, investigation and management of functional FI in children were retrieved and assessed. Results Community prevalence of this distressing problem ranges from 0.8% to 7.8% globally. Male: female ratio varies from 3:1 to 6:1. The diagnosis of FI is often based on established clinical criteria. The majority (82%) have constipation associated functional FI. Biopsychosocial factors play a crucial role in the pathogenesis. Limited physiological testing of anorectal function is recommended in the diagnostic procedures, particularly in children with atypical symptoms and possible organic disorders. Management of FI needs a multidisciplinary approach which includes establishment of an effective doctor-patient partnership, understanding the underlying mechanisms, pharmacotherapy and behavioural treatment. Approximately 15% of children with functional nonretentive faecal incontinence (FNRFI) had the same symptoms at the age of 18 years. Conclusion Significant therapeutic advances have been made for retentive faecal incontinence, but treatment options for functional nonretentive faecal incontinence are limited. Limited long-term outcome data show that the majority outgrow faecal incontinence. A substantial proportion of children progress to adulthood with faecal incontinence.

Background The relationship between family and health has not been studied in detail in primary care. Aim To evaluate the association between family functioning style and health problems among families receiving primary care. Design and setting Cross-sectional study in an underserved primary care clinic in Santiago, Chile. Method Families registered at the Juan Pablo II Primary Care Clinic in Santiago, Chile from 2006 to 2010 formed the study sample. Each family selected an adult family member to answer a questionnaire to provide data on: family sociodemographics; health problems among family members; and the family functioning style, as assessed with the Family Functioning Style Scale (FFSS). The t -test was used to assess differences in family functioning styles between families with and without health problems, and analysis of variance was used to study the relationship between the family functioning style and the number of health problems present. Results A total of 6202 families, comprising 25 037 people, were assessed. The following diseases and conditions were examined: in children — asthma or recurrent bronchitis, delayed development, enuresis or encopresis, behavioural problems, overweight; in adolescents and adults — teenage pregnancy, asthma or chronic obstructive pulmonary disease, smoking, hypertension, type 2 diabetes, major depression, alcohol or drug abuse, and frailty. Families with health problems had a significantly lower FFSS score than families without health conditions. Mental health diseases had the strongest association with family functioning style. An inverse relationship between the number of health problems and the FFSS score was also observed. Conclusion A better family functioning style was associated with a lower prevalence of health problems in families. Bases for further research considering the family as a target for clinical interventions are provided.

While there are many exchanges that take place during our early development, some have a more profound impact on our developmental trajectory than others. In the milieu of a disturbed mother-child dyad, what becomes of self and other object representations? How do the derivatives of trauma, neglect, and overstimulation become expressed and used during important life transitions? In this paper, convergent themes in the analysis of an eleven-year-old boy and a forty-year-old man illustrate how the evocative nature of smell was used as a means of holding on to early object ties and fantasies of a blissful union. I am proposing that by conceptualizing encopresis and the use of body odors as an expression of the individuals early trauma and object representations, we can advance our understanding of the tenacity of these symptoms and further develop appropriate and effective technical approaches. A select review of the literature is used to establish the relationship between earlier developmental phases and an internalization of early object relations relevant to this paper.Introductionduring my work with eleven-year-old steven, we came to understand his symptom of encopresis as a means of holding on to his relationship with his mother. Steven's comfort with the smell of his feces and the repulsion it provoked in others led to a counterreaction and understanding of how his feces came to represent an internalization of a part-object tie to his mother in the form of a fecal mass. Steven's use of his body products, and their smell, alerted me to the presence of similar dynamics in my work with Michael, a middle-aged man. The scent of Michael's sexual escapades with women clung to his clothes just as he clung to fantasies of a perfect union. Keeping the "scent of the other" with him was Michael's way of conveying his feelings about his childhood experiences and his reason for making messes of his relationships and in his life. Steven and Michael held similar fantasies of uniting with an object that would transform earlier painful relationships into pure narcissistic gratification. Losing their smell meant losing the essence of their re-union fantasy. Loss of this centrally held fantasy was akin to facing death for both Steven and Michael.Literature ReviewHow and with whom we begin our life helps organize who we are within ourselves and with others. It is within the context of our early relationships with others that our experiences, affects, and fantasies become a part of our self-understanding and our later interactions. The tenet that early experiences play a significant role in normal and pathologic developmental has a long history in psychoanalytic theory and practice. One of the first clinical references alluding to the importance of early stages of development on pathological solutions and symptoms was that of Little Hans (S. Freud, 1909). Freud's conceptualization of Hans's phobia and disruptive behaviors was a valuable contribution to our understanding of displacement and childhood fantasies, even though it was strongly influenced by his need to "validate infantile sexuality and positive oedipal conflict as the most important determinant of the child's psychopathology" (Blum, 2007a, p. 756). However, Freud's interpretation of Hans's fear of horses as related to his oedipal strivings and castration anxiety did not incorporate the mother's ministrations and influence on the child's defensive entrance into the "oedipal phase." After the release of previously restricted letters, it became clear that there were multiple reasons why the importance of the early mother-child relationship was not part of Freud's initial interpretations of Hans's symptoms.1 However, in modern reconsiderations of the case of Little Hans, the significance of the early mother-child relationship to Hans's symptom formation and the intensity of his conflict have become apparent (Blum, 2007a, 2007b; Chused, 2007; Ross, 2007). Ross (2007, pp. …

Leanna, a 10-year-old girl with autism, was hospitalized for severe malnutrition and 20 pound weight loss secondary to reduced intake over 4 months. Her food choices became increasingly restrictive to the point where she only ate certain types and brands of foods. She gradually stopped drinking and developed severe constipation and encopresis. A new behavior of collecting saliva in her mouth and spitting onto napkins also emerged. Vital signs and electrolytes were normal on admission. A nasogastric tube was placed because she refused to eat. A behavior modification plan was implemented that awarded points for completing specific tasks related to feeding, which could later be redeemed for specific rewards, such as computer time. Although her ideal body weight increased from 68% to 75% (due to continuous nasogastric tube feeds), her refusal to eat persisted. Upon further data gathering, the staff learned that she moved and changed schools 5 months ago. She was cared for by either a family friend or paid caregiver while her mother worked. Although she could conduct basic self-care activities without assistance and write and draw at a third-grade level, she functioned cognitively at a 4-year-old level. The behavior plan was modified, breaking the tasks into shorter components with immediate and tangible rewards. She soon began eating small portions of food and spitting less frequently. Toileting was later incorporated into this plan. She was referred to a behavioral therapist in the community to work with her at home and school. Weekly visits with her pediatrician and appointments with a child psychiatrist and dietician were made. Orlando, a 3-year-old boy with autism, was evaluated in the emergency room for lethargy and generalized edema for 6 weeks. The history revealed a restrictive diet of commercial pureed fruit and coconut juice for 2 years. He only ate a particular brand and with specific containers; the limited food intake occurred only with his favorite blanket. He refused to eat other types of food. Outpatient treatments were unsuccessful. On physical examination, he was irritable with an erythematous, scaly rash throughout his body. His hair was thin, coarse, and blonde. He had nonpitting edema in his arms, legs, and periorbital region. The laboratory evaluation was significant for anemia, hypoalbuminemia, and hypoproteinemia. He was admitted to the pediatric service where nutritional formula feedings were initiated through a nasogastric tube. Weight gain was adequate, and the hemoglobin, serum albumen, and protein became normal. The rash improved with zinc supplementation. He was transferred to an inpatient feeding disorders unit where a team of occupational therapists implemented a behavioral modification program to overcome his severe food aversion.

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.

Previously, we found that children participating in an empirically supported group behavioral intervention for the treatment of retentive encopresis (Opipari, Miller, Streisand, & Stark, 1999) demonstrated poor adherence (

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.