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Background: According to the Rome III criteria, encopresis without constipation was defined as nonretentive fecal soiling (FNRFS) with not yet well understood etiology. Treatment approaches reported in the literature with varying results include biofeedback, hypnosis, reflexology, and Internet-based educational programs. In developmental age, another behavioral treatment could be identified in the psychomotor approach, which is called psychomotricity in the European countries, or is also known as play therapy. The aim of the present study was to verify the safety and efficacy of play therapy plus toilet training in a small sample of prepubertal children affected by FNRFS. Materials and methods: Twenty-six patients (group 1; 16 males, mean age of 5.92 ± 0.84 years) underwent a psychomotor approach therapy program in association with toilet training for 6 months, and the other 26 subjects (group 2; 17 males, mean age of 5.76 ± 0.69) underwent the sole toilet training program for 6 months. During the observational time period (T0) and after 6 months (T1) of both treatments, the patients were evaluated for FNRFS frequency and for the behavioral assessment. Results: At T0, the FNRFS mean frequency per month for group 1 was 20.115 episodes/month (standard deviation [SD] ± 3.024) and for group 2 was 20.423 (SD ± 1.879) (P = 0.661). At T1 the mean frequency per month was 6.461 (SD ± 1.333) episodes/month and 12.038 (SD ± 1.341), respectively (P < 0.001). Moreover, the delta percent average of the frequency between T0 and T1 was 67.121 ± 8.527 for group 1 and 40.518 ± 9.259 for group 2 (P < 0.001). At T1, a significant improvement in scores on the behavioral scale was identified. Conclusion: Our preliminary results show the importance of a multidisciplinary approach, and suggest the positive effect of an additional psychomotor approach, as this holds a new and interesting rehabilitative purpose for children in a toilet training program, even if further research is necessary. [ABSTRACT FROM AUTHOR]

Purpose: 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. Materials and Methods: 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. Results: 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%, p <0.01), 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. Conclusions: 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. [Copyright &y& Elsevier]

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 (2-17 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<0.0001, OR=2.8). Nail biting and encopresis were the most significant independent predictors of intestinal helminthiasis ( P=0.025 and 0.001, respectively) in the subjects only. Hand washing with water and soap after defecation and frequent de-worming exercise were practices significantly associated with decreased prevalence of intestinal helminthiasis in the subjects and controls. Conclusions: Behavioral modification in children with chronic neurological disorders should be an integral part of the control program for intestinal helminthiasis. [ABSTRACT FROM AUTHOR]

Elimination disorders are very common in children: 10 % of 7-year-olds wet at night (nocturnal enuresis), 2-3 % during daytime (diurnal urinary incontinence) and 1-3 % soil (faecal incontinence). In the past decades, many subtypes of elimination disorders have been identified with different symptoms, aetiologies, comorbid disorders and specific treatment options. The aim of the paper is to present a short overview of the proposed DSM-5, the ICCS and the Rome-III classification systems, of assessment and of treatment. The DSM-5 criteria no longer reflect current research data and a revision is needed. Classification systems of the International Children's Incontinence Society (ICCS) for enuresis and urinary incontinence and the ROME-III criteria for functional gastrointestinal disorders offer new and relevant suggestions for both clinical and research purposes. Assessment of most elimination disorders can be performed in paediatric and child psychiatric primary care settings. The standard assessment consists of a thorough history, frequency/volume charts, specific questionnaires, a full physical examination, sonography and urinalysis. If possible, a child psychiatric assessment is performed. In all other settings, screening with a validated behavioural questionnaire and referral if indicated is recommended. All other investigations are indicated only in complicated cases and if an organic cause is to be ruled out. Treatment is symptom oriented and based on the exact diagnosis of the type of elimination disorder. Counselling is recommended in every case. Most elimination disorders can be treated by specific treatment programmes integrating cognitive-behavioural elements. Nocturnal enuresis is best treated with alarms. Medication can be indicated in nocturnal enuresis (desmopressin), urge incontinence (anticholinergics such as oxybutynin, propiverine, etc.) and faecal incontinence with constipation (polyethylene glycol). Comorbid behavioural and emotional disorders require additional treatment. [ABSTRACT FROM AUTHOR]

This paper attempts to convey how the ideas of Klein, Bion and Bick underpin psychoanalytically based interventions with parents, babies and young children in the Camden Under Fives' Service, Tavistock Clinic. As the title suggests, my focus is on ways in which anxiety relating to separation and loss, can be contained through the transformative function of ‘reverie’. I describe two clinical examples, of a bereaved couple who lost their baby at six weeks and of a three-year-old child suffering from severe constipation, to explore the role of therapeutic work in facilitating a shift away from a defensive ‘holding onto’ a concrete object as a means of evading separation, towards a more symbolic level of functioning, feeling ‘held in mind’. Steiner's description of the mourning process moving along a continuum from ‘fear of the loss of the object’ towards ‘experience of loss of the object’ as the patient shifts away from the ‘paranoid–schizoid’ towards a more ‘depressive position’ and the successful completion of mourning, is linked to Bion's concept of container-contained. The role of the clinician as ‘container’ of unprocessed states in young children, is discussed and linked to the recognition of ‘turning points’ in brief and longer-term work with under fives. [ABSTRACT FROM PUBLISHER]

Encopresis is a medical condition that is associated with incontinence in children. It leads to frustration and anxiety in both parents and children due to the presenting symptoms and the inability to control elimination patterns. There is overwhelming concern among families that a child with encopresis will be ostracized from peers and will suffer long-term psychological effects. It is therefore important to define encopresis to include the etiology, prevalence, and treatment measures in order to ensure a positive outcome. In addition, as a child enters elementary school, the school nurse plays a vital role in assisting the child to reach educational goals and managing health concerns. This article will guide the reader through the origin and diagnosis of encopresis as well as the principles of management. It will also delineate the school nurse role in managing encopresis in the school setting. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to assess behavioral problems in children with encopresis as well as anxiety levels of the mothers and marital problems of the parents. Material and Method: The case group included 31 boys with encopresis and their mothers; the control group included 26 boys who did not have chronic disease and their mothers. Child Behavior Checklist (CBCL), State Trait Anxiety Inventory (STAI-II) and Marital Conflict Questionnaire (MCQ) were used. The mean scores of the scales of the two groups were compared by Mann-Whitney U test the study approved by the ethics committe of Cerrahpasa Medical Faculty. Results: CBCL total problem scores, externalization, aggressive behavior, delinquent behavior and attention problem scores were significantly higher; CBCL competency total scores and school scores were significantly lower in the case group. In addition, MCQ scores were significantly higher in the encopresis group. Maternal STAI-II scores did not differ significantly between the groups. Conclusions: Attention and behavior problems may be the target of interventions for treatment of encopresis in children. Treatment of these problems may increase treatment compliance and prevent conflicts that may occur within the family in relation to these problems. Addressing severe marital problems that may be a source of distress and worsening factor for treatment may contribute to the treatment of these children. [ABSTRACT FROM AUTHOR]

Constipation is a common childhood problem, with both somatic and psychological effects. The etiology of paediatric constipation is likely multifactorial, and seldom due to organic pathology. Children benefit from prompt and thorough management of this disorder. The goal of treatment is to produce soft, painless stools and to prevent reaccumulation of feces. Education, behavioural modification, daily maintenance stool softeners and dietary modification are all important components of therapy. Fecal disimpaction may be necessary at the outset of treatment. Investigations are rarely necessary. Polyethylene glycol is a safe, effective and well-tolerated long-term treatment for constipation. Regular follow-up for children with constipation is important. Referral to a gastroenterologist should be made in refractory cases or when there is a suspicion of organic pathology. [ABSTRACT FROM AUTHOR]

Objective: Information about the relationship between encopresis and parental and familial features is very limited. In addition, only a limited number of studies have examined the psychopathology of children with encopresis. In this study, we aimed to investigate the familial and parental features and also the comorbid psychopathology of children with encopresis. Method: Thirty patients with a diagnosis of encopresis and 30 healthy controls were included in the study. The Family Assessment Device (FAD), the Temperament and Character Inventory (TCI) and the Symptom Check List (SCL-90-R) were administered to parents. Psychiatric diagnoses of the children were determined using the Schedule for Affective Disorders and Schizophrenia for School-Aged Children, Lifetime Version (Kiddie-SADS-PL). Results: In all dimensions of the FAD, parents of the patients indicated worse family functioning compared to controls. Scores of the SCL-90-R did not reveal any significant difference between the two groups. According to the TCI, mothers of the patients scored lower on cooperativeness and compassion measures, and fathers of the patients scored lower on cooperativeness, empathy, self-transcendence, and transpersonal identification measures. Fathers of the patients also scored higher on impulsiveness and shyness measures. The children with encopresis had higher rates of comorbid oppositional defiant disorder according to the Kiddie-SADS-PL. Conclusion: This study indicates that impaired family functioning, particularly personality traits of the parents, may play an important role in the etiology or persistence of encopresis and that some other psychiatric conditions may accompany this disorder in children. [ABSTRACT FROM AUTHOR]

Abstract: Aims: Transcutaneous electrical stimulation (TES) was used to treat children with slow-transit constipation (STC) for 1 to 2 months in a randomized controlled trial during 2006 to 2008. We aimed to determine long-term outcomes, hypothesizing that TES produced sustained improvement. Methods: Physiotherapists administered 1 to 2 months of TES to 39 children (20 minutes, 3 times a week). Fifteen continued to self-administer TES (30 minutes daily for more than 2 months). Mean long-term follow-up of 30 of 39 patients was conducted using questionnaire review 3.5 years (range 1.9-4.7 years) later. Outcomes were evaluated by confidence intervals or paired t test. Results: Seventy-three percent of patients perceived improvement, lasting more than 2 years in 33% and less than 6 months in 25% to 33%. Defecation frequency improved in 30%. Stools got wetter in 62% after stimulation and then drier again. Soiling improved in 75% and abdominal pain in 59%. Laxative use stopped in 52%, and 43% with appendicostomies stopped washouts. Soiling/Holschneider continence score improved in 81% (P = .0002). Timed sits switched to urge-initiated defecations in 80% patients. Eighty percent of relapsed patients elected to have home stimulation. Conclusion: TES holds promise for STC children. Improvement occurred in two thirds of children, lasting more than 2 years in one third, whereas symptoms recurred after 6 months in one third of children. [Copyright &y& Elsevier]

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Comorbidity of Attention Deficit Hyperactivity Disorder (ADHD) with other psychiatric disorders is a common condition and frequently causes difficulties in treatment. Also comorbidity of ADHD and encopresis is known to be common. Despite behavioral methods are known to be effective in treatment of encopresis, some psychotropic drugs are stated to be effective in treatment of encopresis in the literature. However, the mechanisms of these drugs in treatment of encopretic symptoms are not known exactly. In this article two boys are presented who admitted to a Child Psychiatry clinic with complains of gaita incontinence and overactivity. After clinical assessment, these boys were diagnosed as encopresis and ADHD. Firstly, short acting methylphenidate medication was administered to the patients, however, because of need for single dose medication, short acting methylphenidate treatment was switched to the extended release methylphenidate in both patients. Despite encopresis symptoms did not change with short acting methylphenidate, these symptoms disappeared with extended release methylphenidate treatment and did not recur during four and fifteen months of follow-up. The cases are presented and possible mechanisms of ADHD-encopresis comorbidity and possible mechanisms of effect of extended release methylphenidate on encopresis are discussed in this article. As a conclusion, searching and treating ADHD symptoms may lead to recovery of encopretic symptoms in patients with ADHD and comorbid encopresis. [ABSTRACT FROM AUTHOR]

Purpose: We provide an overview of the psychological and psychiatric aspects of nocturnal enuresis, urinary and fecal incontinence. Clinical behavioral disorders and subclinical psychological symptoms are reviewed. Aspects of screening, assessment, counseling and in severe cases treatment are outlined, and recommendations are formulated. Materials and Methods: Relevant publications on psychological and psychiatric aspects are reviewed. The recommendations passed several rounds of consensus finding, and were circulated among International Children''s Continence Society members and external experts. Results: In addition to subclinical effects on self-esteem, quality of life and distress, the rate of comorbid clinical behavioral disorders is increased. In fact, 20% to 30% of children with nocturnal enuresis, 20% to 40% with daytime urinary incontinence and 30% to 50% with fecal incontinence fulfill the criteria for ICD-10 or Diagnostic and Statistical Manual of Mental Disorders IV psychiatric disorders. These concomitant disturbances require assessment and counseling, and in severe cases treatment. They have a negative effect on compliance and outcome if not addressed and left untreated. Conclusions: Because the comorbidity rate is high, screening for psychological symptoms is recommended for all children in all settings with enuresis and/or daytime urinary and/or fecal incontinence. Standardized, validated questionnaires are recommended. In addition to clinical observation and history, a short screening questionnaire can be used as a first step. If problem behaviors are present a longer broadband questionnaire is recommended. If problem items in the clinical range are noted, a full child psychiatric or psychological assessment is recommended. [Copyright &y& Elsevier]

Elimination disorders are common in childhood and adolescence. Enuresis is defined as wetting from the age of 5 years and encopresis as soiling from 4 years onwards-after excluding organic causes. In the past few decades, many subtypes of elimination disorders have been identified with different symptoms, aetiologies and specific treatment options. The DSM-IV criteria no longer reflect this wealth of research data and a revision is needed. Classification systems of the International Children's Incontinence Society (ICCS) for enuresis and urinary incontinence and the ROME-III criteria for functional gastrointestinal disorders offer new and relevant suggestions for both clinical and research purposes. These are presented and discussed. Integration of these into DSM-5 is highly recommended. [ABSTRACT FROM AUTHOR]

Abstract: 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. [ABSTRACT FROM AUTHOR]

Abstract: Our aim was to assess the potential of Escherichia coli O157:H7 to persist in a processing environment. We studied E. coli behaviour under conditions modelling those of meat plants to establish one initial bacterial load that allows persistence and another that does not. Polyurethane coupons (3.5cm2) were contaminated once with E. coli in meat exudate before being subjected daily to a cleaning product and a disinfectant, both at half the recommended in-use concentrations, and a further soiling with the exudate. This procedure aimed to model what occurs in harbourage sites. Because previous experiments showed that persistence could not be achieved at 15°C (temperature of slaughter halls), we incubated the coupons at 20°C. Viable cells were determined by ethidium monoazide-qPCR (EMA-qPCR). When the first chemical treatment (CT) was applied to 24-hour biofilms with 5.4logCFU/cm2, cells were no longer detectable after the first week. However, on 66-hour biofilms with 6.7log CFU/cm2, after initially decreasing, E. coli numbers reached 6.6logCFU/cm2 and 8.3logviable cells/cm2 on the 11th day. When E. coli was cultured with a Comamonas testosteroni previously shown to increase E. coli biofilm formation, and subjected to CT on alternate days, E. coli stabilized at 4.6logCFU/cm2 before the CT, from the 5th day of the experiment. The killing and detachment effects of the CT decreased over time and PCR quantification detected a resumption of growth after 2days (CT on alternate days) or 3days (daily CT). Intracellular pH (pHi) of individual cells was determined during an experiment in which the CT was applied on alternate days. The proportion of cells with no proton gradient towards the environment (pHi≤5.4) increased after the CT as expected. But during the first week of the experiment only, a further increase in this proportion occurred 24h after the CT, suggesting that some of the surviving viable but non-culturable cells finally died. This study shows that conditions leading to E. coli O157:H7 persistence are not likely to arise when good refrigeration and hygiene practices are applied, and highlights the usefulness of EMA or PMA-qPCR as a complement to CFU determination in studying bacterial survival after cleaning and disinfection. [Copyright &y& Elsevier]

Objective To examine the efficacy of an enhanced intervention (EI) compared to standard care (SC) in increasing daily water intake and fluid goal adherence in children seeking treatment for retentive encopresis. Methods Changes in beverage intake patterns and fluid adherence were examined by comparing 7-week diet diary data collected during participation in the EI to achieved data for families who had previously completed the SC. Results Compared to children in SC (n = 19), children in the EI (n = 18) demonstrated a significantly greater increase in daily water intake from baseline to the conclusion of treatment ( p &leq; .001), and were four and six times more likely to meet fluid targets in Phases 1 (Weeks 3–4) and 2 (Weeks 5–6) of fluid intervention, respectively (both p &leq; .001). Conclusions Enhanced education and behavioral strategies were efficacious in increasing children’s intake of water and improving fluid adherence. Future research should replicate the findings in a prospective randomized clinical trial to discern their effectiveness. [ABSTRACT FROM PUBLISHER]

Objective: Data about sociodemographic features, enuresis type, etiological types, family history, copying strategies, and approach to drug therapy of families towards enuresis, comorbid disorders, conducted treatment modalities are aimed to inquire in this study. Method: Data of 61 patients, who admitted to our policlinic and had enuresis nocturna with this diagnosis September 2007 to June 2008, were screened. Findings: Of the subjects, 57.4% were males and 42.6% were females. Most of the cases (63.9%) were observed at 5-10 years of age while 36.1% occurred 11-16 years of age. Positive family history was found in 78.7% of children with enuresis. In the history deep sleep and difficulty in awakening is obtained in 60.7% of the children with enuresis. In 37.7% of cases stressor factors accomEtpany enuresis. Primary enuresis was seen in 70.5% of cases. There was another accompanying psychiatric disorder in 72.1% of enuresis nocturna cases; the most common concomitant disorder was encopresis (27.9%). The other frequent disorders are mental retardation (19.7%), attention deficit hyperactivity disorder (18%), and enuresis diurna (18%) respectively. It was determined that behavioral treatment had been used in 93.4% of cases. Discussion and Conclusion: All of the families were determined to take prevention against enuresis. Presence of significantly high stress in secondary enuresis implies need to assessment of psychosocial factors in etiopathogenesis. Enuresis nocturna must be treated, as it is a disease that can result in low self-esteem, and some secondary psychological problems. It is necessary to inform the parents wherever they are met, especially at primary health care settings. [ABSTRACT FROM AUTHOR]

Abstract: 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. [Copyright &y& Elsevier]

Objective Limited data are available regarding whether children being treated for retentive encopresis are adherent to recommendations to increase their daily fluid intake. The purpose of this study was to examine fluid adherence in children who received treatment for retentive encopresis. Methods A retrospective chart review was performed using diet diary data for 26 children (ages 3–12) who completed a group behavioral intervention for retentive encopresis. Results Mean daily intake of clear fluid increased significantly during treatment and children relied primarily on water and juice to make this dietary change. However, adherence rates to clear fluid goals were <50%. Conclusions Children's increased clear fluid intake did not equate to high fluid adherence. Children's high juice consumption is concerning as it could place them at risk for other negative health consequences. Future research should examine whether enhanced fluid education and use of behavior change strategies yield higher fluid adherence. [ABSTRACT FROM PUBLISHER]

Objective: The aim of this study is to present the clinical features of children with encopresis, their comorbid psychiatric disorders, the relation between types of encopresis and comorbid psychiatric disorders and the relation between the suggested treatment type and continuation of treatment. Method: The study population consisted of children who were older than 4 years and referred to the Karadeniz Technical University Faculty of Medicine, Department of Child and Adolescent Psychiatry Clinic with soiling, between July 2005 and June 2007. Clinical charts of patients with fecal soiling were examined retrospectively. Findings: Of a group of children who were referred to our department with a complaint of soiling, 107 [83 boys, 24 girls] were found to fulfill the diagnostic criteria for encopresis according to Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Of the 107 participants, 22 [20.6%] had primary encopresis and 85 [79.4%] had secondary encopresis. 74 [69.2%] of the patients met the criteria for at least one comorbid disorder. The patients with secondary encopresis had a significantly higher rate of comorbidity [p=0.039]. Behavioral treatment was provided to 44.9% of the patients, psychopharmacologic treatment was given to 18.7% and a combined treatment was provided to 36.4% of the patients. Discussion and Conclusion: Encopresis is a disruptive impairment that may affect a child's social, emotional, and educational development. Encopresis is frequently accompanied by a psychiatric disorder. This study shows significantly high rates of behavioral and emotional problems in children who soil. Clinicians need to inquire about symptoms of other psychiatric disorders in patients who present with encopresis. [ABSTRACT FROM AUTHOR]

Abstract: Children and adults with developmental disabilities are more likely to evince encopresis, soiling and constipation than the general population. This set of related behaviors can produce a great deal of stress and can be a major restriction in independent living. This paper provides a review of the current state of knowledge on the prevalence, etiology, assessment and treatment of this co-occurring set of disorders. These problems are more common in persons with developmental disabilities then the general population. Furthermore, classical and operant treatment methods appear to be the best supported interventions for most cases. Strengths and weaknesses of the current research base are discussed along with potential avenues for future research. [Copyright &y& Elsevier]

Abstract: Introduction: Idiopathic constipation is a source of significant morbidity in children. A subset of patients is refractory to medical therapy and requires surgical intervention. We present a novel surgical technique for the management of these patients. Methods: We reviewed the records of 288 patients with severe idiopathic constipation and soiling. Patients who were refractory to medical management and had a megarectosigmoid underwent a transanal full-thickness rectosigmoid resection with a primary colo-anal anastomosis. Results: Fifteen patients underwent a transanal rectosigmoid resection. The preoperative contrast enema demonstrated an enormously dilated rectosigmoid in 14. An average of 43 cm (range, 8-98 cm) of rectosigmoid was resected. Of 14 patients with more than 3 months of follow-up, the preoperative laxative dose was 68 mg of senna/d (range, 52-95 mg), which decreased to 8.6 mg postoperatively (P < .001). Nine patients are clean without soiling, 1 is more prone to diarrhea, but is clean. Two patients soil occasionally, but are noncompliant, and 2 were lost to follow-up. Conclusion: Transanal rectosigmoid resection for medically intractable idiopathic constipation resulted in a dramatic reduction or elimination in laxatives use while preserving continence. It is a useful alternative to surgical options such as other colonic resections, antegrade enemas, and stomas. [Copyright &y& Elsevier]

To investigate whether parental worry about their children's health predicts usage of a pediatric Internet intervention for encopresis. Methods Thirty-nine families with a child diagrosed with encopresis completed a national clinical trial of an Internet-based intervention for encopresis (www.ucanpooptoo.com). Parents rated worry about their children's health, encopresis severity, current parent treatment for depression, and parent comfort with the Internet. Usage indicators were collected while participants utilized the intervention. Results Regression analyses showed that parents who reported higher baseline levels of worry about their children's health showed greater subsequent intervention use (Eβ = .52, p = .002), even after accounting for other plausible predictors. Exploratory analyses indicated that this effect may be stronger for families with younger children. Conclusions Characteristics of individuals using Internet-based treatment programs, such as parental worry about their children's health, can influence intervention usage, and should be considered by developers of Internet interventions. [ABSTRACT FROM AUTHOR]

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

Aim: To identify risk factors for urinary tract infection (UTI) in children to inform the development of preventative strategies. Method: A validated questionnaire covering demographic factors, perinatal, developmental, bowel and urinary history was sent to a cross-sectional sample of parents of elementary school children randomly selected from the first 4 years of school. UTI was ascertained by parental report, verified by cross-referencing with microbiological reports for all positive cases and 50 randomly selected negative cases. Results: Parents of 2856 children (mean age 7.3 years, range 4.8–12.8 years) responded. A total of 3.6% of children had a bacteriologically verified UTI, compared with 12.6% by parental report alone. Multivariate polychotomous logistic regression showed that a history of structural kidney abnormalities (odds ratio (OR) 15.7, 95% confidence interval 8.1–30.4), daytime incontinence (OR 2.6, 1.6–4.5), female gender (OR 2.4, 1.5–3.8), and encopresis (OR 1.9, 1.1–3.4) were independently associated with UTI. Daytime incontinence increased risk more in boys (8.3% vs. 1.2%) than girls (8.1% vs. 4.6%), and kidney problems increased risk in older compared with younger children (29% vs. 2% in ≥8 year olds, 0% vs. 4% in 4–6 year olds). Conclusions: Parents over-report UTI by about threefold. Effective treatment of daytime urinary incontinence and encopresis may prevent UTI in children, especially boys. [ABSTRACT FROM AUTHOR]

We aimed to evaluate general features of children with chronic constipation and classified them according to the Iowa criteria and Rome II criteria in order to analyze applicability of these criteria in our population. The medical records of 485 children who were referred for chronic constipation over a six- year period were evaluated retrospectively. We found that 7.7% of the cases had an organic pathology, and short segment Hirschsprung disease was the leading cause. Other children (92.3%) were classified as functional constipation, with a mean age of 6.4±4 years and with slight male dominance. Encopresis was found in 117 children (51.7%) aged over four years, and was associated with older age, male predominance and long duration of symptoms. Both of the classification systems showed a similar prevalence of constipation, but 9.9% of the children with pediatric constipation were not recognized by Rome II criteria. Additionally, 1.8% of the children were not recognized by either Iowa or Rome criteria. Functional constipation is common in primary care, and most of the children were school-aged. Constipation associated with encopresis and nutritional problems such as obesity is less common in developing countries. Rome II criteria are too restrictive and do not recognize approximately 12% of the children. A new classification system must be simple, easy to understand especially by the primary care physician, and must include the common features of constipation recognized by the parents. [ABSTRACT FROM AUTHOR]

Objectives To assess the outcome of patients presenting with functional constipation in childhood during a 10-year period and to determine any risk factors for developing persistent constipation throughout adolescence and adulthood. Patients and Methods 72 children (mean age 4 years; 40 boys) referred for constipation were included in a longitudinal set of observations. Initial workup included segmental colonic transit time and anorectal manometry; 45 of the 72 patients could be reevaluated 10 to 12 years later. Results 21 of 45 patients (46%; 95% confidence interval 29% to 67%) remained constipated at follow-up. Encopresis and recurrent abdominal pain were present in 25% and 56% of patients, respectively. Patients with anorectal dyssynergia remained more frequently constipated at follow-up than the others: 61% versus 29% (P < .05). Conclusion Almost 50% of patients presenting with constipation during childhood remained constipated on long-term follow-up. Anorectal dyssynergia is associated with a worse prognosis. [ABSTRACT FROM AUTHOR]

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

To date, due to the increasing prevalence of psychiatric diseases, the use of antipsychotic drugs has expanded. One of the proven side effects of these drugs is incontinence. Treatment of this complication improves the quality of life in these patients, increases self-confidence, and betters cope with their psychiatric illness. The exact mechanism of this side effect is not fully understood, but various methods have been used experimentally to deal with it. Strategies such as behavior therapy, discontinuation or change of drugs, reducing the dose of drugs, and adding drugs with less incontinence have been used. Each of these methods and studies has different results that need to be summarized to make optimal use of them. Since most of these reports are case reports with a low statistical population, our study has systematically reviewed these studies to find a comprehensive model to deal with this complication. [ABSTRACT FROM AUTHOR]

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

The article reports on the pharmacotherapy in the management of voiding and storage disorders, including enuresis and encopresis. The complexity of voiding and storage dysfunction of bladder and rectum highlight possibilities of overdiagnosis or underdiagnosis as well as possible miscommunication with patients or parents. An understanding of the standardized terminology and basic science of continence and incontinence greatly enhances clinical effectiveness. Also, web site and bowel treatment protocols greatly enhance parent-patient compliance.

Purpose: This longitudinal, population based study describes trajectories of daytime wetting and soiling in children 4.5 to 9.5 years old. Materials and Methods: Participants consisted of a cohort of nearly 11,000 children forming part of the United Kingdom population based cohort study known as ALSPAC (Avon Longitudinal Study of Parents and Children). Repeated measures of parentally reported incidents of daytime wetting and soiling were modeled using longitudinal latent class analysis. Results: Developmental variation could be adequately described by 4 trajectories for each of daytime wetting and daytime soiling. Trajectory shapes could be interpreted as normative (daytime wetting 86.2%, daytime soiling 89.0%), delayed (6.9%, 4.1%), persistent (3.7%, 2.7%) and relapsing (3.2%, 4.1%). There were gender differences among many of the nonnormative groups defined by these trajectories. In particular, girls outnumbered boys by a ratio of 1.25:1 among those with persistent wetting and a ratio of 1.39:1 among those who suffered a relapse in daytime wetting. In contrast, boys outnumbered girls by a ratio of 1.63:1 among those who were delayed in bowel continence, 1.93:1 among those with persistent soiling and 1.80:1 among those who suffered a relapse in soiling. Conclusions: Identification of trajectories of daytime wetting and soiling in children is an essential starting point in understanding the development of bladder and bowel control. These findings can be used to examine risk factors for the different trajectory groupings identified in the study. [Copyright &y& Elsevier]

Faecal incontinence (FI) is a socially devastating problem. The treatment algorithm depends on the aetiology of the problem. Large anal sphincter defects can be treated by sphincter replacement procedures: the dynamic graciloplasty and the artificial bowel sphincter (ABS). Patients were included between 1997 and 2006. A full preoperative workup was mandatory for all patients. During the follow-up, the Williams incontinence score was used to classify the symptoms, and anal manometry was performed. Thirty-four patients (25 women) were included, of which, 33 patients received an ABS. The mean follow-up was 17.4 (0.8–106.3) months. The Williams score improved significantly after placement of the ABS ( p < 0.0001). The postoperative anal resting pressure with an empty cuff was not altered ( p = 0.89). The postoperative ABS pressure was significantly higher then the baseline squeeze pressure ( p = 0.003). Seven patients had an infection necessitating explantation. One patient was successfully reimplanted. The artificial bowel sphincter is an effective treatment for FI in patients with a large anal sphincter defect. Infectious complications are the largest threat necessitating explantation of the device. [ABSTRACT FROM AUTHOR]

Authors from Belgium, the Netherlands and Germany tried to clarify the relationship between disordered defecation and non-neuropathic bladder-sphincter dysfunction; they found few arguments for a casual relationship between these conditions. OBJECTIVE To clarify the relationship between disordered defecation and non-neuropathic bladder-sphincter dysfunction (NNBSD) by comparing the prevalence of symptoms of disordered defecation in children with NNBSD before and after treatment for urinary incontinence (UI), and assessing the effect of such symptoms on the cure rate for UI. PATIENTS AND METHODS In the European Bladder Dysfunction Study, a prospective multicentre study comparing treatment plans for children with NNBSD, 202 children completed questionnaires on voiding and on defecation, at entry and after treatment for UI. Four symptoms of disordered defecation were evaluated; low defecation frequency, painful defecation, fecal soiling, and encopresis. RESULTS At entry, 17 of the 179 children with complete data sets had low defecation frequency and/or painful defecation (9%), classified as functional constipation (FC). Of the 179 children, 57 had either isolated fecal soiling or soiling with encopresis (32%), classified as functional fecal incontinence (FFI). After treatment for UI, FFI decreased to 38/179 (21%) (statistically significant, P = 0.035); for FC there were too few children for analysis. After treatment for UI, 19 of the 179 children (11%) reported de novo FFI. Symptoms of disordered defecation did not influence the cure rate of treatment for UI. CONCLUSIONS FFI improved significantly after treatment for UI only, but not in relation to the outcome of such treatment. FFI did not influence the cure rate for UI. There was little to support a causal relation between disordered defecation and NNBDS (‘functional elimination syndrome’). [ABSTRACT FROM AUTHOR]

Functional encopresis (FE) refers to the repeated passage of feces into inappropriate places at least once per month for at least 3 months. Treatment of FE targets the processes that cause or exacerbate the condition, including reduced colonic motility, constipation, and fecal impaction. The cardinal elements of successful treatment include "demystifying" the elimination process, bowel evacuation, stool softeners, prompts and reinforcement for proper toileting habits, and dietary modifications. Despite misinformation and misinterpretations of encopresis, the assessment and treatment of this condition actually represent one of the more successful achievements of behavior therapy. [ABSTRACT FROM AUTHOR]

OBJECTIVE. Our aim was to compare 2 laxatives, namely, polyethylene glycol 3350 without electrolytes and milk of magnesia, evaluating the efficacy, safety, acceptance, and 1-year outcomes. METHODS. Seventy-nine children with chronic constipation and fecal incontinence were assigned randomly to receive polyethylene glycol or milk of magnesia and were treated for 12 months in tertiary care pediatric clinics. Children were counted as improved or recovered depending on resolution of constipation, fecal incontinence, and abdominal pain after 1, 3, 6, and 12 months. An intent-to-treat analysis was used. Safety was assessed with evaluation of clinical adverse effects and blood tests. RESULTS. Thirty-nine children were assigned randomly to receive polyethylene glycol and 40 to receive milk of magnesia. At each follow-up visit, significant improvement was seen in both groups, with significant increases in the frequency of bowel movements, decreases in the frequency of incontinence episodes, and resolution of abdominal pain. Compliance rates were 95% for polyethylene glycol and 65% for milk of magnesia. After 12 months, 02% of polyethylene glycol-treated children and 43% of milk of magnesia-treated children exhibited improvement, and 33% of polyethylene glycol-treated children and 23% of milk of magnesia-treated children had recovered, Polyethylene glycol and milk of magnesia did not cause clinically significant side effects or blood abnormalities, except that 1 child was allergic to polyethylene glycol. CONCLUSIONS. In this randomized study, polyethylene glycol and milk of magnesia were equally effective in the long-term treatment of children with constipation and fecal incontinence. Polyethylene glycol was safe for the long-term treatment of these children and was better accepted by the children than milk of magnesia, [ABSTRACT FROM AUTHOR]

Constipation is a common problem throughout the world. It occurs in about 10–20% of adults in Western Countries and 0.3% to 28% of children worldwide. Most childhood constipation results from intentional withholding of stool following a painful experience with defecation. Thus, an extensive evaluation is often not necessary in a child presenting with constipation. Treatment should include education, evacuation of the rectum with oral or rectal laxatives if an impaction is present, laxatives to ensure soft stools and behavior modification. [ABSTRACT FROM AUTHOR]

OBJECTIVES. Previous studies, based on clinic samples, report that childhood soiling is associated with behavior problems and reduced self-esteem. This population-based study investigates the prevalence of psychological problems associated with childhood soiling. METHODS. A total of 8242 children aged 7-8 years born to mothers in the United Kingdom-based Avon Longitudinal Study of Parents and Children were studied. Parents completed postal questionnaires assessing common childhood emotional and behavioral problems, and children were asked questions at a research clinic concerning their behavior, friendships, bullying, and self-esteem. The rate of psychological problems was compared in children who soil frequently (once a week or more), those who soil occasionally (less than once a week), and those with no soiling problems (controls). Analyses were adjusted for developmental delay, gender, sociodemographic background, and stressful life events. RESULTS. Children who soil were reported by their parents to have significantly more emotional and behavioral problems compared with children who do not soil. Children who soil frequently had significantly more problems than those who soil occasionally. The rate of attention and activity problems, obsessions and compulsions, and oppositional behavior was particularly high in frequently soiling children. Children with soiling problems reported significantly higher rates of involvement in overt bullying (as both perpetrator and victim) and antisocial activities compared with controls. CONCLUSIONS. The current study finds significantly higher rates of behavior and emotional problems, bullying, and antisocial activities in children who soil compared with those who do not soil. Children who soil frequently are more likely to have these problems than those who soil occasionally. [ABSTRACT FROM AUTHOR]