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Background Cloacal anomalies are the severest and most complex of all anorectal malformations (ARMs). They require careful evaluation and meticulous surgery tailored to suit each variant. We present our experience in a series of nine cases. Methods This includes a retrospective review of 9 cases of cloaca managed at a tertiary care centre between 2015 and 2019. Results Associated anomalies were seen in 44% cases. The definitive surgery was performed at a mean age of 15.2 months (10 months-19 months), the definitive surgery being rectal separation with total urogenital mobilisation. The common channel as measured during panendoscopy was up to 3 cm in 7 patients (78%), and only 2 patients had a common channel of more than 3 cm (22%). Of the 34 procedures that these nine patients underwent, there were four complications (12%). The median follow-up period after stoma closure was 18 months (5-32 months), and the mean age at last follow-up was 38 months (22-48 months). Five children (63%) had spontaneous voiding and remained dry in the intervening period. Three patients (37%) had poor urinary stream with dribbling and high postvoid residue requiring clean intermittent catheterisation. Six patients had faecal soiling (66%); four had daily soiling; and two had occasional soiling. Four patients had constipation (44%). Seven patients (77%) required daily enemas for bowel evacuation and to remain dry. Conclusion Cloacal anomalies are rare and complex ARMs. Satisfactory urinary and bowel continence rates can be achieved even in these complex anomalies.

Objective This study assessed the prevalence, causes, pattern of management and outcome of care among patients SCI in University College Hospital, Ibadan, Nigeria. Methods The study adopted a retrospective research design and case files of all patients with spinal cord injury that received treatment at the hospital from 2015 to 2018 were used for the study. A self-developed checklist was used for data collection. Collected data were analysed using the statistical package for the social sciences (SPSS) version 25. The data were presented with descriptive and inferential statistics at a significance level of p = 0.05. Results Findings showed that 132 admitted patients out of a total of 850 admissions over four years had SCI with a prevalence rate of 15.5% with highest percentage in 2018 and 65.2% of the SCI resulted from trauma and 34.8% were non-traumatic. Majority of the patients (99.2%) were given analgesics, 97.7% were placed on bed resting, 90.2% received psychotherapy, 89.4% were placed on adequate nutrition, 71.2% were placed on anticoagulants 68.2% placed on catheterization and 57.6% benefited from surgery. Findings also showed that outcomes of care for spinal cord injury ranges from Paraplegia (29.5%), salvaging of bladder or bowel continence (25.0%) and Quadriplegia (15.2%). Conclusion The study concluded that there is high prevalence of SCI and trauma, road traffic accident and occupational hazard were the major causes of spinal cord injury.

BACKGROUND: Ethnic disparities in continence rates in spina bifida (SB) have been studied regionally but not nationally. National SB Patient Registry (NSBPR) data were analyzed to explore differences in prevalence of bowel and bladder continence and interventions between Hispanics/Latinos and others. METHODS: Participants 5 to 21 years were categorized into Hispanic/Latino and non-Hispanic/non-Latino. Bladder/bowel continence was defined as dry/no involuntary stool leakage during the day or none/⩽ monthly incontinence. Chi-square test, Wilcoxon Two Sample Test, and generalized estimating equation (GEE) were used for statistical analysis. RESULTS: Twenty-five percent of the 4,364 patients were Hispanic/Latino. At their most recent clinic visit, Hispanics/Latinos demonstrated lower rates of urinary continence (38.6% vs. 44.9%; p = 0.0003), bowel continence (43.9% vs. 55.8%, p < 0.0001), private insurance (p < 0.0001), bowel (p < 0.0001) or bladder surgeries (p = 0.0054), and more vesicostomies (p = 0.0427) compared to others. In multiple GEE models, Hispanic/Latino participants demonstrated lower odds of bowel continence as compared to non-Hispanic/non-Latino participants (estimated odds ratio, 0.82, 95% CI, 0.72–0.94, p = 0.0032). CONCLUSIONS: After controlling for covariates, Hispanics/Latinos with SB are less likely to report bowel continence. Clinicians are encouraged to consider the risk of negative health disparities for Hispanic patients with SB and work to mitigate this risk.

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 and aimsThe rectosigmoid brake, characterized by retrograde cyclic motor patterns on high-resolution colonic manometry has been postulated as a contributor to the maintenance of bowel continence. Sacral neuromodulation (SNM) is an effective therapy for faecal incontinence, but its mechanism of action is unclear. This study aims to investigate the colonic motility patterns in the distal colon of patients with faecal incontinence, and how these are modulated by SNM.MethodsA high-resolution fibre-optic colonic manometry catheter, containing 36 sensors spaced at 1-cm intervals, was positioned in patients with faecal incontinence undergoing Stage 1 SNM. One hour of pre-meal and post-meal recordings were obtained followed by pre- and post-meal recordings with suprasensory SNM. A 700-kcal meal was given. Data were analysed to identify propagating contractions.ResultsFifteen patients with faecal incontinence were analysed. Patients had an abnormal meal response (fewer retrograde propagating contractions compared to controls; p=0.027) and failed to show a postmeal increase in propagating contractions (mean 17 ± 6/h pre-meal vs 22 ± 9/h post-meal, p = 0.438). Compared to baseline, SNM significantly increased the number of retrograde propagating contractions in the distal colon (8 ± 3/h pre-meal vs 14 ± 3/h pre-meal with SNM, p = 0.028). Consuming a meal did not further increase the number of propagating contractions beyond the baseline upregulating effect of SNM.ConclusionThe rectosigmoid brake was suppressed in this cohort of patients with faecal incontinence. SNM may exert a therapeutic effect by modulating this rectosigmoid brake.What You Need to KnowBackground and contextThe rectosigmoid brake, characterized by retrograde propagating motility patterns, has been postulated to contribute to the maintenance of continence. The mechanisms of action of sacral neuromodulation remain inadequately understood and may include modulation of the rectosigmoid brake.New findingsWe found that patients with faecal incontinence had an impaired rectosigmoid brake, characterized by a reduced frequency of colonic motor patterns in response to a meal. Rectosigmoid brake activity was upregulated by sacral neuromodulation.LimitationsThis was a small cohort of patients with heterogenous faecal incontinence subtypes.ImpactAttenuation of the rectosigmoid brake is a biomarker of faecal incontinence. Rectosigmoid brake responses offer a therapeutic target to evaluate and refine sacral neuromodulation protocols.Lay summaryPatients with faecal incontinence had an attenuated rectosigmoid brake, characterised by fewer postprandial retrograde propagating contractions in the distal colon, however, the rectosigmoid brake function was improved by sacral neuromodulation.

As a consequence of high-type anorectal malformations (ARMs) pathogenesis, the pelvic floor muscles remain severely underdeveloped or hypoplastic, the rectal pouch is located at the level or above the puborectalis sling, and the bowel terminates outside the sphincter muscle complex support. For children with high-type ARMs the ultimate objective of therapy is mainly to grow up having bowel continence function that is compatible with a good quality of life, and the final prognosis depends significantly on the grade of development of pelvic floor muscles and the successful entering of the anorectum fully within the support of the external anal sphincter due to intraoperative conservation of the puborectalis sling. Pelvic magnetic resonance imaging (MRI) has recently become the preferred imaging study for prediction of functional outcomes, since it can define the anatomy and evaluate the development of the sphincteric muscles before and after surgical correction. Based on recent literature and our clinical experience, we will discuss the relevance of pelvic floor muscles MRI to the clinical outcome of children with high type ARMs.

Background When born with spina bifida, there are numerous neurologic disorders that accompany this birth defect, including neurogenic bowel. Proactive, systematic, and rational approaches can lead to continence and a more functional lifestyle [1]. Methods Based on the evidence in the literature and expert experience, our approach to bowel management was developed as a step by step, individualized approach. This was converted to a decision tree for easy guidance of treatment decisions. The approach includes teaching patients and families normal bowel function, changes resulting from neurogenic bowel, common pitfalls in bowel management, and techniques that may improve outcomes. The decision tree, starting with dietary management, breaks into a two-fold attack, oral and rectal. Our data as part of the National Spina Bifida Patient Registry (NSBPR) database was compared to public data from the NSBPR. Results Preliminary data from the NSBPR in 2011 reported bowel continence in 42.1% (n = 898) compared to our clinical outcomes of 72.1% (n = 43). As the variable of bowel continence was further defined and more patients were enrolled, the clinic results were comparable to the national reports. Conclusion Consistency among providers and caregivers is critical to evaluating the management of continence in spina bifida. While this protocol warrants further evaluation, it is offered as an evidence-based, step by step, approach to bowel management in spina bifida with good outcomes for patient management.

Aim Restoration of bladder and bowel continence after pudendal nerve anastomosis has been shown successfully in animal models and may be applicable in humans. Aim of this cadaveric study was to assess feasibility of pudendal nerve neurotization using motor fascicles from sciatic nerve. Methods Pudendal and sciatic nerves were exposed via gluteal approach in 5 human cadavers (10 sites). Size of pudendal and sciatic nerves and the distance between two nerves was measured. Results There were four male and one female cadavers. Mean age was 62 (range, 50–70) years. Mean pudendal nerve diameter was 2.94 mm (right side) and 2.82 mm (left side). Mean sciatic nerve diameter was 11.2 mm (right side) and 14.2 mm (left side). The distance between two nerves was 23.4 mm on both sides. Conclusion Transfer of the motor fascicles from sciatic nerve to pudendal nerve to restore the bladder and bowel continence is feasible.

Background The National Spina Bifida Patient Registry (NSBPR) was established in 2008, as a partnership between the CDC and spina bifida (SB) clinics throughout the United States. The purpose of this study is to explore the initial work of this project through a literature review of published studies from the NSBPR and provide a description of how this body of literature has developed overtime. Methods We included studies indexed in MEDLINE by means of PubMed from January 2009 through April 2018. Included articles were appraised to identify key themes relevant to SB demographics, interventions, and outcomes. Additionally, information regarding objectives, hypotheses, and results of each study was summarized. Results We identified 13 articles meeting inclusion criteria. These publications described findings or explored associations using NSBPR variables. They were grouped into four categories: general characteristics (4 studies), mobility and skin injury (2 studies), bowel continence (3 studies), and bladder continence (5 studies). Conclusions The NSBPR represents one of the largest described clinical samples of individuals living with SB. The first decade of studies have focused primarily on descriptive analyses and on identifying predictors of clinical outcomes. These initial results may help develop interventions (including culturally appropriate initiatives), be a resource for developing international evidence-based standards of care and best-practices, and lead to improved outcomes for individuals living with SB globally. Additionally, the results underscore the strengths of the NSBPR's design and highlight the potential breadth of research topics that could be addressed in the future.

More than 60% of women over age 65 living independently experience bladder and/or bowel incontinence, and the prevalence among institutionalized older adults is even higher. While its impact on quality of life cannot be overstated, incontinence is also associated with social isolation, depression, falls, and institutionalization. A thorough history, medication review, and physical exam are the most important components of the evaluation of incontinence symptoms. Urinary incontinence may be associated with activity (stress incontinence), urgency (urge incontinence), or both (mixed). Bowel incontinence may be without awareness (passive) or urge-associated, and may depend on stool consistency. Constipation may result in overflow bowel incontinence. Initial treatment recommendations include behavior modifications and pelvic floor muscle training for most women with bladder or bowel incontinence. Additional treatment options vary based on symptoms and may include bladder re-training, biofeedback, fiber supplementation, medication, rectal or vaginal inserts (including pessaries), nerve stimulation therapy, or surgery. Despite the existence of effective solutions, most women with incontinence do not discuss their symptoms with a healthcare provider due to existing stigma. It is therefore imperative that medical providers screen for incontinence routinely and provide counsel that while incontinence is a common condition with aging, it is always abnormal, and there are effective solutions to improve symptoms.

Purpose Continence is low in individuals with spina bifida, but published prevalence varies markedly across studies. The objective of this study was to examine bladder and bowel continence among patients served by multidisciplinary clinics participating in the National Spina Bifida Patient Registry and to examine whether variation in prevalence exists across clinics. Methods Data were obtained from patients 5 years and older from March 2009 to December 2012. Data were gathered at clinic visits using standardized definitions. Results Data from 3252 individuals were included. Only 40.8% of participants were continent of urine; 43% were continent of stool. Bladder and bowel continence differed by spina bifida type, with those with myelomeningocele having significantly lower reported prevalence of continence than those with other forms of spina bifida. Bladder and bowel continence varied across registry sites. Adjustment based on demographic and condition-specific variables did not make substantive differences in prevalence observed. Conclusion Less than half of spina bifida patients served in multidisciplinary clinics report bladder or bowel continence. Variability in prevalence was observed across clinics. Further research is needed to examine if clinic-specific variables (e.g., types of providers, types of interventions used) account for the observed variation.

Aim To investigate the current practice of continence advisors in the United Kingdom. Method Continence advisors were contacted by email or letter to participate in a survey. The survey contained 27 questions which addressed the practice of each continence advisor, their knowledge of continence management and the adequacy of their training. Results Two hundred and twenty six out of a total of 448 continence advisors (50.4%), responded. One hundred and seventy (76.9%) advisors treated both faecal and urinary incontinence, 51 (23.1%) treated urinary incontinence. Thirty-six advisors (16.1%) were lone workers and 130 (58.6%) had more than 10 years’ experience. The majority of the advisors (75.6%) performed a digital rectal examination as part of their assessment. Regarding the management of faecal incontinence, 148 prescribed suppositories, 127 offered enemas and 147 advised on rectal irrigation. Most of the advisors taught pelvic floor exercises (n=207) and urge resistance techniques (n=188). One hundred and fifty-nine (87.4%) prescribed the Peristeen coloplast® anal and 78 (47.6%) prescribed the Renew® anal insert. Eighty-nine advisors (42.6%) felt they had not been adequately trained to provide a bowel continence service. Conclusion The majority of continence advisors in the UK manage faecal incontinence. They are able to initiate a broad range of conservative treatment options; however, almost half of the advisors who answered the survey felt inadequately trained and may be better supported by further training. This article is protected by copyright. All rights reserved.

Summary Introduction Patients with spina bifida and other spinal dysraphisms commonly suffer from fecal incontinence and constipation, which can be treated with antegrade continence enemas. Currently, information regarding outcomes and satisfaction in children who have Chait cecostomy tubes is lacking. The aim of our study was to evaluate the effectiveness of Chait cecostomy tubes in management of constipation in children with spinal dysraphisms. Materials and methods A questionnaire was completed by patients and/or their families during office visits at the University of Iowa or Nationwide Children's Hospital during follow-up pediatric urology office visits. Two study groups completed the questionnaires: 1) Patients with neurogenic bowels who had a cecostomy tube in place (CT) and 2) patients with neurogenic bowels with no cecostomy tube (NCT). The survey used Likert scaled and nonrated questions to assess demographics, bowel continence, and satisfaction. Results A total of 86 patients completed the questionnaire: 53 CT patients and 33 NCT patients. CT patients rated the effectiveness of their cecostomy tube in managing their constipation significantly higher than the NCT group rated the effectiveness of their conventional bowel management methods (p Figure ) and 92% would have the cecostomy tube placed again. In addition, hygiene, independence, and social confidence were significantly improved compared with baseline. Complications associated with the Chait tube included granulation tissue that required treatment (60%) and pain with irrigation (24%). Conclusions CT patients reported significantly improved constipation management, fecal continence, and improved quality of life compared with NCT patients. Our pilot study demonstrates that the Chait cecostomy tube is a well-tolerated, effective means for treating constipation and achieving fecal continence with minimal side effects in patients with neurogenic bowels. Download : Download high-res image (105KB) Download : Download full-size image Figure . Overall satisfaction with current bowel management methods.

Female pelvic floor: anatomy and normal function Abstract. In the course of evolution, the complex interaction of anatomical structures of the pelvic floor has led to bladder and bowel continence, sexual sensations and reproduction. All these functions and abilities play an important individual and social role, thanks to which higher interactions have become possible. For a better understanding of these functions, underlying anatomical concepts are essential. The knowledge gained through dissection of corpses in earlier centuries is now being expanded through modern imaging techniques and image processing. In the following article, we want to give readers an overview of the anatomically important structures and the functions of the pelvic floor.

Anorectal physiology and bowel continence is a complex and dynamic coordination of the reservoir functional capacity of the rectum, dynamic interplay with pelvic floor musculature, and timely contraction and relaxation of the sphincter muscle complex. Surgical alteration of the rectum in the form of partial or complete resection significantly impacts the patient’s bowel habits. Transanal surgical partial or total resection is associated with postoperative functional impairment in bowel incontinence. This chapter reviews the impact of TAMIS and taTME on bowel functional outcomes.

The long-term effects of 1 or 2 consecutive obstetrical anal sphincter injuries on bowel continence are still inadequately investigated, and published results remain contradictory.This study aimed to present detailed descriptive measures of the current bowel incontinence 20 years after the first birth in women who had 2 vaginal deliveries with and without sphincter injuries.Birth register data were used prospectively and linked to information from a questionnaire survey about current symptoms. Women with 2 singleton vaginal births, from 1992 to 1998, and no further births were retrieved and surveyed by the Swedish Medical Birth Register and Statistics Sweden in 2015. A simple random sample of 11,000 women was drawn from a source cohort of 64,687 women. The cumulative effect was studied in all women with a repeat sphincter injury from 1987 to 2000. Postal and web-based questionnaires were used. The study population consisted of 6760 women with no sphincter injury, 357 with 1 sphincter injury, and 324 women with 2 sphincter injuries. Women with 2 deliveries without sphincter injuries aged 40 to 60 years as reference, were compared with those of women that sustained 1 or 2 consecutive sphincter injuries. Here, third- and fourth-degree perineal tears were presented as 1 group. Fecal incontinence was defined as current involuntary leakage of solid or liquid stool, with and without concomitant leakage of gas. The Fisher exact test and the Mann-Whitney U test were used to compare the results of the 2 groups. The trend was analyzed using the Mantel-Haenszel statistics. Logistic regression models obtained the estimated age-related probability of fecal incontinence components.The risk of sphincter injury at first delivery was 3.9%, and the risk of a repeat sphincter injury was 10.0% (odds ratio, 2.70; 95% confidence interval, 1.80-4.07). The overall prevalence of fecal incontinence in women without sphincter injuries was 11.7%, which doubled to 23.8% (odds ratio, 2.27; 95% confidence interval, 1.75-2.94) in those with 1 sphincter injury and more than tripled to 36.1% (odds ratio, 3.97; 95% confidence interval, 3.11-5.07) after 2 sphincter injuries (trend P.0001). The proportion of women with severe fecal incontinence increased 3-fold and 5-fold from 1.8% after no obstetrical anal sphincter injury to 5.4% (95% confidence interval, 3.3-8.2) and 9.0% (95% confidence interval, 6.1-12.6) after 1 or 2 obstetrical anal sphincter injuries, respectively (trend P.0001). In women without sphincter injuries, the estimated probability of fecal incontinence increased from 7.0% at the age of 40 years to 19.8% at the age of 60 years. In contrast, in women with 1 or 2 sphincter injuries, the estimated probability of fecal incontinence increased from 26.1% and 33.3%, respectively, at the age of 40 years to 36.8% and 48.8% at the age of 60 years. The prevalence of fecal incontinence increased after 52 years of age in women with 1 or 2 sphincter injuries. The dominant types of leakage in women with fecal incontinence were the combination of liquid stool and gas, and the triple combination consisting of solid and liquid stools and gas. The triple combination increased from 18.9% in those without sphincter injury to 28.2% in women with 2 injuries (trend P=.0204).The risk of sustaining a repeat sphincter injury at the second delivery was almost tripled compared with the risk at the first delivery. Furthermore, 1 or 2 sphincter injuries brought severe long-term consequences for bowel continence. Accidental leakage of stool and gas increased with each sphincter injury, and the effect was proportionally cumulative. After the age of 52 years, the prevalence of fecal incontinence seemed to accelerate.

Aim Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive treatment for faecal incontinence. Many patients with faecal incontinence have coexisting pelvic floor disorders such as urinary incontinence and vaginal symptoms. We utilized a pelvic floor assessment tool to analyse any effect of PTNS on global pelvic floor function. Methods Patients with faecal incontinence attending our institution who had failed to respond sufficiently to biofeedback were offered a course of PTNS. Patients underwent pre- and post-stimulation assessment with a validated electronic Personal Assessment Questionnaire - Pelvic Floor (ePAQ-PF) for pelvic floor disorders. Scores were compared to assess the effect of treatment on global pelvic floor function. Results During the study period pre- and post-stimulation ePAQ-PF data were available for 60 patients (55% of all patients starting PTNS). In this cohort there was a significant improvement in bowel continence, bowel related quality of life, irritable bowel syndrome and bowel evacuation with a large effect size for continence and bowel related quality of life. There was also a significant improvement in non-bowel related symptoms, including urinary pain and stress incontinence, urinary related quality of life and bowel related sexual function. Sixty-five per cent of those who answered the question reported improvement in global health after stimulation. Conclusion For patients presenting with faecal incontinence, PTNS appears to have a positive effect on bowel related function in approximately two-thirds of patients. However, for treatment responders, improvement appears to relate mainly to improvement in bowel related function rather than a global pelvic floor effect.

BACKGROUND Myelomeningocele (MMC) is a congenital malformation that results from a failure in the process of neurulation. A multidisciplinary follow-up is required to manage and treat all associated sequelae. The aim of the study was to present the epidemiological data and the results of the multidisciplinary follow-up of children born in Slovenia with myelomeningocele (MMC) between 2007 and 2017. METHODS We presented a retrospective analysis of all children born in Slovenia with between 2007 and 2017. The multidisciplinary follow-up included neurosurgical, urological, neurological, endocrinological and orthopedic expertise. RESULTS Twenty children were treated in Slovenia for MMC from 2007 to 2017 (mean follow-up of 7.7 years). 9 MMC were thoracic, 2 higher lumbar, 5 lower lumbar and 4 sacral. Thirteen children needed a CSF shunt, 1 was treated with endoscopic ventriculostomy (ETV). Four children needed a craniocervical decompression and 2 needed a detethering procedure. 14 children had a neurogenic bladder and 17 referred bowel continence. Orthopedic correction of the lower limbs was required in 9 cases. 4 children had seizures, 10 had endocrinological deficits. Among 16 children attending school, 11 were inserted in special educational classes. CONCLUSIONS The prevalence of MMC in Slovenia between 2007 and 2017 was 1/10000 births. Our follow-up results are comparable with those of previous, larger studies and confirm the efficacy of treating hydrocephalus with ETV in selected cases and with CSF shunt only in cases of clearly increased intracranial pressure. By adopting this strategy, we reduced the CSF shunt rate to 65%.

OBJECTIVEIn spina bifida (SB), transition of care from the pediatric to adult healthcare settings remains an opportunity for improvement. Transition of care is necessarily multidimensional and focuses on increasing independence, autonomy, and personal responsibility for health-related tasks. While prior research has demonstrated that effective transition can improve health outcomes and quality of life while reducing healthcare utilization, little is known about the most advantageous transition program components/design. The individualized transition plan (ITP) was developed to optimize the readiness of the adolescent with SB for adult healthcare. The ITP is a set of clearly articulated, mutually developed goals that arise from best available data on successful transition and are individualized to meet the individual challenges, needs, and attributes of each patient and family.METHODSProspectively completed ITPs were retrospectively reviewed from June 2018 to May 2019. Demographic and disease characteristics were collected, and specific goals were reviewed and categorized.RESULTSThirty-two patients with an ITP were included. The cohort was 50% male and had a mean age of 16.4 years. For goal 1 (maximize education), the most common goal was to complete a career interest survey (44%), followed by researching application/admission requirements for programs of interest (25%), shadowing in and/or visiting a workplace (16%), and improving high school performance (16%). For goal 2 (bowel management), most patients (59%) had a working bowel program with few or no bowel accidents. Eight patients (25%) were having more than the desired number of bowel accidents and received formal consultation with a gastroenterologist. Five patients (16%) needed only minor adjustments to their bowel management regimen. Goal 3 (SB program coordinator goal) focused on documenting medical and/or surgical history for the majority of patients (66%). Other goals aimed to increase patient communication in healthcare settings or utilize available community resources.CONCLUSIONSThe authors developed an evidence-based ITP that focuses around 5 goals: maximizing education, bowel continence, and goals set by the SB clinic coordinator, parent/caregiver, and patient. Although developed for the authors’ SB clinic, the ITP concept is applicable to transition of care in any chronic childhood illness.

The urologic management of children with spinal cord injury (SCI) differs from that of the adult insofar as the care involves a developing organ system and will be ongoing for years. Preservation of renal function as well as prevention of urinary tract infection in concert with both bladder and bowel continence are the essential guiding principles. This is a non-systematic review of the literature and represents expert opinion where data are non-existent. This review focuses on special considerations in children with spinal cord injuries. SCI in children is less frequent than in adults and affects mainly older children and teenagers. The etiology of SCI in children is usually motor vehicle accidents. The cervical spine is often injured. The urologic evaluation is similar to that for adults but may involve more frequent radiologic and urodynamic assessment to monitor renal function as the child grows. Treatment may be divided into medical vs. surgical and mirrors the approach to children who have a neurogenic bladder due to spina bifida. Bladder management should be associated with bowel management to achieve the goals of continence and social acceptability.

With increased use of explosive devices in warfare, anal trauma is often seen coupled with more complex pelviperineal injury. While the associated mortality is high, casualties that survive are often left with disabling fecal incontinence from damage to the anosphincteric complex. After resolution of the acute insult, the initial evaluation mandates a thorough physical exam, including endoscopic evaluation with rigid proctoscopy and flexible sigmoidoscopy, as well as adjunctive testing, specifically anal manometry and endoanal ultrasound. First-line therapy favors bulking agents and antidiarrheals, in conjunction with biofeedback, due to a minimal risk profile. Surgical options range from direct sphincter repairs to complex anosphincteric reconstruction with widely variable results. Most recently, burgeoning therapies in the treatment of fecal incontinence, including sacral nerve stimulation and magnetic anal sphincters, offer excellent alternatives with promising long-term outcomes. In summation, the goal of all interventions is the re-establishment of bowel continence, but, in its absence, permanent fecal diversion for devastating fecal incontinence is a reasonable option with excellent patient satisfaction scores.

INTRODUCTION: Advances in care have allowed most children with spina bifida (SB) to live to adulthood. The majority have neuropathic bowel dysfunction (NBD), resulting in constipation, incontinence, and diminished quality of life. We sought to 1) describe contemporary NBD management and continence outcomes of adults with SB; 2) describe differences from younger patients; and 3) assess for association with socio-economic factors. METHODS: We analyzed data on NBD management and continence from the National Spina Bifida Patient Registry (NSBPR). Patients were segregated into young children (5–11 years), adolescents (12–19 years), and adults (20 years and older). A strict definition of continence was utilized. Statistical analysis compared cohorts by gender, ethnicity, SB type, lesion level, insurance status, educational attainment, employment status, and continence. RESULTS: A total of 5209 SB patients were included, of whom 1370 (26.3%) were adults. Management and continence varied by age and SB type. Oral medication use did not differ between groups (5.2–6.6%). Suppositories and rectal enemas were used only by 11.5% of adults, which was significantly less than among school-aged children. Antegrade enemas were used by 17.7% of adults which was significantly less than among adolescents (27.2%). Adults were more likely to use digital stimulation or disimpaction or have undergone a colostomy. Bowel continence was reported by 58.3% of overall adult cohort: 55.6% of adults with myelomeningocele and 74.9% with non-myelomeningocele. Bowel continence was significantly associated with employment (p = 0.0002), private insurance (p = 0.0098), non-myelomeningocele type of SB (p = 0.0216) and educational attainment (p = 0.0324) on univariate analysis but only with employment on multivariable logistic regression (p = 0.0027). CONCLUSIONS: Bowel management techniques differed between adults and younger patients with SB. Bowel continence was reported by over half of SB adults and was associated with socio-economic factors.

Purpose of the study This study provides benchmarks for likelihood, number of days until, and sequence of functional decline and recovery. Design and methods We analyzed activities of daily living (ADLs) of 296,051 residents in Veteran Affairs nursing homes between January 1, 2000 and October 9, 2012. ADLs were extracted from standard minimum data set assessments. Because of significant overlap between short- and long-stay residents, we did not distinguish between these populations. Twenty-five combinations of ADL deficits described the experience of 84.3% of all residents. A network model described transitions among these 25 combinations. The network was used to calculate the shortest, longest, and maximum likelihood paths using backward induction methodology. Longitudinal data were used to derive a Bayesian network that preserved the sequence of occurrence of 9 ADL deficits. Results The majority of residents (57%) followed 4 pathways in loss of function. The most likely sequence, in order of occurrence, was bathing, grooming, walking, dressing, toileting, bowel continence, urinary continence, transferring, and feeding. The other three paths occurred with reversals in the order of dressing/toileting and bowel/urinary continence. ADL impairments persisted without any change for an average of 164 days (SD = 62). Residents recovered partially or completely from a single impairment in 57% of cases over an average of 119 days (SD = 41). Recovery rates declined as residents developed more than 4 impairments. Implications Recovery of deficits among those studied followed a relatively predictable path, and although more than half recovered from a single functional deficit, recovery exceeded 100 days suggesting time to recover often occurs over many months.

Anorectal malformations (ARM) include congenital anomalies of the distal anus and rectum with or without anomalies of the urogenital tract. Posterior sagittal anorectoplasty (PSARP) and minimally invasive laparoscopically assisted anorectal pull-through (LAARP) procedure are now mainly used to surgically treat ARMs. Magnetic resonance imaging (MRI) is the modality of choice for interval follow-up assessment of structural and functional outcome after these surgeries to assess future bowel continence. Well-developed pelvic musculature has been found to be a reflector of better anal continence after ARM surgery. Thus, MRI plays an important role in evaluating the external sphincter complex, puborectalis, and levator ani muscles. Other parameters that need to be noted include the position of the neoanus, rectal diameter, anorectal angle, presence or absence of megarectum, and other ancillary anomalies in the spine. Thus, MRI due to superior soft-tissue resolution is the modality of choice and indispensable for post-operative pelvic evaluation in children.

The primary physiologic function of the posterior pelvic floor is bowel continence and evacuation. The muscles of the pelvic floor act as both a supportive base for the abdominal viscera and provide mechanisms for continence. The bony pelvis provides the attachments for these muscles that surround the external orifices. These muscles are innervated by both the parasympathetic and sympathetic nervous systems. Dysfunction of the pelvic floor contributes to morbidity and decreased quality of life in many patients, especially the geriatric population. Baseline pelvic floor muscle tone and neurologic integrity both play a role in the maintenance of fecal continence. In addition, there can be variation in the regulation of stool due to systemic disease, bowel motility, stool consistency, as well as cognitive and emotional factors. Understanding the anatomy, innervation, and reflexes of the pelvic floor and anal sphincters is the key to assessing disorders of continence and treating this patient population.

Toilet training is a social learning process requiring interactions between young children and their parents and caregivers over extended periods of time, typically in the first 2 to 4 years of life. It is a complex process involving both developmental maturation and learning, and not all children respond sufficiently to the conventional techniques encountered in their specific family and cultural context to achieve excretory continence and culturally appropriate toileting practices (Kaerts et al., Scandinavian Journal of Urology and Neophrology 46:424–430, 2012). Thus, for some, additional strategies are needed in order for continence and toileting to be learned (Kaerts, et al., Scandinavian Journal of Urology and Neophrology 46:424–430, 2012). Such strategies may include motivating and prompting the behavior, manipulation of antecedent stimulus control, and/or facilitative environmental modifications, as well as providing salient consequences for correct performance. In this chapter, selected strategies will be described, guidelines for implementing them provided, and the research base supporting their use evaluated. First, to put these intervention options in context, the chapter begins with a brief biobehavioral analysis of the development of bladder and bowel continence and of the key skills that must be acquired for toileting to be done reliably and independently.

Introduction: Myelomeningocele patients deal with multiple medical issues, including lower extremity neurological deficits, bowel and bladder incontinence and the sequelae of hydrocephalus secondary to a Chiari II malformation. In utero intervention holds the promise of reversing some of the sequelae and improving outcome. Material and Methods: Between 1998 and 2003 (preceding the formal Management of Myelomeningocele Study, MOMS), an initial group of 58 patients underwent in utero repair of their myelomeningocele between 21 and 25 weeks' gestation. Long-term (5-year) follow-up has occurred in this cohort of patients. Previous reports have documented decreased incidence of ventriculoperitoneal shunting and neuromotor functioning, showing improved outcomes compared with historical controls. Results: Overall, 4 fetal deaths occurred, while the majority of patients returned for follow-up for up to 5 years after closure. Phone follow-up has also been conducted for those who could not return. To date, 10 patients (18.5%) have successfully toilet-trained, while 2 patients have bowel continence and 1 has bladder continence but requires enemas; 2 patients who successfully toilet-trained developed spinal dermoid cysts requiring surgical resection. Discussion: Historically, in utero repair of myelomeningocele patients yields a greater percentage of patients who have achieved continence compared with those undergoing postnatal repair. The MOMS trial will compare contemporary urological outcomes of those patients undergoing either prenatal or postnatal repair in a randomized fashion. The results of this trial showed a decreased need for ventriculoperitoneal shunting in those patients who underwent in utero repair as well as an improvement in lower extremity function.

Introduction: Elimination disorders consist of enuresis and encopresis. When a child fails to successfully achieve toilet training by the age of five and has repeated voiding of urine on the bed or clothing at least twice per week for at least 3 consecutive months it is called enuresis; while bowel continence if not achieved by age 4 years, is encopresis. This study seeks to determine parental/caregiver concerns and help-seeking behaviors toward elimination disorders. Materials and Methods: This study was cross-sectional and was conducted over a 3-month period from January 2017 to March 2017. Convenience sampling method was adopted, and pretested researchers-administered questionnaires were used. Results: Two hundred individuals were recruited consisting of 104 (52%) males and 96 (48%) females with a male-to-female ratio of 1.1:1. About 194 (97%) of the respondents were aware of elimination disorders, 62 (31.0%) of them reported elimination disorder occurred in their wards, only 24.2% of the caregivers had sought for medical treatment for elimination disorder. Majority of the caregivers did not know the cause of elimination disorder, but 2% of them believed evil spirits were responsible for elimination disorders. Enuresis was the most commonly reported elimination disorder and most occurred at night (80.6%), and none had isolated encopresis. Ethnicity and educational qualification of respondents had no relationship with their help-seeking behavior toward elimination disorder ([Fishers' exact test = 11.337, P = 0.023] and [Fishers' exact test = 8.074, P = 0.089]). Conclusion: Elimination disorders were prevalent; however, few caregivers seek for medical help/treatment, and their help-seeking behavior was not influenced by their ethnicity or educational qualification.

The aim was to evaluate the relationship between age and the impact of pelvic floor disorders (PFD) using a multi-dimensional pelvic floor questionnaire Questionnaire data on 4,311 women attending urogynaecology clinics with PFD were stratified by age into four groups: ≤35, 36–50, 51–65 and >65 years. The symptom frequency (ranging from 0 to 100) was divided in to mild (0–33), moderate (34–67), and severe (68–100) symptoms. Impact scores for equivalent levels of symptom frequency (mild, moderate and severe symptoms) were compared in women of different ages. Overall, bowel continence was associated with the greatest bother and constipation the least. Older women were significantly less bothered by mild to moderate urinary, bowel and vaginal symptoms (except IBS and vaginal capacity) than younger women. There was no difference in the impact of severe symptoms in different ages. In contrast, for sexual symptoms, there was a significant difference in the impact in older women for all grades of severity. Women’s views and attitudes towards symptoms are variable and age is a significant factor. In women attending urogynaecology clinics with pelvic floor symptoms the impact of most symptoms (particularly sexual dysfunction) become less bothersome with age.

Sale P, Mazzarella F, Pagliacci MC, Agosti M, Felzani G, Franceschini M. Predictors of changes in sentimental and sexual life after traumatic spinal cord injury. Objective To investigate changes and identify predictors in interpersonal functioning and sexual life after traumatic spinal cord injury (SCI). Design Prospective, multicenter, follow-up observational study. Setting Subjects at home, interviewed by phone during a 6-month period, 3.8 mean years after discharge from 24 centers participating in a previous epidemiologic prospective survey. Participants Subjects (N=403) with traumatic SCI. Interventions Not applicable. Main Outcome Measures Dependent variables: satisfaction with sentimental life and satisfaction with sexual life compared with before the injury. Independent variables: demographic (age, sex, marital status, vocational status), SCI related (severity, level, bowel/bladder continence), car-driving ability, perceived quality of life (QoL), and impact of sentimental life, social integration, and vocational status on QoL. Results Satisfaction with sentimental life was reportedly increased or the same as before SCI in 69% of the sample, but satisfaction with sexual life in only 31%. Lesser satisfaction with sexual life was reported by men than women ( P =.002) and by married people than singles ( P R 2 =.195). Bladder continence was positively associated with a better satisfaction with sexual life ( R 2 =.368). Bowel continence did not remain a significant predictor of satisfaction with sexual life in multivariate analysis. Conclusions The challenge of a comprehensive rehabilitation of SCI, addressing the recovery of well-being including a satisfying sentimental and sexual life, requires identifying new issues that should be considered in up-to-date rehabilitation programs. The results indicate associations between driving ability and a better satisfaction with sentimental life. Further investigations are needed to explore whether the relationship is causative.

of an underlying problem and is defined as involuntary leakage or any involuntary loss of faeces (solid or liquid) that is a social or hygienic problem (National Institute for Health and Care Excellence), 2007). FI and/or urgency is thought to affect approximately 10% of adults in the UK (NICE, 2007) and this can have a devastating impact on quality of life. Prevalence increases with age and in some patient groups (Box 1). Outside these groups, it is more common in women, where it is usually associated with obstetric injury to the pelvic floor. It is also a frequent complication of pelvic organ prolapse, colonic resection or anal surgery, pelvic radiotherapy and ingestion of some medications. FI is often more difficult to control if the patient has loose stool or diarrhoea (NICE, 2007). Bowel continence requires an individual to sense when the rectum is filling, store the faecal material for a period of time and prevent unwanted leakage from the anus. Bowel continence is maintained by the closure of the internal and external anal sphincters and adequate functioning of the muscles of the pelvic floor (Woodward, 2012). Neurological disorders or trauma can result in faecal incontinence as the nervous supply to the muscles of the pelvic floor and anal sphincters is impaired. This may result in a lax anus and passive leakage, depending on the level of neurological damage (Norton and Chelvanayagam, 2004). In some cases of faecal incontinence the pelvic floor and anal sphincter muscles are intact and functioning normally. Faecal incontinence can also occur as the result of other factors such as profuse diarrhoea, constipation and faecal impaction (which distends the anal sphincters) with faecal fluid overflow. Loss of motivation to maintain continence or cognitive decline can also result Supporting patients to manage faecal incontinence

Summary Introduction The attainment of continence is an important milestone in all children, including those with disability. Objective To describe the age of bladder and bowel continence in children with bilateral cerebral palsy (BCP), and the association with intellectual impairment (II) and severity of motor disability. Patients and methods The parents of 346 children with BCP were interviewed as part of a population-based prospective study of the children at 3, 7, and 17 years of age. The age of bladder and bowel continence by day and night was ascertained and compared with controls from the Avon Longitudinal Study of Parents and Children (ALSPAC). Results The median age for daytime bladder and bowel continence in BCP children was 5.4 years compared with 2.4 years in the controls. At 13.8 years of age, 59.4% of BCP children and 99% of controls were continent by day. In BCP children, there was no difference between the attainment of daytime bladder and bowel control. Night-time bladder and bowel control was slower and less completely attained, with 50% of BCP children continent by the age of 11.8 years compared with 3 years in control children. At 13.8 years of age, 51.9% of BCP children compared with 99.4% of controls were continent for bowel and bladder at night. Gross Motor Functional Classification Score (GMFCS) and intellectual ability (IA) (II) were strongly associated with continence attainment (P Discussion Delayed and less complete continence attainment was noted in other clinic series of children with cerebral palsy (including hemiplegics) and children with II. Severity of motor disability (GMFCS), and II impacted on other aspects of toilet training, such as: motivation, understanding, communication, and independence skills. The presence of neurogenic bladder and bowel dysfunction can occur in all levels of GMFCS. Thus, there are many reasons that can prevent continence attainment. Conclusions Children with BCP achieved day and night-time bladder and bowel continence more slowly and less completely than controls, with 60.8% being continent by day and 54.6% by night at the age of 17 years. The majority of BCP children who were continent by day had achieved this by the age of 5.5 years (86%). At least 88% of BCP children with GMFCS I/II and normal, specific or mild learning impairment were continent for bladder and bowel by day and night. Expectations should be shared with parents, and failure to attain expected continence should be actively investigated.

Background and aims:\ud Faecal incontinence (FI) related to inflammatory bowel disease (IBD) affects up to 74% of patients and is often under-reported in clinical encounters. A previous study found that several important bowel function concerns of patients with IBD are not addressed by existing FI questionnaires, especially differences between symptoms in relapse and remission. We have therefore adapted an existing FI assessment questionnaire specifically for patients with IBD.\ud \ud Methods:\ud A total of 190 people participated in this study. Phase 1 (development): the initial draft of the new questionnaire was developed from previously collected data and from results of a modified Delphi survey of IBD clinicians; questions were refined through six rounds of cognitive interviewing (n=24). Phase 2 (validation): the final version was tested (n=166) and retested (n =143) 3–4 weeks later.\ud \ud Results:\ud Missing data were minimal (1–4%). Weighted kappa analysis showed moderate-to-good agreement for test–retest data. Factor rotational analysis revealed the relationship of questions with each other. The new questionnaire has two domains: ‘Symptoms’ and ‘Quality of Life’, recording remission and relapse scores with simple summary scores for each. An additional 10 stand-alone questions address issues of specific concern to patients with IBD. The questionnaire demonstrates the ability to capture changing symptoms and concerns between remission and relapse.\ud \ud Conclusion:\ud The new questionnaire has good content validity and is stable and reliable. Further testing to establish sensitivity to change is needed. The scale can be used by patients, researchers and practitioners to assess severity, fluctuation and impact of IBD-related FI.

This article reviews the developmental considerations involved in helping the family of a child with spina bifida who needs to achieve bowel continence. Strategies for success based on an algorithm are interwoven throughout the discussion. The current medications and techniques used at the developmentally appropriate times designed for optimal success are presented.

The urologist plays an important role in the multidisciplinary team of physicians who provide care for patients with spina bifida. We review common strategies for managing the urinary tract in these patients. The primary objective in all phases of life is protecting kidney function by minimizing bladder hostility and establishing a good capacity, low-pressure urinary reservoir. Ensuring adequate bladder and bowel continence is also paramount for enhancing self-esteem and independence. Medical therapy incorporating clean intermittent catheterization and antimuscarinic medication is the cornerstone of neurogenic bladder management and often the only intervention required to achieve the above goals. Others may require formal lower urinary tract reconstruction to prevent urinary tract deterioration. As will be shown, current management, while effective, is not supported by strong evidence-based protocols; and the impact of any intervention upon quality of life, while subjectively seen as positive, does not have objective validation. These limitations are recognized and currently the subject of urologic investigation.

BACKGROUND:A National Spina Bifida Patient Registry (NSBPR) was begun in 2009 to help understand the natural history of spina bifida (SB) and the effects of treatments provided by SB clinics. We used the NSBPR to explore the relationship of sociodemographic characteristics with SB outcomes.METHODS:Using NSBPR data collected in 2009 to 2012, we examined the unadjusted association between demographic characteristics and 4 SB outcomes: bowel continence, bladder continence, mobility, and presence of pressure sores. We then developed multivariable logistic models to explore these relationships while controlling for SB clinic, SB type, and level of lesion.RESULTS:Data were available on 2054 patients CONCLUSIONS:Sociodemographic attributes are associated with SB outcomes. In particular, males, non-Hispanic blacks, and patients without private insurance have less favorable outcomes, and age has an impact as well. These characteristics need to be considered by clinicians who care for this patient population and factored into case-mix adjustment when evaluating variation in clinical and functional outcomes among different SB clinics.

Increasingly, the prevention and management of radiotherapy side-effects have become a fundamental part of the care given to patients diagnosed with cancer. Pelvic IMRT in anal cancer allows sparing of normal tissues, such as genitalia, bowel and bladder, at least in terms of dose-volume data [2]. However, the effect on patient outcomes is what matters and for this reason it is important to quantify toxicity in these structures and collect specific data to provide a baseline against which the outcomes for future technical developments can be compared. Furthermore, at the present time we have few quantitative data to provide patients with more details regarding expected long-term consequences and to ensure that consent is truly informed [1e3]. We conducted a post-IMRT follow-up on a cohort of patientsdiagnosedwithanalcancerandtreatedwithIMRTsince late 2010 to assess late side-effects and chronic symptoms. We used validated questionnaires including Inflammatory Bowel Disease Questionnaire (IBDQ), IBDQ-B, Vaizey and a pelvic symptom questionnaire, which take into account not only symptoms but also the patient’s feelings and perception of disease and side-effects, and the effect on normal life [4,5]. From a preliminary analysis of our data, most patients maintained good bowel continence and the treatment was also well tolerated in terms of genitalia toxicity. Over a 3 year follow-up period, IBDQ, IBDQ-B and Vaizey scores appeared to be either stable or improving, indicating no progressive change in function.

This study was designed to determine whether patients with fecal incontinence and endoanal ultrasound evidence of anal sphincter disruption may be successfully treated by sacral nerve stimulation. Five consecutive females with incontinence to solids and endoanal ultrasound evidence of anal sphincter disruption were treated by a two-week trial of sacral nerve stimulation. If successful, patients then proceeded to permanent sacral nerve stimulation implantation. Five patients, aged 34 to 56 years, were treated by temporary sacral nerve stimulation. Four had symptoms starting after childbirth. Two had previously had an anterior sphincter repair. After a two-week trial, three females reported full continence and an improvement in all aspects of their Rockwood fecal incontinence quality of life scores. These three females underwent permanent sacral nerve stimulation implantation. The remaining two patients reported no improvement and underwent dynamic graciloplasty or end colostomy respectively. Sacral nerve stimulation may successfully restore bowel continence in some patients with endoanal ultrasound evidence of a defect in their external anal sphincter.

To survey Canadian health care professionals about their willingness to offer elective cesarean delivery and to evaluate how their knowledge of obstetric-related pelvic-floor injury influences their practice. A voluntary questionnaire was distributed to health care professionals attending the 58th Annual Meeting of the Society of Obstetricians and Gynaecologists of Canada in 2002. Appropriate statistical analysis was used. One hundred and sixty-two questionnaires were completed. One hundred respondents were female (62%). Twenty-three percent (37/162) of respondents approved elective cesarean delivery after informed request in nulliparous women without an obstetrical indication. Males were more likely than females to perform cesarean delivery in these circumstances (34% versus 16%; OR 2.7, CI 1.2, 6.0). When questioned about the impact of mode of delivery on bladder and bowel continence, the number of respondents who answered "usually" or "always has a detrimental effect" were: vaginal birth, 16%; forceps, 20%; and cesarean delivery "reduces bladder and bowel problems", 44%. Males were more likely to emphasize a protective effect of cesarean delivery (55% versus 38%; OR 1.9, CI 1.0, 4.0). Health care professionals would opt for cesarean delivery for themselves when forceps delivery was the alternative more often than they would offer cesarean delivery to their patients (OR 1.98, CI 1.1, 3.5). While a significant number of women's health care professionals are prepared to offer cesarean delivery to nulliparous women, informed choice seems to motivate the offer rather than a conviction that cesarean delivery will protect the pelvic floor.

This research compares profiles of residents with multiple sclerosis (MS) at admission to the nursing facility with profiles of these same residents one year later using the Minimum Data Set (MDS) to determine how their health and care received changed after one year in the facility. We matched MDS admission assessments with their first annual assessment for 1309 residents with MS. These residents with MS demonstrated deterioration in cognitive performance, communication skills, motor performance and bladder/bowel continence after one year in the facility. However, the proportion of residents with urinary tract infections and the proportion of residents with pressure ulcers declined after one year. A significantly larger proportion of these MS residents had a diagnosis of depression one year after admission, with significantly increased use of antipsychotic and antidepressant medications but little and declining use of psychological therapy after one year in the facility. In addition, there was a significant decline after one year in the use of physical, occupatio nal, and speech therapies. These longer stay residents with MS may benefit from support services directed toward mental health and increased use of physical, occupational and psychological therapies provided in the nursing facility.

For thousands of years, anal complaints were treated symptomatically with ointments, suppositories and, in isolated cases, even surgically. Since the middle of the last century injection sclerotherapy has been by far the most widespread out-patient treatment for the very common haemorrhoidal disease. This is based on the notion that haemorrhoids are varicosities, and while this idea has been contested by the theory of a spongy body for over 200 years, it is nonetheless only in the last 40 years that the spongy body theory has become accepted, giving rise to further important functional investigations on the anal structures involved in bowel continence and to rational treatment for haemorrhoids. The conditions necessary for out-patient treatment of haemorrhoids and the options available are presented in this paper and discussed with reference to acceptance, inherent risks, and the possible complications. While diet and behavioural methods, and also anal dilatation and treatment with ointments, can be managed by the patient without any problems, regardless of how effective sclerotherapy and rubber band ligation are, these involve risks whose ramifications are often underestimated. One operative procedure that may well become established as an effective out-patient method in the future is Doppler-guided isolated haemorrhoidal artery ligation (HAL) after Morinaga. Traditionally, day surgery is not so well accepted for haemorrhoidectomy in Germany; unless the operation planned is not very extensive, in-patient treatment is still considered preferable.

Purpose: The aim of this study was to evaluate the outcomes of reconstruction of all cloacal exstrophy cases seen by the authors from 1974 to 1999. Methods: A retrospective chart review and personal follow-up was conducted on all 50 patients, who ranged in age from newborn to 35 years. Thirty-eight were secondary cases, 12 were primary (no previous surgery). Twenty-eight (56%) were genetic boys; 6 were raised as boys and 22 as girls. Forty patients underwent extensive reconstructive surgery; 6 await reconstruction, and 4 were seen only in consultation. For urinary continence, 21 had bladder neck narrowing, 7 received a bowel nipple, and 12 had a Mitrofanoff catheterizable conduit on the abdominal wall, using tapered intestine in 8, ureter in 3 and the appendix in 1. Four patients had a urostomy. Bladder augmentation was performed in 35 patients (18 with stomach, 11 small bowel, and 6 with both). Twenty-five patients had pull-through of their colon to the perineum. Thirty-two have had a vagina constructed. Forty-seven of the 50 patients had spinal cord tethering, and most underwent neurosurgical release. Results: Overall survival rate was 98%; 1 patient died preoperatively at another institution. Acceptable bowel continence was achieved with enema washouts in 19 of 25 pullthroughs; 4 failed and were reversed. One case is too recent to judge. Of 40 reconstructed cases, 31 were dry, 3 had slight leakage, and 1 is too early to evaluate. Five had enough leakage to require further surgery. Conclusions: The once hopeless anomaly of cloacal exstrophy is treatable with extensive reconstructive surgery. Continence of urine (mainly by catheterization) and stool (mainly by enema washouts) is achievable in most. The hindgut, including the cecum and the usually rudimentary distal colon, should be saved and used as colon, not for urinary or vaginal reconstruction. In genetic boys, the authors continue to believe that gender assignment should depend on the likelihood for reconstructing an adequate phallus. J Pediatr Surg 36:68-75. Copyright © 2001 by W.B. Saunders Company.

Bowel continence is one of the most difficult challenges for patients with spina bifida. Incontinence acts as a social stigma for children and a barrier for adults seeking employment. We present an algorithm for stepwise decision-making in construction of personalized continence programs for greater likelihood of success. The protocol contains 13 assessment points including; stool consistency, frequency and amount; mobility; level of paraplegia: diet; medication; anal/rectal canal tone; prior programs attempted; family routines; age; accessibility; and learning issues. Based on outcomes of these assessments, an individualized bowel program is constructed. The algorithm helps the practitioner and patient decide on components and indicators of a successful continence program. The recommended program might include timed toileting, suppository, continence enema, and ACE procedure, or a combination. Evaluation and patient education address adequate fluid/fiber, appropriate toileting equipment, and use of stool softeners/laxatives. Descriptions are available. Key elements in monitoring a continuing plan for continence include: the degree of constipation and its etiology; changing age; family availability for assistance until interdependence is optimal; wheelchair accessibility of the toilet; and ability to transfer to and from the toilet. Use of the algorithm allows for careful decision-making based on information from the patient and family. This has led to greater success in bowel continence in children with spina bifida.

Although many rehabilitation clients have neurogenic bowels requiring special bowel protocols, a review of the literature affirmed the authors' assumptions and experiences as professional nurses that any bowel program must begin with a good nursing assessment, a clean bowel, and eight keys to success. Once these criteria are met, bowel care can be individualized to meet the needs of the specific patient. This article presents a review of the literature and provides references for nurses seeking additional information on bowel programs.

Biofeedback is an effective treatment for anal sphincter dysfunction in many cases of childhood constipation and soiling. Conventional methodologies centre on clinic-based manometric apparatus but are compromised by equipment being thinly available and practice sessions often infrequent. To counter these shortcomings, we have designed a portable anorectal biofeedback apparatus (the Easograph) for domiciliary use. It can be lent to families, enabling carers to mediate what is an intrinsically sensitive procedure. In this paper, we provide a technical description of the device which is based on an inexpensive pressure transducer. Casework experience suggests it is reliable in operation and readily understood by users. In a pilot study of eight patients treated with the apparatus, five achieved bowel continence after lifelong soiling in one to eight weeks of daily practice. We believe this is an innovative approach that has good potential for treating faecal retentive and expulsive disorders in childhood associated with poor anal sphincter control.