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Aims Neurodevelopmental disorders (NDs) are incapacitating disorders, which begin early in life, are mainly caused by genetic and neurobiological factors, and show a tendency to persist. They are associated with higher rates of incontinence in children and adolescents, including nocturnal enuresis, daytime urinary incontinence, fecal incontinence, and constipation. Without diagnosis and treatment, they will interfere with incontinence treatment leading to less favorable outcomes. The aim of this International Children's Continence Society (ICCS) document is to provide an overview of the three most important NDs, that is, attention-deficit/hyperactivity disorder, autism spectrum disorder (ASD), and intellectual disability (ID). Methods This consensus paper was commissioned by the ICCS. A selective, nonsystematic review was performed. Guidelines, reviews, and selected studies were included. The recommendations are consensus-based. Results ADHD is the most common ND with special relevance in clinical practice. ASD and ID are less common, but more severe disorders than ADHD. Basic principles of the assessment and treatment of NDs are provided. Incontinence is common among patients with NDs. Specific modifications and practical approaches in the treatment of incontinence in children with NDs are outlined. Conclusions Incontinence in children and adolescents with NDs is common. Effective treatment of incontinence should be adapted and modified to the specific needs of patients with NDs. A multiprofessional approach is recommended.

Summary Background Urotherapy is an umbrella term for all non-surgical, non-pharmacological interventions for lower urinary tract disorders (LUTD) in children and adolescents. Urotherapy is a specialized practice, which has become mainstay therapy not only for daytime urinary incontinence, but also for nocturnal enuresis, functional constipation and fecal incontinence. The aim of urotherapy is to achieve the normalization of the micturition and bowel pattern and to prevent further functional disturbances by repeated training. It is well known that in the treatment of adult and childhood incontinence a team approach is best, where there are shared areas of expertise and also discipline-specific expertise available. Aim We present a consensus view from a cross-professional team of experts affiliated with the International Children's Continence Society on definitions, indications and practice of urotherapy. This is a selective, non-systematic review with practical recommendations for the implementation and research on urotherapy. Methods The document uses the globally accepted ICCS terminology. Evidence-based literature serves as the basis, but in areas lacking in primary evidence, expert consensus is used. Before submission, a full draft was made available to all ICCS members for additional comments. Results Urotherapy uses non-pharmacological, non-surgical methods and focuses on behavioral interventions, largely based on cognitive-behavioral psychotherapy (CBT). Standard urotherapy comprises components such as provision of information, instructions, life-style advice, counselling and registration of symptoms. Specific urotherapy is tailored towards specific disorders and includes alarm treatment, biofeedback training, pelvic floor training, neurostimulation and other interventions. Fig. 1. Urotherapy is a treatment that addresses all aspects of incontinence, leading to the best clinical outcome. This includes somatic, psychosocial, and behavioral problems and quality of life. Therefore urotherapy is recommended by the ICCS as the first-line treatment for most types of LUTD. The document is intended to be clinically useful in primary, secondary and tertiary care. Download : Download high-res image (226KB) Download : Download full-size image Summary Figure 1 . Daytime urinary incontinence and enuresis.

Lower urinary tract symptoms (LUTS) are common in children, with underlying conditions including overactive bladder, underactive bladder, voiding postponement and dysfunctional voiding. Evaluation for potential LUT dysfunction involves a thorough history of bladder and bowel symptoms, physical examination and assessment of voiding. Treatment is multimodal and multidisciplinary. Approaches need to be tailored to the individual child and refined in view of response.

Nocturnal enuresis remains a prevalent clinical problem in childhood and adolescence. Despite a natural resolution rate, the potential for adverse psychosocial impacts of enuresis on a child’s development mandates thorough evaluation and effortful treatment. This chapter reviews contemporary concepts of pathogenesis and management.

Little research has been undertaken regarding pelvic floor muscle function and dysfunction in children. Apart from dysfunctional voiding, whether specific dysfunction of these muscles contributes to different types of childhood incontinence is not documented. The two areas of practice, that is adult and paediatric incontinence, are quite different; nevertheless, there may be lessons to be learned from the extensive work done in pelvic floor dysfunction and rehabilitation in adults. In this paper key points regarding pelvic floor muscle function and dysfunction in adults, and lessons that can be learned from how studies are reported and how muscle function is measured are presented. The aim is to prompt deeper thought regarding the direction in which further research in children may proceed. There are challenges in first validating muscle measurement standards and making the work relevant to children across different age groups with differing cognitive and motor abilities.

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

Purpose: We updated the terminology in the field of pediatric lower urinary tract function. Materials and Methods: Discussions were held in the board of the International Children's Continence Society and an extensive reviewing process was done involving all members of the International Children's Continence Society, the urology section of the American Academy of Pediatrics, the European Society of Pediatric Urology, as well as other experts in the field. Results and Conclusions: New definitions and a standardized terminology are provided, taking into account changes in the adult sphere and new research results.

Summary Purpose We reviewed and collated information concerning the available tools for the measurement of symptoms and outcomes in pediatric continence. Materials and methods MEDLINE, EMBASE, and CINHAL databases were searched for relevant articles published prior to December 2016 and independently screened by two researchers. Expert opinion was also widely sought through consultation with the ICCS Board membership and their professional networks and the multidisciplinary authorship group. The most relevant materials were then selected for analysis and inclusion and resulted in a document available on the ICCS website for all members to review. Insights and feedback were considered with consensus and agreement reached to modify the document. Results and conclusions A variety of useful tools for the assessment and measurement of bladder and bowel dysfunction and quality of life and behavioral comorbidities are presented together with their indications and potential pitfalls. ICCS cannot recommend one over another as the most useful for each clinician will vary depending on the clinical setting, available time, and patient population. We provide a framework for choosing those that are most appropriate based on our findings.

PURPOSE: We present a consensus view of members of the International Children's Continence Society (ICCS) together with pediatric gastroenterologists, experts in the field of functional gastrointestinal disorders, on the management of functional constipation in children with lower urinary tract symptoms.MATERIALS AND METHODS: Discussions were held by the board of the ICCS and a multidisciplinary core group of authors was appointed. The draft document review process was open to all ICCS members via the website. Feedback was considered by the core authors and, by agreement, amendments were made as necessary.RESULTS: Guidelines on the assessment, and pharmacological and nonpharmacological management of functional constipation in children with lower urinary tract symptoms are outlined.CONCLUSIONS: The final document is not a systematic literature review. It includes relevant research when available, as well as expert opinion on the current understanding of functional constipation in children with lower urinary tract symptoms. The document is intended to be clinically useful in primary, secondary and tertiary care settings.

In slow-transit constipation (STC) pancolonic manometry shows significantly reduced antegrade propagating sequences (PS) and no response to physiological stimuli. This study aimed to determine whether transcutaneous electrical stimulation using interferential current (IFC) applied to the abdomen increased colonic PS in STC children.Eight children (8-18 years) with confirmed STC had 24-h colonic manometry using a water-perfused, 8-channel catheter with 7.5 cm sidehole distance introduced via appendix stomas. They then received 12 sessions (20 min/3× per week) of IFC stimulation (2 paraspinal and 2 abdominal electrodes), applied at a comfortable intensity (40 mA, carrier frequency 4 kHz, varying beat frequency 80-150 Hz). Colonic manometry was repeated 2 (n=6) and 7 (n=2) months after IFC.IFC significantly increased frequency of total PS/24h (mean ± SEM, pre 78 ± 34 vs post 210 ± 62, p=0.008, n=7), antegrade PS/24h (43 ± 16 vs 112 ± 20, p=0.01) and high amplitude PS (HAPS/24h, 5 ± 2:10 ± 3, p=0.04), with amplitude, velocity, or propagating distance unchanged. There was increased activity on waking and 4/8 ceased using antegrade continence enemas.Transcutaneous IFC increased colonic PS frequency in STC children with effects lasting 2-7 months. IFC may provide a treatment for children with treatment-resistant STC.

Aims To review studies using electrical neural stimulation (ENS), to treat children with non-neurogenic lower urinary tract dysfunctions (LUTD), and to establish the efficacy of this treatment. Methods This review was based on an electronic search of the MEDLINE database and the Cochrane Central Search library, from January 1990 to March 2010. Inclusion criteria: (1) participants aged 0–17 years, (2) participants with a diagnosis of LUTD not related to congenital abnormalities or neurological disease, (3) English language, and (4) treatment by ENS. Results Seventeen papers were evaluated. Type of ENS varied among studies: sacral transcutaneous ENS in seven, sacral implanted device in four, posterior tibial percutaneous in three, and anogenital, endoanal, and intravesical in one each. There were two randomized clinical trials. Clarity regarding the LUTD being treated was variable. The populations studied were not homogeneous. The duration of treatment and the number of sessions a week were variable among the studies. Electrical parameters used also varied. A range of subjective and objective measures was used to measure treatment success. Rates of complete resolution of the symptoms of OAB, urgency, and daytime incontinence ranged from 31% to 86% [Trsinar and Kraij, Neurourol Urodyn 15: 133–42, 1996; Hagstroem et al., J Urol 182: 2072–8, 2009], 25% to 84% [Hoebeke et al., J Urol 168: 2605–8, 2002; Lordelo et al., J Urol 182: 2900–4, 2009], 13% to 84% [Malm-Buatsi et al., Urology 70: 980–3, 2007; Lordelo et al., J Urol 184: 683–9, 2010], respectively. For sacral transcutaneous ENS recurrence ranged from 10% to 25%. Apart from the sacral implantation studies, any reported side effects were mild and transitory. Conclusions The literature in the area of interest is sparse. Parasacral TENS has been shown to be more effective than sham in randomized trials in treating OAB. This deserves further research to elucidate the optimal parameters and the children for whom it is most useful. Neurourol. Urodynam. Neurourol. Urodynam. 30: 1429–1436, 2011. © 2011 Wiley Periodicals, Inc.

We evaluated long-term outcomes in boys treated for hypospadias at Royal Children's Hospital, Melbourne.Boys who underwent hypospadias surgery were reviewed at ages 13 to 15 years. Surgical results were evaluated using the Hypospadias Objective Scoring Evaluation. Lower urinary tract function was assessed using uroflowmetry and symptom questionnaire. Self-report surveys measured quality of life, patient satisfaction, memory of surgery, psychosexual outcomes and parent satisfaction with care.By Hypospadias Objective Scoring Evaluation score 80% of patients had an excellent surgical outcome. Two independent reviewers assessed lower urinary tract function as normal in 82% and 86% of cases, respectively. Quality of life scores were comparable to published values in normal children. Parents rated the institution highly. Overall 90% and 81% of boys were satisfied with the body and genital appearance, respectively. Those dissatisfied with genital appearance had poorer psychosexual outcomes than satisfied patients. When surgery was completed before age 5 years, boys had no perioperative memories. An association was found between no recollection of surgery and satisfaction with body appearance.Objective surgical and functional outcomes are excellent after early surgery. Post-repair quality of life is comparable to published data on normal children. Parents are pleased with care. Most boys are satisfied with the body and genital appearance. However, those dissatisfied with genital appearance must be identified in the interest of psychosexual development. The association between no recollection of treatment and satisfaction with body appearance suggests that surgery should be completed before age 5 years when possible to allow the development of good body image in adolescence.

Background Slow transit constipation (STC) causes intractable symptoms not responsive to medical treatment. Children have irregular bowel motions, colicky abdominal pain, and frequent soiling. Transcutaneous electrical stimulation using interferential current (interferential therapy [IFT]) is a novel treatment of STC. This study assessed quality of life (QOL) in STC children before and after IFT treatment. Methods Eligible STC children were randomized to receive either real or placebo IFT (12 sessions for 4 weeks). Questionnaires (Pediatric Quality of Life Inventory) were administered before and 6 weeks after treatment, with parallel parent and child self-report scales. Higher scores indicate better QOL. Holschneider and Templeton scores were also obtained. The QOL scores were compared using paired t tests. Results Thirty-three children (21 male), with a mean age of 11.8 years (range, 7.4-16.5 years), were recruited; 16 received real IFT. Child-perceived QOL was improved after real IFT compared with baseline (81.1 vs 72.9, P = .005) but not after placebo IFT (78.1 vs 74.9, P = .120). The Holschneider score improved after real IFT (10 vs 8, P = .015) but not after placebo IFT (9 vs 8, P = .112). Parentally perceived QOL was similar after real IFT (70.1 vs 70.3, P = .927) and placebo IFT (70.2 vs 69.8, P = .899). There were no differences in Templeton scores. Conclusion Interferential therapy is a novel therapy for children with STC that improves their self-perceived QOL.

Purpose Slow transit constipation (STC) is a form of chronic constipation, with delayed colonic passage of stool. Possible etiologies include reduced neurotransmitter levels, reduced interstitial cells of Cajal density, or a disorder of connective tissue (CT) synthesis. A common CT disorder is generalized joint hypermobility (GJH). This study aimed to investigate whether there was a greater prevalence of GJH among patients with STC than controls. Methods Children (aged 7-17) diagnosed with STC by radio/nuclear transit study were recruited from outpatient clinics. Controls (no history of constipation) were recruited from outpatient clinics and a scout jamboree. Hypermobility was assessed using the Beighton score (4 or more=hypermobile). This project received ethical approval by the human research ethics committee. Results Thirty-nine STC subjects and 41 controls were measured. Of 39 STC subjects, 15 (38%) were hypermobile, compared to 8 (20%) of 41 controls ( P = .06). Analyzed by gender, 10 (38%) of 26 STC males and 1 (4%) of 23 control males were hypermobile ( P Conclusions These results show that GJH is higher in STC children, particularly males, suggesting that a disorder of CT synthesis plays a role in the etiology of STC. Further research is required to ascertain the nature of any relationship and how this knowledge may aid our understanding and treatment of STC.

Successful management of dysfunctional voiding in children hinges on retraining inappropriate pelvic floor muscle recruitment. Recently dynamic pelvic floor muscle activity was visualized in adults using transabdominal ultrasound. We evaluated transabdominal ultrasound for visualizing and measuring pelvic floor muscle activity in normative children.A total of 21 volunteers, including 10 boys and 11 girls 7 to 16 years old (mean age 11.6) who were free of bladder disorders consented to participate in the study. Subjects were screened and demonstrated normative bladder emptying before being imaged while supine and standing using a sagittal curved linear array 2 to 5 MHz transducer over the suprapubic region. After pelvic floor muscle contraction was explained 4 parameters were measured 3 times each, including the direction of movement/displacement from freeze-frame ultrasound images, and endurance and coordination from ultrasound movie loops. The methodology for digitizing movie data were developed, tested and found to be reliable. New variables of endurance as a percent of maximum coordination amplitude and coordination as the amplitude between maximum and minimum effort were created.Overall 66% and 71% of subjects demonstrated anterior displacement of the pelvic floor during voluntary contraction while lying and standing, respectively, with no significant difference in lying vs standing. However, coordination displacement was greater while lying than standing. During 20-second contractions pelvic floor muscle activity attained peak amplitude at 5.5 seconds, followed by a marked decay with 1 or more cycles of muscular re-recruitment. It was observed that fatigue led to repeat recruitment of the rectus and oblique abdominal muscles.In children free of voiding dysfunction pelvic floor displacement and coordination are highly variable. Noninvasive ultrasound of the pelvic floor provided visual assessment of muscular activity, a biofeedback component for the patient and measurement potential for the therapist.

Background: Chronic constipation in children may have organic or behavioral causes. The purpose of the present study was to investigate the effect of treatment with transcutaneous electrical stimulation (using interferential current) in children with chronic treatment-resistant constipation with proven organic disorders. Methods: Eight children (7–16 years) with at least 4 years of chronic treatment-resistant constipation and soiling, who had failed diet, laxative treatment and behavioral therapy were given 1 month of transcutaneous electrical stimulation. The three most severe cases had appendicostomies with antegrade washouts every 2–3 days to prevent impaction and reduce their soiling. Children and carers kept a daily diary of bowel habits, recording number of spontaneous defecations, episodes of soiling, use of bowel washouts and medications. Transcutaneous stimulation using interferential current was applied three times per week for 3–4 weeks using four surface electrodes, two to the paraspinal area of T9–10 to L2 and one to either side of the anterior abdominal wall beneath the costal margin. Diaries were recorded for 1 month before, during, and after stimulation and for 2 weeks 3 months later. Results: Transcutaneous electrical stimulation using interferential current stopped soiling in 7/8 children and increased the frequency of spontaneous defecations in 5/8. Defecations remained high and soiling low for 3 months in 3/6 children (with data). Conclusions: These results suggest that transcutaneous electrical stimulation using interferential current has a beneficial effect for children with chronic treatment-resistant constipation. Further trials using larger series of patients are needed to confirm this benefit, to determine the ideal stimulation parameters and to investigate why electrical stimulation might be effective. © 2005 Blackwell Publishing Asia Pty Ltd

PURPOSE: The impact of the original International Children's Continence Society terminology document on lower urinary tract function resulted in the global establishment of uniformity and clarity in the characterization of lower urinary tract function and dysfunction in children across multiple health care disciplines. The present document serves as a stand-alone terminology update reflecting refinement and current advancement of knowledge on pediatric lower urinary tract function.MATERIALS AND METHODS: A variety of worldwide experts from multiple disciplines in the ICCS leadership who care for children with lower urinary tract dysfunction were assembled as part of the standardization committee. A critical review of the previous ICCS terminology document and the current literature was performed. In addition, contributions and feedback from the multidisciplinary ICCS membership were solicited.RESULTS: Following a review of the literature during the last 7 years the ICCS experts assembled a new terminology document reflecting the current understanding of bladder function and lower urinary tract dysfunction in children using resources from the literature review, expert opinion and ICCS member feedback.CONCLUSIONS: The present ICCS terminology document provides a current and consensus update to the evolving terminology and understanding of lower urinary tract function in children. For the complete document visit http://jurology.com/.

To review studies using electrical neural stimulation (ENS), to treat children with non-neurogenic lower urinary tract dysfunctions (LUTD), and to establish the efficacy of this treatment.This review was based on an electronic search of the MEDLINE database and the Cochrane Central Search library, from January 1990 to March 2010.(1) participants aged 0-17 years, (2) participants with a diagnosis of LUTD not related to congenital abnormalities or neurological disease, (3) English language, and (4) treatment by ENS.Seventeen papers were evaluated. Type of ENS varied among studies: sacral transcutaneous ENS in seven, sacral implanted device in four, posterior tibial percutaneous in three, and anogenital, endoanal, and intravesical in one each. There were two randomized clinical trials. Clarity regarding the LUTD being treated was variable. The populations studied were not homogeneous. The duration of treatment and the number of sessions a week were variable among the studies. Electrical parameters used also varied. A range of subjective and objective measures was used to measure treatment success. Rates of complete resolution of the symptoms of OAB, urgency, and daytime incontinence ranged from 31% to 86% [Trsinar and Kraij, Neurourol Urodyn 15: 133-42, 1996; Hagstroem et al., J Urol 182: 2072-8, 2009], 25% to 84% [Hoebeke et al., J Urol 168: 2605-8, 2002; Lordêlo et al., J Urol 182: 2900-4, 2009], 13% to 84% [Malm-Buatsi et al., Urology 70: 980-3, 2007; Lordêlo et al., J Urol 184: 683-9, 2010], respectively. For sacral transcutaneous ENS recurrence ranged from 10% to 25%. Apart from the sacral implantation studies, any reported side effects were mild and transitory.The literature in the area of interest is sparse. Parasacral TENS has been shown to be more effective than sham in randomized trials in treating OAB. This deserves further research to elucidate the optimal parameters and the children for whom it is most useful.

Transcutaneous electrical stimulation (TES) speeds up colonic transit in children with slow-transit constipation (STC). This study examined if concurrent upper gastrointestinal dysmotility (UGD) affected response to TES. Radio-nuclear transit studies (NTS) were performed before and after TES treatment of STC as part of a larger randomised controlled trial. UGD was defined as delayed gastric emptying and/or slow small bowel transit. Improvement was defined as increase of ≥1 Geometric Centre (median radiotracer position at each time [small bowel = 1, toilet = 6]). Forty-six subjects completed the trial, 34 had NTS after stimulation (21 M, 8–17 years, mean 11.3 years; symptoms >9 years). Active stimulation increased transit in >50% versus only 25% with sham (p = 0.04). Seventeen children also had UGD. In children with STC and either normal upper GI motility (NUGM) and UGD, NTS improved slightly after 1 month (57 vs. 60%; p = 0.9) and more after 2 months (88 vs. 40%; p = 0.07). However, mean transit rate significantly increased with NUGM, but not UGD (5.0 ± 0.2: 3.6 ± 0.6, p

Background and Aim: It appears that there are no published reports on childhood slow transit constipation (STC) that have considered the state of the musculoskeletal components of the trunk in these children. The present study aimed to determine whether children with STC have different trunk musculoskeletal characteristics that might be related to their defecation difficulties, compared to controls. Methods: With the aid of computer-analyzed photographs and clinical testing, 41 children with STC and 41 age-matched controls were examined for Marfanoid features, sitting posture, spinal joint mobility and trunk muscle strength. The latter was assessed by measuring maximum voluntary abdominal bulging and retraction in sitting, and active trunk extension in prone-lying. Levels of general exercise and sedentary activities were evaluated by questionnaire. Results: STC subjects were more slumped in relaxed sitting (P ≤ 0.001), less able to bulge (P ≤ 0.03) and less able to actively extend the trunk (P = 0.02) compared to controls. All subjects sat more erect during abdominal bulging (P ≤ 0.03). Conclusion: The results show that STC children have reduced trunk control and posture, which indicates that clinicians should include training of trunk muscles and correction of sitting posture. There was no evidence that children with STC exercised less than the controls.

Transcutaneous electrical stimulation (TES) (3 sessions/wk) over the abdomen stimulated bowel functions in a randomized controlled trial. This pilot study assessed whether daily TES at home with a safe, portable machine would be possible and more efficacious than trial results.Eleven patients (6 male/5 female; mean age, 14 years; range, 12-18 years) with slow-transit constipation who relapsed or responded poorly in the trial were recruited (11 +/- 5 months later). An EPM-IF-4160 (Fuji Dynamics, Hong Kong) portable machine (sine waveform, 4 kHz carrier frequency, 80-160 Hz beat frequency, intensity33 mA) delivering interferential current (2 electrodes over epigastrium + 2 over kidneys) was applied 1 hour daily at home. Continence diaries were kept for 1 month before and 2 months during treatment.All children completed more than 1 month of treatment after baseline recording. Defecation increased in 9 of 11 children, and soiling decreased in 4 of 11 children. There was a significant increase in total episodes of defecation per week (mean +/- SD, 2.5 +/- 2.1 vs 6.7 +/- 4.4; P = .008) and a nonsignificant decrease in soiling (3.8 +/- 1.6 vs 1.1 +/- 0.5 episodes/wk, P = .1). Daily stimulation does not affect abdominal pain. No adverse events occurred.Daily TES at home is safe and significantly improved bowel function in children who did not respond to 3 times per week of TES. Home TES may be a novel treatment of intractable slow transit constipation, avoiding hospital visits.

Purpose: We present a consensus view of members of the International Children's Continence Society on the management of dysfunctional voiding in children.Materials and Methods: Discussions were held by the board of the International Children's Continence Society and a multi-disciplinary core group of authors was appointed. The draft document review process was open to all International Children's Continence Society members via the web site. Feedback was considered by the core authors and, by agreement, amendments were made as necessary.Results: Guidelines on the assessment, and nonpharmacological and pharmacological management of dysfunctional voiding are presented.Conclusions: The final document is not a systematic literature review. It includes relevant research when available as well as expert opinion on the current understanding of dysfunctional voiding in children.

Slow transit constipation (STC) is a form of chronic constipation characterised by prolonged passage of faecal matter through the colon. It is diagnosed by demonstrating delayed colonic transit on gastrointestinal transit studies. Traditionally, radio-opaque marker studies are performed. Recently, radioisotope nuclear transit studies (NTS) have been used in our centre to assess gastrointestinal transit time. This study aimed to evaluate if there are changes in colonic transit in STC children resistant to standard medical treatment over a prolonged period. Children with STC resistant to standard medical therapy for ≥2 years who had undergone two separate NTS to assess their colonic transit (where the first study had identified slow colonic transit without anorectal retention) were identified after ethical approval. The geometric centre (GC) of radioisotope activity at 6, 24, 30 and 48 h was compared in the two transit studies to determine if changes occurred. Seven children (4 males) with proven STC resistant to standard medical therapy and two transit studies performed at different times were identified. Mean age was 7.0 years (5.4–10.8 years) at first study, and 11.4 years (9.7–14.2 years) at second study, with a mean of 4.4 years (1–8.5 years) between studies. There was no significant difference in colonic transit at any timepoint in the two tests (paired t test). We conclude that nuclear transit studies are reproducible in assessing slow colonic transit in children with treatment-resistant STC and demonstrate that conventional medical treatment over many years has no effect on underlying colonic motility.

Constipation is a common problem in children, with childhood prevalence estimated at between 1 and 30%. It accounts for a significant percentage of referrals to paediatricians and paediatric gastroenterologists. It commonly runs in families, suggesting either an underlying genetic predisposition or common environmental factors, such as dietary exposure. The peak age for presentation of constipation is shortly after toilet training, when passage of hard stools can cause pain on defecation, which then triggers holding-on behaviour in the child. At the time of the next call to stool the toddler may try to prevent defecation by contraction of the pelvic floor muscles and anal sphincter. Unless the holding-on behaviour is quickly corrected by interventions to soften faeces and prevent further pain, the constipation can very rapidly become severe and chronic. Until recently, this mechanism was thought to be the only significant primary cause of constipation in childhood. In this review, we will summarise recent evidence to suggest that severe chronic constipation in children may also be due to slowed colonic transit.

Purpose Idiopathic slow transit constipation (STC) describes a clinical syndrome characterised by intractable constipation. It is diagnosed by demonstrating delayed colonic transit on nuclear transit studies (NTS). A possible new treatment is interferential therapy (IFT), which is a form of electrical stimulation that involves the transcutaneous application of electrical current. This study aimed to ascertain the effect of IFT on colonic transit time. Methods Children with STC diagnosed by NTS were randomised to receive either 12 real or placebo IFT sessions for a 4-week period. After a 2-month break, they all received 12 real IFT sessions—again for a 4-week period. A NTS was repeated 6 to 8 weeks after cessation of each treatment period where able. Geometric centres (GCs) of activity were calculated for all studies at 6, 24, 30, and 48 hours. Pretreatment and posttreatment GCs were compared by statistical parametric analysis (paired t test). Results Thirty-one pretreatment, 22 postreal IFT, and 8 postplacebo IFT studies were identified in 26 children (mean age, 12.7 years; 16 male). Colonic transit was significantly faster in children given real treatment when compared to their pretreatment NTS at 24 (mean CG, 2.39 vs 3.04; P ≤ .0001), 30 (mean GC, 2.79 vs 3.47; P = .0039), and 48 (mean GC, 3.34 vs 4.32; P = .0001) hours. By contrast, those children who received placebo IFT had no significant change in colonic transit. Conclusions Transcutaneous electrical stimulation with interferential therapy can significantly speed up colonic transit in children with slow transit constipation.

Slow transit constipation (STC) causes intractable symptoms not readily responsive to laxatives, diet, or life-style changes. Children with STC have irregular bowel motions associated with colicky abdominal pain and frequent uncontrollable soiling. This study assessed the physical and psychosocial quality of life (QOL) in children with long-standing (or =2 years) STC vs healthy controls.Children (aged 8-18) were recruited from gastrointestinal and surgical clinics and a Scout Jamboree. After informed consent was obtained, the questionnaire (Pediatric Quality of Life Inventory) was administered. This consists of parallel child and parent self-report scales encompassing physical functioning, emotional functioning, social functioning, and school functioning. Higher scores indicate better QOL. P value less than .05 was considered statistically significant.In 51 children with STC (mean, 11.5 years; male/female, 2:1) and 79 controls (mean, 12.1 years; male/female, 1.9:1), Pediatric Quality of Life Inventory QOL score was significantly lower in the STC group (72.90 vs 85.99; P.0001). In addition, parents of children with STC reported a significantly lower QOL score than their child compared with the child's own report (64.43 vs 72.90; P = .0034). Parents of controls did not (84.25 vs 85.99; P = .12).Slow transit constipation is a debilitating condition affecting both physical and emotional functioning in children. Parental perception of QOL is significantly worse, highlighting the considerable family impact of constipation and uncontrollable soiling.

Chronic constipation in children may have organic or behavioral causes. The purpose of the present study was to investigate the effect of treatment with transcutaneous electrical stimulation (using interferential current) in children with chronic treatment-resistant constipation with proven organic disorders.Eight children (7-16 years) with at least 4 years of chronic treatment-resistant constipation and soiling, who had failed diet, laxative treatment and behavioral therapy were given 1 month of transcutaneous electrical stimulation. The three most severe cases had appendicostomies with antegrade washouts every 2-3 days to prevent impaction and reduce their soiling. Children and carers kept a daily diary of bowel habits, recording number of spontaneous defecations, episodes of soiling, use of bowel washouts and medications. Transcutaneous stimulation using interferential current was applied three times per week for 3-4 weeks using four surface electrodes, two to the paraspinal area of T9-10 to L2 and one to either side of the anterior abdominal wall beneath the costal margin. Diaries were recorded for 1 month before, during, and after stimulation and for 2 weeks 3 months later.Transcutaneous electrical stimulation using interferential current stopped soiling in 7/8 children and increased the frequency of spontaneous defecations in 5/8. Defecations remained high and soiling low for 3 months in 3/6 children (with data).These results suggest that transcutaneous electrical stimulation using interferential current has a beneficial effect for children with chronic treatment-resistant constipation. Further trials using larger series of patients are needed to confirm this benefit, to determine the ideal stimulation parameters and to investigate why electrical stimulation might be effective.

HRONIC CONSTIPATION has been thought previously to be idiopathic once Hirschsprung’s disease was excluded. It is a frequent cause for referral to a pediatrician or surgeon and for many years has been managed with behavior modification, a high-fiber diet, and laxatives. However, many children did not respond to standard therapies, raising the possibility of a psychogenic cause, or even Munchausen’s syndrome by proxy. Because no rational paradigm was available to approach these patients, they tended to become “lost” in a range of different clinics, from general pediatrics through to psychiatry. This short review describes a new paradigm for assessing these patients, which arose after chance observations 10 years ago suggested that some of these children had organic causes for their symptoms. Since that time, we have developed a progressively more systematic approach to intractable constipation, based on the initial assumption that organic causes are likely to be more common than a primary psychogenic problem. Our index case was a child with megacystis-microcolon syndrome, in whom a bowel biopsy showed increased immunofluorescence labelling for substance P in the colonic nerves. This was part of an independent study of the role of neuropeptides in the gut but suggested to us that other patients with disordered gut function, such as constipation, may also have anomalies in neuropeptide immunofluorescence. We began looking for histologic anomalies of substance P, initially from incidental laparotomy specimens and then deliberately in full-thickness rectal biopsy sections and, subsequently, via laparoscopic muscle biopsy sections. We found a group of children with specific signs and symptoms, abnormal colonic transit, and abnormal histology. They have slow transit constipation (STC), and this new diagnosis has

The relationship between self-concept and sensorimotor function was explored in a quasi-experimental pretest-posttest design in which the Piers-Harris Children's Self-Concept Scale was administered to 16 children with learning difficulties. Test-retest reliability (temporal stability) was statistically supported. Statistically significant gains were made in the group's mean posttest score. Although conclusions were limited by design and sample size, it was suggested that the changes in self-concept are related to changes in body image and adaptive behavior due to the therapeutic camp program.