Faecal incontinence

Key points:

• most likely caused by constipation 
• RCH website has good summary on laxatives
• don't forget psychological cause 
• refer early if not winning, as this can be problematic for the child and the family 

What causes faecal incontinence?

• Functional 
• constipation associated faecal incontinence, involuntary
• non retentive faecal incontinence (encopresis)
• may have a psychosocial basis 
• Organic 
• anorectal malformation, spinal disorders, hirschsprung's disease, CP, mental retardation etc

Assessment ?

• General history
• Bowel habit details
• frequency of defecation 
• consistency of stool 
• intestinal hurry - soiling 
• toilet posture, school practices re: toilet 
• Fluid intake 
• Diet/fibre intake/cow's milk history
• Bristol stool chart. Normal is type 3 and 4.

Examination?

• Developmental 
• nutritional 
• abdominal 
• neurological 
• spine/reflexes
• anorectal exam ? PR (not necessary)
• anal tone/sensation 

What are the investigations?

• bowel chart/diary
• abdominal x-rays (esp if no faecal retention found on rectal exam)
• abdominal ultrasound (rectal diameter for rectal distention > 2.9 cm). Not every centre knows how to do it, check with radiology first, otherwise, it will just be wasting of time
• anorectal manometry 
• blood tests limited value (TFTs, Ca)

What is the management ?

• Good flow chart from DCH lecture 

• Education 
• Laxatives 
• disimpact if significant retention 
• maintenance therapy, 6 months at least 
• Toileting program: bowel opening post meals 
• Treat anal fissures
• Toilet diary (behaviour modification) 

Toileting program 

• Ensure adequate fluid intake (50ml/kg/day)
• Ensure adequate fibre intake
• Toilet posture
• support feet with a stool, it helps relaxing pelvic floor muscle
• toilet sit after meals (gastrocolic reflex)

References

• Diploma of child health: encopresis and enuresis lecture