History and exam
Key diagnostic factors
common
history of anorectal, neurological, or spinal abnormalities, or gastrointestinal surgery
May be associated with organic faecal incontinence; particular diagnosis determines patient's risk of faecal incontinence.
faecal soiling or diarrhoea
Required for diagnosis of faecal incontinence. May be related to overflow diarrhoea in constipated children or due to increased stool frequency and diarrhoea.
constipation
Required for a diagnosis of faecal incontinence associated with chronic constipation.
peri-anal skin irritation
Due to moisture and faecal enzymes.
uncommon
abnormal rectal examination
May note abnormal tone, large faecal mass in dilated rectum in faecal incontinence associated with chronic constipation, or empty rectal vault in functional non-retentive faecal incontinence.
spinal deformities
Defects of varied severity associated with varied degrees of faecal incontinence.
weakness and decreased or absent reflexes
On neurological examination, weakness and decreased or absent reflexes in lower extremities may be found, indicative of organic or neurogenic bowel disease.
Other diagnostic factors
common
behaviour problems
May display anxiety, depression, and social isolation.
Associated with all types of faecal incontinence, perhaps aetiological factor or consequence.
painful bowel movements
Related to faecal incontinence associated with chronic constipation.
abdominal pain/cramping
Related to faecal incontinence associated with chronic constipation.
posturing described as tightening of buttocks
Related to functional faecal incontinence associated with chronic constipation.
enuresis
Associated mostly with functional faecal incontinence with chronic constipation and organic faecal incontinence.
anorectal malformation
Defects of varied severity associated with varied degrees of faecal incontinence.
abnormal abdominal examination
Abdominal examination may reveal the presence of a faecal mass and gas in the lower quadrants.
uncommon
history of underlying medical condition
Hypothyroidism, coeliac disease, and cystic fibrosis may present with faecal incontinence.
Risk factors
strong
chronic constipation
Major cause of faecal retention, which causes overflow incontinence.
May be related to an underlying medical condition such as hypothyroidism.
male sex
Boys are generally more affected than girls. In one epidemiology survey of 2686 children aged 10 to 16 years, of the 55 (2.0%) with faecal incontinence, 43 (78.2%) were boys.[6]
age: 5 to 6 years
A study from Amsterdam found faecal incontinence more frequently among 5- to 6-year-olds than 11- to 12-year-olds (4.1 versus 1.6%).[4]
diet lacking in fibre
Can cause constipation.
inadequate fluid intake
Can cause constipation.
delayed or inadequate toilet training
In younger children, particularly boys, a refusal or unwillingness to use the toilet/potty to empty the bowels is not uncommon. Continual 'holding on' may ultimately lead to constipation and faecal incontinence.
anorectal malformations
Defects vary from minor to complex, and likelihood of persistent incontinence depends on the defect.
Patients with hypodeveloped sacrum are much more likely to be incontinent.[13]
Approximately 50% of affected children occasionally soil their underwear, and 25% have persistent faecal incontinence that requires daily treatment.[7]
Hirschsprung's disease
More than 50% of patients may experience faecal incontinence after surgery, but most are continent by adolescence.[8]
Faecal continence is an important predictor of overall quality of life after surgical repair.
spinal abnormalities
Neural tube defects, specifically spina bifida, occur in about 2500 newborns per year and with an incidence of 1 in 1200 to 1400 live births.[9] Virtually all affected children will experience some degree of faecal incontinence.
Other spinal abnormalities that can lead to faecal incontinence include myelodysplasia and tethered cord.
weak
psychological or behavioural problems due to stressful family events
Significant family events such as divorce of parents, birth of a sibling, or death of a family member may result in psychological stress causing children to regress in their development (including bowel and bladder habits).
psychiatric disorders
It is unknown if a behavioural or psychiatric disorder (i.e., anxiety, depression) is a risk factor for or may result from faecal incontinence.[10]
medication overuse
Faecal incontinence may rarely be due to overuse of medication (i.e., laxatives, orlistat), used mainly by adolescents and adults.
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