Approach

The treatment of pediatric fecal incontinence depends on the underlying cause and any associated conditions. The goal of therapy is for the patient to stool 1 to 3 times per day in the toilet with no episodes of soiling.

Chronic constipation and severe fecal impaction in functional or organic fecal incontinence

Patients presenting with constipation and severe fecal impaction should follow a 2-step process to disimpact the colon, then maintain regular bowel habits to avoid reaccumulation of retained fecal matter. In organic fecal incontinence specifically, treatment should also be tailored to diagnosis and treatment of underlying disease.

1. Acute disimpaction of fecal matter

  • Oral laxatives are the first-line option for disimpaction of fecal matter in patients with functional or organic fecal incontinence presenting with fecal impaction and constipation. Oral laxatives are preferred, as they are better tolerated and more acceptable. If the patient does not respond to oral laxatives, an enema is indicated as second-line treatment to soften the stool. However, if disimpaction is unsuccessful with a single treatment of laxative or enema, combination of both treatments may be necessary as a third-line option.

  • Acute disimpaction can be done on an outpatient basis, but may require inpatient services if the patient is noncompliant or the treatment fails. A result is usually expected in 2 to 5 days.

2. Ongoing maintenance phase to avoid reaccumulation of retained fecal matter

  • Treatment consists of laxative use, dietary interventions, and establishing good bowel habits.

  • Laxatives should be used daily and stool softeners are recommended as they are not habit-forming.

  • Dietary interventions involve increasing free daily water intake to at least 4 to 8 glasses per day, increasing daily intake of fiber (the suggested number of grams of fiber per day equals the patient's age plus 5), and consuming 5 fruits or vegetables per day.[12] The use of soluble or insoluble fiber supplementation is decided on a case-by-case basis. Soluble fibers tend to bulk the stool, while insoluble fibers tend to make the stool looser. Soluble fibers (e.g., psyllium, pectin) are therefore preferred, though their effectiveness is inconsistent and one meta-analysis found that there is no evidence to support the prescription of fiber supplementation in the diet of constipated children.[29][30]

  • Good bowel habits involve the child sitting on the toilet for 5 to 10 minutes in the morning, after school, and after meals.[16] While sitting on the toilet, the child's knees should be bent and feet placed up on a step stool. The child should push out the feces, even without the sensation of defecation, so that the muscles are retrained.

  • A systematic review found that behavioral interventions plus laxative treatment improves functional incontinence more than laxative therapy alone.[31]

In patients with organic fecal incontinence, if aggressive medical treatment is unsuccessful, surgical treatments may be used in rare instances to keep the bowel disimpacted. Residual incontinence after surgery is then treated by the use of a laxative, dietary interventions, and establishing good bowel habits.

Nonretentive functional or organic fecal incontinence without constipation

In patients presenting without constipation, interventions include a bowel retraining program, increasing fiber in the diet, biofeedback, and possible use of the antidiarrheal loperamide as a last resort if incontinence interferes with social activities. In patients with organic fecal incontinence, any underlying cause (e.g., anatomical malformation, underlying medical condition) should also be addressed.

A bowel retraining program is aimed at strengthening the internal muscles or internal sphincter and regaining rectal sensation.[10] This is usually achieved by asking the patient to sit on the toilet and push for 5 to 10 minutes, 2 or 3 times daily.

Biofeedback is usually only performed in patients who have had abnormal results on anorectal manometry, although its usefulness remains unconfirmed.[31] It should be done in a specialized tertiary care center.

Patients may benefit from a behavioral medicine consultation from a mental health professional or psychologist if psychosocial factors are the underlying etiology.[10]

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