Fecal Incontinence
Fecal continence is one of the most important achievements in a child's development. Ability to control passage of stool is one of the first manifestations of independence by which interaction with parents and environment is exerted by the child.
Fecal continence, which is usually reached by the age of two to three, may be partially or entirely compromised in children born with some anomalies of the large bowel (anorectal anomalies and Hirschsprung's disease) or anomalies of the pelvic organs such as spina bifida.
Fecal incontinence has a significant social impact regardless of the age it arises. Moral conditioning, which is usually associated with toilet training, leads to a close association between stool and something "dirty" and negative. It is not difficult to imagine the kinds of difficulties a child can go through when he or she is unable to have bowel control. Fecal incontinence represents a devastating problem; it is often a barrier to social acceptance. It can affect many children including those with prior surgery (for anorectal malformationsand Hirschsprung's disease) as well as those with spinal problems or injuries.
Nowadays, much can be done for children with fecal incontinence. An accurate evaluation along with an appropriate follow-up program can have an enormous impact on psychological and social consequences of being incontinent.
Management and treatment involves distinguishing between true and pseudoincontinence, and then determining the proper protocol of treatment. Treatment of incontinence should be regarded as "care" aimed at raising a child in a normal context with a normal lifestyle. Pseudoincontinence (encopresis) can be treated with disimpaction followed by laxative therapy. True incontinence requires an enema program, with treatment tailored to either hypo or hypermotile colons. Bowel management is a treatment program which has been purposely conceived for children born with imperforate anus: however, it can be applied to all children with fecal incontinence. Surgery for pseudoincontinence, rarely required, takes the form of colonic resection but only for patients with a demonstrated ability to have voluntary bowel movements, albeit with enormous laxative requirements. Removal of the rectosigmoid in this situation can reduce or eliminate the need for laxatives. Surgery for true fecal incontinence involves changing the route for a successfully demonstrated enema program to an antegrade, i.e., a Malone appendicostomy.
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