What is the treatment for fecal incontinence in children?

Treatment of Fecal Incontinence in Children

The treatment of fecal incontinence in children depends critically on whether constipation is present: for the 80% with constipation-associated fecal incontinence, aggressive bowel management with disimpaction and maintenance laxatives is the cornerstone of therapy, while for the 20% with functional nonretentive fecal incontinence (FNRFI), treatment centers on education, structured toileting programs with rewards, and addressing behavioral/psychosocial comorbidities. 1, 2

Initial Assessment and Classification

The first step is determining whether fecal incontinence is retentive (constipation-associated) or nonretentive:

• Retentive fecal incontinence occurs in approximately 80% of cases and results from overflow soiling due to functional fecal retention 1, 2
• Functional nonretentive fecal incontinence (FNRFI) occurs in 20% of children where no constipation or organic cause can be identified 1
• Bowel diaries and the Bristol Stool Scale are essential tools for evaluation and monitoring treatment response 3
• Ultrasound can help identify rectal impaction and monitor treatment response 3

Treatment for Constipation-Associated Fecal Incontinence (Retentive Type)

Phase 1: Disimpaction

• Begin with oral laxatives for fecal disimpaction (cleanout phase) before initiating maintenance therapy 4, 5
• The goal is to clear the rectal vault of impacted stool that causes overflow incontinence 2

Phase 2: Maintenance Bowel Management

• Aggressive and prolonged constipation management is essential, as this frequently coexists with and exacerbates fecal incontinence 6
• The goal is to achieve one non-forced bowel movement every 1-2 days 4
• Continue maintenance laxatives for several months; premature discontinuation is a common pitfall, with treatment typically needed for at least 6 months 6
• Increase dietary fiber if the child has adequate fluid intake 4
• Ensure adequate hydration to support fiber intake 4

Phase 3: Behavioral Interventions

• Implement a regular toileting routine after meals to take advantage of the gastrocolic reflex 4
• Establish timed voiding/toileting with a reward system 4
• Ensure proper toilet posture with buttock support, foot support, and comfortable hip abduction to facilitate relaxed defecation 6, 4
• Maintain daily bowel diaries to track progress 1
• Address hygiene issues including changing wet clothing, proper skin care, and correct wiping technique 6

Treatment for Functional Nonretentive Fecal Incontinence (FNRFI)

FNRFI is often difficult to treat, requiring prolonged therapies with incremental improvement and frequent relapses. 1

Core Treatment Components

• Education and nonaccusatory approach: Explain the condition to child and family, alleviate guilt, and enhance self-esteem 1, 2
• Structured toileting program with daily bowel diary and reward system 1
• Behavioral and psychosocial interventions: Special attention must be paid to psychosocial or behavioral problems, as these frequently occur in affected children 1, 7
• A multidisciplinary approach involving child psychiatry may be necessary to address complex family dynamics and psychiatric comorbidities preventing remission 7

Pharmacological Considerations for FNRFI

• Antidiarrheal agents (loperamide) can increase stool consistency and facilitate continence 2
• Caution: Loperamide is contraindicated in children less than 2 years of age due to risks of respiratory depression and serious cardiac adverse reactions 8
• Use laxatives with extreme caution in FNRFI, as they may exacerbate incontinence 9
• Loperamide increases anal sphincter tone, reducing incontinence and urgency 8

Advanced Therapies for FNRFI

• Biofeedback for FNRFI remains controversial; its efficacy is unproven for this specific condition 2, 9
• Interdisciplinary occupational and physical therapy approaches focusing on pelvic floor muscle coordination, emotional regulation, and functional bathroom training have shown promise in recent studies 5

Treatment for Organic Causes (Congenital/Neuropathic Incontinence)

For children with congenital anorectal malformations or neurogenic causes (e.g., spina bifida):

Medical Management

• Combine interventions to modify stool consistency, colonic transit, anorectal function, and rectosigmoid evacuation 9
• Use antimotility agents to slow transit or laxatives to accelerate transit as needed 9
• Induce bowel movements with suppositories or enemas 9
• Biofeedback may improve anorectal function in this population 9

Surgical Options

• Antegrade Colonic Enema (ACE) procedure/Malone procedure: Creates a continent conduit from skin to cecum for self-administration of enemas, providing predictability and independence 2, 9
• Fluoroscopically guided percutaneous cecostomy can be used as treatment for fecal incontinence in children, with technical success rates approaching 100% and 94% patient satisfaction 3
• The cecostomy allows antegrade colonic washouts that completely cleanse the colon, increase autonomy, and decrease soiling accidents (89% reported decrease) 3, 2
• Surgical cecostomy, appendicostomy, sphincter reconstruction, or artificial sphincters may be considered, though high-quality randomized trials are lacking 2

Common Pitfalls to Avoid

• Premature discontinuation of bowel management: Continue for at least 6 months even after symptoms improve 6
• Using laxatives in FNRFI: This can worsen symptoms rather than improve them 9
• Ignoring psychosocial comorbidities: These are frequently present and must be addressed for successful treatment 1, 7
• Inadequate hydration when increasing fiber: Fiber without adequate fluids can worsen constipation 4
• Accusatory approach: This increases guilt and decreases treatment success; a supportive, nonaccusatory approach is essential 1, 2

Expected Outcomes and Timeline

• Improvement is typically gradual, taking several months 6
• Up to 20% of urge incontinence cases may be cured by initial conservative measures alone 6
• Success rates with escalating treatment approaches can reach 90-100% for urinary symptoms; fecal incontinence outcomes vary by etiology 6
• FNRFI often requires prolonged therapy with frequent relapses 1
• For cecostomy in organic causes, satisfaction rates reach 94% with 89% reporting decreased soiling accidents 3