What are the treatment options for rectal impaction in children?

Treatment Options for Rectal Impaction in Children

For rectal impaction in children, polyethylene glycol (PEG) is the first-line treatment, with high-dose oral PEG (1.5 g/kg/day for 6 days) being equally effective as enemas but better tolerated, though manual disimpaction under sedation may be necessary for severe cases that fail initial medical management. 1, 2

Initial Assessment and Disimpaction Strategy

First-Line Medical Management

• Begin with high-dose oral polyethylene glycol (PEG) with electrolytes at 1.5 g/kg/day for 6 consecutive days as the primary disimpaction method 2
• PEG achieves successful disimpaction in 68-80% of children with rectal fecal impaction 2
• For severe fecalomas, consider combining PEG (2-8 sachets of 14.7g initially, reducing to 2-6 sachets by day 3) with sodium picosulphate (15-20 drops on days 2-3), which resolves fecalomas in approximately 45% of severe cases 3
• This combined approach produces large volume soft stool output (median 2.2 liters over 7 days) and significantly reduces colonic stool loading 3

Alternative Disimpaction Methods

• Enemas (phosphate or saline) once daily for 6 days are equally effective as PEG (80% success rate) but may be less acceptable to patients 4, 2
• Glycerine suppositories can be administered for less severe impaction 4
• Mineral oil retention enemas may be used as an adjunct 4

Manual Disimpaction

• Manual disimpaction under sedation or anesthesia is indicated when oral and rectal treatments fail 4
• Pre-medicate with analgesics and anxiolytics before the procedure 4
• This should be performed after attempting medical management first 4

Maintenance Phase After Disimpaction

Long-Term Laxative Therapy

• After successful disimpaction, continue maintenance PEG therapy for many months (not weeks) to restore normal bowel motility and rectal sensation 1
• Add bisacodyl 10-15 mg daily to three times daily with a goal of one non-forced bowel movement every 1-2 days 4
• Consider adding other laxatives if constipation persists: polyethylene glycol, lactulose 30-60 mL 2-4 times daily, magnesium hydroxide 30-60 mL daily to twice daily, or magnesium citrate 8 oz daily 4

Behavioral and Supportive Measures

• Implement scheduled toilet sits 15-30 minutes after meals to leverage the gastrocolic reflex 1
• Ensure proper positioning with buttock support, foot support, and comfortable hip abduction to facilitate relaxed defecation 1
• The child must feel stable and secure to prevent muscle tension that interferes with defecation 1

Critical Parent Education

Treatment Duration Expectations

• Emphasize that bowel management must continue for months, not weeks—this is the most common pitfall where parents discontinue treatment prematurely 1
• Explain the pathophysiology of constipation and realistic timelines for recovery 1
• Have parents maintain a bowel movement calendar or diary to track patterns and treatment response 1

Important Pitfalls to Avoid

• Do not rely on education and behavioral therapy alone if constipation is present—comprehensive approaches that include aggressive constipation management are superior 1
• Do not use anticholinergic medications, as they worsen constipation 1
• Avoid premature discontinuation of laxative therapy before normal bowel motility is restored 1
• Do not perform colectomy for fecal impaction in children, as outcomes are poor; if surgery is considered, a reversible defunctioning loop ileostomy is preferable 4

Special Considerations

• PEG causes more fecal incontinence and watery stools compared to enemas, but behavior scores and tolerability are comparable 2
• Children presenting younger than 4 years of age and those with an associated underlying condition have better prognosis with conservative management 5
• Rectal examination is now performed less often as it can be distressing and may be deceptive if the child had a recent bowel movement 4
• Ultrasound observation of rectal impaction may assist diagnosis and monitor treatment response 4