Fecal Incontinence

Fecal soiling can cause children intense embarrassment for both parents and children. The good news is that with the right treatment, most children can develop good bowel control and live normal lives.

What is Soiling and Fecal Incontinence?

Fecal incontinence (accidentally having bowel movements) is a very common problem in children. It can be caused by medical conditions like chronic constipation or congenital conditions that may disrupt bowel control, including:

  • Spina bifida
  • Anorectal malformations
  • Hirschsprung disease

Fecal soiling can cause children intense embarrassment and social problems, and can be frustrating for both parents and children. The good news is that with patience, encouragement and the right treatment, most children can develop good bowel control and live normal lives.

There are two types of fecal incontinence:

  • True fecal incontinence occurs in children who do not have the normal mechanisms needed for controlling their bowel movements. Typically, these children have:
    • Anorectal malformations (imperforate anus)
    • Hirschsprung disease
    • Spinal problems

    These conditions may have prevented their bodies from developing normal bowel structures or control of those structures. While surgical repair can help restore bowel function, it cannot always insure bowel control. Children with true fecal incontinence can also be classified as having a slow or fast bowel – and the treatment for each is different.

    Through a bowel management boot camp or surgery, children can successfully manage bowel movements and avoid soiling.

  • Pseudoincontinence or encopresis typically occurs in children with the ability to toilet train but who have developed severe, chronic constipation. This leads to stools that are infrequent or hard to pass.

    It can also occur in children with anatomical abnormalities that predispose them to developing constipation.

    While most of these children have the ability to control their bowel movements, they become so constipated that stool impacts and overflows. Treatment is focused on preventing constipation and can be done through:

    • Diet
    • Medications

There is also a promising new therapeutic modality for pediatric urinary and fecal incontinence, and chronic constipation in children when all other treatments have been unsuccessful. Sacral nerve stimulation (SNS) technology can be compared to a pacemaker for the heart, but provides stimulation to the anal canal area and lower part of the colon and the bladder.

While a few other children’s hospitals in the United States offer sacral nerve stimulation based on subjective criteria and clinical symptoms, Nationwide Children’s is one of the first to formally structure this therapy by evaluating objective bladder and bowel function studies before and after the procedure to assess treatment response.

How Does Continence Work?

When it comes to eliminating feces (solid waste), the body goes through a series of complicated processes which depend on:

  • Voluntary muscle control
  • Sensation
  • Involuntary movements of the colon that push stool along

Toilet training and bowel control are only able to happen when these three things are working together properly.  An issue with just one part of the process can lead to bowel problems like constipation or fecal incontinence.

Voluntary Muscles

Once the large intestine has pushed stool to the anorectal area, sphincter muscles that control feces leaving the body are used. Children are able to voluntarily control those muscles to hold stool, or relax the muscles to go to the bathroom. Sometimes these sphincter muscles can be weak in children born with an anorectal malformation/imperforate anus or spinal problems. If a child chooses to hold stool too often, it can lead to chronic constipation.

Sensation

In order to know when to use sphincter muscles, the child must first feel something in the area, a sensation provided by the anal canal.  This part of the body provides detailed sensory information to the brain to let it know when it’s “time to go.”

Surgery can reduce sensation in the anal canal when correcting:

  • Anorectal malformations
  • Hirschsprung disease
  • Certain types of spinal problems

Because of this, the brain does not get the message when the rectum is full of stool.

Motility (Slow or Fast)

Bowel issues can also be triggered by how fast the colon pushes feces through to the rectum before it reaches the sphincter muscles.

Hypomotility: In patients where the colon pushes stool slowly, feces tends to gather in the rectum – which is larger than normal in most such patients. These children may not be able to feel the fullness, developing severe constipation and then soiling due to overflow. The issue can also develop in children who don’t have any malformations and have never had surgery. In this case, the soiling due to idiopathic (unknown cause) constipation is called encopresis. Treatment for these patients with slow motility can involve:

  • Diet changes
  • Medication
  • Treatments
  • Bowel management programs

Hypermotility: Patients who may have had surgery that removed parts of their colon experience stool that moves through too fast. This can result in loose, watery stools that can leak out of the anus. Treatment for this may involve diet modifications and medication.

What Causes Soiling and Fecal Incontinence?

Fecal incontinence can be caused by medical conditions like chronic constipation or congenital conditions that may disrupt bowel control, including: spina bifida, anorectal malformations and Hirschsprung disease.

How is it Treated?

Children with true fecal incontinence lack the ability to voluntarily have a bowel movement, so they require daily interventions to empty the colon of stool. However, there are two different types of true fecal incontinence and treatment for each varies:

  • Children with a slow colon with constipation. This group represents the majority of children with true fecal incontinence. These are patients typically have:

They will require a daily enema that cleans the colon (see below), but many children won’t need a special diet or medicines.  

  • Children with a fast colon and loose stools. Loose stools can be a problem with some children who have had anorectal surgery and can also occur in some patients with Hirchsprung disease.  In addition to a daily enema, these children will also need a constipating diet, and medicine to slow the colon.

Physicians are usually able to predict which children with these issues will go on to have fecal incontinence so that parents can set expectations for potty training.  In some cases, parents are asked to try typical potty training around the age of three. If that isn’t successful, the child can begin a bowel training bootcamp. Potty training can be tried again during vacation or summer breaks to assess bowel control.  As a child with true fecal incontinence ages, they typically become more engaged with managing their condition.

Treatment Plans to Manage Bowel Control

Bowel management programs are tailored for each individual child and often require trial and error to determine which combination of interventions, diets and medications will work best.

  • Enemas: The typical approach is to use an enema to empty the colon and to train the bowel to stay “quiet” in between enemas. An enema involves inserting a tube into the rectum, and flushing out the stool with a prescribed solution, usually made from water and saline. The enema can be administered rectally, or a surgical procedure can be done to allow the enema to be given from the top of the colon down.

    The procedure, called a Malone appendicostomy is sometimes preferred by older children because it allows them to perform the enema by themselves. By completing the bowel training program and choosing the right enema, the child can usually stay clean and wear normal underwear. Enemas and laxatives are never used together because that could cause an accident in between enemas. Children with little or no potential for bowel control will need to use enemas for the rest of their lives.
  • Diet: If the child soils after eating a newly introduced food, that food should be excluded from the diet.
Foods to Encourage Food to Avoid (To Loosen Bowels)
Bananas Dairy products (milk, cheese)
White bread, bagels Fried and oily foods (French fries)
White pastas without sauce, rice Sugar
Boiled, baked, broiled meats (chicken, fish)
Chocolate
Apples without skin, applesauce
Spices
Water soluble fiber (pectin)
Fruits, fruit juices
Tea and soft drinks (with artificial
 sweetners)

Vegetables
Potatoes
Jelly (no jam)
  • Medications: Loperamide may be given to help slow down the colon. Physicians will work to gradually reduce the dose of medications to identify the lowest amount needed to keep the child clean for 24 hours.

    In a few cases, if a child with some capacity for bowel control has been successful with diet and enemas, they may be able to try a “laxative trial.”  This is just like the bowel training program, but instead of using enemas, the child uses laxatives to prompt bowel movements. Just like the enema bowel training program, the healthcare team will use daily abdominal x-rays to help establish if the laxatives are working and tailor a dose that might allow the child to eliminate the need for enemas.

  • Surgery: For some children who have had surgery to correct an anorectal malformation, a repeat procedure may help improve their potential for bowel control. For certain patients who have borderline bowel control, a new technology called sacral nerve stimulation (SNS) may eliminate the need for enemas. SNS uses a device to send a small electrical signal to help modulate nerves that control continence.

Prognosis

For children born with anorectal defects or Hirschsprung disease, doctors are able to predict the potential for bowel control fairly accurately. Once a child’s reconstructive surgery has healed, physicians will evaluate several factors and give caregivers an idea of what to expect. This is particularly important to help parents set expectations around potty training, and to determine if they need to adopt a long-term bowel management program.

Factors that indicate good prognosis for future bowel control:

  • Normal sacrum (the large triangular bone at the base of the spine)
  • Good sphincter muscles
  • Anorectal malformation types of rectal atresia, rectoperineal fistula, imperforate anus without fistula, small cloacas and rectourethral bulbar fistula
  • Good bowel movement pattern, of 1-2 well formed bowel movements per day
  • Evidence of sensation when passing stool (ability to push)

Factors that indicate a poor prognosis for future bowel control:

  • Abnormal sacrum
  • Poor sphincter muscles
  • Anorectal malformation types including rectobladderneck fistula, rectoprostatic fistula, larger cloacas, complex malformations
  • Constant passing of stool
  • No sensation (no pushing)
  • Urinary incontinence, dribbling of urine

Whether the prognosis for bowel control is considered good or poor, it’s important to note that most children who have undergone surgery to correct anorectal malformations or Hirshsprung disease will need some type of consistent dietary or medical intervention to prevent constipation or true fecal incontinence. The good news is that when good bowel control can be established, these kids can go on to live confident, independent lives.