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316
20 Bowel Management for the Treatment of Fecal Incontinence
individual basis, the kind of bowel management
that we will implement, which is different in
every patient, depending on the results of our
evaluation.
For the following days, the patient receives the
treatment (enema) we have chosen, plus the specifi c diet and/or medication when indicated. In
addition, the parents will bring the child to the
hospital every day and have an abdominal x-ray
fi lm taken. The parents then call one of our nurses
daily and report to them the results of the enema.
The nurse asks the parents how the patient tolerated the enema, whether or not it was uncomfortable, the reaction of the patient including vomiting
and pallor (vagal refl ex types of reaction), and an
estimate from the parents about the amount of
stool that came out with the enema. The nurses
will also ask what happened in the patient’s underwear during the 24 h after the enema and how
much time it took to implement the management
(from the beginning of the enema application
until the patient has fi nished evacuating his/her
colon). Sometime in the afternoon, the members
of our staff (surgeons and nurses) meet in a conference room, see each one of the abdominal
fi lms, and discuss the information obtained by the
nurses about each one of the patients. The abdominal fi lms show us the amount and location of the
stool in the colon which refl ects the effi ciency of
the enema. That information, plus the description
of the nurse about the patient’s reaction, allows us
to implement changes in the enema that may
include volume, concentration, or content (ingredients) of the fl uid that we use. We may also make
recommendations about diet and/or medication
when indicated. Our nurses then call the parents
of our patients and notify them of our decision.
This routine is carried out daily until we are successful. Success is defi ned as a completely clean
and happy patient and parents. Usually, about a
week after this process, 95 % of our patients are
clean [
1 – 3 ].
The rationales for the use of enemas, in patients
suffering from fecal incontinence, are based on
the idea of administering a volume of fl uid in the
colon to provoke a peristaltic wave, followed by
a partial or total expulsion of stool (Animation
20.1 ). Under normal circumstances, and in the
majority or our patients, the colon moves slowly;
therefore, the new stool that reaches the colon
will travel through it in a period of time not
shorter than 24 h. During those 24 h, the patient
is expected to remain clean in the underwear. It
is therefore easy to understand that the success
of the program depends on the effi ciency of the
enema to clean the colon and the motility of the
colon. In other words, if the patient passes stool
in the underwear, there are only two possible
explanations:
A. The enema did not clean the colon.
B. The enema cleaned the colon, but the colon is
moving too fast, and the new stool reaches the
anus before 24 h (Animation 20.2 ).
The only way to know which one of these two
circumstances is occurring is by taking an
abdominal x-ray fi lm. The presence of signifi cant
amount of stool in the colon, shortly after the
administration of the enema, means that the
enema is not cleaning the colon, and therefore it
must be upgraded. On the other hand, a rather
clean colon in a patient that is passing stool in the
underwear means that the colon is moving too
fast (liquid stool is not easily seen in a regular
abdominal fi lm).
20.4 Individualization
of the Management
Based on the studies already mentioned, we
learn several very important facts that allow us
to design and individualize the management plan.
It took us several years to realize that within the
population of children suffering from fecal incontinence, there are two main groups of patients.
The contrast enema is the most valuable study to
identify these two groups:
• Group A : Incontinent patients that suffer from
megarectosigmoid and constipation (hypomo-
tility of the colon) (Fig.
patients belong to this group.
• Group B : Incontinent patients with a non-
dilated, spastic, or short colon that suffer from
a tendency to diarrhea (hypermotility of the
colon). This includes patients who underwent
different types of resection of the colon for a
20.2 ). The majority of
20.4 Individualization of the Management
317
Fig. 20.2 Contrast enema of a patient with megarecto-
sigmoid and constipation (hypomotility)
variety of reasons (Fig. 20.3 ). This group also
includes patients who suffer from different
types of enteritis or colitis (infl ammatory
bowel disease, food allergy, acquired phosphate enema-induced colitis, or idiopathic
hypermotility).
The separation of patients into these two
groups represents an essential element of our
program as well as a key to success. We have not
found in any of the previous publications [
4 – 12 ]
a description of this classifi cation of patients. The
management of patients in each group is radically different as will be described.
In Group A, patients that suffer from hypomotility (constipation) and megarectosigmoid, the
management will put emphasis on trying to fi nd
the enema (large and concentrated enough) to be
capable of cleaning a large fl oppy colon. Once
we fi nd that enema, the patient will most likely
stay clean in the underwear for 24 or even sometimes 48 or 72 h due to the fact that the colon
suffers from hypomotility. No special diet or
medication is necessary to keep these patients
clean.
Patients who belong to Group B have a
hyperactive, non-dilated, spastic, or short colon
(hypermotility). Such a colon is very easy to clean
with a small enema. These patients need a rather
small volume, not a concentrated type of enema
(usually plain, normal saline solution is adequate).
However, the main challenge in this group of
patients is to keep the colon quiet or to reduce
its peristalsis enough to avoid bowel movements
in between enemas. In other words, the enema is
capable of cleaning the colon very well and very
easily, but because the patients have increased
motility of the colon or a short colon, new stool
will come out through the anus only a few hours
after the administration of the enema. This can
only be treated with medication to slow down the
4
colon such as loperamide
(Animation 20.3 ), pectin (a water-soluble fi ber that helps bind the stool
and make it bulkier), and/or a constipating diet
(Fig. 20.4 ), depending on the severity of the hyper-
motility. In addition, we must try to identify and
eliminate irritating factors that may be responsible
for the increased colonic motility (infl ammatory
disease, food allergy, phosphate enemas).
Not recognizing these two categories of
patients represents the main reason for unsuccessful attempts to keep the patients clean.
We never prescribe enemas and laxatives to
the same patient, since that would make no sense.
The enema is meant to clean the colon; after that,
we hope to make the colon move very slowly to
allow the patient to remain clean for 24 h. Giving
laxatives will make the colon move fast, which
will result in “accidents” (passing stool in the
underwear) before the next scheduled enema.
There is a small subgroup of patients that
emerges from the clinical evaluation and the
studies that we have already mentioned. These
patients were born with what we call “benign
malformations” (malformations that are associated with an excellent functional prognosis in
our experience), underwent a technically correct
operation, have a good sacrum, have no tethered cord, and suffer from severe constipation,
and yet, they behave like fecally incontinent
patients. The contrast enema shows a severe
4
See footnote 1.
318
ab
20 Bowel Management for the Treatment of Fecal Incontinence
Fig. 20.3 Contrast enema of a patient with no rectosigmoid (previously resected), hyperactive and tendency to diar-
rhea. ( a ) Diagram. ( b ) Contrast enema
megarectosigmoid (Fig. 20.2 ). Interestingly,
even when they were born with a “good” prognosis type of malformation and everything indicates that they should be continent, they come to
our clinic complaining of “fecal incontinence.”
We have learned that those patients have a great
chance of suffering from what we call “overfl ow
pseudoincontinence.” In this group, we follow
a completely different strategy. The treatment
consists in the administration of enemas, until
the colon is completely clean, as radiologically demonstrated (disimpaction) (see Chap.
25 ; Animation 20.4 ). Once we have evidence
that the colon is completely clean, we start the
process of determining (by trial and error) the
laxative requirements of the specifi c patient. We
have learned that such requirements are different in each patient and much higher than what
the books recommend. It is extremely important
to recognize the fact that every patient will need
a different amount of laxative, which is not easy
to predict. The dosage of laxatives that a patient
needs is defi ned as the amount of laxative capable of emptying the colon completely, as demonstrated radiologically (see Chap.
25 ). We have
the patient come to the clinic every day, take an
abdominal x-ray fi lm, and increase daily the
amount of laxatives, until we see a clean colon.
At that point, we know the amount of laxative
that the patient needs. We then ask the parents
whether the bowel movements are occurring in
the diaper or in the toilet. If it is in the toilet,
it means that the patient is fecally continent; in
fact, he/she never suffered from fecal incontinence, but actually was always “overfl ow pseudoincontinent.” All that he/she needed was the
administration of the right amount of laxatives
that had never been previously determined!!
Once we determine the required amount of laxative, it is up to the parents if they are willing to
give their child that amount of laxative for life
in order to keep the patient clean. Alternatively,
we offer them an operation designed to reduce
the laxative requirement that consists in the
20.4 Individualization of the Management
319
Fig. 20.4 List of
constipating and laxative
types of food
Constipating Foods
Apple Sauce
Apple Without Skin
Rice
White bread
Bagels
Boiled, broiled, baked meat, chicken or fish
Soft drinks
Banana
Pasta
Pretzels
Tea
Potato
Jelly (no jam)
resection of the most dilated part of the colon,
preserving the rectum (Fig. 20.5 ), a subject
that will be discussed later. This third group of
pseudoincontinent patients unfortunately represents only about 5 % of our series. The diagnosis and management of this group has not
been mentioned in the available literature. It is
extremely rewarding to treat patients like these,
because with a little effort we really dramatically change their quality of life. On occasion
we see a patient with potential for bowel control
and with hypermotility. In those rare patients,
slowing down the colon, so the patient has one
or two well-formed stools per day, allows them
to perceive rectal fullness and thus succeed in
having voluntary bowel movements.
The evaluation of our patients also allows us
to determine whether or not the bowel management is going to be implemented on a permanent basis or it is going to be a temporary one.
That will depend on the functional prognosis
of the malformation that the patient was born
with, including of course the characteristics of
the sacrum and the presence or absence of tethered cord. In our experience, patients with bladder neck fi stulas only have a 20 % chance of
having voluntary bowel movements by the age
of three [ 13 ], rectoprostatic fi stulas 60 %, recto-
urethral bulbar fi stulas 85 %, and rectoperineal
Laxative Foods
Milk or milk products
Fats
Fried foods
Fruits
Vegetables
Spices
Fruit juices
French Fries
Chocolate
fi stulas 100 %. In females, perineal 100 % and
vestibular fi stulas have 95 % chance. Cloaca
patients with a common channel shorter than
3 cm and a normal sacrum have about 70 %
chance of having voluntary bowel movements
13 ]. The characteristic of the sacrum is very
[
important as it has been recognized over many
years. Patients with a sacral ratio less than 0.4
most likely will need bowel management for
life. (For more information about the way to
estimate the sacral ratio, go to Chap. 6 .) We
have not seen continent patients who have a
sacral ratio shorter than that. For patients that
are in the middle of the spectrum such as rectoprostatic fi stula (60 % chance of voluntary
bowel movements) or sacral ratio around 0.5,
we explain to the parents that it will not be easy
for them to have bowel control, yet their children have “some potential” for bowel control
that must not be underestimated. We, therefore,
offer these patients the implementation of our
bowel management program when they reach
the age of three, as an expeditious and effective way to keep them clean and get them into
normal underwear. We explain that every 6 or
12 months, preferably during the summer vacations, we will give the child the opportunity to
become toilet trained and see if we can stop the
enemas. We call that a “laxative trial.”
320
20 Bowel Management for the Treatment of Fecal Incontinence
Fig. 20.5 Sigmoid resection with preservation of the rectum
20.5 Laxative Trial
We fi rst implement the bowel management, and
the patient remains completely clean and is sent
home to enjoy the fact that he is clean for the fi rst
time in his/her life, attending school like a normal child. In the summer vacation we suggest
that they come back for one entire week for the
“laxative trial.” During that week, we encourage
the parents to stop the enemas and fi nd out
together with us the amount of laxative that is
capable of producing 1, 2, or 3 soft but formed
bowel movements every day, emptying the colon
as radiologically demonstrated. We encourage
them to have only three meals per day, hopefully
with the same kinds of food. We do that with the
specifi c purpose to try to condition the colon to
produce a bowel movement at the same time
every day, hopefully at a predictable time, which
makes the process of toilet training much easier.
We also give the patients a special type of
fi ber called pectin (used to make jams) that does
not have a laxative effect, but rather has a bulking effect on the stool. A patient with borderline
fecal control may not be able to feel a liquid
stool; yet he or she may be able to feel a bulky
type of stool that is produced by this kind of
fi ber. Working by trial and error, manipulating
the amount of the laxative as well as the amount
of fi ber and giving three meals per day, we fi nd
out over a period of 1 or 2 weeks whether or not
the patient is capable of having voluntary bowel
movements, remaining completely clean in the
underwear without receiving enemas. If we are
not successful, then we encourage the family to
go back to the bowel management (enemas) for
another year. Every year, we will deal with a
patient that is usually more cooperative and
more mature and therefore will have a better
chance of success.
20.6 About Our Program
321
Patients with borderline fecal control do have
some sensation, but it is not the exquisite sensation of a normal person. That is why a great deal
of interest and cooperation is required from the
patient in order to perceive when the stool is
approaching the anus. A child that is too young
and/or hyperactive or suffers from attention defi cit disorder most likely will not respond to that
faint sensation. Something similar can be said
about the sphincter. Most patients with anorectal
malformations have some kind of sphincter
mechanism, never as good as in a normal child,
but they can certainly try to use it. Some patients
are even capable of having bowel control with
diarrhea; yet, most of them cannot cope with an
episode of diarrhea. Therefore, during a laxative
trial, we try to keep the patients right in between
diarrhea and constipation. We want them to have
soft but formed stools and hopefully a minimal
number of times (1–3 times per day).
It is not easy to switch from enemas to laxatives. We emphasize this to the parents to avoid
false expectations. Sometimes, we are successful,
but the patients prefer to continue with enemas,
because it requires less effort and discipline.
20.6 About Our Program
On the fi rst day of the program, parents frequently express skepticism when hearing about
the results of our treatment. Many of them say
that they already gave enemas to the child in the
past with no success. This is certainly understandable. Giving an inadequate enema to a
child that is fecally impacted and not being able
to clean the colon completely would make the
patient feel worse. An enema that is not good
enough to clean the entire colon just softens the
hard stool, increasing the leakage (Fig.
A fecally impacted incontinent patient soils day
and night, but does not leak stool, and they rather
soil and stain the underwear. Therefore, an enema
that does not clean the colon, but rather softens
the hard stool, may produce more leakage and
will make the patient more uncomfortable due to
a more obvious problem of fecal incontinence.
We have to explain to the parents with special
20.6 ).
diagrams the reason why they believe that an
enema makes the child feel worse; we ask them
to give us a chance to demonstrate that fi nding
the right type of enema will eventually keep him
or her clean.
Also, many of the parents express their dissatisfaction or skepticism because their previous experience indicates that an enema was something
painful or uncomfortable. Again, we have to
explain to them that giving the right type of enema,
at the right time, in the right way, and using the
right concentration, should not hurt. If an enema
hurts, something has not been done well. We ask
the parents to be patient with us and allow us to
demonstrate, by trial and error, and over a period
of 1 week, that an enema does not hurt.
Many times, patients with fecal incontinence
suffer from severe, chronic diaper rash equivalent to a second-degree burn of the perianal area.
It is therefore not surprising that they refuse to
any kind of rectal maneuver. If somebody tries to
give them an enema with a tube in a careless way,
touching the ulcerated skin around the anus, the
patient will confi rm that this is a painful maneuver. Actually, we have to explain to the parents
that inside the bowel there is no sensation, and we
have to convince the patient to allow us to pass a
tube that he will not feel. Interestingly, a successful bowel management will cure the worst diaper
rash in about 48 h. At that point, the patient and
the family get the positive feedback that encourages them to cooperate more.
During the administration of the enema, some
patients experience symptoms suggestive of a
vagal refl ex. That is understandable and means
that most likely the enema was either given too
fast, has an excessively large volume, is too concentrated, or all of the above. The quick administration of a high volume of fl uid inside the bowel
provokes stretching of the bowel wall, followed
by a smooth muscle spasm which is manifested
in cramp or colic, sometimes including vomiting.
The treatment of this problem is very obvious.
We have to advise the parents to give the enema
slowly (over a period of 5–10 min). Sometimes
we also advise them to warm the fl uid of the
enema to body temperature. We also suggest that
they start giving the enema slowly, watching the
322
20 Bowel Management for the Treatment of Fecal Incontinence
a
b
c
Fig. 20.6 Ineffi cient enema in an impacted colon. ( a ) Enema fl uid did not go in. ( b ) Enema given against gravity. ( c )
Kinked enema tube
20.7 Content of the Enema
323
child’s reaction, who should be doing something
that he likes and that keeps him busy, like watching TV or reading a book. The moment the child
starts complaining of any discomfort in the
abdomen, the parents should reduce the speed of
administration of the enema, until those symptoms disappear. If in spite of all this the patient
complains of having cramps, it means that perhaps the patient’s colon is hypersensitive to the
type of enema that we are trying to administer.
Some colons respond in a very violent way
to certain kinds of enemas, and others do not
respond, even to very concentrated enemas. We
do not have an explanation for this. A patient that
has these kinds of vagal symptoms usually needs
a lower volume or lower concentration of the
substances that we use in the enemas (glycerin,
phosphate, and/or soap.)
20.7 Content of the Enema
The enemas that we use in our clinic may contain
one or several of the following components:
• Normal saline solution
• Glycerin
• Castile soap 5
• Phosphate (Fleet) 6
• Others (Dulcolax, 7 polyethylene glycol)
Early in our experience, we frequently allowed
the parents to prepare the saline solution by mixing salt from the kitchen with tap water (normal
0.9 % saline = 960 cc water plus 1.5 teaspoons
salt). Most parents are very diligent and careful to
do this, but we had two scary experiences, with
patients who came unconscious to the emergency
room. When we measured the amount of sodium
in their blood, it was extremely high. In retrospect, when we asked the mothers of those
patients exactly how much salt they put in the
water, they could not give an accurate, reliable
answer, which means that most likely they were
5
Castile soap – 0.30 fl uid oz. packets (1 packet = 9 ml);
mild, gentle soap ideal for soft soap enemas
6
Fleet – monobasic sodium phosphate 19 g, dibasic
sodium phosphate 7 g
7
Dulcolax ® bisacodyl
rather liberal in the administration of salt and
were not paying very much attention during the
preparation of the solution. Because of that, we
now advise to use only normal saline solution
from the pharmacy. Of course this is more expensive, but we prefer to take the safe route.
During the fi rst consultation we determine,
rather arbitrarily, the volume of saline solution to
be used. We do that estimate based on our experience and the image of the contrast enema. The
volumes that we used vary from 200 to 1,500 ml,
depending on the patient’s age and degree colonic
dilatation.
For glycerin, we usually use about 20 mL for
every 500 mL of saline solution. We increase or
decrease the amount of glycerin depending on
the patient’s reaction.
For Castile 8 soap, we usually use one package
(9 cc) for every 500 mL of saline solution. Yet,
we modify this amount according to the patient’s
response.
The phosphate is added in the commercial
form known as Fleet 9 enema. We use a pediatric
Fleet 9 (60 mL) in patients up to 10 years of age.
In older patients, we use an adult Fleet 9 (120 mL).
We never give more than one Fleet 9 per day.
Giving more than that exposes the patients to suffer from hyperphosphatemia, hypocalcemia, and
tetany [ 16 – 29 ]. We had only one patient who
experienced those problems after receiving three
Fleet 9 enemas in a day.
We try to be as conservative as possible in the
use of these different solutions. This means that
if we can manage a patient with plain, normal
saline solution and keep him completely clean,
then that is all we use. We try not to use any
other ingredient. However, many patients receiving a saline enema only do not respond; in other
words, 2 or 3 h go by, after the administration
of the enema, and nothing comes out through
the rectum, indicating that the enema that we are
using is not concentrated enough. In that case, the
next option for us is to add glycerin, which frequently makes the patient respond. Some patients
do not respond to the administration of glycerin,
8
See footnote 5.
9
See footnote 6.
324
20 Bowel Management for the Treatment of Fecal Incontinence
Fig. 20.8 Spastic left colon, secondary to the prolonged
use of phosphate enemas
Fig. 20.7 Colon with signifi cant amount of stool. This is
an indication to increase the volume and the concentration
of the enema
or they respond, but the colon does not empty
completely. The patient continues passing stool
during the day. An x-ray fi lm of the abdomen will
show that the colon still has a signifi cant amount
of stool (Fig. 20.7 ). Under those circumstances
we add phosphate (Fleet
10
) to the enema solution.
The phosphate is an extremely powerful ingredient and usually makes the patient respond well.
Unfortunately, we have seen a number of patients
who received Fleet 11 enemas for a long period of
time and behave like patients with tendency to
diarrhea (hypermotility). In such cases, a contrast
enema shows a spastic, narrow, hyperactive left
colon (Fig. 20.8 ). A colonoscopy shows signs of
colitis, due to the chronic irritation produced by
the phosphate solution on the colonic mucosa.
The patient may have signs and symptoms of a
severe colitis, including the presence of blood and
10
See footnote 5.
11
See footnote 6.
mucus in the stool. We have seen patients who
came to us originally suffering from constipation
and megasigmoid, received phosphate enemas,
and gradually changed, developing a tendency to
diarrhea and a spastic colon. It is rather impressive to see the change in symptoms and radiologic image, related to the use of phosphate. In
these cases the administration of phosphate is
immediately suspended. It takes several weeks or
months for the symptoms to disappear. Because
of this, nowadays we try to stay away from the
use of phosphate and leave it as a last resource.
We try to manage our patients with saline, plus
glycerine and soap if necessary.
The administration of an enema may require a
signifi cant amount of teaching from the nurses,
many times “hands-on” type of teaching. It is
wrong to prescribe an enema to a child and
assume that the father or the mother knows what
an enema is and how to give it.
We have learned that many parents think they
are giving an enema, and actually the enema fl uid
leaks all over the place and the fl oor; the fl uid is
not really going inside the patient.
The position of the patient during the administration of an enema is very important. Parents
20.8 Rationale to Change the Type of Enema
Fig. 20.9 Patients’ positions to receive an enema, according to age
325
sometimes try to give an enema to a child standing up, and obviously the fl uid will leak on the
fl oor. The position of the patient must facilitate
the effect of gravity for the enema fl uid to go
into the colon (Fig. 20.9 ). The position of the
patient also depends on his/her age, as can be
seen in Fig. 20.9 .
If the enema fl uid keeps leaking in spite of an
adequate patient’s position, then we advise the
parents to use a Silastic tube (14–18 F) and pass
it through the rectum as high as possible in the
colon, to be sure that the fl uid really goes inside
the colon and does not leak during the enema
administration (Fig.
20.10 ). If that is not enough,
then we advise the use of a Foley catheter. The
catheter is introduced (5–10 cm), the balloon is
infl ated (10 ml), and then the mother or father
must pull on the catheter in order for the balloon
to act as a plug and prevent leakage (Fig. 20.11 ).
Every patient has a different caliber anus and a
different-sized rectum; therefore, a differentsized balloon is needed for each patient. We start
by testing a 10-mL balloon. The balloon is
infl ated and traction is applied. If the balloon
comes out through the anus, this means that the
patient needs a larger balloon (20 ml), and if that
comes out, then we try a 30-mL balloon. The
patients that are more prone to leak during the
administration of the enema are patients suffering from myelomeningocele. Patients with anorectal malformations respond better because they
have a certain degree of fi brosis in the anal verge
that usually allows them to hold the balloon
inside during the administration of the enema.
20.8 Rationale to Change
the Type of Enema
If we see that the abdominal x-ray fi lm shows a
signifi cant amount of stool in the colon (Fig. 20.7 )
and the patient is still passing stool in the underwear, we have to increase the volume of the
enema. On the other hand, if the parents say that
it took a long time for the patient to pass stool
after the administration of an enema that means
we must also increase the concentration of the
enema. We typically start by increasing the concentration of glycerin. Some patients have a negative reaction to glycerin (severe cramps, nausea);
in such cases we try Castile 12 soap. In some
patients we go as high as 30 mL of glycerin, and
12
See footnote 5.