Educational articleManagement of functional nonretentive fecal incontinence in children: Recommendations from the International Children's Continence Society
Introduction
Fecal incontinence (FI) is defined as the loss of stools in places inappropriate to the social context at least once per month in children with a developmental age of ≥4 years [1]. Fecal incontinence reflects a difficult and distressing problem for children and their parents. It can lead to feelings of guilt and embarrassment, and can cause children to be either the victim of bullying [2], [3], or actively involved in bullying [4]. Fecal incontinence significantly impacts quality of life [3], and may lead to issues with social functioning and lower self-esteem [5].
In approximately 95% of children with FI, no organic cause can be identified, and it is regarded as a functional defecation disorder [1], [6]. In 80% of children with functional FI, this symptom is associated with functional constipation (FC) with fecal impaction causing overflow incontinence; this is characterized by the involuntary loss of soft stools that pass an obstructing fecal mass [7], [8]. In the remaining 20% of children with functional FI, there are no signs of fecal retention; this is classified as functional nonretentive fecal incontinence (FNRFI) [1], [8]. This report summarizes the current recommendations of the International Children's Continence Society for the evaluation and management of children with FNRFI.
For many years, a comprehensive definition of the disorder that is now classified as FNRFI has been lacking and FI has been described in many different ways. First, the term encopresis was used to describe the loss of a normal quantity of feces [9]. Later the term soiling was introduced, referring to passage of small amounts of stool, which stain the underwear [9], [10]. This was seen as a characteristic sign of fecal overflow incontinence. However, these terms have been used interchangeably in medical literature.
Currently, the Rome III criteria are used to define functional gastrointestinal disorders. These criteria have adopted the more neutral term fecal incontinence rather than the terms encopresis and soiling (Table 1) [1]. Throughout this report, the terms relating to FI, FNRFI and FC are consistently used in accordance with the definitions provided by the Rome pediatric committee (Table 1).
Section snippets
Epidemiology
Studies on the prevalence of FNRFI in children are scarce, and many studies investigating functional FI do not differentiate between FNRFI and constipation-associated FI. To date, only an epidemiological survey performed in Sri Lanka has assessed the true prevalence of FNRFI in the pediatric population. They reported that 2.0% of children (10–16 years) experienced FI, of whom 18% were considered to have FNRFI [11]. The prevalence of FNRFI is higher among younger children [7], [12], and it is
Pathophysiology
The exact pathophysiology of FNRFI is unknown, its etiology is considered to be multifactorial. The presence of FI in general is associated with younger age, a positive family history, non-Caucasian race, male gender, important life events such as the birth of a younger sibling, parental discord, a change in living conditions, and other psychological factors [14], [15], [16], [17], [18], [19].
Urinary incontinence (UI) is commonly found in children with FNRFI [20], [21], [22]. Prevalence rates
Evaluation
In children presenting with FI without an underlying organic cause, the most important objective is to differentiate between constipation-associated FI and FNRFI. Functional nonretentive fecal incontinence and FC are both clinical diagnoses, mainly based on medical history and physical examination (Table 1).
Treatment
The International Children's Continence Society recommends a multimodal approach to treat FNRFI.
Prognosis
Functional nonretentive fecal incontinence is often a long-lasting problem; treatment can prove to be quite challenging [16]. After 2 years of intensive treatment in a tertiary center, 29% of FNRFI patients were cured [14]. Most recovered before they reached adulthood; nevertheless, by 18 years of age, 15% still suffered from FI problems [14]. Regular follow-up is recommended so that children and their parents can maintain motivation and to prevent relapses. If treatment does not lead to
Conclusions
Of all children presenting with FI, approximately 20% may be attributed to FNRFI. Functional nonretentive fecal incontinence is a frustrating, long-lasting functional defecation disorder. It is a clinical diagnosis based on medical history and physical examination. Determining CTT may prove useful in the diagnosis of FNRFI, yet other additional investigations are seldom needed. Treatment mainly consists of education, a nonaccusatory approach, and, most of all, a toileting program (with a daily
Conflict of interest/Funding
None.
References (69)
- et al.
Childhood functional gastrointestinal disorders: child/adolescent
Gastroenterology
(2006) - et al.
Pathophysiology of pediatric fecal incontinence
Gastroenterology
(2004) - et al.
Longitudinal follow-up of children with functional nonretentive fecal incontinence
Clin Gastroenterol Hepatol
(2006) - et al.
Why is toilet training occurring at older ages? A study of factors associated with later training
J Pediatr
(2004) - et al.
Factors associated with toilet training in the 1990s
Ambul Pediatr
(2001) - et al.
Lack of benefit of laxatives as adjunctive therapy for functional nonretentive fecal soiling in children
J Pediatr
(2000) - et al.
Encopresis and sexual abuse in a sample of boys in residential treatment
Child Abuse Negl
(1997) - et al.
Sexual abuse: another causative factor in dysfunctional voiding
J Urol
(1995) - et al.
Rectal examination in children: digital versus transabdominal ultrasound
J Urol
(2013) - et al.
Transabdominal ultrasound of rectum as a diagnostic tool in childhood constipation
J Urol
(2008)
Use of pelvic ultrasound in the diagnosis of megarectum in children with constipation
J Pediatr Surg
The diameter of the rectum on ultrasonography as a diagnostic tool for constipation in children with dysfunctional voiding
J Urol
New insight into rectal function in pediatric defecation disorders: disturbed rectal compliance is an essential mechanism in pediatric constipation
J Pediatr
No role for increased rectal compliance in pediatric functional constipation
Gastroenterology
Peristeen integrated transanal irrigation system successfully treats faecal incontinence in children
J Pediatr Urol
Modulation of abnormal defecation dynamics by biofeedback treatment in chronically constipated children with encopresis
J Pediatr
Biofeedback training in treatment of childhood constipation: a randomised controlled study
Lancet
Health related quality of life in disorders of defecation: the defecation disorder list
Arch Dis Child
Health-related quality of life in young adults with symptoms of constipation continuing from childhood into adulthood
Health Qual Life Outcomes
Psychological differences between children with and without soiling problems
Pediatrics
Psychological and psychiatric issues in urinary and fecal incontinence
J Urol
Functional fecal incontinence in children
Ann Nestle
Review article: faecal incontinence in children: epidemiology, pathophysiology, clinical evaluation and management
Aliment Pharmacol Ther
Is encopresis always the result of constipation?
Arch Dis Child
Studies on encopresis
Acta Paediatr Scand
Constipation-associated and nonretentive fecal incontinence in children and adolescents: an epidemiological survey in Sri Lanka
J Pediatr Gastroenterol Nutr
Functional nonretentive fecal incontinence in children
J Pediatr Gastroenterol Nutr
The prevalence of encopresis in a multicultural population
J Pediatr Gastroenterol Nutr
Early constipation and toilet training in children with encopresis
J Pediatr Gastroenterol Nutr
Functional nonretentive fecal incontinence in children: a frustrating and long-lasting clinical entity
J Pediatr Gastroenterol Nutr
Toilet training and toileting refusal for stool only: a prospective study
Pediatrics
Functional defecation disorders in children with lower urinary tract symptoms
J Urol
Functional nonretentive fecal incontinence, do enemas help?
Gastroenterology
Bladder and bowel dysfunction and the resolution of urinary incontinence with successful management of bowel symptoms in children
Acta Paediatr
Cited by (58)
Everyday life with childhood functional constipation: A qualitative phenomenological study of parents' experiences
2022, Journal of Pediatric NursingA Child Psychiatry Perspective on Encopresis
2022, Journal of the American Academy of Child and Adolescent PsychiatryElimination Disorders in Children and Adolescents
2022, Comprehensive Clinical Psychology, Second EditionEvaluation of a bladder and bowel training program for therapy-resistant children with incontinence
2021, Journal of Pediatric UrologyCitation Excerpt :Group programs have also the advantage of being very efficient. In children with FI, treatment recommendations are based on behavioral modifications, including education and demystification, regular toilet sitting times, a reward system, and on laxatives in case of constipation [10,11]. For FI and constipation, the evidence for the effects of standard urotherapy or group programs are lower, but do show positive effects, as well [12,13].