Educational article
Management of functional nonretentive fecal incontinence in children: Recommendations from the International Children's Continence Society

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Summary

Background

Fecal incontinence (FI) in children is frequently encountered in pediatric practice, and often occurs in combination with urinary incontinence. In most cases, FI is constipation-associated, but in 20% of children presenting with FI, no constipation or other underlying cause can be found – these children suffer from functional nonretentive fecal incontinence (FNRFI).

Objective

To summarize the evidence-based recommendations of the International Children's Continence Society for the evaluation and management of children with FNRFI.

Recommendations

Functional nonretentive fecal incontinence is a clinical diagnosis based on medical history and physical examination. Except for determining colonic transit time, additional investigations are seldom indicated in the workup of FNRFI. Treatment should consist of education, a nonaccusatory approach, and a toileting program encompassing a daily bowel diary and a reward system. Special attention should be paid to psychosocial or behavioral problems, since these frequently occur in affected children. Functional nonretentive fecal incontinence is often difficult to treat, requiring prolonged therapies with incremental improvement on treatment and frequent relapses.

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.

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      Citation 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].

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