Bowel Management Program

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The bowel management program consists of teaching the patient or his/her parents how to clean the colon once daily so as to stay completely clean in the underwear for 24 h. This is achieved by keeping the colon quiet in between enemas. The program, although simplistic, is implemented by trial and error over a period of 1 week. The patient is seen each day and an x-ray film of the abdomen is taken so that they can be monitored on a daily basis for the amount and location of any stool left in the colon as well as the presence of stool in the underwear. The decision as to whether the type and/or quality of the enemas should be modified as well as changes in their diet and/or medication can be made [3].

It is important to differentiate real fecal incontinence from overflow pseudoincontinence. In patients with real fecal incontinence, the normal mechanism of bowel control is deficient for the reasons described. Pseudoincontinence occurs when a patient behaves like they are fecally incontinent, but really have severe constipation and overflow soiling. Once the disimpaction is treated and the patient receives enough laxatives so as to avoid constipation, he/she becomes continent. This patient group is described in Chaps. 29 and 30. It is extremely important to distinguish between real incontinence and pseudoincontinence in order to identify the origin of the problem and consequently to plan the best treatment.

Of all children with ARM who have undergone a correct and successful operation, 75% have voluntary bowel movements after the age of 3 years [2]. About half of these patients soil their underwear on occasion. Those episodes of soiling are usually related to constipation. When the constipation is treated properly, the soiling frequently disappears. Thus, approximately 40% of all children have voluntary bowel movements and no soiling. In other words, they behave like normal children. Children with good bowel control may still suffer from temporary episodes of fecal incontinence, especially when they experience severe diarrhea. Some 25% of all children suffer from real fecal incontinence, and these are the patients who must receive bowel management to keep them clean.

The surgeon should be able to predict in advance which children have good functional prognosis and which children have a poor prognosis. Table 29.1 shows the most common indicators of good and poor prognosis. After the main repair and the colostomy closure, it is possible to establish the functional prog

Table 29.1 Prognostic signs

Good prognosis signs:

Bad prognosis signs:

• Good Bowel movement patterns:

1-2 bowel movement per day - no soiling in between

• Constant soiling and passing stool

• Evidence of sensation when passing stool (pushing, making faces)

• No sensation (no pushing)

• Urinary control

Urinary incontinence, dribbling of urine

Table 29.2 Predictors of prognosis

Indicators of good prognosis for bowel control

Indicators of poor prognosis for bowel control

• Normal sacrum

• Abnormal sacrum

• Prominent midline groove (good muscles)

• Flat perineum (poor muscles)

• Some types of anorectal malformations:

- Rectal atresia

- Vestibular fistula

- Imperforate anus without a fistula

- Cloacas with a common channel < 3 cm

- Less complex malformations: perineal fistula

• Some types of anorectal malformations:

- Rectobladderneck fistula

- Cloacas with a common channel > 3 cm

- Complex malformations

nosis (Table 29.2). Parents must be realistically informed as to their child's chances for bowel control, avoiding needless frustration later on. It is imperative to establish the functional prognosis of each child as early as possible, sometimes even in the newborn period, in order to avoid creating false expectations for the parents. Once the diagnosis of the specific defect is established, the functional prognosis can be predicted. If the child's defect is of a type associated with good prognosis, such as a vestibular fistula, perineal fistula, rectal atresia, rectourethral bulbar fistula, or imperforate anus with no fistula, one should expect that the child would have voluntary bowel movements by the age of 3 years. These children will still need supervision to avoid fecal impaction, constipation, and soiling (see Chaps. 29, 30 and 33).

If the child's defect is of the type associated with a poor prognosis, for example, a very high cloaca with a common channel longer than 3 cm, a rectoblad-derneck fistula, or if they have a very hypodeveloped sacrum or associated spinal anomalies the parents must understand that their child will most likely need a bowel management program to remain clean. This should be implemented when the child is 3 or 4 years old, before he/she begins spending a great deal of time away from home. Children with rectoprostatic fistula have an almost 50:50 chance of having voluntary bowel movements or of being incontinent. In these children, an attempt should be made to achieve toilet training by the age of 3 years. If this proves to be unsuccessful, bowel management should be implemented. Each summer, during school vacation, re-attempts can be made to assess the child's ability to potty train.

In patients previously operated on for an ARM with fecal incontinence, a reoperation with the hope of obtaining good bowel control can be considered if the child was born with a good sacrum, good sphincter mechanism, a malformation with good functional prognosis, and the rectum is mislocated (see Chap. 24). A redo posterior sagittal anorectoplasty (PSARP) can be performed and the rectum can be relocated within the limits of the sphincter mechanism. Approximately 50% of the children operated on under these very specific circumstances have a significant improvement in bowel control [4].

Patients with fecal incontinence and a tendency toward constipation cannot be treated with laxatives, but instead need bowel management for fecal incontinence. Such children are usually those born with a defect that carries a bad prognosis and severe associated defects (e.g., defect of the sacrum, poor muscle complex).

Children operated on for ARM that suffer from fecal incontinence can be divided into two well-defined groups that require individualized treatment plans: (1) those with constipation (colonic hypomotility), and (2) children with loose stools and diarrhea.

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Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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