Group C Sequelae of Constipation

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Group C includes those patients referred to our institution because of fecal incontinence who actually had untreated severe constipation, chronic impaction, and therefore suffered from overflow pseudoincontinence. All of these patients have several factors in common. All were born with a malformation with good functional prognosis and underwent a technically correct, successful operation. Postoperatively, they all had severe constipation which was not adequately treated and developed megasigmoid and chronic fecal impac-tion. Adequate treatment of their constipation, with or without a sigmoid resection [25], rendered them fecally continent (see Chaps. 29, 30 and 32].

Constipation is the most common functional disorder observed in patients who undergo posterior sagittal anorectoplasty [1]. Interestingly the incidence of constipation is inversely related to the frequency of voluntary bowel movements. This means that patients with the best prognosis for bowel control have the highest incidence of constipation. Patients with very poor prognosis, such as bladder neck fistula, have a rather low incidence of constipation.

It seems from analysis of our series that constipation is related to the degree of preoperative rectal ectasia. Colostomies that do not allow cleaning and irrigation of the distal colon lead to megarectum. Transverse colostomies lead to a micro left colon with dilatation of the rectosigmoid. Loop colostomies allow for passage of stool and distal fecal impaction. It is clear that keeping the distal rectosigmoid empty and not distended from the time the colostomy is established and proceeding with pull-through and subsequent colostomy closure as early as possible within several months results in better ultimate bowel function [26].

All patients in this pseudoincontinent group underwent a laxative test to determine whether they were fecally continent. First, large-volume enemas were administered until the patient's colon was clean (disimpacted). Daily laxatives were then administered, increasing the amount each day until the amount necessary to produce colonic evacuation was determined. A plain abdominal x-ray was obtained every day to assess the colonic emptying (see Chaps. 29, 30 and 32). If the patient demonstrated the capacity to feel the stool in the rectum, reach the bathroom, have voluntary bowel movements, and remain clean every day, the patient was considered continent. The patient was then offered the option of continuing the treatment with large quantities of laxative for an indefinite period of time or a sigmoid resection [25] in order to make the constipation more manageable and thereby decreasing the laxative requirement.

It is extremely important to recognize this group of patients. Some may be wrongly diagnosed as suffering from true fecal incontinence and some have even undergone reoperations such as gracilis muscle or artificial sphincters, which can actually make the patient worse. This problem should be suspected when one sees a patient who was born with a benign malformation, who underwent a technically correct operation, but who was not treated correctly for constipation.

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Constipation Prescription

Constipation Prescription

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