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Management Principles of Organic Causes of Childhood Constipation

Nan Tobias, RN, MSN, CNP; Debby Mason, RN, MSN, CPNP; Marlene Lutkenhoff, RN, MSN; Marilyn Stoops, RN, MSN,
CPNP; Denise Ferguson, RN, MSN, CPNP

J Pediatr Health Care. 2008;22(1):12-23.

Abstract and Introduction

Constipation is extremely common in the pediatric population; however, it is a symptom and not a disease. Organic causes of
constipation include Hirschprung's disease, anorectal malformation, and spina bifida. This article also discusses constipation
and urinary tract pathology and dysfunction. The function of the gastrointestinal and urinary tracts are intertwined, and this
concept will assist the practitioner in managing patients accordingly. Children and adolescents who experience bowel
dysfunction require patience and sensitive support from their health care providers so that they can live productive and
emotionally healthy lives.

Constipation is extremely common in the pediatric population. It is the chief complaint in 5% of all pediatric outpatient visits to a
primary care provider and 20% to 25% of pediatric gastroenterology consultations (Limbos, 2005). While the vast majority of
cases (90%-95%) are functional, certain diagnoses are indicative of an organic etiology. This article will describe constipation
management in children with Hirschprung's disease, spina bifida, anorectal malformation, and voiding dysfunction.

Definitions of Constipation

Constipation is a symptom, not a disease. Despite its common occurrence, constipation has no single definition upon which
practitioners agree. It is, however, described in terms of stool frequency, size, consistency, and ease of passage. Constipation in
children is defined by stool frequency less than 3 times per week, "hard, large, dry stools," painful bowel movements, and stool
withholding behaviors, sometimes accompanied by encopresis (Loening-Baucke 2002, Wenner 1998). At times, the stools may
be hard, dry, and pellet-like. Chronic constipation leads to a stretched colon with poor muscle tone. This poor muscle tone
inhibits the propulsion of stool through the bowel. The longer the presence of stool in the bowel, the more moisture that is
reabsorbed by the body, which results in an extremely hard stool that is difficult to pass. Liquid stool may seep around the hard
rectal stool, giving the appearance that diarrhea is present. An astute practitioner will be able to discern the varied presentations
of constipation.

Diagnosis and Treatment of Constipation

In caring for children with organic causes of constipation, a full understanding of the pathophysiology of the specific condition
that contributes to an abnormal defecation process helps determine successful treatment. This understanding saves the child
and family from time-consuming treatment plans that may be frustrating and unsuccessful.

One of the most important aspects of treatment is to educate the family about constipation. When the family understands the
problems leading to constipation, therapy becomes more effective. It is important to inform the family that while treatment for
constipation is effective, it usually requires at least 6 to 12 months (Homsy & Austin, 2002) to ensure successful outcomes. This
is an important first step to avoid unrealistic expectations for a quick cure. It may take up to a year to allow the bowel to regain
its peristaltic activity and normal diameter (Homsy & Austin).

Treatment for constipation is divided into three phases (see ) and involves a combination of medications, behavioral changes,
and dietary therapy. Proper attention to each of these areas is imperative for successful outcomes. In the first week of treatment
it is important to begin by cleaning out any hard stool or impaction. The rectum must be emptied in this initial phase. Whereas in
the past "clean-outs" typically were done by administering enemas, now more options exist to offer oral therapies. In our
institution, 99% of cleanouts can be handled with oral medications. For children who refuse high doses of oral therapy, a
nasogastric administration of polyethylene glycol/electrolyte solution may be necessary. This approach usually requires an
inpatient admission (Wenner, 1998). An abdominal film may be done before the child is discharged to confirm that he or she is
completely cleaned out. When cleanouts are unsuccessful, the family should be referred to a pediatric gastroenterologist.

Treatment for Constipation

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In the past, it has been common practice to use milk and molasses enemas for cleanouts. A review of their use with children at
our medical center has shown that they are not as safe as once thought (Walker, 2003). Milk and molasses enemas have been
associated with significant deleterious cardiovascular compromise and should not be used without careful supervision.
Supervision can best be provided in an inpatient setting, which allows for intervention in case a potential severe fluid shift occurs
in the colon (M. Farrell, Personal Communication, April 27, 2006).

During the next 6 to 12 months, a maintenance program is used that includes use of oral laxatives along with a high-fiber diet,
increased fluids, behavior modifications, and reassurance (Loening-Baucke, 1993). The third phase is considered the weaning
phase and includes gradual tapering of laxatives as well as continued encouragement of a high-fiber diet and increased fluids.
Throughout all phases, repeat evaluation, reassurance, and support are necessary. Structured follow-up visits are necessary
with the focus on education to help prevent, cope with, and treat recurrences.

Hirschprung's Disease

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Hirschprung's disease, with an incidence of about 1 in 5000 live births, is the best known cause of lower intestinal obstruction in
neonates (Loening-Baucke, 2002). It is a rare cause of intractable constipation in older children. A lack of ganglion cells in the
myenteric and submucous plexuses of the distal colon characterizes this disease. In 80% of cases the disease is limited to the
rectosigmoid area (Lloyd & Kenny, 2004). The bowel proximal to the anganglionic zone, which is contracted, becomes dilated
due to the functional distal obstruction, giving rise to the transition zone in between (Lloyd & Kenny).

More than 90% of neonates with Hirschprung's disease do not pass meconium until after the first 24 hours of life (Swenson,
Sherman, & Fisher, 1973). Therefore, a delayed passage of meconium in a full-term infant raises suspicion of Hirschprung's
disease. Commonly, children with Hirschprung's disease present with symptoms of intestinal obstruction, including bilious
vomiting, abdominal distention, and refusal to feed. Children with short-segment Hirschprung's disease may not be diagnosed
until they are older. These children have ribbon-like stools, a distended abdomen, and oftentimes failure to thrive.

Hirschprung's disease is diagnosed in the vast majority of cases during the first 3 months of life (Imseis & Gariepy, 2004). On
physical examination, the majority of children present with a distended abdomen and contracted anal sphincter and rectum. The
rectum will have no stool except in cases of short segment aganglionosis. During the rectal examination, as the finger is
withdrawn, there may be an explosive discharge of foul-smelling liquid stool and air with decompression of the proximal normal
bowel (Imseis & Gariepy).

Once Hirschprung's disease is suspected, diagnostic studies are necessary. Rectal biopsy with histopathology and rectal
manometry are the only tests that can reliably exclude Hirschprung's disease (Imseis & Gariepy, 2004). Rectal biopsies that
indicate the absence of ganglion cells in the submucosal plexus are diagnostic of Hirschprung's disease. Confirmation of this
diagnosis is obtained when cholinesterase staining shows hypertrophied nerves.

A delay in diagnosis places a child at increased risk of enterocolitis, which is the most feared complication of Hirschprung's
disease. Enterocolitis usually begins with the sudden onset of fever, abdominal distention, foul-smelling liquid stools, explosive
stools, and, at times, bloody diarrhea. Enterocolitis occurs most often during the second and third months of life and has a 20%
mortality rate (DiLorenzo, 1998).

In all cases of Hirschprung's disease, surgery is the definitive treatment. Surgery consists of resection of the aganglionic bowel
and anastamosis of the proximal normal bowel to the anal canal. Long-termcomplications in children with Hirschprung's disease
include constipation and fecal incontinence. The incidence of these problems is up to 50% in some series (Langer, 2005).
Anorectal stenosis is a common problem that leads to constipation. Some cases can be managed with anal dilatation, but 20%
to 30% may require anal myectomy or myotomy to adequately treat constipation (Imseis & Gariepy, 2004). Studies suggest that
over time, constipation and incontinence do resolve (Yanchar & Soucy, 1999).

Anorectal Malformations

Anorectal malformations vary in degree of complexity from anal stenosis, which may be diagnosed at a newborn office visit, to
the more severe malformation, imperforate anus, which is diagnosed shortly after birth. While constipation is likely to resolve
after surgical repair for anal stenosis, children with imperforate anus may have difficulty with constipation and incontinence long
after the surgical repair.

Anorectal malformations occur in 1 out of every 4000 to 5000 newborns and are slightly more common in boys (Guardino,
2000). Anorectal anomalies result from abnormal development of the urorectal septum that occurs midway through the first
trimester in pregnancy. This results in incomplete separation of the cloaca into the urogenital and anorectal portions (Guardino).
The severity of the malformation depends on the level at which the septum failed to separate, and the defects are classified
using anatomic descriptions (see Figure 1).

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Classification of anorectal malformations. Reprinted with kind permission of Springer Science and Business Media (Pena,
2006).

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A cutaneous or perineal fistula is a low defect; this is the most benign type of anorectal malformation. In this defect, an anal
opening is present but is displaced anterior to the anal dimple. In boys the anus may be located in the perineum or at the base
of the scrotum or penis (Guardino, 2000). In girls, the anus is interior, but the rectum and vagina are clearly two separate
structures. The displaced anal opening may be narrow or stenotic, or stenosis can occur with the anus in normal anatomic
position. Even though a cutaneous fistula is present and the anus is poorly positioned, the rectum is located mostly within the
normal sphincteric mechanism (Pena, 2000). As a result, these children have an excellent prognosis for normal long-term bowel
function.

Other anorectal malformations are more complex and involve an abnormal communication, or fistula, between the rectum and
the urinary tract. In boys, the fistula can be located anywhere along the urethra or bladder and the rectum. In girls, a vestibular
fistula may be present where the rectum opens through an abnormally narrow orifice located behind the hymen. The rectum and
vagina are separated by a thin wall. The most severe and rare anorectal malformation in females is a cloaca where the rectum,
vagina, and urethra form a long common channel. Imperforate anus can occur in boys and girls without a fistula, but this is rare.

Children who have cutaneous fistulae may present with constipation during infancy or childhood. The defect may be subtle and
may not have been appreciated on previous well-child examinations (Loenig-Baucke, 2002). In addition, when a rectal
examination is performed to evaluate for constipation, narrowing or stenosis may be evident. These patients also may exhibit
abdominal distention, failure to thrive, and other findings consistent with their history of constipation.

The diagnosis of the more complex anorectal malformation is usually made shortly after birth when attempts to perform rectal
temperature reveal an absent anus. These infants may have abdominal distention and vomiting. In a male infant, specks of
meconium may be seen in urine passing from the penis, which is indicative of a fistula between the rectum and urinary tract.
Female infants with an imperforate anus and a fistula may have small amounts of stool noted on their genitalia in the newborn
period (Hollands & Hoffman, 1998).Examination of the perineum, which includes noting the presence of an anal dimple, and
appearance of the gluteal muscles and gluteal crease can be indicative of the severity of the malformation. A flat perineum,
absent anal dimple, poorly developed gluteal muscles with incomplete midline groove (gluteal cleft), and an abnormally
developed sacrum seen on radiologic examination can mean the presence of a high fistula and is associated with poor long-
term functional outcomes (Pena, 2000).

It is important to recognize that other anomalies in patients with imperforate anus may be present. VACTERL association is a
nonrandom set of birth defects of unknown etiology that affects multiple organ systems. This acronym stands for vertebral
anomalies, anorectal malformations, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities.
Children diagnosed with VACTERL association generally have at least three of these anomalies (Lloyd and Kenny 2004, Paidas
et al 2005). In addition, children with anorectal malformation have a high incidence of anomalies involving the genitourinary tract
and spinal cord (Taskinen, Valanne, & Rintala, 2002). A thorough evaluation of all these systems should be undertaken in any
child with an anorectal malformation.

Surgical correction of a low defect or cutaneous fistula is performed with anoplasty. The procedure involves enlarging the anus
and moving it posteriorly into the correct position and within the center of the sphincter complex. The child with a cutaneous
fistula does not need to receive a colostomy (Pena, 2000). The child with a recto-urinary or rectovaginal fistula will have
colostomy placed within the newborn period. The corrective procedure, a posterior sagittal anorectoplasty, is performed
between the ages of 3 and 12 months, depending on the surgeon's preference (Pena). During this procedure, the fistula is
divided and the rectum is mobilized to its correct position. A "neonanus" is created in the appropriate position, which is
determined by the use of a nerve stimulator on the perineum during the operation. To allow time for proper healing of the
neoanus, the colostomy is closed during a later procedure.

Postoperative care consists of beginning dilations of the neoanus 3 to 6 weeks after surgery. These dilations continue on a daily
basis for several months. Parents are instructed to perform the dilations at home. To prevent the neoanus from scarring and
contracting, it must be emphasized that compliance with this regimen is critical. Noncompliance can result in serious
consequences that can negatively affect the long-term outcome of the surgical procedure.

Three conditions are necessary for children to achieve fecal continence: sensation within the rectum, good colonic motility, and
good sphincteric control (Paidas & Pena, 2005). Children with anorectal malformations tend to lack some or all of these
mechanisms (Guardino, 2000). Following repair of an anorectal malformation, children usually will experience either
constipation or diarrhea.

Typically, after surgical correction and colostomy closure, small frequent stools are common. It is important to determine if this
stooling pattern is caused by leakage around a large amount of retained stool. A rectal examination can determine if narrowing
is present at the surgical site and also can provide information on the amount and consistency of any retained stool within the
rectal vault. A barium enema may be obtained to determine the amount of retained stool and any colonic distention due to
constipation (Paidas & Pena, 2005).

Children are placed on a dietary and bowel regimen in an attempt to achieve one to three large bowel movements a day instead
of nearly constant soiling (Paidas & Pena, 2005). If the patient is constipated, a regimen of daily enemas for several weeks often
is required to clean out the colon. During this time, management with a high-fiber diet should be initiated. Compliance with a
high-fiber diet can be very difficult in children. Medications, which include polyethylene glycol, lactulose, or magnesium

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hydroxide, may be used in conjunction with dietary management (see ). Typically children with organic causes of constipation
will need a stimulant.

For children who do not achieve medical/dietary management of constipation or are incontinent, a daily enema regimen may
allow them to be "socially continent" (Paidas & Pena, 2005). In this situation, a normal saline solution enema is given daily at a
consistent time. This goal is to cleanse the colon and to have no soiling until the next successive daily enema is administered.

If the child approaches school age and continues to have problems with continence and/or requires daily enemas to prevent
soiling, colonic and anorectal manometry may be performed. This testing will help determine the presence or absence of the
components of sensation, motility, and sphincter control necessary for bowel continence. In addition, magnetic resonance
imaging may be performed to evaluate the rectum and its placement within the muscular structures of the pelvis (Paidas &
Pena, 2005). If it is determined that nothing more can be done surgically with the rectum and anus to achieve continence, the
child and family may be offered an antegrade continence enema (ACE) procedure.

The ACE procedure consists of creating a nonrefluxing conduit between the cecum and the skin using the appendix or a piece
of tubularized ileum. Through this abdominal stoma, enema fluid is administered and flushes the entire large bowel (Malone,
2004). The child sits on the toilet during enema administration and bowel contents are released through the rectum into the
toilet.

Spina Bifida

Myelomeningocele or spina bifida is a neural tube defect that occurs within the first 28 days of gestation. The neural tube forms
the future brain, spinal cord, and spinal column. When the neural tube fails to close along the axis of the spine (most commonly
the lumbosacral region), the infant will be born with spina bifida (Tinkle & Sterling, 1997). The child will have motor and sensory
deficits to the lower extremities ranging from mild to complete. Because the nerves that control the bladder and bowel are
located in the sacral spinal cord, the child will mostly likely have deficits in these areas as well.

Bowel dysfunction occurs in children with spina bifida because the recto anal inhibitory reflex is maintained but the defecation
urge is not present (DiLorenzo & Benninga, 2004). When the internal sphincter relaxes, bowel accidents or soiling occur.
Constipation results from an increased colonic transit time and a lack of spincteric contraction with rectal distention (DiLorenzo
& Benninga).

Additional factors leading to bowel dysfunction in children with spina bifida are many. One such factor is a general decrease in
activity due to motor limitation. Movement of gastrointestinal contents is greatly enhanced by daily walking and exercise. Many
persons with spina bifida are unable to walk and do not participate in exercise routines. A second factor is that children with
higher level lesions have weak abdominal muscles, which results in a decreased ability to push out stool. A third factor is that
some medications taken for urinary management decrease colonic motility (Bosch et al., 2002). A fourth factor is that children in
wheelchairs or braces need more time to remove clothing and transfer to the toilet. They may be unable to perform these
manipulations quickly enough to prevent accidents. A final factor, albeit common in the general population, is that some children
with spina bifida are extremely picky eaters, often refusing to eat many of the foods that promote daily bowel evacuations. In
summary, each child will present with a unique set of variables contributing to bowel dysfunction and will respond differently to
various treatment modalities.

A developmental perspective is one method to organize an approach to bowel management for children with spina bifida. Each
period brings with it unique challenges. The interventions that work at one stage in a person's life may not be effective at a
different stage. Achieving and maintaining a successful program is therefore a dynamic process.

During the infancy period, parents begin to assimilate the medical implications of having a child with spina bifida. Parental
attention to bowel functioning is generally not a priority because of other pressing needs. However, it is important that parents
understand the significance of beginning a bowel program early. Normal infant stool does not become formed until about 18
months (Loening-Baucke, 2002). Usually an infant with spina bifida will pass stools without problems, but some present with
constipation. Parents are encouraged to keep the baby's stool soft so that regular elimination can occur. If the baby is having
small hard stools, intervention should begin.

An older infant can be encouraged to drink apple or prune juice or eat strained prunes, which typically soften stools. Increasing
fluids will help, but often a laxative is needed. Lactulose syrup is safe to give to infants who are at least 6 months old. Rarely are
enemas or suppositories recommended at such a young age. Often parents report that when their baby is having a great deal of
difficulty passing stool, massaging the infant's buttocks and/or flexing the infants' legs over the abdomen facilitates stool
passage.

Children who are physically capable of sitting on the toilet safely and comfortably should be encouraged to do so at the usual
developmental age for potty training at 24 to 36 months. Potty training a child with spina bifida consists of routinely having the
child sit on the toilet for a few minutes at consistent times of the day, generally in the morning or after meals. Initially, the child
should be praised for sitting, not actual results. The child will need to be taught to grunt and bear down and should be provided
a stool for foot support. If these toileting maneuvers fail, digital rectal stimulation or suppositories can be used. If suppositories

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are used, they must be inserted past both the external and internal sphincters. The child may need to have the buttocks held
together and to lie quietly for 10 to 15 minutes for the suppository to remain in place and dissolve. Care must be taken when
inserting medications or fingers into a rectum that has little or no sensation.

Healthy nutrition, which includes fruits and vegetables and foods high in fiber, is important. Because it may be difficult for
children to obtain enough dietary fiber, over-the-counter fiber supplements can be added to foods.

When scheduled toileting, high-fiber diets, and suppositories all have failed to provide satisfactory results, high-volume saline
solution enemas may be initiated when the child is about 5 years old (Rintala, 2002). Enemas can be a challenge to administer
to children with poor anal tone. Attaching a cone tip to the enema insertion tube will helpwith the retention of fluid. An alternative
to a high-volume enema is the enemeez mini-enema (TM Western Research Labs), which is a small-volume enema that acts as
a stimulant.

At times, children with spina bifida cannot sit on a toilet because of recent surgery, casting, or lack of stability. Even so, regular
passage of stool through one or more of the various methods described above should be promoted. An enema or suppository
can be administered and resultsevacuated into disposable undergarments instead of the toilet.

By school age, bowel control should be achieved; however, the reality is that many children will continue with bowel dysfunction
during school age years. Because peer involvement plays a much greater role in the life of a school-aged child, bowel accidents
are especially distressing. A child without bowel control is subject to ridicule and will be hesitant to participate in social activities.
Anticipating bowel accidents and taking precautionary steps is crucial because accidents are always a possibility. Children can
be taught the cues their bodies experience prior to having a bowel movement. Depending on how much sensation the child has,
the ability to recognize a feeling of fullness and/or cramping as signals of impending bowel movement may be possible (Rintala,
2002). A child also can learn to recognize odors from escaping gas. Once the child recognizes the cues, a plan of action is
necessary.

Plans of action include preparation for bathroom time, communication with school personnel, and planning for accidents. For
example, the child finds the closest restroom and toilet sits, bears down, or cleans up as necessary. A child with a neurogenic
bowel should have permission to leave the classroom at any time for bowel management. An unobtrusive signal should be
worked out ahead of time between the child and the teacher. Even if the child is able to recognize cues, it is unlikely he will be
able to delay evacuation. There should be a change of clothing available at school at all times. Pants that are the same color
and style will make it less obvious that the child has changed clothes mid day, thus decreasing the likelihood that peers will
notice.

The best antidote to bowel accidents is adhering to a consistent bowel regimen at the same time each day (Rintala, 2002). The
school-aged child's cooperation and participation with the bowel regimen can be facilitated by appealing to their beginning logic
acquisition. Consistent bowel management practices = less chance of accidents = increased opportunities to participate in
social activities.

With the many physical and hormonal changes occurring during adolescence, bowel programs may need adjustment. This is a
difficult time for such issues, because adolescents detest what causes them to feel different. Rebellion against bowel regimens
may occur if it is used as a focus for independence. It may be helpful to emphasize that bowel continence is critical for social
acceptance. Attending school, dating, and acquiring a job require appropriate hygiene and may be the incentive necessary to
keep the adolescent on track with a bowel regimen (Farley & Dunleavy, 2003).

Surgical procedures are utilized when other methods fail to produce the desired outcome of bowel continence. The Malone
antegrade procedure (also described in the section on Anorectal Malformation) has the advantage of complete bowel cleanout
when compared with enemas administered via rectum.

Impact of Constipation on the Urinary Tract

The urinary bladder is located anteriorly and inferiorly to the rectum and sigmoid colon. Distention from a stool-filled sigmoid
colon and rectum can cause bladder compression, which can lead to bladder outlet obstruction. This outlet obstruction from a
compressed, distorted bladder has been shown to lead to voiding dysfunction, impaired bladder emptying, urinary tract infection,
vesicoureteral reflux, and hydronephrosis (Gatti et al 2001, Hellerstein and Linebarger 2003, Homsy and Austin 2002, Koff et al
1998).

Dysfunctional voiding syndromes vary from mild to severe. Mild dysfunction may be manifested by symptoms of frequency and
urgency, with or without daytime enuresis. Moderate dysfunction includes bladder instability (also called infantile, immature, or
uninhibited bladder) and/or detrusor sphincter dyssinergia (incoordination of detrusor and sphincter activity), and a hypotonic
bladder due to chronic urine withholding. Children with large-capacity bladders are infrequent voiders, voiding fewer than four
times daily, and generally have accompanying symptoms of urgency and incontinence between voiding (Strand, 1999). Urinary
tract infection and constipation commonly occur together. Bladder instability manifestations include urgency, urge incontinence,
frequency, enuresis, urinary tract infections, and squatting postures to withhold urine.

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Severe voiding bladder dysfunction manifests itself through a non-neurogenic neurogenic bladder, also termed Hinman
syndrome, or occult neurogenic bladder (Koff et al., 1998). This syndrome consists of day and night enuresis, urinary tract
infection, fecal retention and soiling, radiographic abnormalities including bladder trabeculation (muscular hypertrophy from
excessive pressures), vesicoureteral reflux, hydronephrosis, and renal damage. No neurologic or anatomic obstructive lesion is
demonstrable. Left untreated or treated inadequately, renal failure can result.

It has been estimated that 60% of children experiencing recurrent urinary tract infections (UTIs) have bladder instability and
approximately 30% have vesicoureteral reflux (Koff et al., 1998). Constipation and encopresis are symptoms heavily intertwined
with these urologic difficulties. Mechanisms whereby this relationship between the urinary and gastrointestinal tracts occurs are
twofold: (a) a full rectum can displace the urinary bladder and posterior urethra leading to incomplete voiding and high voiding
pressures (Hellerstein and Linebarger 2003, Koff et al 1998); these processes lead to UTIs, bladder wall inflammation, and
predisposition to subsequent UTIs; and (b) encopretic episodes in girls can precipitate the introduction of bacterial organisms
into the bladder, also leading to a vicious cycle of UTIs, bladder inflammation, exacerbation of bladder instability, and enuresis.

Health care practitioners often overlook the relationship between the gastrointestinal and genitourinary tracts and may treat
each system individually, or even miss or trivialize the gastrointestinal complaints (Koff et al., 1998). The term "dysfunctional
elimination syndrome" has come into use to describe an elimination pattern affecting both the urinary and gastrointestinal tracts
(Koff et al). It is a more accurate term than voiding dysfunction alone and ideally will encourage the practitioners to manage both
systems simultaneously.

The observation that a dilated bowel can lead to urinary tract dilatation was initially noted by surgeons caring for children with
Hirschprung's disease (Swenson, 1955). Others have found an association between renal dilatation and bladder residual and
constipation in a prospective study of children with functional constipation who were age matched with a control population of
healthy children without constipation (Dohil, Roberts, Jones, & Jenkins, 1994).

Additionally, Gatti et al. (2001) identified a population of children evaluated in an emergency department who presented with
urinary retention caused by constipation. These observations lend further evidence of the significant impact that a dysfunctional
bowel can inflict upon the urinary tract.

Signs and symptoms of voiding dysfunction and other urinary tract difficulties will vary among individuals. The most common
symptoms to elicit are enuresis, urinary frequency and urgency, and Vincent's curtsy (squatting down with placement of the
child's heel against the perineum in an attempt to withhold urine). Urinary tract infection must be diagnosed by the attainment of
an appropriately collected midstream or catheterized urine specimen.

Because of the wide variation in presentation of constipation, and because most parents of school-aged children are unaware of
their child's bowel habits, many parents are unaware of the presence of constipation in their child. A written record of stool
frequency and characteristics is necessary. A voiding diary that includes urinary frequency and volume assists in objectively
measuring specific urinary problems.

Examination of the abdomen may reveal abdominal fullness and tenderness. A bowel distended with stool and/or a bladder
distended with urine could be the cause of the fullness and tenderness. In select cases, a rectal examination can be
undertaken. An examination of the sacral spine to look for tufts of hair, vascular lesions, uneven gluteal folds, a non-midline
dimple, or a lipoma should always be included to rule out neurologic lesions (Perez & Rushton, 2001).

Many studies have demonstrated that urinary tract difficulties including day and night enuresis, irritative voiding symptoms,
UTIs, and urinary retention can be relieved with the successful treatment of constipation and encopresis (Hellerstein &
Linebarger, 2003). Ideally, identification and treatment of constipation begins at the presentation of urinary tract difficulties.
Treatment of bladder instability and other genitourinary dysfunction may involve the use of anticholinergic medication. A
potential adverse effect of this medication classification is constipation. If constipation is not addressed at the outset, urinary
tract symptoms may actually worsen instead of improve with treatment.

Treatment of voiding dysfunction and UTIs will include a variety of interventions. Children often need to be encouraged to drink
adequate and appropriate fluids. Not only does this assist in the treatment of constipation, but less concentrated urine may
reduce detrusor irritation and hyperreflexia. For children who void infrequently or retain urine, the recommendation is made to
void every 2 to 3 hours on a timed schedule. To encourage more complete bladder emptying, the technique of double voiding
may be encouraged. This involves unhurried toileting with a several-minute interval between voiding. When children are at
school, they can count slowly to 100 between voids in order to prevent excessive bathroom time (Perez & Rushton, 2001).
Biofeedback therapy may be initiated for those with incoordination of the sphincter and detrusor muscle. In more severe
instances that include upper tract changes, home intermittent catheterization will be initiated.

Children and adolescents with bowel and/or urinary tract dysfunction require considerable patience, effort, and support from
health care providers and family members. The management of elimination disorders is a sensitive issue and most often
requires a prolonged treatment program. This treatment program may last for years as old habits are shed, new habits are
learned and practiced, and the body's genitourinary and gastrointestinal tracts gain or regain normal anatomy and function.

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The evaluation and treatment of bowel and bladder dysfunction is in and of itself quite private and sensitive to most children and
adolescents. American society has very little tolerance for bowel and bladder incontinence, and so the children, upon arriving at
the health care provider's doorstep, already may have experienced numerous injustices or hurt and embarrassed feelings. Upon
discovering the need for invasive and uncomfortable examinations and diagnostic testing, many children and their parents may
deny or minimize the difficulties they are experiencing. It is the health care provider's role to assist the child and family to
understand the necessity of the evaluation and treatment for elimination difficulties, because many have detrimental effects on
the body and the child's development. The health care provider needs to allow time during office visits to offer support and
encouragement to families and to highlight accomplishments that are gained. Huge strides in the child's self esteem and social
development can be accomplished with sensitive, systematic, and logical treatment of bowel and bladder dysfunction.

Conclusion

This article discussed management of organic constipation with select pediatric populations with Hirschprung's disease, spina
bifida, anorectal malformation, and voiding dysfunction. Developmental issues and suggested nursing interventions are
included. Nurses should take an active role in helping children and their families treat and adjust to the physical and emotional
sequelae of bowel dysfunction.

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Acknowledgments

We thank Cheryl Stuckey for her work in preparing this manuscript.

Reprint Address

Correspondence: Nan Tobias, RN, MSN, CS, PNP, Cincinnati Children´s Hospital, Division of Urology, 3333 Burnet Ave, MLC
5037, Cincinnati, Ohio 45229; e-mail: nan.tobias@cchmc.org .

J Pediatr Health Care. 2008;22(1):12-23. © 2008 Mosby, Inc.

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