Fecal incontinence (FI) refers to the inability to control bowel movements at will and the involuntary discharge of rectal contents. Pediatric fecal incontinence is relatively common in clinical practice, and because of its complex etiology, treatment outcomes are poor, causing great pain to the child and family, resulting in a significant decrease in quality of life. The establishment of a standardized diagnosis and treatment process is of great importance for the clear diagnosis of the type of fecal incontinence and targeted treatment according to the etiology, and for the scientific evaluation of the efficacy of different treatment methods.
Diagnostic criteria.
Pediatric fecal incontinence is divided into two types: functional fecal incontinence and organic fecal incontinence. functional fecal incontinence, also called idiopathic fecal incontinence, mainly includes.
1, functional non-retentive fecal incontinence.
(1) symptoms of fecal incontinence at least 1 time per month.
(2) No clear cause of fecal incontinence.
(3) No signs and symptoms of fecal retention. The diagnosis can be made by meeting the above 3 criteria and being older than 4 years old.
2, overflow incontinence due to functional constipation.
(1) ≤ 2 bowel movements per week.
(2) At least 1 occurrence of fecal incontinence per week.
(3) signs of stool retention on rectal examination or X-ray abdominal plain film. The diagnosis is made when all three criteria are met and the patient is older than 4 years of age.
Organic fecal incontinence is due to a clear cause of fecal incontinence, also called secondary fecal incontinence, mainly including.
1, neurogenic incontinence: congenital lumbosacral cremasteric bulge, cremasteric tethering and sacrococcygeal dysplasia and other abnormalities in the development of the nervous system caused by incontinence.
2, congenital anorectal malformation postoperative incontinence: congenital anorectal malformation postoperative incontinence due to anal sphincter or nerve dysplasia.
3.Post-operative incontinence after congenital megacolon: post-operative incontinence after congenital megacolon due to damage to the anal sphincter or pelvic floor nerves.
4.Postoperative incontinence after giant pelvic floor tumor: incontinence caused by damage to the anal sphincter or pelvic floor nerves after surgery for giant sacrococcygeal teratoma, pelvic rhabdomyosarcoma, etc.
5, anorectal trauma or anal fistula incontinence after surgery: anal sphincter injury caused by trauma at the anus or infected fistulas caused by fistula removal.
Treatment process.
1, detailed medical history: detailed medical history is very important for the diagnosis and determination of the cause of fecal incontinence. By following up the medical history (including previous illnesses, surgeries, trauma, etc.) can help to identify the primary disease causing fecal incontinence. It is best to have the child fill out a bowel diary for about two weeks, recording the number of bowel movements and incontinence per day, the nature of the leaking bowel contents, the circumstances under which gas, liquid or formed stools are leaked, whether the nature of the bowel contents can be distinguished from gas, liquid or solid, and the presence or absence of bowel movements, etc. Through the bowel diary, the degree of anal incontinence can be accurately determined.
2.Anorectal function examination includes.
(1) colonic transit time: total colonic transit time, right hemicolectomy transit time, left hemicolectomy transit time and rectosigmoid transit time; (2) X-ray dynamic defecography: recto-anal angle, anal canal length, anal caudal gap, recto-anal intersection shift and protrusion depth.
(3) pelvic floor nerve function examination: examination of three latency tests of perineal-anal reflex, cremaster-anal response and cauda equina evoked potentials, and quantitative analysis of the afferent, efferent and sacral medullary central nerve conduction of three parts of the perineal-anal reflex arc.
(4) Recto-anal manometry: recto-anal resting pressure, systolic pressure, vector volume and recto-anal inhibitory reflex.
(5) Anal sphincter electromyography: the duration and amplitude of muscle potentials in the anal sphincter at rest, during voluntary contraction, and during stimulation.
(6) Anal canal and rectal sensory examination: the sensory threshold of the anal canal and rectum.
(7) Anal ultrasound and magnetic resonance imaging (MRI): examination of morphological changes of pelvic floor muscles.
3.Conservative treatment includes.
(1) Defecation habit training: fixed-point, time-limited, regular defecation. Training to sit on the potty every morning, preferably for 5-10 min, and to use the correct method to defecate and develop a good defecation routine.
(2) medication: prevent or reduce the occurrence of fecal incontinence by inhibiting intestinal peristalsis to form stools, commonly used medications include simethicone, emmenagogue (loperamide hydrochloride), etc.
(3) enema therapy: enema can be divided into retrograde colonic irrigation and paracolic colonic irrigation. General clinical application is more retrograde colonic irrigation.
4.Biofeedback therapy: According to the anorectal function examination results of each child, choose one or more of the following specific biofeedback training methods, system a set of targeted biofeedback training program for training. Specific biofeedback series methods include.
(1) Strengthening perianal muscle strength biofeedback training.
(2) Biofeedback training to improve rectal sensory thresholds.
(3) biofeedback training to shorten sphincter reaction time
(4) biofeedback training to establish the anal sphincter contraction reflex
(5) Biofeedback training to improve defecation power.
5.Surgical treatment: for anal incontinence caused by hard perianal scar, rectal mucosal ectasia, abnormal anal position and size, etc., anal skin plasty should be performed first; for children with congenital anorectal malformation and postoperative incontinence, external anal sphincter reconstruction can be performed; for anal sphincter rupture and incontinence caused by injury, external anal sphincter repair should be performed. After the operation, decide whether to carry out the corresponding conservative treatment according to the anorectal function.
6.Cure standard: defecation more than 3 times a week, the number of incontinence is less than 1 time a month.