Feb, 2008 JOURNAL OF PEDIATRIC SURGERY (v43, 2), Pp. 320-324 Posted on 04/23/2008.

Quality of life in children with slow transit constipation.

Clarke,M.C.C., Chow,C.S., Chase,J.W., Gibb,S., Hutson,J.M., & Southwell,B.R.* Murdoch Childrens Res Inst, Melbourne, Vic 3052, Australia

Search Terms:   Encopresis, slow transit, constipation, motility

Background:   Slow transit constipation (STC) causes intractable symptoms not readily responsive to laxatives, diet, or
life-style changes. Children with STC have irregular bowel motions associated with colicky abdominal pain and frequent uncontrollable soiling. This study assessed the physical and psychosocial quality of life (QOL) in children with long-standing (>= 2 years) STC vs healthy controls.

Methods:   Children (aged 8-18) were recruited from gastrointestinal and surgical clinics and a Scout Jamboree. After informed consent was obtained, the questionnaire (Pediatric Quality of Life Inventory) was administered. This consists of parallel child and parent self-report scales encompassing physical functioning, emotional functioning, social functioning, and school functioning. Higher scores indicate better QOL. P value less than .05 was considered statistically significant.

Results:   In 51 children with STC (mean, 11.5 years; male/female, 2:1) and 79 controls (mean, 12.1 years; male/female, 1.9:1), Pediatric Quality of Life Inventory QOL score was significantly lower in the STC group (72.90 vs 85.99; P <.0001).
In addition, parents of children with STC reported a significantly lower QOL score than their child compared with the
child's own report (64.43 vs 72.90; P=.0034). Parents of controls did not (84.25 vs 85.99; P =.12).

Conclusions:   Slow transit constipation is a debilitating condition affecting both physical and emotional functioning in children. Parental perception of QOL is significantly worse, highlighting the considerable family impact of constipation
and uncontrollable soiling. (C) 2008 Elsevier Inc. All rights reserved.


This research group had focused a lot of research on slow-transit constipation which they argue is much more prevalent than commonly assumed. This study is important for documenting the effects of an ongoing and difficult course of
dealing with this problem. I remain frustrated that they and other research centers are not undertaking a trial of the
Soiling Solutions protocol for Encopresis.  RWC

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May, 2008 GUT (v57-5) Pp. 599-603. Posted on 04/29/2008.

Rectal compliance and rectal sensation in constipated adolescents, recovered adolescents and healthy volunteers.

van den Berg,M.M.*, Voskuijl,W.P., Boeckxstaens,G.E., Benninga,M.A., Emma Childrens Hosp, Acad Med Ctr, Dept
Pediat Gastroentereol & Nutr, Room C2-D12,Meibergdreef 9, NL-1105 AZ Amsterdam, Netherlands

Search Terms: Constipation, motility, transit, manometry

Objectives:   A subgroup of children with functional constipation (FC) are unresponsive to conventional treatment. Abnormal rectal function due to increased distensibility (compliance) might be an underlying mechanism of therapy-resistant FC. It is hypothesised that rectal compliance is normal in patients who are successfully recovered from FC (RC).

Methods:  Using a barostat, a pressure-controlled intermittent distension protocol was performed in FC patients, RC subjects free of symptoms for at least 4 years and healthy volunteers (HVs). Rectal compliance was calculated using a non-linear mixed-effect model for volume-pressure curves.

Results:   Forty- seven FC patients, median (range) age of 12 (11-17) years, and 20 RC subjects, 15 (11-18) years,
were studied and compared with 22 HVs, 14 (8-16) years. The median (5th-95th percentile) rectal compliance in HVs
was 16 (12-20) ml/mm Hg.FC patients had a median rectal compliance of 25 (13-47) ml/mm Hg and RC subjects 20
(12-35) ml/mm Hg, which was significantly higher compared with HVs (p, 0.001 and p = 0.003). RC subjects had lower
rectal compliance when compared with FC patients (p = 0.02). Forty- five percent of RC subjects had a rectal compliance above the upper limit of normal (> 95th percentile of HVs), which was significantly less compared with 75% of FC patients
(p = 0.02).

Conclusion:   While rectal compliance in RC subjects is lower when compared with adolescents with FC, almost half of the RC subjects showed an increased rectal compliance. The role of rectal compliance in therapy-resistant FC seems limited, because recovery is possible despite an increased rectal compliance.


Basically, the idea is that children unresponsive to conventional “top down” treatment for constipation/Encopresis have rectums (and likely higher up) that are too stretched out by comparison to children who have never had this problem and children who have recovered from it. But, the recovered children show a lasting effect (4 years later) of still having a more stretched out rectum, just not as much. The encouraging finding is that children can recover with a still stretched out rectum using the standard “top down” laxative/stool softener approaches. Would it be even more effective with the Soiling Solutions protocol which has shown so much promise with older, long term Encopretic children even after standard “top down” treatments have failed? Should the SS protocol have been attempted earlier for all children who demonstrate Encopresis or chronic constipation? Might it still be effective even with failure of the "top down" treatment and a
weakened, stretched rectum have failed? Should the SS protocol have been attempted earlier for all children? RWC

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May 2008 JOURNAL OF UROLOGY, (v179, 5), Pp. 1997-2002. Posted on 05/06/2008

Transabdominal ultrasound of rectum as a diagnostic tool in childhood constipation

Joensson,I.M.*, Siggaard,C., Rittig,S., Hagstroem,S., and Djurhuus,J.C. Skejby Univ Hosp, Dept Pediat A, DK-8200
Aarhus N, Denmark U1 - Article English
C
Search Terms:   Encopresis, constipation, ultrasound

Purpose:   We tested whether transverse rectal diameter measured by ultrasound could identify rectal impaction, investigated whether transverse diameter is enlarged in constipated children compared to healthy children and
evaluated transverse diameter during treatment of constipation.

Materials and Methods:   A total of 51 children 4 to 12 years old were included in the study. Of the children 27 (mean
age 7.0 +/- 1.8 years) had been diagnosed with chronic constipation by Rome III criteria and 24 (9.1 +/- 2.7 years) were
healthy controls. All patients underwent a thorough medical history. and physical examination, including digital rectal examination and measurement of rectal diameter by transabdominal ultrasound. Constipated children underwent repeat investigations after 4 weeks of laxative treatment.

Results:   Average rectal diameter of children with negative digital rectal examination was 21 +/- 4.2 mm (mean +/- SD), leading to the approximation that a value greater than 29.4 mm (mean +/- 2 SD) indicates rectal impaction. All children
with rectal impaction identified by digital examination had a rectal diameter larger than 29.4 mm. Moreover, constipated children had a significantly larger rectal diameter (42.1 +/- 15.4 mm) than healthy children (21.4 +/- 6.0 mm, p < 0.001). After 4 weeks of laxative treatment constipated children had a significant reduction in rectal diameter (mean 26.9 +/- 5.6 mm, p < 0.001).

Conclusions:   Transverse rectal diameter seems to be a valuable tool to identify rectal impaction and may replace digital rectal examination. Constipated children have a significantly larger rectal diameter compared to healthy children, and
when constipation is treated the diameter is reduced significantly.

The findings of changes in the rectum with constipation were not that surprising. However, the suggestion that an ultrasound would be preferable over a digital exam is something of a surprise because of the expense. This also fits into
a natural reluctance to use an invasive procedure, especially in this culturally sensitive region of the body. However, an ultrasound does have the advantage of no radioactivity and having better definition over the standard abdominal X-Ray.
The study’s findings of a significant return from an expanded colon (megacolon) back to a more normal state after 4
weeks of laxative treatment is of interest. Studies vary widely on the length and degree of a return toward a normal diameter of the rectum. Lay readers may not understand that all scientific reports use metric measurements. To
translate, the rectal diameter for children identified with constipation was 1.7 inches by comparison to 1.1 inches for
healthy children. Dr. C.

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May 2008 JOURNAL OF UROLOGY (v179, 5), Pp. 1970-1975. Posted on 05/06/2008.

Trajectories of daytime wetting and soiling in a United Kingdom 4 to 9-year-old population birth cohort study

Heron,J.*, Joinson,C., Croudace,T., and von Gontard,A. Univ Bristol, Dept Social Med, Avon Longitudinal Study Parents
& Children, 24 Tyndall Ave, Bristol BS8 1TQ, Avon, England

Search Terms: epidemiology, Encopresis, enuresis, longitudinal

Purpose:  This longitudinal, population based study describes trajectories of daytime wetting and soiling in children 4.5 to 9.5 years old.

Materials and Methods:  Participants consisted of a cohort of nearly 11,000 children forming part of the United Kingdom population based cohort study known as ALSPAC (Avon Longitudinal Study of Parents and Children). Repeated
measures of parentally reported incidents of daytime wetting and soiling were modeled using longitudinal latent class analysis.

Results:   Developmental variation could be adequately described by 4 trajectories for each of daytime wetting and
daytime soiling. Trajectory shapes could be interpreted as normative (daytime wetting 86.2%, daytime soiling 89.0%), delayed (6.9%, 4.1%), persistent (3.7%, 2.7%) and relapsing (3.2%, 4.1%). There were gender differences among
many of the nonnormative groups defined by these trajectories. In particular, girls outnumbered boys by a ratio of 1.25:1 among those with persistent wetting and a ratio of 1.39:1 among those who suffered a relapse in daytime wetting. In contrast, boys outnumbered girls by a ratio of 1.63:1 among those who were delayed in bowel continence, 1.93:1 among those with persistent soiling and 1.80:1 among those who suffered a relapse in soiling.

Conclusions:   Identification of trajectories of daytime wetting and soiling in children is an essential starting point in understanding the development of bladder and bowel control. These findings can be used to examine risk factors for the different trajectory groupings identified in the study.


I found the delayed, persistent, and relapsing percentages of children who had daytime wetting (diurnal enuresis) and soiling (Encopresis) to be of interest. The figures are not all that different between the two diagnoses. Dr. C.

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May 2008, PEDIATRICS (v121,5) Pp. E1334-E1341. Posted on 06/10/2008.

Behavioral therapy for childhood constipation: A randomized, controlled trial

van Dijk,M.*, Bongers,M.E.J., de Vries,G.J., Grootenhuis,M.A., Last,B.F. & Benninga,M.A. Univ Amsterdam, Acad Med Ctr, Emma Childrens Hosp, Psychosocial Dept, Room G8-224,POB 22700, NL-1100 DE Amsterdam, Netherlands

Search Terms:   Encopresis, constipation, behavioral therapy.

OBJECTIVE:   It has been suggested that the addition of behavioral interventions to laxative therapy improves continence in children with functional fecal incontinence associated with constipation. Our aim was to evaluate the clinical
effectiveness of behavioral therapy with laxatives compared with conventional treatment in treating functional constipation in childhood.

PATIENTS AND METHODS:   In this randomized, controlled trial conducted in a tertiary hospital in the Netherlands, 134 children aged 4 to 18 years with functional constipation were randomly assigned to 22 weeks (12 visits) of either
behavioral therapy or conventional treatment. Primary outcomes were defecation frequency, fecal incontinence frequency, and success rate. Success was defined as defecation frequency of >= 3 times per week and fecal incontinence frequency of <= 1 times per 2 weeks irrespective of laxative use. Secondary outcomes were stool-withholding behavior and behavior problems. Outcomes were evaluated at the end of treatment and at 6-months follow-up. All of the analyses were done by intention to treat.

RESULTS:   Defecation frequency was significantly higher for conventional treatment. Fecal incontinence frequency showed no difference between treatments. After 22 weeks, success rates did not differ between conventional treatment and behavioral therapy (respectively, 62.3% and 51.5%), nor did it differ at 6 months of follow-up (respectively, 57.3%
and 42.3%). The proportion of children withholding stools was not different between interventions. At follow-up, the proportion of children with behavior problems was significantly smaller for behavioral therapy (11.7% vs 29.2%).

CONCLUSION:   Behavioral therapy with laxatives has no advantage over conventional treatment in treating childhood constipation. However, when behavior problems are present, behavioral therapy or referral to mental health services should be considered.


This is a rather distressing finding about the lack of a significant contribution from behavioral therapy to treating Encopresis via the “top down” method. The University of Virginia’s website, www.ucanpooptoo.com, utilizing behavioral techniques in its Enhanced Toilet Training (ETT) “top down” approach was shown to be superior to conventional
treatment so this appears to be in direct contradiction to their findings. Both groups are to be congratulated for their controlled research, but these findings must be discussed and evaluated by both groups. It is possible that the
Netherlands group did not contain some of the behavioral elements present in ETT. I will seek a reprint of this study for later comment and request inputs from both research groups. Dr. C.

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June 2008 PEDIATRIC SURGERY INTERNATIONAL (v24, 6), Pp. 685-688. Posted on 07/18/2008.

Antegrade continence enema (ACE): current practice

Sinha,C.K.,* Grewal,A., & Ward,H.C. Royal London Hosp, London E1 1BB, England

Search Terms:   ACE, Encopresis

The purpose of this study was to assess current status of antegrade continence enema (ACE) procedure taking into account the recent improvement in the technique and outcome. Reviewing our record of 48 patients with ACE procedure performed between January 2002 and May 2007, we found that the underlying diagnoses were idiopathic constipation in 56%, anorectal malformation in 31%, spina bifida in 8% and Hirschsprung's disease in 4%. Mean age of operation was
10.7 years. Appendix was used as stoma in 73% of cases. Stomal stenosis requiring revision was seen in 6% of cases
and continence was achieved in 92% of cases. A systematic search of database was performed for the same period. Twenty-four studies describing 676 patients were found. The mean age was 10 years and various sites used for ACE
were, right side of abdomen in 71%, umbilicus in 15% and left side of abdomen in 14%. The incidence of open and laparoscopic procedures was 87 and 13%, respectively. Appendix was used for stoma in 76% procedures. Other
operative modalities were retubularised colon, retubularised ileum, caecal button and caecostomy tube, etc. The mean volume of enema fluid used was 516 ml. The mean evacuation time was 42 min. Stomal stenosis requiring revision was seen in 13% of cases. Continence was achieved in 93% of cases. There has been significant improvement in the
outcome during last 5 years in comparison to the outcome published in late 1990s. Advancements in techniques, better-trained stoma care nurses and better stoma appliances could have played major role in this success.


Okay, a rather extreme surgical procedure is applied here for what appears to be the functional disorder of encopresis constituting the majority condition for which this surgery was applied (56%). I find this astonishing when my protocol has been described as too aggressive with the use of suppositories and enemas in a rational, protocolized treatment
program. RWC

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July 2008, PEDIATRIC SURGERY INTERNATIONAL (v24, 7), Pp779-783 Posted 11/19/2008

Botulinum toxin for the treatment of chronic constipation in children with internal anal sphincter dysfunction

Irani,K., Rodriguez,L., Doody,D.P., & AM Goldstein* Harvard Univ, Massachusetts Gen Hosp, Sch Med, Pediat Intestinal Rehabil Program,Dept Pediat Sur, Warren 1153, Boston, MA 02114 USA

Search Terms:   Botulinum, botox, internal anal sphincter, constipation, Encopresis

Internal anal sphincter (IAS) dysfunction is a cause of refractory constipation in children. The goal of this study was to determine whether intrasphincteric injection of botulinum toxin is effective in the treatment of constipation in pediatric patients with IAS dysfunction. A retrospective review was performed of 24 pediatric patients with intractable constipation.
All patients had abnormal anorectal manometry, with either elevated IAS resting pressure (>=100 mm Hg) or an absent
or diminished rectoanal inhibitory reflex. Patients with Hirschsprung's disease were excluded. All patients underwent
botox injection into the IAS and were followed for a minimum of 6 months. Of 24 patients, 22 experienced significant improvement in their constipation lasting greater than 2 weeks. The duration of effect was variable, with 12 patients demonstrating benefit lasting at least 6 months. Transient postoperative incontinence occurred in five patients. Intrasphincteric injection
of botox is a safe and effective treatment for intractable constipation in children with IAS dysfunction.

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May 2008 JOURNAL OF PEDIATRIC SURGERY, (v43,5), Pp. 899-905) Posted 11/19/2008.

Long-term bowel function and quality of life in children with Hirschsprung's disease

Mills,J.L.A., Konkin,D.E., Milner,R., Penner,J.G., Langer,M., & Webber,E.M.* Univ British Columbia, Dept Surg, Div
Pediat Surg, Vancouver, BC V6H 3V4, Canada

Search Terms:   Hirschsprung’s, constipation, encopresis, longitudinal, QOL

Background/Purpose:   Little is known about the quality of life (QOL) of children with Hirschsprung's disease (HD) as
they grow older. The purpose of this study was to measure the QOL and bowel function of these children as they
mature.

Methods: All children who were surgically treated for HD at British Columbia Children's Hospital, Vancouver, British Columbia, Canada between 1986 and 2003 were invited to participate. Each family was sent 3 previously validated questionnaires exploring current QOL and bowel function. Results: Fifty-one families participated (49%), with children between the ages of 3 and 21 years. Fecal continence improved significantly with age (P = .04) and was the strongest predictor of QOL scores of all variables in our study. There was no statistically significant difference in QOL scores
between children with HD and healthy children, although a clinically relevant impairment in QOL may be present,
especially in psychosocial scores.

Conclusions:   Fecal continence is an important predictor of overall QOL in children surgically treated for HID. Although continence tends to improve with age, a number of older children still have ongoing continence problems, and they
seem to be a group at risk for impaired QOL. Our study indicates that interventions for children with incontinence may
offer gains in QOL as well as bowel function.


I have treated surgically corrected HD children with success using my protocol. Biofeedback also appears to be effective with adults who have relapsed to fecal incontinence, typically because of an overholding response and failure to relax
the pelvic floor for defecation. {Digestive Health Matters, (v17,3) Pp. 7-9}  Dr. C.

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July 2008, JOURNAL OF CLINICAL GASTROENTEROLOGY (v42,6), Pp. 692-698 Posted 11/19/2008.

Clinical significance of quantitative assessment of rectoanal inhibitory reflex (RAIR) in patients with constipation.

Xu,X.H., Pasricha,P.J., Sallam,H.S., Ma,L., & Chen,J.D.Z.* Univ Texas Galveston, Med Branch, Div Gastroenterol, 221 Microbiol Bldg,Route 0632,301 Univ Blvd, Galveston, TX 77555 USA

Search Terms:   RAIR, IAS, constipation, encopresis.

Background:   Rectoanal inhibitory reflex (RAIR) is routinely assessed in anorectal manometry and is of clinical value
in the diagnosis of patients with constipation. However, no quantitative analysis is currently available for the assessment
of RAIR. The aim of this study as to evaluate the diagnostic value of quantitative assessment of RAIR in patients with constipation.

Methods:   Nine healthy subjects, 22 constipation patients (CO) and 26 fecal incontinence patients (FI) were enrolled in
this study. RAIR was solicited by inflating the balloon with various volumes from 10 to 50mL. The percentage of relaxation was determined on the basis of the rectal resting sphincter
pressure and residual pressure with the balloon distention.

Results:   Percentage of internal sphincter relaxation induced by rectal distention in constipation patients was significantly lower with distention of 20, 30, 40, and 50mL in comparison with that in healthy subjects (Mixed model, P < 0.05). The volume of distention required to achieve a relaxation of 50% was significantly higher in patients with CO (37.3 +/- 3.1 mL) than that in healthy subjects (27.8 +/- 2.6 mL, P < 0.03) or FI (26.3 +/- 2.3 mL, P < 0.05). It was also found that the percentage of relaxation could be used to differentiate the patients with constipation with a specificity of 64% and a sensitivity of 67%.

Conclusions: Patients with CO have impaired RAIR in comparison with healthy subjects and patients with FI. Quantitative assessment of RAIR is valuable in the diagnosis of patients with CO and may be incorporated in the clinical anorectal manometric test.


This demonstrates the role of the IAS in the RAIR. Dr. C.

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September, 2008, PEDIATRIC RESEARCH (v64,3), Pp. 308-311. Posted on 11/24/2008.

The impact of constipation on growth in children

Chao,H.C., Chen,S.Y., Chen,C.C., Chang,K.W., Kong,M.S., Lai,M.W., & Chiu,C.H.* Chang Gung Univ, Coll Med, Chang Gung Childrens Hosp, Dept Pediat, 5 Fu Hsin St, Tao Yuan 33305, Taiwan

Search Terms:   Constipation, Encopresis, Growth, Development

The observation oil the impact of constipation oil nutritional and growth status in healthy children was never reported. During a 4-yr period. we evaluated the consequence of constipation oil growth in children. The enrolled children were
aged between 1 and 15 y with constipation. Medical response of constipation to treatment Was evaluated by the scoring
of constipation symptoms. The correlation of therapeutic effect of constipation with growth status at 12 wk and 24 wk was Statistically evaluated. About 2426 children (1284 boys, 1142 girls) with a mean age of 7.31 +/- 3.65 (range 1.1-14.9) y
were enrolled.

After 12-wk treatment, significant increase of z-scores of height-for-age, weight-for-age, and body mass index-for-age
were all found in patients with good medical responses (1377 cases) than in those with poor medical responses (1049 cases). The 1049 patients with poor medical response received advanced medications; significant increase of z-scores
of height-for-age, weight-for-age, and body mass index were also found in these patients. A marked increase of appetite was significantly
correlated with better gain oil height and weight after treatment. We conclude that chronic constipation may retard growth Status in children. and a long-term medication for constipation in children appears beneficial to their growth status.


I have long suspected growth as a possible consequence of successful treatment which is suggested by this study with a very good number of subjects. Dr. C.

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July-August, 2008, HEPATO-GASTROENTEROLOGY (v55, 85), Pp. 1298-1303 Posted on 11/24/2008.

Pathophysiology of chronic constipation of the slow transit type from the aspect of the type of rectal movements

Hagiwara,N. & Tomita,R.* Nippon Dent Univ Tokyo, Sch Dent Tokyo, Dept Surg, Chiyoda, Ku, 2-3-16 Fujimi, Tokyo 1028158, Japan

Search Terms:   rectal motility, motility, manometry, gastrocolic reflex, constipation.

Background/Aims:   The aim of this study was to analyze the defecation function, in particular the development of the gastrocolic reflex arising in coordination with the upper gastrointestinal tract, in patients with chronic constipation of the slow transit type (STC).

Methodology:   The rectal movement types in adult patients with STC were compared with those in normal subjects as a control. A force transducer was inserted transanally into the rectum of 10 patients with STC (Group A), and the intrarectal pressure waveforms were recorded for 2 hours before and after the ingestion of test diets. Similar recordings were obtained from control subjects who had no abnormalities of defecation (Group B).

Results:   On the basis of the recordings obtained pre- and postprandially, the waveforms in the Group B subjects were classified into 4 types (Type I, continuous waves of low amplitude; Type II, continuous waves of high amplitude or with elevation of basal tone; Type III, only elevation of the basal tone; Type IV, monophasic contraction waves). In fasting state, only Type I waves were recorded in both Group A and B subjects. Postprandially, all the subjects in both the groups showed Type I waveforms. In addition, the frequency of this type of waveform was significantly increased in Group B (p <0.01). Type III and IV waveforms were also recognized only in Group B. There was no difference in the frequency of
Type If waveforms between Groups A and B, but the time required for the appearance of Type 11 waveforms After ingestion of the test diet was significantly (p < 0.01). shorter in Group B than in Group A. Thus, there were no differences in the preprandial movement type between the 2 groups. However, postprandially, in Group A, the appearance of continuous waves of high amplitude was delayed, although their frequency was not significantly increased, as compared
to those in Group B, and there were few giant contraction waves.

Conclusions:   Functional disturbances of the rectal movements were recognized after food ingestion in patients with
STC, and this result was considered to be attributable to decreased strength of the gastrorectal reflex.


This is a small N for adult subjects and I can’t tell from this summary if they ruled out megacolon or if the STC is confirmed throughout the length of the colon? If it is true STC then this information just appears to indicate a continuation of weak propagation into the rectal area contributing to the weak gastrocolic reflex. Dr. C.

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September, 2008 GASTROENTEROLOGY CLINICS OF NORTH AMERICA (v37,3), Pp 569-VIII
Posted on 12/04/2008

Dyssynergic defecation and biofeedback therapy.

SSC Rao, Univ Iowa Hosp & Clin, Div Gastroenterol Hepatol, Univ Iowa, Carver Coll Med, 4612 JCP, 200 Hawkins Dr, Iowa City, IA 52242 USA

Search Terms:   biofeedback, constipation, Encopresis

Constipation caused by dyssynergic defecation is common and affects up to one half of patients with this disorder. It is possible to diagnose this problem through history, prospective stool diaries, and anorectal physiologic tests. Randomized controlled trials have now established that biofeedback therapy is not only efficacious but superior to other modalities
and that the symptom improvement is caused by a change in underlying pathophysiology. Development of user friendly approaches to biofeedback therapy and use of home biofeedback programs will significantly enhance the adoption
of this treatment by gastroenterologists and colorectal surgeons.

This is a significant endorsement for the use of biofeedback in treating constipation or Encopresis by a leading
researcher. Again, my issue is that my Soiling Solutions protocol is much cheaper and less complex with fewer personnel and less instrumentation than is required by biofeedback and should be tried clinically before biofeedback or surgery is employed. I support research on comparison treatment trials using randomly assigned subjects and regret that I do not have the resources to do so. The existence of the recently revised Clean Kid Manual (4th revision) should assist in providing a good basis for guiding treatment in clinical trials. RWC

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December 2008 NEUROGASTROENTEROLOGY AND MOTILITY (v 20,12), Pp. 1269-1282. Posted on 12/15/2008

American Neurogastroenterology and Motility Society consensus statement on intraluminal measurement of
gastrointestinal and colonic motility in clinical practice.

Camilleri,M.,* Bharucha,A.E., Di Lorenzo,C., Hasler,W.L., Prather,C.M. Rao,S.S., Wald,A. Mayo Clin, CENTER Program, Charlton 8-110,200 1st St SW, Rochester, MN 55905 USA

Search Terms:  manometry, constipation, Encopresis, motility, transit

Tests of gastric, small intestinal and colonic motor function provide relevant physiological information and are useful for diagnosing and guiding the management of dysmotilities. Intraluminal pressure measurements may include concurrent measurements of transit or intraluminal pH. A consensus statement was developed and based on reports in the literature, experience of the authors, and discussions conducted under the auspices of the American Neurogastroenterology and Motility Society in 2008.

The article reviews the indications, methods, performance characteristics, and clinical utility of intraluminal measurements of pressure activity and tone in the stomach, small bowel and colon in humans. Gastric and small bowel motor function
can be measured by intraluminal manometry, which may identify patterns suggestive of myopathy, neuropathy, or obstruction. Manometry may be most helpful when it is normal. Combined wireless pressure and pH capsules provide information on the amplitude of contractions as they traverse the stomach and small intestine.

In the colon, manometry assesses colonic phasic pressure activity while a barostat assesses tone, compliance, and
phasic pressure activity. The utility of colonic pressure measurements by a single sensor in wireless pressure/pH
capsules is not established. In children with intractable constipation, colonic phasic pressure measurements can identify patterns suggestive of neuropathy and predict success of antegrade enemas via cecostomy. In adults, these
assessments may be used to document severe motor dysfunction (colonic inertia) prior to colectomy. Thus, intraluminal pressure measurements may contribute to the management of patients with disorders of gastrointestinal and colonic motility.

Consensus statements typically reflect the state of the art or science in an area of concern, and this is no exception. The authors are well known and respected in the field. This statement reflects the maturity and the state of excellent progress in the use of manometry for GI assessment. My hope is that it will help to shed some light on differences in colonic
function between retentive and non- retentive Encopresis. The latter appears to be more resistant to treatment and that
is why the ACE surgical approach is sometimes recommended for it. My issue is that perhaps my Soiling Solutions
protocol should be attempted first before these intrusive measurements and surgery is recommended. RWC

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Dec 2008, ARCHIVES OF DISEASE IN CHILDHOOD, (v93, 12), Pp. 1044-1047. Posted on 12/23/2008.

Prevalence of atopy in children with chronic constipation

Simeone,D., Miele,E., Boccia,G., Marino,A., Troncone,R., & Staiano,A.* Univ Naples Federico 2, Dept Pediat, Via
Pansini 5, I-80131 Naples, Italy

Search Terms:   constipation, Encopresis, allergy, milk

Objectives:   To evaluate the prevalence of chronic constipation (CC) in unselected children, its association with atopy
and the efficacy of a cow's milk protein (CMP) elimination diet on refractory constipation.

Study design:   The study was conducted by six primary care paediatricians, serving a population of 5113 children aged from birth through to 12 years; only 2068 children were 6 months to 6 years. During a 3- month period, prevalence of CC was determined for the entire study population, ages 0-12 years. In the second part of the study, all patients aged 6 months to 6 years with CC, and age- and sex-matched controls, were evaluated for atopy and its association with CC. A questionnaire was completed including personal and family history of atopy and bowel-movement characteristics.
Patients were tested for atopy by specific serum IgE and/or skin-prick tests. Constipated patients, refractory to osmotic laxatives, underwent a 4-week CMP elimination diet.

Results:   91 (1.8%) children had CC, and 69 (3.3%) of the 6 months to 6 years age group fell into the atopy study age range. All 69 constipated children (mean age 34.9 (18.0) months) and 69 controls completed the questionnaire. Twelve
of the 69 constipated children (17.3%) and 13 out of the 69 control children (18.8%) had a diagnosis of atopy. Eleven out of 69 (15.9%) constipated children were refractory to constipation treatment, and three (27.3%) of these had atopy. The
4-week trial of dietary elimination did not result in improvement in any of these 11 children.

Conclusions:   In our study group, prevalence of atopy among children with CC is similar to that in the general population. The level of refraction of CC does not seem to be related to cow's milk allergy.


This large scale study contradicts the usual assumptions of parents about the possibility of cow’s milk allergy contributing to the chronic constipation or Encopresis in their children. This assumption resembles an “illusory correlation” or the “aberrant actuary” phenomenon noted in research on clinical judgment and it is very hard to counter in any rational way. RWC

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February 9, 2009 ARCHIVES OF DISEASE IN CHILDHOOD (v94,2), Pp. 117-131). Posted on 02/24/2009.

Currently recommended treatments of childhood constipation are not evidence based: a systematic literature review
on the effect of laxative treatment and dietary measures

Pijpers,M.A.M.,* Tabbers,M.M., Benninga,M.A., & Berger,M.Y. Erasmus MC, Dept Gen Practice, Room Ff323,POB 2040, NL-3000 CA Rotterdam, Netherlands

Search Terms:   Constipation, encopresis, PEG, Lactulose, softeners. Review

Introduction:   Constipation is a common complaint in children and early intervention with oral laxatives may improve complete resolution of functional constipation. However, most treatment guidelines are based on reviews of the literature that do not incorporate a quality assessment of the studies. Objective: To investigate and summarise the quantity and quality of the current evidence for the effect of laxatives and dietary measures on functional childhood constipation.

Methods: The Medline and Embase databases were searched to identify studies evaluating the effect of a
medicamentous treatment or dietary intervention on functional constipation. Methodological quality was assessed using
a validated list of criteria. Data were statistically pooled, and in case of clinical heterogeneity results were summarized according to a best evidence synthesis.

Results:   Of the 736 studies found, 28 met the inclusion criteria. In total 10 studies were of high quality. The included studies were clinically and statistically heterogeneous in design. Most laxatives were not compared to placebo. Compared to all other laxatives, polyethylene glycol ( PEG) achieved more treatment success ( pooled relative risk (RR): 1.47; 95%
CI 1.23 to 1.76). Lactulose was less than or equally effective in increasing the defecation frequency compared to all other laxatives investigated. There was no difference in effect on defecation frequency between fibre and placebo (weighted standardised mean difference 0.35 bowel movements per week in favour of fibre, 95% CI -0.04 to
0.74).

Conclusion:   Insufficient evidence exists supporting that laxative treatment is better than placebo in children with constipation. Compared to all other laxatives, PEG achieved more treatment success, but results on defecation frequency were conflicting. Based on the results of this review, we can give no recommendations to support one laxative over the other for childhood constipation.


The lack of placebo comparisons for assessing the effectiveness of “top down” laxatives in the treatment of Encopresis/constipation was a bit of a surprise, but the comparative treatment studies and the usual longitudinal demonstration of improved outcomes lends assurance that laxatives are useful in the usual pediatric conventional treatments. The findings on fiber as being ineffective alone in treatment is consistent with the literature as I know it. Of course, I remain hopeful that my “bottom up” protocol will be adequately tested in time. RWC

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February 9, 2009 ARCHIVES OF DISEASE IN CHILDHOOD (v94,2), Pp.156-160. Posted on 02/24/2009.

Macrogol (polyethylene glycol) laxatives in children with functional constipation and faecal impaction: a systematic review.

Candy,D.,* & Belsey,J. Royal W Sussex NHS Trust, Paediat Gastroenterol Serv, Chichester PO19 6SE, W Sussex,
England

Search Terms:   Constipation, Encopresis, PEG

As the evidence base supporting the use of laxatives in children is very limited, we undertook an updated systematic
review to clarify the issue. A comprehensive literature search was carried out to identify randomized controlled trials of polyethylene glycol ( PEG) versus either placebo or active comparator, in patients aged,18 years with primary chronic constipation. Outcomes were assessed as either global assessments of effectiveness or differences in defaecation rates. Seven qualifying studies involv ing 594 children were identified. Five were comparisons of PEG with lactulose, one
with milk of magnesia and one with placebo. Study duration ranged from 2 weeks to 12 months. PEG was significantly
more effective than placebo and either equivalent to (two studies) or superior to (four studies) active comparator. Differences in study design precluded meaningful meta-analysis. Lack of high quality studies has meant that the management of childhood constipation has tended to rely on anecdote and empirical treatment choice. Recent
publication of well designed randomized trials now permits a more evidence-based approach, with PEG-based treatments having been proven to be effective and well-tolerated first-line treatment.


This study and the one above it basically confirm my comments above. I like the observation that the “top down” PEG-based treatment is a “well-tolerated first-line treatment”. My complaint is that there really is no viable second-line of treatment which I believe my “bottom up” protocol to be! It should be studied given my report which is shortly to appear in “Digestive Health Matters”, a publication of the International Foundation of Gastrointestinal Disorders (www.iffgd.com). RWC

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June 30, 2008 JOURNAL OF MEDICAL INTERNET RESEARCH (v10,2), Pp. 78-88. Posted on 02/24/2009.

Real World Use of an Internet Intervention for Pediatric Encopresis

Ritterband,L.M.,* Ardalan,K., Thorndike,F.P., Magee,J.C., Saylor,D.K., Cox,D.J., Sutphen,J.L., & Borowitz,S.M. Univ
Virginia Hlth Syst, Dept Psychiat & Neurobehav Sci, POB 801075, Charlottesville, VA 22908 USA

Search Terms:   Encopresis, internet, U1 - Article English

Background:   The Internet is a significant source of medical information and is now being shown to be an important
conduit for delivering various health-related interventions.

Objective: This paper aimed to examine the utility and impact of an Internet intervention for childhood Encopresis as
part of standard medical care in a "real world" setting.

Methods:   Patients diagnosed with Encopresis were given a Web-based information prescription to use an Internet intervention for pediatric Encopresis. A total of 22 families utilized the intervention between July 2004 and June 2006. A chart review and phone interview were undertaken to collect user characteristics; defecation-related information,
including frequency of soiling, bowel movements (BMs) in the toilet, and amount of pain associated with defecation; and information on computer/ Internet usage. Three questionnaires were used to examine the utility of, impact of, and adherence to the Internet intervention. Program utilization was obtained from a data tracking system that monitored
usage in real time.

Results:  Overall, parents rated the Internet intervention as enjoyable, understandable, and easy to use. They indicated that the Internet intervention positively affected their children, decreasing overall accidents and increasing child
comfort on the toilet at home. Of the 20 children who initially reported fecal accidents, 19 (95%) experienced at least a
50% improvement, with a reduction of accident frequency from one fecal accident per day to one accident per week. Although it is not clear whether this improvement is directly related to the use of the Internet intervention, patient
feedback suggests that the program was an important element, further establishing Internet interventions as a viable and desirable addition to standard medical care for pediatric Encopresis.

Conclusions:  To our knowledge, this is the first time a pediatric Internet intervention has been examined as part of a
"real world" setting. This is an important step toward establishing Internet interventions as an adjunctive component to treatment of pediatric patients in a clinical setting, particularly given the positive user feedback, possible cost savings,
and significant potential for large-scale dissemination.

This is an important demonstrational study on the use of the internet as a disseminator for the treatment of the
“top down” approach to treating Encopresis. This would fit into the “first-line” method of treatment for Encopresis and should help pediatricians to have a source to refer parents to while doing periodic and reinforcing monitoring visits for progress. My own Soiling Solutions (SS) “bottom up” protocol substitutes a manual for the internet equivalent here, but then my Clean Kid Manual parent’s forum would provide continuous and ready support by other parents using the SS protocol. The physician would thus have the opportunity to serve as a backup monitor for any difficulties that may arise, while reducing unnecessary office visits. RWC

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March 9, 2009 GUT Prucalopride (Resolor) in the treatment of severe chronic constipation in patients dissatisfied with laxatives. (v58,3), Pp. 357-365. Added on 03/22/2009.

Tack,J.,* van Outryve,M., Beyens,G., Kerstens,R., & Vandeplassche,L. Univ Hosp Gasthuisberg, Dept Internal Med, Div Gastroenterol, Herestr 49, B-3000 Louvain, Belgium

Search Terms: vPrucalopride, Resolor, Encopresis, constipation, laxatives

Objective:  To determine the efficacy, impact on quality of life (QOL) and safety of prucalopride, a selective, high-affinity
5-HT4 receptor agonist, in patients with chronic constipation.

Methods: In this multicentre, randomised, placebo controlled, parallel-group, phase III study, patients with chronic constipation (two or fewer spontaneous complete bowel movements (SCBM)/week) received 2 mg or 4 mg prucalopride
or placebo, once daily, for 12 weeks. The primary efficacy endpoint was the proportion of patients reaching three or more SCBM/week. The key secondary efficacy endpoint was the proportion of patients having an increase of one or more SCBM/week. The primary QOL endpoint was the patient assessment of constipation QOL satisfaction subscale score. Safety parameters included adverse events, laboratory values and cardiovascular events.

Results:   Efficacy was evaluated over 713 patients. Averaged over 12 weeks, higher proportions of patients on
rucalopride 2 mg (19.5%; p<0.01), 4 mg (23.6%; p<0.001) had three or more SCBM/ week (or normalisation of bowel function) compared with placebo (9.6%). Similar results were seen in the subgroup (83%) of patients dissatisfied with previous laxative treatment. Both doses of prucalopride also significantly improved secondary efficacy and QOL
endpoints, including the proportion of patients with an increase of one or more SCBM/week, evacuation completeness, perceived disease severity and treatment effectiveness and QOL. Prucalopride 4 mg significantly reduced the need for straining versus placebo (p<0.05). The most frequent treatment-related adverse events were headache and diarrhoea. Both doses of prucalopride were safe and well tolerated.

Conclusion:   Prucalopride significantly and consistently improved bowel function, associated symptoms and satisfaction
in chronically constipated patients.


I suspect that this study was for adults only and I include it because of concern for those parents with Encopretic children who are unusually resistant even to the SS protocol and may have severe chronic constipation into adulthood. Dr. C.

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02/09/2009 JOURNAL OF PEDIATRICS Health Utilization and Cost Impact of childhood Constipation in the United States. (v154,2), Pp. 258-262. Added on 03/22/2009.

Liem,O., Harman,J., Benninga,M., Kelleher,K., Mousa,H., & Di Lorenzo,C. (No address or institution indicated, Benninga
is at Emma Children’s Hospital in Amsterdam, Netherlands and C Di Lorenzo is at Nationwide Childrens Hosp, Dept Pediat, 700 Childrens Dr, Columbus, OH 43205 USA).

Search Terms:   Encopresis, constipation, cost.

Objective:  To estimate the total health care utilization and costs for children with constipation in the United States.

Study design: We analyzed data from 2 consecutive years (2003 and 2004) of the Medical Expenditure Panel Survey (MEPS), a nationally representative household survey. We identified children who either had been reported as
constipated by their parents or had received a prescription for laxatives in a given year. Outcome measures were service utilization and expenditures.

Results:  The MEPS database included a total of 21 778 children age 0 to 18 years. representing 158 million children nationally. An estimated 1.7 million US children (1.1%) reported constipation in the 2-year period. No differences with respect to age, sex, race. And socioeconomic status were found between the children with constipation and those without constipation. The children with constipation used more health services than children without constipation, resulting in significantly higher costs: $3430/year vs $1099/year. This amounts to an additional cost for children with constipation of $3.9 billion/year.

Conclusions:   This study demonstrates that childhood constipation has a significant impact on the use and cost of
medical care services. The estimated cost per year is 3 times than that in children without constipation, which likely is an underestimate of the actual burden of childhood constipation.


Here is an economic argument strongly recommends going to the SS protocol much earlier than is typical for medical practice today. Dr. C.

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October, 2007 JOURNAL OF UROLOGY (178, 4 Pt 1), Pp. 1458-1462. Posted on 10/22/2007.

The effect of obesity on treatment efficacy in children with nocturnal enuresis and voiding dysfunction.

Guven,A., Giramonti,K.*, Kogan,B.A. Albany Med Coll, Div Urol, Sect Pediat Urol, 23 Hackett Blvd, Albany, NY 12208 USA

Search Terms:   Enuresis, Obesity

Purpose:   Obesity continues to be a leading public health concern in the United States. Our previous studies have suggested that there is a high rate of obesity in children with dysfunctional voiding, especially nocturnal enuresis. We investigated the correlation between body mass index and the efficacy of treatment in obese patients.

Materials and Methods:  We evaluated retrospectively records from patients seen with a diagnosis of nocturnal enuresis
or dysfunctional voiding between January 2004 and July 2005. Bladder and bowel symptoms and urinary diary data were evaluated, and body mass index percentile was determined. Response to treatment was evaluated and correlated with body mass index percentile.

Results:  We evaluated 250 children, of whom 96 (38%) had nocturnal enuresis and 154 (62%) had dysfunctional voiding. Body mass index was normal in about half of the patients, and half were above the 85th percentile for body mass index. Patients with a body mass index above the 85th percentile had a reduced response to therapy. After treatment patients with a normal body mass index bad a lower nocturnal accident frequency than those above the 85th percentile. Similarly,
in those with voiding dysfunction the response rate was 65% in association with a normal body mass index vs. 35% with a high body mass index. Furthermore, patients with a normal body mass index had a significantly higher rate of completing
a urinary diary compared to those with a high body mass index.

Conclusions:   Obesity correlates with a lower voiding diary completion rate and lower efficacy of treatment in children with nocturnal enuresis or dysfunctional voiding.


My own research on enuresis with the bedwetting alarm found a lower diary completion rate for treatment failures. I did
not look at obesity as a factor and don't recall any observations about it at the time. This was years ago before obesity became a major problem in our culture. Why obesity is associated with lower diary completion rate and a poor response rate is unclear. I will avoid speculation, but the finding is interesting in its own right. RWC

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October  2007 JOURNAL OF UROLOGY (v178, 4 Pt 2), Pp. 1758-1761. Posted on 10/22/2007.

Office management of pediatric primary nocturnal enuresis: A comparison of physician advised and parent chosen alternative treatment outcomes.

Saldano,D.D.*, Chaviano,A.H., Maizels,M., Yerkes,E.B., Cheng,E.Y., Losavio,J., Porten,S.P., Sullivan, C., Zebold,K.F., Hagerty,J., & Kaplan,W.E. Childrens Mem Hosp, 2300 Childrens Plaza, Chicago,
IL 60614 USA

Search Terms:   Enuresis, Pediatric, Alarm.

Purpose:   We compared the remission of pediatric primary nocturnal enuresis in groups of children who used a physician advised practice plan vs a parent chosen alternative.

Materials and Methods: Between January 2004 and January 2006 there were 119 patients with primary nocturnal
enuresis enrolled in this prospective, nonrandomized study. For this study primary nocturnal enuresis was defined as wetting at night during sleep during any 6-month interval without any known causative problem. A total of 76 children received the physician advised treatment plan and used an alarm, oxybutynin, desmopressin, an elimination diet and a bowel program, as indicated. A total of 43 children received a parent chosen alternative treatment plan, which consisted
of any single or combination of treatments involving an alarm, oxybutynin, desmopressin and an elimination diet or bowel program. Parents from each group completed an intake survey that measured functional bladder capacity using a 3-day home diary and
they identified demographic variables. Followup occurred at 2 weeks and then monthly for 12 weeks to study end.

Results:  We found that the probability of remission by the end of the study for the physician advised treatment group
was significantly higher than that of the parent choice group (88% vs 29%, Kaplan-Meier curve p <0.0001).

Conclusions:   The group of children who followed physician advised treatment for primary nocturnal enuresis showed significantly earlier remission of primary nocturnal enuresis than children who followed the parent choice treatment (25th percentile 2 vs. 10 weeks).


This was an interesting comparison. It would also be interesting to know if diary completion was significantly difference between the two groups (see study immediately above). Were the physicians more invested and demanding of
compliance for their own treatment plan versus one chosen by their patient? RWC

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September 2007 JOURNAL OF UROLOGY (v178, 3 Pt1), Pp. 769-774. Posted on 10/22/2007.

Overactive bladder in children. Part 2: Management

Franco,I. Pediat Urol Associates PC, 19 Bradhurst Ave,Suite 2575, Hawthorne, NY 10532 USA

Search Terms:   bladder, constipation, overactive bladder, Enuresis, Encopresis

Purpose:  The management of pediatric overactive bladder syndrome has relied primarily on anticholinergics and a bowel regimen. In many cases the results have been ineffective and they have frustrated many parents, patients and practitioners. We explored other treatment modalities that may be more effective than the regimens that we currently use.
A thorough understanding of the causes of overactive bladder syndrome is essential to help us find the appropriate treatment for individuals.

Materials and Methods:   We looked at numerous treatment modalities that are being used for overactive bladder syndrome and matched them to a specific cause of overactive bladder syndrome that would be best suited to treat the problem. The treatment of constipation as a mainstay for pediatric overactive bladder syndrome was explored as well
as its different options. New treatment modalities involving electrical stimulation were explored as well as botulinum A
toxin injections.

Results:   The effectiveness of each treatment was assessed, thereby providing the reader with a foundation for choosing the appropriate treatment.

Conclusions:   The treatment of pediatric overactive bladder syndrome is not as simple as placing children on anticholinergics and, if there is no response, simply saying that they will outgrow it. The causes of overactive bladder syndrome are multifactorial and a better understanding of the pathophysiology will allow us to target treatments appropriately for individuals.


I find it important to closely question parents on any signs of constipation with daytime bladder accidents and then treat
for it if there are any signs of encopresis--many parents tend to just dismiss "tire tracks" or smears as failing to wipe carefully after a BM. Otherwise I would refer to a urologist for diagnosis and treatment. This study is a good heads up for closely examining any daytime bladder issues. RWC

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December 2007 SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY (v41, 5) Pp. 407-413. Posted on 01/19/2008.

Exploring potential mechanisms in alarm treatment for primary nocturnal enuresis

Butler,R.J.*, Holland,P., Gasson,S., Norfolk,S., Houghton,L., & Penney,M. Leeds Prim Care Trust, Child & Adolescent Mental Hlth Serv, Dept Clin Psychol, Lea House, Gateway,Whackhouse Lane, Yeadon, Leeds LS19 7XY, W Yorkshire, England

Search Terms:   enuresis, alarm, desmopressin, osmality.

Objective:   In the treatment of childhood nocturnal enuresis the enuresis alarm has consistently proved effective.
However, the various proposals advanced to explain its therapeutic mechanism generally lack empirical support. In this clinical trial we investigated the hypothesis that the alarm promotes reduced nocturnal urine production through
increased urine concentration (enabling the child to sleep through the night).

Material and methods:   Measurements of urinary vasopressin and osmolality were made pre- and post-alarm treatment
in a group (n = 12) of outpatient children (aged 7-12 years) with severe (more than four times a week) nocturnal enuresis.

Results. Of the study group, 75% achieved the success criteria, with 89% predominantly sleeping through the night on
dry nights, confirming that arousability is unlikely to be the principal mode of action. All those becoming dry showed an increase in urine concentration post-treatment. For half this was associated with an increase in post-treatment
vasopressin whilst for the rest, although increases in osmolality were observed, there was no associated increase in vasopressin.

Conclusions:  Although based on a small sample this study offers an insight into possible therapeutic mechanisms of an enuresis alarm. It suggests that most children who become dry sleep through the night and that increased nocturnal
urine concentration (and thus reduced urine volume) is likely to be the means whereby this is achieved. Furthermore, the study suggests two possible mechanisms whereby nocturnal urine concentration is achieved: either increased production of vasopressin or enhanced water transport across the urothelium.


This has been a long anticipated and hoped for study by yours truly. I never had the resources to measure morning osmality during the course of a bedwetting alarm study and have long thought that increased osmality could well be
an effect of the alarm treatment. An increase in bladder capacity has long been demonstrated in my research and that
of others over the course of treatment, but that increased volume never appeared to be anywhere near normal daytime voiding volumes. Osmality had never been assessed to my knowledge. I speculated that an internal biofeedback
mediated process for added concentration could result from nighttime holding triggered by the alarm. RWC

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January/February 2008 JOURNAL OF PAEDIATRICS AND CHILD HEALTH (v44, 1-2), Pp. 19-27.
Posted on 01/19/2008.

The frequency of constipation in children with nocturnal enuresis: a comparison with parental reporting.

McGrath,K.H., Caldwell,P.H.Y.*, Jones,M.P. Univ Sydney, Childrens Hosp, Ctr Kidney Res, NHMRC Ctr Clin Res
Excellence Renal Med, Locked bag 4001, Westmead, NSW 2145, Australia

Search Terms:   constipation, enuresis, Encopresis

Aim:   To identify the prevalence of constipation in children with nocturnal enuresis presenting to a tertiary paediatric outpatient service and to assess parental and clinician recognition of constipation.

Methods:   A prospective cross-sectional study of children with nocturnal enuresis at presentation to a continence
service. Data relating to the child's bowel habits, pattern of enuresis and other history items were obtained from
parental questionnaires and pediatrician assessments. Presence and severity of constipation was assessed
independently by parents and clinicians. Kappa was used to compare agreement between parental reporting and
clinician assessment of constipation.

Results:   Of the 277 participants aged 4.8-17.5 years (median 8.6 years), 36.1% (n = 95) were identified as constipated
by the clinician-based scoring method ('Constipation Score') compared with 14.1% from parental reporting
(Kappa = 0.155, P = 0.003). Despite the poor overall recognition of constipation by parents, parental and clinician assessment of frequency of bowel motions (Kappa = 0.804) and soiling (Kappa = 0.384) were similar. Major factors influencing parental reporting of constipation were frequency of bowel motions and soiling with less emphasis on
straining and stool consistency.

Conclusions:   Prevalence of constipation was high among children with nocturnal enuresis as assessed by clinicians despite poor identification by parents. This may limit optimal diagnosis and management.


The evidence is clearly mounting of an association between enuresis and Encopresis and this study documents a failure
of parental or professional insight into this connection. This finding accords strongly with my clinical impressions where further questioning elicits surprise by parents that occasional smears and “tire tracks” in underwear may be an issue for their child’s bedwetting. They had largely dismissed such signs as irrelevant and never had an idea of their possible indications for the presence of constipation and it's possible contribution to bedwetting. My current edition of the Dry Bed Manual makes very strong statements not to proceed with treatment unless the Encopresis or constipation is managed
as a first priority. RWC

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June 2008 JOURNAL OF DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS (v29,3), Pp. 191-196. Posted 11/19/2008.

Toilet training of healthy young toddlers: A randomized trial between a daytime wetting alarm and timed potty training

Vermandel,A., Weyler,J., De Wachter,S., & Wyndaele,J.J.* Univ Antwerp, Dept Urol, Wilrijkstr 10, B-2650 Edegem,
Belgium

Search Terms:   alarm, daytime, Enuresis

Objective:  Toilet training (TT) is important for every child, but there is no agreement on what is the best training method. We evaluated in a randomized way the comprehensive use of a daytime wetting alarm at home for 5 days in healthy children and compared it with timed potty training. Methods: Thirty-nine children, between 20 and 36 months of age,
were randomized to wetting alarm diaper training (WAD-T; n = 20) or timed potty training (TP-7; n = 19). Toilet behavior was observed by parents and independent observers before, at the end, and after 2 weeks of training. Late evaluation
at 1 month was done by telephone.

Results:   The WAD-T group did significantly better than the UP-T group at the end training (p =.041), at 14 days (p = .027), and 1 month after training (p = .027). Independent bladder control was achieved in 88.9% of the WAD-T group.

Conclusions:    The WAD-T method is a structured, child-friendly, highly effective option for TT young healthy children. it offers the parents clear guidelines, a limited time needed to complete TT, a high success rate, and minor emotional conflicts. Results must now be confirmed in a larger sample size.


The bedwetting alarm has been show to be effective for nocturnal enuresis over the years by a variety of comparison treatment studies, including my own. The application to daytime wetting is quite innovative and looks to be very promising for young children. I should think that any indications of encopresis should be ruled out first. Dr. C.

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April, 2009 NEUROUROLOGY AND URODYNAMICS (v28,4), Pp. 305-308. Posted on 05/08/2009

The Efficacy of a Wetting Alarm Diaper for Toilet Training of Young Healthy Children in a Day-Care Center: A
Randomized Control Trial

Vermandel,A., Van Kampen,M., De Wachter,S., Weyler,J., & Wyndaele,J.J.* Univ Antwerp, Dept Urol, Fac Med, Wilrijkstr
10, B-2650, Edegem, Belgium

Search Terms:   Enuresis, alarm, daytime Enuresis, diurnal Enuresis, bedwetting

Aims:   To evaluate, in a randomized controlled way, the use of a daytime wetting alarm in a day-care center during three consecutive weeks in healthy children.

Methods:   Thirty-nine healthy young children, between 18 and 30 months old, were selected at random for a wetting
alarm diaper training (n = 27) or control wearing a placebo alarm (n = 12). Toilet behavior was observed during a period
of 10 hr by independent observers before, at the end of, and 2 weeks after training. Children were defined as completing daytime toilet training when the child wore undergarments, showed awareness of a need to void, initiated the toileting without
prompts or reminder from the trainer and had maximum one leakage accident per day.

Results:   Children in the wetting alarm diaper training group achieved independent bladder control in 51.9% and did significantly better than in the control group (8.3%) (P = 0.013). The results were sustained during the following 14 days
(P = 0.013).

Conclusion:   The wetting alarm diaper training is an effective option for toilet training young healthy children in a day-
care center. It offers day-care providers clear guidelines and limits the time to complete toilet training in many children without putting too much burden on the child and the day-care center activities.


The efficacy of the bedwetting alarm has been well-documented in the literature which also included a placebo alarm device treatment comparison which I reported on long ago in several scientific reports. It only makes sense that this
would work for the daytime as well and now that more miniaturized devices are available it is more practical for application. The use in a day-care center is of particular note and should be very helpful for parents. Dr. C.

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(Month?) 2009, SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY, (v43,5), Pp. 365-368. Reboxetine in therapy-resistant enuresis: A retrospective evaluation. Added 12/07/2009.

Lundmark,E.*, & Neveus,T. Uppsala Univ, Childrens Hosp, Nephrol Unit, SE-75185 Uppsala, Sweden

Search Terms: Enuresis, Imipramine, Reboxetine.

Objective:   Imipramine is the only evidence-based treatment available for Enuretic children resistant to standard therapy. The drug's antienuretic effect is probably due to noradrenergic facilitation. The drug is, however, potentially cardio toxic.
In this study, the non-cardio toxic noradrenergic antidepressant reboxetine was tested as an alternative to imipramine.

Patients and methods:  61 patients, aged 7-19 years, with enuresis-resistant to desmopressin, the alarm, urotherapy and anticholinergics, were given 4-8 mg reboxetine at bedtime, if necessary combined with desmopressin.

Results:   32 patients became dry on reboxetine treatment, although 21 of them required combination treatment with desmopressin to achieve this. Eighteen children did not respond and eight children discontinued because of side-effects before treatment could be evaluated. No serious adverse events occurred.

Conclusions:   These results need to be confirmed with randomized controlled studies, but indicate that reboxetine will become a safe and efficient treatment alternative for enuretic children resistant to standard therapy.


This article is important in coming up with an alternative to the use of imipramine, an old trycyclic antidepressant,
because of its cardio toxic effects which has caused deaths primarily in children under 2 years of age residing in chaotic households. Dr. C.

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February 2010 Journal of Urology. Evaluation of and Treatment for Monosymptomatic Enuresis: A Standardization Document From the International Children's Continence Society. (v183,2), Pp. 441-447. Added 02/02/2010.

Neveus,T.,* Eggert,P., Evans,J., Macedo,A., Rittig,S., Tekgul,S., Walle,J.V., Yeung,C.K., & Robson,L. Uppsala Univ, Childrens Hosp, Nephrol Unit, S-75185

Search Terms:   Enuresis, alarm, ADH, imipramine.

Purpose:   We provide updated, clinically useful recommendations for treating children with monosymptomatic nocturnal Enuresis.

Materials and Methods:   Evidence was gathered from the literature and experience was gathered from the authors with priority given to evidence when present. The draft document was circulated among all members of the International Children's Continence Society as well as other relevant expert associations before completion.

Results:   Available evidence suggests that children with mono-symptomatic nocturnal enuresis could primarily be treated by a primary care physician or an adequately educated nurse. The mainstays of primary evaluation are a proper history and a voiding chart. The mainstays of primary therapy are bladder advice, the enuresis alarm and/or desmopressin. Therapy resistant cases should be handled by a specialist doctor. Among the recommended second line therapies are anticholinergics and in select cases imipramine.

Conclusions:   Enuresis in a child older than 5 years is not a trivial condition, and needs proper evaluation and treatment. This requires time but usually does not demand costly or invasive procedures.


I very much appreciated the observation that Enuresis is “not a trivial condition….” coming out of an international consensus report. Note too that the enuresis alarm is listed among the mainstays of primary therapy. From my
experience this readiness to recommend the enuresis alarm on a more equal par with medication is much more likely in other countries. Dr. C.

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TOILET TRAINING

(Month?) 2008 NEUROUROLOGY AND URODYNAMICS (v27, 3), Pp. 162-166. Posted on 04/14/2008. How to toilet train healthy children? A review of the literature.

Vermandel,A., Van Kampen,M., Van Gorp,C., & Wyndaele,J.J.* Univ Antwerp, Dept Urol, Wilrijkstr 10, B-2650 Edegem, Belgium

Search Terms:   Toilet training; diapers, Encopresis, Enuresis.

Aims:   To review the literature on toilet training (TT) in healthy children.

Methods:  Through an extended literature search, all data on developmental signs of readiness for TT, TT methods, definitions of being toilet trained, TT problems, and predictive factors for success were reviewed.

Results:   Specific studies on this topic are few. Two main methods for TT have been described so far in the last decades: the gradual child-oriented training and the structured, endpoint-oriented training. In the former method parents mainly respond to the child's signals of toileting "readiness". The latter method consists of actively teaching several independent toileting behaviors. Data are too few to be able to compare the methods. Literature does not give a consensus about the optimal age for starting nor on the expected mean age of completing TT. Recent studies show most children to start training between 24 and 36 months of age with a current trend toward a later completion than in previous generations.
The consequence of this can be stress for the parents and more use of diapers, with its negative effect on the environment.

Conclusion:   There are as yet little data to be found on this important topic, only few studies have been published in
peer-reviewed journals. Standardization of terminology and critical evaluation of the described techniques in large
sample sizes is needed. With this approach, general. principles of training, evidence based and easy to use in the
majority of children, may become available to parents.


The authors' classification of two main methods for toilet training is reasonable. However, the first method of "readiness" has been challenged by adherents of infant potty training or "eliminative communication" which has been noted in the foreword to my “Clean Kid Manual”. The review and observations do show a lack of research in this area, unfortunately economic forces and backing for research just does not exist in the main for behavioral interventions over and against
the interests of diaper manufacturers and pharmaceutical companies. The delay in training in my view actually fosters prolonged incontinence and dependence on diapers and desperate parents later seeking medications. RWC

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October 2009 JOURNAL OF DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS (v30, 5), Pp. 385- 393. Posted on 10/25/2009.

A Prospective Study of Age at Initiation of Toilet Training and Subsequent Daytime Bladder Control in School-Age
Children

Joinson,C.*, Heron,J., Von Gontard,A., Butler,U., Emond,A., & Golding,J. Univ Bristol, Dept Community Based Med,
Cotham House,Cotham Hall, Bristol BS6 6JL, Avon, England

Search Terms:   Toilet training, Enuresis, bladder

Objective:  This study investigates the association between age at initiation of toilet training and development of daytime bladder control. The main aim is to examine whether initiation of toilet training after 24 months is associated with
increased odds of daytime wetting in school-age children.

Method:  The study is based on more than 8000 children, aged 4.5 to 9 years, from a UK birth cohort -The Avon Longitudinal Study of Parents and Children. Using multinomial logistic regression, the analysis examined the association between age at initiation of toilet training and 4 previously established trajectory groups representing different patterns
of development of daytime bladder control (described as "normative development," "delayed acquisition," "persistent daytime wetting," and "relapse").

Results:  Compared with children whose toilet training was initiated between 15 and 24 months, initiation of toilet training after 24 months was associated with higher odds of membership to the trajectory groups representing persistent daytime wetting (1.52 [1.23-1.88], p < .001), delayed acquisition of daytime bladder control (1.47 [1.29-1.66], p < .001), or
relapse in daytime wetting (1.52 [1.28-1.80], p < .001). Adjustment for confounding variables, including sex,
developmental delay, difficult temperament, and the mother's self-reported depression, did not alter the main conclusions.

Conclusion:   There is evidence that initiating toilet training after 24 months is associated with problems attaining and maintaining bladder control. it is possible that delaying the onset of toilet training until after 2 years prolongs the
exposure time to potential stressors that could interfere with the acquisition of bladder control, resulting in delays in achieving continence and susceptibility to relapses in daytime wetting.


I have long maintained and have read other literature suggesting that delays in toilet training actually results in
subsequent difficulties for the onset of Encopresis. It is interesting to see this confirmed in a larger scale study, but with Enuresis instead of Encopresis. Dr. C.

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Check back for weekly and monthly and updates. I may miss some relevant publications out there. I would deeply appreciate your calling my attention to any that you come across that you believe to be uniquely relevant.

If you are an active investigator/author, please forward a preprint or reprint to me. Also, your comments, speculations, and suggestions would be very much appreciated. This includes you parents who have gotten this far! RWC