Encopresis
Please Comment on the Following Recently Published Study on Encopresis (See Question) and My Answer.
Oct 2009 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY (v7,10), Pp. 1069-1074.
A Randomized Controlled Trial of Enemas in Combination With Oral Laxative Therapy for Children With Chronic Constipation
Bongers,M.E.J., van den Berg,M.M., Reitsma,J.B., Voskuijl,W.P., & Benninga,M.A.*
Univ Amsterdam, Acad Med Ctr, Emma Childrens Hosp, Dept Pediat Gastroenterol & Nutr, Room G8-261,Meibergdreef 9, NL-1105 AZ Amsterdam, Netherlands
Search Terms—Encopresis, Incontinence, Fecal, Constipation, Enema
BACKGROUND & AIMS: After 5 years of intensive oral laxative use, up to 30% of constipated children still have an unsuccessful outcome. Children refractory to oral laxatives might benefit from regular rectal evacuation by enemas. This randomized controlled trial compared the effects of additional treatment with rectal enemas (intervention) with conventional treatment alone (oral laxatives, control) in severely constipated children. METHODS: In a tertiary hospital in the Netherlands, 100 children, aged 8-18 years, with functional constipation for at least 2 years were randomly assigned to intervention or control groups. The control group received education, behavioral strategies, and oral laxatives. The intervention group was also given 3 rectal enemas/week, reduced by I enema/week every 3 months. Outcome measures were defecation and fecal incontinence frequency and overall success at 12, 26, 39, and 52 weeks. Overall success was defined as 3 or more defecations/week and less than 1 fecal incontinence episode/week, irrespective of laxative use.
RESULTS: Defecation frequency normalized in both groups but was significantly higher in the intervention group compared with controls at 26 and 52 weeks (5.6 vs 3.9/week, P = .02, and 5.3 vs 3.9/week, P = .02, respectively). There were no significant differences between groups in reduction of fecal incontinence episodes (P = .49) and overall success rates (P = .67). After 1 year of treatment, the overall success rate was 47.1% in the intervention group versus 36.1% in the control group.
CONCLUSIONS: There is no additional effect of enemas compared with oral laxatives alone as maintenance therapy for severely constipated children.
Interesting, here is an admission of up to a 30% failure rate for 5 years of “top down” laxative use in dealing with fecal incontinence for severely constipated children. 1, 2, 3, 4, 5 years and a 30% failure rate! That result could occur via time and trial and error alone! This is the same research group that showed the colon does not completely restore even after 4 years of the successful remission of fecal incontinence! Their innovation here was to add enemas to their standard treatment protocol. No training aspect was introduced, just so called “maintenance therapy” to assure repeated "clean outs?" Really, does the medical profession wish to "maintain" fecal incontinence? How odd! This would appear to be a variation on, "First do no harm," but adding on, "and do no good?" Why is that? They did not use enemas in a rational bowel retraining protocol such as that pioneered by Soiling Solutions. Basically, these authors used a “brainless” approach to the treatment of encopresis or fecal incontinence. The authors left out the critical component of a normal reflex arc engaging colo-rectal signals>>a brain connection with sitting on toilet stool cues>>voiding reflex. The authors appear to be trying to improve on “maintaining” the dominant prepotent sequence of colo-rectal signals>>brain-wherever, including the toilet stool>>holding reflex! My hope is that now they will do a follow up with the Soiling Solutions protocol to reprogram the necessary and desired BRAIN mediated VOIDING reflex arc. I would be pleased to offer free copies of my Clean Kid Manual for any such research project. DrC.
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