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It is difficult for pediatric providers to objectively evaluate bowel control. There are several useful scoring systems, mainly for adult patients, which attempt to measure the severity of fecal incontinence. But even useful systems have severe limitations and aren’t universally accepted in the evaluation of fecal incontinence in children.
Researchers from the International Center for Colorectal and Urogenital Care at Children’s Hospital Colorado reviewed literature for 13 of the most frequently used and validated fecal incontinence scoring systems. They then evaluated which ones were the most objective and applicable to managing fetal incontinence symptoms in children.
Adult scoring systems
Patients who suffer from constipation and overflow pseudo-incontinence aren’t differentiated from patients who are fecally incontinent. The adult-designed scores are not useful in pediatrics because overflow pseudo-incontinence is common in those patients.
Pediatric fecal incontinence scoring systems
All the pediatric scoring systems include at least one subjective parameter such as sensation of rectal fullness, sphincter squeeze and anal shape. They also include unrelated factors such as frequency of bowel movements, rectal prolapse, abdominal pain, blood in the stool, leakage of urine, fecal consistency, diarrhea and constipation.
Reviewers found the most objective evaluation method was Krickenbeck. The method relied on these two simple factors: absence of voluntary bowel movements and the presence of soiling in underwear.
Many of the methods for scoring fecal incontinence were created to score an individual’s quality of life, but none measure fecal control. The methods measure the individual’s capacity to adapt to the medical condition or effectiveness of a multidisciplinary approach to care for these patients. While important, they don’t help pediatric caregivers quantify fecal control, nor to do they compare results with different treatment modalities for bowel control in children.
Fecal soiling is commonly considered a diagnosis, but it is actually a symptom of poor bowel control. Bowel control requires sensation, sphincter mechanism and colonic motility. Though there are gaps in the understanding of each of these elements and their interactions, fecal soiling can be seen when examining a patient’s underwear.
Bowel control is the ability to voluntarily pass bowel movements and to retain stool after. Voluntary means feeling the urge to defecate, avoiding the immediate passage of stool and coordination to pass stool into the toilet. Retaining must not cause fatigue. The Krickenbeck system focuses on voluntary bowel movements and fecal soiling; thus it is completely aligned with this definition of bowel control.
Other pediatric bowel control scoring systems include subjective or unrelated elements, and they convey little information related to control.
After managing thousands of pediatric patients born with anorectal malformations at the International Center for Colorectal and Urogenital Care, the researchers have learned that some borderline patients with fecal soiling have the potential for bowel control if given the proper medical management. These patients must be evaluated after medical management to determine the potential for bowel control.
The most common borderline patients have anorectal malformations and severe constipation. For these patients, constipation is the more common cause of the fecal soiling rather than the anorectal malformation. It is more accurate to classify these patients as having overflow pseudo-incontinence.
A treatment challenge can help distinguish patients with overflow pseudo-incontinence from patients with no bowel control. Constipated patients are offered laxatives and their response is assessed:
Some borderline patients with an anorectal malformation experience diarrhea because the flow of their fecal system travels too fast and the liquid consistency is hard to control.
A treatment challenge can also help distinguish these patients. Imodium is administered to slow their fecal stream and dietary modifications are made to thicken their stool consistency:
Researchers conclude that continence scoring systems (especially those that measure quality of life) are flawed because of subjective assessments and aren’t helpful for managing pediatric patients.
The Krickenbeck scoring system is the most applicable and objective evaluation method. Its score can be adapted easily to evaluate pediatric patients after they receive medical treatment. For anorectal malformations, this proposed modification allows for a more accurate diagnosis and better treatment of pediatric patients.
This research was featured in the August 2016 issue of Pediatric Surgery International.