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Bremen, Germany
Author Affiliations: Department of Pediatric Surgery and Urology (Schmiedeke E, Lorenz C); Department of Clinical Psychology (Busch M); Department of Physiotherapy (Stamatopoulos E), Children's Hospital, Klinikum Bremen-Mitte, Bremen, Germany
Corresponding Author: Eberhard Schmiedeke, Klinik f¨¹r Kinderchirurgie und Kinderurologie, Klinikum Bremen Mitte, 28177 Bremen, Germany (Tel: 0049-421-497-5410; Fax: 0049-421-497-3766; Email: eberhard.schmiedeke@klinikum-bremen-mitte.de)
Background: Fecal incontinence and constipation are major problems after correction of anorectal malformation (ARM), caused not only by the somatic defects but also by a psychosomatic dysfunction of defecation. To better release patients from this dysfunction we offered a multidisciplinary, psycho- and physiotherapeutic therapy according to an approach developed in Nijmegen (Netherlands). We herein summarize the preliminary results to evaluate whether the approach can be adopted with similar success.
Methods: Since January 2002 multidisciplinary behavioural treatment (MBT) has been offered to children above 3 years of age and suffering from fecal incontinence and constipation after surgical correction of ARM in our department or elsewhere. Prerequisites included no anal stenosis, regulation of stool consistency, and a suitable defecation diary over 2 weeks. MBT contained regular consultations by a pediatric psychologist and a physiotherapist, teaching the child to establish a regular defecation pattern and how to push while relaxing the pelvic floor. The entry- and post-treatment situation was prospectively monitored by means of defecation and constipation scoring systems.
Results: Complete data were available in 10 patients (9 males, 1 female) with high (8 patients) and low (2) forms of anal atresia initially, who finished MBT 2-36 months ago (mean: 13 months). The average amount of stool reaching the toilet was 27% before and 90% after therapy. Clean days were absent before, reaching 3.7 days on average after therapy. Constipation was present in 6 patients before (3 of them on enemas) and in 2 after therapy (no enemas needed). The duration of MBT was 7 months on average, range 3-23 months, with 8-9 sessions per patient, each lasting 60-90 minutes. An observation period of 7 months after treatment confirmed stable results. MBT turned out to improve body-consciousness and self-confidence.
Conclusions: MBT is effective in reducing incontinence and constipation in patients after ARM. It helps the children and their families to relieve psychosocial stress. The approach can be successfully adopted, if a team of committed specialists is available and sufficient compliance of patients and families is given.
Key words: anorectal malformation; behavioural therapy; constipation; fecal incontinence; physiotherapy; psychotherapy
World J Pediatr 2008;4(3):206-210
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