The Effect of Anorectal Manometry on the Outcome of Treatment in Severe Childhood Constipation: A Randomized, Controlled Trial

Abstract

ABSTRACT.Objective. Approximately 50% of constipated children contract rather than relax the external sphincter complex during a defecation attempt. Although biofeedback training (BF) is able to change this defecation behavior, there is no additional effect of BF to conventional treatment (CT) on clinical outcome compared with CT alone. It has been postulated that the absence of a significant difference between these 2 treatment options might be because of a therapeutic, "demystifying" effect of performing anorectal manometry in conventionally treated children, necessary to obtain basal manometric data. The objective of this prospective, controlled, randomized study was to evaluate the effect of CT with 2 anorectal manometry sessions compared with CT alone (dietary advice, diary, toilet training, oral laxatives, and enemas) on clinical outcome.Methods. A total of 212 constipated children (143 boys) who were visiting a referral pediatric gastroenterologic practice were randomized prospectively to CT alone (115 patients) or to CT combined with 2 manometry sessions (CTM; 97 patients). Patients were included in the study when they fulfilled at least 2 of the 4 following criteria: stool frequency fewer than 3 per week, 2 or more soiling and/or encopresis episodes per week, periodic passage of very large amounts of stool every 7 to 30 days, or a palpable rectal or abdominal fecal mass. CT comprises dietary advice, a daily diary, toilet training, and oral laxative treatment preceded by rectal disimpaction with enemas on 3 consecutive days. During both manometries, the child and the parent could watch the tracing on the computer screen. No explanation was given to either the child or the parents during the procedure. When the procedure was finished, the tracings were clarified. Successful treatment was defined as a defecation frequency of 3 or more per week and fewer than 1 soiling/encopresis episode per 2 weeks and no use of laxatives.Results. Only 4 and 2 children from the CT and CTM groups showed no soiling and/or encopresis, whereas 76% and 65%, respectively, reported the periodic passage of large stools. In 26% and 30% of the patients, a rectal scybalum was found on physical examination. The success rates at 6, 26, 52, and 104 weeks' follow-up were 4%, 24%, 32%, and 43% and 7%, 22%, 30%, and 35% in the CT and CTM group, respectively. No significant difference in success percentage was observed between the 2 groups at any time of follow-up with relative risks (CT/CTM) and 95% confidence intervals, respectively, of 0.55 (0.16 -1.89), 1.13 (0.67-1.89), 1.07 (0.69 -1.65), and 1.23 (0.81-1.85). A significant increase in defecation frequency was observed between the first (intake) and second visits, which was sustained at all subsequent visits and stages of follow-up in both groups (not significant). Also in relation to the first visit, a significant decrease in encopresis episodes was shown and a further slow but significant decrease at 52 weeks of follow-up in both groups. The manometric data obtained from the CTM grou...

Behavioral Therapy for Childhood Constipation: A Randomized, Controlled Trial

“…Regardless of high visit frequency and duration, this did not lead to a higher success rate compared with those studies with 2 to 6 visits in a time period of 6 months. 18,19,26,31,34,35 Generalization of the findings may also be hampered, because the pediatric gastroenterologists involved in this study are highly specialized and experienced in treating chronic constipation. However, CT in our study was based on the clinical practice guideline from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, 36 which provides recommendations for the management of functional constipation by the primary care provider.…”

“…It was estimated that CT reached success in 35% of the children at follow-up. 26 Under the additional assumption of a significance level of .05, a power of .80, and 2-sided hypothesis testing, a minimal sample size of 124 with 62 children in each group was determined.…”

Psychosocial co-morbidity affects treatment outcome in children with fecal incontinence

“…Children with severe constipation were treated with rectal stimulant laxatives or enemas. Before and after each biofeedback training session, parents and the children received psychosocial intervention, including: (1) daily registration; (2) toilet training and anal sphincter exercises (squeeze and push to increase rectal sensitivity, and squeeze in endurance to improve muscle strength); (3) behavioral modification techniques; (4) positive approach; (5) demystification (explanation of relationship between constipation, fecal incontinence, and child behavior); (6) individual psychosocial analysis (using DSM classifications to characterize the child) [19]; (7) biofeedback training (biofeedback training is based on operant conditioning [9,15] and is described in detail elsewhere [2,9,14,19,20]). The number of training sessions varies from 3 to 9 consecutive weeks (average number of six sessions).…”

Rééducation et constipation : pour qui et comment ?

“…Lors de cet examen, on peut concevoir que les données de la dynamique défécatoire soient expliquées à la fois à l'enfant et à l'entourage et qu'elles suffisent à une prise de conscience du problème par l'enfant : les bons résultats observés lors du recours aux seules méthodes conventionnelles étant de ce fait partiellement attribuables à la manométrie inaugurale elle-même. Cette hypothèse a été testée dans un essai contrôlé randomisé évaluant l'apport de l'examen manométrique (en temps qu'exploration et non-traitement) sur l'issu thérapeutique des enfants souffrant d'encoprésie et traités par ailleurs de façon simple et conventionnelle [9]. Les enfants ayant subi cette exploration n'obtenaient pas de béné-fice symptomatique supérieur au terme d'un an de suivi.…”