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Information for Parents

Bowel Management Program in Children for Fecal Incontinence

  • The Bowel Management Program is a one-week intensive program for children who are unable to anticipate or control their bowel activity. The Bowel Management Program is useful for patients with:

    • Anorectal malformations / imperforate anus

    • Hirschsprung disease

    • Fecal incontinence

    • Idiopathic constipation

    • Cloacal exstrophy

    • Neurogenic bowel

    • Neural tube defects

  • The basis of the bowel management program is to clean the colon with the use of enemas once a day and to decrease the motility of the colon with medication or diet to keep the patient clean for the following 24 hrs. It consists of

    • Modification of the diet (if necessary)

    • Medications (if necessary)

    • Bowel cleaning (enemas)

  • Team and process

    • The team involved in bowel management program includes pediatric surgeons and Pediatric Gastroenterologist. After reviewing clinical history, records and imaging ( like X-ray, colonic motility studies, Water soluble contrast enema etc.), the team will classify the children into one of the groups

      • kid with fecal incontinence and constipation (pseudo incontinence)

      • kid with fecal incontinence and diarrhoea (increased motility of gut)

    • Bowel management of kids with fecal incontinence and constipation (pseudo incontinence)

      • Consists of finding, by trial and error, the specific type of enema capable of cleaning the colon of a specific patient, so that he is dry for 24h

      • Consists of rectal and colonic wash

      • No diet or drugs given

      • Takes advantage of decreased bowel motility in constipating children

    • Bowel management of kids with fecal incontinence and diarrhoea (increased motility of gut)

      • Consists of finding, by trial and error, the specific type of enema capable of cleaning the colon of a specific patient, so that he is dry for 24h

      • Consists of rectal and colonic wash/enema 

      • Constipating diet and drugs are given.

      • There are some medications that are able to slow the motility of the colon. The use of these specific medications such as Lomotil or Immodium must be decided on with the physician.

    • After starting treatment, most of the children will have daily or alternate day abdominal X-ray to determine how empty the colon is of stool. Depending upon the clinical and radiological results, adjustments to the treatment plan as appropriate will be done. The child and parents will be educated about the Bowel Management Program. Most of the children who complete this program will need to maintain a bowel management regimen for their entire lives. Further, when the child becomes older (8-12 years of age) and is embarrassed to receive enemas, creation of a continent appendicostomy (Malone procedure) may be done. It is an operation that consists in connecting the tip of the appendix to the deepest portion of their umbilicus and plicating the cecum around the appendix to create a one-way-valve mechanism that allows the passing of a catheter to deliver an enema while sitting on the toilet. Those without an appendix can undergo a neo-appendicostomy.

  • Results

    • The result will depend upon dedication, timing and teamwork between the child, family and medical team. Each child’s regimen will be decided according to his or her specific needs. The child’s outcomes will also depend in part on the cause and severity of their condition. Some children may achieve bowel control only through diet and/ or medication while some will continue to need enemas. However, many of them are in normal underwear by the end of the week and are having better quality of life and self-esteem.


Bowel cleaning  by Enema

  • Equipment Needed for Enema

    • Enema bag/can or enema set

    • Water soluble lubricant/ Xylocaine Jelly 2%

    • Catheter- A catheter of 20-22 CH.( can use soft Intercostal drainage tube). Sometimes it is useful to use a Foley catheter (22 or 24 French) with a 30cc balloon.

    • The determined enema (i.e. phosphate enema, saline enema etc.) at body temperature to decrease cramps

  • Available enemas

    • Ready-made solutions available in drugstore- phosphate enemas are most convenient since it is already in a prepared vial.

      • Older than 8 years of age or heavier than 30 kg- one adult phosphate enema daily (240cc).

      • Children between 3 and 8 years of age or between 15 and 30 kg -one pediatric phosphate enema each day (120cc).

      • Children should never receive more than one phosphate enema a day because of the risk of phosphate intoxication, and others with impaired renal function should use these enemas with caution.

    • Solutions prepared at home- based on water and salt -Just as effective, easier and less expensive. Use water  250 cc and 1 tsf (5gm) Salt to make 250 ml enema.

  •  Administering the Enema

    • Gather all  equipment

    • Position your child as instructed 

    • Lubricate the catheter tip

    • Gently insert the catheter into the anus as high as possible. The catheter is flexible so it can be manoeuvred it into the colon. If any resistance is met you a small amount of fluid may be installed to dislodge some stool. Occasionally leakage occurs with this technique, resulting from kinking of the catheter.

    • Attach the catheter to the enema bag

    • Instill the enema at this time, the higher the bag is held the faster the flow, the lower the bag is held the slower the flow. Giving the enema should take about 5 –10 minutes, if there are cramps  slow down the flow, by lowering the enema bag to help decrease cramping.

    • Once the enema is instilled remove the catheter and hold the buttock cheeks together, trying to retain the fluid for at least 5 minutes if possible.

    • After the retention time is up, now ask child to sit on the toilet for about 30-45 minutes for optimal results. Check the results of the enema, look into the toilet. If no stool or minimal stool, the child may require a different or larger enema.

  •  Trial and error approach for enema

    • One suggested protocol (step up approach)-  If one enema is not enough to clean the colon (as demonstrated by an X-ray, or if the child keeps soiling), step up.

      • Start with one phosphate enema daily according to age.

      • If inadequate, add a saline enema (similar volume) to the phosphate one.

      • If inadequate results ,then glycerin can be added

      • If inadequate results, add high colonic washings with a balloon catheter.

    • Aim is to reach right enema which is the one that can empty the child’s colon and allow him to stay clean for the following 24 h. This can be achieved only by trial and error and learning from previous attempts and will vary for each child.

    • The enema administered on a regular basis should result in a bowel movement followed by a period of 24 h of complete cleanliness.

  • When  to start Bowel Management in Anorectal Malformation?

    • It is advisable to start the bowel management at approximately 3 years of age in a anorectal malformation child.. At this age most of the children do not wear diapers.

  • When to give enema?

    • Recommendations are to give an enema after the main meal of the day so as to take advantage of the gastrocolic refex (this reflex happens after each meal).

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