Role of anal dilatation in treatment of idiopathic constipation in children: long-term follow-up of a double-blind randomized controlled study

Abstract

Constipation in childhood is a common symptom, with an estimated incidence between 0.3% and 8%. Most of the evidence for the current management of constipation and fecal soiling in children is based on reports of nonrandomized retrospective trials. Anal dilatation has had an established role in the management of idiopathic constipation but has never been evaluated by a randomized study. A double-blind randomized controlled trial was done of children who failed to respond to medical treatment and were admitted for investigation and treatment of idiopathic constipation to Guy's Hospital, London, between April 2001 and April 2003. All children had intestinal transit study on admission. They were randomized, using a computer-generated allocation in sealed envelopes, to receive no anal dilatation (control group) or anal dilatation (anal dilatation group). Anorectal manometry and endosonography were done under ketamine anesthesia followed by anal dilatation if necessary under the same anesthesia. Disimpaction of feces from the rectum was done at the end of the procedure under general anesthesia using propofol muscle relaxant to minimize stretching of anal sphincter muscles in the control group. All children had intensification of medical treatment, toilet training, and monitoring of their response to treatment during their hospital stay, which ranged from 3 to 5 days. Outcome was measured using a parent's questionnaire of symptom severity at 3 and 12 months of follow-up by one of the authors, who was blinded to randomization. The symptom severity score ranged between 0 and 65 and consisted of scores for the following: delay in defecation (score range 0-10), difficulty and pain with passing stool (0-5), soiling problem (0-10), intensity of laxative treatment (0-10), child's general health (0-5), behavior related to the bowel problem (0-5), overall improvement of symptoms (0-12,) and assessment of megarectum on abdominal examination (0-8). Of 60 neurologically normal children, 31 (19 males) were randomized in the control group and 29 (18 males) in the anal dilatation group. All children had findings consistent with idiopathic constipation and positive anorectal reflex on manometry, no anal sphincter damage on endosonography, and no anal fissure on examination under anesthesia. The median age for control and anal dilatation groups was 7.97 (range 4.1-14.25) years and 7.78 (4-13.25) years, respectively. Both groups were also comparable with regard to median of duration of laxative treatment (32 months vs. 31.5 months), internal anal sphincter thickness on endosonography (0.90 mm vs. 0.80 mm), resting anal sphincter pressure on manometry (51 mmHg vs. 51 mmHg), total rectal capacity on manometry (260 mmHg vs. 260 mmHg), and total symptom severity score before admission (33 vs. 29), respectively. At 12-month follow-up, the median pre-admission symptom severity score had improved significantly, from 33 (range 12-49) in the control group and 29 (16-51) in the dilatation group to 15 (0-51, p < 0.0001) and 19 (1-46, p < 0.0001), ...

Evaluation of outcome of anorectal anomaly in childhood: the role of anorectal manometry and endosonography

“…Anal endosonography (ES) has been used to assess the anatomy of the pelvic floor and anal sphincters and it has been validated by electromyography, anorectal manometry and histological examination of the sphincters [3,5,[8][9][10][11][12]. ES is easily performed and is of great value for recording sphincter defects in patients with anal fistulas and abscesses, muscular dystrophy, idiopathic faecal incontinence and ARA [8,[13][14][15].…”

Transcutaneous needle-free injection of botulinum toxin: a novel treatment of childhood constipation and anal fissure

“…The outcome of treatment including degree of fecal impaction in the rectum was measured by a symptom severity (SS) score questionnaire validated in 1050 children with chronic IC [15]. The new scoring system correlated well with physiologic and morphological findings of anorectal manometry and endosonography in children with constipation and soiling [1][2][3]. The total SS score ranged between 0 (best) and 65 (worst), also the individual components of total SS scores consisted of delay in defecation (score range, 0-10), pain and difficulty with passing stool (0-5), soiling problem (0-10), intensity of laxative treatment (0-10), child's general health (0-5), behavior related to the bowel problem (0-5), impression of parents and child about overall improvement of symptoms (0-12), and assessment of fecal impaction in rectum on abdominal examination (0-8).…”

“…Patients who had regular bowel motion every 1 to 2 days and were socially clean requiring minimal or no laxatives were considered successfully treated and were discharged from follow-up. The outcome of patients who had TNFBT were compared to 31 children in a comparable historical control group in the previous trial at 3 and 12-month follow-up [1]. Children in the control group had conventional treatment of constipation including disimpaction of stool under anesthesia in 6 and stayed in hospital between 1 and 5 days.…”

“…Evidence from 2 double-blind randomized controlled trials has shown that anal dilatation does not benefit children with chronic idiopathic constipation (IC), and injection of botulinum toxin into the internal anal sphincter (IAS) is as effective as myectomy of the sphincter [1,2]. Functional and morphological evaluation of the IAS by anorectal manometry and endosonography have shown that, contrary to previous reports, the anal resting sphincter pressure is normal and nonobstructive in children with chronic IC [3].…”

Constipation in children

“…Using this over the last 5 years on 4124 consultations, it was only impossible in my ordinary outpatient clinic in 6.9% because of poor cooperation (mainly in toddlers and children along the autistic spectrum). It has taught me that it is very easy to underestimate the degree of rectal loading with palpation alone and persisting retention, despite effective stool softening, is an indication for adding a stimulant laxative in VOLUME 47 __ We have evaluated the commonly used surgical intervention of vigorous anal dilatation under general anesthetic (5) and found no evidence that this provides additional benefit to the manual evacuation of retained feces under the same anesthetic together with the significant placebo benefit from the procedure. We compared internal anal sphincter myectomy with intra internal anal sphincteric botulinum injection(6) finding both procedures leading to benefits in most children although we are awaiting completion of a subsequent randomised control trial of botulinum toxin.…”