Soiling
From Ganfyd
Soiling is the involuntary passage of stools in conjunction with constipation (abnormal if >4 years of age, Boys:Girls = 3:1)
See also Encopresis, faecal incontinence in children
- 95% - functional in origin (due to constipation)
- 5% - due to abnormal behaviour (encopresis)
- rare - organic causes (Hirschsprung's disease, Spina bifida)
Contents |
History:
Involve child if old enough (parents of children who are toilet-trained for a few years have little idea about child’s bowel habits although they often assume great authority on the issue).
- Onset of constipation and soiling. Previously toilet-trained and when?
- Bowel patterns: Frequency, Consistency: (typical are: very large stools, several soft stools daily)
- Painful defecation?, Blood in stools? (--> anal tears)
- Appearance: pale looking, tired, irritable
- Behaviour: stool-withholding-behaviour (standing/hooked in corner, "exaggerated attempts at defecation")
- Previous trials with laxatives: any changes in above features?
- Delay of passage of meconium in neonatal period? (--> Hirschsprung's disease rarely presents with soiling)
- Day-time wetting? (--> ? organic)
- Major psychological and/or behavioural abnormalities? Onset before soiling?
Examination:
• General Examination: mainly for reassurance • Palpation of abdomen: faecal masses (often normal despite of constipation) • Inspection of perianal area: tears, inflammation (--> Candidiasis, streptococcal) • NO rectal examination! - especially not in young girls (Can be traumatic for children already sensitive in this area. Not helpful as empty rectum does not rule out constipation ) • Back: spinal abnormalities, Neuro: ankle reflexes (--> ?spina bifida)
Management:
Should, in first instance, always be treated as secondary to constipation: 70-75% success.
1) Education and Reassurance: (relief of anger and anxiety)
- Soiling is NOT intentional (child doesn't notice until soiling has occurred. - no punishment !!)
- Child is NOT psychologically abnormal!
- It CAN be treated successfully
- Explain mechanisms of overflow-incontinence with picture:
Liquid stools from above pass the hard+impacted stools in the lower bowel (not diarrhoea but constipation!)
2) Disimpaction: with strong Laxative (start when child is off school/kindergarten)
- Bisacodyl (Dulcolax) orally 5 mg mane for 3 days (10 mg if >5 years of age) (NO enemas or suppositories! These are invasive and not necessary)
3) Prevention of Reaccumulation: with a stool softener (start simultaneously with disimpaction) For 6-12 months: for child to regain confidence and colon to return to original tone and shape. Taper off treatment gradually after
- Liquid paraffin (mineral oil) (up to max. 60 mls nocte) titrated to effect (directly from fridge, with yoghurt or ice-cream) (C/I: children <1 year, neurological abnormalities, learning difficulties because of risk of aspiration)
- Dietary fibre (e.g. fruits) + plenty of fluids are important (but on its own it will not be sufficient enough once stool withholding and soiling have established)
- Lactulose may be used in infants <1 year of age (It is less suitable because of day-to-day inconsistency of efficacy, making it difficult to titrate and possibly counterproductive to establish regular bowel pattern)
4) Establishing regular bowel pattern: (start after successful disimpaction)
- Encourage child to sit on toilet regularly, at same time of day, at least once, for at least 5 min, Ideally after breakfast (gastro-colic reflex)
- Continue on daily basis irrespective on whether or not child has passed stools. Footstool or other support to ensure hips can be fully flexed, and child can sit comfortably on toilet
