Table Of ContentFecal Incontinence and
Constipation in Children
Case Studies
Fecal Incontinence and
Constipation in Children
Case Studies
Edited by
Onnalisa Nash, MS, CPNP
Center for Colorectal and Pelvic Reconstruction Surgery
Nationwide Children’s Hospital
Columbus, Ohio, USA
Julie M. Choueiki, MSN, RN, CPEN
Center for Colorectal and Pelvic Reconstruction Surgery
Nationwide Children’s Hospital
Columbus, Ohio, USA
Marc A. Levitt, MD
Center for Colorectal and Pelvic Reconstruction Surgery
Nationwide Children’s Hospital
The Ohio State University
Columbus, Ohio, USA
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Contents
Preface ix
Contributors xi
Acknowledgments xiii
PART I BOWEL MANAGEMENT 1
1 General guidelines for bowel management 2
Stephanie J. Vyrostek
2 Bowel management program setup: The basics and long-term follow-up 6
Stephanie J. Vyrostek and Laura J. Weaver
PART II ANORECTAL MALFORMATIONS 11
3 A patient with good surgical anatomy after an anorectal malformation (ARM) repair with
good potential for bowel control 13
Erin M. Shann
4 A patient with good surgical anatomy following an anorectal malformation (ARM) repair
with fair potential for bowel control 19
Erin M. Shann
5 A patient with a good anatomic anorectal malformation (ARM) repair, but with poor
potential for bowel control 26
Catherine Trimble
6 A patient with a history of a cloacal malformation who needs colorectal, urological, and
gynecological collaboration 30
Kristina Booth
7 A young adult with prior surgery for an anorectal malformation (ARM) with fecal incontinence 35
Onnalisa Nash
8 A patient with an anorectal malformation (ARM) with fecal incontinence who is a candidate
for a sacral nerve stimulator (SNS) 38
Catherine Trimble
PART III HIRSCHSPRUNG DISEASE 43
9 A patient with good surgical anatomy and hypomotility after a Hirschsprung pull-through 46
Leah Moore
10 A patient with good surgical anatomy and hypermotility after a redo pull-through for
Hirschsprung disease 49
Leah Moore
11 A child with Hirschsprung disease (HD) and hypomotility 53
Lindsay Reilly
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Contents
12 A patient with total colonic Hirschsprung disease and soiling 57
Stacie Leeper
13 A teenager with prior surgery for Hirschsprung disease who has constipation 62
Stacie Leeper
PART IV SPINAL ANOMALIES 67
14 A patient with a hypodeveloped sacrum and fecal and urinary incontinence 68
Cassie do Carmo
15 A patient with a spinal anomaly and fecal incontinence 73
Cassie do Carmo
16 A pediatric patient with spina bifida in need of a urological reconstruction 76
Cheryl Baxter
17 A young adult with quadriplegia and fecal incontinence due to spinal cord injury (SCI) 79
Cheryl Baxter
PART V FUNCTIONAL CONSTIPATION 83
18 A case of diffuse colonic dysmotility 85
Sarah Driesbach
19 A patient with chronic constipation and sphincter dysfunction 93
Sarah Driesbach
20 A patient with severe functional constipation, fecal impaction, and no soiling 98
Julie Zipfel and Marc A. Levitt
21 A patient with severe functional constipation, fecal impaction, and soiling 102
Julie Zipfel and Marc A. Levitt
22 A patient with a successful rectal enema regimen but who now is unable
to tolerate rectal administration 108
Andrea Wagner
23 A patient with severe functional constipation who has failed laxative treatment and both
rectal and antegrade enemas 112
Julie Gerberick
24 A patient who has recurrent constipation and soiling following colonic resection 120
Andrea Wagner
25 A young adult with intractable constipation and diffuse colonic dysmotility 124
Alessandra Gasior and Amber Traugott
26 A young adult with pelvic floor dyssynergia 126
Alessandra Gasior and Amber Traugott
27 A patient with severe constipation and a behavioral disorder 128
Katrina Hall, Charae Keys, and Rose Lucey Schroedl
28 A young adult with incontinence after a low anterior resection 132
Alicia Finn, Scott Lake, and Amber Traugott
29 Two adults with incontinence after childbirth 135
Stephanie Dolan, Amber Traugott, and Pooja Zahora
30 A young adult with rectal pain and fecal urgency who is a candidate for sacral
nerve stimulation 141
Alessandra Gasior and Amber Traugott
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Contents
31 An adult with soiling following an ileoanal pouch 144
Alicia Finn and Amber Traugott
PART VI RADIOLOGY 149
32 Which X-ray is worse? 150
Onnalisa Nash
33 Interesting radiological findings 156
Onnalisa Nash and Marc A. Levitt
PART VII MYTHS 163
34 Colorectal surgical myths 164
Julie M. Choueiki
PART VIII MEDICATION PROTOCOLS 173
35 Medication protocols 174
Meghan Fisher and Onnalisa Nash
Index 183
vii
Preface
Patients with anorectal malformations (ARMs), Hirschsprung disease (HD), fecal incontinence from a variety of conditions,
and colonic motility disorders often require care from specialists across a variety of fields throughout their lives. These
include colorectal surgery, urology, gynecology, and GI motility, as well as orthopedics, neurosurgery, anesthesia, pathology,
radiology, psychology, social work, and nutrition, amongst many others. Perhaps most important to their achievement of a
good functional result is their connection to superb nursing care.
Having met many parents with newborns diagnosed with colorectal problems, I have made several observations.
First, no parent ever thinks their child could have a problem with stooling—this is a physiologic ability that is taken for
granted. When told this is a problem, they are usually shocked. Second, when discussing with parents that their child
will need surgery to correct their colorectal anatomy, they do not focus on the surgical technique and elegance of the anal
reconstruction, as I do. Instead, they focus on whether that technique will allow their child to stool without difficulty, and
whether school, sleep overs, and overnight camp will be options for them. As surgeons, we need to remember this—we
always need to understand what it is that the family wishes for us to deliver to them. As proud of our surgical skills as
we are, it is the functional outcome that matters most to our patients.
I like to say that a complex colorectal operation takes about 4 hours to perform, but in order to get a good result, it takes
an additional 96 hours of work—the vast majority of which involves nursing care. From the very beginning of my journey
in the field of pediatric colorectal surgery, which began in 1992 as a budding medical student, the value of a good nursing
partner became clear to me. Patients and their families tell nurses things they would never tell their doctors. Nurses have
a spirit about them that is unique—the genuine devotion to helping their patient and never seeming to want anything
in return other than the patient’s smile. Their skills in identifying problems, solving them, being willing to get down in
the weeds, and always striving to fill the gaps are unique to the profession.
We have attempted in this book to capture some of these special moments represented in the illustrated cases you are
about to encounter. We strove to help other caregivers understand the daily struggle of improving a patient’s quality of
life and to convey to the readers of this book the skills and tricks to achieve good results. I am so convinced, and often
shout from the rooftops that, without my nursing partners, I would have achieved very little as a surgeon. It was an honor
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