Kids Pee Poo Physio


Constipation in Children


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Constipation



• Children who experience pain or discomfort when pooping quickly learn to withhold their poop because they are afraid that the poop will hurt. They learn that the pain or discomfort can be avoided by simply contracting the muscle (sphincter) around their anus whenever they feel the need to poop.

• Withholding begins as a voluntary response (a conscious decision), but if the painful or uncomfortable bowel movements continue, withholding can become involuntary. This means that the anal muscle "closes" automatically whenever the rectum contracts which is what causes the feeling of urgency, the need to poop. Withholding is no longer a conscious decision it has become a habit.

• Constipation has a peak incidence between the age of 2 and 4 when potty training starts


The rectum transitions from a sensory organ to a storage organ and it becomes so stretchy that it loses its tone and can’t pump the stool out as effectively.



Why So Many Kids Are Constipated



• The highly processed Western diet

• The rush to potty train

• Minimal potty-training follow-up

• Restrictive school bathroom policies

• There are a few exceptions: some children end up constipated because they have an anatomical disorder such as Hirschsprung disease, a condition where nerve cells are missing from the last part of the large intestine, or because a portion of their colon does not work



How Constipation Triggers Bedwetting and Accidents



• A normal rectum is no wider than about 3 cm. Bedwetting patients have rectums stretched to 6 or 7 cm — sometimes wider.

• When a child regularly withholds, stool piles up in the rectum, forming a large, hard mass. The rectum stretches to accommodate this mass. Eventually, the stretched rectum becomes so large that it squishes and aggravates the bladder.


The stretched rectum can cause poop accidents (encopresis). The rectum becomes so stretched that it loses tone and sensation, so poop drops out of the child’s bottom, often without the child even noticing.



types of Constipation



1. Functional constipation: 95%​


• No organic cause is present but stay into adulthood despite adequate laxative treatment.

• Associated with lower urinary tract symptoms (LUTS) (30-50%)

• Faecal incontinence 2.9%

• Causes:

- Multifactorial e.g. food intolerance

- Withholding – painful experience

- Change in routine, toilet availability, illness, school changes and toilet access rules

- Genetic link

- Low socio-economic status

- Inadequate dietary intake

- Insufficient fluid intake

- Immobility


2. Organic constipation: 5%


• Hirschsprung disease

• Anorectal malformation

• Neuromuscular disease

• Metabolic endocrine disease

• Slow transit constipation- delay in transit time of gut caused by dysmotility of colon.

• Potentially due to:

- Reduced colonic pacemaker cells

- Dysfunctional enteric nervous system

- Reduced trunk control and posture



Treatment of Constipation



- Education

- Disimpact

- Maintenance therapy with laxatives at least 2 months of symptom free


- Physiotherapy:

• Toilet training

• Effective straining

• Increasing awareness of sensation as urge e.g. integrating sensory info, balloon training

• Pelvic floor muscle training i.e. awareness, relaxation during bowel movement or activation of pelvic floor muscle to prevent faecal incontinence

• Balance and core stability

• Posture

• Breathing exercise

• EMG: The use of animated computer game has expedited results, allowing excellent resolutions of dysfunctional voiding and co existing conditions, such as vesicourethral reflux and constipation with outpatient treatment

• Neuromodulation: electrode placed in the sacral foramen supplying low amplitude electrical stimulation

• Interferential stimulation of the pelvic floor muscle and abdominal wall

• Surgical treatment:

- Botox of internal anal sphincter as well as the external anal sphincter to relax the muscle fibres

- Anal myomectomy -removal of anal internal sphincter with anal sphincter stretch

- Bowel resection and colonoscopy



Antoinette Jansen van Vuuren



Suite 13, Netcare Pretoria East Hospital, Cnr Garsfontein Road & Netcare Ave, Pretoria East