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Tags >> Pediatric Incontinence
Mar 07, 2014


In 2011, H&W was thrilled to add a new course to our list of offerings. Pediatric Incontinence and Pelvic Floor Dysfunction was a much-needed addition to our pelvic floor courses. Despite the growing number of pelvic rehab specialists treating men and women with PF dysfunction, children in this patient population remain woefully under-served, which can cause undo stress for the child and family, as well as the development of internalizing and externalizing psychological behaviors. Dawn Sandalcidi, the author of this course, and Robin Lund, her co-instructor, sat down with Pelvic Rehab Report to talk more about this course and their work with children.


PRR: Dawn, you developed this course many years ago. What initially inspired you to write this course?

May 06, 2013

While the co-existence of fecal incontinence (FI) and constipation is well-recognized in the pediatric and geriatric population, the authors of this article suggest that the relationship is under-appreciated in the adult population. Samuel Nurko, MD, and Mark Scott, PhD, describe the association between pediatric functional fecal incontinence and constipation, stool retention, and incomplete evacuation. In adults, they point out, constipation may also be related to pelvic floor dysfunction and denervation. The negative impact on quality of life creates the need for these issues to be addressed more readily, both in adults and in children. 


The study mentioned above cites a prevalence of fecal incontinence in school-aged children of 1-4%. The majority of the research cited in the article report that this incontinence is related to underlying constipation. Factors that may contribute to childhood holding of stool or to rectal dysfunction include constipation early in childhood, painful bowel function, "coercive toilet training practices and social stressors", fecal impaction, and treatments involving anal manipulation. It has been surprising to me how many adult patients describe psychologically stressful childhood associations with bowel function. Fortunately, the psychological stress, low self-esteem, and decreased quality of life that is associated with childhood bowel dysfunction improves with successful treatment of the condition. Childhood behavioral issues including bullying, disruptive behavior, and social withdrawal also are noted to improve following improvement in fecal issues, suggesting that the terrible social impact of fecal incontinence may be to blame for some of the behavioral issues. 


In relation to the adult population, the authors state that while the coexistence of constipation and FI may not be known, constipation has been shown to be an independent risk factor for FI and incomplete emptying is associated with fecal incontinence.  In the patient who has poor emptying of the bowels, overflow can occur, and this type of leakage is then associated with constipation. It follows, then, that treatment of the constipation should improve the fecal leakage.  Three mechanisms are described regarding the pathophysiology of incontinence caused by constipation: overflow due to fecal impaction; post-defecation leakage caused by rectal stool retention from a rectal evacuatory disorder; and general pelvic floor weakness or denervation. Certainly, neurological or other disease conditions can cause bowel dysfunction, yet this article focuses on "functional" constipation not caused by such diseases. 

Jun 05, 2012

Pelvic floor muscle training has been found to be an effective approach for treating fecal incontinence in children following surgical correction for Hirschprung disease. This disease can cause severe constipation or intestinal blockage due to a lack of nerve cells in the large intestine that are responsible for creating contractions in the smooth muscles of the bowels. Most of the time, Hirschprung disease is identified and corrected in infancy, but it can also be treated in childhood and sometimes in the adult patient. There are several different types of "pull-through' surgical procedures that can be used to remove the diseased portion of the large intestine and attach a functioning portion of bowel to the anus. This type of procedure can injure tissues including the internal anal sphincter, creating the issue of fecal leakage or incontinence. 


A case series appears in the European Journal of Pediatric Surgery that reports on 24 cases of children who became incontinent following a Soave pull-through procedure for Hirschprung disease. 16 of the children were treated with 2 weeks of biofeedback training in the hospital followed by home program for pelvic muscle exercises, while 8 children served as a control group, receiving no therapy following the surgery. At baseline and at one year follow-up, measures were taken via anorectal manometry for resting anal canal pressure, squeeze pressure, and for rectal sensation. At one year post-surgery, the children in the treatment group were found to have significantly increased resting rectal pressure as well as squeeze pressure. Rates of fecal incontinence were significantly reduced with only 3 of the 16 children reporting occasional soiling after completing the pelvic muscle training.


This research is encouraging as biofeedback therapy is a non-invasive, inexpensive option for patients who have already been through a surgical procedure to correct a biological dysfunction. The International Foundation for Functional Gastrointestinal Disorders (www.iffgd.org) has a wonderful website with more information for rehabilitation providers and for patients, and they also have a website designed for kids and teens who have functional gastrointestinal issues. That website can be accessed at www.aboutkidsGI.org

Nov 23, 2011

Research about animated biofeedback and its effects on children who have elimination disorders appears in the December issue of the Journal of Urology. A report by Rueters can be accessed here, the PubMed abstract can be accessed here


Dr. Kajbafzadeh of the Tehran University of Medical Sciences in Iran led a study that involved a total of 80 children randomly assigned with 40 subjects in either Group A or Group B. The average age group was 8-9 years with more than 75% of the children being female. Group A received 6-12 sessions of animated biofeedback in addition to behavioral modification while Group B received behavioral modification only. The animated biofeedback used a computer program with images of dolphins or monkeys to get children to activate and relax the pelvic floor muscles. This type of training could then help the children understand how to relax the muscles with emptying the bowels or bladder, and to have active, more healthy muscles in general. Behavioral modification included education in hydration, high fiber diet, and scheduled voiding. At baseline, and at 6 and 12 months, data was collected regarding dysfunctional voiding scores, constipation and fecal soiling episodes/week, and uroflowmetry.


The results were very positive, with vesicoureteral reflux resolving in 7 of 9 children. (Vesicoureteral reflux occurs when urine moves from the bladder towards the upper urinary tract instead of flowing out of the urethra. This can create urinary tract infections (UTI), kidney scarring, and in severe cases, kidney failure.) 10 of 14 children did not have a return of UTI within 1 year from the start of the study. Bladder capacity and voided volume did not significantly change. The authors report that PVR (post-void residual, or how much urine is left in the bladder after voiding) improved as did urine flow. Within 12 months after treatment, children who reported fecal soiling at baseline were symptom-free, and 17 of 25 who had constipation were symptom-free. The control group also had improvements in symptoms but these were not as significant as in the group receiving animated biofeedback therapy. 

Jul 25, 2011

I recently had the opportunity to sit down for a chat with Dawn Sandalcidi, PT, faculty member and national leading expert in pediatric continence. In truth, she was indulging me with her vast experience and giving me tips and encouragement towards treating children who have incontinence. I, perhaps like many of you reading this, have taken Dawn's pediatric incontinence course, yet I have not yet launched a pediatric incontinence program. Until now. After I took her course a few years ago, I vowed that I would begin treating children with bowel and bladder issues. After all, how many times have you heard the response "ever since I can remember?" when you ask your adult patients how long they have dealt with their current pelvic dysfunctions?


I (kindly and respectfully) challenge us as pelvic rehabilitation specialists to dive further into the realm of helping children who no doubt have no one else to turn to for meaningful advice. If you already treat children, good on you! It has been my experience that it is very difficult to find a provider who can treat children as well as adults. Often I believe that we get so busy with our clinic caseloads that it feels overwhelming to begin another program. Like many other challenges, if you take the first step, the rest you can figure out with some helpful resources. 


If you have a biofeedback program, then you have all the special equipment you need. To begin a pediatric program, you might also like to acquire the Pediatric Pelvic Floor Manual  as it has age-appropriate educational tools.  Another great resource that Dawn recommends is the International Children's Continence Society website.  It has an immense amount of evidenced-based work as well as patient-friendly literature. Click here to find out when the next pediatric course will be taught by Dawn Sandalcidi, or contact the Institute if you would like to host a course. 

Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Durham, NC (SOLD OUT)
Apr 25, 2014 - Apr 27, 2014
Location: Duke University Medical Center

Myofascial Release for Pelvic Dysfunction - Portland, OR
Apr 25, 2014 - Apr 27, 2014
Location: Legacy Meridian Park Medical Center

Finding the Driver in Pelvic Pain - Milwaukee, WI
May 01, 2014 - May 03, 2014
Location: Marquette University

Visceral Mobilization of the Urologic System - Winfield, IL
May 02, 2014 - May 04, 2014
Location: Central DuPage Hospital Conference Room

Rehabilitative Ultrasound Imaging: Women's Health and Orthopedic Topics - Seattle, WA
May 03, 2014 - May 05, 2014
Location: Swedish Hospital - Issaquah campus

Rehabilitative Ultrasound Imaging Orthopedic Topics - Seattle, WA
May 03, 2014 - May 04, 2014
Location: Swedish Hospital - Issaquah campus

Pelvic Floor Level 1 - Scottsdale, AZ (SOLD OUT)
May 16, 2014 - May 18, 2014
Location: Womens Center for Wellness and Rehabilitation

Pelvic Floor Level 2A - Maywood, IL (SOLD OUT!)
May 16, 2014 - May 18, 2014
Location: Loyola University Stritch School of Medicine

Pelvic Floor Level 3 - San Diego, CA
May 30, 2014 - Jun 01, 2014
Location: FunctionSmart Physical Therapy

Pelvic Floor Level 1 - Arlington, VA (SOLD OUT)
Jun 06, 2014 - Jun 08, 2014
Location: Virginia Hospital Center

Care of the Postpartum Patient - Houston, TX
Jun 07, 2014 - Jun 08, 2014
Location: Texas Children’s Hospital

Bowel Pathology and Function - Minneapolis, MN
Jun 07, 2014 - Jun 08, 2014
Location: Park Nicollet Clinic--St. Louis Park

Oncology and the Female Pelvic Floor - Orlando, FL
Jun 21, 2014 - Jun 22, 2014
Location: Florida Hospital Sports Medicine and Rehabilitation

Myofascial Release for Pelvic Dysfunction - Dayton, OH
Jun 22, 2014 - Jun 23, 2014
Location: Southview Hospital

Pelvic Floor Level 2A - Derby, CT
Jun 27, 2014 - Jun 29, 2014
Location: Griffin Hospital