*4.4.1.6 Treatment of chronic constipation/fecal incontinence*

It is important to recognize the defecation disorder, because it has been proven that the treatment of constipation alone significantly reduces the symptoms of the lower urinary tract. In the group of children with increased post-void residual urine and constipation, 66% had an improvement in bladder emptying after constipation treatment. Urinary incontinence, nocturnal enuresis, and recurrent urinary tract infections were cured in most children treated only for constipation [20]. Therefore, treatment begins with chronic constipation management.

In the treatment of chronic constipation, four steps are applied: education, disimpaction of fecal mass, prevention of its re-accumulation and follow-up [27]. Treatment is usually applied for 3-6 months, but the relapses are frequent [28]. The cure rate of chronic functional constipation after application of standard treatment that includes laxatives and behavioral approaches is only 50-60% [29].

More than half of children with chronic constipation have an abnormal defecation pattern because they contract the external anal sphincter and the *M. puborectalis* during defecation [30]. This form of abnormal defecation is considered to be learned resulting from the habit of delaying defecations. Physiotherapy

**Figure 3.** *Correct position when urinating.*

interventions such are diaphragmatic breathing exercises and pelvic floor exercises with or without biofeedback were introduced in order to educate a child to relax the external anal sphincter and the PFMs during defecation [31–35]. In refractory cases, even botulinum toxin injections are administrated into the external anal sphincter [36].

Interferential current stimulation (IFS) has been used in the treatment of chronic constipation resistant to standard therapy in children. Significant improvements in clinical symptoms (increased frequency of defecation, reduction of fecal incontinence and abdominal pain) were seen in 67% of children and lasted for more than two years in one third of the treated patients [37]. In addition, the time of colonic transit on colonic scintigraphy was shorter after the application of IFS [38]. Although the mechanism of action of IFS is still insufficiently known, the proposed theories are the activation of local sensory nerves in the skin, spinal nerves (sensory and motor T9-L2), sympathetic and parasympathetic nerves in the intestine, enteric nerves, pacemaker cells (Cajal's interstitial cells) or smooth muscle cells in the intestinal wall [39].
