Preface

**Section 3 Therapy and Outcome 105**

**VI** Contents

Gouveia Santos

Chapter 9 **Traumatic Cloaca 139**

John Camilleri-Brennan

Constantine P. Spanos

Talal Abdallah Al-Malki

**Malformation 161**

Chapter 11 **Long Term Outcome After Surgery for Anorectal**

Chapter 7 **Pelvic Floor Rehabilitation in Anal Incontinence 107**

Claudia Regina de Souza Santos, Tania das Graças de Souza Lima, Fernanda Mateus Queiroz Schmidt and Vera Lúcia Conceição de

Chapter 8 **Anal Injectables and Implantables for Faecal Incontinence 123**

Chapter 10 **Medical and Surgical Management of Fecal Incontinence after Repair of High Imperforate Anus Anomalies 153**

Anthony G. Catto-Smith, Misel Trajanovska and Russell Taylor

#### *"A good reliable set of bowels is worth more to a man than any quantity of brains" [Josh Billings]*

The normal functioning of the gastrointestinal tract is one of the most pivotal yet under-appreci‐ ated aspects of good health. Often it is only when something goes wrong that we begin to glimpse the importance of what goes into being well. This is only too true of normal bowel function. The effective and safe management of human waste has been a critical pillar for the development of much of what we have in society today. Once huge mortalities associated with cholera or infantile gastroenteritis are largely forgotten in most western societies. At an individ‐ ual level, the control of fecal continence is seen as a crucial developmental step in human matu‐ ration, with enormous ramifications for self-esteem if it is either not achieved or lost.

Although control of fecal continence superficially appears to be a relatively simple concept, it is surprisingly complex and can be extraordinarily difficult to manage. This book address‐ es the causes, evaluation, management and outcome for continence of a number of different conditions. The individual authors come with a rich variety of experiences.

The normal acquisition of bowel control in childhood is seen as a crucial developmental step and there is enormous pressure on families whose child is identified as being "slow". This is usually related to variations in physiological development, but can be secondary to anatomi‐ cal abnormalities such as after the repair of congenital anorectal malformations. It is very difficult to achieve normal physiological functioning with surgery.

A second very important cause of fecal incontinence is that of childbirth-induced traumatic injuries to the pelvic floor with subsequent long-term loss of bowel control. This continues to be an important health issue in the developing world and is covered in the book.

Before proceeding to any effective treatment, it is crucial to understand normal functioning and to be able to meaningfully evaluate the pathophysiology.

The range of different treatment options that are potentially available can be extremely con‐ fusing. They include physiological retraining techniques, injectables to supplement sphinc‐ ter function, and surgery. Defining the correct initial approach can be challenging, but it can be even more difficult to define the next line of management for treatment failures. Many practitioners simply cross their fingers, hoping that it will improve in time.

Good quality clinical research in this area is also surprisingly sparse. Whether it is in defin‐ ing normal maturation, the advantages or limitations of investigations, or critical evaluation of treatment options, this is clearly an important area to encourage. This book goes some way toward defining future directions for research.

#### **Anthony G. Catto-Smith**

Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital Professorial Fellow, Department of Paediatrics, University of Melbourne, Australia

**Section 1**

**Pathophysiology**

**Section 1**

**Pathophysiology**

**Chapter 1**

**Childhood Encopresis — Pathophysiology, Evaluation**

Encopresis is defined as persistent faecal incontinence without associated anatomic abnor‐ mality. It is a common, disabling condition of children often associated with functional defaecation disorders potentially open to nonsurgical treatments. It is considered to be primarily a disorder associated with chronic constipation, with stool retention in 96% of

The symptom of constipation is defined broadly as difficulty or delay in defaecation [2], often associated with large calibre stools and the presence of stool in the rectal ampulla. [3-5] Anecdotal evidence from parents often shows a transition from early simple constipation to

Constipation may not be easy to identify on history. Barr et al. noted that 45 percent of children when asked the most commonly used screening question for constipation relating to frequency of bowel motions gave an answer within the normal range. [5] These children were obviously constipated based on other criteria. Some children with encopresis have daily bowel motions but apparently incomplete evacuation as evidenced by periodic passage of very large amounts of stool. [7] Conversely, infrequent defaecation alone may not indicate constipation as this may simply represent the lower limit of normality. [8] In the literature the terms 'constipation' and

A period of continence is often defined as a period of at least one month without faecal incontinence. However, the frequency of soiling episodes does not necessarily correlate with severity of constipation. [9] Soiling in childhood encopresis is variable in quantity and frequency and may occur in the range of monthly to many times a day. It can occur at night but rarely exclusively so. [10] Children may have always soiled (primary) or may have

> © 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

children over the age of four years presenting with faecal incontinence. [1]

**and Treatment**

C. Coffey and A.G. Catto-Smith

http://dx.doi.org/10.5772/57071

**1. Introduction**

Additional information is available at the end of the chapter

chronic constipation, faecal retention and soiling. [6]

'faecal retention' are used interchangeably.
