APSP Online Webinar | Marc Levitt & team | Bowel Management Program for Fecal incontinence

For every 4-8 hours a patient spends in the operating room for colorectal surgery, they will need up to 96 hours of nursing care for bowel management in the immediate postoperative period.

Patients with anorectal malformations are categorized by three predictors of bowel control: type of ARM, quality of sacrum (sacral ratio), and quality of spine (conus termination and filum appearance).

A sacral ratio of 0.7 or greater indicates much better chance of bowel control than a ratio of 0.4 or under. Sacral ratio is calculated by dividing the distance from sacroiliac joint to tip of sacrum by the distance from iliac crest to sacroiliac joint, measured on lateral X-ray view.

Normal spine quality for continence prediction requires conus termination between L1 and L2 with normal filum appearance, as opposed to tethered cord with low-lying conus at L4-L5 and fatty filum.

For Hirschsprung patients, continence predictors include dentate line integrity (dissecting 0.5-1 cm above dentate line helps protect sensation), intact sphincters, and colonic motility assessed by colonic studies.

Functional constipation patients typically have normal anatomy (intact sphincters, dentate line, good anal canal) but continence is affected by colonic dilation severity, colonic motility, and behavioral withholding patterns.

The bowel management program is structured as an intensive one-week 'boot camp' that is difficult but produces significant results, with patients entering with heads down due to embarrassment and leaving confident because they are clean.

Essential components of bowel management program include: contrast enema evaluation, exam under anesthesia (preferred over office exam to avoid trauma), daily X-rays during the 6-day period, three in-person clinic visits, daily email communication from families, comprehensive education, and psychosocial support.

Families need education to understand why interventions are necessary; they should be partners in care rather than just following instructions, which leads to better outcomes.

For mechanical bowel management, enemas/flushes must be given at the same time every day so that adjustments to components can be made based on consistent colonic filling patterns.

For retrograde enemas, use a 24-French Foley catheter with balloon inflated to 30-90ml to create a tight seal in the rectum, allowing solution to stay in place for 5-10 minutes before evacuation.

Enema base solution is saline to prevent hyponatremia, but water may be used for children over approximately 10kg. Stimulant is added to base: glycerin first-line, then Castile soap or baby shampoo if glycerin causes cramping or is insufficient, then bisacodyl for refractory cases.

Enema titration is guided by daily X-rays at consistent times: if X-ray shows stool remaining or patient is soiling, increase flush strength; if colon is clean but patient soiling, decrease strength; if clean without accidents, maintain current dose.

To manage enema-related cramping: slow infusion rate, warm the solution, switch from glycerin to baby soap. For nausea/vomiting: avoid doing enema within 2 hours before or after eating. For gas: change stimulant from glycerin to Castile soap or bisacodyl.

For children under age 2-3 (before potty training age), laxatives are used primarily to prevent constipation; timing of bowel movements is not critical. As children approach potty training, temporary enemas help retrain the colon by giving a period without stool so they can learn what being clean feels like.

Before starting laxative therapy, obtain abdominal X-ray to ensure no large stool burden or fecal impaction, because laxatives prevent constipation but are not strong enough to treat existing severe constipation and may cause vomiting if given with impaction present.

Senna is the preferred stimulant laxative because it is a natural herbal medication derived from Senna plant leaves that irritates bowel lining to increase peristalsis. Starting dose is 2mg/kg with no fixed maximum; titrate based on patient tolerance and effect.

Miralax (polyethylene glycol) is not used as maintenance medication because it is an osmotic laxative that softens stool without stimulating bowel movement, and loose stools make it difficult for ARM patients to sense rectal/colonic tension needed to recognize need to defecate.

Literature supports no long-term complications or contraindications to prolonged Senna use. Senna burns to buttocks skin occur only in smaller/younger patients on high doses with prolonged stool-skin contact; prevented by appropriate dosing and frequent diaper changes.

Senna takes approximately 12 hours to take effect, so evening dosing typically results in morning bowel movement. During initial titration, have patients sit on toilet first thing in morning and after every meal/large snack to establish their pattern.

Bisacodyl is second-line stimulant laxative (also irritates bowel lining) but tends to provoke frequent smaller bowel movements rather than fewer consolidated movements that patients prefer. Available in pill form that can be crushed; side effects include cramping and nausea.

If patient on Senna does not stool for 24 hours, give Fleet enema from below before increasing Senna dose to avoid making patient sick by increasing medication while stool accumulates.

Water-soluble fiber is essential with Senna to bulk stools that become loose from accelerated colonic transit. Nutrisource is preferred because it is flavorless, unlike orange-flavored Metamucil/Citrucel. Start 2 grams twice daily, spread throughout day as dose increases for best efficacy.

Pectin and Nutrisource work best in hypermotile patients. Titrate fiber based on stool frequency and consistency; no maximum dose except Nutrisource capped at 6 scoops. Beyond 4-6 grams/day fiber, add other interventions rather than continuing to increase fiber.

Water-soluble fibers (Citrucel, Metamucil, pectin, Nutrisource) have different effects than water-insoluble fibers (Benefiber, Fiber One bars, dietary fiber), which have more laxative effect. Families are often unaware of this distinction.

A subset of ARM and Hirschsprung patients have hypermotility (colon moves too fast) causing incontinence from frequent stooling rather than constipation. These patients need to be slowed down with constipating diet, water-soluble fiber, loperamide, hyoscyamine, and possibly small-volume nightly enemas.

For hypermotile patients, small-volume nightly enemas (approximately half the volume used in large-volume enemas) can keep them clean overnight and help consolidate to 1-2 bowel movements daily, avoiding need for additional medications with side effects.

Laxative foods that accelerate colonic transit include high-sugar foods, berries, and high-fat/greasy/fried foods. Constipating foods include bananas, rice, pasta, and bread. Families often don't realize dietary changes cause bowel management program failures.

A paper from Mexico City comparing Miralax and Senna for ARM patients found Senna much more effective. Miralax makes stool soft without helping it come out, losing the rectal stretch that is probably the most important factor for ARM patients to feel stool and have control.

Senna pushes out stool (which would normally make it very liquid), so water-soluble fiber is given to provide bulk, resulting in a single well-formed section of stool that the patient can feel much better than soft stool from Miralax.

In Duhamel pull-through patients, the colon is usually hypomotile. Contrast studies should be evaluated for Duhamel pouch size, presence of spur, and any areas of persistent narrowing that might indicate stricture.

For hypermotile patients not controlled with loperamide and hyoscyamine, consider twice-daily low-volume enemas to keep them clean and consolidate bowel movements to a manageable frequency.

For refractory functional constipation cases, workup should include anorectal manometry to assess for recto-anal inhibitory reflex (RAIR). If RAIR is absent (no internal sphincter relaxation), biopsy for Hirschsprung and treat with Botox for possible internal sphincter achalasia.

Functional constipation patients who cannot successfully empty on laxatives or find them difficult to take are good candidates for either rectal enemas (if tolerated) or antegrade enemas with Malone flush, with most responding very well to antegrade flush.

When titrating Senna, increase by one unit/tablet (or 5ml) when going up, decrease by half a unit when going down. Cramping is normal if it resolves with bowel movement; cramping between bowel movements indicates dose is too high.

Patients with severe colonic dilation from chronic constipation may benefit from temporary enemas (rectal or antegrade) to allow colonic distension to decrease, after which they may respond better to laxatives at lower doses.