Abstract
Constipation in childhood is a common symptom, with an estimated incidence between 0.3% and 8%. Most of the evidence for the current management of constipation and fecal soiling in children is based on reports of nonrandomized retrospective trials. Anal dilatation has had an established role in the management of idiopathic constipation but has never been evaluated by a randomized study. A double-blind randomized controlled trial was done of children who failed to respond to medical treatment and were admitted for investigation and treatment of idiopathic constipation to Guy’s Hospital, London, between April 2001 and April 2003. All children had intestinal transit study on admission. They were randomized, using a computer-generated allocation in sealed envelopes, to receive no anal dilatation (control group) or anal dilatation (anal dilatation group). Anorectal manometry and endosonography were done under ketamine anesthesia followed by anal dilatation if necessary under the same anesthesia. Disimpaction of feces from the rectum was done at the end of the procedure under general anesthesia using propofol muscle relaxant to minimize stretching of anal sphincter muscles in the control group. All children had intensification of medical treatment, toilet training, and monitoring of their response to treatment during their hospital stay, which ranged from 3 to 5 days. Outcome was measured using a parent’s questionnaire of symptom severity at 3 and 12 months of follow-up by one of the authors, who was blinded to randomization. The symptom severity score ranged between 0 and 65 and consisted of scores for the following: delay in defecation (score range 0–10), difficulty and pain with passing stool (0–5), soiling problem (0–10), intensity of laxative treatment (0–10), child’s general health (0–5), behavior related to the bowel problem (0–5), overall improvement of symptoms (0–12,) and assessment of megarectum on abdominal examination (0–8). Of 60 neurologically normal children, 31 (19 males) were randomized in the control group and 29 (18 males) in the anal dilatation group. All children had findings consistent with idiopathic constipation and positive anorectal reflex on manometry, no anal sphincter damage on endosonography, and no anal fissure on examination under anesthesia. The median age for control and anal dilatation groups was 7.97 (range 4.1–14.25) years and 7.78 (4–13.25) years, respectively. Both groups were also comparable with regard to median of duration of laxative treatment (32 months vs. 31.5 months), internal anal sphincter thickness on endosonography (0.90 mm vs. 0.80 mm), resting anal sphincter pressure on manometry (51 mmHg vs. 51 mmHg), total rectal capacity on manometry (260 mmHg vs. 260 mmHg), and total symptom severity score before admission (33 vs. 29), respectively. At 12-month follow-up, the median pre-admission symptom severity score had improved significantly, from 33 (range 12–49) in the control group and 29 (16–51) in the dilatation group to 15 (0–51, p<0.0001) and 19 (1–46, p<0.0001), respectively. There was no significant difference between the two groups with regard to symptom severity score improvement at 12-month follow-up (p<0.92). We found a significant correlation between total rectal capacity measured on manometry and symptom severity score before admission and at 12-month follow-up (r=0.30, p<0.01 and r=0.25, p<0.05, respectively). Our results indicate that anal dilatation does not contribute to the management of school-aged children with idiopathic constipation. Admission to hospital for clarification of diagnosis and intensification of medical treatment with disimpaction of stool from the rectum is beneficial.
Similar content being viewed by others
References
Agnarsson U, Clayden GS (1990) Constipation in childhood. Matern Child Health 15:252–256
Benninga MA, Wijers OB, van der Hoeven CW, Taminiau JA, et al. (1994) Manometry profilometry, and endosonography: normal physiology and anatomy of the anal canal in healthy children. J Pediatr Gastroenterol Nutr 18:68–77
Clayden GS, Lawson JON (1976) Investigation and management of long-standing chronic constipation in childhood. Arch Dis Child 51:918–923
Clayden GS (1977) Anal dilatation and chronic constipation in childhood. Maternal Child Health 2:38–40
Clayden G, Keshtgar AS (2003) Management of childhood constipation. Postgrad Med J 79:616–621
Freeman NV (1984) Intractable constipation in children treated by forceful anal stretch or anorectal myectomy: preliminary communication. J Royal Soci Med 77:6–8
Gui D, Cassetta E, Anastasio G, Bentivoglio AR, Maria G, Albanese A (1994) Botulinum toxin for chronic anal fissure. Lancet 344:1127–1128
Keshtgar AS, Ward HC, Clayden GS, Sanei A (2004) Thickening of the internal anal sphincter in idiopathic constipation in children. Pediatr Surg Int 20:817–823
Levine MD (1975) Children with encopresis: a descriptive analysis. Pediatrics 56:412–416
Loening-Bauke VA (1984) Abnormal rectoanal function in children recovered from chronic constipation and encopresis. Gastroenterology 87:1299–1304
Loening-Bauke V (1993) Constipation in early childhood: patient characteristics, treatment, and longterm follow up. Gut 34:1400–1404
Loening-Baucke V, Yamada T (1995) Is the afferent pathway from the rectum impaired in children with chronic constipation and encopresis? Gastroenterology 109:397–403
Lord PH (1969) A day case procedure for the cure of third degree haemorrhoids. Br J Surg 56:747–749
MacDonald A, Smith A, McNeill AD, Finlay IG (1992) Manual dilatation of the anus. Br J Surg 79:1381–1382
MacIntyre IMC, Balfour TW (1972) Results of the Lord non-operative treatment for haemorrhoids. Lancet 1:1094–1095
Nielsen MB, Rasmussen OO, Pedersen JF, Christiansen J (1993) Risk of sphincter damage and anal incontinence after anal dilatation for fissure-in-ano. An endosonographic study. Dis Colon Rectum 36:677–680
Papadopoulou A, Clayden GS, Booth IW (1994) The clinical value of solid marker transit studies in childhood constipation and soiling. Eur J Pediatr 153:560–564
Plas van der RN, Benninga MA, Buller HA, Bossuyt PM, Akkermans LMA, Redekop WK, Taminiau JA (1996) Biofeedback training in treatment of childhood constipation: a randomized controlled study. Lancet 348:776–780
Snooks S, Henry MM, Swash M (1984) Fecal incontinence after anal dilatation. Br J Surg 71:617–618
Speakman CTM, Burnett SJD, Kamm MA, Bartram CI (1991) Sphincter injury after anal dilatation demonstrated by anal endosonography. Br J Surg 78:1429–1430
Yoshioka K, Keighley MR (1987) Randomized trial comparing anorectal myectomy and controlled anal dilatation for outlet obstruction. Br J Surg 74:1125–1129
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Keshtgar, A.S., Ward, H.C., Clayden, G.S. et al. Role of anal dilatation in treatment of idiopathic constipation in children: long-term follow-up of a double-blind randomized controlled study. Ped Surgery Int 21, 100–105 (2005). https://doi.org/10.1007/s00383-004-1336-y
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00383-004-1336-y