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Daily enema regimen is superior to traditional therapies for non-neurogenic pediatric incontinence
Steve J. Hodges, MD1, Marc A. Levitt, MD2.
1Wake Forest University School of Medicine, Winston Salem, NC, USA, 2Nationwide Childrens Hospital, Columbus, OH, USA.

Dr. Sean O’Regan linked uninhibited bladder contractions and pelvic floor dysfunction to acquired megarectum in children (Yazbeck S, Schick E, O'Regan S. Relevance of constipation to enuresis, urinary tract infection and reflux. A review. Eur Urol. 1987;13(5):318-21.) It has been proven that megarectum often goes undiagnosed and undertreated in pediatric incontinence patients (Hodges SJ, Anthony EY Occult megarectum--a commonly unrecognized cause of enuresis. Urology. 2012 Feb;79(2):421-4. doi: 10.1016/j.urology.2011.10.015. Epub 2011 Dec 14). We hypothesized that a daily enema regimen directed to the resolution of chronic rectal dilation would be an effective therapy for pediatric incontinence.
Materials and methods:
We prospectively evaluated 60 children with non-neurogenic daytime incontinence with History and Physical, urinalysis, Bristol Stool Scale, Rome III criteria, KUB x-ray, and pediatric voiding dysfunction questionnaire. Forty children were treated with traditional therapies including timed voiding, PEG3350 regardless of bowel history to maintain daily, soft bowel movements, and in select cases anticholinergic medications and/or biofeedback therapy. Twenty children were prescribed only a daily enema (Pedialax liquid glycerin suppository for ages 2-5, Pedialax fleet enema for ages 6-11), with no other therapy or voiding schedule. All children were followed up at 3 months.
The average age of patients was 5 years old. As a whole, of the 60 patients evaluated only 5 patients (8.3%) had a reported history of constipation (per parental report, Bristol stool scale score of 1-2 or Rome III score of 2 or greater), yet all patients met the diagnostic criteria for constipation of a maximal rectal diameter of 3cm or greater regardless of timing of last defecation (Singh SJ, Gibbons NJ, Vincent MV, Sithole J, Nwokoma NJ, Alagarswami KV. Use of pelvic ultrasound in the diagnosis of megarectum in children with constipation. J Pediatr Surg. 2005 Dec;40(12):1941-4.). The average pediatric voiding dysfunction score of all patients was 14, while upon follow up the average score for traditionally treated patients was 12 while for enema treated patients was 4. Only 30% of the traditionally treated patients’ parents reported resolution of symptoms at 3 months’ time while 85% of enema patients did.
In this limited study daily enema therapy is superior to traditional methods for the treatment of pediatric incontinence. These results raise questions regarding the current teachings on the origins of dysfunctional elimination in children and challenge us to re-evaluate theories first postulated by Dr. O’Regan almost 30 years ago.

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