It is the purpose of this communication to present the symptoms and the findings associated with chronic fecal impaction in children, and to outline a method of treatment. This distressing condition is not rare, and it may easily go unrecognized. It causes disturbing psychologic problems for both the child and the parents — problems that can quickly abate when the cause is known and the treatment started.
The series here reported upon included 17 patients, nine females and eight males varying in age from three months to ten years. The average age was 7.25 years. Nine of the patients were between seven and ten years of age. The duration of the symptoms varied from two months to five years, with an average of 19 months. Clinical data is summarized in Table 1.
|TABLE 1. — Clinical Data on 17 Cases of Fecal Impaction in Children|
|Case||Age||Sex||Duration||Degree of Pain*||Degree of Soiling*||Degree of Bleeding*||Anal Injuries*||Degree of Patulous Sphincter*|
|1||7 years||M||3 months||0||3||0||0||1|
|2||8 years||M||5 years||0||4||0||0||3|
|3||9 years||F||3 years||3||0||%||2||0|
|4||8 months||F||6 months||4||0||2||3||0|
|5||5 years||F||18 months||1||1||1||1||1|
|7||10 years||F||30 months||2||0||1||1||0|
|9||7 years||M||2 years||3||0||2||2||0|
|10||23 months||F||5 months||1||0||2||2||0|
|11||8 years||M||2 years||0||4||0||0||3|
|12||5 years||M||10 months||1||0||1||1||0|
|13||6 ½ years||F||1 year||0||3||0||0||3|
|14||4 years||F||11 months||0||4||0||0||4|
|15||8 years||M||2 years||3||0||2||2||0|
|16||5 years||F||14 months||1||0||1||1||0|
|17||7 ½ years||M||27 months||0||4||0||0||3|
|* Symptoms are graded from 0 to 4 to indicate degree of severity.|
The chief complaint in all cases was severe constipation. Large stools were passed at intervals of from three to twelve days. The stools, often large enough to obstruct the plumbing, usually caused pain and slight bleeding because of minor injuries to the anal canal. Soiling of the underclothes was a common secondary complaint. Soiling often caused a characteristic walk with the knees brought together and the back slightly bent in an apparent attempt to separate the skin from the soiled undergarments.
Anxiety on the part of the child and parents was expressed in all cases. The children were afraid to attempt a bowel movement; those of school age were reluctant to try passing an impaction in the morning since the slow painful process might make them late for school. At school they were unwilling to have a movement for fear of obstructing the plumbing or taking too much time. For the same reasons they were unwilling to defecate anywhere but at home, and they refused invitations to their friends’ and relatives’ homes.
Nine of the children expressed the fear that there was something very unusual about their inner anatomic structure, and exhibited both embarrassment and feelings of inferiority. The seven who soiled their underpants had the most serious psychological symptoms. They seemed withdrawn, embarrassed by their walk, fearful of offending by their odors. They often refused to play with other children.
The parents in all cases were concerned about the problems of the child and about the obvious helplessness of the child to cope with them. They feared some unusual anomaly, malformation or disease, and they disliked the soiling because of the odors, the isolation of the child and the extra laundering required.
The initial impaction was apparently the result of a number of factors: Ignoring the urge to defecate, taking drugs such as codeine during infection of the upper respiratory tract, and minor injuries to the anal canal caused by a hard stool and resulting in painful defecation. Once the impaction formed, an attempt to pass it caused much discomfort and anxiety and initiated an obvious vicious cycle. The soiling was apparently the result of the inability of the sphincter to retain small amounts of liquid fecal material that seeped down over the impaction. This, plus the impaction itself, seemed to exhaust the sphincter and to cause a loss of tone.
The children were healthy and, although usually shy, anxious for help. In most cases the impaction could be palpated abdominally and there was a mild degree of abdominal distention. No abnormalities were noted upon external inspection of the anus except that in cases in which soiling was a factor the perianal skin was contaminated with feces. Before digital examination was attempted, an applicator dipped in a topical anesthetic ointment was inserted into the anal canal and left there for five minutes.
Large impacted stools felt on digital examination were not necessarily hard. In some cases they were soft and gummy although more often firm and formed. In the cases in which soiling occurred there was a varying degree of patulous anus. Patients with minor injuries of the anal canal had some degree of sphincter spasm. An anoscope of the size used for adults was passed in all cases. In five patients small cracks were observed in the anoderm at the level of the mucocutaneous line and just below it. In no case was there a true fissure-in-ano or cryptitis. The lesions were superficial and obviously of traumatic origin.
Proctoscopic examination was not attempted until after treatment was started and the rectum was reasonably empty. There were no cases of clinically recognizable megacolon and there were no polyps, ulceration or other disease. It was interesting that patients who had frequent soiling had patulous anus but no pain, bleeding or ulceration and that patients who were not soiling had an increase in sphincter tone and frequent pain, bleeding and ulceration.
Ten of the patients had been observed previously by physicians and had been given a number of laxatives with no significant relief. Enemas of soapsuds or of saline, peroxide or sodium phosphate solutions gave occasional temporary relief but were more often ineffective. In four instances, impacted feces had been removed with the patient under general anesthesia. Four patients were being given psychiatric treatment because of the soiling.
Management of this condition involved topical, dietary, systemic and psychological aspects. The traumatized areas in the anal canal were cauterized with 3 per cent silver nitrate solution. Where these lesions were numerous or deep, insertion of a 5 per cent ichthyol ointment twice daily for a week was recommended. A regular diet with some emphasis on leafy vegetables and fruit was outlined. Adequate intake of fluids, including a good sized glass of cold fruit juice for breakfast and four to six glasses of liquid during the day, was emphasized. Skimmed milk was substituted for whole milk. Rich candies and dessert were omitted.
Fifteen to 30 drops of dioctyl sodium sulfosuccinate (a wetting agent which so affects the surface of the stool as to permit the penetration of water or oil) was prescribed to be taken morning or evening in milk or fruit juice. A flavored petrolatum given along with the dioctyl sodium sulfosuccinate in an average dose of one tablespoonful morning and night, in the early weeks of treatment seemed to bring about better results than dioctyl sodium sulfosuccinate alone. The dosages were adjusted downward as time passed. Encouragement was given both to the parents and the child.
Wherever possible the child was seen alone in the consultation room and was encouraged to make reports to the physician over the telephone. The family was told that results would come during the next 30 days and not to be discouraged if nothing remarkable occurred during the first week or two. Development of habits of defecation was stressed. The time suggested as preferable was before school in the morning, but if necessary any time at which the child could go to the toilet regularly each day at the same time was acceptable. Sphincter exercises were suggested for patients who had soiling, but only after some regularity of defecation had been brought about.
In all cases the chronic fecal impaction ceased and the children developed regular bowel habits. Absence of pain was noted in all cases after one week. For the first two weeks, there would be one or two large stools per week, and the frequency increased after that; by the end of four weeks the average frequency was five times weekly, and by six weeks all children were having a bowel movement daily. Discontinuation of the medicine was begun after 30 days of daily regular bowel movement. At first both the oil and dioctyl sodium sulfosuccinate were reduced in dosage and then the oil was eliminated.
The drops were continued until 60 days of regular bowel movements had elapsed. An occasional setback during this period (following an emotional upset or minor illness) was dealt with by temporarily raising the dosages. In five cases there was a minor recurrence of constipation after cessation of all treatment. In those cases a return to medication for a few days sufficed. These patients or their parents reported by telephone twice weekly. Considerable adjustment in dosage was indicated. A remarkable change in the psychological attitudes of these children and their parents occurred. The children returned to normal relationships with their chums. Bowel movements were no longer a topic of conversation in the home. This was especially gratifying in the cases in which soiling had occurred.
Dioctyl sodium sulfosuccinate is also known as Aerosol — O. T. Benaglia, Robinson, Utley and Cleverdon studied the toxicity of the drug in rats. Fifty rats given oral doses of 0.87 grams per kilogram of body weight developed no significant growths or microscopic pathologic changes in a period of six months. The erythrocyte and leukocyte content and the leukocyte differential were unaffected. Wilson and Dickinson reported the use of this agent for 12 years in many hundreds of cases without development of evidence of toxicity of any sort. The preparation is distributed commercially in capsule and liquid form or may be prescribed in the 1 per cent aqueous solution, each milliliter containing 10 milligrams.
An attempt is being made to obtain barium enema roentgen examination in all the cases here reported upon. Although none of the patients have had any symptoms of congenital megacolon, they will all be carefully observed and in the younger patients, especially if there is repeated recurrence of symptoms, biopsy for ganglia will be done. Clinically, however, no cases in this group seemed to raise a question of Hirschsprung’s disease.