Chronic Constipation

Constipation is a common childhood problem. Chronic constipation is an extreme form of constipation and more difficult to treat. A slow moving or hypomotile colon often contribute to this problem. Chronic constipation can be very stressful for parents and children.

Normal bowel movements should be soft and easy to pass. Children who are constipated often have hard, dry and sometimes painful bowel movements. They may also go several days without a bowel movement. Some children with severe constipation soil their underwear. This soiling is involuntary and caused by liquid stool leaking around hard pieces of stool. This condition is called encopresis or pseudo incontinence.

Causes of Constipation:

• Functional: diet (lack of fiber, dehydration, malnutrition), decreased motility of the colon, stool withholding (behavioral), uncoordinated contraction and relaxation of the pelvic and sphincter muscles (dyssynergia), immobility
• Structural Abnormalities: imperforate anus, anal stenosis, Hirschsprung disease
• Endocrine, Metabolic, Immunologic Conditions: Celiac disease, cystic fibrosis, hypercalcemia, hyperparathyroidism, hypokalemia, hypothyroidism
• Neurogenic Conditions: Cerebral palsy, hypotonia, spinal cord anomalies (spina bifida, spinal tumors, tethered cord)
• Medications: opiates, antacids, anticholinergics, tricyclic antidepressants, bismuth, phenobarbital, sympathomimetics (examples: methylphenidate or Ritalin®, ephedrine, pseudoephedrine)

Symptoms of constipation include:

Infants to 4 years old:

• Producing fewer than 2 bowel movements per week
• Excessive stool retention
• Stool-retentive posturing
• Painful or hard bowel movements
• Large fecal mass in rectum
• Fecal incontinence

4 years of age to adolescent:

• Two or fewer bowel movements per week
• Fecal incontinence
• Stool-retentive posturing or excessive stool holding
• Painful or hard bowel movements
• Large-diameter stools that could obstruct the toilet
• Large fecal mass in rectum or toilet

Chronic constipation occurs when these symptoms continue for weeks or months. Children with chronic constipation complain of pain while having a bowel movement and feeling like they can’t completely evacuate their bowels.

Constipation may be mild at first, but as a child goes 1-3 days without a bowel movement, the stool becomes hard and difficult to pass. As stool continues to accumulate, the rectum becomes dilated or stretched out. A dilated rectum loses its sensitivity, causing the child to be unable to tell when he needs to have a bowel movement. Liquid stool leaks around the hard stool, which is difficult to control, and leads to soiling or accidents. Chronic constipation is difficult to cure but can be managed through prolonged treatment.

In order to get the right treatment for chronic constipation, the gastroenterology (GI) specialists will first determine the cause of constipation. The GI specialists may complete motility testing to determine how the child’s digestive system is functioning and evaluate the child’s toileting behaviors. If there are no underlying medical or anatomical causes of constipation (functional constipation) the GI team may refer the child to our bowel management program.

The management of constipation requires an understanding of the cause. The goal of treatment is to empty the rectum daily with the use of laxatives and/or diet. The first step is to remove any fecal impaction, then laxatives can be started. The goal of laxative treatment is for the child to have a daily bowel movement.

Primary Children’s Colorectal Center provides a Bowel Management Program to treat children with chronic constipation. We specialize in treatment of children with structural and neurological abnormalities and work closely with pediatric gastroenterologists in the management of children with severe, chronic constipation.

Some children with chronic constipation may benefit from anorectal manometry testing and pelvic floor physical therapy.