title: Multidisciplinary behavioural treatment of fecal incontinence and constipation after correction of anorectal malformation.
abstract: BACKGROUND
  Fecal incontinence and constipation are major problems after correction of anorectal malformation (ARM), caused not only by the somatic defects but also by a psychosomatic dysfunction of defecation. To better release patients from this dysfunction we offered a multidisciplinary, psycho- and physiotherapeutic therapy according to an approach developed in Nijmegen (Netherlands). We herein summarize the preliminary results to evaluate whether the approach can be adopted with similar success.
  
  
  METHODS
  Since January 2002 multidisciplinary behavioural treatment (MBT) has been offered to children above 3 years of age and suffering from fecal incontinence and constipation after surgical correction of ARM in our department or elsewhere. Prerequisites included no anal stenosis, regulation of stool consistency, and a suitable defecation diary over 2 weeks. MBT contained regular consultations by a pediatric psychologist and a physiotherapist, teaching the child to establish a regular defecation pattern and how to push while relaxing the pelvic floor. The entry- and post-treatment situation was prospectively monitored by means of defecation and constipation scoring systems.
  
  
  RESULTS
  Complete data were available in 10 patients (9 males, 1 female) with high (8 patients) and low (2) forms of anal atresia initially, who finished MBT 2-36 months ago (mean: 13 months). The average amount of stool reaching the toilet was 27% before and 90% after therapy. Clean days were absent before, reaching 3.7 days on average after therapy. Constipation was present in 6 patients before (3 of them on enemas) and in 2 after therapy (no enemas needed). The duration of MBT was 7 months on average, range 3-23 months, with 8-9 sessions per patient, each lasting 60-90 minutes. An observation period of 7 months after treatment confirmed stable results. MBT turned out to improve body-consciousness and self-confidence.
  
  
  CONCLUSIONS
  MBT is effective in reducing incontinence and constipation in patients after ARM. It helps the children and their families to relieve psychosocial stress. The approach can be successfully adopted, if a team of committed specialists is available and sufficient compliance of patients and families is given.
authors.affiliation: Department of Pediatric Surgery and Urology, Children's Hospital, Klinikum Bremen-Mitte, Bremen, Germany. eberhard.schmiedeke@klinikum-bremen-mitte.de
authors.forename: Eberhard
authors.initials: E
authors.lastname: Schmiedeke
authors.forename: Monika
authors.initials: M
authors.lastname: Busch
authors.forename: Elektra
authors.initials: E
authors.lastname: Stamatopoulos
authors.forename: Christian
authors.initials: C
authors.lastname: Lorenz
mesh_terms: D000293:Adolescent; D001006:Anus, Imperforate / Q000601:surgery*; D001521:Behavior Therapy / Q000379:methods*; D002648:Child; D003248:Constipation / Q000209:etiology / Q000523:psychology / Q000628:therapy*; D005242:Fecal Incontinence / Q000209:etiology / Q000523:psychology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000523:psychology / Q000628:therapy*; D013315:Stress, Psychological / Q000628:therapy; D016896:Treatment Outcome