title: Prospective evaluation of comorbidity and psychosocial need in children and adolescents with anorectal malformation. Part one: paediatric surgical evaluation and treatment of defecating disorder.
abstract: BACKGROUND
  Anorectal malformations represent a continuing challenge for the paediatric surgeon. Faecal and urinary incontinence can occur even with an excellent anatomic repair. We undertook a prospective evaluation of comorbidity and psychosocial needs in children and adolescents with anorectal malformation to test the hypothesis whether psychosocial workup in concert with an improved continence situation would lead to a better functional outcome in patients suffering from defecating disorders. Treatment of defecating disorder was based on differentiation between overflow pseudo-incontinence and true faecal incontinence.
  
  
  METHODS
  Patients who presented with soiling regardless of the type of anomaly were included in the study: 44 patients were investigated, 14 patients did not meet the criteria of the study, 30 patients aged 4-18 were evaluated. The surgical diagnostic program comprised a careful clinical history, physical examination, exact classification of the malformation, evaluation for associated defects, stool protocol.
  
  
  RESULTS
  Patients were grouped in two different management programs according to their continence situation. Patients with pseudo-incontinence were treated with enemas, diet, anal hygiene, behavioural therapy and physiotherapy. Patients with true faecal incontinence were included in a bowel management program: 28 patients were free of symptoms of soiling after 3 days of hospital treatment and remained free of symptoms 6 months and 1 year later at re-evaluation. Two patients did not follow the therapeutic regime and therefore did not show an improved condition concerning soiling in the long run.
  
  
  CONCLUSIONS
  Differentiating between overflow pseudo-incontinence and true faecal incontinence is the basis of an effective treatment of defecating disorders. All patients born with anorectal malformation can be kept clean of stool if they are subjected to an adequate treatment. A multidisciplinary approach is a valuable supplement to standard therapy.
authors.affiliation: Department of Pediatric Surgery, Campus Virchow Clinic, Charité University Hospital Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. stefanie.maerzheuser@charite.de
authors.forename: S
authors.initials: S
authors.lastname: Maerzheuser
authors.forename: D
authors.initials: D
authors.lastname: Schmidt
authors.forename: H
authors.initials: H
authors.lastname: Mau
authors.forename: S
authors.initials: S
authors.lastname: Winter
mesh_terms: D000293:Adolescent; D001003:Anal Canal / Q000002:abnormalities*; D002648:Child; D002675:Child, Preschool; D003672:Defecation; D004065:Digestive System Abnormalities / Q000150:complications / Q000523:psychology* / Q000601:surgery*; D005242:Fecal Incontinence / Q000209:etiology*; D005260:Female; D006801:Humans; D008297:Male; D011446:Prospective Studies; D020127:Recovery of Function; D012007:Rectum / Q000002:abnormalities*