Friday, 18 March 2016

Bladder Control - An Enema Every Second Day for Nine Years!

A 12.5 year old girl with a history of developmental delay was referred for constipation and for day and night wetting.

At about the age of 3 years, once walking, she stopped pooping regularly and after five days without a poop the parents attended an emergency department and the girl was treated with an enema. She continued to poop infrequently and with the advice of a local physician, the parents treated her with an enema every two days. The girl and the parents accepted this intervention and nine years later the girl was still wearing a pull up by day and night and the parents continued to treat her with alternate days enemas.

A few times a year the girl told her parents she needed to poop, and she used a conventional toilet. By day at home, she wore underwear and voided attentively without any wetness in her underwear. At her school for children with disabilities, she wore a pull up and changed this promptly if she wet even a small amount, and she otherwise voided attentively at school. She wet every night.

I knew the ultrasound of her pelvis would tell an interesting story. What does a rectum look like, when courtesy of an enema, the rectum has emptied faithfully every two days for nine years?

The rectum looked normal. The diameter was only 19 mm. I hardly ever see a rectal diameter under 25 in my office and mostly I see diameters in the thirties and forties on the first visit.

This story fascinated me. Enemas are mostly given intermittently, often in an emergency department. At home, enemas are usually only used intermittently when tummy pain or another constipation symptom becomes too problematic. Occasionally I see a child with a history of an enema every 3 to 7 days, used intermittently and only as necessary. Routine treatment with an an enema is uncommon and usually only offered in neurologically devastated children who are bedridden or in ambulatory children with a neurogenic bladder.

The good news for this child is that the alternate day enemas insured that her rectum was not “stretched” with a consequent loss in muscle tone, and that her rectal function was preserved. She will be able to have normal daily bowel movements. Since the girl was attentive to bladder signals and had a history of intermittent (albeit uncommon) attentiveness to bowel signals, the child was clearly ready for the transition to normal movements in the toilet and to wear underwear by day. The child can be cured and she can achieve normal social control of her bladder and bowel. 

The “sort of” bad news was that she had alternate day enemas for 9 years. But, was this really bad? I would never prescribe regular enemas in this situation, but I commonly see children with a chronic history of withholding poop for a week or more and in these children I tell the parents that treatment will “control” but might not “cure” the constipation. Which is better? Poor control and a rectum that is “stretched” with the result that the constipation can only be controlled, or very good control with alternate day enemas and the ability to cure the constipation? Interesting question. Of course this is an oversimplified question. The correct answer is that physicians need to teach parents how to prevent constipation in the first place and that their are good alternatives to enemas that also preserve bowel function.

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