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Medical Treatment for Functional ConstipationHello and welcome to this introduction to Managing Incontinence in School Setting. My name is Kelly Savitri. I’m a DNP student at Elms College, and this quality improvement project is part of the fulfillment of my Doctor of Nursing Practice Degree in collaboration with the Vermont Continence Project. Incontinence can be a complex topic, and as a former school nurse myself, I know that many of you are very busy, so my goal for this project is to provide you with practical evidence-based information in as concise a format as possible so that you know what to do when you encounter a child who seems to be struggling with incontinence.
So what do we mean by incontinence? Incontinence is basically any kind of elimination that is happening anywhere other than the toilet. It falls into three main categories, fecal incontinence, which is poop accidents. Urinary incontinence or pee accidents, and nocturnal enuresis, which is urination that occurs in a child’s bed while they are asleep. All three categories of incontinence have been associated with negative mental health outcomes for children. Many of these factors such as bullying and peer rejection tend to get worse as the child gets older, so there’s compelling motivation to treat these issues as soon as possible.
Throughout these videos, I’m going to share many interventions that the school nurse and other personnel can implement to support children who are struggling with incontinence. As we move through the material, I would like you to keep these goals in mind. One, preserve the child’s dignity. Two, facilitate medical treatment. Three, support the psychosocial health of the child and the family. And four, minimize disruptions to academic learning.
First, some myth busting. Unfortunately, the physiologic cause of incontinence is not widely understood outside of the medical community. Many studies report that parents assume soiling is due to laziness, indifference, attempts to gain attention, or even as an act of defiance. The reality is that most incontinence is due to chronic, long-term constipation. Because parents don’t know that their child’s soiling accidents are due to a medical issue, many do not think to bring it to their doctor’s attention.
To understand how constipation causes incontinence, you need to know that stretch receptors in the bowel and bladder are responsible for creating the sensation that we interpret as the indication that we need to pee or poop. As the rectum fills with feces, it triggers stretch receptors and we learn to identify that sensation as the need to poop. If we then empty the rectum, it resets those stretch receptors to their resting state, and the process starts again. The problem is, if we don’t respond to that sensation, it will eventually go away. If a large amount of feces collects in the rectum becoming harder and drier as more water gets absorbed from it, those stretch receptors stop working and the child will no longer feel that sensation. This is important because a child cannot learn how to respond to a sensation that they cannot feel. Also, the bands of muscle that make up the colon where the feces is collecting, become distended and eventually lose their normal tone.
Constipation can be triggered by many things, but regardless of how it starts, it sets in motion a cycle that we’ve represented in this infographic. On the outside in green, you’ll see the physiologic part of the cycle. The process that I just described causes loss of feeling and muscle tone. This makes it so even when the child has a bowel movement, it’s often incomplete with some stool being retained, which contributes to further constipation.
A further complication occurs when a child starts to associate bowel movements as painful and scary. Their natural response is to withhold to avoid pain, which of course contributes to further constipation. This is represented in yellow. All of these factors ultimately result in both fecal and urinary incontinence.
When this cycle’s been going on for a while, many children develop encopresis. This occurs when there is an impaction of hard stool in the rectum. Remember that feces is liquid when it enters the colon. Eventually, this liquid or sometimes just very soft stool can leak around the impaction. This often comes out involuntarily as streaks or smears in the child’s undergarments. Parents often misinterpret this as diarrhea. If there is a children in your school who frequently misses school due to diarrhea, you should consider the possibility of encopresis.
When this occurs, the child usually does not notice the smell or the feeling. Sometimes parents have a really hard time understanding how an older child does not smell this, but it’s true, children become nose blind and do not recognize the scent of a soiling episode. Also, the lack of sensation can lead to an overall loss of control. This means that it’s not just the soft liquid stool that leaks out involuntarily, fully formed stools of any size and consistency can also be passed without the child having any awareness of it.
So how can constipation cause urinary incontinence and bedwetting? First, there is the mechanical stress of a fecal impaction. If an impaction is pressing on the pelvic floor, it can weaken the muscles that are necessary to hold back urine. Also, it can prevent the bladder from filling to its full capacity, so the receptors do not send a strong enough signal for the child to feel it. This usually results in a child not recognizing the sensation of a full bladder until it is extremely urgent, and then they don’t make it to the bathroom in time. Also, the nerves of the bladder and bowel follow the same pathway to the brain, so constipation can cause dysfunction along that pathway.
Sometimes these changes are not enough to cause daytime incontinence, but the sensation of a full bladder is just simply not strong enough to wake a child from sleep. Even if the child’s only episodes of incontinence are at night, the root cause may still be constipation.
In the school setting, it’s helpful to know which children are at higher risk of developing functional constipation. Often there’s a source of stress either at home or at school, such as parental divorce or separation, child maltreatment, severe illness in the family, parental job loss, bullying, a change in schools, separation from a best friend or academic struggles. Other factors that have been associated with functional constipation include children with an anxious or strong-willed temperament. Children who are very sensitive to sensory stimuli, or those with an ADHD or autism diagnosis. It’s also worth noting that children in more rural areas tend not to be diagnosed as quickly, and parents with lower levels of education tend to be less adherent with treatment.
So if you have a child who’s struggling with any kind of incontinence, the first thing that we recommend is to collect data about their bowel movements for a week or two. This should happen both at home and at school. We have a video to guide this process as part of the suggested curriculum for educating parents. We recommend using the Bristol Stool Scale, which is the most widely used validated tool to assess bowel function. People tend to think of constipation as episodes of no bowel movements, and it can be difficult to convince parents that their child is constipated when it seems like they are cleaning up poop all the time.
Sometimes it’s more helpful to think of constipation as sort of “incomplete evacuation.” They may be stooling every day or nearly every day, but they’re never fully emptying their bowels. That’s why it is important to look at factors like size and frequency as well as consistency. While most of us know that type one or two stools or strong indicators of constipation, it’s important to realize that type six or seven stools are often seen with encopresis. Mixed consistency, meaning stool that is watery with some form chunks is also an indicator of encopresis.
The only person who can officially diagnose a child with functional constipation is a healthcare provider such as a PCP or a gastroenterologist. So it’s important to communicate the child’s bowel history to their provider. That’s why we created the bowel symptom checklist. This includes the official diagnostic criteria known as the Rome Four Criteria. Notice that fecal soiling is a key symptom. Also, the bottom three criteria, withholding or posturing, painful or hard BMs and large or wide BMs, they say history, because even if they’re not currently being observed, they’re still important indicators. If those symptoms went away, it’s not necessarily because the child’s condition improved. It might just be because they’re so impacted that only small amounts of stool are coming out or because they just can’t feel the sensation anymore. Our bowel symptom checklist also includes additional symptoms. While these are not officially diagnostic criteria, they’re still part of the clinical picture, and we want the child’s healthcare provider to be aware if any of the following are present. Straining or discomfort with bowel movements, fear or avoidance of using the toilet, if they’re unaware of the need to stool, unaware of the odor, or unaware that they’ve gone, stool accidents while sleeping, many small peas throughout the day, a history of urinary tract infections, a round belly, a gassy system, very limited food variety or a low appetite.
We want parents or guardians, as well as school personnel to know that this is a medical condition that qualifies for an individual health plan or a 504 plan. School accommodations can be made, but it requires a diagnosis and a treatment plan from a PCP. We’ve created a suggested curriculum to help guide you in how to talk to parents and teaching staff about functional constipation and associated incontinence. The first step is to have caregivers and teaching staff watch some of our videos, which explain everything I told you in the first half of this presentation without any medical jargon. The caregiver should then schedule a visit with the PCP, and in the meantime, the home and school teams can collaboratively take some data and complete the bowel symptom checklist. We suggest asking the parents or guardians to sign a release so that you can communicate directly with the PCP. That way you can fax your data and checklist directly to the provider.
Thank you for your time. The information contained in this video is for informational purposes only. It is not a substitute for professional health or medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider.
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Medical Treatment for Functional Constipation