Efficacy of Pelvic Floor Muscle Training for the Treatment of Fecal Incontinence after Soave Procedure for Hirschsprung Disease

Abstract

Objective The main objective of this study is to evaluate the efficacy of pelvic floor muscle exercise for the treatment of fecal incontinence after Soave procedure for Hirschsprung disease (HD).

Methods A case series study was performed in 24 incontinent children after Soave pull-through surgery for HD. Out of the 24 patients, 16 patients (training group) received pelvic floor muscle training while the other 8 patients (control group) did not receive further treatment. For children who received pelvic floor muscle training, biofeedback treatment was given for 2 weeks in hospital and they were then instructed to carry out pelvic floor muscle exercise at home. At the baseline and after 1 year of training, anorectal manometry was performed to measure resting anal canal pressure, squeeze pressure, and rectal sensation. Efficacy of pelvic floor muscle exercise for the treatment of postoperative fecal incontinence was evaluated by the difference between baseline and 1-year follow-up values. At the baseline, the characteristics of the incontinent children were also compared with 18 children who were performed Soave operation for HD and had normal anal function.

Results Lower resting anal canal pressure distinguished the incontinent children from the continent ones. Resting pressure of the incontinent children was significantly improved by pelvic floor muscle exercise: the baseline and 1-year follow-up values of the treatment group were 18.6 ± 6.2 and 35.4 ± 8.7 mm Hg, respectively. Squeeze pressure and clinical outcomes were also improved after the pelvic floor muscle training: only 3 out of the 16 patients had occasional soiling after the training. No significant changes in clinical outcome and manometry measurements were observed in the control group.

Conclusions The damage of internal anal sphincter might be one of the causes of fecal incontinence after Soave procedure. The damage of internal anal sphincter could be caused by lower level of dissection, vigorous anal dilation, and excessive anal canal traction during operation. Pelvic floor muscle training is one procedure of choice to treat this complaint.

Keywords

Hirschsprung disease - Soave procedure - fecal incontinence - pelvic floor muscle training

• References

• 1 Bax KN. Duhamel lecture: the incurability of Hirschsprung's disease. Eur J Pediatr Surg 2006; 16 (6) 380-384
• 2 Diseth TH, Bjørnland K, Nøvik TS, Emblem R. Bowel function, mental health, and psychosocial function in adolescents with Hirschsprung's disease. Arch Dis Child 1997; 76 (2) 100-106
• 3 Bai Y, Chen H, Hao J, Huang Y, Wang W. Long-term outcome and quality of life after the Swenson procedure for Hirschsprung's disease. J Pediatr Surg 2002; 37 (4) 639-642
• 4 Catto-Smith AG, Trajanovska M, Taylor RG. Long-term continence after surgery for Hirschsprung's disease. J Gastroenterol Hepatol 2007; 22 (12) 2273-2282
• 5 Kelly JH. The clinical and radiological assessment of anal continence in childhood. Aust N Z J Surg 1972; 42 (1) 62-63
• 6 Keshtgar AS, Ward HC, Clayden GS, de Sousa NM. Investigations for incontinence and constipation after surgery for Hirschsprung's disease in children. Pediatr Surg Int 2003; 19 (1–2) 4-8
• 7 Yamataka A, Kaneyama K, Fujiwara N , et al. Rectal mucosal dissection during transanal pull-through for Hirschsprung disease: the anorectal or the dentate line?. J Pediatr Surg 2009; 44 (1) 266-269 , discussion 270
• 8 Heikkinen M, Rintala R, Luukkonen P. Long-term anal sphincter performance after surgery for Hirschsprung's disease. J Pediatr Surg 1997; 32 (10) 1443-1446
• 9 Kuwahara M, Iwai N, Yanagihara J, Tokiwa K, Fukata R. Endosonographic study of anal sphincters in patients after surgery for Hirschsprung's disease. J Pediatr Surg 1999; 34 (3) 450-453
• 10 Kaul A, Garza JM, Connor FL , et al. Colonic hyperactivity results in frequent fecal soiling in a subset of children after surgery for Hirschsprung disease. J Pediatr Gastroenterol Nutr 2011; 52 (4) 433-436
• 11 Peña A, Levitt MA. Colonic inertia disorders in pediatrics. Curr Probl Surg 2002; 39 (7) 666-730
• 12 Langer JC, Minkes RK, Mazziotti MV, Skinner MA, Winthrop AL. Transanal one-stage Soave procedure for infants with Hirschsprung's disease. J Pediatr Surg 1999; 34 (1) 148-151 , discussion 152
• 13 Foster P, Cowan G, Wrenn Jr EL. Twenty-five years' experience with Hirschsprung's disease. J Pediatr Surg 1990; 25 (5) 531-534
• 14 Shankar KR, Losty PD, Lamont GL , et al. Transanal endorectal coloanal surgery for Hirschsprung's disease: experience in two centers. J Pediatr Surg 2000; 35 (8) 1209-1213
• 15 Fujiwara N, Kaneyama K, Okazaki T , et al. A comparative study of laparoscopy-assisted pull-through and open pull-through for Hirschsprung's disease with special reference to postoperative fecal continence. J Pediatr Surg 2007; 42 (12) 2071-2074
• 16 Langer JC, Caty M, de la Torre-Mondragon L , et al; International Pediatric Endosurgery Group. IPEG colorectal panel. J Laparoendosc Adv Surg Tech A 2007; 17 (1) 77-100
• 17 Niramis R, Watanatittan S, Anuntkosol M , et al. Quality of life of patients with Hirschsprung's disease at 5 - 20 years post pull-through operations. Eur J Pediatr Surg 2008; 18 (1) 38-43
• 18 Bischoff A, Levitt MA, Bauer C, Jackson L, Holder M, Peña A. Treatment of fecal incontinence with a comprehensive bowel management program. J Pediatr Surg 2009; 44 (6) 1278-1283 , discussion 1283–1284
• 19 Engel BT, Nikoomanesh P, Schuster MM. Operant conditioning of rectosphincteric responses in the treatment of fecal incontinence. N Engl J Med 1974; 290 (12) 646-649
• 20 Baeten CG, Konsten J, Spaans F , et al. Dynamic graciloplasty for treatment of faecal incontinence. Lancet 1991; 338 (8776) 1163-1165
• 21 Sun XB, Zhang L, Li YH, Li JL, Chen YL. The effects of biofeedback training of pelvic floor muscles on fecal incontinence. J Pediatr Surg 2009; 44 (12) 2384-2387
• 22 Tantiphlachiva K, Rao S. Biofeedback therapy for bowel problems in adults after surgical treatment for childhood Hirschsprung's disease. Dev Neurorehabil 2009; 12 (6) 442-449