Constipation-associated and Nonretentive Fecal Incontinence in Children and Adolescents: An Epidemiological Survey in Sri Lanka

Abstract

Objectives: 

Fecal incontinence (FI) has a great effect on quality of life of children with the condition. Epidemiological data related to FI from developing countries are sparse. Studies differentiating functional nonretentive and retentive (constipation-associated) FI are not available.

Patients and Methods: 

This was an island-wide, cross-sectional study. Information was collected from children (ages 10–16 years) from 5 randomly selected schools in 3 geographically and socioeconomically different provinces in Sri Lanka, using a validated, self-administered questionnaire. FI was defined as defecation into places inappropriate to the social context, at least once per month, for a minimum period of 2 months. Constipation was diagnosed using Rome III criteria.

Results: 

A total of 2770 questionnaires were distributed and 2686 (97.0%) were included in the analysis. Of them, 55 (2.0%) had FI (mean age 11.96 years, SD 1.59 years, 43 [78.2%] boys). Forty-five (81.8%) had constipation-associated FI and 10 (18.2%) had nonretentive FI. The highest prevalence of FI was seen in children aged 10 years (5.4%). A significant negative correlation was observed between age and the prevalence of FI (r = −0.893, P = 0.007). FI was significantly higher in boys (boys 3.2%, girls 0.9%), those exposed to recent school- and family-related stressful life events, and those from lower social classes (P < 0.05).

Conclusions: 

FI is not uncommon among children and adolescents of 10 to 16 years of age in Sri Lanka with a male predilection. Some predisposing factors, such as exposure to stressful life events and being bullied at school, which are similar to those described in the literature for FI, could be clearly recognized.

Fecal incontinence (FI) is defined as involuntary loss of formed or liquid stools into the child's underwear after developmental age 4 years ⁽¹⁾. Prevalence of FI varies from less than 1% to more than 4% in children around the world ^(2–6). It is more common among boys ⁽⁷⁾, younger children, and those from lower socioeconomic background ⁽⁴⁾.

Even though FI is uncommon, it is worrisome to the affected children, their families, and physicians who manage them. Children with FI leak stools into their underwear, smell bad, and have social isolation and excessive dependency. They commonly have behavioral, emotional, and upbringing problems ^(4,5,8). Moreover, they often have learning difficulties and frequently face child abuse ⁽⁴⁾. In addition, anxiety and depression are more common among these children ⁽⁹⁾. Parents are also frustrated because they may have to compromise family activities ⁽¹⁰⁾. Furthermore, approximately 15% of affected children continue to have symptoms as adults ⁽¹¹⁾.

All of the previous epidemiological data on FI are from the developed countries, and its prevalence in developing countries and Asia is lacking. This study assessed the prevalence of FI in Sri Lankan schoolchildren and adolescents and the factors associated with it.

PATIENTS AND METHODS

This was a school-based, island-wide, cross-sectional survey in Sri Lanka. Three provinces were randomly selected out of 9 provinces in the country, and from them, 5 schools were randomly selected from the list of schools. In every selected school, 12 classes were randomly selected from academic years 6 to 11 (2 from each academic year), and all of the children in selected classes (ages 10–16 years) were included in the study. Two schools were from the Eastern Province affected by the separatist war.

Details regarding bowel habits during the preceding 2 months (developed from the Questionnaire on Pediatric Gastrointestinal Symptoms) ⁽¹²⁾ were collected with demographic information, exposure to stressful life events during the previous 3 months, and presence of other symptoms using a validated, self-administered questionnaire (see the online-only questionnaire at https://links.lww.com/MPG/A18). The questionnaire was in the native language (Singhalese). School administration and parents were informed before the study and consent was obtained. The questionnaire was administered in examination setting to ensure confidentiality and privacy and was filled out under the guidance of research assistants.

FI was defined as defecation into places inappropriate to the social context, at least once per month, for a minimum period of 2 months ⁽¹³⁾. Nonretentive fecal incontinence (NRFI) and constipation were defined using Rome III criteria ⁽¹³⁾. Because this study was a questionnaire-based epidemiological study, we did not perform rectal examinations in children.

Data were analyzed using χ² and Fisher exact test using EpiInfo (EpiInfo 6, version 6.04 [1996] Centres for Disease Control and Prevention, Atlanta, GA, and World Health Organization, Geneva, Switzerland). P < 0.05 was taken as significant. Multiple logistic regression analysis was performed on variables that were found to have significant association. This study protocol was approved by the Ethical Review Committee of the Sri Lanka College of Paediatricians.

RESULTS

A total of 2770 questionnaires were distributed, of which 2686 (97.0%) were included (mean age 13.2 years, SD 1.7 years, 1362 [50.7%] boys). A total of 84 (3%) incompletely filled-out questionnaires were excluded from the analysis.

Prevalence of FI

Fifty-five (2.0%) subjects had FI (mean age 12.0 years, SD 1.6 years, 43 [78.2%] boys). Forty-five (81.8%, prevalence of 1.7%) had constipation-associated FI and 10 (18.2%, prevalence 0.4%) had NRFI. The highest prevalence was seen in children aged 10 years (5.43%) (Fig. 1). A significant negative correlation was observed between age and the prevalence of FI (r = −0.89, P = 0.007). According to logistic regression analysis, FI was significantly higher in boys (adjusted odds ratio [OR] 3.88, 95% confidence interval [CI] 1.90–7.94, P < 0.0001). The boy-to-girl ratio of FI was 3.6:1. Children fulfilling the criteria for FI were compared with 2631 children without FI (controls).

FIGURE 1: Prevalence of fecal incontinence according to age and sex.

Sociodemographic Variables and FI

Table 1 shows the association between FI and demographic characteristics. Multiple logistic regression analysis shows that FI was significantly higher in children with unskilled and unemployed fathers (adjusted OR 1.22, 95% CI 1.08–1.39, P = 0.001), whereas it was not so in children living in the war-affected area (adjusted OR 0.55, 95% CI 0.29–1.07, P = 0. 077).

TABLE 1: Demographic and family characteristics of children with fecal incontinence compared with controls

Association Between FI and Exposure to Stressful Events

Table 2 shows the association between FI and exposure to stressful life events. After multiple logistic regression analysis, exposure to stressful life events (adjusted OR 4.94, 95% CI 1.76–13.88, P = 0.002), being bullied at school (adjusted OR 2.57, 95% CI 1.19–5.52, P = 0.016), and hospitalization of the child for another illness (adjusted OR 2.74, 95% CI 1.32–5.69, P = 0.007) remained significant.

TABLE 2: Distribution of responders according to exposure to stressful life events

Bowel Habits in Children With FI

Table 3 compares the bowel habits in children with NRFI and constipation-associated FI. Following multiple logistic regression analysis, bulky stools were significantly less common in those with NRFI (adjusted OR 0.59, 95% CI 0.004–0.79, P = 0.032). The bowel habits of all 55 children with FI and controls are also presented in Table 3. After multiple logistic regression analysis, painful defecation (adjusted OR 2.53, 95% CI 1.10–5.83, P = 0.029), bulky stools (adjusted OR 5.25, 95% CI 2.39–11.53, P < 0.0001), retentive posturing (adjusted OR 4.07, 95% CI 1.98–8.34, P < 0.0001), and blood-stained stools (adjusted OR 9.17, 95% CI 2.39–11.53, P < 0.0001) were significantly more common in those with FI.

TABLE 3: Bowel habits of children with fecal incontinence and controls

Other Symptoms Seen in Children With FI

Other gastrointestinal symptoms seen in these patients included abdominal pain, nausea, and vomiting (Table 4). Abdominal pain was reported in 30 (66.7%) children with constipation-associated FI and 3 (30%) patients with NRFI. After performing multiple logistic regression analysis, abdominal pain was independently associated with FI (adjusted OR 2.52, 95% CI 1.29–4.91, P = 0.007).

TABLE 4: Symptoms associated with fecal incontinence

DISCUSSION

In this epidemiological study, we found FI in 2% of children and adolescents. Previous studies from Western countries showed prevalence of FI ranging from 0.8% among 10 to 12 years old to 4.1% in 5 to 6 years old ^(2,4). In contrast, hospital-based studies have reported higher prevalence of FI (3%–5.7%) ^(14,15). Much higher prevalence (15%) was reported in obese children ⁽¹⁶⁾.

It is of paramount importance to distinguish between retentive FI and NRFI because their management strategies are entirely different ⁽¹⁷⁾. The major drawback of all previous studies is that no attempt was made to discriminate between these 2 entities. Constipation-associated FI was 4.5 times more common than NRFI. This indicates the probable significance of constipation in the pathogenesis of FI.

In this study, prevalence of FI was highest at the age of 10 years and showed a significant negative correlation with the age. van der Wal et al ⁽⁴⁾ have shown a relatively lower prevalence in older children, but failed to report an exact correlation. It is possible that older children may have a better control over their bodily functions including bowel motions. Furthermore, as in previous studies, FI was more common among boys ^(1,4,14). Prevalence of FI was higher in those from lower socioeconomic background, which is in agreement with a study done among Dutch children ⁽⁴⁾. Poor toilet facilities leading to stool withholding and delay in seeking health care are likely contributory factors.

In our study, children exposed to stressful life events were more likely to develop FI. The stressful life events that associated with FI were being bullied at school and hospitalization of the child for other illnesses. According to Joinson et al ⁽⁵⁾, bullying (both bully and victim) was significantly higher in children who had frequent FI. Bullying is a common problem in schools and occurs in toilets, which could prevent children from using school toilets ⁽¹⁸⁾. Similarly, the condition of toilets in Sri Lankan hospitals is unsatisfactory and children admitted to hospitals are likely to withhold stools. In addition, fecal retention associated with bed rest probably contributes to FI in hospitalized children. Emotional stress is known to be associated with other functional gastrointestinal diseases ^(19,20). It seems likely that stress modulates colonic motility through brain gut axis, leading to pathogenesis of both retentive and NRFI in our study sample.

A previous study has shown a high incidence of FI among children evacuated from London during World War II ⁽²¹⁾. In contrast to this, we did not find a higher prevalence of FI among children living in war-affected areas. Compared with the previous study, our children were not evacuated from their homes, not living in refugee camps, and experienced no severe disruption to their lifestyle. This has probably reduced the influence of war on their bowel habits.

Bowel habits significantly associated with FI were pain during defecation, bulky stools, and retentive posturing. Unlike in a previous study, we fail to find a significant association between FI and stool frequency of fewer than 3 per week ⁽⁴⁾. In the present study, large-caliber stools and abdominal pain were significantly associated with FI, which is similar to the findings by Levine ⁽¹⁴⁾. Another clinical feature associated with FI was blood in the stool, which is most likely to be due to anal fissures caused by chronic constipation. We compared bowel habits of children with retentive FI and NRFI, which has not been reported previously. Large-diameter stools, which indicate stool retention, were significantly less common in those with NRFI. We did not find a significant difference in defecation frequency and consistency between these 2 groups.

In this school-based epidemiological study, which involved a large number of schoolchildren, it was not possible to perform rectal examination. Therefore, we were restricted to use only symptom-based criteria for the diagnosis of constipation-associated FI. Similar to this study, most of the previous epidemiological surveys had used only symptom-based criteria to diagnose constipation ⁽²²⁾ and FI ^(4,5). Even though physical examination is recommended in diagnosis of defecation disorders, previous studies have reported low rates of rectal examination in children with FI ⁽²³⁾. The value of rectal examination in pediatric defecation disorders has not been reported previously, but in elderly patients, digital rectal examination was reported to be unreliable as an indicator of constipation ⁽²⁴⁾.

The main problem we encountered when diagnosing constipation using Rome III criteria was the requirement of weekly symptoms. Three children with defecation frequency of less than 3 per week also had FI once per month, which satisfy criteria for FI, but not sufficient to diagnose constipation-associated FI. None of them had any other symptom related to fecal retention including large-diameter stools, painful defecation, and stool-withholding behavior. In previous studies, the presence of large-diameter stools had been considered the best indicator of fecal retention ⁽²⁵⁾ and this symptom was not present in any of these 3 children. Furthermore, all 3 of them had complete bowel evacuation to their underwear, not just staining or leaking small amount of stools, which indicate stool retention. Therefore, they were diagnosed as having NRFI.

CONCLUSIONS

Two percent of schoolchildren and adolescents, aged 10 to 16 years, are experiencing FI. The majority of them have constipation-associated (retentive) FI. NRFI is relatively uncommon in children. FI is more common in boys, those from low socioeconomic background, and those who are exposed to stressful life events.