Possibilities and results of management of bowel incontinence in children.

Continence depends on many factors; hence, management varies depending on individual deficiencies be they motor, sensory, anatomic, psychological, local or general. As would be expected, correctly performed primary operation has produced better results than secondary salvage surgery. The high (supralevator) anomalies lack an internal sphincter. This is believed to be the reason that the best results do not approach those of low (infralevator) anomalies. Continence in patients with high anomalies is slowly learned, as opposed to the natural development of continence at the normal time in individuals with low anomalies. Although the puborectalis sling is accepted as the most important muscle in continence, true normal as opposed to socially satisfactory continence requires an internal sphincter as a persistently tonic "anti-leak" device. The orthodox pull-through operations add to problems with continence by removing specific rectal sensation and, hence, the reflex between the rectal distension and the striated muscle of the pelvic floor. Early operation on high anomalies to allow of "minimal mobilisation" before disuse retraction of the rectal ampulla is, therefore, being reassessed. Many neuropathic patients, e.g. those with spina bifida, acquire satisfactory learned continence by voluntary efforts with or without a regimen of aperients or enemas. A minority have an automatic rectum responding to a small volume of stool and/or an active colon producing a loose stool. These patients may benefit by the recently available drug Loperamide. Our incontinent patients are assessed by anorectal manometry, barium defaecogram, as well as by examination and pelvic floor stimulation under general anaesthesia. Treatment may include: 1) a training regimen with or without drugs, e.g., Loperamide; 2) local anoplasty for stenosis or redundant mucosa; 3) levator plasty if the levator is active though not effecting closure of the lumen; 4) bilateral gracilis sling (not the original ring technique) if the levator is not active due to iatrogenic damage or neuropathy. In assessing the results, it is important to recognise the frequent spontaneous improvement in continence around puberty. Although present techniques have seemed unreliable, use of gluteus maximus, a natural synergist, should have therapeutic potential. A satisfactory technique for an internal sphincter substitute appears to be the most urgent present need.