Constipation and faecal incontinence: Case

This girl shows the full picture of functional constipation with retentive faecal incontinence: infrequent large painful stools, an anal fissure driving withholding, toilet avoidance, and daily overflow soiling around a palpable faecal mass, all with normal growth and no red flags. The story allows a positive functional diagnosis, while the fissure, the fear of the toilet, and the family and school strain are the factors management must address. [1]

Clinical findings

The pattern is clearly functional and retentive. The large hard stools, pain, and anal fissure explain the withholding, and the daily leaking is overflow of soft stool around the impaction confirmed by the palpable faecal mass. The normal growth, normal spine, and normal lower limb neurology, with an onset well after infancy, make Hirschsprung disease and other organic causes unlikely, so no routine bloods or abdominal radiograph are needed. The fissure is a consequence of the hard stool rather than a primary diagnosis, and safeguarding is considered but not suggested by the history. [1]

Investigations and diagnosis

Investigation is not required here because the diagnosis is clinical. Routine blood tests and an abdominal radiograph would add nothing and the film is unreliable for confirming faecal loading. The diagnosis is functional constipation with retentive faecal incontinence, made positively using the Rome IV criteria. I would reserve coeliac serology and thyroid function for atypical features or treatment failure, and referral for rectal biopsy for any suggestion of Hirschsprung disease, none of which is present in this child. [1]

Management and outcome

Management begins with a clear, non-punitive explanation that the soiling is involuntary overflow around trapped stool and that treatment runs over months. Because she has a significant impaction, I would disimpact first with high-dose oral polyethylene glycol at around 1 to 1.5 g/kg/day for three to six days, chosen over an enema because the trial evidence shows it is as effective and better tolerated, warning the family that soiling may worsen transiently as the blockage clears. Treating the constipation will also allow the fissure to heal. [2]

I would then start maintenance polyethylene glycol at about 0.4 g/kg/day, titrated to a soft painless daily stool and continued for months with slow weaning, adding a stimulant laxative if needed. Behavioural measures follow: unhurried post-meal toilet sitting with foot support, a reward chart for sitting, and attention to fluid, diet, and activity, alongside liaison with the school to support a non-punitive plan. With early adequate treatment and family engagement the outlook is good, though relapses are common and a minority of children have persistent symptoms into adulthood, so regular review, sustained dosing, and clear safety-netting are arranged. [3]