Editorial Comment
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20. Berger MY, Tabbers MM, Kurver MJ et al: Value of abdominal radiography, colonic transit time, and rectal ultrasound scanning in the diagnosis of idiopathic constipation in children: a systematic review. J Pediatr 2012; 161: 44. 21. van der Plas RN, Benninga MA, Redekop WK et al: How accurate is the recall of bowel habits in children with defecation disorders? Eur J Pediatr 1997; 156: 178. 22. Combs AJ, Van Batavia JP, Horowitz M et al: Short pelvic floor electromyographic lag time: a novel noninvasive approach to document detrusor overactivity in children with lower urinary tract symptoms. J Urol 2013; 189: 2282. 23. Joensson IM, Siggaard C, Rittig S et al: Trans- abdominal ultrasound of rectum as a diagnostic tool in childhood constipation. J Urol 2008; 179: 1997. 24. Lewis SJ and Heaton KW: Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 1997; 32: 920. EDITORIAL COMMENT Recognizing the wide spectrum of pathological con- ditions caught within the general term “dysfunc- tional elimination syndrome,” the authors perform an admirable job of establishing the association of constipation/encopresis and specific lower urinary tract symptoms. Their data suggest that bowel dys- function is particularly correlated with dysfunc- tional voiding and detrusor overactivity, which could tempt the clinician into more aggressive diagnosis and treatment of underlying constipation/encopresis in patients with those complaints. However, and as noted by the authors, even use of Rome III question- naires, bowel diaries and imaging studies does not provide a means to definitively prove that a partic- ular patient does or does not have constipation. Un- til such a gold standard exists, and given the low morbidity and cost of laxative therapy, it may be best to start all children who present with LUTS on a trial period of laxatives and bowel management. J. Todd Purves Department of Urology Medical University of South Carolina Charleston, South Carolina REPLY BY AUTHORS We agree that more work is needed in terms of more accurately identifying who is truly constipated and improving our understanding of the relationships among constipation, encopresis and LUTD. As to the suggestion that all patients with LUTS should ini- tially be given a trial course of laxatives and bowel management given its low cost and morbidity, it is an approach that, despite its increasing popularity, we find difficult to embrace. Unless there is a rea- sonable suspicion that the patient is constipated, we believe this represents a bit of “overkill.” Were over- treatment entirely benign, we would have no strong feelings regarding those who elected this initial ap- proach to treat patients with LUTD. While we readily acknowledge that a significant portion of children with LUTD ultimately require concomitant bowel therapy either for preexisting constipation or that which is acquired during treat- ment, and also that there are some children whose LUTS resolve when the constipation is effectively treated, we nonetheless have 2 main concerns with this approach. Our first concern is that some take this approach far too literally and not infrequently we have seen children with LUTD come to us for a second opinion having been on a bowel regimen for months with little notice taken of or on other ther- apy directed towards the associated LUT condition. Second, for the child with encopresis, particularly in the milieu of severe urgency and no obvious consti- pation, it has been our experience that these pa- tients respond best in terms of bowel and LUTS when placed on anticholinergics and that when they have received laxatives, encopresis has worsened, not improved. DYSFUNCTIONAL ELIMINATION SYNDROMES 1020
Transcript of Editorial Comment
DYSFUNCTIONAL ELIMINATION SYNDROMES1020
20. Berger MY, Tabbers MM, Kurver MJ et al: Valueof abdominal radiography, colonic transit time,and rectal ultrasound scanning in the diagnosis ofidiopathic constipation in children: a systematicreview. J Pediatr 2012; 161: 44.
21. van der Plas RN, Benninga MA, Redekop WK
EDITORIAL COMMENT
REPLY BY AUTHORS
concomitant bowel therapy either fo
in children with defecation disorders? Eur J Pediatr1997; 156: 178.
22. Combs AJ, Van Batavia JP, Horowitz M et al:Short pelvic floor electromyographic lag time: anovel noninvasive approach to document detrusoroveractivity in children with lower urinary tract
r preexisting not improved.
23. Joensson IM, Siggaard C, Rittig S et al: Trans-abdominal ultrasound of rectum as a diagnostictool in childhood constipation. J Urol 2008; 179:1997.
24. Lewis SJ and Heaton KW: Stool form scale as auseful guide to intestinal transit time. Scand J
et al: How accurate is the recall of bowel habits symptoms. J Urol 2013; 189: 2282. Gastroenterol 1997; 32: 920.
Recognizing the wide spectrum of pathological con-ditions caught within the general term “dysfunc-tional elimination syndrome,” the authors performan admirable job of establishing the association ofconstipation/encopresis and specific lower urinarytract symptoms. Their data suggest that bowel dys-function is particularly correlated with dysfunc-tional voiding and detrusor overactivity, which couldtempt the clinician into more aggressive diagnosisand treatment of underlying constipation/encopresisin patients with those complaints. However, and as
naires, bowel diaries and imaging studies does notprovide a means to definitively prove that a partic-ular patient does or does not have constipation. Un-til such a gold standard exists, and given the lowmorbidity and cost of laxative therapy, it may bebest to start all children who present with LUTS ona trial period of laxatives and bowel management.
J. Todd Purves
Department of UrologyMedical University of South Carolina
noted by the authors, even use of Rome III question- Charleston, South Carolina
We agree that more work is needed in terms of moreaccurately identifying who is truly constipated andimproving our understanding of the relationshipsamong constipation, encopresis and LUTD. As to thesuggestion that all patients with LUTS should ini-tially be given a trial course of laxatives and bowelmanagement given its low cost and morbidity, it isan approach that, despite its increasing popularity,we find difficult to embrace. Unless there is a rea-sonable suspicion that the patient is constipated, webelieve this represents a bit of “overkill.” Were over-treatment entirely benign, we would have no strongfeelings regarding those who elected this initial ap-proach to treat patients with LUTD.
While we readily acknowledge that a significantportion of children with LUTD ultimately require
constipation or that which is acquired during treat-ment, and also that there are some children whoseLUTS resolve when the constipation is effectivelytreated, we nonetheless have 2 main concerns withthis approach. Our first concern is that some takethis approach far too literally and not infrequentlywe have seen children with LUTD come to us for asecond opinion having been on a bowel regimen formonths with little notice taken of or on other ther-apy directed towards the associated LUT condition.Second, for the child with encopresis, particularly inthe milieu of severe urgency and no obvious consti-pation, it has been our experience that these pa-tients respond best in terms of bowel and LUTSwhen placed on anticholinergics and that when theyhave received laxatives, encopresis has worsened,
