Peristeen integrated transanal irrigation system successfully treats faecal incontinence in children

https://doi.org/10.1016/j.jpurol.2013.08.006Get rights and content

Abstract

Objective

Faecal incontinence secondary to myelomeningocele, Hirschsprung disease, and anorectal anomalies remains a significant and common problem. We aimed to report our 5-year experience with the Peristeen trans-anal irrigation system (TAIS) to manage such children.

Patients and method

This study was a combination of a retrospective case note review and assessment using a validated quality of life questionnaire (QOL) to determine pre- and post-TAIS bowel function and continence. QOL scores and functional outcomes before and during TAIS use were compared using Wilcoxon matched pairs test (p < 0.05 significant).

Results

Twenty-four children (median age 6 years) were managed with the TAIS 2006–2011 to treat faecal incontinence. Three did not tolerate the system. Median QOL scores in 20 out of 21 patients using TAIS demonstrated significant improvement in bowel management and continence. Two discontinued use due to failure to improve continence; one underwent the Malone antegrade continence enema (MACE) procedure and one returned to oral/rectal medications. Nineteen of 24 patients (79%) continue to use TAIS.

Conclusions

The Peristeen TAIS is an effective, safe, non-operative alternative to MACE in children with faecal incontinence, if initial compliance can be achieved.

Introduction

Faecal incontinence and constipation associated with myelomeningocele, anorectal malformation, and Hirschsprung disease are common, debilitating, and difficult to treat [1], [2], [3]. In the quest to achieve continence, oral and rectal medications have limited value in children with these conditions. The Malone Antegrade Continence Enema (MACE) has been used for over two decades, with measurable improvements in bowel function and quality of life. MACE requires surgery with an associated complication rate, particularly stomal stenosis [4], [5], [6], [7], [8]. There is often reluctance to commit to a surgical stoma in younger children (4–7 years), in whom compliance is unpredictable.

The Peristeen trans-anal irrigation system (TAIS) (Coloplast, Denmark) instils water or irrigation solution via a disposable balloon catheter to the colon and rectum. The instillate, along with the contents of the descending colon, sigmoid, and rectum, is then evacuated in a controlled manner [9]. We selected this system over simple rectal or conus irrigation because of the element of controlled evacuation that the system manufacturer claimed to provide. Our centre began offering this management regimen 5 years ago to families with children suffering from constipation and faecal incontinence who were responding poorly to medication. The carers (and child, if competent) are taught by a specialist nurse how to use the system. The volume and frequency of the instillations are decided on a case by case basis.

Small series of children using TAIS have been published and demonstrated improved continence but the impact on quality of life was not assessed [10], [11]. We aimed to assess any change in bowel function and quality of life of the patients and their carers following introduction of TAIS, as well as overall compliance and complications.

Section snippets

Patients and methods

Since its introduction to our centre in 2006, we have offered the Peristeen TAIS to all patients with faecal incontinence who we would previously have considered for MACE. All patients/carers to whom TAIS was offered, agreed to trial its use. We retrospectively reviewed the case notes of all children who used TAIS over the next 5 years.

We also conducted an interview with each patient's primary carer using the validated Fecal Incontinence/Constipation Quality Of Life (FICQOL) questionnaire [12].

Results

Twenty-four patients (13 male) were instructed in the use of TAIS. The goal in these patients (aged 4 years and over) was to achieve faecal continence.

Median age at commencement was 6 years (range 4–16 years). Primary diagnosis was neuropathic bowel (secondary to myelomeningocele and sacral agenesis) in 15, anorectal malformation in five (1 with additional spinal anomaly), and Hirschsprung disease in four. Eight of the children with neuropathy had reduced mobility, requiring either a wheelchair

Discussion

This study has demonstrated that there are measurable improvements in faecal incontinence and quality of life when using TAIS for children with a range of underlying disorders where soiling is the end result. A small proportion of patients (12%) were unable to cooperate with its use; unfortunately, the sample size (3 patients) was insufficient to identify any prognostic factors regarding successful use, e.g. nature of underlying condition, sex, and age. There were no significant adverse

Conclusion

The Peristeen TAIS is a safe and effective method of improving bowel management in children with intractable faecal incontinence associated with myelomeningocele, anorectal malformation, and Hirschsprung disease. There were no significant complications associated with its use and tap water appears to be safe. Peristeen may be an effective non-operative “bridge” to MACE in younger children, or even a long-term alternative to MACE, if initial compliance can be achieved.

Ethical approval

The authors obtained ethical approval from their institutional ethics committee before commencement of the study and comply with the standards set forth in the Journal of Pediatric Urology.

Conflict of interest

None.

Funding

None.

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