A total of 26 children were diagnosed with dyssynergia.
20 patients were diagnosed with Type I Dyssynergia with an average age of 9.9 years and a standard deviation (SD) = 2.6. There was a male: female ratio of 1.5:1.
6 patients were diagnosed with Type II Dyssynergia with an average age of 10.8 years, SD = 3.7. There was a male: female ratio of 2:1.
Clinical Presentation
20 patients (16 Type I and 4 Type II) displayed faecal soiling; 10 stated soiling occurred at least three times a week; 5 of these children reported daily soiling (Table 1). 19 patients (14 Type I and 5 Type II) documented long standing constipation, some existing for several years before their first gastroenterology visit. Stool size varied for all patients. 3 patients (2 Type I and 1 Type II) reported blood in their stool. 2 patients displayed withholding (1 Type I and 1 Type II).
Table 1: Table demonstrating the range of clinical features on presentation for different types of dyssynergia. Brackets by the type, denote the number of patients for each type (20 for Type I and 6 for Type II). Clinical presentation included soiling, constipation, blood in stool, nausea (and vomiting with number vomiting in brackets and abdominal pain.
(Table 1) Type of Dyssynergia
|
Clinical presentation
|
Soiling
|
Constipation
|
Blood in stool
|
Nausea (+ Vomiting)
|
Abdominal pain
|
Type I (20)
|
16
|
14
|
2
|
2(+ 2)
|
2
|
Type II (6)
|
4
|
5
|
1
|
1(+ 1)
|
1
|
Associated gastrointestinal symptoms
3 patients (2 Type I and 1 Type II) reported vomiting where 1 Type I patient had cyclical vomiting. 3 additional patients (2 Type I and 1 Type II) reported nausea. 3 patients (2 Type I and 1 Type II) reported abdominal pain. 5 cases (3 Type I and 2 Type II) reported difficulty with appetite. 6 patients had concerns with weight (3 Type I and 3 Type III).
Relevant past medical history (Table 2)
9 patients (8 Type I and 1 Type II) suffered from genito-urinary symptoms including enuresis, overactive bladder, dysfunctional voiding, bladder reflux of urine, balanitis xerotica obliterans and a transplanted kidney secondary to chronic kidney disease. 2 patients (both Type I) suffered from Ehlers Danlos Syndrome. 3 patients (all Type I) suffered from Eczema. 2 patients (both Type I) suffered from Asthma. 4 patients (2 Type I and 2 Type II) suffered from a food allergy including cow’s milk and peanut. 2 patients (both Type I) suffered from a neurological condition which included cerebral palsy and epilepsy. 3 patients (1 Type I and 2 Type II) underwent a surgical procedure unrelated to any prior condition above including adenoidectomy and tonsillectomy for a single patient as well as a hernia repair.
Table 2: Table showing comorbidities (Eczema, Asthma, Food allergy EDS – Ehlers Danlos Syndrome, Neurology, Urology/Nephrology, Autism, SLT – Speech and Language therapy and Psychiatric) for each type of dyssynergia. Brackets by the type, denote the number of patients for each type (20 for Type I and 6 for Type II). Neurology includes cerebral palsy and epilepsy. Urology/Nephrology includes eneuresis, overactive bladder, dysfunctional voiding, bladder reflux of urine, balanitis xerotica obliterans and a transplanted kidney secondary to chronic kidney disease. Psychiatric includes anxiety/family anxiety, suicidal ideation, traumatic event and known to psychology.
(Table 2) Types of Dyssynergia
|
Co-morbidities
|
Eczema
|
Asthma
|
Food Allergy
|
EDS
|
Neurology
|
Urology/Nephrology
|
Autism
|
SLT
|
Psychiatric
|
Type I (20)
|
3
|
2
|
2
|
2
|
2
|
8
|
0
|
2
|
13
|
Type II (6)
|
0
|
0
|
2
|
0
|
0
|
1
|
2
|
1
|
3
|
Birth History
3 patients (2 Type I and 1 Type II) were born premature, 2 of these patients were born as twins at 24 + 5weeks (1 Type I and 1 Type II) and spent three months on the neonatal intensive care unit. 2 patients (1 Type 1 and 1 Type II) were born by caesarean section.
Developmental History
2 Type II patients had a diagnosis of Autism (with an additional Type I patient undergoing Autism assessment). 3 patients (1 Type I and 2 Type II) suffered from short stature with 1 of these patients treated for failure to thrive. 3 patients (1 Type I and 2 Type II) were described as having poor coordination. 3 patients (2 Type I and 1 Type II) suffered from a speech and language problem including dyslexia and sensory/processing issues.
Psychological Health
13 patients (10 Type I and 3 Type II) were known to psychology. 6 of these patients reported longstanding anxiety with 2 mentioning significant family anxiety.
Family and Social Health
4 Type I patients had siblings who suffered from a developmental condition (with 3 being Autism and 1 Cerebral palsy). 3 Type I patients were listed as having some form of social issue. 1 Type II patient was diagnosed with foetal alcohol syndrome and adopted at 14 months. 4 patients (2 Type I and 2 Type II) have required adjustments at school ranging from toilet passes to permission for day’s off for disimpaction. 2 Type I patients who suffer from Ehlers Danlos Syndrome required home assessment by occupational health, and currently use a wheelchair.
Treatment
Table 3: Laxative: Table illustrating the number of patients who took each laxative for each type of dyssynergia. . Brackets by the type, denote the number of patients for each type (20 for Type I and 6 for Type II) Osmotic (Movicol, lactulose), Stimulant (sodium picosulphate, bisacodyl, senna), Docusate sodium (stool softener) and Glycerine suppositories. Where listed the maximum dose a patient was taking for each laxative is shown in brackets.
(Table 3) Type of Dyssynergia
|
Laxatives
|
Movicol (Osmotic)
|
Lactulose (Osmotic)
|
Sodium Picosulphate (Stimulant)
|
Bisacodyl (Stimulant)
|
Senna (Stimulant)
|
Docusate sodium (stool softener)
|
Glycerine suppositories
|
Type I (20)
|
14 (8 sachets)
|
2
|
13 (20ml)
|
6 (20mg)
|
4 (5ml)
|
1 (5ml)
|
1
|
Type II (6)
|
4 (24 sachets)
|
2 (20ml)
|
2 (10ml)
|
2 (20mg)
|
1 (50ml)
|
0
|
0
|
Laxatives
18 of the 20 patients with Type I dyssynergia were on at least one laxative. Of these patients 14 were on Movicol, 2 on Lactulose, 13 on sodium picosulphate, 6 on bisacodyl, 4 on senna, 1 on docusate and 1 on glycerine suppositories (Table 3). 4 of the 6 patients with Type II dyssynergia were on at least one laxative. Of these patients all 4 were on Movicol, 2 on lactulose, sodium picosulphate and bisacodyl while only 1 was taking senna (Table 3).
Disimpaction
15 of the 20 patients with Type I dyssynergia underwent disimpaction. Of these 15, 12 had underwent Transanal irrigation (TAI), 2 Klean prep, 1 phosphate enema and 6 had citrafleet (Table 4). All 6 patients with Type II dyssynergia underwent disimpaction, with all 6 using TAI, 1 phosphate enema and 2 citrafleet (Table 4).
Table 4: Disimpaction: Table demonstrating the number of patients for each type of dyssynergia who underwent a variant of disimpaction (Peristeen Transanal Irrigation, Klean Prep, Phosphate enema and Citrafleet. Brackets by the type, denote the number of patients for each type (20 for Type I and 6 for Type II)
(Table 4) Type of Dyssynergia
|
Disimpaction
|
Peristeen Transanal Irrigation System
|
Klean Prep
|
Phosphate Enema
|
Citrafleet
|
Type I (20)
|
12
|
2
|
1
|
6
|
Type II (6)
|
6
|
0
|
1
|
2
|
Antimotility agents
4 patients with Type I dyssynergia were using loperamide. 2 patients (1 Type I and 1 Type II) were taking buscopan.