Medical Problems that Can Arise Because of Constipation

Anal fissure/blood in the stool

Constipated children occasionally pass small amounts of bright red blood on the outside of the stool, on the toilet paper, or in the diaper. Most rectal bleeding comes from one or more small cuts or tears on the outside of the anus.

These anal fissures are caused (in part) by injury from hard stools and from trauma from wiping too hard or too much. Despite their small size, fissures can hurt a lot (like a paper cut) and they can bleed more than you would have expected.

Now imagine being 2 and having stinging pain with every poop. We’ve discussed this concept in our article on fear of pooping. A fissure can be painful enough to make children hold their stool much longer than they need to. The treatment for an anal fissure is to:

a. Get excess stool out of the colon (see our article on a plumbing plan to get poop out.)

b. Keep poops mushy enough to prevent re-injuring the fissure (see our article on osmotics, which are poop softeners.)

c. Sitzbaths: warm water + Epsom salt baths (link to sit baths)

d. “Tender Loving Care” when wiping the bottom. Chemical free baby wipes, gentle creams, less friction

e. A gentle topical steroid cream (typically 2.5% hydrocortisone)

Not all blood in the stool is from constipation or from anal fissures. Blood in stool, regardless of source, should be reported to the primary care doctor. This is the place to decide if a more extensive medical workup is needed.

Belly pain

The range of discomfort with childhood constipation is really all over the map. Some kids haven’t pooped in a week and you’d never know it by how they are acting. Others complain of pain throughout the day. More often than you would expect, pain from constipation is severe enough to send a family to the emergency department for an evaluation for appendicitis.

Many children with constipation complain of belly pain after a meal. While eating, our body sends a message to the colon to start squeezing harder and faster. This is a normal process called the gastro-colic reflex. It is designed to clear some room for the new food entering the intestinal system. If you have a lot of hard and compressed stool being pushed towards the exit point can cause cramping and discomfort.

When belly pain is severe enough to interfere with eating, sleeping, playing, or going to school, a cleanout can be effective in getting pain down and poop out. For more on clean outs, see above.

Bed wetting and daytime urine accidents

Urinary incontinence (urinating in underwear at night and/or during the daytime) is common in children who retain too much stool. A lot of stool in the colon will apply pressure on to the neighboring bladder. This pushing on the bladder prevents it from fully emptying out. Children with this problem are essentially always walking around with a semi-full bladder.

Parents do the obvious: They make their child urinate RIGHT before they leave the house for the birthday party—until there’s nothing left!–but nonetheless, they wet their pants right when they arrive. They were never empty to begin with.

Many parents are surprised by daytime wetting, because it seems easier to avoid than when one is asleep in bed. But remember, that with very stretched out bowels, children have often lost sensation to defecate. The same applies to the bladder: A chronically stretched out bladder will lead to loss of sensation to urinate. And thus, daytime wetting even while sitting in class.

Many women who have experienced pregnancy have also experienced urinary leakage. It commonly occurs during later stages of pregnancy because a fetus is pushing on the bladder. It’s the pushing (whether by poop or by a baby) that leads to all the trouble.

Urinary Tract Infections

Urinary tract infections (UTIs) occur for the same reason that wetting occurs: Too much urine sitting around. Urine sitting too long in the bladder is vulnerable to getting infected. This is similar to why stagnant pools of water get scummy so it’s cleaner to keep water flowing.

UTI’s can lead to permanent injury or scarring of the kidneys if they are serious or frequent enough. Thus, they are often a “call to action” to get aggressive in managing constipation.

Tests and specialists: when to do a workup

So what I could we be missing medically?

This is the questions that keeps many families up at night. They worry that their doctor “just keeps pushing laxatives”. They question whether more needs to be done.

To re-word this common frustration in to a question: Wouldn’t it be worth doing some testing just to make sure we aren’t missing anything? Maybe there’s something wrong with the anatomy. There could be nerve problems! Food allergies!

While there are some easy tests to do, each test only rules out one or two things each. So you can do a lot of tests if you want to. But of course you have to balance this with not wanting to put your child through anything UNNECESSARY.

So I’ve found it most helpful for families to understand WHAT COULD WE BE MISSING? What’s out there? What could we even conceivably think about testing for? What questions do they answer? What are the downsides?

Easy blood tests

The first three conditions are grouped together because they are easily tested for with blood work. Blood tests are commonly ordered to rule out or screen for:

1. Celiac disease (sensitivity to gluten)

2. Hypothyroidism (low thyroid hormone)

3. Electrolyte abnormalities (low calcium, low magnesium)

And while negative tests should provide some peace of mind, you must weigh that reassurance against putting your child through a blood draw. For some families, it will feel worth it. For others it won’t. Your doctor should be able to help you sort out the value of getting blood tests.

Imaging tests

In some cases, there may be a concern for an anatomic problem—a birth defect in the anus that has rendered a child prone to serious constipation. These conditions are collectively referred to as anorectal malformations. For these patients, the test of choice is a barium enema. In this test, we have to squirt contrast from an enema into a child’s bottom, and then we take XRAYS of the pelvis from multiple positions. Your child is awake for this….and typically not happy with any of us. The test requires more radiation than a typical XRAY.

An MRI of the spinal cord is used to rule out a tethered cord (5 to 6 per 100000 live births). In tethered cord, the very bottom of the spinal cord is caught inside the lowest part of your spine—the sacrum. There is a wide range of symptoms that patients may have, but one of the symptoms can be constipation, stool incontinence, and/or urinary incontinence. The test to rule this out is an MRI of the spine. Most children under age 6 need to be sedated in order to get them to lay still for the amount of time needed to get an MRI done (typically 30-60 minutes). That’s a major downside for families who want to get testing done.

XRAYs have their place. In constipation, they help in the following ways:

1. Assessing how much stool is retained in the colon

2. Ruling out fecal impaction (stool stuck in the rectum)

3. Ruling out an obstruction of the intestines.

Doctors love to order them to “see how much stool is in there”, but there are a lot of convincing scholarly arguments against their use. You really have to ask yourself whether getting the information on the XRAY will actually help you decide what to do, and XRAYS aren’t necessarily that helpful. Since there is radiation involved in XRAY tests, we owe it to our patients to use that test only when we think the test will be helpful.

At some point, I will delve head first in to the discussion of how little role a plain XRAY of the belly actually plays in making medical decisions. But we will have to save that for a future post.

Manometry testing

Anorectal manometry measures the pressures of the anal (sphincter) muscles, the sensation in the rectum, and the nerve reflexes that are needed for normal bowel movements. It is primarily used to rule out disorders involving the anal sphincter. including Hirschsprung’s disease. This is rare (about 1 in 5000 births). It is caused by an absence of nerve cells in the intestine. It leads to the anus being unable to relax. If the anus cannot relax, infants and children have trouble passing poop out. In a majority of patients it presents as an obstruction in infancy. In fact most patients are discovered in the first few days of life because they fail to pass meconium (the initial sticky/tarry stool that your baby makes) in the first 48 hours of life. It is felt that about 5% of children with Hirschsprung’s disease will not be diagnosed in this early infancy period. That’s not a lot of patients. So if you are a parent trying to decide whether it’s worth putting a catheter up into your child’s rectum while they are awake, you should consider with your doctor how likely it is to help give you answers.

Important Red Flags

A red flag isn’t actually a call to action per se. A red flag is something in your child’s story that is at least worth a mention to your primary care office (by phone, secure message, or office visit). It may be worth some additional testing or perhaps treatment.

1. Blood in the stool: Sometimes blood in the stool is not concerning–like after some hard poops have led to

2. Mucous persistently seen in the stool

3. Recurring or persisting fevers

4. Vomiting

5. Food refusal or decreased appetite

6. Weight loss

7. Pooping regularly in the middle of the night: This suggests that there is some sort of inflammation in the bowels and it probably means it’s time to see the doctor, to figure out what’s wrong.

8. Didn’t pass meconium within the first 48 hours of life: This would make me wonder about Hirschsprung’s disease

9. Numbness, tingling, or progressive weakness in the legs: Nerve impingement (tethered cord) could do this and it can lead to issues with bowel and bladder incontinence.