[size=6]A 4-year-old with a history of perineal anoplasty for a recto-perineal fistula presents with longstanding constipation. The anoplasty is well situated within the sphincter complex without a stricture. X-rays demonstrate copious stool throughout the colon. The most appropriate first step in bowel management for this patient is:

 

a Manual disimpaction

 

b Initiate weight-based daily senna

 

c Exam under anesthesia

 

d Start a psyllium-based fiber supplement

 

e Water-soluble contrast enema study[/size]

E

correct answer

e Water-soluble contrast enema study

 

The first step in successful bowel management is starting with a clean colon. This can be achieved with a water-soluble contrast enema, which not only kick starts clean-out of the colon, but also provides anatomical data regarding focal dilations or narrowing. Invasive procedures and utilization of the operating room and sedation should be minimized to better ensure longitudinal buy-in from the patient and their family. Fiber supplementation, particularly in the setting of impaction and without other measures such as stimulants or enemas should be avoided.

B.

Constipation following repair of a rectoperineal fistula is commonly managed with a stimulant laxative such as senna when the anoplasty is anatomically satisfactory. The dose is adjusted to achieve effective daily colonic emptying. Fiber alone is unlikely to adequately treat substantial stool retention.

A water-soluble contrast enema is a diagnostic investigation; it does not provide the initial therapeutic cleanout needed for established fecal impaction. It can assess colonic anatomy, dilation, or a suspected structural obstruction. In this question, the anoplasty is well positioned with no stricture, so the intended priority is to clear retained stool, followed by maintenance senna.