Chronic constipation is fairly common in children and is the primary diagnosis in 25 percent of children referred to pediatric gastroenterologists. In a majority of these children, a nonorganic cause is at fault. The physical evaluation of a child with chronic constipation should include an abdominal and a rectal examination. The rectal examination is important for detecting organic pathology as well as fecal impaction. Gold and colleagues conducted a study to assess the frequency of digital rectal examination by primary care physicians before referral to a pediatric gastroenterologist.
All children referred to a pediatric gastroenterologist with a diagnosis of chronic constipation were included in the study. At the time of the initial evaluation, the parents, as well as the child (if possible), were questioned about the duration of constipation, what treatments had been used and whether the referring doctor had performed a digital rectal examination. All children subsequently underwent a rectal examination by the gastroenterologist. Treatment recommendations were then compared with prior regimens.
The study included 128 children ranging in age from one month to 13 years of age with a mean age of approximately four years. The mean duration of constipation was 23.3 months. Treatment before referral included dietary changes, lubricants, stimulant laxatives and suppositories. It was noted that enemas were rarely used. Of the entire group, 98 children (77 percent) did not have a rectal examination before referral. After examination, 53 were found to have a fecal impaction, and only 19 were found to have no stool in the rectal vault. In the remaining 26 children, varying amounts of stool were found. Forty-seven children had received stimulant laxative therapy without a rectal examination. In the entire group, an organic cause for the problem was found in three children. Two were diagnosed with an anterior rectal mass (hematocolpos) and did not have a prior rectal examination. The third child who reportedly had a preconsultation rectal examination was found to have anal stenosis. Two children were found to have large anal fissures and one had sacral asymmetry. None of these three children previously had a rectal examination.
Treatment recommendations by the pediatric gastroenterologists for the 98 children without a prior rectal examination included aggressive enemas followed by high-dose laxative therapy in 69 children; 15 others were given aggressive laxative therapy without enemas, and three were treated with mineral oil. Nine children younger than seven months of age were treated conservatively with glycerin suppositories, corn syrup solids or malt soup extract. The two children with hematocolpos required surgery.
The authors' primary observation from this study is that a rectal examination in children with chronic constipation is infrequently performed. Reasons for the examination not being performed could include the primary care physician's lack of comfort with performing rectal examinations or fear of traumatizing the child. The appropriate evaluation of any child with chronic constipation should include visual inspection of the perianal region, along with an abdominal and digital rectal examination. The latter can help distinguish constipation with a functional cause from constipation with an organic cause and will affect subsequent therapy.