Last reviewed: 5 Nov 2021
Last updated: 01 Feb 2019



History and exam

Key diagnostic factors

  • history of anorectal, neurological, or spinal abnormalities, or gastrointestinal surgery
  • faecal soiling or diarrhoea
  • constipation
  • peri-anal skin irritation
  • abnormal rectal examination
  • spinal deformities
  • weakness and decreased or absent reflexes

Other diagnostic factors

  • behaviour problems
  • painful bowel movements
  • abdominal pain/cramping
  • posturing described as tightening of buttocks
  • enuresis
  • anorectal malformation
  • abnormal abdominal examination
  • history of underlying medical condition

Risk factors

  • chronic constipation
  • male sex
  • age: 5 to 6 years
  • diet lacking in fibre
  • inadequate fluid intake
  • delayed or inadequate toilet training
  • anorectal malformations
  • Hirschsprung's disease
  • spinal abnormalities
  • psychological or behavioural problems due to stressful family events
  • psychiatric disorders
  • medication overuse

Diagnostic investigations

Investigations to consider

  • unprepared barium enema
  • spinal x-ray
  • MRI spine
  • radiopaque marker transit x-ray
  • colonic and rectal manometry studies
  • rectal biopsy
  • serum thyroid-stimulating hormone level
  • serum free T4 level
  • sweat chloride test
  • tissue transglutaminase IgA

Treatment algorithm



Linda S. Nield, MD, FAAP
Linda S. Nield

Professor of Pediatrics

West Virginia University School of Medicine




LSN is an author of a reference cited in this topic.

Brian D. Riedel, MD

Associate Professor of Pediatrics

Section Chief of Pediatric Gastroenterology, Hepatology and Nutrition

West Virginia University School of Medicine




BDR declares that he has no competing interests.


Dr Linda S. Nield and Dr Brian D. Riedel would like to gratefully acknowledge Dr Uwe Blecker, a previous contributor to this topic.


UB declares that he has no competing interests.

Peer reviewers

John C. Thomas, MD

Assistant Professor

Division of Pediatric Urology

Monroe Carell Jr. Children's Hospital at Vanderbilt




JCT declares that he has no competing interests.

David C. A. Candy, MBBS, MSc, MD, FRCP, FRCPCH, FCU

Consultant Paediatrics Gastroenterologist

Western Sussex Hospitals NHS Trust


Honorary Consultant Paediatric Gastroenterologist

Royal Alexandra Children's Hospital

Brighton and Sussex University Hospitals




DCAC has received research grants, consultancy fees, and reimbursement of conference expenses from Norgine UK, the manufacturer of Movicol. He is the author of a systematic review of polyethylene glycol-based laxatives; convenor of the Paris Consensus on Constipation Terminology Group; and external advisor of the National Institute for Health and Care Excellence paediatric constipation guideline development group.

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