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Surgical Treatment of Urinary and Fecal Incontinence

The Children's Hospital Department of Pediatric Urologic Surgery


ACE (Antegrade Continence Enema)

Some children are born with neurogenic bowels, or bowels that don’t work properly. This can lead to problems with stool incontinence, or stool accidents. While this may not be much of a problem in a child’s younger years, it may become a very difficult and embarrassing issue when your child is older. In addition, it will be more difficult for a parent to manage the neurogenic bowels in an older child.

An ACE is a surgical procedure that will provide a way for your child to be continent of stool. This is an option that that may be used after all other medical bowel regimens have failed. A channel or tunnel is created that extends from the large intestine out to the abdomen. Typically the appendix can be used to create this tunnel. Once this channel is created you and/or your child will be able to insert a catheter through this channel and give tap water enemas to clean out the bowels. The goal is to train the bowels to empty at one time during the day thus preventing accidents throughout the rest of the day.

The Malone Antegrade Continence Enema (MACE) uses the Mitrofanoff principle to allow catheter access to the bowel. Through the catheter a large volume tap water enema is infused to allow stool evacuation. This has become the mainstay of bowel therapy in recalcitrant stool incontinence in children with congenital anatomical and neurological fecal incontinence: spina bifida, imperforate anus, and cloacal anomalies.

Surgical Procedure

Prior to surgery your child will need a bowel prep to clean out the bowels. You will receive the bowel prep instructions along with prescriptions for antibiotics and bowel cleansers. This is started 48 hours before surgery.

 Antegrade Continence Enema

 

         An ACE being flushed.

The surgery itself will take approximately three hours. After surgery your child will have a foley catheter in the ACE for 4-6 weeks, which allows the surgery site to heal. The tap water enemas will be initiated several days after surgery, once your child is tolerating food. While your child is still in the hospital one of the urology nurses will teach you how to give the enemas through the ACE. The catheter will be plugged when is not being used.

Clinic Follow-up

Your child will need an appointment in our clinic 4-6 weeks after surgery for a x-ray called a KUB (Kidneys, Ureters and Bladder) and for tube removal. The x-ray will help us to evaluate whether the bowels are getting cleaned out well. Tube removal is very simple and quick. After the tube is removed you will just insert a catheter once a day to give the enema and then remove the catheter after the enema is complete.

Long-term Care

Taking care of the ACE is quite simple. The most important thing is to use the ACE daily. Possible problems with the ACE include:

    • The ACE closing, leading to difficulty inserting a catheter
    • Constipation

 It is important to notify the urology office immediately if you are having problems getting a catheter in the ACE.

If there is stool leaking around the ACE, it may be due to stool backing up secondary to constipation. You may need to use mineral oil in the ACE to help soften the stool. This is a good place to start if you are having problems with leaking stool and have poor results with your irrigations.

It may take up to 6 months BEFORE you have consistent results with the enemas. It is certainly not uncommon to have to adjust your irrigations and diet to assist in having a successful program. Try to be patient and persistent with the irrigations as you will eventually have success!

You may always reach one of the urology nurses if you are having problems with the ACE.