Improvement in functional constipation while under chiropractic care in a pediatric patient with primary vesicoureteral reflux: a case report
Virginia A. Barber, DC1, Joseph M. Carfora, DC2, Thomas A. Wicks, PhD, DC, FACO1
1 Associate professor, Palmer College
2 Private Practice, Newburgh, NY
Journal of the Academy of Chiropractic Orthopedists
December 2016, Volume 13, Issue 2
This article is available from: http://www.dcorthoacademy.com © 2016 Barber, Carfora, Wicks and the Academy of Chiropractic Orthopedists. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Primary vesiculoureteral reflux (VUR) is the most common pediatric urologic abnormality. Severity is graded I (mildest) to V (most severe). Increasing severity, bilaterality, and presence of dysfunctional elimination syndrome, particularly constipation, decrease the likelihood of spontaneous resolution.
Objective: Describe the clinical presentation, treatment, and response of a 31-month-old female patient previously diagnosed with grade I right-sided VUR and grade IV left-sided VUR and chronic constipation to application of chiropractic manipulative therapy (CMT), abdominal massage, and probiotic supplementation.
Clinical Features: The patient was originally diagnosed at seven months with bilateral grade V VUR after hospitalization for Escherichia coli septicemia. She presented to a chiropractic clinic four days after her most recent visit to a pediatric urologist, who reiterated that her chronic constipation was the most negative prognostic factor for future non-surgical improvement in her grade IV left VUR.
Intervention and outcome: This patient was treated via instrument adjusting and manual CMT, abdominal massage, and probiotic supplementation over ten visits. During care, the child’s frequency of evacuation increased, her pain and fear of evacuation decreased, and stool consistency normalized.
Conclusion: Chronic constipation in a pediatric patient with VUR improved after initiation of a CAM care plan.
Primary vesiculoureteral reflux (VUR) is defined as the retrograde flow of urine from the bladder into the ureter(s) or the renal pelvis . Primary VUR is a heterogenous disease which may be related to congenital renal dysplasia, aberrant bladder contractility or function, or a predisposal to urinary tract infections (UTIs) . It is the most common urologic abnormality in children . Some studies indicate a prevalence of 25-40% in young children, and as high as 65% in infants up to six months . The International Reflux Study in Children produced a widely accepted radiographic grading scale for reflux severity. Grade I, the mildest form, indicates the backflow of urine into the distal ureter; grade V represents the most severe form, indicating gross dilation of the ureter, renal pelvis, and renal calyces (Figure 1). 
Figure 1: International Classification of Vesiculoureteral Reflux [1,2]. Illustration by
Alec Schielke, DC
Vesiculoureteral reflux has a 25-80% chance of spontaneous remission as the child matures [1,2, 8]. Several factors have been identified which make resolution less likely and slower to occur. Among these are the severity (grade) of the reflux, the presence of recurrent urinary tract infections (UTIs), and the comorbidity of chronic functional constipation [1,5].
Functional constipation refers to constipation without organic cause. It is one of the most common gastroenterological problems of childhood, and is defined as two or fewer defecations per week, consisting of large, hard, and painful bowel movements causing stool- withholding postures and abdominal pain . Constipation is a hallmark of dysfunctional elimination syndrome (DES), which is now considered to play a large part in predicting resolution of reflux and even the success of corrective surgery if deemed necessary [1,6,7,8].
DES refers to a broad spectrum of functional disturbances that may affect the urinary tract. These include attempts to suppress bladder contractions, or sphincter relaxation, by inappropriately contracting the pelvic floor muscles and tightening the sphincter. This in turn produces an increase in voiding pressure and an inability to completely drain the bladder, thereby encouraging reflux. Many authors now regard dysfunctional elimination behavior as not just related to but potentially causative of VUR [5,6,7,8,10]. Several studies have noted that higher rates of dysfunctional elimination syndrome (DES) and chronic constipation are seen in girls . Even after being diagnosed with VUR, and while on continuous antibiotic prophylaxis (CAP), girls have a greater risk of “breakthrough” UTIs than do boys, due to the higher frequency among girls of DES and constipation [6,7,8].
One author reports that 30% of children with constipation experience urinary incontinence or UTIs; these are children without the concomitant diagnosis of VUR . A hard, enlarged fecal mass can impact on the bladder or bladder neck, increasing storage pressure in the bladder and creating a residual urine volume perfect for microbial overgrowth . In children whose urinary tracts are already compromised functionally by VUR, constipation in childhood increases the likelihood of urinary incontinence, bladder overactivity, discoordinate voiding, a large capacity and poorly emptying bladder, recurrent UTI, and deterioration of VUR” 
A 31-month old patient was brought to a chiropractic clinic by her mother with a complaint of chronic functional constipation secondary to VUR. The child was diagnosed with grade V bilateral VUR at age seven months when she was hospitalized with a high fever. Escherichia coli septicemia was diagnosed, secondary to a urinary tract infection, and the patient was hospitalized and started on intravenous antibiotics. A voiding cystourethrogram (VCUG) revealed bilateral grade V reflux (Figure 2). Upon discharge, the patient was placed on CAP with Bactrim, and prescribed Miralax (to increase stool bulk) and Lactulose (osmotic agent to soften stool.) The child underwent repeat VCUGs every six months to evaluate for renal scarring and reflux grade status.
Figure 2: Voiding Cystourethreogram: The patient’s initial voiding cystourethrogram (VCUG), shown above, depicts bilateral grade V reflux. Subsequent VCUG tests have graded the patients left kidney at a IV while the right kidney has improved to a grade I.”
Her most recent VCUG in early 2015 showed an improvement in reflux on the right (to grade I) but little improvement on the left (now grade IV). The pediatric urologist managing her case reiterated the importance of controlling her constipation to maximize the chance of the reflux resolution, and possibly prevent surgical intervention. The child’s mother decided to consult a chiropractor about a trial of spinal manipulative therapy (SMT) to treat her daughter’s constipation. The urologist was open to this idea.
At the time of presentation to the chiropractor, the patient was having a bowel movement only every seven to ten days. The bowel movements were hard, painful, large, and protracted, and began with a prodrome of the child climbing into her mother’s lap and screaming and crying.
Upon examination, the patient appeared as a normally developed two-and-a-half-year-old child with a slight build. She scored in the 35th percentile for weight, 33rd for height, and 42nd for head circumference. Vital signs were normal. Abdominal examination revealed a taut, rounded contour over the entire abdomen, with tenderness and guarding on both light and deep palpation. The child’s mother noted that it had been at least two days since her last evacuation. The child was mildly anxious, and resistant to abdominal pressure. No obvious masses or pulsations were noted.
Chiropractic examination revealed sacral base posteriority on the right side with significant decrease in posterior to anterior (P-A) passive joint motion. In addition, the patient exhibited decreased lumbar extension with bilateral paraspinal hypertonicity in the upper lumbar region.
Treatment on the initial visit was performed by the chiropractor on a Zenith drop table. Thrusts were applied P-A over the right sacral base and bilaterally on the L1 and L2 mammillary processes. The patient was then placed supine on a pelvic bench with her knees flexed as the chiropractor performed external manual massage of the large intestine, starting in the right lower quadrant and proceeding clockwise along the flow direction of the large intestine. The parent was then taught this maneuver and asked to demonstrate it correctly. They were then directed to repeat it at home 1-3 times daily to patient tolerance. In addition, it was suggested that the parents administer a child-dosed probiotic daily, based on evidence of its stool-softening qualities as well as the child’s long-term antibiotic use. 
Initially, the child was seen weekly for adjustments and abdominal massage. Her bowel movements increased in frequency after the first and third adjustments, but not after the second. At this time the chiropractor recommended adding dried prunes to the child’s diet, as well as prune juice with prune pulp added. The parent was complaint, and fortunately the child enjoyed prunes. From the third visit on, the patient’s evacuations became more frequent and less dramatic. The parent stated that her child’s stools were softer, defecation was quicker, and there was no more crying as evacuation became imminent. By the sixth visit, the mother stated that her child was defecating “normally” every three days and that defecation had become pain- and anxiety-free for the child. By the 13th week of care, the child’s bowel movements were occurring every other day. At this point, care was reduced in frequency due to geographic hardship and holiday schedules. When the child returned for care after a four- week absence from the clinic, the parent reported one nine-day period without a bowel movement. However, the stools had not returned to their former hard consistency, and the child did not evince the fear behaviors previously noted. The parents plan to continue care for their daughter every two to three weeks as possible.
Functional constipation is considered to be multifactorial in origin and difficult to eradicate [6,11]. This young patient had had no improvement in her chronic constipation from the stool bulk enhancer or the osmotic stool softening agent she had been prescribed. Her parents were highly invested in adding a complementary and alternative medical (CAM) approach to her established treatment protocol for VUR. The pediatric urologist who had warned them about the gravity of unmanaged constipation in the resolution of VUR was supportive of their desire to add CAM care, which made their decision easier.
A review of the chiropractic literature on children and constipation yielded 14 case reports, one case series, one review of the literature, and a recent integrative review of the chiropractic literature. No randomized controlled trials (RCTs) have been performed to study the effectiveness of spinal manipulative therapy (SMT) in the reduction or elimination of constipation . Each case report provides anecdotal evidence of clinical success, and posits several plausible mechanisms by which SMT might effect a change in colonic motility, pelvic floor contractility, and coordination and sensitivity of the sphincters. The balance needed between the sympathetic and autonomic nervous systems in order to allow coordinated normal defecation may be directly interfered with by vertebral and /or sacral segmental dysfunction, particularly in the area of sacral nerves 2-4 and the pudendal nerve. Alternately, the negative effect may be via noxious input from mechanoreceptor derangement or other afferent “white noise”. In either case, a positive response to SMT does not seem implausible.
The logic for employing abdominal massage was twofold. First, there is some evidence in the literature that abdominal massage can positively impact constipation, although no RCTs have been performed . Second, we hoped to reduce this young patient’s apprehension of and discomfort with having her abdomen touched or pressed. We felt that her fear of the sensation of any type of pressure on or in her lower abdomen might have contributed to her dysfunctional ressponse (tightening the pelvic floor and sphincters when she felt the urge to defecate). In adults, preliminary work has been done on pelvic floor retraining via computer feedback which has shown a positive effect on constipation .
In addition, we chose to suggest administration of a probiotic supplement after consideration of her long-term antibiotic use via CAP, and the known effects of antibiotics on the balance of gut flora. We also considered findings in the literature which supported the efficacy of a mixture of Lactobacillus and Bifidobacterium in “…increasing stool frequency and improving stool consistency” in adults . For both the abdominal massage and the probiotic therapy, we felt strongly that giving the parents an active role in potentially ameliorating their daughter’s chance to avoid surgery was important enough to balance the lack of higher-level studies definitely proving that either approach was guaranteed to work. Neither abdominal massage nor probiotic supplementation has been linked to adverse events when properly administered. The child’s urologist was comfortable with both interventions as adjuncts to the trial course of SMT.
Finally, we must consider the placebo effect. Both pediatric and adult patients with functional gastrointestinal disorders often show high success rates for placebo (60% in one study) . However, even if some of the overall improvements in this case were attributed to a placebo effect, the objective improvement in this patient’s functional constipation, as measured by increased frequency of evacuation, enhanced bulk and softness of stool, and decreased pain around and during defecation, has been exciting and rewarding for the family as well as the clinicians.
All the limitations of the case report format apply here, and thus we are very restricted in drawing inferences from this one patient as to the efficacy of SMT in the management of pediatric functional constipation. However, the significant and ongoing improvement in this patient’s presentation suggests that higher-level investigation of SMT for childhood constipation may be warranted.
Written informed consent was obtained from the patient’s guardians for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
VB conceived of the case report, researched the literature before beginning patient care, reviewed and annotated the literature search for case report, was supervising physician on the case, drafted the introduction and discussion, and wrote final version of paper.
JC researched the literature before beginning patient care, performed the literature search after case report was conceived, performed his own annotations of literature search, designed patient management protocol, was the treating intern throughout care, and participated in each revision of manuscript.
TW read and annotated literature search, participated in patient care supervision when VB was absent, and assisted with revisions of introduction and discussion.
All authors read and approved the final manuscript.
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