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Functional fecal incontinence in infants and children: Definition, clinical manifestations, and evaluation

Functional fecal incontinence in infants and children: Definition, clinical manifestations, and evaluation
Literature review current through: Jan 2024.
This topic last updated: Jun 06, 2022.

INTRODUCTION — Fecal incontinence, also known as encopresis or soiling, refers to the repetitive, voluntary or involuntary, passage of stool in inappropriate places by children four years of age and older, at which time a child may be reasonably expected to have completed toilet training and exercise bowel control.

Fecal incontinence usually is related to underlying constipation [1]. In many cases, the constipation is well recognized before the child presents with fecal incontinence. In other cases, the underlying constipation is not recognized by the child's family/caregivers and is only identified after a focused history and physical examination is performed. Treatment of fecal incontinence differs depending on the presence or absence of underlying constipation.

The definition, clinical manifestations, and evaluation of fecal incontinence will be discussed here. Related material is presented in the following topic reviews:

(See "Constipation in infants and children: Evaluation".)

(See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis".)

(See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment".)

DEFINITIONS AND DIAGNOSTIC CRITERIA — Guidelines for the diagnosis of functional gastrointestinal disorders have been published by the panel of the Multinational Working Teams to Develop Criteria for Functional Disorders (Rome IV) [2,3] and affirmed by international societies for pediatric gastroenterology [4].

Functional constipation — Functional constipation is defined by criteria that include stool frequency, hardness, and size; fecal incontinence; painful defecation; or volitional stool retention (table 1) [2,3]. Although abdominal pain is often associated with functional constipation, it is not among the diagnostic criteria.

Functional fecal incontinence — Functional fecal incontinence is the involuntary passage of stool in the underwear after the acquisition of toileting skills, in the absence of overt neuromuscular anorectal dysfunction. This term is preferred rather than encopresis or soiling. It is classified into two types [3]:

Retentive — Functional fecal incontinence is classified as "retentive" if it is associated with functional constipation (ie, a history of retentive posturing or excessive volitional stool retention, history of hard or painful bowel movements, presence of large fecal mass in the rectum, or history of passing large-diameter stool [2,3]).

Nonretentive — Functional fecal incontinence is considered "nonretentive" if it occurs in the absence of symptoms and signs of functional constipation. The diagnostic criteria for nonretentive functional fecal incontinence are [3]:

At least a one-month history of the following symptoms in a child with a developmental age older than four years:

Defecation in locations inappropriate to the social context

No evidence of fecal retention

After appropriate medical evaluation, the fecal incontinence cannot be explained by another medical condition

In these children, the physical examination is normal and excessive stool is absent on rectal or radiologic examinations. By definition, there is no evidence of underlying disorders of motility or anorectal sensorimotor function.

EPIDEMIOLOGY — Functional fecal incontinence affects approximately 1 to 4 percent of four-year-old children and 1 to 2 percent of children seven years and older [5].

Retentive – Approximately 80 percent of children with fecal incontinence have retentive fecal incontinence (ie, have underlying constipation) [5-7]. Conversely, fecal incontinence is a common symptom of constipation. In a study of 418 constipated children, 68 percent of boys and 52 percent of girls presented with fecal incontinence [8]. Functional constipation and associated fecal incontinence is particularly common among children with attention deficit hyperactivity disorder (ADHD) [9,10] and autism spectrum disorder [11], as well as those with anxiety and depressive symptoms. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis".)

Nonretentive – Approximately 20 percent of children with fecal incontinence have nonretentive fecal incontinence (ie, do not have underlying constipation) [5-7]. This proportion varies among studies depending on the population and diagnostic criteria; in one study involving nearly 500 children with fecal incontinence, only 5 percent met criteria for the nonretentive form [1]. The disorder is approximately four times more common in boys than girls [12].

PATHOGENESIS

Retentive – Functional constipation is associated with several types of environmental triggers. In particular, there are three periods in which the developing child is particularly prone to develop constipation [13]. The first occurs after the introduction of cereals and solid food into the infant's diet, the second with toilet training, and the third during the start of school. Other common triggers are psychosocial stressors such as separation from parents or schedule changes. Any of these triggers can lead to a painful, frightening, or otherwise distressing experience associated with defecation. Because the child wishes to minimize this experience, they attempt to avoid evacuation ("stool withholding"), which further contributes to the constipation. The pathophysiology of functional constipation is discussed in detail separately. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Contributing factors'.)

The triggers and pathophysiology that cause functional constipation are also associated with the development of retentive fecal incontinence. It is not clear why fecal incontinence develops in some children with constipation and not in others. Among children with constipation, there are no clear differences in pathophysiology or psychology between those with and without fecal incontinence. In both groups, constipation in children is frequently triggered by dietary changes, psychosocial stressors such as separation or schedule changes, and/or behavioral adaptations such as stool withholding.

Nonretentive – The causes of nonretentive fecal incontinence remain unclear [5]. As for functional constipation, there is some association with psychological and behavioral symptoms, including attention problems and anxiety and mood disorders. In a large study, behavioral problems were somewhat more common in children with nonretentive fecal incontinence compared with those with retentive fecal incontinence (59 versus 49 percent) [14]. Fecal incontinence episodes are generally linked to certain persons or situations (eg, visits to a divorced parent), suggesting that there are specific triggers for the acute soiling episodes [13]. However, up to 40 percent of children have never been toilet trained properly, suggesting a longstanding underlying physical or environmental cause [5]. It is unclear whether the associated psychosocial problems are a cause or consequence of the incontinence. Nonretentive fecal incontinence appears to be somewhat more common in children with a history of sexual abuse compared with the general population and has also been reported in children referred for psychiatric problems [15]. However, although some cases of fecal incontinence are associated with emotional stress, the isolated symptom of fecal incontinence does not appear to be a marker for sexual abuse.

Nonretentive fecal incontinence also can result from surgical resection of the rectosigmoid colon, eg, in children following pull-through surgery for Hirschsprung disease [16] or following surgery for imperforate anus, especially in patients who have suboptimal anal sphincter pressure. Proctitis may cause urgency and fecal incontinence and can usually be distinguished by its acute or subacute onset and associated rectal bleeding. Proctitis in children usually results from inflammatory bowel disease but may also be due to cow's milk protein intolerance, infection, or radiation injury.

CLINICAL MANIFESTATIONS — Children with fecal incontinence most commonly present with repeated soiling of their underwear. Some parents may mistake this type of soiling for diarrhea [17]. The child frequently denies both the visible and olfactory signs of soiling of their underwear. The child may appear oblivious or nonchalant about the problem, even though it may be a source of considerable embarrassment and confusion for the child, frustration for the parents, and a cause of social stigmatization among peers. In some cases, the episodes appear to be triggered by emotional stress; this is somewhat more likely in the nonretentive form of fecal incontinence. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Contributing factors'.)

Other symptoms may coexist with fecal incontinence. In one series, more than one-half of children had abdominal pain ranging in quality from vague chronic discomfort to severe attacks several days before a large bowel movement or even daily [18]. If the abdominal pain persists after the child begins to pass soft, regular bowel movements with laxatives, the possibility of constipation-predominant irritable bowel syndrome should be considered. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation".)

Among children with nonretentive fecal incontinence, 15 to 50 percent have concurrent daytime and/or nighttime urinary incontinence [19-21]. Some experts consider concurrent fecal and urine incontinence in otherwise healthy children without signs of fecal retention as a combined bowel and urine elimination dysfunction disorder [22]. An underlying behavioral or neurodevelopmental disorder is thought to be the cause. Urinary incontinence is also reported in up to 45 percent of children with functional constipation, with or without fecal incontinence [23]. (See "Constipation in infants and children: Evaluation", section on 'Constipation and bladder dysfunction' and "Etiology and clinical features of bladder dysfunction in children", section on 'Bowel and bladder dysfunction'.)

HISTORY AND PHYSICAL EXAMINATION — The initial evaluation of a child presenting with fecal incontinence is similar to that of a child presenting with constipation and is discussed in detail separately. (See "Constipation in infants and children: Evaluation".)

Goals — In the child with fecal incontinence, the evaluation has three goals:

Exclude underlying organic or anatomic disease as a cause of the incontinence

Determine whether the child has underlying constipation

Assess for psychosocial precipitants that may contribute to the underlying constipation or to nonretentive fecal incontinence

History

Exclude organic causes — The history should evaluate for organic disorders that may be associated with the incontinence by causing underlying constipation, interfering with regular toileting habits, or affecting sphincter control (table 2) [4]. These are responsible for a small minority of cases of fecal incontinence (approximately 5 percent) [19] and include:

Static neurologic disorders (cerebral palsy, hypotonia, or intellectual disability).

Congenital anterior displacement of the anus (ectopic anus). (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Anorectal anomalies'.)

Progressive neurologic disease, such as tethered cord or other manifestations of spinal cord dysraphism. These disorders are rare causes of fecal incontinence but should be considered in patients with refractory constipation. There may be associated muscle weakness or back pain, but some children have no other neurologic symptoms [24]. (See "Closed spinal dysraphism: Clinical manifestations, diagnosis, and management".)

Hirschsprung disease is occasionally first identified in children presenting with chronic constipation if it is a short-segment form and is not diagnosed at birth but is unlikely in a child with fecal incontinence. A subset of children who have undergone pull-through surgery for Hirschsprung disease develop fecal incontinence due to resection of the rectosigmoid colon, which is the storage region for stool. In these patients, high-amplitude colon contractions can propagate right up to the anal verge and the frequency of high-amplitude colon contractions can also be increased [16]. These patients tend to present with history of passing multiple soft and painless bowel movements every day and can have associated urgency. (See "Congenital aganglionic megacolon (Hirschsprung disease)", section on 'Postoperative outcomes and management'.)

Organic causes of constipation are discussed in more detail separately. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Differential diagnosis'.)

Evidence of constipation — It is critical to distinguish between children in whom the fecal incontinence is related to constipation and those with nonretentive fecal incontinence or incontinence following colorectal surgery because the treatment will differ. The constipation may be obvious and well recognized before the child presents with fecal incontinence. In other cases, the symptoms of constipation are subtle and have not been previously recognized by the child's family/caregivers. Even if constipation is initially excluded, the parents and provider should remain vigilant for new evidence of constipation.

Valuable information to determine if there is underlying constipation includes (table 3):

The intervals between bowel movements and amount, diameter, and consistency of the stool deposited into the toilet and of stools deposited into the underwear (table 1) [18]. Information about stool consistency and volume is important because some children have daily bowel movements but evacuate incompletely. Stools that tend to clog the toilet strongly suggest underlying constipation.

The timing of episodes of incontinence. Many children with underlying constipation will have episodes of incontinence during sleep, whereas children with functional nonretentive fecal incontinence will more often have episodes during the afternoon and evening [5].

Psychosocial precipitants and comorbidities — Children with fecal incontinence should be screened for psychological symptoms, including anxiety, depression, and behavioral symptoms; validated questionnaires may be useful for this purpose [19]. In addition, understanding the psychosocial context in which the problem arose may provide clues to whether there is underlying constipation and whether there are psychosocial stressors that either exacerbate the problem or interfere with treatment.

A history of events that may have precipitated the onset of symptoms. Common triggers for constipation and encopresis include toilet training, separation (eg, starting school or divorce), or other emotional stressors or a change in the child's daily schedule that may have interfered with regular toileting.

Attention deficit hyperactivity disorder (ADHD) is associated with higher prevalence of fecal and urinary incontinence. Although the underlying mechanism for fecal incontinence in ADHD is poorly understand, it is likely to be multifactorial. Altered communication between the central nervous system and the enteric nervous system causing altered signaling of rectal distention, medication side effects, and delayed gastrointestinal motility have been implicated. Because of the distracted behavior, children with ADHD may not respond appropriately to physical cues signaling a need for defecation or urination and may have difficulty interrupting other tasks for these bodily functions [9]. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Predisposing conditions'.)

The child's relationships with family members, peers, people at school, and adults with whom they come into contact. The answers can disclose an important influence on the child's toileting behavior. In some cases, they can reveal a hidden focal point for his or her constipation and/or fecal incontinence. Careful questioning may reveal a troublesome, threatening, or confusing event associated with certain important persons (power figures such as a parent or teacher), places (such as the school and school bathroom), events (such as parental divorce), or things (such as the toilet itself).

Children who are victims of sexual abuse may present with physical symptoms or findings, including fecal incontinence, enuresis, or anogenital problems [25]. Behavioral changes may be disclosed during the history, including sexual acting out, aggression, depression, eating disturbances, and regression. A history of sexual acting-out behavior can be a marker for sexual abuse and warrants referral for further psychiatric evaluation, if not already done [15]. If there are any concerns of sexual abuse, it is important for the clinician to carefully obtain and record the child's statements since physical findings are often within normal limits; referral to an appropriately trained child psychologist should be considered. (See "Evaluation of sexual abuse in children and adolescents".)

Physical examination — The physical examination for a child with fecal incontinence is similar to that for a child with constipation (table 3), except that the clinician should be particularly alert for signs of neurologic dysfunction. It is important to exercise sensitivity and patience during the examination since children with constipation may be particularly fearful of anal and digital rectal examination and a few may have a history of physical or sexual abuse.

Abdomen – An abdominal fecal mass, indicating underlying constipation, can be palpated in approximately one-half of the children with fecal incontinence [18].

Digital rectal examination – In patients with fecal incontinence, a digital examination of the rectum should be performed if at all possible. By contrast, a digital examination is not routinely needed for patients with a typical presentation of functional constipation. The rectum is significantly dilated and packed with stool in more than 90 percent of children with underlying functional constipation, except in those who have recently had a large bowel movement. Children who have retentive fecal incontinence often resist the examination by squeezing their buttocks tight and voluntarily increasing the external anal sphincter tone. In contrast, reduced tone of the anal sphincter as assessed during the digital examination suggests either large fecal retention (with inhibition of resting sphincter tone) or a disease involving the sphincter (or both). A patulous anal canal suggests an underlying neurologic disorder or can be due to surgical repair of imperforate anus.

Perineum and anus – Examination of the perineum and perianal area may reveal fecal material, anal irritation, or fissures. Ectopic or anterior displacement of the anus can be diagnosed on inspection of the perineum by observing the relationship of the perineal pigmentation to the anus (figure 1).

Spine – Examination of the lower back for a sacral dimple, excess hair, or lipoma might indicate a form of closed spinal dysraphism (spina bifida occulta), which may cause fecal incontinence because of neurologic impairment. (See "Constipation in infants and children: Evaluation", section on 'External examination' and "Closed spinal dysraphism: Clinical manifestations, diagnosis, and management", section on 'Cutaneous'.)

Neurologic examination – On neurologic examination, using a cotton swab to elicit an anal wink tests the perianal sensation and function. Sensation and strength of the lower extremities should be examined. Abnormalities in this examination may indicate spinal cord dysraphism or impingement and should prompt further work-up, including magnetic resonance imaging of the spinal cord. (See "Closed spinal dysraphism: Clinical manifestations, diagnosis, and management", section on 'Evaluation and diagnosis'.)

The physical examination for specific organic causes of constipation is discussed in more detail separately. (See "Constipation in infants and children: Evaluation", section on 'Physical examination'.)

FURTHER EVALUATION — Most children with fecal incontinence associated with constipation require minimal testing or imaging work-up. However, specific testing may be appropriate in some cases, especially for those with nonretentive fecal incontinence.

Imaging

Abdominal radiograph

Retentive fecal incontinence – Evaluation with a plain abdominal radiograph is not recommended for routine evaluation of children with constipation, including those with constipation-associated (retentive) fecal incontinence, if the abdominal or rectal examinations confirm the presence of a large stool mass [4]. This is because an abdominal radiograph is not particularly specific for constipation, is inconsistently interpreted by different clinicians, and rarely adds value to the diagnosis if the constipation has already been identified by rectal examination. However, in selected cases, radiography can be helpful to document retained stool when there is inadequate relevant historical information or if the physical examination is limited by patient cooperation or obesity or is deferred for psychological considerations. In children with constipation and any findings highly suspicious for spinal dysraphism or neurologic dysfunction, advanced imaging is indicated to exclude lower spine abnormalities. (See "Constipation in infants and children: Evaluation", section on 'Imaging' and "Closed spinal dysraphism: Clinical manifestations, diagnosis, and management", section on 'Evaluation and diagnosis'.)

Nonretentive fecal incontinence – An abdominal radiograph is reasonable but not required for children with suspected nonretentive fecal incontinence. Nonretentive fecal incontinence should be suspected if there is no evidence of constipation on physical examination or history, and the radiograph may help to confirm that there is no occult constipation.

Colonic transit studies – Colonic transit studies evaluate colonic motility by tracking the passage of radiopaque markers using radiography. These studies are not necessary for the routine evaluation of constipation. However, they may be useful to help distinguish between retentive (constipation-associated) fecal incontinence and nonretentive fecal incontinence if the diagnosis is unclear after a thorough initial evaluation [4]. Colonic transit time is prolonged in a majority of children with constipation and normal or rapid in most children with nonretentive fecal incontinence [6]. (See "Constipation in infants and children: Evaluation", section on 'Radiopaque marker studies'.)

Laboratory testing — Laboratory testing is not needed for the routine evaluation of a child with constipation, with or without fecal incontinence [4]. However, certain tests may be appropriate if an underlying cause of the constipation is suspected based on the history and physical examination (table 2). Tests may include celiac serology, thyroid-stimulating hormone, electrolytes and calcium, or blood lead level. A urine culture is appropriate if the child has enuresis or daytime wetting. (See "Constipation in infants and children: Evaluation", section on 'Laboratory tests'.)

In addition, laboratory testing is appropriate for patients who fail to respond to an appropriate and carefully administered intervention program, including disimpaction, frequent and effective use of laxatives, and behavioral management.

Anorectal manometry — Anorectal manometry does not generally help to distinguish between children with retentive (constipation-related) and nonretentive fecal incontinence [26]. However, it may be helpful to evaluate selected children with intractable symptoms who have been unresponsive to treatment or those who have had a pull-through operation for Hirschsprung disease. (See "Constipation in infants and children: Evaluation", section on 'Anorectal manometry'.)

If manometry is performed, the findings may provide evidence supporting the following diagnoses:

Retentive (constipation-related) fecal incontinence – Supportive findings include colonic inertia (with a high rectal sensation threshold), anal sphincter spasm (eg, increased sphincter tone in the presence of an anal fissure due to fear of pain), or paradoxical external sphincter contraction. These findings are not always present [26,27].

Nonretentive fecal incontinence – Children with this condition usually have normal manometric findings (ie, no abnormalities of anorectal sensorimotor function), but they may have abnormal defecation dynamics (coordination) [6,26].

Neurologic dysfunction caused by spinal cord abnormalities – Typically associated with robust anal sphincter relaxation with relatively small rectal balloon size and anal sphincter spasm following balloon distension [28].

Disruption of the anal sphincter – Manometric findings may include low anal sphincter pressure; the sphincter disruption can be further evaluated with magnetic resonance imaging. One cause of anal sphincter disruption is sexual abuse with anal penetration. Other causes include anorectal malformations such as imperforate anus. (See "Evaluation of sexual abuse in children and adolescents".)

Incontinence after pull-through surgery – Patients who have had anorectal pull-through surgery for Hirschsprung disease are at risk for either retentive or nonretentive fecal incontinence. If these types cannot be distinguished by history or physical examination, anorectal manometry sometimes helps to identify the mechanism and guide treatment. (See "Congenital aganglionic megacolon (Hirschsprung disease)", section on 'Postoperative outcomes and management'.)

Dyssynergic defecation – In this condition, anorectal manometry demonstrates failure to relax the pelvic floor muscles when the patient is straining to defecate [29]. (See "Constipation in infants and children: Evaluation", section on 'Anorectal manometry'.)

Anal achalasia – In this condition, the rectal anal inhibitory reflex is absent (similar to Hirschsprung disease), but rectal suction biopsy reveals ganglion cells (in contrast with Hirschsprung disease). Affected children usually present with early-onset constipation, and fecal incontinence is rare.

MANAGEMENT — Management of children with fecal incontinence includes screening for and addressing any psychological symptoms, including anxiety, depression, and behavioral symptoms. Parents should be advised that the symptom is involuntary and will not respond to blaming or disciplining the child. (See 'Psychosocial precipitants and comorbidities' above.)

Further management depends on the type of fecal incontinence:

For children with constipation-associated (retentive) functional fecal incontinence, management focuses on treating the underlying constipation using both behavioral modification and laxatives. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment".)

For children with nonretentive fecal incontinence, management involves similar behavioral interventions, with particular attention to identifying the trigger for the episodes of incontinence but without laxative therapy. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment", section on 'Treatment of nonretentive fecal incontinence'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Constipation".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Fecal incontinence in children (The Basics)" and "Patient education: Constipation in infants and children (Beyond the Basics)")

Beyond the Basics topics (see "Patient education: Constipation in infants and children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Definition – Functional fecal incontinence refers to the involuntary passage of stool in the underwear after the acquisition of toileting skills, in the absence of overt neuromuscular sphincter dysfunction. (See 'Functional fecal incontinence' above.)

Types – Functional fecal incontinence can be categorized into two types, which guide the evaluation and management:

Retentive – Refers to fecal incontinence with underlying constipation, which is present in at least 80 percent of children with functional fecal incontinence. The symptoms of constipation may be obvious and well recognized by the child's family/caregivers or may be subtle. Evaluation and management of these children is similar to that of other children with functional constipation. (See 'Retentive' above and 'Evidence of constipation' above.)

Nonretentive – Refers to fecal incontinence without underlying constipation; this is the case for approximately 20 percent of children with functional fecal incontinence. The pathophysiology of this disorder is not clear, but there is a strong association with psychosocial triggers and dysfunction. (See 'Nonretentive' above and 'Pathogenesis' above.)

Clinical manifestations – Children with fecal incontinence frequently deny knowledge of stool in their underwear and give the impression that they are unable to sense the need to defecate. Because the stool smear is usually soft, parents often presume that the child has diarrhea, even when there is underlying constipation. (See 'Clinical manifestations' above.)

Evaluation – Evaluation of children with fecal incontinence should seek to exclude organic causes of the symptom (table 2) and to determine if there is underlying constipation (table 3). If the history and physical examination (including a digital examination) do not show evidence of constipation, radiographic imaging should be performed to confirm that there is no occult constipation. (See 'History and physical examination' above.)

Management – Management for children with fecal incontinence includes screening for and addressing any underlying psychological symptoms and advising the parents that the symptom is involuntary and will not respond to disciplining the child.

The main interventions depend upon the type:

Retentive – Management focuses on treating the underlying constipation using both behavioral modification and laxatives. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment".)

Nonretentive – Management involves similar behavioral interventions but without laxative therapy. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment", section on 'Treatment of nonretentive fecal incontinence'.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges George D Ferry, MD and William J Klish, MD, who contributed to an earlier version of this topic review.

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