Constipation and faecal incontinence: Viva

Branch 1: Framing the soiling and taking the history

The candidate should first reframe the parents' view that the soiling is deliberate, explaining that most soiling at this age is involuntary overflow around a hard rectal impaction rather than naughtiness. A strong answer takes a structured bowel history: stool frequency, size, and consistency, the presence of withholding behaviour, pain, and blood, and the timing and awareness of the soiling. The candidate should ask about the onset in relation to toilet training and starting kindergarten, both classic triggers for withholding. ^[1]

The candidate should give equal weight to the psychosocial context, asking how toilet training went, whether toileting has ever been frightening or punitive, and how the family and school respond to the soiling. They should screen for red flags at this point and keep safeguarding in mind for any child with unexplained soiling. Recognising that a previously clean child who soils daily after a school transition most likely has functional constipation with overflow, rather than a behavioural or organic problem, marks a candidate who understands the condition. ^[2]