Teach your children to listen to their bodies, says an expert in paediatric proctology

What motivated your transition from general surgery to paediatric surgery and anorectal physiology? Can you share a pivotal moment or breakthrough in your career that solidified your focus on this field?

If someone had asked me during my study years whether I intended to work with children, I probably would have burst into laughter. That was one of the last things on my mind. During my practical internship in the paediatric department, I realised that I enjoyed working with children. The nurses in that department also told me I should work with children, as they noticed I didn’t look intimidating to them, and I enjoyed working with them. Furthermore, I value finely tuned operations and seek solutions that allow these children to thrive throughout their lives, hopefully long and healthy.
My involvement in colorectal surgery happened by chance. As a student, I engaged in research within that field, and I quickly recognised some essential questions that needed answering. Since then, my interest in that subject has continued to grow.

What is the current incidence of congenital anorectal malformations in the general population?

The incidence of this disease is estimated to be between 1 in 2,500 and 1 in 5,000 newborns.

Has the focus of your specialisations (anorectal physiology, faecal incontinence and constipation, colorectal diseases, and pelvic physiology) shifted during your professional career?

The more we learn about the remarkable physiology of the last part of the intestine, the more cautious I become when performing operations in that area. Surgery in this region risks inadvertently damaging some of these vital regulatory mechanisms. I am increasingly involved in exploring ways to improve the function of this region using less invasive methods.

I noticed you hold two patents. If I get right, the second one – 'A probe system, a probe, and a method for measuring the functionality of an orifice in the human pelvic region' – is an extension or an alternative to conventional high-resolution anorectal manometry (HRAM). Why is HRAM important, and how does your system differ from it?

In the patent, we combine neurostimulation and manometric measurements. This fits well with the questions we ask ourselves. What makes the muscle contract? That has nothing to do with HRAM. High-resolution manometry is a method for presenting pressure measurements in a different way. If you want to display 3D pressures, it can be helpful; however, for many measurements, it does not improve the quality of reading the measurement results.

What are the most significant physiological mechanisms you’ve discovered in anorectal function?

We have always believed that faecal continence is entirely controlled by the sensation that you need to go to the toilet, along with voluntary contraction of the anal sphincter and pelvic floor muscles. It was an eye-opener to discover that two autonomic mechanisms mostly manage our faecal continence, even during sleep. Only for a small part of each day do we receive a signal from the autonomic nervous system indicating that we need to voluntarily assist in maintaining our continence. Fortunately, most of us experience that we only need to support our faecal continence for a few minutes a day.
Next to that, we discovered that these mechanisms that help us to be continent can sometimes overperform, leading to people becoming seriously constipated. Since we understand this mechanism, we know how we can reverse this overreaction with a relatively minor treatment.

What is the fundamental difference between voluntary and autonomic control of defecation, and could you provide examples of how each functions in everyday life or clinical practice?

It is actually quite simple. For more than 95% of the day, including when we sleep, the autonomic continence systems regulate faecal continence without our support. The autonomic system can hold the stool for hours without getting tired. Only when we urgently need to visit the toilet do these systems signal to our brain that assistance is required. This can happen when we go to the bathroom or when we contract our voluntary muscles, which then move the stool higher up into our large intestine. After that, the sensation of urgency will subside for a while. The voluntary contraction of the external anal sphincter or puborectal muscle can only hold for a maximum of 1.5 minutes!

In your experience, what are the main contributors to childhood constipation?

When I give lectures about faecal continence, I often ask, ‘What did we teach our children about defecating?‘ In most cases, it was: there is the potty, success with evacuating the stool. When you succeed in defecating, warn us and we will come to help you clean your bum! Almost nobody is teaching children to sit correctly on the toilet and to relax their pelvic floor when they want to defecate.

Another significant issue is the erroneous belief in schools that children can only use the toilet during breaks. I always ask teachers to explain the physiology behind that rule. If you feel the urge to use the bathroom, it will happen almost automatically. If you suppress it, it will require much more effort to pass stool afterwards.

Can stress or psychological factors affect bowel movements/defecation? How can this be explained to patients?

Stress and other psychological factors can impede the relaxation of the pelvic floor. In such cases, resolving stool issues will require support from a paediatric psychologist and a paediatric pelvic physiotherapist to address the psychosocial problem and teach techniques to relax the pelvic floor. Psychological issues may both cause and result from faecal problems, such as severe chronic faecal incontinence and constipation. Can you imagine what it would do to a child if they lost control of their stool eight times a day over several years? They would be removed from class each time due to the smell, and they could face severe bullying from other children because of this. Such experiences could lead to psychological difficulties.
Therefore, a paediatric psychologist and a paediatric pelvic physiotherapist are vital team members in addressing faecal issues.

What should I do in order not to become your patient? How should I educate my children?

Teach your children to listen to their bodies. If they feel the urge to use the bathroom, encourage them to go without waiting for the feeling to pass. Consider purchasing a toilet seat reducer for small children; otherwise, they may fear falling into the toilet, which can hinder their ability to relax their pelvic floor. Provide something for their feet when they sit on the toilet bowl to help them relax more easily. Teach them to wait a few minutes; there's no need to rush and finish defecating in one minute.

We talked about using diapers in old age, about dignity that these problems may affect. Could you elaborate on that?

Many people, including doctors, unfortunately, do not always fully grasp what it does to your dignity when you have to wear diapers. This is relevant for older children who are the only pupils in their class, as well as for older adults, especially since there are alternative ways to manage stool loosening without needing to wear diapers. When treating patients with faecal issues, I always explain to the parents that we aim to treat them in a way that allows them to behave like all other children without requiring diapers. This is vital for their psychological and social development. 

How can spinal cord injury affect anorectal function?

We now know, from studying many patients, that the autonomic reflexes are controlled by a centre located low in the spine. Therefore, if you have a spinal cord injury above the level where the centre is situated – where the autonomic reflexes are regulated – the centre continues to function but without the support of the brain. This means that the stool will be controlled (held) until the urgency level is reached, and because there will be no support from the voluntary system, all the stool gathered in the end part of the large colon will be evacuated. After that, the final part of the intestine is empty, and the cycle starts again to hold the stool until it becomes urgent.

What is your experience with getting the tabu topics (constipation, incontinence and so on) to the public? Is it easier now than before to raise awareness about fecal continence? Are there any cultural differences? Do you think it's easier to engage a particular age group with this topic? (I'm referring here to my children's favorite book about poop in the animal kingdom.)

We conducted a representative study of the Dutch population, which revealed that children more often discuss their stool problems with those around them than adults do. However, the same study also showed that adults face significantly more issues with defecation. This also explains why many paediatricians have always believed that defecation problems would resolve as children grow older. Perhaps adults will also need to learn how to discuss defecating issues with their partners and doctors.

In the healthcare sector, there is currently an intense intergenerational debate in the Czech Republic regarding work-life balance. How is this handled in the Netherlands?

The same debate is ongoing in the Netherlands. When I was a young doctor, I spent nearly all my time in the hospital. That wasn't ideal either, but we didn't have a choice. Today, young people are less willing to accept that. This means more doctors will be needed to provide round-the-clock hospital coverage.
It's also a major demographic challenge for the near future! Will there be enough people to fill all these roles in the healthcare sector to care for everyone? In the Netherlands, we are just beginning to consider what this might mean for healthcare in general. From discussions with my Czech colleagues, I understand these issues have also only recently arisen here.

I was intrigued to learn that you studied computer science after completing your medical degree in the late 1980s. Why?

To understand this, you need to know that most people in my family worked in the technical industry. Although I excelled in mathematics and physics, I initially planned to study medicine – a somewhat unconventional decision in my family. During my medical studies, some friends and I grew frustrated because there was very little room for logical thinking. We only had to memorise books, and when we asked a teacher why it functioned as they taught us, there was no discussion possible. Slowly, I began to wonder if I had chosen the right course. My family, of course, completely agreed that I would have done better in the 'beta' subjects. So, I could look back on my whole life and think maybe I had chosen the wrong path, or I could explore other studies and find out what I truly enjoy. Therefore, after obtaining my medical degree, I began to study computer science. Although there were hardly any computers in hospitals at that time, I imagined it would always be beneficial to know that field. After a year of studying computer science, I realised I could pursue a career in it. Still, I really enjoyed working in healthcare and planned to continue my career as a doctor. I have never regretted that decision. I am now sure that I chose the right field of study, and unlike many of my peers, I am not intimidated by computers. I used this knowledge extensively throughout my entire career as a doctor and researcher.

We’ve heard you enjoy Hungarian culture and the Csárdás – what draws you to it? 

As an originally classically trained amateur musician, I loved Eastern European folk music very much. Eventually, I moved to Hungary to learn much more about their folk traditions, because when you see authentic folk groups, three or four musicians play as if the devil himself is behind them on their string instruments. The whole room of people dances as if it were a rock-and-roll concert. It left a deep impression on me, so I tried to learn some of it. To communicate genuinely with the folk musicians, I learned some Hungarian.