Encopresis is the soiling of underwear with stool by children who are past the age of toilet training. Because each child achieves bowel control at his or her own rate, medical professionals do not consider stool soiling to be a medical condition unless the child is at least 4 years old. This stool or fecal soiling usually has a physical origin and is involuntary — the child doesn’t do it on purpose.
In the U.S., it is estimated that 1%-2% of children younger than 10 years are affected by encopresis. Many more boys than girls experience encopresis; approximately 80% of affected children are boys.
Encopresis is commonly caused by constipation, by reflexive withholding of stool, by various physiological, psychological, or neurological disorders, or from surgery (a somewhat rare occurrence).
The colon normally removes excess water from feces. If the feces or stool remains in the colon too long due to conditioned withholding or incidental constipation, so much water is removed that the stool becomes hard, and becomes painful for the child to expel in an ordinary bowel movement. A vicious cycle can develop, where the child may avoid moving his/her bowels in order to avoid the “expected” painful toilet episode. This cycle can result in so deeply conditioning the holding response that the rectal anal inhibitory response (RAIR) or anismus results. The RAIR has been shown to occur even under anesthesia and voluntary control is lost. The hardened stool continues to build up and stretches the colon or rectum to the point where the normal sensations associated with impending bowel movements do not occur. Eventually, softer stool leaks around the blockage and cannot be withheld by the anus, resulting in soiling. The child typically has no control over these leakage accidents, and may not be able to feel that they have occurred or are about to occur due to the loss of sensation in the rectum and the RAIR. Strong emotional reactions typically result from failed and repeated attempts to control this highly aversive bodily product. These reactions then in turn may complicate conventional treatments using stool softeners, sitting demands, and behavioral strategies.
As more and more stool collects in the child’s lower intestine (colon), the colon slowly stretches (sometimes called megacolon).
- As the colon stretches more and more, the child loses the natural urge to pass a bowel movement.
- Eventually, looser, partly formed stool from higher up in the intestine leaks around the large collection of harder, more formed stool at the bottom of the colon (rectum) and then leaks out of the anus (the opening from the rectum to the outside of the body).
- Often in the beginning, only small amounts of stool leak out, producing streaks in the child’s underwear. Typically, parents assume the child isn’t wiping very well after passing a bowel movement and aren’t concerned.
- As time goes on, the child is less and less able to hold the stool in-more and more stool leaks, and eventually the child passes entire bowel movements into his or her underwear.
- Often the child is not aware that he or she has passed a bowel movement.
- Because the stool is not passing normally through the colon, it often becomes very dark and sticky and may have a very foul smell.
The onset of encopresis is most often benign. The usual onset is associated with toilet training, demands that the child sit for long periods of time, and intense negative parental reactions to feces. Beginning school or preschool is another major environmental trigger with shared bathrooms. Feuding parents, siblings, moving, and divorce can also inhibit toileting behaviors and promote constipation. An initiating cause may become less relevant as chronic stimuli predominate.
What causes the constipation in the first place?
- Some experts believe children become constipated when they do not eat enough fiber, available in fruits, vegetables, and whole grain foods.
- Many doctors think that some children become constipated because they do not drink enough water.
- Constipation does seem to run in certain families.
- For many children, no clear cause of the constipation can be identified.
Encopresis is a very frustrating condition for parents. Many parents become angry at the repeated need to bathe the dirty child and to clean or discard soiled underwear. Many parents assume the soiling is the result of the child being lazy or that the child is soiling intentionally. In most cases, this is not the case. Children with encopresis are no more likely than other children to have major behavioral or emotional problems.
Symptoms of Encopresis
More than 80% of children with encopresis have experienced constipation or painful defecation in the past. In many cases, constipation or pain occurred years before the encopresis is brought to a doctor’s attention.
- Most children with encopresis say they have no urge to pass a bowel movement before they soil their underwear.
- Soiling episodes usually occur during the day, while the child is awake and active. Many school age children soil late in the afternoon after returning home from school. Soiling at night is uncommon.
- In many children with encopresis, the colon has become stretched out of shape, so they may intermittently pass extremely large bowel movements.
The psychiatric (DSM-IV) diagnostic criteria for encopresis are:
- Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether voluntary or unintentional
- At least one such event a month for at least 3 months
- Chronological age of at least 4 years (or equivalent developmental level)
- The behavior is not exclusively due to a physiological effect of a substance (e.g., laxatives) or a general medical condition, except through a mechanism involving constipation.
The DSM-IV recognizes two subtypes with constipation and overflow incontinence, and without constipation and overflow incontinence. In the subtype with constipation, the feces are usually poorly formed and leakage is continuous, and occurs both during sleep and waking hours. In the type without constipation, the feces are usually well-formed, soiling is intermittent, and feces are usually deposited in a prominent location. This form may be associated with oppositional defiant disorder or conduct disorder, or may be the consequence of large anal insertions, or more likely due to chronic encopresis that has radically desensitized the colon and anus.
Many pediatricians will recommend the following three-pronged approach to the treatment of encopresis associated with constipation:
- cleaning out
- using stool softening agents
- scheduled sitting times, typically after meals.
The initial clean-out is achieved with enemas, laxatives, or both. The predominant approach today is the use of oral stool softeners like Movicol, Miralax, Lactulose, mineral oil, etc. Following that, enemas and laxatives are used daily to keep the stools soft and allow the stretched bowel to return to its normal size.
The child must be taught to use the toilet regularly to retrain his/her body. It is usually recommended that a child be required to sit on the toilet at a regular time each day and ‘try’ to go for 10–15 minutes, usually soon (or immediately) after eating. Children are more likely to be able to expel a bowel movement right after eating. It is thought that creating a regular schedule of bathroom time will allow the child to achieve a proper elimination pattern. Repeated voiding success on the toilet itself helps it to become a releasor stimulus for successful bowel movements.
Alternatively, when this method fails for six months or longer, a more aggressive approach may be undertaken using suppositories and enemas in a carefully programmed way to overcome the reflexive holding response and to allow the proper voiding reflex to take over. Failure to establish a normal bowel habit can result in permanent stretching of the colon. Certainly, allowing this problem to continue for years with constant assurances that the child “will grow out of it” should be avoided.
Dietary changes are an important management element. Recommended changes to the diet in the case of constipation-caused encopresis include:
- reduction in the intake of constipating foods such as dairy, peanuts, cooked carrots, and bananas
- increase in high-fiber foods such as bran, whole wheat products, fruits, and vegetables
- higher intake of water and liquids, such as juices, although an increased risk of diabetes and/or tooth decay has been attributed to excess intake of sweetened juices
- limit drinks with caffeine, such as cola drinks and tea
- provide well-balanced meals and snacks, and limit fast foods/junk foods that are high in fats and sugars
- Limit whole milk to 16 ounces a day for the child over 2 years of age, but do not completely eliminate milk because children need calcium for bone growth and strength.
The standard behavioral treatment for functional encopresis, which has been shown to be highly effective, is a motivational system such as a contingency management system. In addition to this basic component, seven or eight other behavioral treatment components can be added to increase effectiveness.