Encopresis (Soiling) is the soiling of the underwear with stool by children who are past the age of toilet training. Because each child achieves bowel control at his or her own pace, medical professionals do not consider stool soiling to be a medical condition unless the child is at least 4 years of age. This stool or fecal soiling usually has a physical origin and is involuntary, the child does not soil on purpose. In the majority of cases, the soiling is the result of loose or soft stool leaking around more formed stool trapped inside the colon.
In the United States, it is estimated that 1% to 2% of children younger than 10 years of age suffer from encopresis. Many more boys than girls experience encopresis; approximately 80% of affected children are boys.
Causes
In most cases, encopresis is thought to develop as a consequence of chronic constipation with resulting overflow incontinence. Approximately 80-95% of children with encopresis have a history of constipation or painful bowel movements.
A few children appear to have nonretentive encopresis and no history of constipation or painful defecation; they have no evidence of incomplete evacuation on physical evaluation, radiographic evaluation, or both.
No good prospective data suggest that encopresis, whether retentive or nonretentive, is primarily a behavioral or psychological disorder. Rather, most of the available evidence indicates that children with encopresis do not have an increased incidence of major behavioral or personality disorders compared with their age-matched peers.
No good evidence suggests that encopresis is an indicator of sexual abuse. The incidence of fecal soiling is comparable among children with a history of sexual abuse and children with psychiatric and behavioral disorders.
Children with encopresis are significantly more likely to have attention-deficit disorder/hyperactivity (ADHD) than the general population.
Symptoms
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 medical 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.
Treatment
Although many different regimens have been developed for the treatment of encopresis, most rely on the following principles:
Empty the colon of stool
Establish regular soft and painless bowel movements
Maintain very regular bowel habits
While there is almost always a large behavioral component to chronic encopresis, behavioral therapy alone, such as offering rewards or reasoning with the child, usually is not effective. Rather, a combination of medical and behavioral therapy works best.
Medical professionals usually refer to emptying stool from the colon and rectum as evacuation or disimpaction. Evacuation can be accomplished in the following ways:
Administer an enema or series of enemas: An enema pushes fluid into the rectum. This softens the stool in the rectum and creates pressure within the rectum. This pressure gives the child a powerful urge to pass a bowel movement, and the stool is usually expelled rapidly. The fluid in most enemas is water. Something is usually added to keep the water from being absorbed by the intestinal lining. Widely used enemas include commercial phosphosoda preparations (such as Fleet saline enemas), slightly soapy water, and milk and molasses mixtures. Daily enemas for several days may be needed to completely evacuate the colon.
Administer a suppository or a series of suppositories: A suppository is a tablet or capsule that is inserted into the rectum. The suppository is made of a substance that stimulates the rectum to contract and expel stool. Popular suppositories include glycerin and commercial products such as Dulcolax and BabyLax. Daily suppositories for several days may be needed to completely evacuate the colon.
Administer strong laxatives: Most laxatives work by increasing the amount of water in the large intestine. Some laxatives cause the lower intestine to secrete water and others work by decreasing the amount of water absorbed in the lower intestine. In either case, the end result is much more water in the lower intestine when using laxatives than when not using them. This large amount of water softens formed or hard stool in the intestine and produces diarrhea. Laxatives used for this purpose include magnesium citrate, GoLYTELY, COLYTE, and Fleet Phospho-soda. Treatment for several days may be needed to completely evacuate the colon.
Establishing regular soft and painless bowel movements is mostly a matter of retraining the child to give up the habit of retaining stool. This is accomplished by giving laxatives every day to produce soft bowel movements. The laxative must be given in does large enough to produce 1 or 2 soft bowel movements every day. The soft stool will be passed easily and painlessly, encouraging the child to have regular bowel movements rather than holding the stool in. See Medications for a list of commonly used laxatives. Remember that fecal retention and soiling go together. So, as long as the child has retained stool in the rectum, the soiling will persist.
The final step is working with the child to develop regular bowel habits. This step is just as critical as the first 2 steps and must not be abandoned just because the soiling has improved after the previous steps.
Establish regular bathroom times: The child should sit on the toilet for 5-10 minutes after breakfast and again after dinner EVERY DAY. Some families must alter their daily routines to accomplish this, but it is a crucial step, particularly for school-aged children. Sitting on the toilet right after a meal takes advantage of the “gastrocolic reflex,” intestinal contractions that naturally occur after eating.
Behavioral techniques: Offer age-appropriate positive reinforcement for developing regular toilet habits. For young children, a star or sticker chart can be helpful. For older children, earning privileges, such as extra television or video game time, may be useful.
Training: Children may respond to teaching about the appropriate use of muscles and other physical responses during defecation. This helps them learn how to recognize the urge to have a bowel movement and to defecate effectively.
Biofeedback: This technique has been used successfully to teach some children how to best use their abdominal, pelvic, and anal sphincter muscles, which they have so often used to retain stool.
The duration of encopresis treatment varies from child to child. Treatment should continue until the child has developed regular and reliable bowel habits and has broken the habit of holding back his or her stool. This usually takes at least several months. Generally, it takes longer in younger children than in older children.
Many parents are reluctant to give their child laxatives because they have heard that laxatives are harmful, cause more serious conditions (such as colon cancer), or promote dependency. There is no convincing evidence that any of these are true. Laxatives do not stop working if they are used every day for a long time.
Most cases of encopresis respond to the treatment regimen outlined above. If the soiling does not resolve, your child’s health care provider may refer you to a specialist in digestive and intestinal disorders (pediatric gastroenterologist), a behavioral psychologist, or both.
