Encopresis

Definition

Description

Treatment

Function

Benefits

Precautions

Risks

Research and general acceptance

Resources

Definition

Encopresis is defined as the repeated passage or leaking of feces in inappropriate places in a child over 4 years of age that is not caused by a physical illness or disability.

Description

Over 80% of cases of encopresis begin with the child’s experience of a painful bowel movement or passing a very large bowel movement. Over time, the child comes to associate using the toilet with pain and begins to hold in, or retain, his or her bowel movements to avoid the pain. The child may occasionally try to pass some of the hardened stool and develop a crack in the skin surrounding the anus known as an anal fissure. Anal fissures cause additional pain and usually reinforce the child’s habit of retaining feces. As the mass of stool grows, the colon stretches to many times its normal diameter—a condition known as megacolon. The child also loses the natural urge to have a bowel movement because the muscles in the wall of the colon cannot contract and push the stool out

Encopresis is thought to affect between 1-2% of children in the United States below the age of 10. Boys are six times as likely to develop encopresis. It is not known to be related to race or social class, the size of the family, the child’s birth order, or the age of the parents.

Treatment

There is no universal agreement among doctors as to the best method of treatment for encopresis, including dietary recommendations. It is a disorder resulting from the interaction of bodily, psychological, and social factors in the child’s life. As a result, there have been no large-scale controlled studies of different treatment methods.

Dietary treatment

Dietary treatment of encopresis is intended to help the child develop regular bowel habits after dis-impaction and to minimize the risk of recurrent constipation . Dietary modifications usually include:

• Reducing the child’s intake of milk and other dairy products that tend to cause constipation. Some pediatricians recommend soy milk as a substitute for cow’s milk during maintenance treatment

KEY TERMS

Anal fissure— A crack or slit that develops in the mucous membrane of the anus, often as a result of a constipated person pushing to expel hardened stool. Anal fissures are quite painful and difficult to heal

Biofeedback— A technique for improving awareness of internal bodily sensations in order to gain conscious control over digestion and other processes generally considered to be automatic

Constipation— Abnormally delayed or infrequent passage of feces. It may be either functional (related to failure to move the bowels) or organic (caused by another disease or disorder)

Enema— The injection of liquid through the anus into the rectum in order to soften hardened stools

Impaction— The medical term for a mass of fecal matter that has become lodged in the lower digestive tract. Removal of this material is called disimpaction

Laxative— A drug usually administered by mouth to produce a bowel movement. Laxatives are also known as cathartics

Megacolon— A condition in which the colon becomes stretched far beyond its usual size. Children with long-term constipation may develop megacolon

Suppository— A tablet or capsule, usually made of glycerin, inserted into the rectum to stimulate the muscles to contract and expel feces.

• Adding dietary fiber to the child’s diet in the form of high-fiber breads and cereals, vegetables and fruits that are high in fiber, or over-the-counter fiber supplements
• Increasing the child’s water intake, particularly during warm weather
• Encouraging the child to participate in vigorous physical activity. Exercise helps to move food through the digestive system
• Increasing the child’s intake of fruit and fruit juices. Fruit juices, particularly prune juice, have a laxative effect. Fruit and fruit juices cannot be used by themselves as maintenance treatment for encopresis because few children are able to drink or eat the amounts required for laxative treatment. Fruit is recommended over fruit juice since it has more nutrients

Medical approaches

Medical treatment of encopresis begins with dis-impaction, or softening and removal of the mass of fecal material in the lower colon. Disimpaction may be accomplished by administering enemas or a series of enemas; one or a series of suppositories; laxatives taken by mouth; or a combination of these treatments. Commonly used enemas include homemade soap-and-water solutions and commercial saline preparations. Dulcolax (bisacodyl) and BabyLax are popular brands of suppositories. Laxatives, which work by increasing the amount of water in the large intestine to soften the impacted stool, include citrate of magnesia, Fleet Phospho-soda, Colyte, or GoLYTELY. Other laxatives sometimes used are mineral oil and senna, a plant native to the tropics that has been used to treat constipation for over three thousand years

Following disimpaction, the child is given maintenance medications intended to produce soft stools once or twice daily to prevent constipation from recurring. They also help the child break the mental and emotional connection between defecation and pain. The child may be given glycerine or bisacodyl suppositories once or twice a day, or mineral oil, senna syrup (Senokot), milk of magnesia, lactulose, or sorbitol twice a day by mouth. Maintenance treatment typically takes several months

Glucomannan, a complex sugar derived from the roots of the Japanese konjac plant, is an effective fiber supplement for children that appears to be well tolerated and has fewer side effects than many laxatives. Glucomannan is a water-soluble fiber that forms a gellike mass in the digestive tract and helps to push fecal matter through the lower bowel more rapidly.

Psychological treatment

Psychological treatment is part of maintenance therapy for encopresis because of the emotional stress the condition causes the child and other family members. In many cases the child has become depressed or developed other behavioral problems as a result of punishment, teasing, or social rejection related to episodes of soiling. Psychological treatment begins with education; the doctor explains to the parents as well as the child how encopresis develops, what causes it, and why medications are used to treat it

If the child’s encopresis is involuntary, behavioral therapy is often used. This approach employs such techniques as star charts and daily diaries to teach the child to recognize the body’s internal cues. Some doctors also recommend biofeedback for maintenance therapy in encopresis

If the child’s episodes of soiling are intentional rather than involuntary, he or she will usually be referred to a child psychiatrist for specialized evaluation and treatment.

Function

The function of dietary treatment for encopresis is as a form of maintenance therapy. The goal is to prevent stool from building up in the child’s colon, allow the colon to return to its normal shape and muscular function, and to help the child have bowel movements in the toilet at appropriate times.

Benefits

The benefit of dietary treatment for encopresis is prevention of future episodes of constipation while providing adequate nutrition for the child. Medications are used to clear impacted fecal material from the colon and relieve discomfort associated with defecation.

Precautions

Parents should follow the doctor’s advice about laxatives and enemas during maintenance treatment for encopresis, as some of these products have side effects or interact with other medications that the child may be taking.

Risks

There are no reported adverse effects of dietary treatment for encopresis

Enemas and laxatives often produce side effects including abdominal cramping, intestinal gas, nausea, and vomiting. The child’s doctor may be able to change the dosage or type of product for a child on maintenance treatment. Lactulose should not be given to patients with diabetes because it contains a form of sugar, while sorbitol may reduce the effectiveness of other medications. Mineral oil sometimes causes seepage into underwear and itching in the anal area. Senna and citrate of magnesia may lead to electrolyte imbalance if used in high doses over a long period of time.

Research and general acceptance

Disagreements regarding treatment for encopresis focus on three subjects: whether enemas are preferable to laxatives taken by mouth or whether enemas are emotionally traumatic to the child; whether or not adding fiber to the child’s diet is useful; and whether placing the child on the toilet at set times helps in establishing bowel control or whether it creates emotional conflict between parents and child. Opinion is divided about the effectiveness of placing the child on the toilet at fixed times during the day; some doctors think that taking the child to the toilet after a meal helps to teach good bowel habits, while others think it is not a good idea if the child does not feel an urge to defecate

There is no evidence that long-term use of laxatives creates dependency on them or causes colon cancer .

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth edition. Washington, DC: American Psychiatric Association, 2000

Schaefer, Charles E. Childhood Encopresis and Enuresis: Causes and Therapy. Northvale, NJ: Jason Aronson, 1993

“Toileting Problems.” Chapter 298, Section 19. Merck Manual of Diagnosis and Treatment, 18th ed. Edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck, 2007.

PERIODICALS

Biggs, Wendy S., and William H. Dery. “Evaluation and Treatment of Constipation in Infants and Children.” American Family Physician 73 (February 1, 2006): 469-482

Borowitz, Stephen. “Encopresis.” eMedicine, July 21, 2006. [cited May 6, 2007]. <http://www.emedicine.com/ped/topic670.htm>

Fishman, Laurie, Leonard Rappaport, Alison Schonwald, and Samuel Nurko. “Trends in Referral to a Single Encopresis Clinic over 20 Years.” Pediatrics 111 (May 2003): 604–607

Fleisher, David R. “Understanding Toilet Training Difficulties.” Pediatrics 113 (June 2004): 1809–1810

Kuhn, Brett R., Bethany A. Marcus, and Sheryl L. Pitner. “Treatment Guidelines for Primary Nonretentive Encopresis and Stool Toileting Refusal.” American Family Physician 59 (April 15, 1999): 2171–2186

Loening-Baucke, V., E. Miele, and A. Staiano. “Fiber (Glucomannan) Is Beneficial in the Treatment of Childhood Constipation.” Pediatrics 113 (March 2004): 259–264

McGrath, M. L., M. W. Mellon, and L. Murphy. “Empirically Supported Treatments in Pediatric Psychology: Constipation and Encopresis.” Journal of Pediatric Psychology 25 (June 2000): 225–254

Pashankar, Dinesh S., and Vera Loenig-Baucke. “Increased Prevalence of Obesity in Children with Functional Constipation Evaluated in an Academic Medical Center.” Pediatrics 116 (September 2005): 377–380.

OTHER

Gurian, Anita. “About Encopresis (Soiling).” New York AboutOurKids.org. University Child Study Center. August 2, 2002. [cited May 6, 2007]. <http://www.aboutourkids.org/aboutour/articles/about_encopresis.html>

North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). Treatment of Encopresis/Soiling. Flourtown, PA: NASPGHAN, 2007. [cited May 6, 2007]. <http://www.naspghan.org/user-assets/Documents/pdf/diseaseInfo/Encopresis-Soiling%20E.pdf>.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry (AACAP). 3615 Wisconsin Avenue NW, Washington, DC 20016-3007. Telephone: (202) 966-7300. Website: <http://www.aacap.org/>

American Academy of Pediatrics (AAP). 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. Telephone: (847) 434-4000. Website: <http://www.aap.org>

American College of Gastroenterology (ACG). 6400 Goldsboro Road, Suite 450, Bethesda, MD 20817. Telephone: (301) 263-9000. Website: <http://www.acg.gi.org>

North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). P.O. Box 6, Flourtown, PA 19031. Telephone: (215) 233-0808. Website: <http://www.naspghan.org>

Rebecca J. Frey, PhD

English diet seeNorthern European diet .

Encopresis

Definition

Encopresis is repeatedly having bowel movements in places other than the toilet after the age when bowel control can normally be expected.

Description

Most children have established bowel control by the time they are four years old. After that age, when they repeatedly have bowel movements in inappropriate places, they may have encopresis. In the United States, encopresis affects 1-2% of children under age 10. About 80% of these are boys.

Encopresis can be either involuntary or voluntary. Involuntary encopresis is related to constipation, passing hard painful feces, and difficult bowel movements. Often children with involuntary encopresis stain their underpants with liquid feces. They are usually unaware that this has happened. Voluntary encopresis is much less common and is associated with behavioral or psychological problems. Both types of encopresis occur most often when the child is awake, rather than at night.

Causes and symptoms

Although a few children experience encopresis because of malformations of the lower bowel and anus or irritable bowel disease, most have no physical problems to explain this disorder. Constipation is present in about 80% of children who experience involuntary encopresis. As feces moves through the large intestine, water is removed. The longer the feces stays in the large intestine, the more water is removed, and the harder the feces becomes. The result can be hard or painful bowel movements. In response, children may start to hold back when they feel the urge to eliminate in order to avoid pain. This starts a cycle of constipation that results in retentive encopresis.

Once elimination is avoided, the bowel becomes full of hard feces. This stretches the large intestine. Eventually the intestine becomes so stretched that liquid feces backed up behind the blockage is able to leak around the hard feces. Children with this type of encopresis do not feel the urge to have a bowel movement and are often surprised when their pants are stained with foul smelling liquid feces. This leakage of feces is called overflow incontinence. Parents sometimes mistake this soiling for diarrhea, because the feces expelled is liquid. Every so often, children with involuntary encopresis may pass large stools, sometimes with volumes big enough to clog the toilet, but the relief this brings is temporary.

Although about 95% of encopresis is involuntary, some children intentionally withhold bowel movements. The American Psychiatric Association (APA) recognizes voluntary encopresis without constipation as a psychological disorder. This disorder is said to occur when a child who has control over his bowel movements chooses to have them in an inappropriate place. The feces is a normal consistency, not hard. Sometimes it is smeared in an obvious place, but it may also be hidden from adults.

Voluntary encopresis may result from a power struggle between caregivers and the child during toilet training, or the child may have developed an unusual fear of the toilet. It is also associated with oppositional defiant disorder (ODD), conduct disorder, sexual abuse, and high levels of psychological stress. For example, children who were separated from their parents during World War II were reported to have a high rate of encopresis. However, parents and caregivers should be aware that very few children soil intentionally and most do not have a behavioral or psychological problem and should not be punished for their soiling accidents.

Diagnosis

Diagnosis is based primarily on the child's history of inappropriate bowel movements. Physical examinations are almost always normal, except for a mass of hard feces blocking the lower intestine. Other physical causes of soiling, such as illness, reaction to medication, food allergies, and physical disabilities, may also be ruled out through history and a physical examination. In addition, to be diagnosed with encopresis the child must be old enough to establish regular bowel control—usually chronologically and developmentally at least four years of age.

Treatment

The goal of treatment is to establish regular, soft, pain free bowel movements in the toilet. First the physician tries to determine the cause of encopresis, whether physical or psychological. Regardless of the cause, the bowel must be emptied of hard, impacted feces This can be done using an enema, laxatives, and/or stool softeners such as mineral oil. Enemas and laxatives should be used only at a doctor's recommendation.

Next, the child is given stool softeners to keep feces soft and to give the stretched intestine time to shrink back to its normal size. This shrinking process may take several months, during which time stool softeners may need to be used regularly. Children also need two or three regularly scheduled toilet sits daily in an effort to establish consistent bowel habits. These toilet sits are often more effective if done after meals. Maintaining soft, easy-to-pass stools is also important if the child is afraid of the toilet because of past painful bowel movements. A child psychologist or psychiatrist can suggest treatment for the rare child with serious behavioral problems such as smearing or hiding feces.

Alternative treatment

Many herbal stool softeners and laxatives are available as both tablets and liquids. Psyllium, the seed of several plants of the genus Plantago is one of the most effective. Other natural remedies for constipation include castor seed oil (Ricinus communis ), senna (Cassia senna or Senna alexandrina ), and dong quai Angelica polymorpha or Angelica sinensis ).

Prognosis

For almost all children, once constipation is controlled, the problem of soiling disappears. This make take several months, and relapses may occur, but with effective prevention strategies, encopresis can be eliminated. Children who are in a power struggle over toileting usually outgrow their desire to have bowel movements in inappropriate places. The prognosis for children with serious behavioral and psychological problems that result in smearing or hiding feces depends largely on resolving the underlying problems.

KEY TERMS

Feces— Waste products eliminated from the large intestine; excrement.

Incontinence— The inability to control the release of urine or feces.

Laxative— Material that encourages a bowel movement.

Stools— feces, bowel movements.

Prevention

The best way to prevent encopresis is to prevent constipation. Methods of preventing constipation include:

• increasing the amount of liquids, especially water, the child drinks
• adding high fiber foods to the diet (e.g. dried beans, fresh fruits and vegetables, whole wheat bread and pasta, popcorn)
• establishing regular bowel habits
• limiting the child's intake of dairy products (e.g. milk, cheese, yogurt, ice cream) that promote constipation.
• treating constipation promptly with stool softeners, so that it does not become worse.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. text revision. Washington D.C.: American Psychiatric Association, 2000.

PERIODICALS

Kuhn, Brett R., Bethany A. Marcus, and Sheryl L. Pitner. "Treatment Guidelines for Primary Nonretentive Encopresis and Stool Toileting Refusal." American Family Physician, 59, no. 8 (15 April 1999) 2171-2183. [cited 16 February 2005]. 〈http://www.aafp.org/afp/2001101/1565.html〉.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry, P. O. Box 96106, Washington, D.C. 20090. 800-333-7636. 〈www.aacap.org〉.

OTHER

Borowitz, Stephen. Encopresis, 14 June 2004 [cited 20 February 2005]. 〈http://www.emedicine.com/ped/topics670.html〉.

Encopresis

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

Encopresis is an elimination disorder that involves repeatedly having bowel movements in inappropriate places after the age when bowel control is normally expected. Encopresis is also called “soiling” or “fecal incontinence.”

Description

By four years of age, most children are toilet trained for bowel movements. After that age, if inappropriate bowel movements occur regularly over a period of several months a child may be diagnosed with encopresis. Encopresis can be intentional or unintentional. Intentional soiling is associated with several psychiatric disorders. Involuntary or unintentional soiling is often the result of constipation.

Causes and symptoms

The only symptom of encopresis is that a person has bowel movements in inappropriate places, such as in clothing or on the floor. This soiling is not caused by taking laxatives or other medications and is not due to a disability or physical defect in the bowel. There are two main types of encopresis, and they have different causes.

Involuntary encopresis

With involuntary encopresis, a person has no control over elimination of feces from the bowel. The feces is semi-soft to almost liquid, and it leaks into clothing without the person making any effort to expel it. Leakage usually occurs during the day when the person is active and ranges from infrequent to almost continuous.

Involuntary soiling usually results from constipation. A hard mass of feces develops in the large intestine and is not completely expelled during a regular bowel movement in the toilet. This mass then stretches the large intestine out of shape, allowing liquid feces behind it to leak out. Up to 95% of encopresis is involuntary.

Although involuntary encopresis, called by the American Psychiatric Association (APA) encopresis with constipation and overflow incontinence, is caused by constipation, the constipation may be the result of psychological factors. Experiencing a stressful life event, harsh toilet training, toilet fear, or emotionally disturbing events can cause a child to withhold bowel movements or become constipated. Historically, children separated from their parents during World War II are reported to have shown a high incidence of encopresis, indicating that psychological factors play a role in this disorder.

Voluntary encopresis

A person with voluntary encopresis has control over when and where bowel movements occur and chooses to have them in inappropriate places. Constipation is not a factor, and the feces is usually a normal consistency. Often feces is smeared in an obvious place, although sometimes it is hidden around the house. The APA classifies voluntary encopresis as encopresis without constipation and overflow incontinence.

In young children, voluntary encopresis may represent a power struggle between the child and the care-giver doing the toilet training. In older children, voluntary encopresis is often associated with oppositional defiant disorder (ODD), conduct disorder , sexual abuse, or high levels of psychological stressors.

Demographics

Encopresis occurs in 1-3% of children from ages four to seven years and is seen more often in boys than in girls. The frequency of encopresis appears to be independent of social class, and there is no evidence that it runs in families.

Diagnosis

To receive an APA diagnosis of encopresis, a child must have a bowel movement, either intentional or accidental, in an inappropriate place at least once a month for a minimum of three months. In addition, the child must be chronologically or developmentally at least four years old, and the soiling cannot be caused by illness, medical conditions (e.g., chronic diarrhea, spina bifida, or anal stenosis), medications, or disabilities. However, it may be caused by constipation.

Treatments

Involuntary encopresis is treated by addressing the cause of the constipation and establishing soft, pain-free stools. This can include:

• increasing the amount of liquids a child drinks
• adding high-fiber foods to the diet
• short-term use of laxatives or stool softeners
• emptying the large intestine by using an enema
• establishing regular bowel habits

Once the constipation is resolved, involuntary encopresis normally stops.

Treatment of voluntary encopresis depends on the cause. When voluntary encopresis results from a power struggle between child and adult, it is treated with behavior modification. In addition to taking the steps listed above to ensure a soft, pain-free stool, the adult should make toileting a pleasant, pressure-free activity. Some experts suggest transferring the initiative for toileting to the child instead of constantly asking him/her to use the toilet. Others recommend toileting at scheduled times, but without pressure to perform. In either case, success should be praised and failure treated in a matter-of-fact manner. If opposition to using the toilet continues, the family may be referred to a child psychiatrist or a pediatric psychologist.

With older children who smear or hide feces, voluntary encopresis is usually a symptom of another more serious disorder. When children are successfully treated for the underlying disorder with psychiatric interventions, behavior modification, and education, the encopresis is often resolved.

Prognosis

Because 80-95% of encopresis is related to constipation, the success rate in resolving involuntary encopresis is high, although it may take time to

KEY TERMS

Feces —Waste products eliminated from the large intestine; excrement.

Incontinence —The inability to control the release of urine or feces.

Laxative —Substance or medication that encourages a bowel movement.

Stools —Feces; bowel movements.

establish good bowel habits and eliminate a reoccurrence of constipation. The success rate is also good for younger children in a power struggle with adults over toileting, although the results may be slow. The prognosis for older children with associated behavioral disorders is less promising and depends more on the success of resolving those problems than on direct treatment of the symptoms of encopresis.

Prevention

Power struggles during toilet training that lead to encopresis can be reduced by waiting until the child is developmentally ready and interested in using the toilet. Toilet training undertaken kindly, calmly, and with realistic expectations is most likely to lead to success. Successes should be rewarded and failures accepted. Once toilet training has been established, encopresis can be reduced by developing regular bowel habits and encouraging a healthy, high-fiber diet.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.

Sadock, Benjamin J., and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry, 7th ed. Vol. 2. Philadelphia: Lippincott Williams and Wilkins, 2000.

PERIODICALS

Catto-Smith, Anthony G. “Constipation and Toileting Issues in Children.” Medical Journal of Australia 182 (2005): 242–46.

Kuhn, Bret R., Bethany A. Marcus, and Sheryl L. Pitner. “Treatment Guidelines for Primary Nonretentive Encopresis and Stool Toileting Refusal.” American Family Physician 58 (April 15, 1999): 8–18.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. P. O. Box 96106, Washington, DC 20090. Telephone: (800) 333-7636. <http://www.aacap.org>.

OTHER

American Academy of Family Physicians. “Stool Soiling and Constipation in Children.” (2007) <http://familydoctor.org/166.xml>.

Tish Davidson, A.M.
Emily Jane Willingham, PhD

Encopresis

Definition

Encopresis is defined as repeated involuntary defecation somewhere other than a toilet by a child age four or older that continues for at least one month.

Description

Soiling, fecal soiling, and fecal incontinence are alternate terms used for this behavior. Whatever the cause, parents should talk openly about the problem with the child. When parents treat a bowel problem as a cause for embarrassment or shame, they may unintentionally aggravate or prolong it.

Demographics

About 1 to 3 percent of children are affected by encopresis. More boys than girls are affected.

Causes and symptoms

Encopresis can be one of two types, nonretentive encopresis and retentive encopresis. About 80 to 95 percent of all cases are retentive encopresis. Children with this disorder have an underlying medical reason for soiling. The remaining cases have no physical condition that bars normal toileting behaviors. This type, nonretentive encopresis, is a behavioral condition in which the child refuses to defecate in a toilet.

Retentive encopresis is most often the result of chronic constipation and fecal impaction. In these children, feces have become impacted in the child's colon, causing it to distend. This causes the child to not feel the urge to defecate. The anal sphincter muscle becomes weak and unable to contain the soft stools that pass around the impaction. Despite the constipation, these children actually do have regular, though soft, bowel movements that they are unable to control. The child may not even be aware that he or she has defecated until the fecal matter has already passed. Many children have a history of constipation that extends back as far as five years before the problem is brought to medical attention.

A child may exhibit nonretentive encopresis, or functional encopresis, for several reasons. First, he or she may not be ready for toilet training . When a child is learning appropriate toilet habits during toddlerhood and preschool years, involuntary or inappropriate bowel movements are common. Second, the child may be afraid of the toilet or of defecating in public places like school. Others may use fecal incontinence to manipulate their parent or other adults. These children often have other serious behavioral problems.

When to call the doctor

A doctor should be called whenever children experience unresolved constipation or difficulty controlling their stools.

Diagnosis

Before beginning treatment for encopresis, the pediatrician first looks for any physical cause for the inappropriate bowel movements. The doctor asks parents about the child's earlier toilet training and typical toileting behaviors and inquires about a history of constipation. The doctor will digitally examine the child's anal area to check the strength of the anal sphincter muscle and look for a fecal impaction. An abdominal x ray may be needed to confirm the size and position of the impaction.

Treatment

If the pediatrician makes a diagnosis of retentive encopresis, the physician may recommend laxatives , stool softeners, or an enema to free the impaction. Subsequently, the doctor may make several suggestions for to avoid chronic constipation. Children should eat a high-fiber diet, with lots of fruits, vegetables, and whole grains. They should be encouraged to drink larger amounts of water and get regular exercise . Children should be taught to not feel ashamed of toileting behaviors, and psychotherapy may help decrease the sense of shame and guilt that many children feel.

If no fecal impaction is found, the pediatrician works with a counselor or psychiatrist to analyze the variables that characterize the encopresis. If the child is not physically or cognitively ready for toilet training, it should be postponed.

In the remainder of nonretentive encopresis cases, treatment should then center on making sure the child has comfortable bowel movements, since some cases of nonretentive encopresis involve some level of discomfort associated with constipation.

Prognosis

The prognosis for most children with encopresis is good, assuming that all underlying problems are identified and appropriately treated.

Prevention

There is no known way to prevent encopresis. Experienced counselors suggest that early identification of problems and accurate diagnosis are useful in limiting the severity and duration of encopresis.

Nutritional concerns

A high-fiber diet may be recommended for persons with encopresis. Affected persons should consume lots of fruits, vegetables, and whole grains. Adequate to copious intake of fluids are also recommended.

Parental concerns

Parents of a child with a serious behavior disorder like oppositional defiant disorder should work with their child's therapist to deal with encopresis in the context of other behavioral problems. Parents should work with their children to establish appropriate stooling behaviors and institute a system of rewards for successful toileting.

KEY TERMS

Constipation —Difficult bowel movements caused by the infrequent production of hard stools.

Impaction —A condition in which earwax has become tightly packed in the outer ear to the point that the external ear canal is blocked.

Resources

BOOKS

Boris, Neil, and Richard Dalton. "Vegetative Disorders." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2003, pp. 73–9.

Brazelton, T. Berry, et al. Toilet Training: The Brazelton Way. Cambridge, MA: Perseus Publishing, 2003.

Perkin, Steven R. Gastrointestinal Health: The Proven Nutritional Program to Prevent, Cure, or Alleviate Irritable Bowel Syndrome (IBS), Ulcers, Gas, Constipation, Heartburn, and Many Other Digestive Disorders. London: Harper Trade, 2005.

PERIODICALS

De Lorijn, F., et al. "Prognosis of constipation: clinical factors and colonic transit time." Archives of Disease in Childhood 89, no. 8 (2004): 723–7.

Loening-Baucke, V. "Functional fecal retention with encopresis in childhood." Journal of Pediatric Gastroenterology and Nutrition 38, no. 1 (2004): 79–84.

Schonwald, A., and L. Rappaport. "Consultation with the specialist: encopresis: assessment and management." Pediatric Reviews 25, no. 8 (2004): 278–83.

Voskuijl, W. P., et al. "Use of Rome II criteria in childhood defecation disorders: applicability in clinical and research practice." Journal of Pediatrics 145, no. 2 (2004): 213–7.

ORGANIZATIONS

American Academy of Pediatrics. 141 Northwest Point Blvd., Elk Grove Village, IL 60007–1098. Web site: <www.aap.org>.

American College of Gastroenterology. 4900 B South 31st St., Arlington VA 22206. Web site: <www.acg.gi.org/>.

WEB SITES

"Encopresis." eMedicine. Available online at <www.emedicine.com/ped/topic670.htm> (accessed January 6, 2005). "Encopresis." MedlinePlus. Available online at <www.nlm.nih.gov/medlineplus/ency/article/001570.htm> (accessed January 6, 2005).

"Encopresis." Merck Manual. Available online at <www.merck.com/mmhe/sec23/ch269/ch269d.html> (accessed January 6, 2005).

"Stool Soiling and Constipation in Children." American Academy of Family Physicians. Available online at <http://familydoctor.org/x1782.xml> (accessed January 6, 2005).

L. Fleming Fallon, Jr., MD, DrPH

Encopresis

Definition

Encopresis is an elimination disorder that involves repeatedly having bowel movements in inappropriate places after the age when bowel control is normally expected. Encopresis is also called "soiling" or "fecal incontinence."

Description

By four years of age, most children are toilet trained for bowel movements. After that age, when inappropriate bowel movements occur regularly over a period of several months, a child may be diagnosed with encopresis. Encopresis can be intentional on unintentional. Intentional soiling is associated with several psychiatric disorders. Involuntary or unintentional soiling is often the result of constipation.

Causes and symptoms

The only symptom of encopresis is that a person has bowel movements in inappropriate places, such as in clothing or on the floor. This soiling is not caused by taking laxatives or other medications, and is not due to a disability or physical defect in the bowel. There are two main types of encopresis, and they have different causes.

Involuntary encopresis

With involuntary encopresis, a person has no control over elimination of feces from the bowel. The feces is semi-soft to almost liquid, and it leaks into clothing without the person making any effort to expel it. Leakage usually occurs during the day when the person is active, and ranges from infrequent or almost continuous.

Involuntary soiling usually results from constipation. A hard mass of feces develops in the large intestine and is not completely expelled during a regular bowel movement in the toilet. This mass then stretches the large intestine out of shape, allowing liquid feces behind it to leak out. Up to 95% of encopresis is involuntary.

Although involuntary encopresis, called by the American Psychiatric Association (APA) encopresis with constipation and overflow incontinence, is caused by constipation, the constipation may be the result of psychological factors. Experiencing a stressful life event, harsh toilet training, toilet fear, or emotionally disturbing events can cause a child to withhold bowel movements or become constipated. Historically, children separated from their parents during World War II are reported to have shown a high incidence of encopresis, indicating that psychological factors play a role in this disorder.

Voluntary encopresis

A person with voluntary encopresis has control over when and where bowel movements occur and chooses to have them in inappropriate places. Constipation is not a factor, and the feces is usually a normal consistency. Often feces is smeared in an obvious place, although sometimes it is hidden around the house. The APA classifies voluntary encopresis as encopresis without constipation and overflow incontinence.

In young children, voluntary encopresis may represent a power struggle between the child and the caregiver doing the toilet training. In older children, voluntary encopresis is often associated with oppositional defiant disorder (ODD), conduct disorder , sexual abuse , or high levels of psychological stressors.

Demographics

Encopresis occurs in 1–3% of children and is seen more often in boys than in girls. The frequency of encopresis appears to be independent of social class, and there is no evidence that it runs in families.

Diagnosis

To receive an APAdiagnosis of encopresis, a child must have a bowel movement, either intentional or accidental, in an inappropriate place at least once a month for a minimum of three months. In addition, the child must be chronologically or developmentally at least four years old, and the soiling cannot be caused by illness, medical conditions (such as chronic diarrhea, spina bifida, anal stenosis, etc.), medications, or disabilities. However, it may be caused by constipation.

Treatments

Involuntary encopresis is treated by addressing the cause of the constipation and establishing soft, pain-free stools. This can include:

• increasing the amount of liquids a child drinks
• adding high-fiber foods to the diet
• short-term use of laxatives or stool softeners
• emptying the large intestine by using an enema
• establishing regular bowel habits

Once the constipation is resolved, involuntary encopresis normally stops.

Treatment of voluntary encopresis depends on the cause. When voluntary encopresis results from a power struggle between child and adult, it is treated with behavior modification . In addition to taking the steps listed above to ensure a soft, pain-free stool, the adult should make toileting a pleasant, pressure-free activity. Some experts suggest transferring the initiative for toileting to the child instead of constantly asking him/her to use the toilet. Others recommend toileting at scheduled times, but without pressure to perform. In either case, success should be praised and failure treated in a matter-of-fact manner. If opposition to using the toilet continues, the family may be referred to a child psychiatrist or a pediatric psychologist .

With older children who smear or hide feces, voluntary encopresis is usually a symptom of another more serious disorder. When children are successfully treated for the underlying disorder with psychiatric interventions, behavior modification, and education, the encopresis is often resolved.

Prognosis

Since 80–95% of encopresis is related to constipation, the success rate in resolving involuntary encopresis is high, although it may take time to establish good bowel habits and eliminate a reoccurrence of constipation. The success rate is also good for younger children in a power struggle with adults over toileting, although the results may be slow. The prognosis for older children with associated behavioral disorders is less promising and depends more on the success of resolving those problems than on direct treatment of the symptoms of encopresis.

Prevention

Power struggles during toilet training that lead to encopresis can be reduced by waiting until the child is developmentally ready and interested in using the toilet. Toilet training undertaken kindly, calmly, and with realistic expectations is most likely to lead to success. Successes should be rewarded and failures accepted. Once toilet training has been established, encopresis can be reduced by developing regular bowel habits and encouraging a healthy, high-fiber diet.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. text revised. Washington DC: American Psychiatric Association, 2000.

Sadock, Benjamin J. and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry. 7th ed. Vol. 2. Philadelphia: Lippincott Williams and Wilkins, 2000.

PERIODICALS

Kuhn, Bret R., Bethany A. Marcus, and Sheryl L. Pitner. "Treatment Guidelines for Primary Nonretentive Encopresis and Stool Toileting Refusal." American Family Physician 58 (April 15, 1999): 8-18.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry, P. O. Box 96106, Washington, D.C. 20090. (800) 333-7636. <www.aacap.org>.

Tish Davidson, A.M.