Encopresis

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Editor(s)-in-Chief: C. Michael Gibson, M.S.,M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Angela Botts, M.D., Beth Israel Deaconess Medical Center Geriatric Medicine [mailto:abotts@bidmc.harvard.edu]

Overview
Encopresis, from the Greek κοπρος (kopros, dung) is involuntary "fecal soiling" in children who have usually already been toilet trained. Children with encopresis often leak stool into their underwear.

Prevalence
The estimated prevalence of encopresis in 5-year-olds is ~1-3%. The disorder is thought to be more common in males than females, by a factor of 3 to 1.

Causes
Encopresis is commonly caused by constipation, by deliberate 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 deliberate 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. 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.

Encopresis may also be due to psychological problems, such as oppositional defiant disorder or conduct disorder which are often viewed as a kind of "parental control" attempt by the child. Or, encopresis may be the result of a fear of the commode and its flushing action, or by simple reluctance to "let go" of the stool into the toilet. Health practitioners, however, typically think of encopresis as mainly a physical problem with a psychological component (but not cause). Encopresis is also a symptom of child sexual abuse

Diagnosis
The psychiatric (DSM-IV) diagnostic criteria for encopresis are:
 * 1) Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether voluntary or unintentional
 * 2) At least one such event a month for at least 3 months
 * 3) Chronological age of at least 4 years (or equivalent developmental level)
 * 4) 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 anal insertion.

Treatment
There is a 3-pronged approach to the treatment of encopresis associated with constipation:
 * 1) cleaning out
 * 2) using stool softening agents
 * 3) scheduled sitting times, typically after meals

The initial clean-out is achieved with enemas, laxatives, or both. Following that, enemas and laxatives are used daily to keep the stools soft and allow the stretched bowel to return to its normal size.

Next, the child must be taught to use the toilet regularly to retrain his/her body. It is 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.

Dietary changes are an important management element. Recommended changes to the diet in the case of constipation-caused encopresis include:
 * 1) reduction in the intake of constipating foods such as dairy, peanuts, cooked carrots, and bananas;
 * 2) increase in high-fibre foods such as bran, whole wheat products, and fruits and vegetables; and
 * 3) higher intake of liquids, such as juices, although an increased risk of diabetes and/or tooth decay has been attributed to excess intake of sweetened juices.

Unless there are immediate, satisfactory results from the above, some practitioners recommend keeping the child on a program of daily laxative use with a laxative recently made available to the public as a generic medicine. Use of laxatives, however, often results in unexpected and/or uncontrollable bowel movements for the child, wherein the child cannot "avoid" soiling. Other practitioners recommend that the child be kept on a regular program of simple, water-based enemas, which can be scheduled for appropriate times when the child is comfortably at home or in other private quarters. One benefit of the enema therapy is that it keeps the child from any attempts at "parent control" by preventing the child from withholding stool. An enema usually results in a fairly timely expulsion at a time and place more convenient to family members.

Additional Resources

 * The Diagnostic and Statistical Manual of Mental Disorders

Encoprese Enkopresis