What Is Encopresis?
Encopresis is usually defined as the soiling of underwear with stool by children who are past the age of toilet training. In most cases, encopresis is accidental. It can embarrass the child very much. The age cutoff for “normality” is set at 4 years, the age at which 95% of children have acquired fecal continence.
Encopresis is not a disease. It is a symptom that can have different causes. Encopresis, also called soiling, is very common, occurring in at least two out of 100 children. Girls achieve bowel control earlier than boys. Nearly 80% of the affected children are boys. Treatment for encopresis is usually successful.
Over 80% of children with encopresis would have experienced painful defecation or constipation in the past. Symptoms of encopresis can include:
- Leakage of liquid stool or stool on underwear
- They may attempt to hide their soiled underwear or clothes
- Often, they cannot feel or even smell that they have soiled
- Constipation with dry, hard stool could cause a tear in the skin around the anus, which leave blood in the toilet, on the stools, or on the toilet paper
- Avoidance of bowel movements
- Lack of appetite
- Abdominal pain
- Withdrawing from friends, school, or family due to getting teased
- They may also have problems with bedwetting or daytime wetting with urine (enuresis)
- Girls can have repeated bladder infections
Causes of Encopresis
In most cases, encopresis occurs consequent to long-standing (chronic) constipation. What leads to constipation to begin with?
- Withholding stool due to fear of using the toilet (especially when away from home) or because stools are painful
- Not eating enough fiber, which is available in vegetables, fruits, and whole-grain foods.
- Not drinking enough water.
- Lack of exercise
- Not taking the time out during play or other activities to go to the bathroom when the child feels the urge to pass stools
- Being too busy playing to take time to use the bathroom
Constipation implies the child has fewer bowel movements than normal. Stools can then become dry, hard, and difficult to pass. The child may avoid using the toilet because it hurts. The stool then becomes impacted in the large intestine. The stool cannot move forward. The large intestine becomes enlarged. Over time, liquid stool can start to leak around the hard, dry, impacted stool. This soils the child’s clothing.
Other risk factors for encopresis include:
- Colonic inertia
- Nerve damage to the anal sphincter, so that it does not close properly.
- Emotional stress, for example, the divorce of a parent or the birth of a sibling
- Other health problems, such as hypothyroidism, diabetes, inflammatory bowel disease, and Hirschsprung disease.
- Attention-deficit/hyperactivity disorder (ADHD)
- Autism spectrum disorder
- Depression or anxiety
DSM-V lists the following diagnostic criteria for encopresis:
- Repeated passage of feces, intentionally or involuntarily, into inappropriate places (e.g., clothing, floor).
- Minimum one such event each month for at least 3 months.
- Age is at least 4 years (or equivalent developmental level).
- Not attributable to the physiological effects of a substance (e.g., laxatives) or another medical condition except through a mechanism involving constipation.
Treatment of Encopresis
Treatment of encopresis includes:
- Emptying the colon of the stool – give enema or laxatives. Treatment may be needed for several days to completely empty the colon.
- Keeping stools soft so that it will pass easily – Drinking plenty of fluid helps keep stools soft and may help prevent constipation in the first place.
- Toilet sitting at least twice a day (if age appropriate) – for 5-10 minutes after breakfast and after dinner. This takes advantage of the “gastrocolic reflex,” intestinal contractions that naturally occur after eating.
- Retraining the intestine and rectum to gain control over bowel movements – teach the child about the appropriate use of muscles and other physical responses during defecation. This helps them recognize the urge to have a bowel movement and to defecate effectively. Biofeedback can successfully 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 treatment varies from child to child. Treatment should continue until the child has developed regular and reliable bowel habits. This could take several months.
Diet and exercise are very important in keeping stools soft and bowel movements regular. The child should eat plenty of fiber-rich foods, such as fresh fruits, dried beans, dried fruits like prunes and raisins, vegetables, and whole-wheat bread and cereal.