Dr. M.J. Bazos, MD Patient Handout


About Your Diagnosis

Encopresis is the repeated passage of stool or feces into inappropriate places such as the clothing or floor, whether intentional or involuntary. To be diagnosed with encopresis, an individual must be at least 4 years of age, and the encopresis must occur at the rate of at least one episode a month for 3 months or more. Finally, the encopresis cannot be due solely to the direct effect of a substance (for example, a laxative), or a medical condition. Encopresis can occur with or without constipation. Less than one third of children in the United States have finished toilet training by their second birthday. Generally, control of bowels is achieved before bladder control. Because about 95% of children have acquired stool continence (the ability to control their bowels) by the age of 4 years, that age is usually established as the normal age by which continence is acquired. As with continence of urine, girls achieve bowel control earlier than do boys. In terms of looking at who has this condition, one study shows that the prevalence of encopresis in children aged 7–8 years is about 1.5% of all children in that age group, with boys being more commonly affected than girls. In this and other studies, by the age of 16 years, the rate of bowel incontinence is almost zero. Of patients who have encopresis, 80% to 90% have associated constipation. The children who have encopresis and constipation often have distention of their colons and can have significant impaction with hard feces.

Living With Your Diagnosis
We don’t really know what causes encopresis, but it may occur after an episode of constipation, after an illness, or it may occur after a change in diet. Stressful events such as the birth of a sibling, starting a new school, or moving have been associated with up to one quarter of cases of secondary encopresis. Excessive stress during the toilet-training period, leading to increased anxiety and socalled “pot phobia” have all been associated with higher rates of encopresis. Hersov has listed three types of identifiable encopresis in children. In the first, it is known that the child can control defecation, but he chooses to defecate in inappropriate places. In the second, there is true failure to gain bowel control, and the child is either unable to prevent the soiling or is unaware of it. In the third case, the child’s soiling is caused by excessively liquid feces, whether from constipation and overflow, or from anxiety. Of course, these three mechanism of encopresis can also overlap. Unlike urinary incontinence, fecal incontinence rarely occurs during the night, and if it does, represents a poor sign for recovery. In the first type of encopresis where the child has some control over the behavior, the encopresis tends to be temporary and often resolves after the stress— such as a new sibling, move, or change in school— is no longer acute. In some families where there is an especially large amount of chaos or overstrict punishment, the feces may even be deposited in places designed to cause anger or irritation, and may even be smeared on furniture or walls. In the second group, where there is failure to learn bowel control, the stool is deposited fairly randomly in clothes, at home, or other places. In these children, there may be some other medical illness, either some kind of brain damage or intellectual deficiency, that has retarded their ability to learn how to control their bowel. In the third group, where there is excessively fluid feces, the child may have a condition that usually produces diarrhea, such as ulcerative colitis, or may just have constipation with overflow diarrhea. The child is extremely self-conscious of their liquid feces and will go to elaborate lengths to avoid having a bowel movement in public. Assessing a child with encopresis obviously involves a complete medical examination with appropriate laboratory and x-ray studies. Most of these medical evaluations will be negative in that there is very rarely a physical cause of the encopresis; however, there may be consequences of the behavior, such as colon dilatation. Ulcerative colitis, Crohn’s disease, and Hirschsprung’s disease should all be ruled out. It is also important to do a psychiatric and psychosocial and family interview to obtain more information about the developmental history, as well as what behaviors or events may have preceded the encopresis.

The management and treatment of encopresis involve four stages. The first stage consists of an assessment to determine whether encopresis is primary or secondary. Also, physical causes are looked for, as well as any other factors that might be contributing to the encopresis. In the second stage, advice is given. This is mainly an educational phase regarding diet and toileting. Also an attempt is made to reduce the parent’s practice of punitive behavior toward the child, as well as to transmit some optimism to the child and the family. The third stage is focused on toileting. It includes focusing on positive achievements related to toilet training, eating a high-fiber diet, and toileting after meals for a maximum of 15 minutes. Also, those patients with “pot phobia” are gradually exposed to toileting. This stage may also involve the use of laxatives, and Senokot and Lactulose syrup are often used. If there is no benefit from laxatives, enemas may be used if the bowel is excessively full of very hard feces. Bisacodyl can often be used for this purpose. The fourth stage consists of biofeedback, and this is done only in those cases where there is a relapse after training. There are a number of other therapeutic tools that are used. Behavior treatments are very popular, including the use of positive reinforcement. It is very important to work with the families because often they are obsessively concerned with the encopretic behavior and make it the center of the family’s attention. Therefore it is very important to shift the family’s focus away from the encopresis. Instead the family should be encouraged to notice and mention positive behavior. This may defuse tension and decrease hostility. Frequently the increased attention that a child gets, and the escape from the usual responsibilities (e.g., not attending school) may provide secondary gain for the encopresis behavior. While mild consequences may be used such as telling the child to clean himself after soiling, it should be pointed out that one must be careful not to carry punitive behavior to the extreme. Generally, behavioral therapy combined with laxatives is effective in about 75% of the cases, in decreasing the encopretic episodes. Finally, biofeedback for external sphincter control has also been effective. Medications for this condition are primarily the ones that we have mentioned: the laxatives and sometimes enemas. Excessive use of laxatives should be avoided because of the potential for drug dependency. It is important for the child to maintain a healthy diet. A high-fiber diet is often recommended. This can be done by adding bran to cereals, fruit, or milkshakes. There are few complications related to the medications used to treat encopresis if they are used appropriately.

When to Call Your Doctor
• If your child has a fever, begins to have nausea or vomiting, or has particularly hard stools.
• If your child has diarrhea and becomes excessively dehydrated.
• If you see any blood in your child’s stool or blood around the rectum, call immediately.