Dr. M.J. Bazos, MD
Patient Handout
ENCOPRESIS
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.
Treatment
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.