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Encopresis

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.

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

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