Encopresis is defined as repeated involuntary defecation somewhere other than a toilet by a child age four or older that continues for at least one month.
Soiling, fecal soiling, and fecal incontinence are alternate terms used for this behavior. Whatever the cause, parents should talk openly about the problem with the child. When parents treat a bowel problem as a cause for embarrassment or shame, they may unintentionally aggravate or prolong it.
About 1 to 3 percent of children are affected by encopresis. More boys than girls are affected.
Causes and symptoms
Encopresis can be one of two types, nonretentive encopresis and retentive encopresis. About 80 to 95 percent of all cases are retentive encopresis. Children with this disorder have an underlying medical reason for soiling. The remaining cases have no physical condition that bars normal toileting behaviors. This type, nonretentive encopresis, is a behavioral condition in which the child refuses to defecate in a toilet.
Retentive encopresis is most often the result of chronic constipation and fecal impaction. In these children, feces have become impacted in the child's colon, causing it to distend. This causes the child to not feel the urge to defecate. The anal sphincter muscle becomes weak and unable to contain the soft stools that pass around the impaction. Despite the constipation, these children actually do have regular, though soft, bowel movements that they are unable to control. The child may not even be aware that he or she has defecated until the fecal matter has already passed. Many children have a history of constipation that extends back as far as five years before the problem is brought to medical attention.
A child may exhibit nonretentive encopresis, or functional encopresis, for several reasons. First, he or she may not be ready for toilet training . When a child is learning appropriate toilet habits during toddlerhood and preschool years, involuntary or inappropriate bowel movements are common. Second, the child may be afraid of the toilet or of defecating in public places like school. Others may use fecal incontinence to manipulate their parent or other adults. These children often have other serious behavioral problems.
When to call the doctor
A doctor should be called whenever children experience unresolved constipation or difficulty controlling their stools.
Before beginning treatment for encopresis, the pediatrician first looks for any physical cause for the inappropriate bowel movements. The doctor asks parents about the child's earlier toilet training and typical toileting behaviors and inquires about a history of constipation. The doctor will digitally examine the child's anal area to check the strength of the anal sphincter muscle and look for a fecal impaction. An abdominal x ray may be needed to confirm the size and position of the impaction.
If the pediatrician makes a diagnosis of retentive encopresis, the physician may recommend laxatives , stool softeners, or an enema to free the impaction. Subsequently, the doctor may make several suggestions for to avoid chronic constipation. Children should eat a high-fiber diet, with lots of fruits, vegetables, and whole grains. They should be encouraged to drink larger amounts of water and get regular exercise . Children should be taught to not feel ashamed of toileting behaviors, and psychotherapy may help decrease the sense of shame and guilt that many children feel.
If no fecal impaction is found, the pediatrician works with a counselor or psychiatrist to analyze the variables that characterize the encopresis. If the child is not physically or cognitively ready for toilet training, it should be postponed.
In the remainder of nonretentive encopresis cases, treatment should then center on making sure the child has comfortable bowel movements, since some cases of nonretentive encopresis involve some level of discomfort associated with constipation.
The prognosis for most children with encopresis is good, assuming that all underlying problems are identified and appropriately treated.
There is no known way to prevent encopresis. Experienced counselors suggest that early identification of problems and accurate diagnosis are useful in limiting the severity and duration of encopresis.
A high-fiber diet may be recommended for persons with encopresis. Affected persons should consume lots of fruits, vegetables, and whole grains. Adequate to copious intake of fluids are also recommended.
Parents of a child with a serious behavior disorder like oppositional defiant disorder should work with their child's therapist to deal with encopresis in the context of other behavioral problems. Parents should work with their children to establish appropriate stooling behaviors and institute a system of rewards for successful toileting.
Constipation —Difficult bowel movements caused by the infrequent production of hard stools.
Impaction —A condition in which earwax has become tightly packed in the outer ear to the point that the external ear canal is blocked.
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L. Fleming Fallon, Jr., MD, DrPH