Encopresis
Repeated fecal soiling in children past toilet-training age.
Encopresis refers to a child who is old enough to be toilet trained but repeatedly passes stool in inappropriate places. This condition is usually linked to long-term constipation and overflow leakage, though it can also occur without constipation. In the DSM-5, it is classified as an elimination disorder.
Quick Facts
- Field
- Psychiatry
- clinical psychology
- pediatrics
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Causes
Encopresis in children often stems from constipation, but it can also happen without it. Other causes include reflexive stool withholding, various physiological, psychological, or neurological disorders, and, less commonly, surgery. Normally, the colon removes excess water from stool. When stool stays in the colon too long—due to conditioned withholding or accidental constipation—so much water is removed that the stool hardens, making it painful to pass. This can start a vicious cycle: the child avoids bowel movements to escape the anticipated pain, deeply conditioning a holding response. This may lead to the rectal anal inhibitory response (RAIR) or anismus, which can occur even under anesthesia when voluntary control is lost. The hardened stool builds up, stretching the colon or rectum until normal sensations of an impending bowel movement disappear. Eventually, softer stool leaks around the blockage, and the anus cannot hold it back, causing soiling. The child typically has no control over these accidents and may not feel them happening due to lost rectal sensation. The onset is usually benign, often linked to toilet training, demands for long sitting periods, or intense negative parental reactions to feces. Starting school or preschool is another common trigger, as are shared bathrooms. Family stressors like feuding parents, siblings, moving, or divorce can also inhibit toileting and promote constipation. As chronic factors take over, the initial cause may become less important.
Diagnosis
Encopresis is diagnosed when a child age four or older repeatedly passes stool in inappropriate places, such as underwear or on the floor, at least once a month for three months. This behavior can be either voluntary or unintentional. It must not be caused solely by a substance like laxatives or a general medical condition, unless constipation is involved. The condition has two subtypes. In retentive encopresis, constipation leads to continuous leakage of poorly formed stool, which can happen during both sleep and waking hours. In non-retentive encopresis, there is no constipation; the child intermittently passes well-formed stool, often in a noticeable location. This type may be linked to oppositional defiant disorder, conduct disorder, or other behavioral and developmental issues.
Treatment
When constipation leads to encopresis, doctors typically suggest a three-part plan. First, the bowel needs a thorough clearing, often done with enemas, laxatives, or both, though oral stool softeners like Movicol, Miralax, lactulose, or mineral oil are now the most common choice. After that initial cleanout, daily enemas or laxatives keep stools soft, giving the overstretched colon a chance to shrink back to its normal size. The behavioral side involves setting a consistent toilet routine: children sit for five to fifteen minutes at the same times each day, ideally after meals, because the gastrocolic reflex makes pooping more likely then. Over weeks, regular successful trips to the toilet help restore normal rectal feeling and the natural urge to go, which chronic holding and stretching may have disrupted. If this approach doesn’t work after six months, a more intensive plan uses suppositories and enemas on a strict schedule to break the reflexive holding pattern and let the proper voiding reflex take over. Without successful treatment, the colon can become permanently stretched, so it’s important not to wait years assuming the child will outgrow it. Diet also matters: increasing fiber with bran, whole grains, fruits, and vegetables, plus drinking more water and fluids, helps. Juices are okay for extra liquid, but too much sweetened juice is limited to protect teeth. Foods that can worsen constipation—dairy, peanuts, cooked carrots, bananas—should be cut back, along with caffeinated drinks like cola and tea. The goal is balanced meals and snacks, limiting fast food high in fat and sugar. For functional encopresis, a motivational system like a contingency plan works well, and adding seven or eight other behavioral techniques can boost its effectiveness.
More in Symptoms and Signs: Digestive System and Abdomen
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