Encopresis

Definition

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.

Description

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.

Demographics

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.

Diagnosis

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.

Treatment

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.

Prognosis

The prognosis for most children with encopresis is good, assuming that all underlying problems are identified and appropriately treated.

Prevention

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.

Nutritional Concerns

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.

Parental Concerns

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.

Resources

Books

Boris, Neil, and Richard Dalton. "Vegetative Disorders." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2003, pp. 73–9.

Brazelton, T. Berry, et al. Toilet Training: The Brazelton Way. Cambridge, MA: Perseus Publishing, 2003.

Perkin, Steven R. Gastrointestinal Health: The Proven Nutritional Program to Prevent, Cure, or Alleviate Irritable Bowel Syndrome (IBS), Ulcers, Gas, Constipation, Heartburn, and Many Other Digestive Disorders. London: Harper Trade, 2005.

Periodicals

De Lorijn, F., et al. "Prognosis of constipation: clinical factors and colonic transit time." Archives of Disease in Childhood 89, no. 8 (2004): 723–7.

Loening-Baucke, V. "Functional fecal retention with encopresis in childhood." Journal of Pediatric Gastroenterology and Nutrition 38, no. 1 (2004): 79–84.

Schonwald, A., and L. Rappaport. "Consultation with the specialist: encopresis: assessment and management." Pediatric Reviews 25, no. 8 (2004): 278–83.

Voskuijl, W. P., et al. "Use of Rome II criteria in childhood defecation disorders: applicability in clinical and research practice." Journal of Pediatrics 145, no. 2 (2004): 213–7.

Organizations

American Academy of Pediatrics. 141 Northwest Point Blvd., Elk Grove Village, IL 60007–1098. Web site: www.aap.org.

American College of Gastroenterology. 4900 B South 31st St., Arlington VA 22206. Web site: www.acg.gi.org/.

Web Sites

"Encopresis." eMedicine. Available online at www.emedicine.com/ped/topic670.htm (accessed January 6, 2005). "Encopresis." MedlinePlus. Available online at www.nlm.nih.gov/medlineplus/ency/article/001570.htm (accessed January 6, 2005).

"Encopresis." Merck Manual. Available online at www.merck.com/mmhe/sec23/ch269/ch269d.html (accessed January 6, 2005).

"Stool Soiling and Constipation in Children." American Academy of Family Physicians. Available online at (accessed January 6, 2005).

[Article by: L. Fleming Fallon, Jr., MD, DrPH]

Encopresis is the name for problems with control of the anal sphincter after the age when such control is normally acquired (two or three years). The condition may be primary or secondary after a period of continence, and is characterized by bowel movements, usually during the daytime, under socially unacceptable conditions and excluding true incontinence, as produced by organic disorders of the sphincter or its related nerve structures. The term, used in clinical pediatric psychiatry, was introduced by Siegfried Weissenberg in 1926.

A clearer understanding of this symptom can be achieved by considering it in relation to the erotogenicity of the anal zone (Freud, 1905d), with its various components, including excitation of the mucous membranes and the pleasures derived from expulsion and muscular control. Michel Soulé views the erotization of retention as the central phenomenon. Non-renunciation of these instinctual satisfactions is rooted in the individual's conflictual relations with the people surrounding him during the period of toilet training—that is, the anal-sadistic stage, which is focused on issues of possession, on mastery of one's own body, and of others. The child's stools are cathected as a part of his or her own body and as representing internal objects; the subject refuses to give them up for exchange and instead saves them, often owing to a deficiency in symbolization that impedes the displacement of interest onto other objects. Anxiety plays a role, sometimes manifesting itself as a genuine defecation phobia with archaic contents, such as the destruction of internal objects, or the destruction of links, often in connection with the traumatic effects upon the child of intrusive parental fantasies or existential events involving loss.

Symptoms of encopresis can also arise from an inadequate cathexis of the body on the part of a child subject to some forms of deprivation. The secondary gains are proportionate to the involvement of the child's entourage: maintaining regressive ties to the mother; feelings of omnipotence; masochistic gratification. The failure of repression and the non-establishment of reaction-formations attest to the resistance of pregenital fixations to oedipal resolution—the definitive aim of toilet training, according to Anna Freud. Although encopresis can have a bearing on all types of psychopathology in the child, ranging from psychosis or perversion to quasi-normality, Bertrand Cramer has noted that the majority of cases involve neurosis.

Bibliography

Cramer, Bertrand, et al. (1983). Trente-six encoprétiques en thérapie. Psychiatrie de l'enfant, 26, 2, 309-410.

Freud, Anna. (1965). Normality and pathology in childhood: assessments of development. New York: International Universities Press.

Freud, Sigmund. (1905d). Three essays on the theory of sexuality. SE, 7: 130-243.

Soulé, Michel, et al. (1995). Les troubles de la defecation. In S. Lebovici, R. Diatkine, and M. Soulé (Eds.), Nouveau traité de psychiatrie de l'enfant et de l'adolescent (Vol. 4, pp. 2679-2700). Paris: Presses Universitaires de France.

Weissenberg, Siegfried. (1926).Über Enkopresis. Zeitung der Kinderpsychiatrie, 1, 69.

—GÉRARD SCHMIT

Incontinence of feces not due to organic defect or illness.

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Encopresis
Classification and external resources
ICD-10	R15. F98.1
ICD-9	307.7, 787.6
DiseasesDB	4221
eMedicine	ped/670
MeSH	D004688

Encopresis, from the Greek κοπρος (kopros, dung) is involuntary "fecal soiling" in children who have usually already been toilet trained. Children with encopresis often leak stool into their underwear.

Contents 1 Prevalence 2 Causes 3 Diagnosis 4 Treatment 5 See also 6 References 7 External links

Prevalence

The estimated prevalence of encopresis in 4-year-olds is ~1-3%. The disorder is thought to be more common in males than females, by a factor of 6 to 1.

Causes

Encopresis is commonly caused by constipation, by reflexive withholding of stool, by various physiological, psychological, or neurological disorders, or from surgery (a somewhat rare occurrence).

The colon normally removes excess water from feces. If the feces or stool remains in the colon too long due to conditioned withholding or incidental constipation, so much water is removed that the stool becomes hard, and becomes painful for the child to expel in an ordinary bowel movement. A vicious cycle can develop, where the child may avoid moving his/her bowels in order to avoid the "expected" painful toilet episode. This cycle can result in so deeply conditioning the holding response that the Rectal Anal Inhibitory Response (RAIR) or anismus results. The RAIR has been shown to occur even under anesthesia and voluntary control is lost. The hardened stool continues to build up and stretches the colon or rectum to the point where the normal sensations associated with impending bowel movements do not occur. Eventually, softer stool leaks around the blockage and cannot be withheld by the anus, resulting in soiling. The child typically has no control over these leakage accidents, and may not be able to feel that they have occurred or are about to occur due to the loss of sensation in the rectum and the RAIR. Strong emotional reactions typically result from failed and repeated attempts to control this highly aversive bodily product. These reactions then in turn may complicate conventional treatments using stool softeners, sitting demands, and behavioral strategies.

The onset of encopresis is most often benign. The usual onset is associated with toilet training, demands that the child sit for long periods of time, and intense negative parental reactions to feces. Beginning school or preschool is another major environmental trigger with shared bathrooms. Feuding parents, siblings, moving, and divorce can also inhibit toileting behaviors and promote constipation. An “initial” cause may become less relevant as “maintaining” causes take over. Sexual abuse can be a cause, but such claims must be independently corroborated by other factors than the encopresis itself.

Diagnosis

The psychiatric (DSM-IV) diagnostic criteria for encopresis are:

1. Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether voluntary or unintentional
2. At least one such event a month for at least 3 months
3. Chronological age of at least 4 years (or equivalent developmental level)
4. The behavior is not exclusively due to a physiological effect of a substance (e.g., laxatives) or a general medical condition, except through a mechanism involving constipation.

The DSM-IV recognizes two subtypes: with constipation and overflow incontinence, and without constipation and overflow incontinence. In the subtype with constipation, the feces are usually poorly formed and leakage is continuous, and occurs both during sleep and waking hours. In the type without constipation, the feces are usually well-formed, soiling is intermittent, and feces are usually deposited in a prominent location. This form may be associated with oppositional defiant disorder or conduct disorder, or may be the consequence of large anal insertions.

Treatment

Many pediatricians will recommend the following three-pronged approach to the treatment of encopresis associated with constipation: 1. cleaning out 2. using stool softening agents 3. scheduled sitting times, typically after meals.

The initial clean-out is achieved with enemas, laxatives, or both. The predominant approach today is the “top down” use of oral stool softeners like Miralax, Lactulose, mineral oil, etc. Following that, enemas and laxatives are used daily to keep the stools soft and allow the stretched bowel to return to its normal size.

The child must be taught to use the toilet regularly to retrain his/her body. It is usually recommended that a child be required to sit on the toilet at a regular time each day and 'try' to go for 10-15 minutes, usually soon (or immediately) after eating. Children are more likely to be able to expel a bowel movement right after eating. It is thought that creating a regular schedule of bathroom time will allow the child to achieve a proper elimination pattern. Repeated voiding success on the toilet itself helps it to become a releasor stimulus for successful BMs.

Alternatively, when this method fails for six months or longer, a more aggressive approach may be undertaken using the “bottom up” approach of suppositories and enemas in a carefully programmed way to overcome the reflexive holding response and to allow the proper voiding reflex to take over. Failure to establish a normal bowel habit can result in permanent stretching of the colon. Certainly, allowing this problem to continue for years with constant assurances that the child "will grow out of it" should be avoided.

Dietary changes are an important management element. Recommended changes to the diet in the case of constipation-caused encopresis include: 1. reduction in the intake of constipating foods such as dairy, peanuts, cooked carrots, and bananas; 2. increase in high-fiber foods such as bran, whole wheat products, fruits, and vegetables; 3. higher intake of water and liquids, such as juices, although an increased risk of diabetes and/or tooth decay has been attributed to excess intake of sweetened juices; 4. limit drinks with caffeine, such as cola drinks and tea; 5. provide well-balanced meals and snacks, and limit fast foods/junk foods that are high in fats and sugars; 6. limit whole milk to 16 ounces a day for the child over 2 years of age, but do not completely eliminate milk because children need calcium for bone growth and strength.

The emotional ramifications of dealing with such an aversive waste product are often very intense and result in much anger and recriminations within the family unit. There are even periodic newspapers accounts of angry parents abusing and even killing these children. Emotional complications are most often a product of the disorder itself rather than causal in nature. Professional help should be sought if these emotional effects obstruct effective treatment.

See also

• Fecal incontinence

References

• Treatment of Encopresis and Chronic Constipation in Young Children: Clinical Results from Interactive Parent-Child Guidance

• Soiling Solutions in Children

• The Diagnostic and Statistical Manual of Mental Disorders

External links

• Aboutencopresis Links
• Beating Sneaky Poo: Ideas for feacal soiling (2nd ed), by Terry Heins & Karen Ritchie. Free downloadable booklet for children, parents, teachers, and health professionals.
• Treatment of encopresis by allowing the overt expression of anger.
• Parents Forum for Encopresis and Enuresis
• Major Gateways for Information on Encopresis
• Treatment Manual for Encopresis
• Encopresis, Cincinnati Children's Hospital Medical Center

v • d • e Symptoms and signs: digestive system and abdomen (R10-R19, 787,789) GI tract Upper GI tract Nausea/Vomiting · Heartburn · Dysphagia (Oropharyngeal, Esophageal) Halitosis Lower GI tract gas: Flatulence · Abdominal distension · Bloating · Belching · Tympanites stool: Fecal incontinence (Encopresis) · Rectal tenesmus blood: Fecal occult blood Diarrhea Accessory Hepatosplenomegaly/Hepatomegaly Jaundice Abdominopelvic cavity Ascites Abdominal – general Abdominal pain (Acute abdomen, Colic) Splenomegaly digestive system navs: anat of tract,glands,perit,diaphragm/physio/dev, noncongen/congen/congen of d+w/neoplasia, symptoms+signs/eponymous, proc

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