Encopresis (fecal soiling) in children

What is encopresis?

Encopresis is when a child who is toilet trained passes stool (bowel movements) into his or her underwear. To have encopresis, the child must be at least 4 years old, the age by which most children can control bowel movements. Encopresis is also called fecal incontinence.

In most children, encopresis is related to chronic constipation. Constipation is when bowel movements don't occur often enough. Also, the stool is hard and dry. Boys have encopresis more often than girls.

When stool needs to be passed, it collects in the lower bowel (rectum). There, it stretches the bowel wall. This feeling of the bowel being stretched is what normally makes us realize we have to go to the bathroom.

However, if the bowel wall is stretched for long periods without passing a bowel movement, the rectum loses its normal muscle tone and feeling. This makes it harder and harder to pass the hard stool collecting in the rectum. Also, it becomes more difficult for your child to know when stool is ready to be passed.

As newer stool continues to be made in the intestines, it leaks around the large chunk of hard stool. It passes out of the rectum and soils the child's underpants. In almost all children with encopresis caused by constipation, this is not done on purpose. In fact, many children do not even realize that the stool has leaked out. The first clue that the child has a problem may come when someone notices that the child smells bad.

Chronic constipation that turns into encopresis can have many different causes. These include:

• tension and anxiety because of problems during toilet training
• a diet that is low in fiber, found in:
  • fruits
  • vegetables
  • whole grains
• a diet that is high in foods that tend to cause constipation, such as:
  • whole milk
  • cheese
  • white rice
  • white bread
• not drinking enough liquids
• an inactive lifestyle with too little exercise (exercise stimulates the intestines to move)
• fear and anxiety about using an unfamiliar bathroom (for example, at school)
• not paying attention to the feeling (urge) that it's time to have a bowel movement: Some children do not go to the bathroom when they have the urge to do so. They might be too busy playing a game, watching television, or doing some other engaging activity. At school, they may be afraid to ask for permission to leave class to use the bathroom.
• a fissure. When a child with constipation finally passes a bowel movement, the abnormally large stool may injure the skin of his or her rectum. This can produce a painful tear in the skin called a fissure. Because of this painful fissure, the child may become more and more anxious about having a bowel movement for fear of pain.
• hypothyroidism. Having low levels of thyroid hormones can make a child's digestive system function more slowly than normal. This can lead to constipation.

No matter what the initial cause of a child's chronic constipation, the end result is the same. A large chunk of stool builds up and stretches the rectum until it loses its normal tone and feeling. This makes it more difficult for the rectum to push out the stool. So, more and more stool builds up.

This unhealthy cycle can only be broken when the bowel is completely cleared of stool. At that point, the bowel can return to its normal size. Then a child can learn how to empty his or her bowel on a more regular schedule.

In rare cases, encopresis is related to:

• medical problems involving the nerves in the spine or the bowel wall
• psychological issues, such as anxiety, depression, oppositional defiant disorder, or trauma.

Symptoms of encopresis

In most children with encopresis, the most obvious signs are:

• soiled underpants
• a foul body odor (the smell of stool).

Other signs and symptoms may include

• periods of constipation (no bowel movements) alternating with very large bowel movements
• streaks of blood on the outside of stool, or on toilet tissue used to wipe after a bowel movement
• pain in the lower abdomen or rectum
• stool-stained clothes hidden in closets, under the bed, or elsewhere
• bedwetting, probably related to pressure from the large chunk of stool in the rectum.

Diagnosing encopresis

The doctor will begin by asking about your child's bowel habits, including

• how often he or she has bowel movements
• the size of your child's bowel movements
• whether the outsides of the stools have been streaked with blood.

The doctor also will ask about your child's diet, especially about:

• foods that tend to cause constipation:
  • milk and other dairy products, white rice, and white bread
• high-fiber foods, which help to keep stools soft:
  • fruits, vegetables, whole grains.

Some doctors ask parents to keep a diary of the child's diet and stools for a week. This can help to figure out how best to treat the child. The doctor also will want to know about any unusual stresses in your child's life, either at home or at school.

The doctor will examine your child. He or she will look for any physical abnormalities in your child's abdomen, genital area, or lower spine. He or she also may examine your child's rectum to look for any fissures or other abnormalities. The doctor may check to see how much stool is in the rectum.

In most cases, your doctor can diagnose encopresis based on your child's

• age
• history and symptoms of chronic constipation
• physical examination.

Usually no further tests are necessary. Sometimes an x-ray is done of the abdomen to see how much stool is present.

If the doctor thinks the problem may be related to abnormalities in your child's lower digestive tract, he or she may order additional tests.

If your child has signs of hypothyroidism, your doctor may order blood tests to measure thyroid hormone levels.

Expected duration of encopresis

With treatment, most children will recover from encopresis. The length of treatment varies greatly depending on the child and the circumstances. Almost all children with encopresis stop soiling by the time they reach their mid-teen years.

Preventing encopresis

To help prevent encopresis caused by chronic constipation, you can:

• Increase the amount of fiber in your child's diet, by giving plenty of fruits, vegetables, and whole grains.
• Make sure your child drinks plenty of fluids — water is best — throughout the day.
• Have your child sit on the toilet for 10 to 15 minutes twice each day, at the same times every day. Your child also should go to the toilet 10 to 15 minutes after every meal.
• Keep your child active. Exercise helps to get the intestines (bowels) moving, so that stool passes through more easily and quickly.
• Encourage and praise your child for each successful "clean" day without soiling. Never punish, shame, or blame.
• Check with your doctor before you give your child enemas or rectal suppositories. Also, avoid using laxatives daily unless this is part of your child's treatment plan.

Remember, even after your child has become completely toilet trained, occasional accidents will happen. It is important that you remain calm and casual as you change your child's soiled clothing. Try not to show disgust, disappointment, or frustration with your child.

Treating encopresis

If your child has encopresis because of chronic constipation, treatment is a three-step process. It involves:

• Clearing the bowel of the large amount of stool. This usually can be done with medications (laxatives) taken by mouth. Sometimes enemas or rectal suppositories are needed.
• Preventing the return of constipation. For six months or more, the child may need to take a stool softener to allow bowel movements to pass more easily and comfortably. Examples of stool softeners are lactulose and mineral oil. It can take several weeks, or even months, of regular emptying before the stretched bowel returns to its normal size and regains its normal muscle tone.
• Teaching normal bowel habits. The child will need to sit on the toilet for 10 to 15 minutes at regular times during the day, including after every meal. This will allow the bowel muscles to respond normally to the urge to pass stool.

Your doctor also may suggest that you try motivating your child. One example is to use a "token reward system." This typically involves using a colorful chart to keep track of your child's progress. A gold star or sticker is awarded for every "clean" day. When the chart is filled, your child will earn some sort of reward. Every child is different when it comes to what motivates them to change.

If your child has encopresis because of a neurological or developmental problem involving the digestive tract, your doctor will refer you to a specialist for treatment. The specialist may be a neurologist or gastroenterologist.

If your child's encopresis seems to be related to serious psychological problems, your doctor most likely will refer your child to a psychiatrist or other mental health professional.

When to call a professional

Call your doctor if your child is older than 4 and consistently soils his pants with stool. Also call if your child has started soiling after being clean for many months or years. Call your doctor if your child frequently has constipation, even if he or she is not having a problem with encopresis.

Call your doctor immediately if your child begins to intentionally drop or smear stool anywhere, including around the home or school.

Prognosis

Most children with encopresis either outgrow the problem or respond to treatment. Treatment may involve changes in diet, medication, and motivational therapy.

When encopresis is related to psychological or emotional problems, treatment may take longer.

Additional info

American College of Gastroenterology (ACG)
https://gi.org

American Academy of Family Physicians (AAFP)
https://www.familydoctor.org/

American Academy of Pediatrics (AAP)
https://www.aap.org/