Encopresis

• Encopresis is the soiling of the underwear with stool by children who are past the age of toilet training.
• Because each child achieves bowel control at his or her own pace, medical professionals do not consider stool soiling to be a medical condition unless the child is at least 4 years of age.
• This stool or fecal soiling usually has a physical origin and is involuntary, the child does not soil on purpose. In the majority of cases, the soiling is the result of loose or soft stool leaking around more formed stool trapped inside the colon.
• In the United States, it is estimated that very few children younger than 10 years of age suffer from encopresis. Many more boys than girls experience encopresis.

Rarely, encopresis is caused by an anatomic abnormality or disease that the child is born with. In the vast majority of cases, encopresis develops as a result of chronic (long-standing) constipation.

What is constipation?

Many people think of constipation as not passing a bowel movement every day. However constipation implies not only infrequent bowel movements, but also having difficulty in passing bowel movements and/or experiencing pain with the passage of stools. In most cases of childhood constipation, the constipation develops after the child experiences pain when passing stools.

• Each person has his or her own schedule for bowel movements, and many healthy people do not have a bowel movement every day.
• A constipated child might have a bowel movement every third day or less often.
• Most importantly, a constipated child tends to pass large and hard stools and experience pain while doing so.

In most children with encopresis, the problem begins with the passage of large stools and/or having pain while passing stools. This often happens long before the encopresis starts, and the child may not remember this when asked.

• Over time, the child becomes reluctant to pass stools and "withholds it" to avoid the pain.
• This "witholding" of stool becomes a habit that often persists long after the constipation or pain with bowel movements has resolved.

• As the colon stretches more and more, the child loses the natural urge to have a bowel movement.
• Eventually, looser, partly formed stool from higher up in the intestine begins to leak around the large collection of harder, more formed stool at the lower part of the colon (rectum) and then leaks out of the anus (the opening from the rectum to the outside of the body).
• Often in the beginning, only small amounts of stool leak out, producing streaks in the child's underwear. Typically, parents assume the child isn't wiping very well after passing stools, and they don't worry about the smears.
• As time goes on, the child is less and less able to hold the stool in more and more stool leaks, and eventually the child passes entire bowel movements into his or her underwear.
• Often the child is not aware that he or she has passed stools.
• Because the stool is not passing normally through the colon, it often becomes very dark and sticky and may have a very foul smell.

Over time, the child with encopresis may also develop incoordination of the muscles used to pass bowel movements. In many children, the anal sphincter contracts rather than relaxes when they are trying to push the stools out. This disturbed coordination of muscle function called anismus or paradoxical contraction of the pelvic floor during defecation, makes it very difficult for the child to empty his or her colon when they go to the toilet.

What causes the constipation in initially?

• The most common cause of constipation in children is the passage of large, hard, and painful bowel movements. The child "withholds" to avoid pain. Over time, this results in the bowel movements becoming larger and harder, and a vicious circle begins.
• Some experts believe children become constipated when they do not eat enough fiber, but others believe there is no connection between diet and constipation. There is no clear evidence that constipation is caused by too little fiber in the diet.
• Many doctors think that some children become constipated because they do not drink enough water. However, other doctors question whether the amount of water the child drinks has much of an effect on constipation.
• Constipation does seem to run in certain families.
• For many children, no clear cause of the constipation can be identified.

Encopresis is a very frustrating condition for parents. Many parents become angry at the repeated need to bathe the dirty child and to clean or discard soiled underwear. Many parents assume the soiling is the result of the child being lazy or that the child is soiling intentionally to annoy them. In most instances, this is not the case. Children with encopresis are however significantly more likely to suffer from attention deficit hyperactivity disorder (ADHD) than the general population. It is important to remember that in almost all cases, encopresis is involuntary - the child does not soil on purpose.

Most children with encopresis have experienced constipation or painful defecation in the past. In many cases, constipation or pain occurred years before the encopresis is brought to medical attention.

• Most children with encopresis say they have do not have an urge to have a bowel movement before they soil their underwear.
• Soiling episodes usually occur during the day, while the child is awake and active. Many school age children soil late in the afternoon after returning home from school. Soiling after the child goes to sleep at night is uncommon.
• Some children with encopresis soil while in the bathtub, shower, or swimming pool.
• In many children with encopresis, the colon has become stretched out of shape, and so they intermittently pass extremely large bowel movements.

Any of the following warrants a visit to your child's primary health care professional:

• Severe, persistent, or recurrent constipation
• Pain when passing bowel movements
• Reluctance to pass bowel movements, including straining to hold the stool in
• Soiling in a child who is at least four years of age

Your child's health care professional will ask many questions about the child's medical history, toilet training history, diet, lifestyle, habits, medications, and behaviors. A thorough physical examination will be done to assess the child's general health as well as the status of the colon, rectum, and anus. The health care professional may insert a gloved finger into the child's rectum to feel for stool and make sure the anal opening and rectum are of normal size and that the anal muscles are of normal strength.

In most cases, blood tests are not part of the evaluation of constipation and/or encopresis. In some cases, an X-ray of the child's abdomen or pelvis may be performed to determine how much stool is present in the colon and to assess if the colon and rectum are enlarged. Occasionally, a contrast barium enema is performed. This is a special type of X-ray in which a small tube is inserted into the child's rectum, and the colon is slowly filled with a radiopaque dye (barium or hypaque). X-rays are taken throughout the procedure to see if there are any areas of narrowing, twisting, or kinking in the lower intestine that might cause the child's symptoms.

In some cases, anorectal manometry may be performed. For this test, a small tube with several pressure sensors is inserted into the child's rectum. During the test, the doctor can determine how the child is using his or her abdominal, pelvic, and anal muscles during defecation. Many children who have chronic constipation and/or encopresis do not use their muscles in a coordinated fashion when trying to pass stools.

The main objective of manometry is to determine whether there is normal pressure within the anus. Manometry can also show whether the nerves controlling the anal sphincter, anus, and rectum are present and working by measuring reflexes in this area. Manometry can measure how far the rectum is distended and whether sensation in this area is normal. Abnormal contractions of the muscles in the pelvic floor can be documented by using manometry.

Anorectal manometry can also be helpful to rule out Hirschsprung's disease, a very rare cause of constipation without encopresis. If Hirschsprung's disease is being seriously considered as a cause of your child's encopresis, a biopsy of the rectum may be necessary. A biopsy is the removal of a very tiny piece of tissue for examination under a microscope. This is done to look for characteristic signs of Hirschsprung's disease in the tissues.

Although parents will be following a regimen recommended by the child's health care professional, most of the work of treating encopresis is done at home.

It is very important that parents and other caregivers keep a complete record of the child's medication use and bowel movements during the treatment period. This record can be very helpful in determining how well the treatment is working and whether adjustments need to be made.

There are many different regimens for the treatment of encopresis however most rely on the following three principles:

1. Empty the colon of stool
2. Establish regular soft and painless bowel movements
3. Maintain very regular bowel habits

While there is almost always a large behavioral component to chronic encopresis, behavioral therapy alone, such as offering rewards or reasoning with the child, usually is not effective. Rather, a combination of medical and behavioral therapy works best.

Medical professionals usually refer to emptying stool from the colon and rectum as evacuation or disimpaction. Evacuation of the colon can be accomplished in the following ways:

• Administer strong laxatives and/or stool softeners: Most laxatives and stool softeners work by increasing the amount of water in the large intestine. Some laxatives and stool softeners cause the lower intestine to secrete water and others work by decreasing the amount of water absorbed in the lower intestine. In either case, the end result is much more water in the lower intestine when using these medicines than when not using them. This large amount of water softens formed or hard stool in the intestine and produces diarrhea. Medicines used commonly for this purpose include polyethylene Glycol 3350 (Miralax, Glycolax, etc), polyethylene glycol electrolyte solution (GoLYTELY, Colyte, etc.) , sodium biphosphate and sodium phosphage (Fleet Phospho-soda) or magnesium citrate (Citrate of Magnesia, Citroma). Treatment for several days may be needed to completely evacuate the colon.
• Administer an enema or series of enemas: An enema pushes fluid into the rectum. This softens the stool in the rectum and creates pressure within the rectum. This pressure gives the child a powerful urge to have a bowel movement, and the stool is usually expelled rapidly. The fluid in most enemas is water. Something is usually added to keep the water from being absorbed by the intestinal lining. Widely used enemas include commercial phosphosoda preparations (such as Fleet saline enemas), slightly soapy water, and milk and molasses mixtures. Daily enemas for several days can be used to completely evacuate the colon.
• Administer a suppository or a series of suppositories: A suppository is a tablet or capsule that is inserted into the rectum. The suppository is made of a substance that stimulates the rectum to contract and expel stool. Popular suppositories include glycerin and commercial products such as Dulcolax and BabyLax. Daily suppositories for several days can be used to completely evacuate the colon.

Establishing regular soft and painless bowel movements is mostly a matter of retraining the child to give up the habit of "withholding" stool. This is accomplished by giving a laxative or stool softener every day in doses sufficient to produce one or two soft bowel movements every day. If the bowel movement is soft enough, the child will not have to strain very hard to pass it, and perhaps more importantly, they will not have pain when they pass it. This will encourage the child to pass regular bowel movements rather than holding stool in. Remember that fecal retention and soiling go together and so, as long as the child has a large amount of stool retained in the rectum, the soiling will persist.

The final step in the treatment is working with the child to develop regular bowel habits. This step is just as critical as the first two steps and must not be abandoned just because the soiling has improved after starting treatment.

• Establish regular bathroom times: The child should sit on the toilet for 5-10 minutes after breakfast and again after dinner every day. Some families must alter their daily routines to accomplish this, but it is a crucial step, particularly for school-aged children. Sitting on the toilet right after a meal takes advantage of the fact that the intestine contracts after eating. This is called the "gastrocolic reflex".
• Behavioral techniques: Offer age-appropriate positive reinforcement for developing regular toilet habits. For young children, a star or sticker chart can be helpful. For older children, earning privileges, such as extra television or video game time may be useful.
• Training: Children may respond to teaching about the appropriate use of muscles and other physical responses during defecation. This helps them learn how to recognize the urge to have a bowel movement and to defecate effectively.
• Biofeedback: This technique has been used successfully to teach some children how to best use their abdominal, pelvic and anal sphincter muscles, which they have so often used to retain stool.

The duration of treatment varies from child to child. Treatment should continue until the child has developed regular and reliable bowel habits and has broken the habit of withholding his or her stool. This usually takes at least several months. Generally, it takes longer in younger children than in older children.

Many parents are reluctant to give their child laxatives or stool softeners because they have heard that they are harmful, cause more serious conditions (such as colon cancer) or can result in dependency. There is no convincing evidence that any of these things are true. Laxatives or stool softeners do not stop working if they are used every day for a long time.

Most cases of encopresis respond to the treatment regimen outlined above. If the soiling does not improve, your child's health care professional may refer you to a specialist in digestive and intestinal disorders (pediatric gastroenterologist), a behavioral psychologist, or both.

Osmotic laxatives: These laxatives contain agents that are not efficiently absorbed by the intestinal lining. This results in large amounts of extra water in the intestine, which softens the stool. Since all osmotic laxatives work by increasing the amount of water in the colon, it is important that your child drinks lots of fluid while taking any of these laxatives. Like any medication, these should be given only as recommended by your child's health care professional. If the laxative does not seem to be working, do not increase the dose without talking to your child's health care professional. Rarely, these products interfere with other medications that your child takes.

• Polyethylene glycol 3350 powder (Miralax, Glycolax, et al): The powder is mixed in at least 8 ounces of water, juice, soda, coffee, or tea. The usual dose is 0.25 – 0.5 g per pound of body weight given once or twice daily. This laxative is tasteless, odorless, and usually quite easy to take. It may take slightly longer to work than some other products.
• Magnesium hydroxide (FreeLax, Philip's Milk of Magnesia, Haley's MO): Besides causing retention of fluid in the intestine, this laxative promotes the release of a hormone called motilin that stimulates contractions in the stomach and upper intestine. Some children experience abdominal cramping when taking magnesium containing laxatives. This laxative is flavorless but has a thick chalky texture that may be more acceptable when mixed with a fluid such as milk or chocolate milk. It should be avoided by children with kidney problems.
• Lactulose (Chronulac, Constilac, Duphalac, Kristalose, Lactulose): This laxative is generally very well tolerated and tastes sweet. It may cause gas and abdominal cramping at usual doses.
• Sorbitol: This is generally well tolerated and tastes quite sweet. It often causes gas and abdominal cramping.
• Magnesium citrate (Evac-Q-mag): This works by the same mechanism as magnesium hydroxide. The product is clear (not chalky like magnesium hydroxide) and may be chilled to improve palatability.
• Polyethylene glycol balanced electrolyte solutions (COLYTE, GoLYTELY): These balanced electrolyte solutions are often used as purgatives in preparation for colonoscopy or abdominal surgery. They require drinking a large volume of fluid, which may be more acceptable if chilled. This laxative may be associated with nausea, bloating, abdominal cramps, and vomiting.

Emollient laxatives: These products decrease the absorption of water from the colon, and thus soften the stool, making it easier to pass.

• Mineral oil (Mineral Oil, Milkinol): This laxative is largely tasteless and has an oily consistency. It may be more palatable if cold or mixed into a fluid such as orange juice. It may cause seepage of orange oil from anus, which can cause anal itching and stain the underwear. This laxative should generally not be given with food.

Stimulant laxatives: These agents have a direct action on the lining of the intestinal wall. They increase water and salt secretion into the colon and irritate the intestinal lining to produce contractions.

• Sennosides (Aloe Vera, Ex-Lax, Fletcher's Castoria, Senokot): This laxative is derived from a plant, stimulates salt and water secretion into the colon, and promotes the movement of stool through the colon. It may cause abdominal cramping at higher doses.
• Bisacodyl (Dulcolax): This colorless and odorless compound increases colonic peristalsis and stimulates salt and water secretion. It can be given by mouth or as a suppository and may cause abdominal cramping at higher doses.
• Dioctyl sodium sulphosuccinate (Colace): This is a detergent that simulates salt and water secretion into the colon and promotes the movement of stool through the colon. It may cause abdominal cramping at higher doses.

Fiber supplements and certain foods, such as fruit juices and prunes, can have a laxative effect. These foods and juices function as osmotic laxatives. They all contain various sugars that are not efficiently absorbed by the intestinal lining, thus increasing the amount of water in the colon. Given in large enough doses, all of these foods and juices are very effective laxatives. However, most children are not willing to take in enough of these fruits and juices day in and day out for many months to serve as primary treatment for encopresis. Eaten in large enough quantities to ensure two soft bowel movements a day, these foods and juices often cause bloating and gas.

There is little evidence that eating a high-fiber diet significantly improves encopresis once it is established, although it may help prevent constipation in the first place.

Drinking plenty of fluids helps keep stools soft and may help prevent constipation initially.

Children with encopresis rarely need surgery. However, surgery may be used in extremely chronic and refractory cases.

Enemas: Most enema preparations contain large amounts of water in addition to something that is not efficiently absorbed by the intestinal lining. This prevents the water in the enema from being absorbed, so the water remains in the colon. The enema is inserted into the rectum. This softens the stool in the rectum and creates pressure within the rectum. This pressure gives the child a powerful urge to have a bowel movement, and the stool is usually expelled rapidly. Common examples include phosphate or saline (salt) solutions or milk and molasses. The effectiveness of any particular enema preparation is probably more dependent on the volume (size) of the enema than on its chemical make-up. The phosphate-sodium enema (Fleet Enema) is probably the most widely used type.

Note: Some gastrointestinal specialists discourage the use of enemas and suppositories or any anal intervention because the child associates fear and pain with the anal area. The child may struggle or feel additional trauma when these types of manipulations are performed. Eventually, all impacted stool can be dissolved or disimpacted by using medications taken by mouth.

The extent of follow-up needed for encopresis varies. Your child's health care professional will probably want to see the child at least once after treatment is well under way to ensure that the treatment is working or to alter treatment if necessary.

The best way to prevent encopresis is to prevent constipation in the first place. Make sure the child gets a varied diet with plenty of fruits and vegetables and whole grain breads and cereals. The child should drink water and other fluids frequently and be physically active every day. Finally, make sure the child has a regular time every day when he or she sits on the toilet. After a meal is the best time for this.

Generally, the outlook is excellent for children who undergo the treatment regimen outlined here. Many children who do not undergo treatment are able to resolve the problem on their own as they grow up, but this can take many years. The problem can persist into adulthood.