Encopresis

Encopresis (en-ko-PREE-sis), sometimes called fecal incontinence or soiling, is the repeated passing of stool (usually involuntarily) into clothing. Typically it happens when impacted stool collects in the colon and rectum: The colon becomes too full and liquid stool leaks around the retained stool, staining underwear. Eventually, stool retention can cause stretching (distention) of the bowels and loss of control over bowel movements.

Encopresis usually occurs after age 4, when a child has already learned to use a toilet. In most cases, soiling is a symptom of long-standing constipation. Far less frequently it occurs without constipation and may be the result of emotional issues.

Encopresis can be frustrating for parents — and embarrassing for the child. However, with patience and positive reinforcement, treatment for encopresis is usually successful.

Signs and symptoms of encopresis may include:

• Leakage of stool or liquid stool on underwear, which can be mistaken for diarrhea
• Constipation with dry, hard stool
• Passage of large stool that clogs or almost clogs the toilet
• Avoidance of bowel movements
• Long periods of time between bowel movements
• Lack of appetite
• Abdominal pain
• Problems with daytime wetting or bedwetting (enuresis)
• Repeated bladder infections, typically in girls

Call your doctor if your child is already toilet trained and starts experiencing one or more of the symptoms listed above.

There are several causes of encopresis, including constipation and emotional issues.

Constipation

Most cases of encopresis are the result of chronic constipation. In constipation, the child's stool is hard, dry and may be painful to pass. As a result, the child avoids going to the toilet — making the problem worse.

The longer the stool remains in the colon, the more difficult it is for the child to push stool out. The colon stretches, ultimately affecting the nerves that signal when it's time to go to the toilet. When the colon becomes too full, soft or liquid stool may leak out around the retained stool or loss of control over bowel movements may occur.

Some causes of constipation include:

• Withholding stool due to fear of using the toilet (especially when away from home) or because passing stool is painful
• Not wanting to interrupt play or other activities
• Eating too little fiber
• Not drinking enough fluids
• Drinking too much cow's milk or, rarely, an intolerance to cow's milk — though research results conflict on these issues

Emotional issues

Emotional stress may trigger encopresis. A child may experience stress from:

• Premature, difficult or conflict-filled toilet training
• Changes in the child's life, such as dietary changes, toilet training, starting school or schedule changes
• Emotional stressors, for example, the divorce of a parent or the birth of a sibling

Encopresis is more common in boys than in girls. These risk factors may increase the chances of having encopresis:

• Using medications that may cause constipation, such as cough suppressants
• Attention-deficit/hyperactivity disorder (ADHD)
• Autism spectrum disorder
• Anxiety or depression

A child who has encopresis may experience a range of emotions, including embarrassment, frustration, shame and anger. If your child is teased by friends or criticized or punished by adults, he or she may feel depressed or have low self-esteem.

Below are some strategies that can help prevent encopresis and its complications.

Avoid constipation

Help your child avoid constipation by providing a balanced diet that's high in fiber and encouraging your child to drink enough water.

Learn about effective toilet training techniques

Educate yourself on effective toilet training techniques. Avoid starting too early or being too forceful in your methods. Wait until your child is ready, and then use positive reinforcement and encouragement to help make progress. Ask your doctor about resources on toilet training.

Get early treatment for encopresis

Early treatment, including guidance from your child's doctor or mental health professional, can help prevent the social and emotional impact of encopresis. Regular follow-up visits with your doctor can help identify ongoing or recurring problems so that adjustments in treatment can be made as needed.

To diagnose encopresis, your child's doctor may:

• Conduct a physical exam and discuss symptoms, bowel movements and eating habits to rule out physical causes for constipation or soiling
• Do a digital rectal exam to check for impacted stool by inserting a lubricated, gloved finger into your child's rectum while pressing on his or her abdomen with the other hand
• Recommend an abdominal X-ray to confirm the presence of impacted stool
• Suggest that a psychological evaluation be done if emotional issues are contributing to your child's symptoms

Generally, the earlier that treatment begins for encopresis, the better. The first step involves clearing the colon of retained, impacted stool. After that, treatment focuses on encouraging healthy bowel movements. In some cases, psychotherapy may be a helpful addition to treatment.

Clearing the colon of impacted stool

There are several methods for clearing the colon and relieving constipation. Your child's doctor will likely recommend one or more of the following:

• Certain laxatives
• Rectal suppositories
• Enemas

Your child's doctor may recommend close follow-up to check the progress of the colon clearing.

Encouraging healthy bowel movements

Once the colon is cleared, it's important to encourage your child to have regular bowel movements. Your child's doctor may recommend:

• Dietary changes that include more fiber and drinking adequate fluids
• Laxatives, gradually discontinuing them once the bowel returns to normal function
• Training your child to go to the toilet as soon as possible when the urge to have a bowel movement occurs
• A short trial of going off cow's milk or checking for cow's milk intolerance, if indicated

Behavior modification

Your child's doctor or mental health professional can discuss techniques for teaching your child to have regular bowel movements. This is sometimes called behavior modification or bowel retraining.

Your child's doctor may recommend psychotherapy with a mental health professional if the encopresis may be related to emotional issues. Psychotherapy may also be helpful if your child feels shame, guilt, depression or low self-esteem related to encopresis.

Avoid using enemas or laxatives — including herbal or homeopathic products — without first talking to your child's doctor.

Once your child has been treated for encopresis, it's important that you encourage regular bowel movements. These tips can help:

• Focus on fiber. Feed your child a balanced diet that includes plenty of fruits, vegetables, whole grains and other foods high in fiber, which can help form soft stools.
• Encourage your child to drink water. Drinking enough water helps keep stool from hardening. Other fluids may help, but watch the calories.
• Arrange toilet time. Have your child sit on the toilet for 5-10 minutes at regular times every day. This is best done after meals because the bowel becomes more active after eating. Praise your child for sitting on the toilet as requested and trying.
• Put a footstool near the toilet. This may make your child more comfortable, and changing the position of his or her legs can put more pressure on the abdomen, making a bowel movement easier.
• Stick with the program. It may take months to resume normal bowel sensation and function and develop new habits. Sticking with the program can also reduce relapses.
• Be encouraging and positive. As you help your child overcome encopresis, be patient and use positive reinforcement. Don't blame, criticize or punish your child if he or she has an accident. Instead, offer your unconditional love and support.
• Limit cow's milk if that's what the doctor recommends. In some cases, cow's milk may contribute to constipation, but dairy products also contain important nutrients, so ask the doctor how much dairy your child needs each day.

You'll likely first bring up your concerns with your child's doctor. He or she may refer you to a doctor who specializes in digestive disorders in children (pediatric gastroenterologist) if needed or to a mental health professional if your child is distressed, very embarrassed, frustrated or angry because of encopresis.

What you can do

It's a good idea to be prepared for your child's appointment. Ask if there's anything you need to do in advance, such as modify your child's diet. Before your appointment, make a list of:

• Your child's symptoms, including how long they've been occurring
• Key personal information, such as any major stresses or recent life changes
• All medications, including over-the-counter medications and any vitamins, herbs or other supplements that your child is taking, and the doses
• What your child eats and drinks on a typical day, including the amount and types of dairy products, types of solid foods, and the amount of water and other fluids
• Questions to ask your child's doctor

Some basic questions to ask the doctor include:

• What's the most likely cause of my child's symptoms?
• Are there other possible causes for these symptoms?
• What kinds of tests does my child need? Do these tests require any special preparation?
• How long might this problem last?
• What treatments are available, and which do you recommend?
• What side effects can be expected with this treatment?
• Are there alternatives to the primary approach that you're suggesting?
• Are there any dietary changes that might help?
• Would more physical activity help my child?
• Are there any brochures or other printed material that I can have?
• What websites do you recommend?

What to expect from your doctor

Your child's doctor will have questions for you. Be ready to answer them to reserve time to go over any points you want to focus on. Questions may include:

• How long has your child been toilet trained?
• Did your child experience any problems with toilet training?
• Does your child have hard, dry stools that sometimes clog the toilet?
• How often does your child have a have a bowel movement?
• Does your child take any medications?
• Does your child regularly resist the urge to use the toilet?
• Does your child experience painful bowel movements?
• How often do you notice stains or fecal matter in your child's underwear?
• Have there been any significant changes in your child's life? For instance, has he or she started a new school, moved to a new town, or experienced a death or divorce in the family?
• Is your child embarrassed or depressed by this condition?
• How have you been managing this issue?
• If your child has siblings, how was their toilet training experience?