Encopresis: What is it?

My eleven year old step-son has had encopresis since age four. The common treatments of enema and mineral oil were initiated by my husband, but my step son is in a joint custody situation, and the treatments are not consistent. My question is a what point does this become a critical situation. He is never able to have a bowel movement without an enema? Are there any other treatments offered?

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Robert Steele

Robert W. Steele, MD, is a board certified pediatrician at St. John's Regional Health Center in Springfield, MO. He graduated from medical... Read more

I have had a number of questions concerning encopresis. A previous answer touched upon the high points of this problem, but with such interest, I thought a little more in-depth discussion might be helpful.

Encopresis is when a child, generally over four years of age, has constipation and then begins to have fecal soiling. With encopresis, the constipation which precedes the fecal soiling is not due to a medical condition. This is opposed to fecal incontinence which is when there is fecal soiling due to a medical condition. This is an important distinction because to treat encopresis, the constipation must be treated and then interventions must be taken to prevent the constipation from recurring. Since with encopresis, no medical condition is causing the constipation, psychological evaluation is an important part of treatment.

Encopresis is reported to affect about 2.8% of 4 year olds, 2.2 % of 5 year olds, and 1.9% of 6 year olds. This percentage continues its decreasing trend as the age goes up. This may appear like a small number of children, but when restated as 1 in every 50 children between 4 and 6 is affected, it seems a lot larger. It affects boys more often than girls by a margin as great as 6 to 1.

To understand what causes encopresis, it is helpful to understand the normal process of having a bowel movement. As stool descends through the rectum, the stretch of the anal canal generates a signal to the brain telling us that we need to have a bowel movement. We then, through voluntary release of sphincters (muscles which hold in the stool), allow the passage of stool.

There are different definitions of constipation depending upon who you ask. You can get differing opinions from doctors, moms, dads, and grandparents. This can sometimes cause family strife when a grandparent forcefully acknowledges the concern to parents about the bowel habits of the grandchild. Clearly, there has been a movement away from "stool counting," however, the point at which a child who just normally has infrequent bowel movements is distinguished from one with true constipation is sometimes difficult.

In general, constipation in children is accompanied by painful bowel movements which causes the child to do some stool retaining maneuvers. This makes sense because, after all, why do something that you know will cause you pain? But this is what sets up the vicious circle which leads to encopresis:

  1. Child has pain or discomfort while having a bowel movement
  2. Stool is voluntarily held in completely or incomplete bowel movements occur
  3. The rectum stretches to accommodate the larger amount of stool build-up
  4. The larger amount of stool is even more difficult and more painful to pass, and thus, there is more incentive to hold it in.

Eventually, the sensation of needing to have a bowel movement disappears because the rectum is stretched too far. The longer the stool is built up in the rectum, the dryer and harder it gets. It is at this point, soft, semi-liquid stool begins to leak around the larger ball of stool and ends up in the underwear. This whole process most often takes many months to occur.

As you can see, it is the constipation that leads to the soiling of the underwear. This relationship is often not seen by the parents who may think that the soiling is due to the child just not wanting to go to the bathroom. Simply stated, encopresis is caused by constipation that has been going on for a long time, and the child has no control over the soiling.

Probably the most important thing to know about treatment for encopresis is that it takes a very long time. If you understand that the process of constipation took months to get to the point of encopresis, it may be easier to realize it will take just as long to get back to point of normal bowel movements. The first part of treatment is getting rid of the build-up of stool. This is generally done by an enema or two. Next comes the retraining of the rectum to sense when the stool is there and then being able to expel the stool. It is this second step that takes such a long-time and often requires the help of a trained psychologist. Treatment includes the use of a laxative, increasing the fiber in the diet, and setting a schedule of sitting on the toilet for 3-5 minutes, three to four times per day after meals. In addition, a daily diary of bowel movements and times of incontinence are recorded. The progress is followed closely by the pediatrician with follow-up visits occurring frequently.

There are a few key things to keep in mind when tackling the problem of encopresis. A big part of the equation is making the child a part of the team. It is quite difficult to conquer the problem if the child is not interested in participating. It can't be done by force, so this is where the child psychologist can be of great help. Most children regain control of bowel movements within a year although continued use of laxatives may be needed. Remember, the most common cause of relapse is not following up with the doctor's advice particularly when it comes to laxative use. This may be particularly difficult in a joint custody situation. Whatever your situation is, try to sit down with all caretakers to discuss a plan that will be consistent. This will serve your step-son best.

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