Encopresis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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.

The estimated prevalence of encopresis in 5-year-olds is ~1-3%. The disorder is thought to be more common in males than females, by a factor of 3 to 1.

An abdominal x-ray may confirm impacted stool in the colon.

Because the causes often are obscure, prevention is difficult. As a general rule, refrain from toilet training that is too early and too coercive.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Constipation is associated with hard, large stools (feces) in the large bowels (colon) and rectum, which become difficult and painful to evacuate (defecation). This leads to stool-withholding. A vicious circle ensues.

The rectum becomes gradually distended with accumulated stool. The distension causes a loss of sensation in the rectum. This leads to further stool-withholding, as the urge to defecate becomes more and more irregular.

Eventually, softer stools from higher up the bowels cannot be accommodated and leak around the bolus of hard stool (overflow). Due to the lack of rectal sensation, this is not noticed by the child until soiling has actually occurred.

Parents are under great stress, as they might think or suspect that their child is soiling intentionally and become irritated and even aggressive. They might have also been advised that their child is psychologically abnormal, which leads to further distress.

Both parents and child often suffer great psychological abuse. Soiling can result in a disruption of relationship between the parents as well as the parents and their child.

Children who soil then become very frightened as they are punished for something over which they have no control. Soiling results in a marked loss of self-esteem in the affected children. Behavioral abnormalities develop.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• Encopresis is commonly caused by constipation, by deliberate 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 deliberate 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. 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.

• Encopresis may also be due to psychological problems, such as oppositional defiant disorder or conduct disorder which are often viewed as a kind of “parental control” attempt by the child. Or, encopresis may be the result of a fear of the commode and its flushing action, or by simple reluctance to “let go” of the stool into the toilet. Health practitioners, however, typically think of encopresis as mainly a physical problem with a psychological component (but not cause). Encopresis is also a symptom of child sexual abuse.^[1]

• Organic causes such as Spina bifida or Hirschsprung’s disease are rare.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

The prevalence of encopresis is 1,000 per 100,000 (1%) among children 5 years of age.^[1] Encopresis is more common among males than females.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Risk factors for encopresis include constipation, medications, and low socioeconomic status.^[1]

• Male gender
• Chronic constipation^[1]
• Low socioeconomic status
• Medications

• Anticonvulsants
• Cough suppressants^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• The child may suffer from low self-esteem and peer disapproval related to this problem.
• If routine bowel habits are not developed, the child may suffer from chronic constipation.

Most children respond to treatment.

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