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Encopresis: Information for Primary Care

Summary: Encopresis is the involuntary (or intentional) passing of feces in inappropriate locations (e.g. underwear or on the floor), occurring at least once/month for three months, in a child over age 4.
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Normal development

  • Bowel control is an important developmental milestone that normally occurs by age 4
  • Steps to toilet training typically consist of
    • Ensuring that a child is ready
    • The child is able to describe the urge to have a bowel movement
    • Sufficient coordination to sit on a potty, and push out a stool
    • Being able to hold urine for two hours
  • Parent training the child, which includes:
    • Parents providing clear instructions and demonstration on how to sit on a potty and have a bowel movement
    • Parents providing routines and opportunity, such as placing the child on a on the potty after meals in order to take advantage of the gastrocolic reflex

Pathophysiology

  • Encopresis typically starts after a period of acute constipation, in which the child experiences a painful bowel movement
  • In an attempt to avoid future pain, the child withholds stool and refuses to defecate
  • As the child withholds, the stool accumulates, and can cause an impaction
  • As stool accumulates in the rectum, there is leakage of stool around the impaction leading to soiling of underwear
  • As it becomes even more painful to force out the impacted stool, it becomes a vicious circle with the child continuing to ignore the urge to defecate, in an attempt to avoid what will eventually be a painful bowel movement
  • In the beginning, there is overflow soiling with release of large stools within 5-7 days
  • Over time, the bowel movements become less frequent, but with large bowel movements  and chronic overflow, with abdominal pain and social withdrawal
  • Over time, the child loses the ability to sense the need to defecate or feel the leakage around the impaction, nor notice the extremely unpleasant smell of feces that others notice
  • Parents, caregivers and teachers invariably become frustrated at the soiling, leading to blame and anger towards the child, which further contributes to the problem

Epidemiology

  • Up to 3% of children under 12 (Fishman, Rappaport, Schonwald & Nurko, 2003)
  • Males > Females with 2:1 ratio

Etiology

  • Risk factors include
    • Chronic, early constipation
    • Experiencing a bowel movement as painful or distressing (e.g. pain on defecation)
    • Low muscle tone and poor coordination
    • Problems with attention span
    • Males  
    • Dietary factors: High fat diet, high intake of sugary fluids (e.g. pop, juice), low fiber intake
    • Low activity level
    • Stresses such as lack of routine at home
    • Children from abusive or neglectful homes: Although most children with encopresis have not been abused, children with sexual abuse have a higher rate of encopresis

Hx/Interviewing Questions

Have you noticed any of the following with your child:

  • Avoidance or fear of using the toilet, such as for bowel movements?
  • Hiding soiled underwear?
  • Having large stools every few days (e.g. 3-7 days) rather than every day or every other day?
  • Bowel movements so large that it plugs the toilet?
  • Abdominal bloating or pain?
  • Smell of feces?
  • Smell of feces to the point where others such as peers, teachers and family members have noticed?
  • Smearing of feces?

 

Other relevant history includes:

  • Past approaches tried
  • Associated issues such as ADHD, learning disabilities, oppositional behaviours

Physical Exam (Px)

  • Rule out underlying neurologic or bowel condition
  • Abdominal exam
  • Developmental screening
  • Recal exam for fecal impaction

Investigations

  • Abdominal XR can reveal presence of constipation, or abdominal distension

DSM-5 Criteria

  1. Repeated passage of feces into inappropriate places (e.g., clothing, floor), whether involuntary or intentional.
  2. At least one such event occurs each month for at least 3 months.
  3. Chronological age is at least 4 years (or equivalent developmental level).
  4. The behavior is not attributable to the physiological effects of a substance (e.g., laxatives) or another medical condition except through a mechanism involving constipation.

Two subtypes

 

  1. With constipation and overflow incontinence: There is evidence of constipation on physical examination or by history.
  2. Without constipation and overflow incontinence: There is no evidence of constipation on physical examination or by history.

Management: Primary Care Interventions

  • Acute treatment of bowel impaction/constipation
    • Most patients will have constipation with overflow incontinence, and hence it is important to start with evacuating the distal colon
    • Treatment includes
      • Oral cathartics
      • Enemas
      • Maintenance laxatives
        • After the colon is cleared, laxatives are used in order with the goal of having 1-2 soft stools daily
           
  • Nutritional / dietary changes
    • Add fiber to diet
    • Add fiber (e.g. bran flakes) to breakfast foods (such as cereal), once daily
    • Continue increasing until dietary recommendations for fiber are reached, or until stools are soft, passing without pain, and occurring once daily
    • Reduce high fat and high sugar foods (e.g. soda pop, cookies, candy, fast foods)
    • Reduce constipating foods (e.g. bananas, dairy such as Greek yoghurt, white rice)
    • Ensure enough hydration, i.e. Drink enough water to ensure that child urinates every 2-hrs
       
  • Lifestyle changes
    • Increase physical activity such as daily walks with family
    • Reduce sedentary activities such as TV or video games
       
  • Bowel training
    • Bowel training is to help the child re-learn bowel control, and learn awareness of a full rectum
    • 20-minutes after breakfast, sit on toilet for 10-minutes
    • 20-minutes after dinner, sit on toilet for 10-minutes
       
  • Behavior management
    • Elements of successful behavior programs (Cochrane Review)
      • Demystifying the condition and educating patients and families
      • Providing specific toileting instruction about appropriate positioning and straining
      • Designing a program of regular, timed, and uninterrupted toileting
      • Maintaining a symptom and toileting diary
      • Defining specific achievable target behaviors
      • Strongly emphasizing consistency
    • Other principles
      • Understand that any parenting strategies work best in context of healthy relationship between parent/child
      • When the child soils, do not respond with anger or punishment; increased stress does not help the child have more success
      • Use natural consequences such as having the child help parent with cleaning soiled clothing; taking a bath
      • Praise the child's for being successful; rewards should not be necessary
         
  • Family support
    • Most children respond to treatment, however it can take several months up to a year before child begins having appropriate bowel elimination
    • Families must deal with the smell of feces in their child, clothing and parts of the home, along with peer issues, and severe frustration
       
  • Medications
    • Oral stool softeners and/or fiber has better results 
    • Enemas are rarely required, though they were used in the past
    • May be helpful with children with
      • Neurological impairment or
      • Severe impactions

When to Refer

  • If significant emotional/behavioral problems

Who to Refer to

  • Paediatricians
  • Psychiatrists

About this Document

Written by members of the eMentalHealth.ca/PrimaryCare team which includes members of the Department of Psychiatry and Family Medicine at the University of Ottawa. Reviewed by members of the Family Medicine Program at the University of Ottawa, including Dr's Farad Motamedi; Mireille St-Jean; Eric Wooltorton.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.

Creative Commons License

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Date Posted: Feb 15, 2014
Date of Last Revision: Nov 27, 2015

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