> Table of Contents > Encopresis
Encopresis
Jay Fong, MD
William T. Garrison, PhD
image BASICS
DESCRIPTION
  • Voluntary or involuntary fecal soilage in a (typically) previously toilet-trained child
    • Age may be chronologic or developmental.
    • No underlying organic disease
    • At least one event per month for 3 months
    • Classified into functional constipation (retentive encopresis) and functional nonretentive fecal incontinence (FNRFI); both cause fecal incontinence. There is no constipation in FNRFI. Functional constipation is more common.
  • System(s) affected: GI; psychological
  • Synonyms(s): fecal incontinence, soiling
EPIDEMIOLOGY
Incidence
Predominant sex: male > female (4 to 6:1). Constipation accounts for 3% of general pediatric referrals; up to 84% of constipated children have fecal incontinence at some point.
Prevalence
Occurs in 1-3% of children 4 years of age
ETIOLOGY AND PATHOPHYSIOLOGY
  • In 90% of cases, encopresis develops as a consequence of chronic constipation, with resulting overflow incontinence (retentive encopresis). The other 10% are caused by specific organic etiologies.
  • Chronic constipation with irregular and incomplete evacuation results in progressive rectal distension and stretching of the internal/external anal sphincters.
  • As a child habituates to chronic rectal distension, they may no longer sense the normal urge to defecate. Eventually, soft or liquid stool leaks around the retained fecal mass.
  • Many children voluntarily withhold stool in response to the urge to defecate for fear of pain or a preoccupation with not interrupting social activities.
  • Psychological
    • Stool withholding, fear, anxiety
    • Difficulty with toilet training, including unusual anxiety or conflict with parent
    • Resistance to using public toilet facilities, such as school bathrooms or outdoor toilets
    • Known association with sexual abuse in boys; likely similar association in girls
    • Developmental delay
  • Anatomic
    • Rectal distension and desensitization
    • Anal fissure or painful defecation
    • Muscle hypotonia
    • Slow intestinal motility
    • Hirschsprung disease
    • Cystic fibrosis
    • Spinal cord defects (e.g., spina bifida)
    • Congenital anorectal malformations
    • Anal stenosis
    • Anterior displacement of the anus
    • Postoperative stricture of anus or rectum
    • Pelvic mass
    • Neurofibromatosis
  • Dietary or metabolic
    • Inadequate dietary fiber
    • Excessive protein or milk intake
    • Inadequate water intake
    • Hypothyroidism
    • Hypercalcemia
    • Hypokalemia
    • Diabetes insipidus; diabetes mellitus
    • Food allergy
    • Gluten enteropathy
  • Medication side effects
Genetics
None known; although incidence may be higher in children with family history of constipation.
RISK FACTORS
  • Male gender
  • Constipation
  • Very low birth weight
  • Painful defecation
  • Difficulty with bowel training, including social pressure related to early daycare placement
  • Organic/anatomic causes
  • Anxiety and depression
  • Insufficient fluid or fiber intake
  • Refusal to use public restrooms
  • Attention deficit
GENERAL PREVENTION
Family education: toilet training when ready, optimize fluid and fiber intake
COMMONLY ASSOCIATED CONDITIONS
  • Constipation, Hirschsprung disease
  • Cerebral palsy, cystic fibrosis
  • Developmental and behavioral diagnoses, urinary incontinence
image DIAGNOSIS
PHYSICAL EXAM
  • Neurologic exam of lower extremities and perineal area, with attention to S1-S4 distribution, perineal sensation, cremasteric reflex, and anal sphincter tone
  • Genital examination and digital rectal exam: Assess for anal fissures, sphincter tone, rectal distension/impaction, occult or visible blood.
  • Abdominal exam: bowel sounds, percussion note (tympany), abdominal distension; palpate for stool (most common in left lower quadrant).
DIAGNOSTIC TESTS & INTERPRETATION
Most cases of encopresis can be diagnosed by history and physical.
Initial Tests (lab, imaging)
  • Only to rule out organic causes
  • UA/urine culture: UTI/glucosuria
  • Thyroid function tests: hypothyroidism
  • Electrolyte panel, including calcium: hypokalemia, hypercalcemia, or hyperglycemia
  • Abdominal plain films if impaction is suspected and not detected by abdominal or rectal exam.
Follow-Up Tests & Special Considerations
  • Failure to pass meconium within 48 hours of birth, failure to thrive, bloody diarrhea, or bilious vomiting in a neonate should be promptly evaluated to exclude aganglionic megacolon.
  • Constipation and diarrhea, rash, failure to thrive, or recurrent pneumonia should prompt evaluation for cystic fibrosis. Patients with abdominal distension or ileus should be evaluated for possible obstruction.
Diagnostic Procedures/Other
Manometric studies may be useful in patients who have constipation that does not respond to treatment.
image TREATMENT
GENERAL MEASURES
  • Anticipatory guidance relative to toilet training including advice about when children should reduce reliance on diapers or use pull-ups during the daytime hours (average age for toilet training in girls is 29 months; 31 months for boys).
  • Eliminate impaction prior to maintenance therapy.
  • Avoid frequent and repeated rectal exams, enemas, and suppositories, especially in infants.
  • Once stools are regular in frequency, child should sit on toilet BID at the same time each day for 10 to 15 minutes and for 10 to 15 minutes after meals. Incorporate positive reinforcement for successful bowel movements.
MEDICATION
  • Remove impaction and start maintenance treatment.
  • No randomized, controlled studies have compared methods of disimpaction: can use oral agents, enemas, and rectal suppositories; oral agents are least traumatic. Glycerin suppositories are best option for infants.
P.335

First Line
  • Disimpaction with polyethylene glycol (PEG)
    • Give 17 g (240 mL) water or juice: 1 to 1.5 g/kg/day for 3 days for disimpaction
    • 0.4 to 0.8 g/kg/day for maintenance
  • Disimpaction with mineral oil for child >1 year; give 15 to 30 mL/year of age to max 240 mL.
    • Maintenance: 1 to 3 mL/kg/day or divided BID
    • May mix with orange juice to make palatable; avoid in infants to avoid aspiration pneumonia.
  • Other maintenance regimens include the following:
    • Milk of magnesia (MOM) 400 mg (5 mL): 1 to 2 mL/kg/day BID
    • Lactulose 10 g (15 mL): 1 to 3 mL/kg/day divided BID
    • Senna syrup 8.8 g sennoside (5 mL): age 2 to 6 years: 2.5 to 7.5 mL/day divided BID; age 6 to 12 years: 5 to 15 mL/day divided BID
    • Bisacodyl suppository 10 mg: 0.5 to 1 suppository once or twice per day
ISSUES FOR REFERRAL
If symptoms do not improve after 6 months of good compliance with a multifactorial treatment model, refer to pediatric gastroenterologist for recommendations and further evaluation.
ADDITIONAL THERAPIES
Behavioral treatment and counseling
SURGERY/OTHER PROCEDURES
If ongoing constipation is refractory to a combination of medical and behavioral therapy, consider anorectal manometry to evaluate for internal anal sphincter achalasia (or ultrashort-segment Hirschsprung disease). If present, this condition can be treated successfully in most patients with an internal sphincter myectomy.
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Children with volitional stool holding who receive behavioral treatment in addition to medications are more likely to have resolution of encopresis at 3 and 6 months than children receiving medication alone (1)[A].
  • No evidence that biofeedback training adds benefit to conventional treatment for functional fecal incontinence in children (2)[A]
  • Behavioral interventions combined with laxative therapy (rather than laxative therapy alone) improve continence in children with functional fecal incontinence associated with constipation (1)[B].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Continued soiling and recurrent impaction on outpatient medical therapy, whether from lack of medication efficacy or patient nonadherence
  • Decreased intake leading to malnutrition or dehydration
  • Recalcitrant vomiting or concern for obstruction
  • Involve appropriate agencies if concern for abuse
  • Hospital admission and abdominal films may be necessary to ensure complete removal of impaction. This may include direct gastric administration of balanced electrolyte-PEG solutions if the patient cannot tolerate by mouth. Serial abdominal films and observation of the rectal effluent can help to determine treatment adequacy.
IV Fluids
IV fluids if the patient is dehydrated and having difficulty tolerating oral hydration
Nursing
Nursing to document stool output and character
Discharge Criteria
  • Stools that are looser in consistency and clearer in appearance are a successful inpatient end point.
  • Abdominal radiographs showing less fecal loading (compared with a pretreatment radiograph) with improving serial abdominal exams
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Continue maintenance treatment for 6 months to 2 years with visits every 4 to 10 weeks for support and to ensure compliance; more frequent visits with oppositional or anxious children
  • Telephone or virtual visits can be used to adjust doses and to provide ongoing encouragement.
  • Treat recurrences of impaction promptly.
  • Emphasize compliance with medication and self-initiation of regular bathroom visits.
  • Children who do not progress using a well-designed behavior plan should be referred for more in-depth mental health evaluation and counseling.
DIET
Adequate fluid and fiber intake (2)[A]. Reduce cow's milk products. Avoid excessive consumption of bananas, rice, apples, and gelatin.
PATIENT EDUCATION
  • Demystify defecation.
  • Carefully explain the treatment plan including medications and dietary changes.
  • Avoid punishment for inadvertent soiling.
  • In children >4 years of age, explain to parents how overreliance on diapers and pull-ups (while convenient) can prolong the problem.
  • Always attempt to use positive reinforcement for successful toilet sits and medication compliance.
  • If positive approach is unsuccessful, consider removing desired privileges (e.g., TV, video games) for noncompliance with behavioral plan. Some children respond well to a token economy (earned privileges) to promote desired behavior.
PROGNOSIS
  • Many children exhibit a good response and relapse due to noncompliance by parents and/or child.
  • From 30% to 50% of children may still have encopresis after 5 years of treatment.
  • Children with psychosocial or emotional problems preceding the encopresis are more recalcitrant to treatment.
REFERENCES
1. Brazzelli M, Griffiths PV, Cody JD, et al. Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev. 2011;(12):CD002240.
2. Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258-274.
Additional Reading
&NA;
  • Borowitz SM, Cox DJ, Tam A, et al. Precipitants of constipation during early childhood. J Am Board Fam Pract. 2003;16(3):213-218.
  • Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43(3):e1-e13.
  • Levitt M, Peña A. Update on pediatric faecal incontinence. Eur J Pediatr Surg. 2009;19(1):1-9.
  • Loening-Baucke V, Pashankar DS. A randomized, prospective, comparison study of polyethylene glycol 3350 without electrolytes and milk of magnesia for children with constipation and fecal incontinence. Pediatrics. 2006;118(2):528-535.
Codes
&NA;
ICD10
  • R15.9 Full incontinence of feces
  • R15.1 Fecal smearing
  • F98.1 Encopresis not due to a substance or known physiol condition
Clinical Pearls
&NA;
  • 90% of encopresis results from chronic constipation.
  • Address toddler constipation early by decreasing excessive milk intake, increasing fruits/vegetables intake, and ensuring adequate fluid and fiber intake.
  • Eliminate fecal impaction before initiating maintenance therapy.