Encopresis

What is encopresis?

Encopresis is when your child leaks stool into his or her underwear. It is also called stool soiling. It is most often because of long-term (chronic) constipation. Encopresis happens to children (generally 4 or older) who have already been toilet trained.

In most cases, stool soiling happens by accident. Encopresis can be very embarrassing for your child.

What causes encopresis?

In most cases encopresis happens because a child has long-term (chronic) constipation.

When a child is constipated, he or she has fewer bowel movements than normal. Bowel movements can then become hard, dry, and difficult to pass. Your child may avoid going to the bathroom because it hurts. Then stool becomes backed up (impacted) in the rectum and the large intestine (colon). The stool can't move forward. The rectum and intestine become enlarged because of the hard, impacted stool.

Over time, liquid stool can start to leak around the hard, dry, impacted stool. This soils your child's clothing.

Other causes of encopresis include:

• Colonic inertia, a condition where the colon doesn't move stool along as it should

• Nerve damage to the muscle at the end of the digestive tract (anal sphincter). This keeps it from closing properly.

• Fear of using the toilet

• Rectal infections or tears

• Emotional stress

Other health problems may cause chronic constipation. These include diabetes, hypothyroidism, Hirschsprung disease, and inflammatory bowel disease.

Who is at risk for encopresis?

Any child who has long-term (chronic) constipation may develop encopresis. Risk factors for constipation include:

• Eating a high-fat, high-sugar, junk-food diet

• Drinking mostly soft drinks and sugary drinks

• Not drinking enough water and fruit juices

• Lack of exercise

• Not wanting to use public bathrooms

• Feeling stressed with family, with friends, or at school

• Being too busy playing to take time to use the bathroom

• Having a change in bathroom routine. This includes starting a new school year, when a child has fewer bathroom breaks.

Encopresis affects boys more than girls. Experts don't know why.

What are the symptoms of encopresis?

Each child's symptoms may vary. Symptoms may include:

• Having loose, watery stools

• Needing to have a bowel movement with little or no warning, called involuntary stooling. Your child may soil underwear if he or she can't get to the bathroom in time.

• Scratching or rubbing the anal area, because it's irritated by watery stools

• Withdrawing from friends, school, or family

• Hiding soiled underwear

Symptoms of encopresis may look like other health conditions. Always see your child's healthcare provider for a diagnosis.

How is encopresis diagnosed?

Your child's healthcare provider will give your child an exam and take a health history. Imaging tests may also be done to check the intestine and rule out other health problems. These tests may include:

• Digital rectal examination (DRE). Your child's provider puts a gloved, greased (lubricated) finger into your child's rectum. The provider will feel for anything abnormal.

• Abdominal X-ray. This test could give a sense of how much stool is in the large intestine.

• Barium enema. This is an X-ray exam of the rectum, the large intestine, and the lower part of the small intestine. Your child will be given a metallic fluid called barium. Barium coats the organs so they can be seen on an X-ray. The barium is put into a tube and inserted into your child's rectum as an enema. An X-ray of the belly will show if your child has any narrowed areas (strictures), blockages (obstructions), or other problems.

• Anorectal manometry. This test checks the strength of the muscles in the anus and the nerve reflexes. It also checks your child's ability to sense that the rectum is full (rectal distension) and a bowel movement is needed. And it looks at how well the muscles work together during a bowel movement.

• Rectal biopsy. This test takes a sample of the cells in the rectum. They are checked under a microscope for any problems.

• Colorectal transit study. This test shows how well food moves through your child's colon. The child swallows pills (capsules) filled with small markers that can be seen on an X-ray. The child eats a high-fiber diet for the next few days. X-rays will be taken 3 to 7 days after your child takes the pills. The X-rays will show how the pills moved through the colon.

• Lab testing. Several tests may be done. These include tests to check for issues such as celiac disease, urinary tract infection, thyroid  problems, metabolic problems, and blood lead level.

How is encopresis treated?

Treatment will depend on your child's symptoms, age, and general health. It will also depend on how severe the condition is.

Treatment for encopresis may include:

• Removing the impacted stool

• Keeping bowel movements soft so the stool will pass easily

• Retraining the intestine and rectum to gain control over bowel movements

Your child's healthcare provider may prescribe an enema to help remove the impacted stool. An enema is a liquid that is placed in your child's rectum. It helps loosen the hard, dry stool. Never give your child an enema without the approval of your child's healthcare provider.

Your child's healthcare provider will likely prescribe medicines to help keep your child's bowel movements soft for several months. This will help stop stool from getting impacted again. Never give your child stool softeners without the approval of your child's healthcare provider.

Treatment may also include diet and lifestyle changes. Help your child to eat more fiber by:

• Adding more fruits and vegetables

• Adding more whole-grain cereals and breads. Check the nutrition labels on food packages for foods that have more fiber.

What are good fiber sources?

Other diet changes that may help include:

• Offering your child fruit juice instead of soft drinks.

• Encouraging your child to drink more fluids, especially water.

• Limiting fast foods and junk foods that are often high in fats and sugars. Offer more well-balanced meals and snacks instead.

• Limiting drinks with caffeine, such as soda and tea.

• Limiting whole milk to 16 ounces a day if your child is 2 years of age or older. But don't remove all milk from your child's diet. Children need the calcium in milk to help their bones grow strong.

It's also a good idea to have your child eat meals on a regular schedule. Eating a meal will often cause a bowel movement within 30 to 60 minutes. Also try to serve breakfast early. This will help give your child time to have a bowel movement at home before rushing off to school.

Try the following ideas to help reduce constipation.

Get more exercise

Exercise helps with digestion. It helps the normal movements the intestines make to push food forward as it is digested. People who don't move around much are often constipated. Have your child go outside and play rather than watch TV or do other indoor activities.

Set good bowel habits

Try to get your child into a regular toilet habit. Have your child sit on the toilet at least twice a day for at least 10 minutes. Try to do this just after a meal. Be sure to make this a pleasant time. Don't get mad at your child for not having a bowel movement. Use a reward system to make it fun. Give stickers or other small treats. Or make posters that show your child's progress.

In some cases these changes may not help. Or your child's healthcare provider may find another problem. If so, the provider may recommend using laxatives, stool softeners, or an enema. These products should only be used if recommended by your child's provider. Don't use them without talking with your child's provider first.

Your child may still have accidents and soil underwear from time to time. This will happen until the intestine and rectum get their muscle tone back again. Preschool children may be able to wear disposable training pants until they can control their bowel. Have your child bring a change of underwear or pants to school. This can help your child feel less embarrassed. It may help improve your child's self-esteem.

What are the complications of encopresis?

Encopresis can cause both physical and emotional problems.

Stool that is backed up (impacted) in the intestine can cause belly (abdominal) pain. It can also cause a loss of appetite. Some children may get bladder infections.

Children with encopresis often feel upset by the accidents they have when they soil their clothes. In most cases they can't control this stool leakage. This can affect how they feel about themselves, or their self-esteem. It can also affect how they deal with other people. Children are often ashamed or embarrassed by this problem. They may avoid going to school, playing with friends, or spending the night away from home.

As a parent, you may feel guilt, shame, and anger. You may be disgusted by the problem. It's important to be patient with your child. Don't blame, get angry at, or punish your child for having an accident. Give your child love and support.

Can encopresis be prevented?

If your child's encopresis is caused by another health problem, treating that condition may help.

You may help prevent stool soiling if you avoid any emotional upsets while your child is toilet training. Children who have a negative experience using the toilet may avoid going to the bathroom. This leads to constipation and, over time, encopresis.

Toilet training should be delayed until your child is emotionally and physically ready. Your child's healthcare provider can help you figure out when your child may be ready. You can also help your child have regular bowel movements by making some diet and lifestyle changes. Give your child high-fiber foods and limit high-fat and high-sugar foods. Make sure your child drinks plenty of fluids, such as water. And keep your child physically active.

Living with encopresis

Making changes in your child's diet and activity level may help prevent constipation and stool soiling. But solving encopresis may be harder for some children. If your child soils his or her underwear, don't get angry or punish your child.

School-age children who don't want to use school restrooms may need to use a private bathroom. You may have to talk with the school principal and teachers. You may need to create a plan so that your child can use the restroom as needed.

It may be helpful to have your child sit on the toilet twice a day for 10 minutes. This helps encourage regular bowel movements. Keeping a notebook or log of stool soiling accidents may also help. You and your child can see if there is a pattern to the accidents. Or you may find there are some triggers that can be controlled. Your child's healthcare provider can also give helpful suggestions and medicines as needed.

Online Medical Reviewers:

• Adler, Liora C, MD
• Albert, Chan, MD
• Watson, L Renee, MSN, RN