AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• MISCELLANEOUS
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• MISCELLANEOUS
• References

Background

According to the Diagnostic and Statistical Manual of Mental Disorders, Third edition (DSM-III), encopresis is defined as the "repeated involuntary passage of feces into places not appropriate for that purpose...the event must take place for at least 6 months, the chronologic and mental age of the child must be at least 4 years."¹

Pathophysiology

In the vast majority of cases, encopresis develops as a consequence of chronic constipation with resulting overflow incontinence,² which is typically termed retentive encopresis. Chronic constipation due to irregular and incomplete evacuation results in progressive rectal distention and stretching of both the internal anal sphincter and the external anal sphincter (EAS). As the child habituates to chronic rectal distention, he or she no longer senses the normal urge to defecate. Soft or liquid stool eventually leaks around the retained fecal mass, resulting in fecal soiling.

Approximately 80-95% of children with encopresis have a history of constipation or painful bowel movements. The remaining 5-20% are said to have nonretentive encopresis; however, many of these children have a remote history of constipation or painful defecation³ or demonstrate incomplete evacuation during defecation upon physical examination or radiographic assessment.⁴ Little or no evidence indicates that encopresis is primarily a behavioral disorder, and most available evidence suggests that behavioral difficulties associated with encopresis may be the result of the encopresis and not the cause.⁵ Low self-esteem or parent-child conflict as a result of the disorder is not uncommon. Embarrassed youngsters also commonly deny having the problem.

Frequency

United States

Although few prospective studies have been conducted to examine the prevalence of encopresis in childhood, an estimated 1-2% of children younger than 10 years have encopresis. In one study, 4.4% of 482 children aged 4-17 years observed over a 6 month period in a primary care pediatric clinic in Iowa experienced fecal incontinence at least once per week.⁶

International

Although population-based studies that examine the prevalence of encopresis are scarce, nearly all published studies have been conducted in North America and Europe. In one population-based study conducted in the Netherlands, 4.1% of children aged 5-6 years and 1.6% of children aged 11-12 years experienced fecal soiling at least once a month.⁷ Studies conducted in Sweden and the United Kingdom⁸ have reported similar numbers.

Sex

In nearly all published series, boys are much more commonly affected than girls. In most series, approximately 80% of affected children are boys.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• MISCELLANEOUS
• References

History

Approximately 80-95% of children with encopresis have a history of constipation or painful defecation. In many patients, the history of constipation or painful defecation is remote, occurring years before the child presents with encopresis. On average, children who have encopresis are symptomatic 5 years before the problem is brought to medical attention.

• Most children with encopresis deny the urge to defecate associated with their soiling episodes. Sometimes, affected children contend that they are unable to differentiate passing gas and passing feces in their underwear.
• In most cases, soiling episodes occur during the daytime when the child is awake and active. Soiling at night when the child is asleep is uncommon.
• As evidence of functional megacolon, many children with retentive encopresis intermittently pass extremely large bowel movements.

Physical

Physical findings, other than those obtained from the abdominal and rectal examinations, are usually normal.

• In many patients, stool can be palpated throughout the distribution of the colon, most notably in the left lower quadrant.
• Upon rectal examination, stool is often found smeared around the anus. The anal sphincter may appear somewhat lax and patulous because massive rectal distention is associated with reflex relaxation of the internal sphincter. The rectum is typically enlarged and filled with soft, Hemoccult-negative stool.
• Neurologic findings should be normal. Patients should have a normal anal wink and normal sensation, strength, and reflexes in the lower extremities.

Causes

In most cases, encopresis is thought to develop as a consequence of chronic constipation with resulting overflow incontinence. Approximately 80-95% of children with encopresis have a history of constipation or painful bowel movements.

• A few children appear to have nonretentive encopresis and no history of constipation or painful defecation; they have no evidence of incomplete evacuation on physical evaluation, radiographic evaluation, or both.
• No good prospective data suggest that encopresis, whether retentive or nonretentive, is primarily a behavioral or psychological disorder. Rather, most of the available evidence indicates that children with encopresis do not have an increased incidence of major behavioral or personality disorders compared with their age-matched peers.⁹
• No good evidence suggests that encopresis is an indicator of sexual abuse.¹⁰ The incidence of fecal soiling is comparable among children with a history of sexual abuse and children with psychiatric and behavioral disorders.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• MISCELLANEOUS
• References

Other Problems to be Considered

Spina bifida
Meningomyelocele
Spinal-cord injury with dysfunction of the anal sphincter
Ultrashort-section Hirschsprung disease (ie, congenital megacolon [rare cause of encopresis])
Imperforate anus with fistula

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• MISCELLANEOUS
• References

Lab Studies

• In most patients, the diagnosis is established with the history and complete physical examination, including a rectal examination.
• Laboratory studies are rarely warranted.

Imaging Studies

• Plain abdominal radiography may be helpful in determining whether a soft fecal impaction is present. This test can be very useful in documenting the nature of the problem to the older child and his or her parents, particularly when a history of constipation is not evident or is denied.

Other Tests

• Anorectal manometry is sometimes helpful in delineating the child's defecation dynamics.¹¹ Many children with encopresis have evidence of megarectum, as evidenced by diminished sensation to distention of the rectum during balloon insufflation. Many children who have encopresis also have paradoxical constriction of the EAS during attempted defecation.
• Anorectal manometry can also be helpful in excluding ultrashort-segment Hirschsprung disease, which is a rare cause of encopresis. With this disorder, intramural ganglion cells in the submucosa and myenteric plexuses of the distal colon are absent. In the absence of these ganglion cells, the internal anal sphincter does not relax in response to rectal distention by balloon inflation.

Procedures

• Although Hirschsprung disease is rarely associated with encopresis, if suspected, this diagnosis can be excluded by identifying ganglion cells in the submucosa and myenteric plexuses of the rectum.
• A biopsy specimen can be obtained with surgery or with use of a suction device.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• MISCELLANEOUS
• References

Medical Care

Despite the frequency with which childhood encopresis occurs, no large, randomized, controlled therapeutic trials have been conducted.¹² As a result, treatment remains largely experiential rather than evidence based and generally consists of demystification and education; colonic evacuation followed by routine laxative therapy;¹³ and “toilet training,” which is composed of regularly scheduled toileting, maintenance of a symptom diary, and an age-appropriate incentive scheme.¹⁴ The aim of this multimodal approach to therapy is to decrease the physical and emotional distress associated with defecation, to develop or restore normal bowel habits with positive reinforcement, and to encourage the child and parents to take an active role during the treatment.¹⁵

• Because approximately 80-95% of children with encopresis have a history of constipation or painful bowel movements, medical therapy generally focuses on evacuation of the distal colon followed by prolonged use of laxatives to ensure that the child passes soft stools frequently without any associated pain.
• Various modalities have been proposed for the treatment of chronic encopresis. Although considerable controversy and conflicting data have been reported, many authors advocate behavioral strategies with or without long-term laxative therapy to encourage bowel movements. The addition of an intensive behavioral program to conventional medical therapy can be of substantial therapeutic benefit for most children with chronic encopresis (see Further Outpatient Care).
• Because more than one half of children with chronic encopresis have paradoxical constriction of their EAS (anismus) during attempted defecation, biofeedback training has been used to treat children with chronic encopresis since the mid 1980s. Biofeedback usually focuses on teaching the child how to relax the EAS during active straining, thus eliminating anismus (see Further Outpatient Care).

When faced with a child with chronic constipation or encopresis, conventional medical therapy is commonly the first therapy attempted. This includes demystification and education; colonic evacuation followed by routine laxative therapy; and “toilet training,” which is composed of regularly scheduled toileting, maintenance of a symptom diary, and an age-appropriate incentive scheme. The literature suggests conventional medical therapy proves successful in approximately one half of children with chronic constipation, encopresis, or both. 

Most available data indicate that if a child has not experienced significant clinical improvement after 2-4 months of therapy, a different therapy program is indicated. As a result, assessing the progress after 2-4 months of therapy is appropriate. If the child remains symptomatic, consider enrolling him or her in an intensive behavior program that supplements conventional medical therapy. Preliminary evidence suggests that this type of intensive behavioral intervention can be successfully performed using the Internet.¹⁶

Surgical Care

No surgical intervention has a proven role in the management of childhood encopresis.

Consultations

In most cases of encopresis, consultation with a subspecialist is not absolutely necessary. Affected children are often referred to a pediatric gastroenterologist, a behavioral psychologist, or both.

Diet

No evidence suggests that dietary interventions are beneficial in the management of encopresis. Although many people advocate high-fiber diets, the authors know of no studies conducted to systematically evaluate the effectiveness of dietary therapy in childhood encopresis.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• MISCELLANEOUS
• References

Because most children with encopresis have retentive encopresis as a consequence of chronic constipation with resulting overflow incontinence, therapy is initially focused on evacuating the distal colon. Disimpaction can be accomplished with aggressive use of oral cathartics, such as polyethylene glycol (PEG), sodium phosphate, or magnesium citrate, or a series of enemas. In uncontrolled trials, disimpaction by the oral route, the rectal route, or a combination of both has proven effective.

After the colon is evacuated, long-term laxative therapy is generally started. Virtually any laxative can be used as long as it is used in sufficient quantity to produce 1-2 soft stools per day.

Drug Category: Osmotic laxatives

These agents cause fluid retention in the colon, lowering the pH, resulting in distention, and increasing colonic peristalsis.

Drug Category: Lubricants and emollients

These agents retard colonic absorption of fecal water and thus soften stool.

Drug Category: Stimulant laxatives

These agents directly act on the intestinal mucosa or nerve plexus. They alter water and electrolyte secretion.

Drug Category: Enemas

Several days of enemas are often used to evacuate or disimpact the colon before the start of a regular laxative regimen. Various enema preparations can be used to evacuate the distal colon. Most enema preparations contain osmotically active agents that are not substantially absorbed in the colon. Common examples include phosphate (eg, Fleet pediatric, adult enemas), saline, or milk and molasses. To the author's knowledge, no studies have been performed to compare the effectiveness of various enema preparations. In all likelihood, the effectiveness of any particular preparation depends more on the volume of the enema than on the composition of the enema solution.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• MISCELLANEOUS
• References

Further Outpatient Care

In addition to the medical therapy outlined above, various modalities have been proposed for the treatment of chronic encopresis.

• Because more than one half of children with chronic encopresis have paradoxical constriction of their EAS during attempted defecation, some literature has advocated the use of EAS biofeedback to treat chronic encopresis.¹⁷
• • Biofeedback focuses on teaching the child to reverse paradoxical constriction by learning how to relax the EAS during straining. Most studies examining the use of biofeedback in childhood encopresis included biofeedback as a supplement to medical-behavioral treatment.¹⁷
  • Both manometric and electromyographic (EMG) biofeedback have been used to treat encopresis, but manometric biofeedback is more invasive than EMG biofeedback. Data from a meta-analysis suggested no significant differences in outcomes by using intra-anal pressure biofeedback compared with surface EMG biofeedback of the perianal skin.¹⁸
  • Authors of a Cochrane review examined the effectiveness of biofeedback therapy in children with chronic encopresis.¹⁸ The addition of biofeedback therapy to conventional medical therapy does not appear to be of substantial therapeutic benefit for most children with chronic constipation, encopresis, or both.¹⁹ Although biofeedback can be used to successfully train children to tighten and relax their perineal muscles and, thus, theoretically increase the efficiency of defecation, achieving this objective is not clearly correlated with successful resolution of the symptoms of chronic constipation, encopresis, or both. In fact, outcomes tend to worsen when children are treated with biofeedback therapy.
• Some authors have advocated the use of behavioral strategies with or without long-term, laxative therapy to encourage frequent bowel movements.^{20, 17, 21, 18}
• • Authors of a Cochrane review concluded that the addition of an intensive behavioral program to conventional medical therapy can be of substantial therapeutic benefit in most children with chronic encopresis.¹⁸
  • Although the critical components of a successful intensive behavioral program have not been systematically elucidated, common elements of existing programs include 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; establishing age-appropriate rewards and consequences;²² and strongly emphasizing consistency. 
  • Preliminary evidence suggests that this type of intensive behavioral intervention can be successfully performed using the Internet.¹⁶

Prognosis

Even with aggressive medical and behavioral interventions, as many as 30% of children remain symptomatic.²³ Unfortunately, no sufficient evidence has enabled clinicians to reliably predict which children successfully respond to specific treatment protocols. 

The few data available suggest that family disorganization correlates with a poor response to all forms of treatment. In contrast, none of the demographic, manometric, behavioral, social, academic, or self-esteem measures are clearly associated with response to therapy. No investigators have systematically examined the child's motivation, the family’s motivation, or the state of change to see if it is predictive of their response to treatment.

Patient Education

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles, Encopresis and Constipation in Children.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• MISCELLANEOUS
• References

Medical/Legal Pitfalls

Unless a physical or psychological contraindication is noted, performing a digital rectal examination on every child with encopresis to exclude any underlying anatomic or neurological abnormality that might account for the encopresis, such as an imperforate anus with perineal fistula, a low or unsuspected meningomyelocele, or ultrashort-section Hirschsprung disease, is important.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• MISCELLANEOUS
• References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3^rd ed. APA; 1981.
2. Di Lorenzo C, Benninga MA. Pathophysiology of pediatric fecal incontinence. Gastroenterology. Jan 2004;126(1 Suppl 1):S33-40. [Medline].
3. Partin JC, Hamill SK, Fischel JE, Partin JS. Painful defecation and fecal soiling in children. Pediatrics. Jun 1992;89(6 Pt 1):1007-9. [Medline].
4. Borowitz SM, Cox DJ, Sutphen JL. Differences in toileting habits between children with chronic encopresis, asymptomatic siblings, and asymptomatic nonsiblings. J Dev Behav Pediatr. Jun 1999;20(3):145-9. [Medline].
5. Joinson C, Heron J, Butler U, et al. Psychological differences between children with and without soiling problems. Pediatrics. May 2006;117(5):1575-84. [Medline].
6. Loening-Baucke V. Prevalence rates for constipation and faecal and urinary incontinence. Arch Dis Child. Jun 2007;92(6):486-9. [Medline].
7. van der Wal MF, Benninga MA, Hirasing RA. The prevalence of encopresis in a multicultural population. J Pediatr Gastroenterol Nutr. Mar 2005;40(3):345-8. [Medline].
8. Joinson C, Heron J, Butler R, et al. A United Kingdom population-based study of intellectual capacities in children with and without soiling, daytime wetting, and bed-wetting. Pediatrics. Aug 2007;120(2):e308-16. [Medline].
9. Cox DJ, Morris JB Jr, Borowitz SM, Sutphen JL. Psychological differences between children with and without chronic encopresis. J Pediatr Psychol. Oct-Nov 2002;27(7):585-91. [Medline].
10. Mellon MW, Whiteside SP, Friedrich WN. The relevance of fecal soiling as an indicator of child sexual abuse: a preliminary analysis. J Dev Behav Pediatr. Feb 2006;27(1):25-32. [Medline].
11. Borowitz SM, Sutphen J, Ling W, Cox DJ. Lack of correlation of anorectal manometry with symptoms of chronic childhood constipation and encopresis. Dis Colon Rectum. Apr 1996;39(4):400-5. [Medline].
12. McGrath ML, Mellon MW, Murphy L. Empirically supported treatments in pediatric psychology: constipation and encopresis. J Pediatr Psychol. Jun 2000;25(4):225-54; discussion 255-6. [Medline].
13. Nolan T, Debelle G, Oberklaid F, Coffey C. Randomised trial of laxatives in treatment of childhood encopresis. Lancet. Aug 31 1991;338(8766):523-7. [Medline].
14. Borowitz SM, Cox DJ, Sutphen JL, Kovatchev B. Treatment of childhood encopresis: a randomized trial comparing three treatment protocols. J Pediatr Gastroenterol Nutr. Apr 2002;34(4):378-84. [Medline].
15. Thapar A, Davies G, Jones T, Rivett M. Treatment of childhood encopresis--a review. Child Care Health Dev. Nov-Dec 1992;18(6):343-53. [Medline].
16. Ritterband LM, Cox DJ, Walker LS, et al. An Internet intervention as adjunctive therapy for pediatric encopresis. J Consult Clin Psychol. Oct 2003;71(5):910-7. [Medline].
17. Cox DJ, Sutphen J, Borowitz S, et al. Contribution of behavior therapy and biofeedback to laxative therapy in the treatment of pediatric encopresis. Ann Behav Med. Spring 1998;20(2):70-6. [Medline].
18. Brazzelli M, Griffiths P. Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev. Apr 19 2006;(2):CD002240. [Medline].
19. Brooks RC, Copen RM, Cox DJ, et al. Review of the treatment literature for encopresis, functional constipation, and stool-toileting refusal. Ann Behav Med. 2000;22(3):260-7. [Medline].
20. Brazzelli M, Griffiths P. Behavioural and cognitive interventions with or without other treatments for defaecation disorders in children. Cochrane Database Syst Rev. 2001;(4):CD002240. [Medline].
21. Young MH, Brennen LC, Baker RD, Baker SS. Functional encopresis: symptom reduction and behavioral improvement. J Dev Behav Pediatr. Aug 1995;16(4):226-32. [Medline].
22. Reid H, Bahar RJ. Treatment of encopresis and chronic constipation in young children: clinical results from interactive parent-child guidance. Clin Pediatr (Phila). Mar 2006;45(2):157-64. [Medline].
23. Rockney RM, McQuade WH, Days AL, et al. Encopresis treatment outcome: long-term follow-up of 45 cases. J Dev Behav Pediatr. Dec 1996;17(6):380-5. [Medline].

Article Last Updated: Mar 24, 2008