Encopresis

February 7, 2017

Encopresis is a problem that children age four or older can develop due to chronic (long-term) constipation. With constipation, children have fewer bowel movements than normal, and the bowel movements they do have can be hard, dry, and difficult to pass. The child may avoid using the bathroom to avoid discomfort. Stool can become impacted (packed into the rectum and large intestine) and unable to move forward. The rectum and intestine become enlarged due to the hard, impacted stool. Eventually, the rectum and intestine have problems sensing the presence of stool, and the anal sphincter (the muscle at the end of the digestive tract that helps hold stool in) loses its strength. Liquid stool can start to leak around the hard, dry, impacted stool, soiling a child’s clothing. Encopresis affects 1 to 3 percent of children and these cases are split into two types:

Retentive encopresis – About 80 to 95 percent of all encopresis cases are retentive encopresis. Their stool accidents are mostly involuntary and are not of normal or healthy consistency. Children with this disorder have an underlying medical reason for soiling.
Non-retentive encopresis – As stated at the end of the retentive encopresis article, the remaining 5 to 20% of encopresis cases have no physical condition that bars normal toileting behaviors. These children aren’t constipated and don’t seem to have any significant medical problems. They usually soil their diapers or pants almost every day and have normal, mostly voluntary bowel movements.

Although parents may find it frustrating, encopresis is very rarely thought to be caused by a child misbehaving. They usually can’t help it and some children may not even realise they’ve had an accident. Children who have this problem may feel ashamed, guilty, frustrated or angry, and may act secretively to try to hide the problem.

Causes

The main causes of encopresis are constipation and emotional stress. Accumulated stool in the colon can affect the nerves that control the bowel, leading to accidental soiling.

Constipation – Prolonged or chronic constipation is the common cause of encopresis. Irregular bowel movements enlarge and harden the stool, making it painful to pass. The anticipation of pain may cause a child to avoid the toilet, worsening the problem. A lack of exercise, poor hydration, a diet low in fiber and certain food allergies can cause constipation. Fighting the body’s natural signals to pass stool also leads to constipation. Children sometimes hold stool when they are in an unfamiliar environment, or simply forget to go because they are too engaged in activity.

Emotional stress – Factors that create emotional anxiety or stress in children may interrupt their regular bowel routine and cause constipation. Events that lead to stress include parental dispute, birth of a sibling, challenges at school or moving to a new home. Children who are not toilet trained or are toilet trained too early may feel emotional and social distress. Other known childhood/adolescence emotional disorders that can trigger encopresis include oppositional defiant disorder and conduct disorder.

Food Allergies – For babies with troublesome constipation, the most common cause is a cow’s milk protein intolerance. Studies show that 80% of constipation in the first year of life is due to a cow’s milk reaction. In older children, the most common cause for constipation is gluten sensitivity.

Without treating the underlying food intolerance, the only treatment is more laxatives.

Gender – For reasons that are not known, boys are six times more likely to develop encopresis.

Risk Factors

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.

Symptoms

The main symptom of encopresis is that the child has bowel movements in inappropriate places, such as in clothing or on the floor. This soiling is not caused by taking laxatives or other medications, and is not due to a disability or physical defect in the bowel. Other symptoms of encopresis may include –

Avoidance of bowel movements
Secretive behavior associated with bowel movements.
Leakage of stool or liquid stool on your child’s underwear. If the amount of leakage is large, you may misinterpret it as diarrhea
Scratching or rubbing the anal area due to irritation from watery stools
Constipation with dry, hard stool
Passage of large stool that clogs or almost clogs the toilet
Loss of appetite
Abdominal pain
Decreased interest in physical activity
Withdrawal from friends and family

Complications

Megacolon – A portion of the colon may stretch out of proportion under the repeated volume and pressure of impacted stools. Doctors call this “megacolon”. This larger-than-normal colon holds even more feces than usual, and can result in bowel movements that are quite impressive for a small child. The worse the deformation is, the less it is reversible. In extreme cases, this may require surgery.
If encopresis is not treated, the child may have low self-esteem and problems making and keeping friends.
If encopresis is not corrected, the child may develop chronic constipation.

Treatment

Colon emptying – Prior to teaching healthy bowel habits, a variety of methods are used to clear compacted fecal matter from the colon. Enemas that flush out fecal matter or laxatives (oral or rectal suppository) that trigger a bowel movement force out the stool. Other methods help by softening hard stools (stool softeners) or lubricating the stool/colon contact points (mineral oil).

Diet – Once the colon is relieved from constipation, a change in diet helps maintain regularity. Proper hydration and eating fruits, vegetables, whole grains and other high-fiber foods will help to produce soft, regular bowel movements. Some children may benefit from avoiding fatty foods and dairy.

Toilet routine – A toilet routine ensures regular attempts at having a bowel movement, with the goal of building healthy habits. This may include a predetermined schedule for using the toilet and various positive incentives to reinforce successes. Negative incentives (punishment for soiled clothes) are counterproductive and may impede progress.

Psychotherapy – Psychotherapy helps address the underlying emotional causes of encopresis. It will also help children cope with depression, anger and other negative psychological consequences of encopresis.

Alternative Treatment

Probiotics – Giving a child probiotics on a regular basis can help in re-establishing a healthy gut flora, which can have a positive impact on transit.

Flaxseeds is an effective bulk laxative

Glucomannan has been shown to be safe and effective in children with this condition.

Magnesium is effective in encopresis. It is used to soften the stool. These oral stool softeners work by pulling water into the stool and are well-tolerated for long periods of time without the child becoming dependant on them

Fiber – Increase fiber intake by encouraging whole grains, fruits, vegetables, peanut butter, dried fruits, and salads. In addition, give at least two Fiber Servings every day

Reference –

http://www.massgeneral.org/conditions/condition.aspx?id=557

http://www.cincinnatichildrens.org/health/e/encopresis/

https://umm.edu/health/medical/ency/articles/encopresis

http://www.innerbody.com/diseases-conditions/encopresis

http://www.hopkinschildrens.org/chronic-constipation-clinic.aspx

http://www.nytimes.com/health/guides/disease/encopresis/overview.html

http://www.rch.org.au/uploadedFiles/Main/Content/kidsinfo/Encopresis_diary.pdf

http://www.med.umich.edu/yourchild/topics/encopre.htm

http://www.encopresis.com/

http://raisingchildren.net.au/articles/encopresis.html

http://www.aafp.org/afp/1999/0415/p2171.html