It is one of the most frustrating disorders of middle childhood.
It is the passage of feces to underwear or pajamas, well beyond the time in which they learn to go to the bathroom.
Encopresis affects approximately 1.5 percent of school-age children and can create tremendous anxiety and embarrassment for children and their families.
Encopresis is not a disease but a symptom of a complex relationship between the body and psychological / environmental stress. Boys with encopresis outnumber girls six to one, although the reasons for this higher prevalence among boys are unknown.
The condition is not related to social class, family size, the child’s position in the family, or the age of the parents.
Types and symptoms of encopresis
Doctors divide cases of encopresis into two categories:
Children with the primary disorder have had continuous spotting throughout their lives, with no period in which they have been successful in using the toilet.
In contrast, children with the secondary form can develop this condition after being toilet trained, such as when entering school or encountering other experiences that can be stressful.
A frustrating condition
Children, parents, grandparents, teachers, and friends alike are often puzzled by this problem. Adults sometimes assume that the child is getting dirty on purpose.
While this may not be the case, children can play an active role in managing the processes involved in this disorder.
The physical aspects of encopresis
When encopresis occurs, it begins with retention of stool in the colon. Many of these youngsters may simply not respond to the urge to defecate and therefore retain their bowel movements.
As the intestinal walls and the nerves within them stretch, the nerve sensations in the area diminish.
Also, the intestines progressively lose their ability to contract and squeeze stool out of the body. Therefore, these children find it increasingly difficult to have a normal bowel movement. Most of these children suffer from chronic constipation.
Over time, these retained stools become harder, larger, and much more difficult to pass. Bowel movements can be painful, further discouraging these children from passing stools.
Eventually, the sphincters (the muscular valves that normally hold stool inside the rectum) can no longer hold all of the stool.
Large, hard stools can be retained in the colon (large intestine) and rectum, but liquid stools can begin to leak around this impacted mass, passing through the anus and staining underwear.
At other times, semi-formed or partial bowel movements may shift into underwear, and due to decreased sensation, the child may not be aware of it.
Some youngsters are predisposed from birth to early colonic inertia, that is, a tendency to constipation because their intestinal tracts lack complete mobility.
Early in life, these children may have experienced constipation that required medical and dietary management.
Some children develop constipation and encopresis due to lack of toilet training as young children. They may have fought the potty training process, been pushed too fast, or been punished for having accidents.
Struggling with their parents for control, they may have voluntarily withheld their bowel movements, striving to hold them for as long as they could. Some children may have been afraid to go to the bathroom, even thinking that they could be expelled themselves.
A number of other factors can also contribute to the eventual development of encopresis. Sometimes children can feel pain when they have a bowel movement due to an infection or tear near the rectum.
Emotional causes may include limited access to a toilet or shyness about its use (at school, for example), or stressful life events (marital discord between parents, moving to a new neighborhood, family mental or physical illnesses or new siblings).
While most children with encopresis are also constipated, some are not. These children may refuse to use the bathroom and simply have normal bowel movements in their underwear or other inappropriate places.
In general, these children are demonstrating their attempts to control some difficult aspects of their lives. Professional help is advisable for these children and their families.
Many parents are surprised that their child with encopresis is not even aware of the smell emanating from the stool in their pants. When this smell is constant, the olfactory centers of the brain can get used to it and, therefore, the child no longer perceives it.
As a result, these youngsters are often surprised when a parent or someone else tells them they have a scent. While the child himself may not be bothered by the smell, the people around him may not be sympathetic to his problem.
Psychological effects of encopresis
Exasperated parents often put great pressure on their child to change this behavior, something the youngster may be unable to do without the help of a pediatrician.
While family members may have ideas about how to solve the problem, their efforts will generally fail when they do not understand the physiological mechanisms at work.
Encopresis can lead to a fight within the family. As parents and siblings become increasingly frustrated and angry, family activities may be curtailed or the child with encopresis may be excluded from them.
At this stage, the problem has often become a family concern.
As the child and family struggle unsuccessfully for the child’s bowel control, the conflict can spread to other areas of the child’s life. Your school work may suffer; your responsibilities and chores at home can be ignored.
You may also get angry, withdrawn, feel anxious, and depressed, often as a result of being teased and feeling humiliated.
Encopresis is a chronic disease, complex – but it has a solution – problem. However, the longer it exists, the more difficult it is to treat. The child should be taught how the intestine works and that it can strengthen the muscles and nerves that control bowel function.
Parents should not blame the child and make him feel guilty, as it contributes to lowering self-esteem and makes him feel less competent to solve the problem.
Parents often use a behavior modification or reward system that encourages proper grooming habits for the child. You may receive a star or a sticker on a chart for each day that passes without getting dirty and a special small toy, for example, after a week.
This approach works best for a child who really wants to solve the problem and is fully involved in that effort.
Some youth have significant emotional and behavioral difficulties that interfere with the treatment program.
Counseling for these children helps them deal with issues such as peer conflict, academic difficulties, and low self-esteem, all of which can contribute to encopresis.
Throughout this treatment process, parents should remind the child that other children have the same problem. In fact, children with the same difficulty probably attend their own school.
Children with encopresis may have occasional relapses and failures during and after treatment; these are actually quite normal, particularly in the early stages.
Final success can take months or even years.
One of the most important tasks of parents is to seek early treatment for this problem. Many mothers and fathers feel embarrassed and unsupported when their child has encopresis. But parents shouldn’t just wait for it to go away.
They should consult their doctor and make a persistent effort to solve the problem. If symptoms are allowed to linger, a child’s self-esteem and social confidence can be further damaged.
The goal of treatment is for the patient to achieve the ability to be in charge of his own continence and defecation. To this end, any significant fecal impact must be alleviated and a regular outlet established.
Treatment for encopresis is divided into three stages:
- The first is initial disimpaction with the initiation of maintenance laxatives or prokinetic agents.
- The second stage is establishing a good bowel habit through the use of behavior modification.
- Third, correction, if necessary, of abnormal defecation dynamics.
The first two modes of treatment are often adequate to solve the problem, but if the encopresis is refractory. Many children respond well, but there is certainly a group that continues to have long-term problems after puberty.
Laxative treatment regimens vary in detail, but generally aim to produce one or two bowel actions per day. The extent of fecal retention determines the type of medication.
Regimens based on polyethylene glycol (macrogol) are increasingly being accepted as a first line, but there is still an occasional place for stimulant laxatives such as those derived from senna or bisacodyl.
Enemas and suppositories are now used infrequently for disimpaction. Increasing fiber is helpful only if current intake is inadequate.
At the same time as laxative medication, a star chart with a reward system for successful toilet bowel movements and soilless days can be used as positive reinforcement aimed at improving the habit of using the toilet.
Regular sitting three times a day for 5-10 minutes, with a minimum of distraction is an effective regimen.
In addition, it is very important to clarify the physiology of encopresis in parents and children to alleviate guilt, as well as careful monitoring of Maintain Compliance and monitor progress.
In a reported population of children with encopresis, this regimen can be expected to result in complete remission of soiling in about half and in addition to being independent of laxatives in the same or less.
Biofeedback for the treatment of anismus
The rationale for the development of biofeedback had been to provide a correction for disturbed anorectal dynamics, and especially for paradoxical sphincter or anismic contraction.
The recommended method for biofeedback is generally the same or an adaptation of anorectal manometry with some type of visual or auditory feedback of sphincter contraction.
Unfortunately, critical appraisal in controlled studies has not provided evidence of superior efficacy to standard treatments.