Encopresis II

Fecal soiling occurs when children leak stool, usually involuntarily, into their underwear, after they have been potty trained. Although soiling can be from fecal incontinence secondary to an anatomic problem, such as an anal malformation, meningomyelocele, muscle diseases, or after anal surgery, it is most commonly due to encopresis.

Although encopresis occurs equally in boys and girls in younger children, by school age, it is much more common in boys.

Encopresis is a complication of chronic constipation, and it is fecal soiling with the loss of semi-formed or usually liquid stools, which may be foul smelling, into a child's underwear. Once a child becomes constipated and has hard and painful stools, he will then begin to hold in his bowel movements to prevent it from hurting again. This creates a cycle that makes the constipation continue and become worse, eventually leading to a large fecal impaction and rectal distention (which can make the rectum less sensitive and unable to hold even small amounts of stool). Stool behind the impaction begins to leak around it, and eventually leaks out of the rectum, without the child noticing it or being able to hold it in.

Your child may also have very large, infrequent, hard bowel movements that are painful or may even plug up the toilet. Or he may have very small, ball-like bowel movements more frequently, but which are still very hard and difficult to pass. After a very large bowel movement, soiling may improve, until enough time passes and the impaction builds up again.

The treatments for encopresis must include treatment for the underlying constipation. This may include a 'clean out' regimen of enemas, suppositories or high dose mineral oil to remove the backed up or impacted stool.

Other treatments are aimed at improving your child's diet. A diet low in fiber or fluids can contribute to constipation. So can drinking too much milk. Some steps to improve your child's diet include:

Increasing fluids: Increase the amount of water and fruit juices (minimum of 2-3 glasses) that your child drinks each day.

Increasing fiber: Increase the amounts of fruits and vegetables that your child eats. Raw, unpeeled fruits and vegetables (especially beans, sweet potatoes, peas, turnip greens, raw tomatoes and corn) have the most fiber. Popcorn also has lots of fiber in it. Give enough grams of fiber to equal their age in years plus 5 each day (check the nutritional label for high fiber foods and snacks with at least 3-4g of fiber per serving). Vegetable soups are especially high in fiber and also add more fluid to your child's diet.

Increasing bran in your child's diet by offering bran cereals, bran muffins, shredded wheat, graham crackers, or whole wheat bread.

Decreasing constipating foods: These include milk, yogurt, cheese, cooked carrots, and bananas. Drinking too much milk (your child may only be drinking 2-3 cups a day, but it may be too much for his system to handle) is heavily associated with being constipated. Switching to soy milk has been shown to soften stools. If your child is unable to drink milk, then offer a daily multivitamin or other sources of calcium.

Until your child's constipation has improved with a non-constipating diet, your child will most likely also be on stool softeners. Most of these medicines are available in the pharmacy over the counter and do not require a prescription. They include Metamucil, Milk of magnesia, Citrucel, or mineral oil. Unlike laxatives in adults, they are generally not considered to be habit forming. You should use them once or twice a day and work up on the dose until your child is having a soft BM each day. If you child starts to have diarrhea, then you are giving too much and you should cut back on the dose. See the table in our Guide to Constipation for dosing information.

Another important treatment of encopresis and constipation is behavior management so that your child learns to have a bowel movement each day. You should encourage your child to have regular bowel patterns. Have your child sit on the toilet for about five to ten minutes after meals 2-3 times each day. The use of simple rewards or a daily calendar with stars or stickers for days that your child takes his medicine and has a bowel movement may be helpful. Your child doesn't necessarily need to have a bowel movement each of these times, and you shouldn't punish him if he doesn't. It is more important that he gets in a regular habit of trying to have a bowel movement.

And remember that the leakage of stool is involuntary. Your child is not doing it on purpose and he shouldn't be punished or shamed when it does happen. The distention and stretching of his rectum from the impacted stool can take a lot of time to get back to normal, and until it does, he may not be able to sense or voluntarily hold in all of his bowel movements, and so leakage may continue even with proper treatment.
Encopresis can sometimes be difficult to treat, and your Pediatrician may consider referring you to a Pediatric Gastroenterologist for further management if he is not improving on his current medical regimen. Difficult cases, especially if your child also has emotional or behavioral problems, may also need treatment by a child psychologist.