Encopresis

Definition

Encopresis usually an involuntary passage of feces (stools) by a child age four or more in inappropriate places such as clothing. It is frequently the result of chronic constipation, which over time results in fecal impaction and in the leakage of liquid stool accumulated above the impacted feces. This leakage may occur during the day or night and it is not under the conscious control of the child. Leakage varies in frequency, and it can range from infrequent occurrences to almost a continuous flow.
Encopresis is categorized according to the subtype that characterizes the presentation -- primary is with constipation and overflow incontinence; secondary is without constipation and overflow incontinence. The primary subtype has evidence of constipation on physical examination or a history of a bowel movement frequency of less than three per week. Feces in overflow incontinence are characteristically poorly formed, and leakage can be infrequent to continuous, occurring mostly during the day and rarely during sleep. Only part of the feces is passed during toileting, and the incontinence resolves after treatment of the constipation. The secondary subtype has no evidence of constipation on physical examination or by history. Feces are likely to be of normal form and consistency, and soiling is intermittent. This is usually associated with the oppositional defiant disorder or conduct disorder.
Also, a child with encopresis often feels ashamed and may wish to avoid situations (such as camp or school) that might lead to embarrassment. The amount of impairment is a function of the effect on the child's self-esteem, the degree of social ostracism by peers, and the anger, punishment, and rejection on the part of caregivers.
Symptoms
The four symptoms used for diagnosis of encopresis are:
Repeated passage of feces into inappropriate places (such as clothing or floor) whether involuntary or intentional.
At least one such event a month for at least three months
Chronological age is at least 4 years (or equivalent developmental level)
The behavior is not due exclusively to the direct physical effects of a substance such as a laxative or a general medical condition except by means of constipation
Causes
Usually, encopresis is a physical disorder associated with chronic constipation, and the development of abnormal patterns of external sphincter muscle practices whereby the muscle is contracted rather than relaxed when a bowel movement is attempted. This is the result of a habitual practice of suppressing signals indicating that it is time for a bowel movement by children engaged in an enjoyable activity. Children then learn to hold back their feces to avoid an accident. When a child ignores the messages sent from his muscles and nerves about an impending bowel movement, the number of such signals decreases. Over time the feces builds up in the colon and becomes impacted. When the impaction becomes large, hard, and dry, bowel movements become very painful. This, when combined with the decreasing number of signals sent from the muscles and nerves, increases the risk of the child having an accident. The occurrence of such accidents does not empty the colon and rectum as they should and feces continue to leak. Unless this pattern of retention is reversed the child becomes less able to perform the many skills necessary to empty the colon.
A number of factors can also contribute to the eventual development of encopresis:
A predisposition from birth to early colonic inertia -- tendency toward constipation because their intestinal tracts lack full mobility. This may have required dietary and medical management
Unsuccessful toilet training as toddlers. They may have fought the toilet training process, been pushed too fast, or were punished for having accidents. Struggling with their parents for control or having an actual fear of the toilet, even thinking that they might be flushed away.
Pain when having a bowel movement due to an infection or a tear near the rectum
Emotional causes can include limited access to a toilet or shyness over its use (at school, for example), or stressful life events (marital discord between parents, moving to a new neighborhood, family physical or mental illnesses or new siblings). They try to demonstrate control over difficult aspects of their lives by refusing to use the toilet and simply have bowel movements in their underwear or other inappropriate places
Treatment
The optimal treatment regimen of encopresis involves both a medical and behavioral approach. The treatment goals will probably be fourfold:
To establish regular bowel habits in the child
To reduce stool retention
To restore normal physiological control over bowel function
To defuse conflicts and reduce concerns within the family brought on by the child's symptoms.
To accomplish these goals, attention will be focused not only on the physical basis of encopresis but also on its behavioral and psychological components and consequences.
In the initial phase of medical care, the intestinal tract often has to be cleansed with medications. For the first week or two the child may need enemas, strong laxatives or suppositories to empty the intestinal tract so it can shrink to a more normal size.
Maintenance involves scheduling regular times to use the toilet in conjunction with daily laxatives like mineral oil or milk of magnesia. Proper diet is important, too, with sufficient fluids and high-fiber foods. These steps will keep the stool soft and prevent constipation. When improperly supervised, these interventions have potential dangers for the health of the child and so should be done only under the supervision of the child's physician. The maintenance phase will usually last two to three months or longer.
Some youngsters have significant behavioral and emotional difficulties that interfere with the treatment program. Counseling for these children helps them deal with issues like peer conflicts, academic difficulties, and low self-esteem, all of which can contribute to encopresis.
When medication and behavioral training are combined most children improve significantly within two weeks and 75 percent maintain these improvements.
Sources:
American Academy of Pediatrics, 2000
American Psychiatric Association, 2000