Encopresis

Background

Encopresis affects 3% to 7% of school-age children and is much more common in boys than girls. Encopresis with constipation and overflow incontinence is the most common type. This type starts when children withhold bowel movements because of previously painful bowel movements, fear of the toilet, or not wanting to stop what they are doing to use the bathroom. Over time, this results in the loss of the urge to defecate and constipation. An overflow of liquid bowel occurs, resulting in soiling of clothing. The child generally doesn't experience the urge to defecate and does not intend to soil. When the child must defecate, the feces are often large and painful to pass. Once this cycle is established, children continue to withhold feces to avoid further painful elimination, and parental attention may reinforce this behavior.

Most children with encopresis do not have significant emotional problems, but do tend to have more social and behavioral problems. Attentional difficulties may be present, and a treatment goal is to help them attend to the internal cues necessary for elimination. Many children with encopresis are not aware of their own soiling, having become accustomed to the odor. They often feel ashamed and embarrassed and fear discovery by peers or parents. Coping strategies include hiding soiled clothing, avoiding peers, and acting indifferently toward the situation.

Some children have the intentional or nonretentive type of encopresis, in which they have entire bowel movements in their clothing and/or in inappropriate places such as a dresser drawer or a closet. This type of encopresis may be associated with oppositional defiant disorder or other emotional issues. Toileting [Page 188]behavior becomes a way for the child to exert control or express anger toward adults. Parents of children with nonretentive encopresis may find discipline and family issues are a challenge.

Treatment

Treatment for retentive encopresis is usually multimodal, including medical, dietary, and behavioral interventions. The goal of treatment is to establish regular bowel habits, and effectiveness rates are between 55% and 82%. Medical intervention (enemas or laxatives) to relieve constipation is the typical first step, followed by the use of laxatives or stool softeners and increasing dietary fiber to foster regular bowel movements. To establish regular toileting times the child sits on the toilet twice daily for at least 10 minutes (usually 20 minutes after breakfast and dinner to take advantage of the natural colon reflex after eating). Behavioral interventions include the use of positive reinforcement for appropriate toileting and clean clothing along with overcorrection for soiling (i.e., the child cleans himself and his clothing after soiling). Intentional or nonretentive encopresis may require individual or family therapy to resolve the problems that lead to encopresis. Controlled studies of treatment effectiveness for nonretentive encopresis are lacking.

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