Encopresis - Stool Holding or Soiling

Overview

By Tina Shahian, PhD

Encopresis is characterized by hardened stool and unintended soiling. It typically affects children over the age of 4 who have infrequent bowel movements. When children with chronic constipation or other types of stress resist the natural urge to pass stool, the stool accumulates in the rectum and large intestine and becomes hardened (impacted). This can eventually cause the colon to swell and lose its ability to sense or control bowels, allowing loose/liquid stool to leak out and soil clothes.

There are two types of encopresis; primary encopresis is associated with children who are not fully toilet trained, while secondary encopresis is associated with children who develop the condition after toilet training. Children suffering from encopresis may feel guilty or embarrassed and lose interest in socializing. Without proper treatment, encopresis can lead to chronic constipation, abdominal pain, poor appetite and bladder infections. The majority of patients develop healthy bowel habits with a combination of treatment and positive encouragement. Encopresis is six times more common in boys than girls.

Causes and Risk Factors

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

Symptoms

Most encopresis symptoms are associated with abnormal bowel habits. These include:

  • Constipation and hard stools
  • Infrequent bowel movements
  • Large stools that clog the toilet
  • Unintentional soiling of clothes (loose/liquid stool)
  • Hiding bowel movements and/or soiled clothes
  • Avoiding friends or social situations
  • Poor appetite
  • Abdominal pain
  • Frequent urinary tract infections.

Diagnosis and Treatment

Diagnosing encopresis begins with a physical exam followed by tests that look for evidence of fecal compaction in the rectum and intestine.

  • Digital rectal exam. Doctors first check for the compacted stool by inserting a finger inside a child’s rectum. A lubricant is used to minimize pain and discomfort.
  • X-ray. An X-ray of the abdominal area is used to visualize and assess the amount of compacted stool in the rectum and intestine. The X-ray may also be used in combination with a barium contrast fluid (barium enema) to enable better inspection of the intestine for physiological abnormalities, such as a physical blockage.
  • Psychological evaluation. A thorough psychological evaluation will help identify underlying emotional stresses that may be playing a role.

The goal of treatment is to clear out the colon and help the child adopt a healthy bowel routine. Most treatment regimens include a shift in diet and establishing a bowel schedule. Treatment depends on the child’s age, toilet training status and other factors.

  • 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.

Prevention

The best way to prevent encopresis is through regular exercise (or outside play) and a healthy diet rich in fruits, vegetables, whole grains and fiber. Fast foods and processed foods should be avoided. Drinking plenty of fluids, especially water, helps keep stool soft. Recognizing and addressing emotional stress in children also reduces the risk of developing encopresis. This includes toilet training children at the right age (usually after 2 years old) and avoiding negative reinforcement tactics.

Sources

  1. “Encopresis ". Medline Plus. Retrieved Mar 27, 2015. http://www.nlm.nih.gov/medlineplus/ency/article/001570.htm.
  2. “Encopresis". Mayo Clinic Foundation. Retrieved Mar 27, 2015. http://www.mayoclinic.org/diseases-conditions/encopresis/basics/definition/con-20029758.
  3. “Encopresis”. Stanford Children’s Health. Retrieved Mar 27, 2015. http://www.stanfordchildrens.org/en/topic/default?id=encopresis-90-P01992.