A single copy of this article may be reprinted for personal, noncommercial use only.
EncopresisBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/encopresis/DS00885
Encopresis occurs when your child resists having bowel movements, causing impacted stool to collect in the colon and rectum. When your child's colon is full of impacted stool, liquid stool can leak around the impacted stool and out of the anus, staining your child's underwear. Encopresis may also be called stool holding.
Encopresis usually occurs after age 4, when your child has already learned to use a toilet. In most cases, encopresis is a symptom of chronic constipation. Less frequently, it may be the result of developmental or emotional issues.
Encopresis can be frustrating for you — and embarrassing for your child. However, with patience and positive reinforcement, treatment for encopresis is usually successful.
Signs and symptoms of encopresis may include:
- Leakage of stool or liquid stool on your child's underwear. If the amount of leakage is large, you may misinterpret it as diarrhea.
- Constipation with dry, hard stool.
- Passage of large stool that clogs or almost clogs the toilet.
- Avoidance of bowel movements.
- Long periods of time between bowel movements, possibly as long as a week.
- Lack of appetite.
- Abdominal pain.
- Repeated urinary tract infections.
When to see a doctor
Call your doctor if your child, who is older than age 4 and already toilet trained, begins exhibiting one or more of the symptoms listed above.
There are several causes of encopresis. The most common are:
- Constipation. Most cases of encopresis are the result of chronic constipation. In constipation, the child's stool is hard, dry and may be painful to pass. As a result, the child avoids going to the toilet — making the problem worse. The longer the stool remains in the colon, the more difficult it is for the child to push stool out. The colon stretches, ultimately affecting the nerves that signal when it's time to go to the toilet. When the colon becomes too full, soft or liquid stool may leak out.
Common causes of constipation include eating too little fiber, not drinking enough fluids or consuming an excess of dairy products. Sometimes, a child with a cow's milk intolerance may experience constipation, although milk intolerance causes diarrhea more often than constipation.
- Emotional issues. Emotional stress also may trigger encopresis. A child may experience stress from premature toilet training or an important life change — for instance, the divorce of a parent or the birth of a sibling.
The following risk factors may increase your child's chances of having encopresis:
- Sex. Encopresis is more common in boys.
- Chronic constipation. This may cause your child to avoid passing stool.
- Not drinking enough fluids. This aggravates existing constipation.
A child who has encopresis may experience a range of emotions, including embarrassment, frustration, shame and anger. If your child is teased by friends or chastised by adults, he or she may feel depressed or have low self-esteem.
Early treatment, including spending time with a mental health professional, can help prevent the social and emotional impact of encopresis.
Preparing for your appointment
You'll probably first bring up your concerns with your child's doctor. He or she may refer you to a doctor who specializes in digestive disorders in children (pediatric gastroenterologist), or a mental health professional if your child seems to be very embarrassed, frustrated or angry because of encopresis.
Because appointments can be brief and there's often a lot of ground to cover, it's a good idea to be prepared for your child's appointment.
What you can do
- Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your child's diet.
- Write down a list of your child's symptoms — including how long they've been occurring.
- Write down key personal information, including any major stresses or recent life changes.
- Make a list of all medications, as well as any vitamins or supplements, that your child is taking.
- Write down questions to ask your child's doctor.
Preparing a list of questions can help you make sure that you cover all of the points that are important to you. Some basic questions to ask your child's doctor include:
- What's the most likely cause of my child's symptoms?
- Are there other possible causes for these symptoms?
- What kinds of tests does my child need? Do these tests require any special preparation?
- How long might this problem last?
- What treatments are available, and which do you recommend?
- What types of side effects can be expected with this treatment?
- Are there any alternatives to the primary approach that you're suggesting?
- Are there any dietary changes that might help ease my child's symptoms?
- What about exercise? Would additional physical activity help my child?
- Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?
What to expect from your doctor
Your child's doctor will have questions for you, too. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:
- How long has your child been toilet trained?
- Did your child experience any problems with toilet training?
- Does your child have hard, dry stools that sometimes clog the toilet?
- Does your child take any medications? If so, which ones?
- Does your child regularly resist the urge to use the toilet?
- Does your child experience painful bowel movements?
- How often do you notice stains or fecal matter in your child's underwear?
- Have there been any significant changes in your child's life? For instance, has he or she started a new school, moved to a new town, or experienced a death or divorce in the family?
- Is your child embarrassed or depressed by this condition?
- How have you been managing this issue?
- If your child has siblings, how was their toilet training experience?
What you can do in the meantime
Give your child high-fiber foods, such as fruits and vegetables, and encourage him or her to drink plenty of liquids.
Tests and diagnosis
Your child's doctor may:
- Ask about your child's symptoms.
- Conduct a physical examination, including a digital rectal examination to check for impacted stool. During this exam, the doctor inserts a lubricated, gloved finger into your child's rectum while pressing on his or her abdomen with the other hand.
- Recommend an abdominal X-ray to confirm the presence of impacted stool.
- Suggest that a psychological evaluation be conducted to help determine the cause of your child's symptoms.
Treatments and drugs
Generally, the earlier treatment begins for encopresis, the better. The first step in treatment focuses on clearing the colon of retained, impacted stool. After that, treatment includes encouraging healthy bowel movements. This includes training your child to go to the toilet as soon as reasonably able when the urge to defecate occurs.
There are several methods for clearing the colon and relieving constipation. Your child's doctor will likely recommend one or more of the following:
- Stool softeners, such as lactulose
- Colon lubricants, such as mineral oil
- Rectal suppositories
- More oral fluids
Your child's doctor may recommend abdominal X-rays to check the progress of the colon clearing.
Once the colon has been cleared, it's important to encourage your child to have regular bowel movements. In addition to recommending self-care measures such as a high-fiber diet, your child's doctor may recommend the use of stool softeners for six months or more.
If your child feels shame, guilt, depression or low self-esteem related to encopresis, psychotherapy can be helpful. A psychologist can help your child deal with these feelings and may also give you techniques for teaching your child not to hold stool. Ask your child's doctor for a recommendation.
Lifestyle and home remedies
Don't use enemas or laxatives — including herbal or homeopathic products — without talking to your child's doctor first.
Once your child has been treated for encopresis, it's important that you take steps to encourage softer stools and regular bowel movements. The following tips can help:
- Focus on fiber. Feed your child a diet that includes plenty of fruits, vegetables and foods high in fiber. Offer whole grains, which are brown — not white — in color.
- Encourage drinking water. Water helps keep stool from hardening. Encourage your child to drink plenty of water. A general guideline is to drink 2 ounces (59.1 milliliters) of nondairy fluid for every gram of fiber.
- Limit dairy products and fats. These can reduce bowel movements. But, dairy products also contain important nutrients, so ask your child's doctor how much dairy your child needs each day.
- Arrange toilet time. Have your child spend five minutes alone on the toilet after two to three meals each day trying to have a bowel movement. This applies only to children who are toilet trained and are at least 4 years old.
- Put a footstool near the toilet. Your child may be more comfortable, and changing the position of his or her legs can put more pressure on the abdomen, making a bowel movement easier.
- Stick with the program for several months. The relapse rate for encopresis is high.
As you help your child overcome encopresis, be patient and use positive reinforcement. Don't blame, criticize or punish your child if he or she has an accident. Instead, offer your unconditional love and support.
Educate yourself on effective toilet training techniques. Avoid starting too early or being too forceful in your methods. Wait until your child is ready, and then use positive reinforcement and encouragement to help him or her progress. Most children are not ready for toilet training until after their second birthdays.
Help your child avoid constipation by providing a diet high in fiber and encouraging your child to drink plenty of water.
- Ferry GD. Definition, clinical manifestations, and evaluation of functional fecal incontinence in children. http://www.uptodate.com/home/index.html. Accessed Sept. 29, 2010.
- Soiling (encopresis). American Academy of Pediatrics (HealthyChildren.org). http://www.healthychildren.org/English/health-issues/conditions/emotional-problems/pages/Soiling-Encopresis.aspx. Accessed Oct. 6, 2010.
- Har AF, et al. Encopresis. Pediatrics in Review. 2010;31:368.
- Ferry GD. Treatment of chronic functional constipation and fecal incontinence in infants and children. http://www.uptodate.com/home/index.html. Accessed Sept. 29, 2010.
- Montgomery DF, et al. Management of constipation and encopresis in children. Journal of Pediatric Health Care. 2008;22:199.
- Nijman RJ. Diagnosis and management of urinary incontinence and functional fecal incontinence (encopresis) in children. Gastroenterology Clinics of North America. 2008;37:731.
- Hoecker JL (expert opinion). Mayo Clinic, Rochester, Minn. Oct. 7, 2010.