Encopresis
Alison Schonwald
Leonard A. Rappaport
Encopresis is defined as repeated passage of stool into inappropriate places in a child over 4 years of age chronologically and developmentally. The behavior is not due exclusively to the direct physiologic effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation. As defined by the Academy of Pediatric Gastroenterologists and Nutritionists, constipation is the delay or difficulty in defecation for 2 or more weeks. Reportedly, encopresis affects 2.8% of 4-year-olds, 1.9% of 6-year-olds, and 1.6% of 10- to 11-year-olds. It typically presents in children under 7 years old. More than 90% of encopresis is due to functional constipation, caused when retained stool distends the rectum and leads to the leakage of stool around a stool mass. Stretch receptors in a distended rectum do not seem to signal to the child to defecate until soiling has occurred. Encopresis is not usually caused by underlying psychopathology, but can be associated with emotional distress. No known genetic findings predict encopresis. Rare cases of encopresis are due to damaged corticospinal pathways or anorectal dysfunction after pull-through surgery. Occasionally, a child with encopresis may impulsively pass stool when anxious or suffering from emotional stressors, without underlying constipation.
ASSESSMENT
History begins at birth, with details surrounding bowel function and any treatments used. Past medical and surgical history may identify systemic diseases or medical causes of constipation that require treatments other than laxatives and maintenance of stool regularity. For example, Hirschsprung disease usually presents with difficulty in evacuation from birth, recurrent abdominal distension, and/or emesis. Failure to thrive and enterocolitis may occur in infancy. Encopresis is unusual and rectal examination includes a tight aganglionic bowel around the examining finger.
In taking a history, it is essential to distinguish encopresis from delayed toilet training, where the child never consolidated the ability to stool independently into the toilet. Treatment will depend on whether constipation underlies the stooling accidents, rather than toilet refusal alone; however, toilet refusal
is often associated with constipation as well. Developmental history highlights details of toilet training, when and which methods were used, and successes or failures. Most children are toilet trained by 3 years of age in the United States. Children who are not toilet trained until after 4 years of age are outliers in this developmental trajectory.
is often associated with constipation as well. Developmental history highlights details of toilet training, when and which methods were used, and successes or failures. Most children are toilet trained by 3 years of age in the United States. Children who are not toilet trained until after 4 years of age are outliers in this developmental trajectory.
History must include details of present bowel patterns, such as frequency of stool evacuation into the toilet, stool accidents, stool consistency, and the urge to defecate. Children with functional constipation and consequent encopresis report uncomfortable, often infrequent stooling into the toilet with uncontrolled stool accidents into underwear or pull-ups. More severe, prolonged constipation suggests the need for more aggressive treatment. Any history of abuse or other trauma should be sought as well. Children who have been abused may become incontinent in times of stress or as part of regressive behavior, and are less suitable candidates for rectal suppositories or enemas.
Urinary patterns, diurnal and nocturnal enuresis, and symptoms of urinary infection must be noted, and may reflect neurologic abnormalities or consequent urine contamination. Particularly in females, constipation and encopresis may be associated with urine infections due to poor hygiene. Even without infection, enuresis can be caused by a dilated rectum pushing on and irritating the bladder, causing spasm. History may reveal that increasing stool backup is temporally associated with urine accidents. Charting calendars may illuminate these details.
History taking allows for an essential opportunity to communicate with the child. The child must be a willing and active participant for treatment to be effective, and often children with encopresis are embarrassed when encopresis is discussed. Conveying an understanding of the child’s perspective can create a connection between the caregiver and patient, and should include questions about present school and family functioning.
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