Encopresis (Fecal Incontinence)

What is Encopresis (Fecal Incontinence)?

Encopresis, also known as fecal incontinence, is when a child over the age of four unintentionally passes stool in inappropriate places like their underwear. This condition can cause significant emotional stress for the child and their family. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), a handbook used by healthcare professionals to diagnose mental conditions, defines encopresis as repeatedly passing stool in inappropriate places, either voluntarily or involuntarily, for at least a three-month period. This diagnosis is not applicable for children under four. Encopresis is also referred to as soiling or fecal overflow incontinence.

What Causes Encopresis (Fecal Incontinence)?

Encopresis is a condition where a child has difficulties controlling their bowel movements. This can be categorised into two types: one that’s connected to constipation and one that isn’t. In the case linked to constipation, which can also be called ‘overflow’ encopresis, the child struggles with stool leakage because of longstanding constipation. This kind is seen in more than 80% of the kids who have encopresis.

There are also other physical causes for encopresis not tied to constipation. These can include issues that affect the rectum or anus, conditions involving the spine (like spinal cord injuries or tumors), cerebral palsy, and muscular conditions that impact the muscles controlling bowel movements.

Furthermore, encopresis can be classified into two types based on a child’s toilet training history. ‘Primary’ encopresis refers to the condition in kids who’ve never been successfully toilet trained, while ‘secondary’ encopresis is when a child starts having bowel accidents again after they were successfully toilet trained.

Risk Factors and Frequency for Encopresis (Fecal Incontinence)

Encopresis, also known as fecal incontinence, is a condition that affects between 0.8% and 7.8% of people worldwide. In the United States, around 4% of children between the ages of 4 and 17 who visited a primary care clinic were found to have the condition. Of these, around 95% were linked to constipation. It’s more frequently seen in boys, with the ratio of boys to girls being anywhere from 3:1 to 6:1.

Encopresis is more likely in younger children. For children aged 5 to 6, the prevalence is 4.1%, while for those aged 11 to 12, it’s 1.6%.
Most children seek medical help around the ages of 7 to 8.
Encopresis can also affect young adults.
The condition mostly happens during the day. If a patient has symptoms only at night, this might be due to different, organic causes.

Signs and Symptoms of Encopresis (Fecal Incontinence)

Encopresis, a condition where a child continues to soil their underwear past the age of toilet training, can have varying symptoms. It’s important to keep in mind that there may also be underlying health issues contributing to the condition. Generally, diagnosing encopresis is based on symptoms, except when there are significant warning signs, then further testing may be needed.

Healthcare providers should complete a thorough examination and medical history check. They need to know if there’s been any rectal or anal surgery due to possible birth defects or malformations. Critical information includes details about the child’s bowel movements, like the size, frequency, and consistency of the stool, and if there are difficulties during defecation. Parents may sometimes mistake a version of encopresis characterized by watery stool for bedwetting. Other potential symptoms to watch out for include a lack of appetite, stomachaches, fever, nausea, weight gain struggles, and any psychological conditions. The child may also experience bedwetting or urinary infections, especially if they have chronic constipation and soiling issues. An account of the child’s diet and any previous attempts to treat the soiling or constipation should be collected, and there should be an assessment for any recent stressful life events like bullying, bereavement, or parental separation that could be triggering the condition.

Anal or rectal surgery history
Characteristics of stool (size, frequency, consistency)
Presence of defecation problems
Frequent episodes of encopresis (day or night)
Other symptoms (poor appetite, stomachache, fever, nausea, weight issues)
Bedwetting or urinary infections
Diet history
Previous treatment attempts for soiling or constipation
Recent stressful life events

In performing a physical examination, the healthcare provider can determine the severity of the condition by examining the abdomen for signs of fecal impaction and gas build-up. Evaluating the perianal area can reveal essential clues such as changes in skin color, irritation, anal malformation, or painful cracks near the opening of the anus. The assessment should also include checking the sensory changes in the perianal area, the position and size of the rectum, the anus’ structure, and its functionality. The assessment is completed with an examination of the lower back region, especially for signs of spinal cord defects such as spina bifida occulta, which may appear as a small, hair-lined dimple.

Testing for Encopresis (Fecal Incontinence)

Encopresis, a condition where a child has little or no control over their bowel movements after the age when they should have gained control, is generally diagnosed based on clinical observations. Mostly, these patients don’t require additional testing. The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition doesn’t recommend routine tests to check for conditions such as hypothyroidism, celiac disease, or high calcium levels unless there are other worrying symptoms present. These conditions are not usually connected to constipation, which accounts for most cases of encopresis in children.

If there is doubt whether the patient is constipated and a rectal examination isn’t possible due to factors like obesity, refusal by the patient, or psychological reasons that might make the examination too traumatic, an X-ray can be used to see if there is a mass of stool in the rectum. In some cases, keeping a record of bowel movements can be enough to diagnose constipation and encopresis.

In rare cases—just 3% in a recent study—children with issues related to bowel movements have been found to have abnormalities such as tethered spine or lipoma (a fat-rich tumor) within the spinal cord. In these rare situations, imaging of the spinal cord is advised only if the child displays additional symptoms of neurological issues or physical signs that might suggest an issue with the spinal cord.

Anorectal manometry, a test that measures the pressure of the anus and rectum and the related sensations, can be helpful for patients who have had chronic constipation. This technique is particularly useful to judge the state of the sphincter muscles, the group of muscles that help control bowel movements. These muscles might be impacted in cases of local injuries, spinal cord injuries, or conditions like Hirschsprung disease where a segment of the bowel lacks the nerves needed to function properly.

However, a barium enema, a type of X-ray of the large intestine, is not recommended for patients with mild constipation. It’s usually only used when there’s a need to evaluate the size of the small or large intestines, which can provide useful clinical evidence if Hirschsprung disease is suspected, or to check the condition of the anus after a surgical procedure.

Treatment Options for Encopresis (Fecal Incontinence)

Encopresis, a condition where a child has difficulty controlling their bowel movement, often stems from chronic constipation. Therefore, the key to treating encopresis is addressing this root cause. Guidelines published by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), suggest a four-phase treatment plan for chronic constipation: education, disimpaction, prevention of reaccumulation of feces, and follow-up.

Firstly, understanding the condition is crucial. Doctors need to convey that constipation can create a cycle where children tend to hold in stool, leading to a buildup and eventually encopresis. They should explain that these accidents happen due to rectal impaction and are not the child’s fault. It’s also important to note the treatment might take 6 to 24 months. Having a clear plan can help alleviate the stress that both parents and children might feel about treatment.

Secondly, the removal of the fecal impaction, or the process of disimpaction, must be undertaken before maintaining regular bowel movements. This can be achieved through oral or rectal medications. Doctors prefer oral laxatives as they are less invasive and cost-effective compared to methods like enemas or manual removal. A drug called polyethylene glycol (PEG) can be used for this purpose, which has been proven safe and effective.

The next phase targets preventing the problem from recurring. Doctors recommend a balanced diet, positive feedback from parents, and appropriate behavioral interventions. They may also refer a child to a psychologist if needed. A training method known as biofeedback can be used to help children regulate their bowel movements better. Regular daily use of oral laxatives, initiated after the disimpaction, can also aid in creating a consistent bowel movement schedule. They can be adjusted according to the individual’s requirement to maintain proper stool consistency and frequency.

Although traditional therapy usually works well in treating constipation-related encopresis in children, a small group continues to have persistent symptoms. For such cases, surgical interventions such as injections of botulinum toxin (Botox), antegrade enemas, and rectosigmoid resection may be considered.

Non-retentive encopresis, where children have difficulty controlling bowel movement without related constipation, is a form of encopresis whose treatment is less definitive. The treatment may include keeping a bowel diary, education, toilet training, and sometimes the use of antidiarrheal drugs to reduce the amount of stool. A reward system combined with toilet training may be used as part of the treatment plan. Currently, surgical treatments are not recommended for non-retentive encopresis.

When figuring out what’s causing encopresis, a condition where a child resists having bowel movements and leaks stool into their underwear, doctors consider several possibilities that are non-functional and physical in nature. These include:

Conditions that may still be present after repairing a malformation in the anus or rectum
Post-surgery effects of Hirschsprung disease, a condition blocking bowel movements
Spinal conditions like spinal dysraphism, spinal cord trauma, or spinal cord tumors
Cerebral palsy which affects muscle control and posture
Myopathies, or diseases that affect the muscles of the pelvic floor and the muscles that close off the anus

What to expect with Encopresis (Fecal Incontinence)

Treatment for retentive encopresis, a condition where children cannot control their bowel movement due to chronic constipation, more often than not, results in improvement, but the time it takes for treatment varies and it’s common to have relapses. Research has shown that after therapy, half of the kids with constipation do well without laxatives for 6 to 12 months. If constipation or loss of bowel control returns, treatment needs to start again. Factors like an early start of constipation and a family history of the condition can indicate that symptoms will continue for longer.

On the other hand, we don’t have a lot of information about the long-term outcomes for kids with non-retentive encopresis, where incontinence of feces is not due to constipation. One study found that after ten years of following up with kids with non-retentive encopresis, only 29% of them experienced less than one episode of fecal incontinence in the span of two weeks, even after two years of medication and behavioural therapy. By the time these kids turned 18, 15% of them still had difficulties controlling their bowel movements. This study did not find any factors to predict successful outcomes.

Frequently asked questions

Encopresis, also known as fecal incontinence, is when a child over the age of four unintentionally passes stool in inappropriate places like their underwear.

Encopresis affects between 0.8% and 7.8% of people worldwide.

Signs and symptoms of Encopresis (Fecal Incontinence) include: - Soiling of underwear past the age of toilet training - Rectal or anal surgery history - Characteristics of stool (size, frequency, consistency) - Presence of defecation problems - Frequent episodes of encopresis (day or night) - Other symptoms such as poor appetite, stomachache, fever, nausea, and weight issues - Bedwetting or urinary infections - Diet history - Previous treatment attempts for soiling or constipation - Recent stressful life events like bullying, bereavement, or parental separation

Encopresis (Fecal Incontinence) can be caused by difficulties controlling bowel movements, constipation, issues affecting the rectum or anus, conditions involving the spine, cerebral palsy, and muscular conditions that impact the muscles controlling bowel movements.

The doctor needs to rule out the following conditions when diagnosing Encopresis (Fecal Incontinence): 1. Conditions that may still be present after repairing a malformation in the anus or rectum. 2. Post-surgery effects of Hirschsprung disease, a condition blocking bowel movements. 3. Spinal conditions like spinal dysraphism, spinal cord trauma, or spinal cord tumors. 4. Cerebral palsy which affects muscle control and posture. 5. Myopathies, or diseases that affect the muscles of the pelvic floor and the muscles that close off the anus.

The types of tests that may be needed for Encopresis (Fecal Incontinence) include: 1. Clinical observations: Encopresis is generally diagnosed based on clinical observations, and additional testing is not usually required. 2. X-ray: If there is doubt about constipation and a rectal examination is not possible, an X-ray can be used to check for a mass of stool in the rectum. 3. Anorectal manometry: This test measures the pressure of the anus and rectum and can be helpful for patients with chronic constipation. It assesses the state of the sphincter muscles and can detect issues such as local injuries, spinal cord injuries, or conditions like Hirschsprung disease. 4. Imaging of the spinal cord: In rare cases, imaging of the spinal cord may be advised if the child displays additional symptoms of neurological issues or physical signs that suggest an issue with the spinal cord. 5. Barium enema: This type of X-ray of the large intestine is not recommended for patients with mild constipation. It is usually used to evaluate the size of the small or large intestines, which can provide clinical evidence if Hirschsprung disease is suspected or to check the condition of the anus after a surgical procedure.

Encopresis (Fecal Incontinence) is treated by addressing the root cause, which is chronic constipation. The treatment plan for chronic constipation, as suggested by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), involves four phases: education, disimpaction, prevention of reaccumulation of feces, and follow-up. The first phase focuses on understanding the condition and conveying that constipation can lead to encopresis. The second phase involves the removal of fecal impaction through oral laxatives. The third phase aims to prevent the problem from recurring through a balanced diet, positive feedback, behavioral interventions, and the use of oral laxatives. In cases where traditional therapy does not work, surgical interventions may be considered. For non-retentive encopresis, treatment may include keeping a bowel diary, education, toilet training, and sometimes the use of antidiarrheal drugs. Surgical treatments are not recommended for non-retentive encopresis.

The prognosis for encopresis (fecal incontinence) can vary depending on the type of encopresis and individual factors. For retentive encopresis (related to chronic constipation), treatment often leads to improvement, but relapses can occur. After therapy, about half of children with constipation do well without laxatives for 6 to 12 months. However, if constipation or loss of bowel control returns, treatment may need to be restarted. Factors like an early start of constipation and a family history of the condition can indicate that symptoms may continue for longer. For non-retentive encopresis (not related to constipation), the long-term outcomes are less clear. One study found that after ten years of follow-up, only 29% of children with non-retentive encopresis experienced less than one episode of fecal incontinence in a two-week period, even after two years of medication and behavioral therapy. By the time these children turned 18, 15% of them still had difficulties controlling their bowel movements. No factors were found to predict successful outcomes in this study.

A healthcare provider or a pediatrician.

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