Encopresis is a condition in which children fail to have normal and regular bowel movements and instead eliminate feces into inappropriate places (e.g., their bed). The exact definition of encopresis varies slightly among experts, but it can generally be defined as fecal incontinence in children who are at least 4 years old (or the developmental equivalent of that age) and past the normal age for toilet training. When adults are unable to control their bowels, it is known simply as fecal incontinence.

Encopresis that is present from birth is called primary encopresis. Secondary encopresis occurs when a child has an established period of fecal continence that is then interrupted by incontinence.

Most cases of encopresis result from chronic constipation that causes stool to become impacted in the child’s colon. Passing this type of stool in a bowel movement can be painful. To avoid such pain, the child may intentionally avoid going to the bathroom. This tends to exacerbate the situation. In a small number of cases, there is no evidence that constipation is causing a child’s encopresis. Experts suspect that lack of proper toilet training (e.g., the child is forced or rushed into toilet training) or behavioral problems are at the root of these cases of encopresis.

Children with encopresis may experience abdominal pain and a loss of appetite (anorexia). In addition, their attempts to resist having bowel movements may be evident when they cross their legs, walk on their tiptoes or dance to prevent having to go to the bathroom. As stool builds up in the colon, it may leak from the anus and stain the underwear. This leakage may be runny or have the consistency of clay and it often smells very bad.

An excess of impacted stool may also stretch the colon, hindering the nerves’ ability to signal the need for a bowel movement. This may result in bowel movements that occur suddenly or at inappropriate times.

A physician will likely perform a digital rectal examination to look for the presence of excess stool in the colon. An imaging technique such as an abdominal x-ray may be used to confirm the presence of impacted stool. The physician will also rule out other medical conditions (e.g., spina bifida) before diagnosing encopresis.

The first goal of treating children with encopresis is to clean out the colon to eliminate impacted stool. Several different techniques may be used to achieve this. Once the impacted stool has been cleansed from the body, the physician and parents will work together on techniques to help encourage the child to develop a pattern of regular bowel movements.

Encopresis is a condition in which children either voluntarily or involuntarily fail to have normal bowel movements, causing them to eliminate stool into inappropriate places, such as on clothing or the floor. The exact definition of encopresis varies – some experts define it as repeated passing of stool in inappropriate places whereas others define it as a pattern of soiling clothes as a result of constipation. Still others define it as a child’s resistance to having a bowel movement. In most cases encopresis is caused by constipation. When adults have problems with bowel movements, it is known simply as fecal incontinence.

Encopresis can be described as fecal incontinence in children who are at least 4 years old (or the developmental equivalent of that age) that occurs in various ways and for different reasons. For most children toilet training usually occurs between 2 and 4 years of age. Developmentally, control over bowel movements usually occurs before urination control.

Bowel movement frequency varies significantly from child to child. Some children have regular bowel movements every day whereas others have bowel movements every few days. If these bowel movements contain soft stool that passes easily, they are considered normal.

However, a problem is indicated when children have difficulty releasing their stool, pass stool that is hard and dry, or pass stool into inappropriate places. In most cases, the fecal soiling just stains the child’s underwear. If a child shows signs of encopresis, it is crucial to seek prompt medical care. The constipation often associated with encopresis can stretch out the colon, which may dull the capability of nerves to signal the brain that a bowel movement is needed. This may exacerbate the cycle of constipation or inappropriate bowel movements. 

Encopresis that is present from birth is known as primary encopresis. Secondary encopresis occurs when a child has an established period of fecal continence that is then interrupted by incontinence. Experts generally divide cases of encopresis into two categories:

• Encopresis with constipation and overflow incontinence. In this type, patients have evidence of constipation and a history of less than three bowel movements per week. It includes retentive encopresis, which occurs when the child withholds stool and makes up two-thirds of all cases of encopresis. Although constipation itself is involuntary, many children who are chronically constipated will intentionally withhold bowel movements. It is important to note that in most cases, a child avoids having bowel movements not out of spite or laziness, but because constipation causes feces to become impacted in the colon, making bowel movements painful. Eventually, the feces in children with retentive encopresis builds to a point where it can no longer be completely contained, and soft or liquid feces may begin to leak out and to stain the child’s undergarments. As constipation worsens, bowel movements may become more painful. This often leads the child to further resist future bowel movements, exacerbating the blockage.
  
  
• Encopresis without constipation and overflow incontinence. In this type, patients have no history of constipation and tend to have feces of normal consistency.  The child has a record of properly controlling bowel movements that is occasionally interrupted by episodes of encopresis. These tend to occur during periods of stress such as the birth of a new sibling or problems in the family unit. Children may defecate in their pants or on the floor. In some cases, they may smear their feces out of spite. This form of encopresis may be associated with mental health conditions such as oppositional defiant disorder (marked by a pattern of defiant behavior toward authority figures) and conduct disorder (marked by defiant, impulsive or antisocial behavior). In some cases, children may develop this form of encopresis simply because they have never learned to properly control bowel movements (often due to a lack of proper toilet training, such as rushed or coerced training) or because the child fears the toilet and tries to avoid it. 

The vast majority of cases of encopresis result from chronic constipation.  In many instances, this constipation cannot be traced back to a medical cause. The fecal incontinence experienced as part of encopresis is usually part of an involuntary physiological response to impacted stool in the rectum.

Improper toilet training methods can cause a child to become stressed about using the toilet, to resist using the toilet or to refrain from expressing the need to use the toilet. Developmentally children are typically ready to begin toilet training between the ages of 2 and 4. However, readiness can vary among children. Toilet training is most likely to be successful when the child is ready and can verbalize the need to use the toilet to caregivers. Rushed or coerced toilet training may stress a child and result in constipation and encopresis.

In other cases, behavioral problems may be the source of a child’s encopresis. Some experts believe that encopresis may result from a child’s efforts to gain attention, or that it is associated with a mental health disorder such as oppositional defiant disorder or conduct disorder.

Symptoms associated with encopresis include behavior which may indicate to parents that a problem is evident. For example, parents of children with retentive encopresis (in which the child withholds stool) may notice that their child has infrequent bowel movements, or in some cases resists having bowel movements (often evident when children cross their legs, walk on their tiptoes or dance to prevent having to go to the bathroom).

When a child resists having bowel movements, the stool that builds up in the colon and rectum may cause abdominal pain and loss of appetite (anorexia). In addition, this stool may leak from the anus and stain the underwear, a condition known as overflow incontinence. This leakage may be runny or have the consistency of clay and is frequently mistaken for diarrhea. It often smells very bad.

When children finally do have a bowel movement, it frequently may be large enough to plug the toilet. Large, dry and hard feces may cause tears in the anus that leave blood in the feces or on toilet paper. In some cases, large masses of stool may create pressure on the bladder that causes the child to wet the bed or results in urinary tract infections.

An excess of impacted stool may also stretch the colon, damaging the nerves and hindering the ability to signal the need for a bowel movement. This may result in bowel movements that occur suddenly or at inappropriate times.

Children who have encopresis are often upset by their condition and may experience feelings of guilt and shame that can adversely affect their self-esteem. School performance sometimes suffers as children with encopresis may be ridiculed by classmates who notice offensive odors emanating from the child.

Parents are usually urged to contact a physician if their child regularly has liquid stool that stains the underwear, hard stool or pain during bowel movements, bowel movements that regularly clog the toilet, abdominal pain or loss of appetite (anorexia).

The physician will perform a complete physical examination and compile a thorough medical history. A digital rectal examination will usually reveal the presence of retained stool. An imaging technique such as an abdominal x-ray may be used to confirm the presence of impacted stool.

The physician will also rule out other conditions before diagnosing encopresis. For example, a history of large bowel movements and the presence of stool in the rectal vault help to rule out Hirschsprung’s disease, which is an obstruction of the large intestine caused by inadequate muscular movement of the bowel. This condition is present at birth, is usually diagnosed when the child is a newborn and requires surgical correction.

Other conditions that may cause irregular bowel movements and that must be ruled out before diagnosing encopresis include:

• Neurologic disorders. Conditions that affect the body’s nervous system.
  
  
• Hypothyroidism. Insufficient production of the thyroid hormone in the body.
  
  
• Hypercalcemia. Abnormally high levels of calcium in the body.
  
  
• Smooth muscle diseases. Conditions that affect the involuntary muscles of the body, such as the muscles that transport stool through the colon and out of the body. 

In most cases, treatment for encopresis can be completed by a primary care physician. However, more complicated cases may require the care of a gastroenterologist.

The first goal of treating children with encopresis is to clean out the colon to eliminate impacted stool is eliminated. Several different techniques can be used to achieve this. Laxatives in the form of colon lubricants such as mineral oil can soften stool, and colon stimulants such as lactulose can aid in stool elimination. Rectal suppositories or enemas may also be used for this purpose. While these treatments are being performed, the physician may check the progress with abdominal x-rays, which can reveal how much of the impacted stool remains in the colon.

Once the impacted stool has been cleansed from the body, the physician will focus on efforts to help the child have regular bowel movements. Children will be instructed to take a stool-softening agent for a period of time to keep feces from hardening and further stretching the colon. Eventually, the colon will shrink back to its normal size and its nerves will begin to work properly again, which will further facilitate bowel movements. This process can take several months to a year to complete.

Encopresis usually resolves in children, and adhering to regular times and places for bowel movements can help increase the odds of regular bowel movements.  

Several steps can be taken to encourage children to have regular bowel movements. Parents are urged to feed their children foods that are high in fiber, especially fruits and vegetables. A dietitian can suggest other tips to increase the amount of fiber in foods in ways that will appeal to children, such as baking cookies with whole-wheat flour and adding raisins or apples to the mix. Exercise helps to promote normal intestinal function, and encouraging children to exercise can help prevent constipation.

Drinking plenty of water and juices – particularly 100 percent fruit juices such as pear, peach or prune juice – can help draw liquid into the colon that will keep stool soft. Cutting back on dairy products and fat and scheduling regular meal times and bed times can all help to keep a child regular. Any changes to a child’s diet should be discussed with a physician to ensure that all dietary requirements are met.

Proper toilet training techniques can help prevent a child from becoming stressed during this process, and withholding bowel movements as a result. Children are typically ready to begin the process of toilet training between the ages of 2 and 4. Patience and resisting coercing a child into early toilet training can help prevent a child from becoming reluctant to use a toilet for bowel movements. However, the time it may take to toilet train a child varies. Temporary relapses of incontinence are common among children during toilet training.

Parents may also want to urge their child to spend at least three minutes in the bathroom after each daily meal in hopes of encouraging bowel movements. However, parents should not overemphasize the importance of having a bowel movement, as some children may view holding in their stool as a way to get attention.

Parents may be asked to keep a diary of their child’s bowel movements in which the frequency, consistency and size of the bowel movements are tracked.

Children who develop encopresis because they are resistant to toilet training, because they are afraid of the toilet, or because of other emotional reasons may benefit from psychotherapy. This form of treatment can help them overcome self-esteem issues that often result from having the condition. Children who develop encopresis out of a fear of the toilet may go through desensitization therapy that gradually helps them to be less afraid of the toilet.

Although encopresis can be frustrating for both the child and the parent, it is important to remain supportive of the child. Occasional setbacks are normal when trying to modify a child’s bowel habits and children should not be punished when they backslide. Encouragement and reward are essential in helping children to stick with their efforts.

Preparing questions in advance can help parents and patients to have more meaningful discussions with their physicians regarding their conditions. Parents may wish to ask their child’s doctor the following encopresis-related questions:

1. What symptoms might indicate that my child has encopresis?
   
   
2. What factors might be causing my child’s encopresis?
   
   
3. How will you diagnose my child’s condition?
   
   
4. What are my child’s treatment options?
   
   
5. How long will it take for my child’s condition to improve?
   
   
6. How can I track my child’s progress following treatment?
   
   
7. How can I encourage my child to have regular bowel movements?
   
   
8. Which foods help encourage regular bowel movements?
   
   
9. How can I help soften my child’s stool?
   
   
10. What should I do if my child experiences encopresis following treatment?