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Encopresis

BASICS

DESCRIPTION

  • Defined by DSM-5 and Rome IV as repetitive and inappropriate passage of feces.
  • Diagnostic criteria:
  • Age ≥4 years (chronological and developmental).
  • Repeated stool passage in inappropriate places (floors, clothes).
  • Mostly involuntary but may be intentional.
  • ≥1 event per month for 3 months.
  • Not explained by other medical conditions or substance use.
  • Excludes constipation mechanisms.
  • Categories:
  • With constipation and overflow incontinence (functional constipation or retentive encopresis) — more common.
  • Without constipation (nonretentive fecal soiling/incontinence).
  • Constipation: delayed/infrequent hard stools with pain and straining.

EPIDEMIOLOGY

  • No clear sex difference in functional constipation incidence.
  • Constipation accounts for 3% of pediatric primary care visits; 25% pediatric GI referrals.
  • Functional constipation = 95% of pediatric constipation.
  • Median onset ~2.3 years (solid foods/toilet training/school start).
  • Prevalence: 1-3% in children ≥4 years.
  • 25% children with functional constipation may have adult GI issues.

ETIOLOGY AND PATHOPHYSIOLOGY

  • 90% encopresis due to chronic constipation with overflow incontinence (retentive).
  • 10% due to organic causes.
  • Painful defecation → stool withholding → harder stools → stool retention → overflow leakage.
  • Withholding behaviors: hiding, rocking, fidgeting.
  • Chronic constipation causes rectal distension, stretching sphincters → loss of urge sensation.
  • Soft/liquid stool leaks around retained mass.
  • Psychological: anxiety, fear, difficult toilet training, abuse, developmental delay.
  • Anatomic: anal fissure, muscle hypotonia, slow motility, Hirschsprung, spinal defects, malformations.
  • Dietary/metabolic: low fiber, excess protein/milk, low water, hypothyroidism, hypercalcemia, hypokalemia, diabetes, allergies.
  • Medications can contribute.
  • Genetics: no known gene but familial tendency reported.

RISK FACTORS

  • Food transitions (breastmilk → formula/solid foods).
  • Parental conflicts, divorce, new sibling.
  • Prior constipation, painful defecation, early daycare pressures.
  • Anxiety, depression, poor fluid/fiber intake.
  • Fear of public bathrooms, attention deficit, abuse history.
  • Medications (opiates, ADHD meds, antidepressants).

GENERAL PREVENTION

  • Family education: start toilet training when ready.
  • Optimize fluid and fiber intake.

COMMONLY ASSOCIATED CONDITIONS

  • Constipation, developmental/behavioral disorders, urinary incontinence, cow’s milk allergy, autism, ADHD, UTIs.

DIAGNOSIS

HISTORY

  • Stool pattern, consistency, frequency.
  • Abdominal pain relieved by stool.
  • Hiding while defecating, toilet avoidance.
  • Signs of constipation: hard/large stools, <3/week, pain, withholding, blood.
  • Diet history: low fiber/fluids, high dairy.
  • Urinary symptoms: recurrent UTIs, enuresis.
  • Stressors, family/social history, medication use.
  • Abrupt onset >5 years may suggest psychological trauma.

PHYSICAL EXAM

  • Neuro exam: lower limbs/perineal sensation, S1-S4, cremasteric reflex, anal tone, neural tube defects.
  • Genital/digital rectal exam: fissures, sphincter tone, distension, blood.
  • Abdominal: bowel sounds, distension, palpable stool, muscle strength.
  • Growth parameters: height, weight, head circumference.
  • Digital rectal exam not routinely indicated without specific signs.

DIFFERENTIAL DIAGNOSIS

  • IBS, celiac disease, hypothyroidism, Down syndrome, anal fissures, trauma, Hirschsprung disease, cerebral palsy, hypercalcemia, neuromuscular disease.

DIAGNOSTIC TESTS & INTERPRETATION

  • History and exam usually sufficient.
  • Labs/imaging to rule out organic causes:
  • UA/culture for UTI/glucosuria
  • Thyroid function
  • Electrolytes including calcium, potassium
  • Abdominal X-ray for impaction if physical exam inconclusive
  • Red flags (e.g., failure to pass meconium, bloody diarrhea) warrant urgent evaluation (e.g., for Hirschsprung, cystic fibrosis).

TREATMENT

GENERAL MEASURES

  • Four key elements: dietary and behavior modification, medications, disimpaction.
  • Toilet training advice: average ~29 months girls, 31 months boys.
  • Remove impaction before maintenance therapy.
  • Scheduled toilet sitting twice daily, post-meal, with positive reinforcement.
  • Sorbitol-containing juices (apple, pear, prune) to soften stools.
  • Recommended fluids: 1-3 yrs: 4 cups; 4-8 yrs: 5 cups; >8 yrs: 7-8 cups.
  • Fiber intake: child’s age + 5 g per day.
  • Address psychosocial issues in child and parents.
  • Recovery rate: 50%-60% after 1 year intensive treatment.

MEDICATION

  • Disimpaction:
  • PEG 1.0–1.5 g/kg/day for 3 days (oral); maintenance 0.4–0.8 g/kg/day.
  • Mineral oil (>1 yr): 15–30 mL/yr age (max 240 mL); maintenance 1–3 mL/kg/day.
  • Saline enema: 5–10 mL/kg once daily (up to 5 yrs).
  • Maintenance: Milk of Magnesia, magnesium citrate, lactulose, senna syrup, bisacodyl suppositories, sorbitol juices.
  • Continue maintenance 1–2 months after symptoms resolve or toilet trained.

ISSUES FOR REFERRAL

  • No improvement after 6 months → pediatric GI referral.
  • No improvement after 3 months → psychologist or combined therapy referral.

ADDITIONAL THERAPIES

  • Behavioral treatment, caregiver education.

SURGERY/OTHER PROCEDURES

  • Consider anorectal manometry for refractory cases (internal anal sphincter achalasia).
  • Internal sphincter myectomy can be curative.

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Behavioral + medication treatment better than medication alone.
  • Biofeedback not proven beneficial.
  • No evidence for probiotics or physical activity benefits.

ADMISSION/INPATIENT CARE

  • Admit if recurrent impaction, malnutrition, obstruction concerns, suspected abuse.
  • May require PEG via NG tube.
  • Monitor stool output, abdominal films to confirm impaction removal.
  • IV fluids if dehydrated.

ONGOING CARE

FOLLOW-UP

  • Monthly review initially; adjust regimen as needed.
  • Maintenance treatment 6 months to 2 years; visits every 4–10 weeks.
  • Treat impaction recurrences promptly.
  • Refer for mental health evaluation if no progress.

DIET

  • Adequate fluids and fiber.
  • Limit cow's milk, bananas, rice, apples, gelatin.

PATIENT EDUCATION

  • Explain defecation physiology.
  • Avoid punishment for soiling.
  • Encourage positive reinforcement.
  • Address overuse of diapers/pull-ups.
  • Use token economy if needed.
  • Encourage physical activity.

PROGNOSIS

  • Good response in many children; relapse possible due to parental noncompliance.
  • 30%-50% may have encopresis after 5 years.
  • Psychosocial/emotional comorbidities predict poorer outcomes.

COMPLICATIONS

  • Colitis from excess enemas/suppositories.
  • Perianal dermatitis.
  • Anal fissures.

ADDITIONAL READING

  • Baird DC, Bybel M, Kowalski AW. Toilet training: common questions and answers. Am Fam Physician. 2019;100(8):468-474.
  • NASPGHAN Constipation Guideline Committee. Evaluation and treatment of constipation in infants and children. J Pediatr Gastroenterol Nutr. 2006;43(3):e1-e13.
  • LeLeiko NS, Mayer-Brown S, Cerezo C, et al. Constipation. Pediatr Rev. 2020;41(8):379-392.
  • Lu PL, Mousa HM. Constipation: beyond the old paradigms. Gastroenterol Clin North Am. 2018;47(4):845-862.

CODES

  • ICD10 R15.9 Full incontinence of feces
  • ICD10 R15.1 Fecal smearing
  • ICD10 F98.1 Encopresis not due to substance or known physiological condition

CLINICAL PEARLS

  • 90% of encopresis due to chronic constipation.
  • Early address of toddler constipation by reducing excessive milk, increasing fiber/fluid intake.
  • Eliminate fecal impaction before maintenance therapy.