Encopresis

ENCOPRESIS

Information for children and parents

Children with encopresis have bowel movements in the wrong places, such as underwear and nightclothes. This is called “soiling.” Sometimes the child will also pass stool in the toilet. Encopresis is very common, occurring in at least 1.5% of all children.

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SYMPTOMS

Encopresis usually follows constipation. The child may have stomachache, cramps, vomiting, or bloating. Some children become pale or flushed, lose their appetites, or even lose weight. Some have small tears in the anal tissue called anal fissures. These are painful and can lead to blood in the stool.

Children with this problem have different bowel habits. Some may not have any bowel movement for many days, and then have a huge, hard stool, large enough to block the toilet! Other children have daily bowel movements on the toilet but also leak liquid, diarrhea-like stool into their clothes. Some children do not stool in the toilet at all.

Children may hide their soiled underwear in drawers or under the bed. This can be very unpleasant for other family members. Another common upsetting behavior is refusal to change dirty clothing even though the odor is very annoying to other people. The child with encopresis may not notice the unpleasant smell. Many children with encopresis also wet the bed at night or wet their clothing during the daytime. This wetting is called enuresis. Children with encopresis and enuresis may be teased by playmates or brothers and sisters. Teasing can lead to embarrassment, school refusal, fighting, and other problems.

 
CAUSES

Usually encopresis is a result of constipation. Constipation often begins when a child holds back a bowel movement. Perhaps the child has had hard, painful stools. Some children naturally have dry, hard stools. A diet change, viral illness, hot weather, or travel can lead to hard stools. A bad diaper rash can cause painful passage of stool. Older children may start holding bowel movements when they go to school or summer camp and are faced with a toilet that is less private than the one they have at home. The initial cause may have occurred many years before the child is seen by a doctor for treatment of encopresis.

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Stool that is held back eventually fills up the colon and stretches it out of its normal shape. Stool retained in the colon dries out as the colon absorbs water from it. The longer the stool is held in the colon, the larger and harder it becomes, making bowel movements even more painful. This starts a vicious cycle. In the normal colon, muscles try to push stool out. Nerves tell the child that a stool needs to come out. However, the stretched-out, flabby colon muscles cannot push. Hard stool gets stuck and only liquid can pass around the rock like stool.

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The stretched colon becomes less sensitive and the child does not feel the leaking stool. The leakage looks like diarrhea or wet staining in clothing or underwear. Since the child always has some stool on his clothes, he gets used to the smell and it no longer bothers him.

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TREATMENT

 The treatment plan commonly has three parts:

 

  • First, the initial clean out clears retained stool out of the colon.

  • Second, maintenance therapy prevents stool build-up, allows the colon to return to its normal shape and muscle tone, and encourages regular bowel movements in the toilet.

  • Third, counseling may occasionally be helpful to children who are embarrassed or feel they are “bad” because of the encopresis. A counselor can help structure the treatment plan and help the child cooperate.

 The Initial Cleanout

The large, rock-like stool in the colon must be softened and broken down before it can be passed. Mineral oil taken by mouth is most frequently used for this purpose. Milk of magnesia or lactulose are also used. Mineral oil is not absorbed into the bloodstream. It stays in the colon and penetrates into the hard stool to soften it. Mineral oil also coats the stool and the walls of the colon to help the stool slide out easily. Lactulose also is not absorbed into the blood; a small amount of magnesia may be absorbed from milk of magnesia. These medicines work by keeping water in the stool so that it remains soft. It is not really possible to give too large a dose of one of these medicines to a normal child; the only effect would be looser stool.

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Enemas and suppositories provide only a partial solution to the problem of constipation since they only work on the bottom part of the colon, near the rectum, and cannot get at the stool that is farther up. However, enemas and suppositories are sometimes used to help the mineral oil work more quickly.

The initial dose of mineral oil or other stool softener is usually 1 to 3 ounces given by mouth 1-3 times per day. Occasionally larger doses are required. In order to decide when the clean out is complete, the parent must watch the stool. First there should be a large amount of stool or stool chunks. This may look like diarrhea because it is mixed with the stool softener. Mineral oil may make an orange oily liquid appear. This watery stool will not cause dehydration. After a while, softer stool will come out, and there will be mostly orange or clear liquid, signaling the end of a cleanout. If there is any doubt about the cleanout, continue giving the large doses until you are sure, or call your Doctor or nurse for advice. Recent studies show that mineral oil does not deplete vitamins or other nutrients from the body so it can be safely used for a long time. Milk of magnesia usually has no side effects; lactulose may cause cramps with large doses.

Cleanouts can be very messy since the child often cannot control the passage of the stool and medicine mixture. Younger children may have to wear diapers again during the cleanout. Older children may have to remain home from school so as to be able to reach the bathroom quickly.

There are many ways to accomplish the initial cleanout. Your doctor will discuss the best plan with you and your child.

Maintenance Therapy

 The goals of maintenance therapy are to prevent stool buildup, allow the colon to return to its proper shape and function, and encourage the child to have bowel movements in the toilet. This takes several steps:

  1.  Decrease the medicine dose as your doctor directs. Slight adjustments of the dose may be needed to prevent stool build up and to keep stools soft but not too runny. Continue each new dose for three to four days to see if the new dose is working.

  2.  The child should sit on the toilet, trying to have a bowel movement, for five minutes, fifteen to thirty minutes after a meal or snack. Try to do this at least twice a day. Listening to a radio may make this less boring but the child should concentrate on pushing with the belly muscles and relaxing the muscles of the anus. After meals, especially after breakfast, is the best time for this toileting practice, because eating makes most people feel the need to have a bowel movement. A large hot drink may increase this feeling. Place a box or stool under the feet of smaller children to raise their knees higher than their hips. Very small children may feel safer if they face backwards on the toilet, or use a potty chair.

  3.  Try to increase fiber intake by encouraging whole grains, fruits, vegetables, peanut butter, dried fruits, and salads.

  4.  Increase all fluids in the diet, especially juice. Start with at least two cups per day of all fluids,   including juice, water, and milk (four cups if over four years old).

  5. Increase physical activity if it seems below average for your child’s age. Exercise helps move stool down in the colon.

 It is important to encourage the older child to take responsibility for his or her own actions. The child should be responsible for taking the medicine without a fight, for sitting on the toilet, and for cleaning up stool accidents. Each family must decide what level of responsibility to expect of the child. Having a calendar to mark down medication doses and toilet sitting can help you keep track of progress.

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Counseling

Seeing a counselor may help reduce tensions children and families feel because of encopresis. The child’s condition often becomes a family problem. The child may have learned to control other people by having accidents. It is important to try to avoid anger or punishment around accidents, even though this may be difficult. Most often, the child is not being naughty; he or she simply cannot feel the stool coming out. It is the child’s responsibility, however, to take the medicine and do the sits without making a scene.

Success!

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Encopresis is curable! Children who follow the treatment plan will be able to control their bowel movements. It may take many months for the intestine to regain strength and feeling after being stretched out for a long time. Relapsing is one of the main problems in long-term management. Some children initially control their bowel movements but after several months or even years again start holding stool back. Restarting the initial cleanout, followed by maintenance therapy, will bring back control. Some children will continue to have constipation into adult life. Continuing a high fiber diet and using the stool softeners as necessary can successfully treat this.