Encopresis

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Chapter 15 ENCOPRESIS

Theodore X. O’Connell

General Discussion

Encopresis refers to the involuntary loss of formed, semiformed, or liquid stool into the child’s underwear after the child has reached the age of 4 years. Encopresis most commonly occurs in the presence of functional constipation, which is constipation not due to organic and anatomic causes or intake of medication. Encopresis also may occur when fecal retention is not a primary etiologic component. Various terms have been used to describe this problem, including functional encopresis, primary nonretentive encopresis, and stool toileting refusal. These children may be further divided into at least four subgroups: (1) those who fail to obtain initial bowel training, (2) those who exhibit toilet “phobia,” (3) those who use soiling to manipulate their environment, and (4) those who have irritable bowel syndrome (IBS). In these cases, constipation is not contributory but rather represents the child refusing the toilet-training process.

Encopresis affects 1% to 3% of children. Of encopresis cases, 80% to 95% involve fecal constipation and retention, with the remainder representing refusal of the toilet training process as described above. Stool retention results when stool expulsion has not occurred for several days. If stool retention persists, then formed, soft, or semiliquid stools leak to the outside around the accumulated firm stool mass. When stool retention remains untreated for a prolonged period, the rectum becomes stretched and a megarectum develops. The intervals between bowel movements then become increasingly longer, and the rectum becomes so large that the stored stool may be palpated as an abdominal mass that can reach the level of the umbilicus.

In general, the constipated school-age child is brought to medical attention because of encopresis, often of many years’ duration, or because of abdominal pain. Encopresis often occurs in the afternoon, when the child is in an upright position, especially during exercise.

A careful history and physical examination allow the physician to make a decision regarding requirements for blood tests, radiographic studies, anorectal manometric studies, or rectal biopsy. An important part of the evaluation is assessment of fecal retention. A positive rectal examination is sufficient to document fecal retention. A negative rectal examination or a child’s refusal to cooperate with rectal examination requires plain abdominal films to confirm the presence of fecal retention. The evaluation of constipation is described in detail in another chapter.

Suggested Work-Up

Most cases of encopresis are of the retentive type and are associated with chronic constipation. For the child who refuses the toilet-training process, an assessment of the child’s physical, cognitive, and emotional maturity is appropriate. If the child possesses readiness skills, then behavior management and toilet training strategies should be discussed with the parents.

1. Boris N.W., Dalton R.. Behrman R.E., Kliegman R.M., Jenson H.B., editors. Nelson Textbook of Pediatrics, 17th ed, Philadelphia: WB Saunders, 2004.

2. Kuhn B.R., Marcus B.A., Pitner S.L. Treatment guidelines for primary nonretentive encopresis and stool toileting refusal. Am Fam Physician. 1999;59:2171–2178.

3. Loening-Baucke V. Encopresis and soiling. Pediatr Clin North Am. 1996;43:279–298.

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