Encopresis: is your child having a potty accident or is it something more?

From time to time, people experience physical changes or symptoms that they might be embarrassed to talk about. Therefore, they might avoid seeking medical attention and the problem goes untreated for longer than it should. One such problem is encopresis. Encopresis is defined as involuntary passage of feces as a result of constipation.

Encopresis is a very frequent symptom in a pediatric gastroenterology practice (like the one where I work). It is likely that in many cases the problem might be erroneously perceived as a behavioral problem and not all parents seek medical attention for their child. The prevalence of this disorder is therefore not well known.

Consider a child’s age and development

First in order to understand when fecal soiling should be considered a medical problem, we must first consider the “normal” toilet training age.

It is amazing how many skills children acquire before achieving toilet training. Most can speak complete sentences, respond to commands, climb, run and interact socially. Toilet training practices vary from culture to culture. In the United States, the average age that parents begin toilet training is around 2 years of age. Typically the process is complete within 6 months.

Toilet training readiness depends upon multiple factors including recognition of bodily sensation signaling the need to have a bowel movement, ability to communicate one’s needs, and understanding how to respond to one’s physical needs. If the child continues to have bowel movements in their diapers, pull-ups, or clothing for several months after starting the toilet training process, they do not necessarily have a medical problem.

Approximately 98% of children are toilet trained by 36 months of age. Failure to achieve toilet training in the early years the child's life should not be confused with encopresis secondary to severe constipation.

Constipation could be the cause

When children develop significant constipation, sometimes loose stool leaks out of the rectum unintentionally. This can be mistaken for uncontrollable diarrhea and if treated as such, the problem will worsen.

To understand how this can happen, let’s imagine a drawstring bag. The bag represents the rectum, which is the part of the colon where stool passes through before it is emptied. The strings represent the anal sphincter muscles, which keep the stool inside the rectum. There are two sets of anal sphincter muscles: the internal anal sphincter muscles, which are under involuntary control and automatically relax when stool enters the rectum and the external anal sphincter muscles, which are under voluntary control and can be tightened to prevent bowel movement passage at an inopportune moment.

When children become severely constipated, often from withholding their stool, the walls of the rectum stretch. What happens when we overfill a draw string bag? Even when we tighten the strings, if it is stuffed enough, the strings cannot close completely and small items fall out. The same principal applies to children with severe constipation.

The ability of the external anal sphincter muscles to contract and keep stool in the rectum is overcome by the stretch of the enlarged rectum and stool then leaks out.

So how can the problem be fixed?

The key to resolving the problem is to treat the constipation. This is a multifaceted process and involves medical treatment, behavior modification and attention to diet including high fiber and fluid. The medical treatment typically involves a “colon clean-out” to relieve the stool impaction and maintenance treatment on a daily basis.

It is very important not to respond to the child with punishment or embarrassment for the soiling. Children with encopresis often suffer from low self-esteem and bullying. Sometimes children hide or throw away their soiled undergarments because they are ashamed or afraid of getting in trouble.

Positive reinforcement for having bowel movements in the toilet are the foundations of the behavioral modification process. For example, parents can keep a calendar documenting the child’s bowel movement frequency and clean underpants days. A point system can be implemented assigning a predetermined point reward for success. Once a certain number of points have been obtained, a privilege or reward is given. One example could be: 1 point for bowel movement on toilet, 2 points for clean undergarments; when 15 points are reached, the child is allowed 30 minutes of video game time, a special privilege or a small toy.

Remember to be patient and stay positive. It might take weeks or even months to resolve the problem.