Gastrointestinal problems are often a taboo subject for most people. It can simply be uncomfortable to talk about the kinds of bodily functions associated with the digestive system since the waste produced by our bodies is unpleasant to see and smell. Navigating the emotions surrounding these functions is an important aspect of growing up, and young children don’t always understand that these natural functions are OK and not a reason for shame or reduced self-esteem. These emotional problems are unfortunately usually the biggest risk factors in the condition known as encopresis.
What is Encopresis?
Encopresis is a gastrointestinal disorder that involves toilet-trained children having involuntary bowel movements. Though this condition can also be called fecal incontinence, the term encopresis is generally used when diagnosing children whose symptoms include anal leakage. Encopresis is typically diagnosed in children who are at least four years of age and who still sometimes soil their clothes. For reasons that are still unknown to doctors, this condition is more common in boys than in girls.
Cases of encopresis can be divided into two types: primary and secondary. Primary encopresis is seen when a child has continually soiled undergarments for their entire lives without ever fully mastering toilet training. Secondary encopresis is diagnosed when the onset of the condition is after a child has already demonstrated a mastery of toilet training. There are also two subtypes that are defined by whether or not a child has constipation in addition to incontinence.
Signs and Symptoms of Encopresis
The primary symptom of encopresis is the actual fecal soiling of undergarments with involuntarily passed fecal material. Early on, this will usually be experienced as minor leaking of liquid stool. But as the ongoing effects of the condition stretch out the large intestine, larger stools can begin to be passed involuntarily. In many cases, the child may not even be aware that the leakage happened. Episodes of incontinence are more likely to happen at night than during the day when the child is active. The following are some other common signs to look for:
- loose, watery stools
- sudden strong urges to defecate with little or no warning
- hiding soiled underwear
- scratching the anal area
- withdrawing from social situations
- abdominal pain
Causes of Encopresis
The most common cause of encopresis is related to the child having a history of constipation. When the digestive system is functioning normally, waste materials enter the colon in a liquid form. As the waste moves through the colon, water is gradually absorbed until solid stool is formed. In cases of functional constipation, the stool remains in the colon too long and therefore too much water is absorbed. As a result, the stool is hard and dry and difficult to pass. Over time, if the stool still isn’t evacuated, looser stools pass around the hardened stool blockage and can involuntarily leak out of the anus.
There are many possible reasons why constipation might arise, but encopresis typically happens when a pattern of constipation starts to cause psychological distress for the child. Difficulty defecating can be painful for a child, and the desire to avoid that pain can eventually lead to a fear of defecating. In some children this fear manifests as avoiding defecation by “holding it in.” This kind of fecal retention, however, actually exacerbates the constipation problem and makes it more and more uncomfortable for the child.
This pattern of holding it in can start to be reflexive for the child, making constipation a regular occurrence. The cycle of withholding a bowel movement and resulting constipation can eventually lead to reduced function of the rectoanal inhibitory reflex (RAIR), the reflex involved with the voluntary and involuntary parts of defecation. What this means is that the child loses the ability to control defecation or to distinguish between gaseous and solid wastes in the rectum. It is at this point that both anal leakage and large involuntary bowel movements become possible.
As noted earlier, the emotional and psychological nature of this condition makes it somewhat unique. In fact, the American Psychiatric Association’s manual of disorders (DSM-5) recognizes encopresis as a condition based in psychiatry as well as gastroenterology. The formative years before the age of four are crucial to healthy digestive development; when parents emphasize negative messaging about defecation or feces, children can begin to associate feelings of shame with their normal bodily functions. This can become even worse when the child starts to use public bathrooms or learn the social cues associated with sharing bathrooms. Negative experiences at this juncture can be the starting point for a pattern of constipation that can eventually lead to encopresis.
Treatment of Encopresis
As noted, the main cause of encopresis is chronic constipation. So while there isn’t a specific cure for encopresis, there are numerous treatment options for constipation. Yet because of the psychological nature of the condition, psychotherapy or psychiatric care are additionally recommended to really address the underlying problem. For constipation, however, there are three elements involved in treatment:
- Clear the bowels: The first step in treating constipation is to clear out the bowels of any impaction. When hard stool remains in the bowels long enough, it becomes impacted and stuck in the colon. This can be accomplished through the use of laxatives or an enema. In more severe cases of impacted stool, a barium enema may be used in conjunction with an abdominal X-ray to determine the extent of the problem.
- Prevent more constipation: After an extended period of chronic constipation, help is often needed to get the child back into a healthy pattern of regular bowel movements. This is usually done with a six-month course of prescription stool softeners. This time frame gives the stretched colon and rectum time to return to normal size.
- Teach new habits: In addition to reinforcing the idea that bodily functions are normal and good, treatment may also include retraining some toilet habits. For instance, parents can institute “toilet sitting” times each day where the child sits on the toilet for 10-15 minutes after each meal (when they’re more likely to have a bowel movement).
When to Contact a Healthcare Provider
Toilet training is a process that can look very different for different children. According to the American Academy of Pediatrics, children are typically physiologically able to begin toilet training by 18 months, but the cognitive ability may trail by up to a couple years. So because there is such a wide range in normal toilet training readiness, doctors usually won’t even diagnose a child with encopresis until they’re four years old.
If your child is four or older and has had bowel control problems after already having been toilet trained, it’s possible that encopresis has developed. A child may also be prone to encopresis if they have a pattern of constipation. If you recognize any of the signs or symptoms, or if your child has had other changes to their bowel habits, you may want to consider seeing a gastroenterologist.
Digestive health is very important for one’s overall health and wellbeing. At Cary Gastro, our friendly and professional staff are dedicated to providing excellent digestive health care. If you would like more information about encopresis, or if your child has any other concerning symptoms, please contact us to request an appointment.