Stool Incontinence in Children
Stool incontinence (encopresis) is the accidental passing of bowel movements that is not caused by illness or physical abnormality.
Stool incontinence occurs in about 3 to 4% of 4-year-old children and becomes less common as age increases. It occurs most often in conjunction with toilet teaching or starting school.
Although it seems to be a contradiction, stool incontinence is usually caused by constipation. Constipation can have many causes (see Constipation in Children), particularly behavioral and dietary ones. But whatever the cause, as stool remains in the bowel, water is absorbed, which hardens the stool. Because it can be painful to pass a large, hard stool, children block the urge to move their bowels even more, resulting in a vicious circle of worsening constipation. Then, soft, wet stool from higher in the large bowel may leak around the hardened lump of stool, resulting in incontinence. If constipation continues, the wall of the rectum and large bowel stretches. The stretching reduces the child's awareness of a full bowel and impairs muscle control, further increasing the risk of stool leakage.
If the cause is constipation, a laxative is prescribed to completely clean out the bowel, which is a necessary starting point. Once the bowel is cleaned out, which is sometimes confirmed by abdominal x-rays, children begin a regular laxative regimen and a behavior plan to ensure regular bowel movements. After regular bowel movements are achieved, children begin a maintenance phase.
The behavior plan typically includes structured toilet-sitting times, in which children sit on the toilet for 5 to 10 minutes after each meal whether or not they feel the urge to move their bowels. If children have accidents during certain times of the day, they also should sit on the toilet immediately before those times. Small rewards are often useful. For example, giving children stickers to place on a chart each time they sit on the toilet (even if there is no stool production) can increase their desire to follow the plan. Often a stepwise program is used in which children receive small rewards (such as stickers) for sitting on the toilet and larger rewards for consistently following the plan. Rewards may need to be changed over time to maintain children’s interest in the plan.
Once regular bowel movements are achieved, the leakage often stops. Maintaining soft stools for several months can be necessary for the stretched bowel wall to return to normal and for awareness of the sensation of rectal fullness to return. In the maintenance phase, some laxatives and regular toilet-sitting times still are needed to encourage a bowel movement before the sensation to move the bowels is felt.
After this maintenance phase, the dose of laxatives is slowly decreased, then stopped, and the number of regular toilet-sitting times is reduced. This is often the time that relapse occurs, so health care practitioners continue to monitor children.
If these measures fail, diagnostic tests may be done, such as abdominal x-rays and rarely a biopsy of the rectal wall, in which a tissue sample is taken and examined under a microscope. If a physical cause for the constipation is found, it often can be treated. In the most severe cases, psychologic counseling may be needed for children whose stool incontinence is the cause or the result of emotional or behavioral problems.