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Stool Incontinence in Children

(Encopresis)

by Teodoro Ernesto Figueroa, MD

Stool incontinence is the voluntary or involuntary passage of stool in inappropriate places in children > 4 yr (or developmental equivalent) who do not have an organic defect or illness with the exception of constipation.

Encopresis is a common childhood problem; it occurs in about 3 to 4% of 4-yr-old children and decreases in frequency with age.

Etiology

Encopresis is most commonly caused by constipation in children with behavioral and physical predisposing factors. It rarely occurs without retention or constipation, but when it does, other organic processes (eg, Hirschsprung disease, celiac disease) or psychologic problems should be considered.

Pathophysiology

Stool retention and constipation result in dilation of the rectum and sigmoid colon, which leads to changes in the reactivity of muscles and nerves of the bowel wall. These changes decrease the efficacy of bowel excretory function and lead to further retention. As stool remains in the bowel, water is absorbed, which hardens the stool, making passage more difficult and painful. Softer, looser stool may then leak around the hardened stool bolus, resulting in overflow. Both leakage and ineffective bowel control result in stool accidents.

Diagnosis

  • Clinical evaluation

Any organic process that results in constipation (see Constipation in Children) can result in encopresis and so should be considered. For most routine cases of encopresis, a thorough history and physical examination can help identify any physical cause. However, if further concerns arise, additional diagnostic tests (eg, abdominal x-rays, rarely rectal wall biopsy, and even more rarely bowel motility studies) can be considered.

Treatment

  • Education and demystification (for parents and child)

  • Relief of stool impaction

  • Maintenance (eg, behavioral and dietary interventions, laxative therapy)

  • Slow withdrawal of laxatives with continued behavioral and dietary intervention (see Treatment of Constipation)

Any underlying disorders are treated. If there is no specific underlying pathology, symptoms are addressed. Initial treatment involves educating the parents and child about the physiology of encopresis, removing blame from the child, and diffusing the emotional reactions of those involved. Next the goal is to relieve any stool impaction.

Stool impaction can be relieved by a variety of regimens and drugs (see Constipation in Children : Treatment); choice depends on the age of the child and other factors. A combination of polyethylene glycol (PEG) with electrolytes plus a stimulant laxative (eg, bisacodyl or senna), or a sequence of Na phosphate enemas plus a 2-wk regimen of oral drugs (eg, bisacodyl tablets) and suppositories are often used.

After evacuation, a follow-up visit should be held to assess whether the evacuation has been successful, make sure soiling has resolved, and establish a maintenance plan. This plan includes encouragement of maintenance of regular bowel movements (usually via ongoing laxative management) and behavioral interventions to encourage stool evacuation. There are many options for maintenance laxative therapy (see Table: Treatment of Constipation), but PEG without electrolytes is used most often, typically 1 to 2 doses of 17 g/day titrated to effect. At times a stimulant laxative may also be continued on the weekends to encourage extra evacuation of stool.

Behavioral strategies include structured toilet-sitting times (eg, having children sit on the toilet for 5 to 10 min after each meal to take advantage of the gastrocolic reflex). If children have accidents during certain times of the day, they also should sit on the toilet immediately prior to those times. Small rewards are often useful incentives. 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 adherence to a plan. Often a stepwise program is used in which children receive small tokens (eg, stickers) for sitting on the toilet and larger rewards for consistent adherence. Rewards may need to be changed over time to maintain children’s interest in the plan. In the maintenance phase, regular toilet sitting sessions still are needed to encourage evacuation of stool before the sensation is felt. This strategy decreases the likelihood of stool retention and allows the rectum to return to its normal size. During the maintenance phase, parent and child education about toilet sitting is instrumental to the success of the regimen.

Regular follow-up visits are necessary for ongoing guidance and support. Bowel retraining is a long process that may take months to years and includes slow withdrawal of laxatives once symptoms resolve and continued encouragement of toilet sitting. Relapses often occur during withdrawal of the maintenance regimen, so it is important to provide ongoing support and guidance during this phase.

Encopresis can recur in times of stress or transition, so family members must be prepared for this possibility. Success rates are affected by physical and psychosocial factors, but 1-yr cure rates are about 30 to 50% and 5-yr cure rates are about 48 to 75%. The mainstay of treatment is family education, bowel cleanout and maintenance, and ongoing support.

Drugs Mentioned In This Article

  • Drug Name
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  • DULCOLAX

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