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Stool Incontinence in Children

(Encopresis)

By

Teodoro Ernesto Figueroa

, MD, Nemours/A.I. duPont Nemours Hospital for Children

Last full review/revision Oct 2019| Content last modified Oct 2019
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Stool incontinence is the voluntary or involuntary passage of stool in inappropriate places in children > 4 years of age (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-year-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 (1, 2) 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.

Diagnosis references

  • 1. Koyle MA, Lorenzo AJ: Management of defecation disorders. In Campbell-Walsh Urology, ed. 11, edited by Wein A, Kavoussi L, Partin A, Peters C. Philadelphia, Elsevier, 2016, pp. 3317–3329.

  • 2. Benninga M: Evaluation of constipation and fecal incontinence. In Pediatric Incontinence, Evaluation and Clinical Management, edited by Franco I, Austin P, Bauer S, von Gontard A, Homsy I. Chichester, John Wiley & Sons Ltd., 2015, pp. 121–130.

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

Any underlying disorders are treated. If there is no specific underlying pathology, symptoms are addressed (1). 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 Table: Treatment of Constipation in Children); 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 sodium phosphate enemas plus a 2-week 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 in Children), 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.

Table
icon

Treatment of Constipation in Children

Type of Therapy

Agent

Dose

Selected Adverse Effects

Disimpaction

Oral

Oral high-dose mineral oil (should not be used in infants < 1 year or in neurologically impaired children to avoid aspiration)

15–20 mL/year of age (maximum 240 mL/day) for 3 days or until stool appears

Fecal incontinence, malabsorption of fat-soluble vitamins (if treatments are repeated)

Oral polyethylene glycol–electrolyte solution

25 mL/kg/hour (maximum 1000 mL/hour) by nasogastric tube until stool appears or 20 mL/kg/hour for 4 hours a day

Nausea, vomiting, cramping, bloating

Oral polyethylene glycol without electrolytes

1–1.5 g/kg dissolved in 10 mL/kg water once a day for 3 days

Fecal incontinence

Rectal

Glycerin suppositories

Infants and older children: 1/2–1 suppository once a day for 3 days or until stool appears

None

Rectal mineral oil enema

2–11 years: 2.25 oz once a day for 3 days or until stool appears

≥ 12 years: 4.5 oz once a day for 3 days or until stool appears

Fecal incontinence, mechanical trauma

Rectal phosphate sodium enema

2–4 years: 1.13 oz once a day for 3 days or until stool appears

5–11 years: 2.25 oz once a day for 3 days or until stool appears

≥ 12 years: 4.5 oz once a day for 3 days or until stool appears

Mechanical trauma, hyperphosphatemia

Maintenance agents

Oral osmotic and lubricant laxatives

Lactulose (70% solution)

1 mL/kg once a day or 2 times a day (maximum 60 mL/day)

Abdominal cramping, flatus

Magnesium hydroxide (400 mg/5 mL solution)

1–2 mL/kg once a day

If overdose, risk of hypermagnesemia, hypophosphatemia, or secondary hypocalcemia

Mineral oil

1–3 mL/kg once a day

Fecal incontinence

Polyethylene glycol 3350 powder dissolved in water

1–18 months: 1 tsp powder in 60 mL (2 oz) water once a day

> 18 months–3 years: 1/2 packet powder (8.5 g) in 120 mL (4 oz) water once a day

≥ 3 years: 1 packet (17 g) in 240 mL (8 oz) water once a day

Fecal incontinence

Oral stimulant laxatives (to be used for a limited period of time)

Bisacodyl (5-mg tablets)

2–11 years: 1–2 tablets once a day

≥ 12 years: 1–3 tablets once a day

Fecal incontinence, hypokalemia, abdominal cramps

Senna syrup: 8.8 mg sennosides/5 mL

Senna tablets: 8.6 mg sennosides/tablet

> 1 year: 1.25 mL once a day up to 2.25 mL 2 times a day

2–5 years: 2.5 mL once a day up to 3.75 mL 2 times a day

6–11 years: 5 mL once a day up to 7.5 mL 2 times a day

≥ 12 years: 1 tablet once a day up to 2 tablets 2 times a day

Abdominal cramping, melanosis coli

Maintenance diet supplements

Dietary fiber supplements

Methylcellulose*

< 6=""> 0.5–1 g once a day

6–11 years: 1 g 1–3 times a day

≥ 12 years: 2 g 1–3 times a day

Less bloating than other fiber supplements

Psyllium*

6–11 years: 1.25–15 g 1–3 times a day

≥ 12 years: 2.5–30 g 1–3 times a day

Bloating, flatus

Sorbitol-containing fruit juices (eg, prune, pear, apple)

Infants and older children: 30 to 120 mL (1–4 oz) a day

Flatus

Wheat dextrin*

2–20 years: 5 g plus 1 g for each year of age once a day

Bloating, flatus

* Numerous commercial products and preparations are available in differing concentrations, so doses are given in terms of grams of fiber.

Behavioral strategies include structured toilet-sitting times (eg, having children sit on the toilet for 5 to 10 minutes 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-year cure rates are about 30 to 50% and 5-year cure rates are about 48 to 75%. The mainstay of treatment is family education, bowel cleanout and maintenance, and ongoing support.

Treatment reference

  • 1. Loening-Baucke V, Swidsinski A: Treatment of functional constipation and fecal incontinence. In Pediatric Incontinence, Evaluation and Clinical Management, edited by Franco I, Austin P, Bauer S, von Gontard A, Homsy I. Chichester, John Wiley & Sons Ltd., 2015, pp. 163–170.

Key Points

  • Encopresis is most commonly caused by constipation in children with behavioral and physical predisposing factors.

  • For most routine cases of encopresis, a thorough history and physical examination can help identify any physical cause.

  • Any organic process that results in constipation can result in encopresis and so should be considered.

  • Treatment is through education, relief of stool impaction, maintenance of proper stooling, and slow withdrawal of laxatives with continued behavioral and dietary intervention.

  • Stool impaction can be relieved by a variety of regimens and drugs.

  • Behavioral strategies include structured toilet-sitting times.

  • Encopresis can recur in times of stress or transition, so family members must be prepared for this possibility.

Drugs Mentioned In This Article

Drug Name Select Trade
CHOLAC
DULCOLAX
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