Stool Incontinence in Children

Encopresis is most commonly caused by constipation Constipation in Children Constipation is responsible for up to 5% of pediatric office visits. It is defined as delay or difficulty in defecation. Normal frequency and consistency of stool varies with children's age... read more 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 Hirschsprung Disease Hirschsprung disease is a congenital anomaly of innervation of the lower intestine, usually limited to the colon, resulting in partial or total functional obstruction. Symptoms are obstipation... read more , celiac disease Celiac Disease Celiac disease is an immunologically mediated disease in genetically susceptible people caused by intolerance to gluten, resulting in mucosal inflammation and villous atrophy, which causes malabsorption... read more ) or psychologic problems should be considered.

Stool retention and constipation result in dilation of the rectum and sigmoid colon, which leads to changes in the reactivity of muscles and sensitivity of 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. Children typically are unable to control the overflow because of the impact on the rectum's sensitivity to stretch. In most cases, the overflow is involuntary and not volitional or intentional.

Both leakage and ineffective bowel control result in stool accidents.

Any organic process that results in constipation (1 Diagnosis references 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... read more , 2 Diagnosis references 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... read more ) 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.

A digital rectal examination in cooperative children can be useful to rule out other disorders and also to assess rectoanal sensation as a proxy for rectal and anal wall nerve sensitivity.

In prolonged or complicated cases, anorectal manometry Anorectal Manometry Manometry is measurement of pressure within various parts of the gastrointestinal tract. Manometry is done by passing a catheter containing solid-state or liquid-filled pressure transducers... read more can assist with making an accurate diagnosis.

(See also the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition's 2014 recommendations for the evaluation and treatment of functional constipation in infants and children.)

Any underlying disorders are treated. If there is no specific underlying pathology, symptoms are addressed (1 Treatment references 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... read more ). Initial treatment involves educating the caregivers 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 agents (see table ); choice depends on the age of the child and other factors. Polyethylene glycol (PEG) with electrolytes, sometimes plus a stimulant laxative (eg, bisacodyl or senna), or a sequence of sodium phosphate enemas plus a 2-week regimen of oral agents (eg, bisacodyl tablets) and suppositories are often used. Sodium phosphate enemas are contraindicated in children younger than 2 years of age.

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 osmotic/lubricant laxative management) and behavioral interventions to encourage stool evacuation. There are many options for maintenance laxative therapy (see table ), but PEG without electrolytes is used most often, typically 1 to 2 doses of 17 g/day titrated to effect (eg, one to two semisoft stools a day). 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 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.

A referral to a behavioral therapist or child psychologist experienced in treating children with encopresis may be needed when caregiver-initiated methods are unsuccessful. These specialists strongly recommend caregivers who are frustrated with incontinence and fecal soiling behaviors avoid punishing the child or showing disappointment with the child for lack of progress or for any subsequent regression after progress. Behavioral therapists and child psychologists also caution caregivers against overly positive praise; rather, they emphasize proportionate praise and neutral feedback depending on the child's level of achievement.

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, improving muscle reactivity and nerve sensation. During the maintenance phase, caregiver 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 up to 50%, and 5- and 10-year cure rates are about 50% and 80% (2 Treatment references 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... read more ).

The mainstay of treatment is family education, bowel cleanout and maintenance, and ongoing support.

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.