Encopresis is repeatedly having bowel movements in places other than the toilet after the age when bowel control can normally be expected.
Most children have established bowel control by the time they are four years old. After that age, when they repeatedly have bowel movements in inappropriate places, they may have encopresis. In the United States, encopresis affects 1-2% of children under age 10. About 80% of these are boys.
Encopresis can be either involuntary or voluntary. Involuntary encopresis is related to constipation, passing hard painful feces, and difficult bowel movements. Often children with involuntary encopresis stain their underpants with liquid feces. They are usually unaware that this has happened. Voluntary encopresis is much less common and is associated with behavioral or psychological problems. Both types of encopresis occur most often when the child is awake, rather than at night.
Causes and symptoms
Although a few children experience encopresis because of malformations of the lower bowel and anus or irritable bowel disease, most have no physical problems to explain this disorder. Constipation is present in about 80% of children who experience involuntary encopresis. As feces moves through the large intestine, water is removed. The longer the feces stays in the large intestine, the more water is removed, and the harder the feces becomes. The result can be hard or painful bowel movements. In response, children may start to hold back when they feel the urge to eliminate in order to avoid pain. This starts a cycle of constipation that results in retentive encopresis.
Once elimination is avoided, the bowel becomes full of hard feces. This stretches the large intestine. Eventually the intestine becomes so stretched that liquid feces backed up behind the blockage is able to leak around the hard feces. Children with this type of encopresis do not feel the urge to have a bowel movement and are often surprised when their pants are stained with foul smelling liquid feces. This leakage of feces is called overflow incontinence. Parents sometimes mistake this soiling for diarrhea, because the feces expelled is liquid. Every so often, children with involuntary encopresis may pass large stools, sometimes with volumes big enough to clog the toilet, but the relief this brings is temporary.
Although about 95% of encopresis is involuntary, some children intentionally withhold bowel movements. The American Psychiatric Association (APA) recognizes voluntary encopresis without constipation as a psychological disorder. This disorder is said to occur when a child who has control over his bowel movements chooses to have them in an inappropriate place. The feces is a normal consistency, not hard. Sometimes it is smeared in an obvious place, but it may also be hidden from adults.
Voluntary encopresis may result from a power struggle between caregivers and the child during toilet training, or the child may have developed an unusual fear of the toilet. It is also associated with oppositional defiant disorder (ODD), conduct disorder, sexual abuse, and high levels of psychological stress. For example, children who were separated from their parents during World War II were reported to have a high rate of encopresis. However, parents and caregivers should be aware that very few children soil intentionally and most do not have a behavioral or psychological problem and should not be punished for their soiling accidents.
Diagnosis is based primarily on the child's history of inappropriate bowel movements. Physical examinations are almost always normal, except for a mass of hard feces blocking the lower intestine. Other physical causes of soiling, such as illness, reaction to medication, food allergies, and physical disabilities, may also be ruled out through history and a physical examination. In addition, to be diagnosed with encopresis the child must be old enough to establish regular bowel control—usually chronologically and developmentally at least four years of age.
The goal of treatment is to establish regular, soft, pain free bowel movements in the toilet. First the physician tries to determine the cause of encopresis, whether physical or psychological. Regardless of the cause, the bowel must be emptied of hard, impacted feces This can be done using an enema, laxatives, and/or stool softeners such as mineral oil. Enemas and laxatives should be used only at a doctor's recommendation.
Next, the child is given stool softeners to keep feces soft and to give the stretched intestine time to shrink back to its normal size. This shrinking process may take several months, during which time stool softeners may need to be used regularly. Children also need two or three regularly scheduled toilet sits daily in an effort to establish consistent bowel habits. These toilet sits are often more effective if done after meals. Maintaining soft, easy-to-pass stools is also important if the child is afraid of the toilet because of past painful bowel movements. A child psychologist or psychiatrist can suggest treatment for the rare child with serious behavioral problems such as smearing or hiding feces.
Many herbal stool softeners and laxatives are available as both tablets and liquids. Psyllium, the seed of several plants of the genus Plantago is one of the most effective. Other natural remedies for constipation include castor seed oil (Ricinus communis ), senna (Cassia senna or Senna alexandrina ), and dong quai Angelica polymorpha or Angelica sinensis ).
For almost all children, once constipation is controlled, the problem of soiling disappears. This make take several months, and relapses may occur, but with effective prevention strategies, encopresis can be eliminated. Children who are in a power struggle over toileting usually outgrow their desire to have bowel movements in inappropriate places. The prognosis for children with serious behavioral and psychological problems that result in smearing or hiding feces depends largely on resolving the underlying problems.
Feces— Waste products eliminated from the large intestine; excrement.
Incontinence— The inability to control the release of urine or feces.
Laxative— Material that encourages a bowel movement.
Stools— feces, bowel movements.
The best way to prevent encopresis is to prevent constipation. Methods of preventing constipation include:
- increasing the amount of liquids, especially water, the child drinks
- adding high fiber foods to the diet (e.g. dried beans, fresh fruits and vegetables, whole wheat bread and pasta, popcorn)
- establishing regular bowel habits
- limiting the child's intake of dairy products (e.g. milk, cheese, yogurt, ice cream) that promote constipation.
- treating constipation promptly with stool softeners, so that it does not become worse.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. text revision. Washington D.C.: American Psychiatric Association, 2000.
Kuhn, Brett R., Bethany A. Marcus, and Sheryl L. Pitner. "Treatment Guidelines for Primary Nonretentive Encopresis and Stool Toileting Refusal." American Family Physician, 59, no. 8 (15 April 1999) 2171-2183. [cited 16 February 2005]. 〈http://www.aafp.org/afp/2001101/1565.html〉.
American Academy of Child and Adolescent Psychiatry, P. O. Box 96106, Washington, D.C. 20090. 800-333-7636. 〈www.aacap.org〉.
Borowitz, Stephen. Encopresis, 14 June 2004 [cited 20 February 2005]. 〈http://www.emedicine.com/ped/topics670.html〉.
"Encopresis." Gale Encyclopedia of Medicine, 3rd ed.. . Encyclopedia.com. (December 12, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/encopresis
"Encopresis." Gale Encyclopedia of Medicine, 3rd ed.. . Retrieved December 12, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/encopresis
Encopresis is defined as repeated involuntary defecation somewhere other than a toilet by a child age four or older that continues for at least one month.
Soiling, fecal soiling, and fecal incontinence are alternate terms used for this behavior. Whatever the cause, parents should talk openly about the problem with the child. When parents treat a bowel problem as a cause for embarrassment or shame, they may unintentionally aggravate or prolong it.
About 1 to 3 percent of children are affected by encopresis. More boys than girls are affected.
Causes and symptoms
Encopresis can be one of two types, nonretentive encopresis and retentive encopresis. About 80 to 95 percent of all cases are retentive encopresis. Children with this disorder have an underlying medical reason for soiling. The remaining cases have no physical condition that bars normal toileting behaviors. This type, nonretentive encopresis, is a behavioral condition in which the child refuses to defecate in a toilet.
Retentive encopresis is most often the result of chronic constipation and fecal impaction. In these children, feces have become impacted in the child's colon, causing it to distend. This causes the child to not feel the urge to defecate. The anal sphincter muscle becomes weak and unable to contain the soft stools that pass around the impaction. Despite the constipation, these children actually do have regular, though soft, bowel movements that they are unable to control. The child may not even be aware that he or she has defecated until the fecal matter has already passed. Many children have a history of constipation that extends back as far as five years before the problem is brought to medical attention.
A child may exhibit nonretentive encopresis, or functional encopresis, for several reasons. First, he or she may not be ready for toilet training . When a child is learning appropriate toilet habits during toddlerhood and preschool years, involuntary or inappropriate bowel movements are common. Second, the child may be afraid of the toilet or of defecating in public places like school. Others may use fecal incontinence to manipulate their parent or other adults. These children often have other serious behavioral problems.
When to call the doctor
A doctor should be called whenever children experience unresolved constipation or difficulty controlling their stools.
Before beginning treatment for encopresis, the pediatrician first looks for any physical cause for the inappropriate bowel movements. The doctor asks parents about the child's earlier toilet training and typical toileting behaviors and inquires about a history of constipation. The doctor will digitally examine the child's anal area to check the strength of the anal sphincter muscle and look for a fecal impaction. An abdominal x ray may be needed to confirm the size and position of the impaction.
If the pediatrician makes a diagnosis of retentive encopresis, the physician may recommend laxatives , stool softeners, or an enema to free the impaction. Subsequently, the doctor may make several suggestions for to avoid chronic constipation. Children should eat a high-fiber diet, with lots of fruits, vegetables, and whole grains. They should be encouraged to drink larger amounts of water and get regular exercise . Children should be taught to not feel ashamed of toileting behaviors, and psychotherapy may help decrease the sense of shame and guilt that many children feel.
If no fecal impaction is found, the pediatrician works with a counselor or psychiatrist to analyze the variables that characterize the encopresis. If the child is not physically or cognitively ready for toilet training, it should be postponed.
In the remainder of nonretentive encopresis cases, treatment should then center on making sure the child has comfortable bowel movements, since some cases of nonretentive encopresis involve some level of discomfort associated with constipation.
The prognosis for most children with encopresis is good, assuming that all underlying problems are identified and appropriately treated.
There is no known way to prevent encopresis. Experienced counselors suggest that early identification of problems and accurate diagnosis are useful in limiting the severity and duration of encopresis.
A high-fiber diet may be recommended for persons with encopresis. Affected persons should consume lots of fruits, vegetables, and whole grains. Adequate to copious intake of fluids are also recommended.
Parents of a child with a serious behavior disorder like oppositional defiant disorder should work with their child's therapist to deal with encopresis in the context of other behavioral problems. Parents should work with their children to establish appropriate stooling behaviors and institute a system of rewards for successful toileting.
Constipation —Difficult bowel movements caused by the infrequent production of hard stools.
Impaction —A condition in which earwax has become tightly packed in the outer ear to the point that the external ear canal is blocked.
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American Academy of Pediatrics. 141 Northwest Point Blvd., Elk Grove Village, IL 60007–1098. Web site: <www.aap.org>.
American College of Gastroenterology. 4900 B South 31st St., Arlington VA 22206. Web site: <www.acg.gi.org/>.
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"Encopresis." Gale Encyclopedia of Children's Health: Infancy through Adolescence. . Encyclopedia.com. (December 12, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/encopresis-0
"Encopresis." Gale Encyclopedia of Children's Health: Infancy through Adolescence. . Retrieved December 12, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/encopresis-0
Encopresis is an elimination disorder that involves repeatedly having bowel movements in inappropriate places after the age when bowel control is normally expected. Encopresis is also called "soiling" or "fecal incontinence."
By four years of age, most children are toilet trained for bowel movements. After that age, when inappropriate bowel movements occur regularly over a period of several months, a child may be diagnosed with encopresis. Encopresis can be intentional on unintentional. Intentional soiling is associated with several psychiatric disorders. Involuntary or unintentional soiling is often the result of constipation.
Causes and symptoms
The only symptom of encopresis is that a person has bowel movements in inappropriate places, such as in clothing or on the floor. This soiling is not caused by taking laxatives or other medications, and is not due to a disability or physical defect in the bowel. There are two main types of encopresis, and they have different causes.
With involuntary encopresis, a person has no control over elimination of feces from the bowel. The feces is semi-soft to almost liquid, and it leaks into clothing without the person making any effort to expel it. Leakage usually occurs during the day when the person is active, and ranges from infrequent or almost continuous.
Involuntary soiling usually results from constipation. A hard mass of feces develops in the large intestine and is not completely expelled during a regular bowel movement in the toilet. This mass then stretches the large intestine out of shape, allowing liquid feces behind it to leak out. Up to 95% of encopresis is involuntary.
Although involuntary encopresis, called by the American Psychiatric Association (APA) encopresis with constipation and overflow incontinence, is caused by constipation, the constipation may be the result of psychological factors. Experiencing a stressful life event, harsh toilet training, toilet fear, or emotionally disturbing events can cause a child to withhold bowel movements or become constipated. Historically, children separated from their parents during World War II are reported to have shown a high incidence of encopresis, indicating that psychological factors play a role in this disorder.
A person with voluntary encopresis has control over when and where bowel movements occur and chooses to have them in inappropriate places. Constipation is not a factor, and the feces is usually a normal consistency. Often feces is smeared in an obvious place, although sometimes it is hidden around the house. The APA classifies voluntary encopresis as encopresis without constipation and overflow incontinence.
In young children, voluntary encopresis may represent a power struggle between the child and the caregiver doing the toilet training. In older children, voluntary encopresis is often associated with oppositional defiant disorder (ODD), conduct disorder , sexual abuse , or high levels of psychological stressors.
Encopresis occurs in 1–3% of children and is seen more often in boys than in girls. The frequency of encopresis appears to be independent of social class, and there is no evidence that it runs in families.
To receive an APAdiagnosis of encopresis, a child must have a bowel movement, either intentional or accidental, in an inappropriate place at least once a month for a minimum of three months. In addition, the child must be chronologically or developmentally at least four years old, and the soiling cannot be caused by illness, medical conditions (such as chronic diarrhea, spina bifida, anal stenosis, etc.), medications, or disabilities. However, it may be caused by constipation.
Involuntary encopresis is treated by addressing the cause of the constipation and establishing soft, pain-free stools. This can include:
- increasing the amount of liquids a child drinks
- adding high-fiber foods to the diet
- short-term use of laxatives or stool softeners
- emptying the large intestine by using an enema
- establishing regular bowel habits
Once the constipation is resolved, involuntary encopresis normally stops.
Treatment of voluntary encopresis depends on the cause. When voluntary encopresis results from a power struggle between child and adult, it is treated with behavior modification . In addition to taking the steps listed above to ensure a soft, pain-free stool, the adult should make toileting a pleasant, pressure-free activity. Some experts suggest transferring the initiative for toileting to the child instead of constantly asking him/her to use the toilet. Others recommend toileting at scheduled times, but without pressure to perform. In either case, success should be praised and failure treated in a matter-of-fact manner. If opposition to using the toilet continues, the family may be referred to a child psychiatrist or a pediatric psychologist .
With older children who smear or hide feces, voluntary encopresis is usually a symptom of another more serious disorder. When children are successfully treated for the underlying disorder with psychiatric interventions, behavior modification, and education, the encopresis is often resolved.
Since 80–95% of encopresis is related to constipation, the success rate in resolving involuntary encopresis is high, although it may take time to establish good bowel habits and eliminate a reoccurrence of constipation. The success rate is also good for younger children in a power struggle with adults over toileting, although the results may be slow. The prognosis for older children with associated behavioral disorders is less promising and depends more on the success of resolving those problems than on direct treatment of the symptoms of encopresis.
Power struggles during toilet training that lead to encopresis can be reduced by waiting until the child is developmentally ready and interested in using the toilet. Toilet training undertaken kindly, calmly, and with realistic expectations is most likely to lead to success. Successes should be rewarded and failures accepted. Once toilet training has been established, encopresis can be reduced by developing regular bowel habits and encouraging a healthy, high-fiber diet.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. text revised. Washington DC: American Psychiatric Association, 2000.
Sadock, Benjamin J. and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry. 7th ed. Vol. 2. Philadelphia: Lippincott Williams and Wilkins, 2000.
Kuhn, Bret R., Bethany A. Marcus, and Sheryl L. Pitner. "Treatment Guidelines for Primary Nonretentive Encopresis and Stool Toileting Refusal." American Family Physician 58 (April 15, 1999): 8-18.
American Academy of Child and Adolescent Psychiatry, P. O. Box 96106, Washington, D.C. 20090. (800) 333-7636. <www.aacap.org>.
Tish Davidson, A.M.
"Encopresis." Gale Encyclopedia of Mental Disorders. . Encyclopedia.com. (December 12, 2017). http://www.encyclopedia.com/psychology/encyclopedias-almanacs-transcripts-and-maps/encopresis
"Encopresis." Gale Encyclopedia of Mental Disorders. . Retrieved December 12, 2017 from Encyclopedia.com: http://www.encyclopedia.com/psychology/encyclopedias-almanacs-transcripts-and-maps/encopresis
Encopresis is the name for problems with control of the anal sphincter after the age when such control is normally acquired (two or three years). The condition may be primary or secondary after a period of continence, and is characterized by bowel movements, usually during the daytime, under socially unacceptable conditions and excluding true incontinence, as produced by organic disorders of the sphincter or its related nerve structures. The term, used in clinical pediatric psychiatry, was introduced by Siegfried Weissenberg in 1926.
A clearer understanding of this symptom can be achieved by considering it in relation to the erotogenicity of the anal zone (Freud, 1905d), with its various components, including excitation of the mucous membranes and the pleasures derived from expulsion and muscular control. Michel Soulé views the erotization of retention as the central phenomenon. Non-renunciation of these instinctual satisfactions is rooted in the individual's conflictual relations with the people surrounding him during the period of toilet training—that is, the anal-sadistic stage, which is focused on issues of possession, on mastery of one's own body, and of others. The child's stools are cathected as a part of his or her own body and as representing internal objects; the subject refuses to give them up for exchange and instead saves them, often owing to a deficiency in symbolization that impedes the displacement of interest onto other objects. Anxiety plays a role, sometimes manifesting itself as a genuine defecation phobia with archaic contents, such as the destruction of internal objects, or the destruction of links, often in connection with the traumatic effects upon the child of intrusive parental fantasies or existential events involving loss.
Symptoms of encopresis can also arise from an inadequate cathexis of the body on the part of a child subject to some forms of deprivation. The secondary gains are proportionate to the involvement of the child's entourage: maintaining regressive ties to the mother; feelings of omnipotence; masochistic gratification. The failure of repression and the non-establishment of reaction-formations attest to the resistance of pregenital fixations to oedipal resolution—the definitive aim of toilet training, according to Anna Freud. Although encopresis can have a bearing on all types of psychopathology in the child, ranging from psychosis or perversion to quasi-normality, Bertrand Cramer has noted that the majority of cases involve neurosis.
See also: Anality; Coprophilia; Eroticism, anal; Gift; Infantile neurosis; Libidinal stage; Mastery; Pregenital; Psychosexual development.
Cramer, Bertrand, et al. (1983). Trente-six encoprétiques en thérapie. Psychiatrie de l'enfant, 26, 2, 309-410.
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