Encopresis

Definition

Encopresis is repeatedly having bowel movements in places other than the toilet after the age when bowel control can normally be expected.

Description

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

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.

Treatment

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.

Alternative treatment

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 ).

Prognosis

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.

KEY TERMS

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.

Prevention

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.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. text revision. Washington D.C.: American Psychiatric Association, 2000.

PERIODICALS

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〉.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry, P. O. Box 96106, Washington, D.C. 20090. 800-333-7636. 〈www.aacap.org〉.

OTHER

Borowitz, Stephen. Encopresis, 14 June 2004 [cited 20 February 2005]. 〈http://www.emedicine.com/ped/topics670.html〉.

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.

GÉrard Schmit

See also: Anality; Coprophilia; Eroticism, anal; Gift; Infantile neurosis; Libidinal stage; Mastery; Pregenital; Psychosexual development.

Bibliography

Cramer, Bertrand, et al. (1983). Trente-six encoprétiques en thérapie. Psychiatrie de l'enfant, 26, 2, 309-410.

Freud, Anna. (1965). Normality and pathology in childhood: assessments of development. New York: International Universities Press.

Freud, Sigmund. (1905d). Three essays on the theory of sexuality. SE, 7: 130-243.

Soulé, Michel, et al. (1995). Les troubles de la defecation. In S. Lebovici, R. Diatkine, and M. Soulé (Eds.), Nouveau traité de psychiatrie de l'enfant et de l'adolescent (Vol. 4, pp. 2679-2700). Paris: Presses Universitaires de France.

Weissenberg, Siegfried. (1926).Über Enkopresis. Zeitung der Kinderpsychiatrie, 1, 69.

encopresis (en-koh-pree-sis) n. incontinence of faeces. The term is used for faecal soiling in a child who has gained bowel control but passes formed stools in unacceptable places.