Stool incontinence is the voluntary or involuntary passage of stool in inappropriate places in children > 4 years of age (or developmental equivalent). Diagnosis is clinical. Treatment is with education, relief of stool impaction, maintenance of proper stooling, and continued behavioral and dietary intervention.
Encopresis is a common childhood problem; it occurs in approximately 2 to 5% of 4-year-old children and decreases in frequency with age.
Encopresis is a condition that requires attention and intervention, not simply reassurance and observation. This condition can be detrimental to both the child and family and also costly to the health care system (1).
General reference
1. Stephens JR, Steiner MJ, DeJong N, et al. Healthcare Utilization and Spending for Constipation in Children With Versus Without Complex Chronic Conditions. J Pediatr Gastroenterol Nutr. 2017;64(1):31-36. doi:10.1097/MPG.0000000000001210
Etiology of Stool Incontinence in Children
Encopresis is most commonly caused by retentive constipation in children with behavioral and/or physical predisposing factors. It rarely occurs without retention or constipation, but when it does, other organic processes (eg, Hirschsprung disease, celiac disease) or psychological problems should be considered.
Pathophysiology of Stool Incontinence in Children
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, particularly in the rectum. These changes decrease the efficacy of bowel excretory function and lead to further retention.
As stool remains in the bowel, water is absorbed from the colon, 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.
Both leakage and ineffective bowel control result in stool accidents.
Diagnosis of Stool Incontinence in Children
Clinical evaluation
Any organic process that results in constipation (1) can result in encopresis.
Most cases of encopresis can be diagnosed with a thorough history and physical examination. However, if the diagnosis is unclear, additional tests (eg, abdominal radiographs, rarely rectal wall biopsy, and even more rarely bowel motility studies) can be considered (1).
A digital rectal examination in cooperative children can be useful to rule out other disorders.
In prolonged or complicated cases, anorectal manometry can assist with making an accurate diagnosis.
Diagnosis reference
1. Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258-274. doi:10.1097/MPG.0000000000000266
Treatment of Stool Incontinence in Children
Education and demystification (for caregivers 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.
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. Clinicians should make clear to caregivers that the treatment and resolution of encopresis may be a long-term effort requiring ongoing attention, intervention, and follow-up with a pediatrician or specialist (1).
After stool impaction is relieved, the mainstay of treatment is family education, increased consumption of water and dietary fiber, bowel maintenance, and ongoing behavioral strategies and support (2).
Stool impaction
Disimpaction may require oral treatment, oral and then rectal treatment, or rectal and then oral treatment. Some children are given only laxatives and do not need enemas or suppositories.
Stool impaction can be relieved by a variety of regimens and agents (see table Treatment of Constipation in Children); choice depends on the age of the child and other factors. Polyethylene glycol (PEG) with electrolytes, sometimes in conjunction with a stimulant laxative (eg, bisacodyl, senna), or a sequence of saline enemas plus a 2-week regimen of oral agents (eg, bisacodyl tablets) and suppositories are often used. Normal saline enemas are being used in children at some institutions.); choice depends on the age of the child and other factors. Polyethylene glycol (PEG) with electrolytes, sometimes in conjunction with a stimulant laxative (eg, bisacodyl, senna), or a sequence of saline enemas plus a 2-week regimen of oral agents (eg, bisacodyl tablets) and suppositories are often used. Normal saline enemas are being used in children at some institutions.
After disimpaction, a follow-up visit should be held to assess whether the regimen 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 Treatment of Constipation in Children), but PEG without electrolytes is used most often, titrated to effect (eg, 1 to 2 semisoft stools a day). At times a stimulant laxative may also be continued on the weekends to encourage extra evacuation of stool.
Behavioral strategies
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 (eg, a trip to the park) 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.
Maintenance
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, clinicians should educate the caregiver and child about how 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 (3), but 1-year cure rates are up to 50%, 5-year cure rates are approximately 50%, and 10-year cure rates are approximately 80% (4). Physicians and families alike should be wary of late recurrence of encopresis without retention/retentive behaviors and should consider further evaluation (5).
Treatment references
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.
2. Freeman KA, Riley A, Duke DC, Fu R. Systematic review and meta-analysis of behavioral interventions for fecal incontinence with constipation. J Pediatr Psychol. 2014;39(8):887-902. doi:10.1093/jpepsy/jsu039
3. Call NA, Mevers JL, McElhanon BO, Scheithauer MC. A multidisciplinary treatment for encopresis in children with developmental disabilities. J Appl Behav Anal. 2017;50(2):332-344. doi:10.1002/jaba.379
4. Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258–274. doi:10.1097/MPG.0000000000000266
5. Koppen IJ, von Gontard A, Chase J, et al. Management of functional nonretentive fecal incontinence in children: Recommendations from the International Children's Continence Society. J Pediatr Urol. 2016;12(1):56-64. doi:10.1016/j.jpurol.2015.09.008
Key Points
Encopresis is most commonly caused by retentive constipation in children, often with overlapping behavioral and physical predisposing factors.
Most cases of encopresis can be diagnosed with a thorough history and physical examination.
Any organic process that results in constipation can result in encopresis.
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 agents.
Behavioral strategies include structured toilet-sitting times; many children benefit from direct behavioral therapy.
Encopresis can recur in times of stress or transition, so family members must be prepared for this possibility.
