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 of Stool Incontinence in Children
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 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. 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.
Diagnosis of Stool Incontinence in Children
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.
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 can assist with making an accurate diagnosis.
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 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
(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). 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 Treatment of Constipation in Children
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 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 (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).
The mainstay of treatment is family education, bowel cleanout and maintenance, and ongoing support.
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. 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 58(2):258–274, 2014. doi: 10.1097/MPG.0000000000000266
Key Points
Encopresis is most commonly caused by constipation in children with overlapping 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 agents.
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.
More Information
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition: Recommendations for the evaluation and treatment of functional constipation in infants and children (2014)
