Encopresis Clinical Presentation

  • Author: Stephen Borowitz, MD; Chief Editor: Carmen Cuffari, MD   more...
 
Updated: May 11, 2012
 

History

Approximately 80-95% of children with encopresis have a history of constipation or painful defecation. In many patients, the history of constipation or painful defecation is remote, occurring years before the child presents with encopresis. On average, children who have encopresis are symptomatic 5 years before the problem is brought to medical attention.

  • Most children with encopresis deny the urge to defecate associated with their soiling episodes. Sometimes, affected children contend that they are unable to differentiate passing gas and passing feces in their underwear.
  • In most cases, soiling episodes occur during the daytime when the child is awake and active. Soiling at night when the child is asleep is uncommon.
  • As evidence of functional megacolon, many children with retentive encopresis intermittently pass extremely large bowel movements.
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Physical

Physical findings, other than those obtained from the abdominal and rectal examinations, are usually normal.

  • In many patients, stool can be palpated throughout the distribution of the colon, most notably in the left lower quadrant.
  • Upon rectal examination, stool is often found smeared around the anus. The anal sphincter may appear somewhat lax and patulous because massive rectal distention is associated with reflex relaxation of the internal sphincter. The rectum is typically enlarged and filled with soft, Hemoccult-negative stool.
  • Neurologic findings should be normal. Patients should have a normal anal wink and normal sensation, strength, and reflexes in the lower extremities.
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Causes

In most cases, encopresis is thought to develop as a consequence of chronic constipation with resulting overflow incontinence. Approximately 80-95% of children with encopresis have a history of constipation or painful bowel movements.

  • A few children appear to have nonretentive encopresis and no history of constipation or painful defecation; they have no evidence of incomplete evacuation on physical evaluation, radiographic evaluation, or both.
  • No good prospective data suggest that encopresis, whether retentive or nonretentive, is primarily a behavioral or psychological disorder. Rather, most of the available evidence indicates that children with encopresis do not have an increased incidence of major behavioral or personality disorders compared with their age-matched peers.[9]
  • No good evidence suggests that encopresis is an indicator of sexual abuse.[10] The incidence of fecal soiling is comparable among children with a history of sexual abuse and children with psychiatric and behavioral disorders.
  • Children with encopresis are significantly more likely to have attention-deficit disorder/hyperactivity (ADHD) than the general population.[11]
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Contributor Information and Disclosures
Author

Stephen Borowitz, MD  Professor of Pediatrics and Public Health Sciences, Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Virginia School of Medicine

Stephen Borowitz, MD is a member of the following medical societies: American Academy of Pediatrics, American Gastroenterological Association, American Pediatric Society, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Jorge H Vargas, MD  Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, University of California, Los Angeles, David Geffen School of Medicine; Consulting Physician, Department of Pediatrics, University of California at Los Angeles Health System

Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Steven M Schwarz, MD, FAAP, FACN, AGAF  Professor of Pediatrics, Children's Hospital at Downstate, State University of New York Downstate Medical Center

Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research

Disclosure: Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor; Johnson & Johnson, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD  Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

References

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  2. Di Lorenzo C, Benninga MA. Pathophysiology of pediatric fecal incontinence. Gastroenterology. Jan 2004;126(1 Suppl 1):S33-40. [Medline].

  3. Partin JC, Hamill SK, Fischel JE, Partin JS. Painful defecation and fecal soiling in children. Pediatrics. Jun 1992;89(6 Pt 1):1007-9. [Medline].

  4. Borowitz SM, Cox DJ, Sutphen JL. Differences in toileting habits between children with chronic encopresis, asymptomatic siblings, and asymptomatic nonsiblings. J Dev Behav Pediatr. Jun 1999;20(3):145-9. [Medline].

  5. Joinson C, Heron J, Butler U, et al. Psychological differences between children with and without soiling problems. Pediatrics. May 2006;117(5):1575-84. [Medline].

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  9. Cox DJ, Morris JB Jr, Borowitz SM, Sutphen JL. Psychological differences between children with and without chronic encopresis. J Pediatr Psychol. Oct-Nov 2002;27(7):585-91. [Medline].

  10. Mellon MW, Whiteside SP, Friedrich WN. The relevance of fecal soiling as an indicator of child sexual abuse: a preliminary analysis. J Dev Behav Pediatr. Feb 2006;27(1):25-32. [Medline].

  11. Johnston BD, Wright JA. Attentional dysfunction in children with encopresis. J Dev Behav Pediatr. Dec 1993;14(6):381-5. [Medline].

  12. Borowitz SM, Sutphen J, Ling W, Cox DJ. Lack of correlation of anorectal manometry with symptoms of chronic childhood constipation and encopresis. Dis Colon Rectum. Apr 1996;39(4):400-5. [Medline].

  13. McGrath ML, Mellon MW, Murphy L. Empirically supported treatments in pediatric psychology: constipation and encopresis. J Pediatr Psychol. Jun 2000;25(4):225-54; discussion 255-6. [Medline].

  14. Nolan T, Debelle G, Oberklaid F, Coffey C. Randomised trial of laxatives in treatment of childhood encopresis. Lancet. Aug 31 1991;338(8766):523-7. [Medline].

  15. Borowitz SM, Cox DJ, Sutphen JL, Kovatchev B. Treatment of childhood encopresis: a randomized trial comparing three treatment protocols. J Pediatr Gastroenterol Nutr. Apr 2002;34(4):378-84. [Medline].

  16. Thapar A, Davies G, Jones T, Rivett M. Treatment of childhood encopresis--a review. Child Care Health Dev. Nov-Dec 1992;18(6):343-53. [Medline].

  17. [Best Evidence] [Guideline] Brazzelli M, Griffiths PV, Cody JD, Tappin D. Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev. Dec 7 20011;CD002240. [Medline].

  18. Ritterband LM, Cox DJ, Walker LS, et al. An Internet intervention as adjunctive therapy for pediatric encopresis. J Consult Clin Psychol. Oct 2003;71(5):910-7. [Medline].

  19. Ritterband LM, Ardalan K, Thorndike FP, et al. Real world use of an Internet intervention for pediatric encopresis. J Med Internet Res. 2008;10(2):e16. [Medline]. [Full Text].

  20. Dobson P, Rogers J. Assessing and treating faecal incontinence in children. Nurs Stand. Sep 16-22 2009;24(2):49-56; quiz 58, 60. [Medline].

  21. Bekkali NL, van den Berg MM, Dijkgraaf MG, van Wijk MP, Bongers ME, Liem O. Rectal fecal impaction treatment in childhood constipation: enemas versus high doses oral PEG. Pediatrics. Dec 2009;124(6):e1108-15. [Medline].

  22. Miller MK, Dowd MD, Friesen CA, Walsh-Kelly CM. A randomized trial of enema versus polyethylene glycol 3350 for fecal disimpaction in children presenting to an emergency department. Pediatr Emerg Care. Feb 2012;28(2):115-9. [Medline].

  23. Cox DJ, Sutphen J, Borowitz S, et al. Contribution of behavior therapy and biofeedback to laxative therapy in the treatment of pediatric encopresis. Ann Behav Med. Spring 1998;20(2):70-6. [Medline].

  24. Brooks RC, Copen RM, Cox DJ, et al. Review of the treatment literature for encopresis, functional constipation, and stool-toileting refusal. Ann Behav Med. 2000;22(3):260-7. [Medline].

  25. Brazzelli M, Griffiths P. Behavioural and cognitive interventions with or without other treatments for defaecation disorders in children. Cochrane Database Syst Rev. 2001;(4):CD002240. [Medline].

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  28. Rockney RM, McQuade WH, Days AL, et al. Encopresis treatment outcome: long-term follow-up of 45 cases. J Dev Behav Pediatr. Dec 1996;17(6):380-5. [Medline].

 
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Overflow incontinence.
Overflow incontinence.
 
 
 
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