Encopresis Follow-up

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

Further Outpatient Care

In addition to the medical therapy outlined above, various modalities have been proposed for the treatment of chronic encopresis.

  • Because more than one half of children with chronic encopresis have paradoxical constriction of their external anal sphincter (EAS) during attempted defecation, some literature has advocated the use of EAS biofeedback to treat chronic encopresis.[23]
    • Biofeedback focuses on teaching the child to reverse paradoxical constriction by learning how to relax the EAS during straining. Most studies examining the use of biofeedback in childhood encopresis included biofeedback as a supplement to medical-behavioral treatment.[23]
    • Both manometric and electromyographic (EMG) biofeedback have been used to treat encopresis, but manometric biofeedback is more invasive than EMG biofeedback. Data from a meta-analysis suggested no significant differences in outcomes by using intra-anal pressure biofeedback compared with surface EMG biofeedback of the perianal skin.[17]
    • Authors of a Cochrane review examined the effectiveness of biofeedback therapy in children with chronic encopresis.[17] The addition of biofeedback therapy to conventional medical therapy does not appear to be of substantial therapeutic benefit for most children with chronic constipation, encopresis, or both.[24] Although biofeedback can be used to successfully train children to tighten and relax their perineal muscles and, thus, theoretically increase the efficiency of defecation, achieving this objective is not clearly correlated with successful resolution of the symptoms of chronic constipation, encopresis, or both. In fact, outcomes tend to worsen when children are treated with biofeedback therapy.
  • Some authors have advocated the use of behavioral strategies with or without long-term, laxative therapy to encourage frequent bowel movements.[25, 23, 26, 17]
    • Authors of a Cochrane review concluded that the addition of an intensive behavioral program to conventional medical therapy can be of substantial therapeutic benefit in most children with chronic encopresis.[17]
    • Although the critical components of a successful intensive behavioral program have not been systematically elucidated, common elements of existing programs include demystifying the condition and educating patients and families; providing specific toileting instruction about appropriate positioning and straining; designing a program of regular, timed, and uninterrupted toileting; maintaining a symptom and toileting diary; defining specific achievable target behaviors; establishing age-appropriate rewards and consequences;[27] and strongly emphasizing consistency.
    • Preliminary evidence suggests that this type of intensive behavioral intervention can be successfully performed using the Internet.[18]
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Prognosis

  • Even with aggressive medical and behavioral interventions, as many as 30% of children remain symptomatic.[28] Unfortunately, no sufficient evidence has enabled clinicians to reliably predict which children successfully respond to specific treatment protocols.
  • The few data available suggest that family disorganization correlates with a poor response to all forms of treatment. In contrast, none of the demographic, manometric, behavioral, social, academic, or self-esteem measures are clearly associated with response to therapy. No investigators have systematically examined the child's motivation, the family’s motivation, or the state of change to see if it is predictive of their response to treatment.
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Patient Education

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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

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. APA; 2000.

  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].

  6. Loening-Baucke V. Prevalence rates for constipation and faecal and urinary incontinence. Arch Dis Child. Jun 2007;92(6):486-9. [Medline].

  7. van der Wal MF, Benninga MA, Hirasing RA. The prevalence of encopresis in a multicultural population. J Pediatr Gastroenterol Nutr. Mar 2005;40(3):345-8. [Medline].

  8. Joinson C, Heron J, Butler R, et al. A United Kingdom population-based study of intellectual capacities in children with and without soiling, daytime wetting, and bed-wetting. Pediatrics. Aug 2007;120(2):e308-16. [Medline].

  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].

  26. Young MH, Brennen LC, Baker RD, Baker SS. Functional encopresis: symptom reduction and behavioral improvement. J Dev Behav Pediatr. Aug 1995;16(4):226-32. [Medline].

  27. Reid H, Bahar RJ. Treatment of encopresis and chronic constipation in young children: clinical results from interactive parent-child guidance. Clin Pediatr (Phila). Mar 2006;45(2):157-64. [Medline].

  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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