eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Encopresis

Author: Stephen Borowitz, MD, Professor of Pediatrics and Public Health Sciences, Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Virginia
Contributor Information and Disclosures

Updated: Mar 24, 2008

Introduction

Background

According to the Diagnostic and Statistical Manual of Mental Disorders, Third edition (DSM-III), encopresis is defined as the "repeated involuntary passage of feces into places not appropriate for that purpose...the event must take place for at least 6 months, the chronologic and mental age of the child must be at least 4 years."1

Pathophysiology

In the vast majority of cases, encopresis develops as a consequence of chronic constipation with resulting overflow incontinence,2 which is typically termed retentive encopresis. Chronic constipation due to irregular and incomplete evacuation results in progressive rectal distention and stretching of both the internal anal sphincter and the external anal sphincter (EAS). As the child habituates to chronic rectal distention, he or she no longer senses the normal urge to defecate. Soft or liquid stool eventually leaks around the retained fecal mass, resulting in fecal soiling.

Approximately 80-95% of children with encopresis have a history of constipation or painful bowel movements. The remaining 5-20% are said to have nonretentive encopresis; however, many of these children have a remote history of constipation or painful defecation3 or demonstrate incomplete evacuation during defecation upon physical examination or radiographic assessment.4 Little or no evidence indicates that encopresis is primarily a behavioral disorder, and most available evidence suggests that behavioral difficulties associated with encopresis may be the result of the encopresis and not the cause.5 Low self-esteem or parent-child conflict as a result of the disorder is not uncommon. Embarrassed youngsters also commonly deny having the problem.

Frequency

United States

Although few prospective studies have been conducted to examine the prevalence of encopresis in childhood, an estimated 1-2% of children younger than 10 years have encopresis. In one study, 4.4% of 482 children aged 4-17 years observed over a 6 month period in a primary care pediatric clinic in Iowa experienced fecal incontinence at least once per week.6

International

Although population-based studies that examine the prevalence of encopresis are scarce, nearly all published studies have been conducted in North America and Europe. In one population-based study conducted in the Netherlands, 4.1% of children aged 5-6 years and 1.6% of children aged 11-12 years experienced fecal soiling at least once a month.7  Studies conducted in Sweden and the United Kingdom8 have reported similar numbers.

Sex

In nearly all published series, boys are much more commonly affected than girls. In most series, approximately 80% of affected children are boys.

Clinical

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.

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.

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.

More on Encopresis

Overview: Encopresis
Differential Diagnoses & Workup: Encopresis
Treatment & Medication: Encopresis
Follow-up: Encopresis
References
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References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. APA; 1981.

  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. 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].

  12. 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].

  13. 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].

  14. 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].

  15. 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].

  16. 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].

  17. 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].

  18. [Best Evidence] Brazzelli M, Griffiths P. Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev. Apr 19 2006;(2):CD002240. [Medline].

  19. 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].

  20. 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].

  21. 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].

  22. 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].

  23. 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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Further Reading

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Keywords

encopresis, fecal incontinence, soiling, fecal soiling, retentive encopresis, nonretentive encopresis, feces, stool, rectal distention, overflow diarrhea, overflow, chronic diarrhea, constipation, painful bowel movements, soiling episodes, megacolon

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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
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.

Medical Editor

Jorge H Vargas, MD, Clinical Professor of Pediatrics, Division of Pediatric Gastroenterology, Hepatology & Nutrition
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.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, State University of New York, Downstate Medical Center College of Medicine; Distinguished Lecturer, New York Medical College, School of Public Health
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: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership

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.

 
 
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