Encopresis Treatment & Management

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

Medical Care

Despite the frequency with which childhood encopresis occurs, no large, randomized, controlled therapeutic trials have been conducted.[13] As a result, treatment remains largely experiential rather than evidence based and generally consists of demystification and education; colonic evacuation followed by routine laxative therapy;[14] and “toilet training,” which is composed of regularly scheduled toileting, maintenance of a symptom diary, and an age-appropriate incentive scheme.[15] The aim of this multimodal approach to therapy is to decrease the physical and emotional distress associated with defecation, to develop or restore normal bowel habits with positive reinforcement, and to encourage the child and parents to take an active role during the treatment.[16]

  • Because approximately 80-95% of children with encopresis have a history of constipation or painful bowel movements, medical therapy generally focuses on evacuation of the distal colon followed by prolonged use of laxatives to ensure that the child passes soft stools frequently without any associated pain.
  • Various modalities have been proposed for the treatment of chronic encopresis. Although considerable controversy and conflicting data have been reported, many authors advocate behavioral strategies with or without long-term laxative therapy to encourage bowel movements. The addition of an intensive behavioral program to conventional medical therapy can be of substantial therapeutic benefit for most children with chronic encopresis (see Further Outpatient Care).
  • Because more than half the children with chronic encopresis have paradoxical external anal sphincter (EAS) constriction (anismus) during attempted defecation, biofeedback training focusing on teaching the child how to relax the EAS during active straining and thus eliminate anismus has been used since the mid 1980s to treat children with chronic encopresis (see Further Outpatient Care). While biofeedback may help selected children, there is no evidence that biofeedback adds any benefit to conventional treatment in the management of childhood encopresis.[17]

When faced with a child with chronic constipation or encopresis, conventional medical therapy is commonly the first therapy attempted. This includes demystification and education; colonic evacuation followed by routine laxative therapy; and “toilet training,” which is composed of regularly scheduled toileting, maintenance of a symptom diary, and an age-appropriate incentive scheme. The literature suggests conventional medical therapy proves successful in approximately one half of children with chronic constipation, encopresis, or both.

Most available data indicate that if a child has not experienced significant clinical improvement after 2-4 months of therapy, a different therapy program is indicated. As a result, assessing the progress after 2-4 months of therapy is appropriate. If the child remains symptomatic, consider enrolling him or her in an intensive behavior program that supplements conventional medical therapy.[17] Preliminary evidence suggests that this type of intensive behavioral intervention can be successfully performed using the Internet.[18, 19]

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Surgical Care

No surgical intervention has a proven role in the management of childhood encopresis.

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Consultations

In most cases of encopresis, consultation with a subspecialist is not absolutely necessary. Affected children are often referred to a pediatric gastroenterologist, a behavioral psychologist, or both.

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Diet

No evidence suggests that dietary interventions are beneficial in the management of encopresis. Although many people advocate high-fiber diets, the authors know of no studies conducted to systematically evaluate the effectiveness of dietary therapy in childhood encopresis.

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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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  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].

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  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].

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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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