Encopresis Treatment & Management

Updated: Oct 20, 2017
  • Author: Stephen M Borowitz, MD; Chief Editor: Carmen Cuffari, MD  more...
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Treatment

Approach Considerations

Despite the frequency with which childhood encopresis occurs, no large, randomized, controlled therapeutic trials have been conducted. [16] As a result, treatment remains largely experiential rather than evidence based. Conventional medical therapy is commonly the first therapy attempted, generally consisting of the following:

  • Demystification and education

  • Colonic disimpaction followed by routine laxative therapy [17]

  • "Toilet training," which is composed of regularly scheduled toileting, maintenance of a symptom diary, and an age-appropriate incentive scheme [18]

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. [19]

Conventional medical therapy proves successful in approximately one half of children with chronic constipation, encopresis, or both. If a child has not experienced significant clinical improvement after 2-4 months of therapy, a different therapy program may be indicated. Accordingly, it is appropriate to assess progress after 2-4 months of treatment. If the child remains symptomatic, consider enrolling him or her in an intensive behavior program that supplements conventional medical therapy. [20]

Although no surgical intervention has a proven role in the management of childhood encopresis, performing an appendicostomy or cecostomy to perform antegrade enemas in children who have proven refractory to medical therapy may improve their quality of life. [21]  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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Behavioral Therapy and Biofeedback

Although controversy remains and conflicting data have been reported, many authors advocate behavioral strategies, with or without long-term laxative therapy, to encourage bowel movements in patients with chronic encopresis. The addition of an intensive behavioral program to conventional medical therapy can be of substantial therapeutic benefit for most children with chronic encopresis (see Long-Term Monitoring).

Because more than 50% of 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 in this population since the mid-1980s. Although biofeedback may help selected children, there is no evidence that it adds any benefit to conventional treatment in the management of childhood encopresis. [20]

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Pharmacologic Therapy

Because most children with encopresis have retentive encopresis as a consequence of chronic constipation with resulting overflow incontinence, medical therapy is initially focused on disimpaction of the distal colon, [22] which is followed by prolonged use of laxatives to ensure that the child passes soft stools frequently without any associated pain.

Disimpaction can be accomplished with aggressive use of oral cathartics (eg, polyethylene glycol [PEG], sodium phosphate, or magnesium citrate) or a series of enemas. In clinical trials, disimpaction is reported to be equally effective whether done via the oral route or via the rectal route. [23, 24]

Most enema preparations contain osmotically active agents that are not substantially absorbed in the colon (see Medication). To the author’s knowledge, no studies have yet been performed to compare the effectiveness of these preparations. In all likelihood, the effectiveness of any particular preparation depends more on the volume of the enema than on the composition of the enema solution.

After the colon is disimpacted, long-term laxative therapy is generally started. Virtually any laxative can be used, provide that it is administered in sufficient quantity to produce 1-2 soft stools daily.

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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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Long-Term Monitoring

In addition to the long-term laxative therapy outlined above, various modalities have been proposed for the treatment of chronic encopresis.

As noted (see Behavioral Therapy and Biofeedback), EAS biofeedback focuses on teaching the child to reverse paradoxical constriction by learning how to relax the EAS during straining. [25] Most studies examining the use of biofeedback in childhood encopresis included biofeedback as a supplement to medical-behavioral treatment. [25]

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 between intra-anal pressure biofeedback and surface EMG biofeedback of the perianal skin. [20]

Adding biofeedback therapy to conventional medical therapy appears not to offer substantial therapeutic benefit to most children with chronic constipation, encopresis, or both. [20, 26] Although biofeedback can be used to train children to tighten and relax their perineal muscles (thereby, in theory, increasing the efficiency of defecation), this achievement is not clearly correlated with successful resolution of chronic constipation or encopresis. In fact, outcomes tend to worsen when children are treated with biofeedback therapy.

Some authors advocate the use of behavioral strategies, with or without long-term laxative therapy, to encourage frequent bowel movements. [27, 25, 28, 20] 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. [20] Although the critical components of a successful intensive behavioral program have not been systematically elucidated, common elements of existing programs include the following:

  • 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 [29]

  • Strongly emphasizing consistency

Preliminary evidence suggests that this type of intensive behavioral intervention can be successfully performed by using the Internet. [30, 31]

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