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Quick reference medical handouts used by Pediatric offices


The Anguish of Accidental Soiling


Encopresis is a little known disorder whose incidence among children would surprise most people. The term is used to describe older youngsters who stain their underwear with small amounts of loose bowel movements several times a day. Despite its obscurity as a medical problem, encopresis is fairly common, accounting for up to 3% of all pediatric office visits and 10-20% of visits to a pediatric gastroenterologist.

The parental complaint that prompts a visit to the physician is "he soils his pants"(it usually is "he" because the problem is six times more common in boys). The child claims that he is unable to control the leaking, which may occur several times a day, usually at home in the late afternoon or evening. At first, most parents believe their child has a case of intestinal flu with diarrhea. When the problem continues, parents become frustrated and begin to think that the soiling is laziness. Their child simply does not bother to go to the bathroom in time. To make matters worse, most youngsters do not seem bothered by the problem. Some even deny the soiling, hiding their stained underwear under the bed or in the closet to keep their parents from discovering the evidence. The child’s nonchalant attitude and the growing laundry pile causes parents to become both upset and angry. After various forms of punishment and bribery are tried without success, mom and dad often become concerned that the soiling is a reflection of poor parenting ability (after all, the child soils mostly at home and not when he is asleep). Confused, the parents arrange an office visit with their child’s physician.

 

Encopresis usually starts around the age of 4, and almost half of the parents recall their child was hard to toilet train. Some children with encopresis have never had a bowel movement on the toilet and many were treated for constipation during the first two years of life. Painful bowel movement and resulting stool-withholding causes the formation of a large stool in the rectum (the child will sometimes pass this large stool, occasionally blocking up the toilet). This incomplete obstruction eventually causes the bowel to malfunction. The child thus loses the ability to know when to go to the bathroom and liquid stool leaks around the blockage. "Accidents" are a complete and embarrassing surprise to him as well!

Many encopretic children have variable symptoms of increasingly severe soiling, loss of appetite, abdominal pain, and decreased physical activity. The passage of a huge bowel movement often relieves these symptoms. These children then feel better, eat better, and experience no soiling for a time, until the cycle begins again. Many children with encopresis also have bedwetting at night thought to be due to decreased bladder size due to the distended rectum.

By the time the child sees their physician, about one-fourth have developed emotional problems. The child may be doing poorly in school, is withdrawn, and depressed. The social consequences of the soiling frequently exacerbate these behavioral and emotional problems. They live in constant fear of being discovered and encountering the peer ridicule that result. Self-esteem declines and the child tries to isolate himself. Family life becomes chaotic as parents, grandparents, neighbors, and the child get caught in a crossfire of conflicting theories as to why the child soils. Frequently, at least one parent believe the soiling is done on purpose and marital discord sometimes develops over the handling of this condition.

"A unique feature of encopresis is that most parents are unaware of this common medical problem," comments Dr. Dan McClenathan, St. Petersburg pediatric gastroenterologist. "They certainly do not know any other child who soils their pants and feels alone with the problem." Dr. McClenathan went on to state that parents frequently do not bring the condition to their child’s doctor attention because they feel the soiling is laziness on their child’s part or poor parenting on their part.

The investigation of encopresis is a simple one. Once inside the doctor’s office, a physical examination is done to rule out other conditions that are associated with constant constipation. In children with encopresis, the checkup is usually normal except for the finding of fecal impaction. The physician may order laboratory tests to detect the presence of other disorders, but this is rare

A three-step treatment program is designed to clear impactions, overcome withholding, and promote a regular bowel habit. The first phase in treating encopresis is removal of the impaction and usually needs enemas and suppositories. The second phase consists of giving large amounts of mineral oil daily to prevent reaccumulation of the stool. During the second phase ( may last 6--12 months) the child is encouraged to sit on the toilet and try to defecate twice daily. Teachers need to be involved during this stage and be sensitive to the child’s concerns. Temporary excuse from gym class and showers to avoid being discovered may be needed, and the child should be allowed to use the bathroom whenever necessary. Of course, school personnel should keep the child’s problem in strict confidence.

The third phase consists of gradually reducing the cathartic, and two thirds of children treated will have an occasional relapse during this time. It is important for both child and parent to learn in advance that relapses are not their fault. The dosage of mineral oil is reduced in the final phase. About 75% of children can successfully discontinue medication without significant relapse. Another 15-20% will relapse and may require a second course of laxative along with the resumption of daily mineral oil before they will respond.

Encopresis is a challenging medical condition and treatment needs patience and sensitivity to help both the child and his family. According to Boston pediatrician Melvin Levine, "Fecal incontinence is a situation in which a child is blamed and ridiculed for something he did not cause over which he had little, if any control." This is the saddest aspect of this common childhood problem.

 

As a reminder, this information should not be relied on as medical advice and is not intended to replace the advice of your child’s pediatrician. Please read our full disclaimer.

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