Encopresis
Encopresis: Excerpt from The 5-Minute Pediatric Consult
Victor M. Pineiro-Carrero, MD
Encopresis - BASICS
Encopresis - description
Repeated passage of feces into inappropriate places (usually clothing or floor) after the age of 4 years without any organic cause:
- Most commonly associated with functional constipation
- A 2nd subtype is functional nonretentive fecal incontinence (FNRFI) that refers to encopresis in the absence of constipation and structural or inflammatory diseases (also known as solitary or nonretentive encopresis).
Encopresis - epidemiology
- The reported ratio of boys to girls ranges from 2:1–6:1. Boys are more likely to experience nonretentive fecal incontinence than girls at a ratio of 9:1.
- There is no association with family size, ordinal position in the family, age of parents, or socioeconomic status.
Encopresis - prevalence
Encopresis is reported in 1.5–2.8% of children >4 years. Between 10% and 30% of children with encopresis have nonretentive fecal incontinence.
Encopresis - risk factors
Encopresis - genetics
Monozygotic twins have a 4-fold higher incidence than do dizygotic twins.
Encopresis - risk factorss
- Constipation with a rectal fecal mass is most common risk for encopresis.
- Children with FNRFI have more behavioral problems, poor self esteem and higher prevalence of attention deficit disorder.
Encopresis - pathophysiology
Chronic constipation with fecal impaction results in overflow incontinence and reduced sensation secondary to rectal distention. The pattern of holding fecal matter, leading to chronic constipation and overflow incontinence, may result from a variety of causes, such as a painful experience from a fissure, difficult toilet training, or refusal to use school bathrooms. However, the history often does not reveal a triggering event.
Encopresis - etiology
- Chronic constipation leads to a dilated rectum, decreased rectal sensation, shortening of the anal canal, and decreased anal sphincter tone in some patients.
- Findings on anorectal manometry include increased rectal sensory threshold and paradoxic contraction of the external anal sphincter during attempts at defecation (known as “anismus”).
- Functional nonretentive fecal incontinence occurs in children without constipation. The soiling may be a manifestation of an emotional disturbance and it may be associated with specific triggers (person or place) or may represent an impulsive action triggered by unconscious anger. All studies in these patients are normal, including normal anorectal manometry and normal colonic transit times.
Encopresis - associated conditions
Enuresis is more frequently seen in patients with FNRFI (45% have daytime and 40% have nighttime enuresis) compared to constipated children.
Encopresis - DIAGNOSIS
Encopresis - signs & symptoms
Encopresis - history
- Toileting habits:
- Constipation: Frequency and size of bowel movements (large-diameter bowel movements are common in children with encopresis associated with functional constipation)
- Bowel movements that obstruct the toilet and/or chronic abdominal pain relieved by enemas or laxatives
- Retentive posturing: Avoiding defecation by contraction of pelvic floor, squeezing the buttocks together (leg scissoring, crossing the legs, standing on tiptoes)
- Irritability, abdominal cramps, decreased appetite (symptoms improve after passage of large stool)
- Onset: Elicit history of triggering events (perianal infection, diet changes, toilet training, avoidance of school bathrooms, sexual abuse, or other stressful events).
- Enuresis (secondary daytime enuresis may occur in patients with megarectum compressing the bladder)
- Timing in the neonatal period of meconium passage as well as past surgeries, medical history, and medications are relevant.
- Unsteady or clumsy gait may suggest a neuromuscular disorder.
- Children with FNRFI do not have any history of constipation and have daily bowel movements. The incontinence is diurnal, usually in the afternoon.
Encopresis - physical exam
- Encopresis with functional constipation:
- Fecal mass palpable in 40% of patients; fecal soiling in the perianal region
- Dilated rectum but a normally positioned anus
- Anal sphincter tone may be normal or slightly decreased; the anal canal is usually shorter than normal.
- Functional nonretentive fecal incontinence:
- No palpable fecal mass
- Normal-size rectum
- Normal sphincter length
- Examine deep tendon reflexes, anal wink, rectal examination, and documentation of normal growth.
- In patients with extreme fear of anal exam, attempt a perianal inspection and obtain a plain radiograph of the abdomen to establish a fecal impaction. In children who fear painful defecation, the necessity of a rectal exam remains debatable.
Encopresis - tests
Referral to a pediatric gastroenterologist for further evaluation, including anorectal manometry, is often a useful adjunctive modality for patients recalcitrant to standard management.
Encopresis - lab
No tests are needed if both the history and physical exam are consistent with functional constipation and associated encopresis. If the patient’s history or physical exam is atypical and a systemic disorder is suspected, appropriate diagnostic tests should be done.
Encopresis - imaging
- Abdominal radiography is often necessary for patients who refuse a rectal exam, or when a rectal impaction is not palpable on abdominal exam (e.g., in obese patients).
- MRI of the spine can be done for children with suspected spinal abnormalities. This is rarely necessary if the neurological exam is normal.
- Colonic transit study with radio-opaque markers to confirm the patients complaints or assess for slow transit constipation
Encopresis - diag proced-surgery
Anorectal manometry can be done in selected cases to evaluate anorectal function. The main indication is to demonstrate the rectoanal inhibitory reflex to exclude Hirschsprung’s disease. It may also show an increased threshold to rectal sensation, providing important information to the patient and the parents.
Encopresis - differencial diagnosis
Determine whether stool leakage is caused by functional constipation or an underlying anatomic, metabolic, or neurologic abnormality. Fecal incontinence may be secondary to diarrheal diseases or defective neuromuscular control, such as in children with spinal defects.
- Neuromuscular:
- Spinal cord tumor
- Tethered spinal cord
- Meningomyelocele
- Anal abnormalities:
- Anteriorly displaced anus
- Ectopic anus
- Inflammatory:
- Proctitis (infectious or ulcerative)
- Fistula secondary to Crohn disease
- Stricture (after necrotizing enterocolitis or inflammatory bowel disease)
- Abdominal pelvic mass (sacral teratoma, meningomyelocele)
- Hypotonia (cerebral palsy, amyotonia congenita, familial visceral myopathy)
- Hirschsprung disease (constipation common, fecal incontinence rarely seen)
- Postsurgical repair of imperforate anus or Hirschsprung disease
- Endocrine:
- Hypothyroidism
- Panhypopituitarism
- Diabetes mellitus
- Constipating drugs:
- Opiates
- Calcium supplements
- Psychotropics
Encopresis - TREATMENT
Encopresis - initial stabilization
Management combines pharmacology, behavioral modification, and dietary alterations.
Encopresis - general measures
Encopresis - diet
Encopresis - special therapy
Behavior modification:
- Decrease family stress.
- Have the child sit on toilet for 5–10 minutes 1–2 times per day (ideally after a meal, tailored to the age of the child).
- Delay toilet training if the child is in diapers (to reduce stress).
- Motivate
- Biofeedback has a limited role in the treatment of encopresis
Encopresis - medication
- Cathartic regimen, including laxatives, to remove fecal impaction:
- Magnesium citrate, milk of magnesia, or high-dose MiraLax (1.5 g/kg/d) combined with a stimulant laxative such as senna or docusate
- Although some authors favor the use of enemas, they should be avoided for toddlers and school-age children with fear of anal manipulation.
- Stool softeners:
- MiraLax (0.75 mg/kg/d) is the preferred agent because of its palatability and lack of taste.
- Milk of magnesia (0.5–1 mL/kg/d) is a good option.
- Mineral oil may also be used.
Encopresis - FOLLOW UP
Encopresis - disposition
Encopresis - issues for referral
Patients with nonretentive fecal incontinence usually require referral to a mental health professional for more intensive behavioral intervention.
Encopresis - complications
- Social problems
- UTIs, especially in girls
- Abdominal discomfort
- Decreased appetite
Encopresis - patient monitoring
- 1st follow-up visit is at 2 weeks to ensure compliance and success with the initial management.
- If the fecal impaction has been successfully removed, a reward system is started.
- The patient is followed at monthly intervals to ensure motivation and to be supportive.
- Treatment with stool softeners is needed until behavior and diet have improved and until rectal dilation has resolved.
- Medication is often needed for 6 months or longer.
- Parents may misconstrue stool-withholding behavior as an attempt to defecate.
- Parents may think their child’s soiling is deliberate. They may not understand that the child can neither feel the passage of stool nor prevent it. The usual urge to defecate, which comes from stretching of the ampulla and internal anal sphincter, is not felt because the rectal ampulla is massively distended.
- Patients or their parents often stop stool softeners as soon as a normal stool pattern starts. If therapy has been ended prematurely, the patient’s constipation and encopresis returns immediately because rectal tone is still poor and no other behavior or dietary modifications have been made.
Encopresis - bibliography
- 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;2:260–267.
- Di Lorenzo C, Benninga MA. Pathophysiology of pediatric fecal incontinence. Gastroenterology. 2004;126(1 suppl 2):S33–S40.
- Griffiths DM. The physiology of continence: Idiopathic fecal constipation and soiling. Semin Pediatr Surg. 2002;11:67–74.
- Kuhn BR, Marcus BA, Pitner SL. Treatment guidelines for primary nonretentive encopresis and stool toileting refusal. Am Fam Physician. 1999;59:2171–2178, 2184–2186.
- Loening-Baucke V. Encopresis. Curr Opin Pediatr. 2002;14:570–575.
- Loening-Baucke V. Functional fecal retention with encopresis in childhood. J Pediatr Gastroenterol Nutr. 2004;38:79–84.
- Rasquin-Weber A, Hyman PE, Cucchiara S, et al. Childhood functional gastrointestinal disorders. Gut. 1999;45(Suppl II):II60–II68.
- Rasquin A, Di Lorenzo C, Forbes D, et al. Childhood functional gastrointestinal disorders: Child/adolescent. Gastroenterology. 2006:130:1527–1537.
Encopresis - CODES
Encopresis - icd9
787.6 Incontinence of feces
Encopresis - FAQ
- Q: Is the medicine addictive?
- A: Stool softeners rather than cathartics are chosen for long-term therapy because the colon does not become dependent.
- Q: Will my child become sick if this problem is not resolved?
- A: Most children with chronic constipation and encopresis grow well and do not develop other health problems. The major problems are social and should be taken seriously. Social development is crucial for the school-aged child.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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