Encopresis, also called fecal soiling, is when a child passes stool (feces, bowel movements) into his or her underpants or some other inappropriate place. The medical definition of encopresis says that the child must be at least 4 years old, the age by which most children can control bowel movements. However, some experts say that any child over age 3 who is not toilet trained has encopresis. Encopresis occurs in 1% to 2% of all school-aged children in the United States. Boys have the problem more often than girls.

In 9 out of 10 children with encopresis, the problem is related to chronic constipation, which means bowel movements don't occur often enough, and the stool is hard and dry.

When stool needs to be passed, it collects in the lower bowel (rectum), stretching the bowel wall. This feeling of the bowel being stretched is what normally makes us realize we have to go to the bathroom. However, if the bowel wall is stretched for long periods without passing a bowel movement, the rectum loses its normal muscle tone and feeling. This makes it harder and harder to pass the chunk of hard stool collecting in the rectum. As newer stool continues to be made in the intestines, it leaks around the large chunk of hard stool and passes out of the rectum, soiling the child's underpants. In almost all children who have encopresis caused by constipation, this is not done on purpose. In fact, many children do not even realize that stool has leaked out. The first clue that the child has a problem may come when a parent, teacher or playmate notices that the child smells bad.

Chronic constipation that turns into encopresis can have many different causes, including:

• Tension and anxiety because of problems during toilet training



• A diet that is low in fiber (such as fruits, vegetables and whole grains) and high in foods that tend to cause constipation (such as whole milk, cheese, bananas, white rice and white bread)



• Not drinking enough liquids



• An inactive lifestyle with too little exercise (exercise stimulates the intestines to move)



• Fear and anxiety about using an unfamiliar bathroom, for example, one at school, a friend's house, a hotel or at summer camp



• Not paying attention to the feeling (urge) that it's time to have a bowel movement: Some children do not go to the bathroom when they have the urge to do so because they are too busy playing, watching television or doing some other engaging activity. At school, they may be afraid to ask for permission to leave class to use the bathroom.



• A fissure � When a child with constipation finally passes a bowel movement, the abnormally large stool may injure the skin of his or her rectum, producing a painful tear in the skin called a fissure. Because of this painful fissure, the child may become more and more anxious about having a bowel movement fearing this pain.



• Hypothyroidism � Having low levels of thyroid hormones can make a child's digestive system function more slowly than normal, leading to constipation.

No matter what the cause of a child's chronic constipation, the end result is the same. A large chunk of stool builds up and stretches the rectum until it loses normal tone and feeling. This makes it more difficult for the rectum to push out stool, More and more stool builds up. This unhealthy cycle can only be broken when the bowel is completely cleared of stool, allowing it to return to its normal size. Then a child can learn how to empty his or her bowel on a more regular schedule.

In rare cases, encopresis is related to medical problems involving the nerves in the spine or bowel wall, or to psychological issues, such as anger, abnormally impulsive behavior, grief over the death of a loved one, sexual abuse or some other stress.

In most children with encopresis, the most obvious signs are soiled underpants and a foul odor (the smell of feces). Other signs and symptoms may include:

• Periods of constipation (no bowel movements) alternating with very large bowel movements



• Streaks of blood on the outside of stool, or on toilet tissue used to wipe after a bowel movement



• Pain in the lower abdomen or rectum



• Stool-stained clothes hidden in closets, under the bed or elsewhere



• Bedwetting, probably related to pressure from the large chunk of stool in the rectum; this occurs in about 40% of cases of encopresis.

In very rare cases, when encopresis is caused by serious psychological problems, a child may drop or smear stool on floors, walls or furniture.

The doctor will ask about your child's bowel habits, including how often he or she has bowel movements, the size of your child's bowel movements, and whether the outsides of the stools have been streaked with blood. The doctor will ask about your child's diet, especially about foods that tend to cause constipation (whole milk, cheese, bananas, white rice, white bread) and about high-fiber foods (fruits, vegetables, whole grains), which help to keep stools soft. Some doctors ask parents to keep a diary of the child's diet and stools for a week to help figure out how best to treat the child. The doctor will want to know about any unusual stresses in your child's life, either at home or at school.

The doctor will examine your child to look for any physical abnormalities in your child's abdomen, genital area or lower spine. The doctor may examine your child's rectum to look for any fissures or other abnormalities, and may check to see how much stool is in the rectum.

In most cases, your doctor can diagnose encopresis based on your child's age, the history and symptoms of chronic constipation, and the physical examination. Usually no further tests are necessary.

If the doctor thinks the problem may be related to abnormalities in your child's lower digestive tract, he or she may order an X-ray procedure called a barium enema or a procedure called a rectal biopsy. In a biopsy, a small piece of tissue from the rectum is removed and examined in a laboratory. If your child has signs of hypothyroidism, your doctor may order blood tests to measure thyroid hormone levels.

In about half of children with encopresis, the problem stops on its own within two years. Almost all children with encopresis stop soiling by the time they reach their mid-teen years.

To help prevent encopresis caused by chronic constipation, you can:

• Temporarily avoid feeding your child foods that tend to cause constipation, especially bananas, apples, white rice, cheese and gelatin. Even too much milk can be a problem, so ask your doctor how much milk is too much for your child.



• Gradually increase the amount of water and fiber in your child's diet. Your doctor can guide you about the number of glasses of water and the amount of daily fiber recommended for your child's age.



• Have your child sit on the toilet for 10 to 15 minutes twice each day, at the same times every day. Your child also should go to the toilet 10 to 15 minutes after every meal.



• Keep your child active. Exercise helps to get the intestines (bowels) moving, so that stool passes through more easily and quickly.



• Encourage and praise your child for each successful "clean" day without soiling. Never punish, shame or blame.



• Check with your doctor before you give your child enemas or rectal suppositories. Avoid using laxatives every day unless this is part of your child's treatment plan.

Remember, even after your child has become completely toilet trained, occasional accidents will happen. Remain calm and casual as you change your child's soiled clothing. Try not to show disgust, disappointment or frustration with your child.

If your child has encopresis because of chronic constipation, treatment is a three-step process that involves:

If your child has encopresis because of a neurological or developmental problem involving the digestive tract, your doctor will refer you to a specialist, such as a neurologist or gastroenterologist, for treatment.

If your child's encopresis seems to be related to serious psychological problems, your doctor most likely will refer you to a psychiatrist or a developmental specialist.

Call your doctor if your child is older than age 4 and consistently soils his or her pants with stool, or has started soiling after being clean for many months or years. Call your doctor if your child frequently has constipation, even if he or she is not having a problem with encopresis.

Call your doctor immediately if your child begins to intentionally deposit or smear stool anywhere, including around the home or school.

Most children with encopresis either outgrow the problem or respond to treatment, including changes in diet, medication and motivational therapy.

When encopresis is related to psychological or emotional problems, treatment may take longer.

National Digestive Diseases Information Clearinghouse (NDDIC)
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Bethesda, MD 20892-3570
Toll-Free: 1-800-891-5389
Phone: 301-654-3810
Fax: 301-907-8906
Email: nddic@info.niddk.nih.gov
http://digestive.niddk.nih.gov/

American College of Gastroenterology (ACG)
P.O. Box 342260
Bethesda, MD 20827-2260
Phone: 301-263-9000
http://www.acg.gi.org/

American Academy of Family Physicians (AAFP)
11400 Tomahawk Creek Parkway
Leawood, KS 66211-2672
Phone: 913-906-6000
Toll-Free: 1-800-274-2237
Email: email@familydoctor.org
http://www.familydoctor.org/

American Academy of Pediatrics (AAP)
141 Northwest Point Blvd.
Elk Grove Village, IL 60007-1098
Phone: 847-434-4000
Fax: 84-434-8000
Email: kidsdocs@aap.org
http://www.aap.org/