Understanding Encopresis and Elimination Disorders

Encopresis is a common but frequently misunderstood elimination disorder in children that presents unique challenges to the affected child and their family—repeated passing of stool in inappropriate places, such as in clothing, either voluntarily or involuntarily.

Encopresis, which may initially appear simple and related to toilet training, is a complex condition often associated with complex physical, emotional, or behavioral issues. In families, the disorder can result in substantial emotional strain, feelings of guilt or frustration, and shame on the part of the child.

Like many conditions, understanding the causes, symptoms, and treatment options can help reduce the impact and promote a supportive recovery environment ^[1].

What Is Encopresis?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) places encopresis (or encopretic disorder) in the category of elimination disorders. It is based on the passage of stool in inappropriate locations at least once a month for at least three months in children aged 4 years or older ^[2]. Accidents are part of toilet training, but with encopresis, they persist and interfere with a child’s daily life.

Based on prevalence estimates, encopresis affects 1 – 3 percent of school-aged children and is disproportionately common in boys^[3]. Although most commonly diagnosed in children between the ages of 4 and 7, older children and even adolescents can struggle with the condition if it is not treated ^[1].

There are two primary types of encopresis:

1. Retentive encopresis: The most common form of this condition results from chronic constipation, which leads to stool retention. With time, the stool will build up and eventually leak out involuntarily due to overflow ^[4].
2. Non-retentive encopresis: The less common type occurs without underlying constipation. It may be due to behavioral problems, for example, a refusal to toilet train, or psychological problems, such as stress or trauma ^[2].

The type of encopresis will determine a treatment plan specific to the child’s unique circumstances.

Signs and Symptoms of Encopresis

The involuntary or voluntary soiling of underwear or clothing is the most visible and distressing symptom of encopresis. However, you often see additional symptoms as part of the condition that a parent or caregiver might not notice right away.

• Changes in bowel habits: Infrequent bowel movements are often painful, and the stools are large. All these irregular patterns may be an indicator of stool retention issues ^[4].
• Constipation: Retentive encopresis is characterized by a hard, dry stool that is difficult to pass and, in many cases, results in overflow incontinence ^[3].
• Abdominal pain: Children with chronic stool retention often experience persistent discomfort, bloating, or abdominal cramping ^[2].
• Behavioral issues: Children with encopresis often feel embarrassed about accidents and may avoid social situations, get angry, or not do as they’re told as a result^{[ 3]}.
• Fecal odor: The odor itself may be so noticeable and persistent that peers tease the child, thus isolating them. Of course, this would impact the young person’s emotional well-being ^[4].

Parents should also look out for signs of withholding, like crossing their legs, squatting, or clenching their muscles so as not to have a bowel movement, which can worsen the situation ^[3].

Causes of Encopresis

Chronic constipation accounts for up to 80 percent of cases of encopresis ^[2]. If a child suffers a painful or uncomfortable bowel movement, they may develop anxiety about defecation and subsequently become afraid to pass a stool^[3].

The withholding worsens over time until, eventually, stool builds up, and subsequent bowel movements become even more difficult and painful. The rectum eventually is stretched out so much that it is less able to respond to the signal that you have a stool there, resulting in involuntary leakage ^[4].

Other potential contributors to encopresis include:

• Psychological factors: Some things that can make withholding worse and increase the likelihood of constipation are increased emotional stress, anxiety, or a significant life change, such as moving, going to school, or having a new baby sibling ^[2].
• Poor dietary habits: Hard, dry stools that can be difficult to pass, caused by eating a diet low in fiber and water, can raise your chances of being unable to pass a stool (stool retention) ^[3].
• Toilet training challenges: Excessively strict, punitive, or rushed toilet training can create negative associations with the bathroom, thus making the child reluctant to use the toilet when necessary ^[4].
• Medical conditions: Although unusual, encopresis can be linked with health problems, including Hirschsprung’s disease, hypothyroidism, or spinal abnormalities ^[1].

Knowing why and how your child developed encopresis is integral to treatment and prevention ^[3].

Diagnosis of Encopresis

The encopresis diagnosis starts with obtaining a complete medical history and conducting a physical examination. The healthcare provider will ask about the child’s bowel habits, eating history, toilet training, and whether the child has emotional or behavioral issues ^[2].

Key diagnostic steps include:

1. Medical history: The provider will want to ask detailed questions about the frequency, consistency, and size of this child’s bowel movements, as well as any signs that this child is withholding or if pain is involved ^[3].
2. Physical examination: During a physical exam, abdominal distension or impacted stool may be checked during a rectal exam to determine the severity of constipation^[4].
3. Imaging: Stool retention can be confirmed by X-rays or ultrasounds to rule out anatomical abnormalities ^[3].
4. Laboratory tests: When symptoms continue for a few weeks or get worse, healthcare providers may need blood work or stool samples to rule out other medical conditions like hypothyroidism or celiac disease ^[1].

Diagnosis relies on meeting the criteria in the DSM-5, which includes repeated soiling in children over the age of four and excludes other possible causes of incontinence. Early diagnosis is vital for successful treatment and the prevention of complications ^[2].

Treatment of Encopresis

Treatment of encopresis is often successful if medical intervention, behavior strategies, and lifestyle changes are combined and tailored to the child’s needs^{[ 3]}.

Medical Interventions

A common treatment for constipation and stool retention involves using laxatives or stool softeners, such as polyethylene glycol (MiraLAX)^[4]. These drugs operate by softening the stool, so it is easier and less painful to pass.

In the most severe cases of impaction, before beginning maintenance therapy, the rectum must be cleared by enema or manual disimpaction ^[2].

Behavioral Modifications

Ideally, a toilet routine should be established. Making the child sit on the toilet for 5–10 minutes after meals will train the bowels to redevelop their skills ^[3].

Praise, rewards, or sticker charts are examples of positive reinforcement training methods that can encourage children to treat or persist against resistance ^[4].

Dietary Changes

Foods rich in fiber, such as fruits, vegetables, and whole grains, help move food through the digestive system and keep stool soft so it doesn’t harden or dry ^[2].

The same is true for maintaining soft stools and preventing constipation. Increasing water intake is equally important for encouraging adequate hydration ^[3].

Psychotherapy

Children who have major emotional or behavioral problems with encopresis may be helped by seeing a counselor or therapist. Cognitive-behavioral therapy (CBT) can also treat subordinate anxiety, low self-worth, or feelings of shame, which could block recovery ^[1].

How to Manage Encopresis at Home

Encopresis management works best when parents actively support their child’s recovery. While professional guidance is key, a structured and supportive home environment can make a massive difference in treatment outcomes.

• Establish a toilet schedule: Try having the child sit on the toilet for 5 to 10 minutes after meals, using a step stool for comfort and correct positioning. This routine also ensures eating and bowel movements are coordinated for proper regularity.
• Promote a healthy diet: Add fiber-rich foods like apples, carrots, and oatmeal into your child’s meals, and have them drink plenty of water to loosen up stools and facilitate easy passage.
• Use positive reinforcement: Reward small successes (e.g., sitting on the toilet, reporting the urge to go) to build confidence and reinforce progress.
• Avoid punishment: React to accidents with patience and compassion, telling your child that accidents are a natural part of life. Criticism or punishment increases anxiety and makes the condition worse.
• Provide emotional support: Create an open atmosphere without judgment, in which people are not afraid to talk about their fears and struggles.

Minimizing stress for the child and their caregivers requires consistency in patience and approach.

Conclusion

Encopresis is an emotionally and physically challenging condition for the children affected and their families. Although it might initially seem daunting, knowing the causes, symptoms, and treatment options is essential for recovery. Early intervention, medical care, behavioral strategies, and emotional support help children regulate normal bowel functions and regain confidence.

Family is crucial, too, as it encourages a supportive and patient response that allows the individual to recover. Proper care and guidance help most children overcome enuresis or encopresis and improve their quality of life and long-term well-being. The keys to success are patience, education, and collaboration between the family and the healthcare provider.