context: Encopresis is the soiling of underwear with stool by children who are past the age of toilet training. Because each child achieves bowel control at his or her own rate, medical professionals do not consider stool soiling to be a medical condition unless the child is at least 4 years old. This stool or fecal soiling usually has a physical origin and is involuntary -- the child doesn't do it on purpose. In the U. S., it is estimated that 1%-2% of children younger than 10 years are affected by encopresis. Many more boys than girls experience encopresis; approximately 80% of affected children are boys. Rarely, encopresis is caused by an anatomic abnormality or disease that the child is born with. In the great majority of cases, encopresis develops as a result of chronic (long-standing) constipation. What is constipation? Many people think of constipation as not passing a bowel movement every day. However, each person has his or her own schedule for bowel movements, and many healthy people do not have a bowel movement every day. A constipated child might pass a bowel movement every third day or less often. Constipation implies not only infrequent bowel movements, but also having difficulty or experiencing pain when doing so. In most children with encopresis, the problem begins with painfully passing very large stools. This may have happened long before the encopresis starts, and the child may not remember this when asked. Over time, the child becomes reluctant to pass bowel movements and holds it in to avoid the pain. This âholding inâ becomes a habit that often remains long after the constipation or pain with passing bowel movements has resolved. As more and more stool collects in the child's lower intestine (colon), the colon slowly stretches (sometimes called megacolon). As the colon stretches more and more, the child loses the natural urge to pass a bowel movement. Eventually, looser, partly formed stool from higher up in the intestine leaks around the large collection of harder, more formed stool at the bottom of the colon (rectum) and then leaks out of the anus (the opening from the rectum to the outside of the body). Often in the beginning, only small amounts of stool leak out, producing streaks in the child's underwear. Typically, parents assume the child isn't wiping very well after passing a bowel movement and aren't concerned. As time goes on, the child is less and less able to hold the stool in-more and more stool leaks, and eventually the child passes entire bowel movements into his or her underwear. Often the child is not aware that he or she has passed a bowel movement. Because the stool is not passing normally through the colon, it often becomes very dark and sticky and may have a very foul smell. Over time, the child with encopresis may also develop incoordination of the muscles used to pass bowel movements. In many children, the anal sphincter contracts rather than relaxes when they are trying to push out bowel movements. This disturbed coordination of muscle function, which causes fecal retention, is a key to the diagnosis and is also called anismus or paradoxic contraction of the pelvic floor to defecation. What causes the constipation in the first place? Some experts believe children become constipated when they do not eat enough fiber, available in fruits, vegetables, and whole grain foods. Many doctors think that some children become constipated because they do not drink enough water. Constipation does seem to run in certain families. For many children, no clear cause of the constipation can be identified. Encopresis is a very frustrating condition for parents. Many parents become angry at the repeated need to bathe the dirty child and to clean or discard soiled underwear. Many parents assume the soiling is the result of the child being lazy or that the child is soiling intentionally. In most cases, this is not the case. Children with encopresis are no more likely than other children to have major behavioral or emotional problems. More than 80% of children with encopresis have experienced constipation or painful defecation in the past. In many cases, constipation or pain occurred years before the encopresis is brought to a doctor's attention. Most children with encopresis say they have no urge to pass a bowel movement before they soil their underwear. Soiling episodes usually occur during the day, while the child is awake and active. Many school age children soil late in the afternoon after returning home from school. Soiling at night is uncommon. In many children with encopresis, the colon has become stretched out of shape, so they may intermittently pass extremely large bowel movements. Any of the following warrants a visit to your child's primary care provider: Severe, persistent, or recurrent constipation Pain during bowel movements Reluctance to have bowel movements, including straining to hold stool in Soiling in a child who is at least 4 years old To diagnose enopresis, your child's health care provider will ask many questions about his medical history, toilet training history, diet, lifestyle, habits, medications, and behavior. A thorough physical exam will be done to assess the child's general health as well as the status of the colon, rectum, and anus. The examiner may insert a gloved finger into the child's rectum to feel for stool and make sure the anal opening and rectum are of normal size and that the anal muscles are of normal strength. In most cases, blood tests are not part of the evaluation of constipation and/or encopresis. In some cases, an X-ray of the child's abdomen or pelvis is performed to determine how much stool is present in the colon and assess if the colon and rectum are enlarged. Occasionally, a barium enema is performed. This is a special type of X-ray. A small tube is inserted into the child's rectum, and the colon is slowly filled with a radiopaque dye (barium). X-rays are taken throughout the procedure to see if areas of narrowing, twisting, or kinking in the lower intestine are causing the child's symptoms. In some cases, anorectal manometry may be performed. With this test, a small tube is inserted into the child's rectum. The tube has several pressure sensors in it. During the test, the doctor can determine how the child is using his or her abdominal, pelvic, and anal muscles during defecation. Many children who have chronic constipation and/or encopresis do not use their muscles in a coordinated fashion during bowel movements. The main objective of manometry is to confirm increased pressure within the anus. Manometry can also show whether the nerves controlling the anal sphincter, anus, and rectum are present and working by measuring reflexes in this area. Manometry can measure how far the rectum is distended and whether sensation in this area is normal. Abnormal contractions of the muscles in the pelvic floor can be documented by using manometry. Anorectal manometry can also be helpful to rule out Hirschsprung disease, a very rare cause of constipation without encopresis. If Hirschsprung disease is seriously considered as a cause of your child's encopresis, a biopsy of the rectum may be necessary. A biopsy is the removal of a very tiny piece of tissue for examination under a microscope. This is done to look for the absence of nerve function in the rectum, a characteristic sign of Hirschsprung disease. Although parents will be following a regimen recommended by the child's health care provider, most of the work of treating encopresis is done at home. It is very important that parents and other caregivers keep a complete record of the child's medication use and bowel movements during the treatment period. This record can be very helpful in determining whether the treatment is working. Although many different regimens have been developed for the treatment of encopresis, most rely on the following principles: Empty the colon of stool Establish regular soft and painless bowel movements Maintain very regular bowel habits While there is almost always a large behavioral component to chronic encopresis, behavioral therapy alone, such as offering rewards or reasoning with the child, usually is not effective. Rather, a combination of medical and behavioral therapy works best. Medical professionals usually refer to emptying stool from the colon and rectum as evacuation or, in severe cases when the doctor needs to remove the stool manually, disimpaction. Evacuation can be accomplished in the following ways: Give an enema or series of enemas: An enema pushes fluid into the rectum. This softens the stool in the rectum and creates pressure within the rectum. This pressure gives the child a powerful urge to pass a bowel movement, and the stool is usually expelled rapidly. The fluid in most enemas is water. Something is usually added to keep the water from being absorbed by the intestinal lining. Widely used enemas include commercial sodium phosphate preparations (such as Fleet saline or Pedia- Lax enemas), saline, and mineral oil enemas. Daily enemas for several days may be needed to completely evacuate the colon. Give a suppository or a series of suppositories: A suppository is a tablet or capsule that is inserted into the rectum. The suppository is made of a substance that may stimulate the rectum to contract and expel stool or it may soften the stool by drawing extra water from the body into the bowel. Popular stimulant suppositories include Dulcolax or Fleet Bisacodyl. Popular stool softening suppositories with glycerin are provided by Fleet or Pedia- Lax. Daily suppositories for several days may be needed to completely evacuate the colon. Give strong laxatives: Most laxatives work by increasing the amount of water in the large intestine. Some laxatives cause the lower intestine to secrete water and others work by decreasing the amount of water absorbed in the lower intestine. In either case, the end result is much more water in the lower intestine when using laxatives than when not using them. This large amount of water softens formed or hard stool in the intestine and produces diarrhea. Laxatives used for this purpose include magnesium citrate, Miralax, Go LYTELY, and COLYTE products. Treatment for several days may be needed to completely evacuate the colon. Establishing regular soft and painless bowel movements is mostly a matter of retraining the child to give up the habit of retaining stool. This is accomplished by giving laxatives every day to produce soft bowel movements. The laxative must be given in doses large enough to produce one or two soft bowel movements every day. The soft stool will be passed easily and painlessly, encouraging the child to have regular bowel movements rather than holding the stool in. See Medications for a list of commonly used laxatives. Remember that fecal retention and soiling go together. So, as long as the child has retained stool in the rectum, the soiling will persist. The final step is working with the child to develop regular bowel habits. This step is just as critical as the first two steps and must not be abandoned just because the soiling has improved after the previous steps. Establish regular bathroom times: The child should sit on the toilet for 5-10 minutes after breakfast and again after dinner EVERY DAY. Some families must alter their daily routines to accomplish this, but it is a crucial step, particularly for school-aged children. Sitting on the toilet right after a meal takes advantage of the âgastrocolic reflex,â intestinal contractions that naturally occur after eating. Behavioral techniques: Offer age-appropriate positive reinforcement for developing regular toilet habits. For young children, a star or sticker chart can be helpful. For older children, earning privileges, such as extra television or video game time, may be useful. Training: Children may respond to teaching about the appropriate use of muscles and other physical responses during defecation. This helps them learn how to recognize the urge to have a bowel movement and to defecate effectively. Biofeedback: This technique has been used successfully to teach some children how to best use their abdominal, pelvic, and anal sphincter muscles, which they have so often used to retain stool. The duration of encopresis treatment varies from child to child. Treatment should continue until the child has developed regular and reliable bowel habits and has broken the habit of holding back his or her stool. This usually takes at least several months. Generally, it takes longer in younger children than in older children. Many parents are reluctant to give their child laxatives because they have heard that laxatives are harmful, cause more serious conditions (such as colon cancer), or promote dependency. There is no convincing evidence that any of these are true. Laxatives do not stop working if they are used every day for a long time. Most cases of encopresis respond to the treatment regimen outlined above. If the soiling does not resolve, your child's health care provider may refer you to a specialist in digestive and intestinal disorders (pediatric gastroenterologist), a behavioral psychologist, or both. Enemas: The use of enemas for encopresis is described above. The effectiveness of any particular enema preparation is probably more dependent on the volume (size) of the enema than on its chemical make-up. The phosphate-sodium enema ( Fleet Enema) is probably the most widely used type. Note: Some gastrointestinal specialists discourage the use of enemas and suppositories or any anal intervention because the child associates fear and pain with the anal area. The child may struggle or feel additional trauma when these types of manipulations are performed. Eventually, all impacted stool can be dissolved or disimpacted by using medications taken by mouth. Osmotic laxatives: These laxatives contain agents that are not efficiently absorbed by the intestinal lining. This results in large amounts of extra water in the intestine, which softens the stool. Since all osmotic laxatives work by increasing the amount of water in the colon, it is important that your child drinks lots of fluid while taking any of these laxatives. Like any medication, these should be given only as recommended by your child's health care provider. If the laxative does not seem to be working, do not increase the dose without talking to your child's health care provider. Rarely, these products interfere with other medications that your child takes. Magnesium hydroxide ( Philip's Milk of Magnesia, Pedia- Lax) -- Besides causing retention of fluid in the intestine, this laxative promotes the release of a hormone that stimulates movement of stool through the intestine. Some children experience abdominal cramping. This laxative is flavorless but has a thick chalky texture that may be more acceptable when mixed with a fluid such as milk or chocolate milk. It should be avoided by children with kidney problems. Lactulose ( Constulose, Enulose, Generlac, Kristalose) -- This laxative is generally very well tolerated and tastes sweet. It may cause gas and abdominal cramping at usual doses. Polyethylene glycol powder ( Miralax) -- This may pose less risk of dehydration or electrolyte imbalance than other osmotic laxatives. The powder is mixed in 8 ounces of water, juice, soda, coffee, or tea. The usual dose is 17 grams (fill to measuring line in cap of bottle) of powder per day. This laxative is tasteless, odorless, and usually quite easy to take. It may take slightly longer to work than other products. Sorbitol -- This indigestible sugar tastes quite sweet. It often causes gas and abdominal cramping. Magnesium citrate (several generic versions or Mag Citrate) -- This works by the same mechanism as magnesium hydroxide and should not be used if kidney disease is suspected. The product is clear (not chalky like magnesium hydroxide) and may be chilled to improve palatability. Polyethylene glycol balanced electrolyte solutions ( COLYTE, Go LYTELY) -- These balanced electrolyte solutions are based on the same ingredients as Miralax, but are used to clean the colon entirely in preparation for colonoscopy or abdominal surgery. They require drinking a large volume of fluid, which may be more acceptable if chilled. This laxative may be associated with nausea, bloating, abdominal cramps, and vomiting. Emollient laxatives: These products decrease the absorption of water from the colon, and thus soften the stool, making it easier to pass. Mineral Oil, Milkinol -- This laxative is largely tasteless and has an oily consistency. It may be more palatable if cold or mixed into a fluid such as orange juice. It may cause seepage of orange oil from the anus, which can cause itching and stain the underwear. This laxative should generally not be given with food. Stimulant laxatives: These agents have direct actions on the lining of the intestinal wall. They increase water and salt secretion into the colon and irritate the intestinal lining to produce contractions. Sennosides ( Ex- Lax, Fletcher's Castoria, Senokot) -- This laxative is derived from a plant, stimulates salt and water secretion into the colon, and promotes movement of stool through the colon. It is used rarely and under close supervision in children. It may cause abdominal cramping at higher doses. Bisacodyl ( Dulcolax or Fleet Bisacodyl) -- This colorless and odorless compound increases muscle contractions in the colon and stimulates salt and water secretion. It can be given by mouth or as a suppository and may cause abdominal cramping at higher doses. It is also used rarely and under close supervision in children. Dioctyl sodium sulphosuccinate ( Colace, Dulcoease stool softener, Fleet Sof- Lax) -- This is a detergent that simulates salt and water secretion into the colon and promotes movement of stool through the colon. It may cause abdominal cramping at higher doses. For encopresis, fiber supplements and certain foods, such as fruit juices and prunes, can have a laxative effect. These foods and juices function as osmotic laxatives. They all contain various sugars that are not efficiently absorbed by the intestinal lining, thus increasing the amount of water in the colon. Given in large enough doses, all of these foods and juices are very effective laxatives. For weight management and prevention of constipation, vegetables and fruit should be encouraged for all children. However, most children are not willing to take in enough of these items every day for many months to serve as primary treatment for encopresis. Eaten in large enough quantities to ensure two soft bowel movements a day, these foods and juices may cause bloating and gas. Drinking plenty of fluid helps keep stools soft and may help prevent constipation in the first place. Children with encopresis rarely need surgery. However, surgery may be used in extremely chronic and cases that don't respond to treatment. The extent of follow-up needed for encopresis varies by situation. Your child's health care provider will probably want to see him at least once after treatment is well under way to ensure that the treatment is working or to alter treatment if necessary. The best way to prevent encopresis is to prevent constipation in the first place. Make sure the child gets a varied diet with plenty of fruits and vegetables and whole grain breads and cereals. The child should drink water and other fluids frequently and be physically active every day. Finally, make sure the child has a regular time every day when he or she sits on the toilet. After a meal is the best time for this. Generally, the outlook for encopresis is excellent for children who undergo the treatment regimen outlined here. Many children who do not undergo treatment are able to resolve the problem on their own as they grow up, but this can take many years. The problem can persist into adulthood.