Encopresis - Types, Effects, Diagnosis, and Treatment

Introduction

Encopresis is the involuntary passage of stool or feces in children. Children with fecal incontinence will experience bowel movements and leak a small amount of feces in their underclothes, pants, or pajamas. It is common in children less than four years of age, especially those who are toilet trained. It may occur due to chronic constipation, and the diagnosis can be made only after four years of age.

How Is Encopresis Classified?

Encopresis can be broadly categorized into two categories:

1. Constipation-Associated Encopresis Or Retentive Encopresis: When the child experiences constipation, the stool becomes hard and dry and gets impacted in the colon, which may make it very difficult for the child to pass it out. This may result in tightening the bottom and becoming fussy. Over time the loose stool gets leaked into their underpants, and the hard solid stool gets impacted.

2. Non-Retentive Encopresis: This occurs in the following condition.

• Repaired anorectal malformations.

• Spinal cord trauma, tumor.

• Cerebral palsy.

• Psychological causes of stress.

• Myopathies affect the pelvic floor and the anal sphincter muscles.

Encopresis can also be subclassified into:

• Primary Encopresis: Encopresis that occurs before toilet training.

• Secondary Encopresis: Encopresisthat occurs after successful toilet training.

How Does Encopresis Affect Your Baby?

• Not able to hold the stool.

• Loss of appetite.

• Pain in the abdomen and bloating.

• Refusal to take medications.

• Constipation, hard stool pain, and difficulty during bowel movements.

• Tightening of the bottom muscles (buttocks) and clenching of the teeth due to pain during bowel movements.

• Soiling of the undergarments. Some children may also hide their soiled clothes.

• Refusal to sit on the toilet.

• Bedwetting and accidental urine leakage or urine retention.

What Happens to Your Child During Encopresis?

You may now be familiar that constipation is one of the main causes of encopresis. It results in hard, dry stools that are difficult to pass out. A large amount of hardened stool gets impacted in the rectum and colon. This impaction causes the stretching and enlargement of the rectum. The enlarged rectum and intestine lose their ability to detect the presence of stool. This may also be due to the weakening of the anal sphincter muscles (the muscles that help to hold the stool). When constipation occurs for a prolonged duration, stool gets collected, making it difficult for the child to let out. So eventually, some of the soft stool gets leaked without the awareness of the child, while the hardened stool remains impacted.

Who Is More Prone to Encopresis?

• Generally, boys are six times more prone to encopresis, but the reason for this is unknown.

• Children with chronic constipation.

• Inadequate intake of water and fruit juices and more soft and sugary drinks.

• Junk foods and a low-fiber or high-fat diet.

• Family stress may contribute to stress or stress factors at school.

• Lack of physical activity and exercise.

• Some children are busy playing and avoiding the use of the bathroom even if there is a need.

• Reluctant to use the public toilets.

• Changes in the bathroom routine, especially while entering school.

How to Diagnose Encopresis?

Diagnosis is generally made clinically by the doctor after a thorough physical examination and the history obtained from their parents. However, some investigations may be required to confirm the diagnosis of encopresis. They are:

1. Imaging Tests: Checks the intestines to rule out health conditions.

2. Abdominal X-Ray: This rules out only the amount of stool present in the large intestine.

3. Barium Enema: The barium fluid that shows up clearly in the X-ray. The fluid is put into a tube and inserted into the child’s rectum as an enema. Then the X-ray is taken. It rules out the presence of any obstructions or narrowed parts of the intestines (strictures).

4. Anorectal Manometry: This is a beneficial tool for diagnosing chronic constipation. It analyses the anal pressure and the rectal sensation.

5. Spinal Cord Imaging: Imaging of the spinal cord may be required to check for neurological abnormalities. This is because children with defecation problems are often associated with spinal cord abnormalities. This test checks for conditions such as gluteal cleft deviation suggestive of spinal cord abnormalities.

6. Psychiatric Therapy: Psychological evaluation to rule out stress or behavioral changes.

7. Other Tests:

• Urinalysis and urine culture.

• Thyroid function tests.

• Celiac disease screening.

• Serum calcium.

• Serum electrolytes test.

How Can This Condition Be Managed?

The majority of the encopresis cases reported are due to retentive fecal incontinence or chronic constipation. So the management should be in treating the root cause. Chronic constipation should be treated under four stages.

1. Education: The family should be well educated that maintaining therapy takes about six to 24 months. Explain to them priorly about their child’s health condition. This eliminates the unnecessary stress about their child's health.

2. Disimpaction: One effective treatment plan repeats a three day cycle consisting of an enema on day one, a Bisacodyl tablet on day two, and a Bisacodyl suppository on day three. The cycle is repeated three times for 12 to 15 days. Several cleanout schedules can be used regularly, including molasses enemas, Polyethylene glycol with electrolyte cleanouts, and high doses of polyethylene glycol without electrolytes. The major objective should be to avoid increasing the child's accident frequency during school hours.

3. Prevention From Reaccumulation: This can be achieved by implying dietary changes, behavioral changes, and medications. A healthy balanced diet with extra fiber and fluids etc. Biofeedback training on how to control their perineal muscles for bowel movements can be taught to the children.

4. Regular Follow-Ups: It is always advised to have a routine checkup after any treatment to look for the outcome of the treatment.

5. Maintaining Good Bowel Habits: Encourage your child to toilet sit at least twice a day.

6 . Exercises: Having good physical activity may help with digestion. This helps the food to get pushed forward as it gets digested. So encourage your child to play outside instead of watching television or other indoor activities.

7. Dietary Changes:

• Increase the fiber content in your child’s diet, such as whole-grain cereals.

• Include more fruits and vegetables.

• Replace the soft drinks with fresh juices and more water.

• Limit the caffeine drinks such as coffee, coke, etc.

• Serve your child's food early so that they can have a bowel movement before leaving for school.

If your child is facing pain during each bowel movement for longer periods and frequently soiling the clothes, then it is advised to take them for a physical examination with a doctor. This may rule out the health conditions and help in early treatment planning.

Conclusion:

Fecal incontinence is not a serious condition to worry about. However, it may create unnecessary stress for the child as well as the parents. Early diagnosis and initialization of appropriate treatment will prevent any serious conditions. Parents are always advised to toilet train their kids only at the right time. Most often, early toilet training may cause the condition in children. And if encopresis is not due to constipation, as in cases of retentive encopresis, diagnosing the underlying medical condition is essential. Generally, children respond well to the treatment of encopresis, so parents need not panic about their child’s health.