Editing Encopresis

{{short description|Fecal incontinence in children}}
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{{Infobox medical condition (new)
| name            = Encopresis
| synonyms        = Paradoxical diarrhea
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| field           = [[Psychiatry]], [[Clinical Psychology]], [[Pediatrics]]
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'''Encopresis''' ({{ety|grc|''ἐγκόπρησις'', enkóprēsis}}) is voluntary or involuntary [[Defecation|passage of feces]] outside of [[toilet training|toilet-trained]] contexts (fecal soiling) in children who are four years or older and after an organic cause has been excluded.<ref name="von Gontard A" /> Children with encopresis often leak [[feces|stool]] into their undergarments.

This term is usually applied to children, and where the symptom is present in adults, it is more commonly known as ''[[fecal incontinence]]'' (including [[fecal soiling]], [[fecal leakage]] or [[fecal seepage]]).<ref>{{cite book |editor=Bruce G. Wolff |title=The ASCRS textbook of colon and rectal surgery |year=2007 |publisher=Springer |location=New York |isbn=978-0387248462 |display-authors=etal}}</ref>

==Signs and symptoms==
(In)voluntary soiling of undergarments. There are two types: with or without constipation.<ref>{{cite web|title=Encopresis|publisher=Mayo Clinic|url=https://www.mayoclinic.org/diseases-conditions/encopresis/symptoms-causes/syc-20354494|access-date=14 October 2020}}</ref> Those with constipation may experience decreased appetite, abdominal pain, have pain on defecation, have fewer bowel movements, and have hard or soft stools.<ref name="von Gontard A">von Gontard A. Encopresis. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2012.</ref> Those without constipation do not have these symptoms.<ref name="von Gontard A" />

==Causes==

Encopresis is commonly caused by [[constipation]] in children,<ref name="Mulhem 2022">{{cite journal |last1=Mulhem |first1=E |last2=Khondoker |first2=F |last3=Kandiah |first3=S |title=Constipation in Children and Adolescents: Evaluation and Treatment. |journal=American Family Physician |date=1 May 2022 |volume=105 |issue=5 |pages=469–478 |pmid=35559625}}</ref> by reflexive withholding of stool, by various physiological, psychological, or neurological disorders, or from surgery (a somewhat rare occurrence).

The colon normally removes excess water from feces. If the feces or stool remains in the colon too long due to conditioned withholding or incidental constipation, so much water is removed that the stool becomes hard, and becomes painful for the child to expel in an ordinary bowel movement. A vicious cycle can develop, where the child may avoid moving his/her bowels in order to avoid the "expected" painful toilet episode. This cycle can result in so deeply conditioning the holding response that the rectal anal inhibitory response (RAIR) or [[anismus]] results. The RAIR has been shown to occur even under anesthesia and when voluntary control is lost. The hardened stool continues to build up and stretches the colon or rectum to the point where the normal sensations associated with impending bowel movements do not occur. Eventually, softer stool leaks around the blockage and cannot be withheld by the anus, resulting in soiling. The child typically has no control over these leakage accidents, and may not be able to feel that they have occurred or are about to occur due to the loss of sensation in the rectum and the RAIR. Strong emotional reactions typically result from failed and repeated attempts to control this highly aversive bodily product. These reactions then in turn may complicate conventional treatments using stool softeners, sitting demands, and behavioral strategies.

The onset of encopresis is most often benign. The usual onset is associated with toilet training, demands that the child sit for long periods of time, and intense negative parental reactions to feces. Beginning school or preschool is another major environmental trigger with shared bathrooms. Feuding parents, siblings, moving, and divorce can also inhibit toileting behaviors and promote constipation. An initiating cause may become less relevant as chronic stimuli predominate.

==Diagnosis==
The psychiatric ([[DSM-5]]) diagnostic criteria for encopresis are:
# Repeated passage of feces into inappropriate places (e.g., underwear or floor) whether voluntary or unintentional
# At least one such event a month for at least 3 months
# Chronological age of at least 4 years (or equivalent developmental level)
# The behavior is not exclusively due to a physiological effect of a substance (e.g., laxatives) or a general medical condition, except through a mechanism involving constipation.

The DSM-5 recognizes two subtypes: with constipation and overflow incontinence, and without constipation and overflow incontinence. In the subtype with constipation, the feces are usually poorly formed and leakage is continuous, and this occurs both during sleep and waking hours. In the type without constipation, the feces are usually well-formed, soiling is intermittent, and feces are usually deposited in a prominent location. This form may be associated with [[oppositional defiant disorder]] (ODD) or [[conduct disorder]], or may be the consequence of large anal insertions, or more likely due to chronic encopresis that has radically desensitized the colon and anus.

==Treatment==
Many [[pediatricians]]{{weasel-inline |date=March 2025}} will recommend the following three-pronged approach to the treatment of encopresis associated with constipation:
# Cleaning out
# Using stool-softening agents
# Scheduled sitting times, typically after meals

The initial clean-out is achieved with enemas, laxatives, or both. The predominant approach today is the use of oral stool softeners like [[Movicol]], [[Miralax]], [[lactulose]], [[mineral oil]], etc. Following that, enemas and laxatives are used daily to keep the stools soft and allow the stretched bowel to return to its normal size.

The child must be taught to use the toilet regularly to retrain his/her body.{{citation needed |date=March 2025}} It is usually recommended{{weasel-inline |date=March 2025}} that a child be required to sit on the toilet at a regular time each day and "try to go" for 10–15 minutes (timed toileting), usually soon (or immediately) after eating. Children are more likely to be able to expel a bowel movement right after eating (due to the [[gastrocolic reflex]]). It is thought that creating a regular schedule of bathroom time will allow the child to achieve a proper elimination pattern. Repeated voiding success on the toilet itself helps it become a releasor stimulus for successful bowel movements.

Alternatively, when this method fails for six months or longer, a more aggressive approach may be undertaken using [[suppository|suppositories]] and enemas in a carefully programmed way to overcome the reflexive holding response and to allow the proper voiding reflex to take over. Failure to establish a normal bowel habit can result in [[Megacolon|permanent stretching of the colon]]. Certainly, allowing this problem to continue for years with constant assurances that the child "will grow out of it" should be avoided.

Dietary changes are an important management element. Recommended changes to the diet in the case of constipation-caused encopresis include:{{citation needed |date=March 2025}}
# Reduction in the intake of constipating foods such as dairy, peanuts, cooked carrots, and bananas
# Increase in high-fiber foods such as bran, whole wheat products, fruits, and vegetables
# Higher intake of water and liquids, such as juices, although an increased risk of tooth decay has been attributed to excess intake of sweetened juices
# Limit drinks with caffeine, including cola drinks and tea
# Provide well-balanced meals and snacks, and limit fast foods/junk foods that are high in fats and sugars
# Limit whole milk to {{convert|500|mL|USfloz|0|abbr=on}} a day for the child over two years of age, but do not eliminate milk because children need calcium for bone growth and strength.{{citation needed|date=April 2018}}<!-- 500 mL per day seems like a lot of milk. Isn't that more milk than what is consumed by most children? This item is also redundant with the first item, which includes reduction in dairy intake. -->

The standard behavioral treatment for functional encopresis, which has been shown to be highly effective, is a motivational system such as a [[contingency management]] system.<ref name="Patrick C">Patrick C. Friman, Kristi L. Hofstadter and Kevin M. Jones (2006): [https://psycnet.apa.org/record/2014-52016-005 A Biobehavioral Approach to the Treatment of Functional Encopresis in Children.] ''Journal of Early and Intensive Behavior Intervention (JEIBI) 3 (3)'',  page 263–272. {{doi|10.1037/h0100340}}</ref> In addition to this basic component, seven or eight other behavioral treatment components can be added to increase effectiveness.<ref name="Patrick C" />

==Epidemiology ==

The estimated [[prevalence]] of encopresis in four-year-olds is between one and three percent.<ref>{{cite journal|last1=von Gontard|first1=Alexander|title=Encopresis|journal=The Practitioner|volume=243|issue=1602|pages=644, 648–52|pmid=10715861|publisher=Prax Kinderpsychol Kinderpsychiatr|year=1999}}</ref> The disorder is thought to be more common in males than females, by a factor of 6 to 1.{{cn |date=March 2025}}

==References==
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==External links==
{{Medical resources
 | DiseasesDB     = 4221
 | ICD10          = {{ICD10|R|15||r|10}} {{ICD10|F|98|1|f|90}}
 | ICD9           = {{ICD9|307.7}}, {{ICD9|787.6}} 
 | ICDO           = 
 | OMIM           = 
 | MedlinePlus    = 001570
 | eMedicineSubj  = ped
 | eMedicineTopic = 670
 | MeshID         = D004688
}}

{{Digestive system and abdomen symptoms and signs}}
{{Authority control}}

[[Category:Mental disorders diagnosed in childhood]]
[[Category:Symptoms and signs: Digestive system and abdomen]]
[[Category:Constipation]]
[[Category:Gastrointestinal motility disorders]]
[[Category:Elimination disorders]]