This page contains information on encopresis which I pulled off the web. Authors and sight address included when available.
What is encopresis?
When somebody suffers from encopresis it means that he or she can't control their bowel movements and so they pass bowel movements in their underwear. Sometimes people use the words "soiling" or "fecal incontinence" to mean the same thing.
The Children's Medical Center of the University of Virginia
In encopresis, a child who is above age 4 — the age when most
children achieve bowel control — passes stool into his or her
underpants or some other inappropriate place. Encopresis occurs in
about 1 percent of all school-age children in the United States,
with boys affected three to six times more often than girls.
In nine out of 10 children with encopresis, the problem is directly
related to chronic constipation. In chronic constipation, the lower
bowel becomes distended with a large mass of hard, dry accumulated
stool. As newer stool is produced in the intestines, it leaks
around the mass of hard stool, passes out of the rectum, and soils
the child's underpants with a foul-smelling liquid or paste. In
almost all children with this type of encopresis, fecal soiling is
not done on purpose. In fact, some children do not even realize
that the stool has leaked out. The first embarrassing clue to their
problem may come when a parent, teacher or playmate notices that
the child "smells bad."
When chronic constipation triggers encopresis, it can have many
different causes. Just a few of these causes are:
No matter what the initial cause of a child's chronic constipation,
the end result is the same. As the large mass of stool accumulates,
it stretches out the bowel and makes the bowel lose its normal
muscle tone and sensation. Without normal muscle tone and
sensation, the bowel finds it harder and harder to move the mass of
accumulated stool. This creates an unhealthy cycle that can only be
broken when the bowel is finally cleared of stool, allowed to
return to its normal width, and then "taught" to empty itself
according to a more regular schedule.
In the 10 percent of children with encopresis who do not have
chronic constipation, the disorder may be related to neurological
problems involving the child's spinal nerves or bowel wall, or to
psychological issues. If psychological issues are the cause, then
the child's underlying problem may really be anxiety, anger,
abnormally impulsive behavior, grief over the death of a loved one,
sexual abuse or some other stress.
In most cases, encopresis develops as a result of long-standing
constipation. The vast majority of of children suffering from
encopresis have a history of constipation or a history of passing
large and/or painful bowel movements. In many cases, the child or
the parents do not recall the constipation since it was so long
ago.
With constipation and painful bowel movements, children may not
completely empty themselves when they go to the bathroom. Over a
long period of time the large intestine slowly fills with stool and
stretches out of shape. As the large intestine stretches larger and
larger, liquid stool from the small intestine begins to "leak"
around the more formed stool in the colon. In the beginning, this
leakage is usually small amounts that streak or stain the underwear
and most parents just assume their child isn't wiping him or
herself very well.
As the intestine stretches further, the amount of leakage increases
so that eventually children begin having "accidents" - they pass
whole bowel movements in their underwear! This is called
encopresis. Because the accidents consist of stool that is
"leaking" through the intestine and not getting completely
digested, they are usually very dark and sticky, smell very badly,
and they have to scraped off the skin and clothing.
Since these accidents represent "leaking" of soft stool through the
colon, children don't usual feel the "accidents" happening -
rather, they just seem to happen. The accidents tend to occur more
often during the daytime when the child is active and moving
around, and only rarely do they occur at night while the child is
asleep.
In most cases, encopresis is not primarily a behavioral problem -
children with encopresis do not have their accidents out of spite
or because they are lazy. Rather, many behavioral problems develop
because of the encopresis, and once the encopresis is treated, many
of the behavioral problems may resolve
Symptoms
In most children with encopresis, the most obvious signs are soiled
underpants and a foul body odor (the smell of stool). Other signs
and symptoms include:
Diagnosis
The doctor will begin by asking about your child's bowel habits,
including the frequency and size of your child's bowel movements,
and whether the stools have been streaked with blood. In addition,
the doctor will ask about your child's diet, especially daily
intake of water, protein (meat), dairy products, and high-fiber
fruits and vegetables. (Some doctors ask parents to keep a diary
of the child's diet and digestive symptoms for five to seven days
prior to the first office visit.)
Also, to check for psychological problems as a cause of encopresis,
your doctor will want to know about any unusual stresses in your
child's life, either at home or at school.
In most cases, your doctor can make a correct diagnosis based on
your child's age, the history and symptoms of chronic constipation,
and the results of a physical examination. During the physical
exam, your doctor will look for any physical abnormalities in your
child's abdomen, genital area and lower spine. Your doctor will
also perform a digital rectal examination to check for structural
abnormalities of the rectum, fissures and accumulated stool.
In most children, no further tests are necessary. Rarely, a barium
enema or a rectal biopsy may be needed if the doctor suspects that
your child's encopresis is due to a structural or developmental
problem in the lower digestive tract. Also, if your child has signs
of hypothyroidism, your doctor may order blood tests to measure
thyroid hormone levels.
In about 50 percent of cases, the problem stops spontaneously
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:
Remember, even after your child has become completely toilet
trained, occasional accidents will happen. It is important that
you remain calm and casual as you change your child's soiled
clothing. Try not to show disgust or disappointment.
If your child has encopresis because of chronic constipation, treatment is a three-step process that involves:
Since most cases of childhood encopresis result from constipation,
treatment is similar to the treatment outlined for chronic
constipation. It is important to remember that while most
encopresis begins with constipation, by the time soiling develops,
most children are no longer experiencing lots of pain with bowel
movements. In children with encopresis, avoidance of the toilet is
often a habit that began long ago. It is also important to remember
that children with encopresis often don't have the normal urge to
go to the bathroom.
There are many different ways to treat childhood encopresis, but
in the end, most treatments revolve around three basic principals:
The Children's Medical Center of the University of Virginia
There are many different ways of accomplishing these three
principals. While most children with encopresis have some behavior
problems associated with toileting, behavior therapy alone is
usually not sufficient to eliminate the problem. Most of the time,
laxatives are needed to re-establish regular bowel movements.
In most cases, as soon as the colon is completely evacuated, the
encopresis improves or stops, however it is important to continue
treatment long enough to assure regular bowel habits are
established and intestinal coordination recovers.
There are three commonly used methods of emptying the large
intestine:
When we administer an enema, we push fluid into the rectum. The fluid softens the stool in the rectum but it also stretches the rectum giving the child a tremendous urge to pass a bowel movement. Almost all enemas consist mostly of water with something else mixed in to keep the water inside the intestine. The most commonly used enemas are:
Administer suppositories -
By administering a suppository, we irritate the bottom of the intestine, causing it to contract (squeeze) and push out a bowel movement. Some suppositories also stimulate the intestine to secrete salt and water softening the stool in the rectum and making it easier to push out. Commonly used suppositories include:
Administer powerful laxatives to "flush out" the lower intestine -
When we administer very powerful laxatives to "flush out" the lower intestine, we are generally keeping lots and lots of water in the intestine, softening any stool in the lower intestine, and causing diarrhea. Laxatives used to flush out the intestine include:
Once the large intestine has been emptied, laxatives are administered regularly to produce soft bowel movements once or twice each day. Virtually any laxative preparation will be effective if it is given in high enough doses. Most of the commonly employed laxatives work by keeping large amounts of water in the intestinal tract, thus making the bowel movements very soft and keeping the stool moving quickly through the large intestine. Commonly employed laxative preparations include:
In high enough doses, many foods are very effective laxatives
however it is often difficult to eat or drink enough of these foods
day in and day out to be effective long-term treatments. In high
doses most fruits and juices can be very effective laxatives. Many
people are familiar with using prunes as laxatives. Much like
fiber laxatives, prunes contain complex sugars that are not
digested or absorbed in the intestine. As a result, the sugars
remain in the intestine and keep water with them. The end result is
that there is much more water in the stool, keeping it very soft,
and causing it to move through the intestine more quickly. As with
fiber laxatives, high doses of prunes often produce bloating and
gas.
While many parents and physicians are worried about using laxatives in children, most of their concerns are unfounded. Some common misconceptions include:
Laxatives lose their effectiveness if they are used for prolonged periods.
Children who use laxatives have an increased risk of developing colon cancer.
Early on, most medical treatment regimens revolve around evacuating the intestine and using laxatives to keep the stools soft, but to assure long-term success, it is crucial that the child develops very regular bowel habits.
Children should get in the habit of sitting on the toilet for five to ten minutes after breakfast and again after supper. Many families have very busy schedules and their children are not in the habit of "making time" to pass bowel movements. By establishing regular "bathroom times" after meals, we take advantage of intestinal contractions that occur after we eat. These contractions are often called the "gastro-colic reflex" and they explain why some people pass bowel movements every morning after breakfast or every evening after supper. It is also useful to establish regular bathroom times after breakfast and after supper because many children are completely unwilling to pass bowel movements at school (just as many adults are unwilling to go to pass bowel movements at work).
For many children, positive reinforcement techniques can be very helpful in promoting very regular bathroom times. Younger children often do well with "star charts" however these may not work as well for older children and parents may need to use another more age-appropriate scheme.
Some pediatric centers offer biofeedback therapy as a way of improving the muscle coordination associated with passing bowel movements. Remember, many children with chronic constipation have become quite incoordinated and use muscles against one another when they try to pass bowel movements. With biofeedback, several small wires are taped to the skin around the anus and on the abdomen. These wires can measure what the different muscle are doing and display this information on a television screen. By playing a type of video game, a child can learn how to tighten and relax his or her muscles in ways that make passing bowel movements more efficient.
At the Children's Medical Center at the University of Virginia, we have developed an "enhanced toilet training program" that helps children understand how to use their muscles correctly while straining using a variety of behavioral modification techniques. Our enhanced toilet training program generally includes colonic evacuation and laxatives as outlined above. Additionally, the child and his or her parents are taught about the psychophysiology of chronic constipation and encopresis and they are given a reinforcement scheme to promote responsiveness to rectal distension. The child and parents also receive training and modeling of appropriate toileting behaviors. This includes instruction on appropriate breathing techniques, effective abdominal straining, relaxation of the legs, and relaxation of the external anal sphincter when they are trying to pass a bowel movement. Various incentive programs are established depending on the developmental age and the motivation of the child. Target behaviors are spontaneous trips to the toilet and clean underwear. More recently, we have begun to develop interactive multimedia computer based teaching modules to complement the program.
The Children's Medical Center of the University of Virginia
1. Administering enemas -
Children may become "dependent" on laxatives if they use them too long.
Since nearly all available laxatives work by keeping large amounts of water in the stool, they can be used for very prolonged periods of time without significant risk. There is no evidence that any of the laxatives described above can result in dependency with chronic usage.
No studies have ever convincingly demonstrated that any of the laxatives described above lose their effectiveness over time.
While several studies have suggested that adults with untreated constipation may be at increased risk for developing colon cancer, there is no evidence to suggest that laxatives increase this risk.