Question and Answer: Encopresis (Fecal Soiling) and Functional Fecal Retention
Answer by: Paul E. Hyman, M.D., Professor of Pediatrics, Chief of Pediatric Gastroenterology, University of Kansas Medical Center, Kansas City, KS
My son was diagnosed with encopresis almost 2 years ago. My doctor thinks it is my fault my son has encopresis, saying I am not medicating him or I am not feeding him the right foods. This is wrong, I am medicating and feeding him the way I have been told. But with still no joy. My son is on a laxative and stool softener. He has had enemas, but the treatments only work for a short time. Could there be anything else wrong with him?
Encopresis (or fecal soiling) is usually associated with constipation. Only a small percentage of constipation in children is caused by disease. Most constipation in children has a functional cause, meaning that the symptoms are real, but there is no sign of injury or infection, blood, or anatomic abnormality.
Functional fecal retention is the most common problem in children that come to see a pediatric gastroenterologist. It is defined by passage of big, hard stools at infrequent intervals, days or weeks apart; and by the child trying to avoid having a bowel movement by stiffening and straightening his or her legs and buttocks.
Functional fecal retention is most often due to frightening or painful defecation experiences, which result in voluntary avoidance of passing stools. Repeated retention of feces causes an increase in size of stools leading to more painful defecation experiences and further attempts at avoidance.
We understand what causes the soiling. Even though the child is able to hold back the stool for days or weeks, he still needs to pass gas many times each day, like everyone else. When he relaxes his bottom to let out the gas, liquid that has seeped around the retained stool may also leak out and soil the underclothes.
As the retained stool accumulates, the child is often irritable and eats poorly. As soon as the stool comes out, the child is relieved and happy, and eats to make up for lost meals, until it starts all over again. Diet rarely has any impact on functional fecal retention, because the problem is no longer just constipation, but the child's fear of painful passage of stool.
Enemas and suppositories take personal control away from the child, and do not help the child to learn the correct toilet behaviors. Although many practitioners use enemas, suppositories, and even surgery, there is a more child-friendly way to get rid of this problem.
Functional fecal retention is not a disease. It is not dangerous, even though the child and family may suffer. There is a lot we can do to help the child make it go away.
From age 6 months to age 5 years, treatment is all about taking away the fear of having a bowel movement. In most cases, taking away fear requires about a year of daily medication to assure painless passage of stool: stool that is soft with the consistency of oatmeal or applesauce.
There are many medicines that soften the stool without causing cramps the way senna does. For example, polyethylene glycol is the most popular in the U.S. because it is a colorless, odorless, and tasteless mix in the child's favorite drink. Lactulose, Milk of Magnesia, and sorbitol are all satisfactory. None of these agents cause cramps or go into the body. They simply soften the stool, and the child retains control of when he chooses to go. The key to treatment is to make sure that it will not hurt whenever he or she decides to go.
When children with functional fecal retention get to be about 6 years old, they begin pretending that there is no problem. They may become secretive about bowel movements, and hide soiled underclothes or even pieces of stool around the house. They deny smelling any stool, even when they have soiled their pants. They deny having the sensation that they have to go. This denial stage can last 6 or 7 years. It is very difficult to treat children who deny that there is a problem, because it is their bottom and there is no way that parents or clinicians can control it.
Some school-aged children are motivated to get better. All they want is to hear the explanation for the problem, and someone to coach them through the problem.
Many others suffer for years, until they are old enough to think through the problem like an adult. Then they find a way to get better, with or without the clinician's help.