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Functional Encopresis

Functional encopresis is a chronic disorder which is seen in children aged four years and older, who have been previously toilet trained.


Presentation

The clinical picture of both the subtypes of encopresis is not only different, but also important for planning the mode of treatment. Diagnostic criteria have been laid down for clinically classifying nonretentive encopresis. These include:

  • Child's age above four years of age
  • Fecal incontinence occurring at least once in a week
  • Passing of bowel movement at socially inappropriate places
  • No pathological causes

There is a total absence of constipation and no signs of fecal retention and passage of normal stools at regular intervals. Children with functional encopresis do have bowel movements at least once a day with soft stool. No pain occurs during bowel movement and there is normal colon transit time. Thus, children with nonretentive encopresis have a completely different presentation which is important to note for forming an appropriate plan of treatment [8].

Constipation
  • In these cases, there is no evidence of constipation or fecal retention.[symptoma.com]
  • Soiling without constipation appears to be less common than soiling with constipation.[dsm.wikia.com]
  • Chronic constipation will lead to... (other than encopresis) After puberty, which sex is more likely to be constipated? What other disease do you have to always have to consider when it looks like constipation? Two other major ones.[quizlet.com]
  • This issue of Pediatrie Annals focuses on childhood constipation, its associated problems, and its management. Drs. Nowicki and Bishop address the extremely important problem of organic causes of constipation in children.[healio.com]
  • Causes There are several causes of encopresis, including constipation and emotional issues. Constipation Most cases of encopresis are the result of chronic constipation. In constipation, the child's stool is hard, dry and may be painful to pass.[mayoclinic.org]
Fecal Incontinence
  • Families Perspectives on the Effect of Constipation and Fecal Incontinence on Quality of Life. JPGN 2010;53(6):747-52 42. van Tilburg, Miranda A. L, Squires M, Nanette B. M, Benninga M. A, at al. Parental Knowledge of Fecal Incontinence in children.[degruyter.com]
  • incontinence NOS nonorganic origin F98.1 Loss (of) control, sphincter, rectum R15.9 ICD-10-CM Diagnosis Code R15.9 Full incontinence of feces 2016 2017 2018 2019 Billable/Specific Code Applicable To Fecal incontinence NOS nonorganic origin F98.1 ICD-[icd10data.com]
  • Fecal incontinence related to other medical conditions (e.g., chronic diarrhea, spina bifida, anal stenosis) would not warrant a DSM-5 diagnosis of encopresis.[dsm.wikia.com]
  • Pathophysiology of pediatric fecal incontinence. Gastroenterology, 126 (Suppl 1), SS33-40. Har, A.F., & Croffie, J.M. (2010). Encopresis. Pediatrics in Review, 31 , 368-374.[societyofpediatricpsychology.org]
  • Bowel Incontinence Also called: Encopresis, Fecal incontinence, Stool soiling Bowel incontinence is the inability to control your bowels. When you feel the urge to have a bowel movement, you may not be able to hold it until you get to a toilet.[icdlist.com]
Abdominal Pain
  • Physical problems abdominal pain, a loss of appetite and stool accidents urinary tract bladder infections urine accidents during the day or night rash and irritated skin painful bowel movements Emotional problems A child with encopresis can feel ashamed[childrenshospital.org]
  • pain Problems with daytime wetting or bedwetting (enuresis) Repeated bladder infections, typically in girls When to see a doctor Call your doctor if your child is already toilet trained and starts experiencing one or more of the symptoms listed above[mayoclinic.org]
  • Pain Decrease in appetite Urinary symptoms Enuresis Dysuria or Urinary Tract Infection Medications Family History of Constipation IV.[fpnotebook.com]
  • They may present with urinary complaints and abdominal pain or distention. The physical examination is usually suggestive of constipation.[aafp.org]
  • Those with constipation may experience decreased appetite, abdominal pain, have pain on defecation, have less bowel movements, and have hard or soft stools. [3] Those without constipation do not have these symptoms. [4] Causes [ edit ] Encopresis is commonly[en.wikipedia.org]
Neglect
  • Springer Science & Business Media , 30.11.1994 - 296 Seiten 1 Rezension Preschool children have been largely neglected in the mental health treatment literature, although research has established that many behavioral and emotional disorders in children[books.google.com]
  • Sections cover psychiatric evaluation; disorders seen in infants, children, and adolescents; treatment modalities and treatment planning; and special circumstances including psychiatric emergencies, child neglect and abuse, and family issues.[books.google.com]
  • Examples include: Abuse or neglect; Diet that is rich in fat and/or sugar; Inadequate water intake; Presence of chaos or unpredictability in the patient’s life; Lack of physical exercise; Refusal to use the bathroom, especially public restrooms; Presence[theravive.com]
  • Abuse and/or neglect. Inadequate water intake. Presence of chaos or unpredictability in a child’s life. Lack of physical exercise or a diet that is rich is fat/ sugar.[childpsychologist.com.au]
  • Arresting this neglected problem of the child is an important issue in this 21 st century.[ajmhs.org]

Workup

The most important aspect of diagnosis is taking a complete and thorough history. Examination of children with encopresis should be non invasive as far as possible and should involve a parent or guardian. A complete evaluation regarding toilet pattern should be asked to rule out any potentiating pathological causes. Detailed questions and case taking should be done regarding medical history, toilet training, diet, lifestyle and other habits.

Physical examination includes complete general pediatric as well as neurological examination. Examination of perianal and perigenital areas is a must. If no organic or structural abnormalities are suspected, rectal examination can be avoided and replaced by an ultrasound. Ultrasound of abdomen, kidneys, bladder and retrovesical region is advisable.
If rectal examination is done stool can be palpated in lower part of colon along with laxity of anal sphincters. If the rectum is enlarged and distended with stool then functional encopresis can usually be ruled out. Psychiatric evaluation may be required to rule out any coexisting behavioral disorders. Blood tests are not required in functional encopresis.

Treatment

Prior to deciding the plan of treatment, a complete medical evaluation has to be done to [9] eliminate any kind of organic causes. The child's development needs to be understood to formulate a suitable plan for each child is different. A child has to be ready for being toilet trained not only physiologically, but also cognitively and should have fine motor and verbal development. Lastly, behavioral assessment has to be done in case of some multifactorial behavioral disorder. In cases of nonretentive encopresis, importance should be given to behavioral therapy and toilet training. Prior to that, it is important to ensure that your child is passing soft stools, if not then laxatives should be given. Dietary modifications should be done to improve bowel habits.

In functional encopresis, usually phobia or toilet refusal is the main cause, this behavior should be addressed in a gradual and slow process without putting pressure on the child. Encourage short duration of sits on the toilet where the child is comfortable and without fear. Engage in talking and reading in order to distract the child. Once the child is comfortable, schedule fixed timings for toilet training, mainly after meals to ensure normal regular functioning of bowels. Rewards or incentives can be given to children to encourage them and refrain from scolding or shouting at them in case of soiling. Positive reinforcement helps in many cases of behavioral disorders. This can aggravate matters tremendously and cause relapses frequently. In case the child continues to withhold stool, stool softeners or laxatives might be needed temporarily. The success of treatment mainly depends upon the extent of parental involvement [10]. Though a challenging disorder, functional encopresis can be cured within a few months during which relapses are possible.

Prognosis

The prognosis of such disorders depends upon the cause and period of onset. Any behavioral disorder along with this medical condition can affect outcome rates. Most of encopresis cases are self limiting and rarely persist beyond adolescence [7]. Most of the children with this disorder are ostracized by society which leads to poor self esteem and self worth. Children become drawn in and tend to deny soiling their clothes. Peer pressure and embarrassment aggravates such conditions. It can persist into adulthood, but is rare. With a number of treatment options available, outcomes are favorable and with parental encouragement and active participation, children can overcome this challenging condition. Early detection and guidance can prevent social and emotional issues attached with this condition.

Etiology

The single most important factor responsible for nonretentive encopresis is that the child is not ready to be toilet trained. Emotional issues such as too early toilet training or any family disturbances such as parents fighting, divorce or any kind of life changing situation can also lead to this condition. This tends to make the child feel threatened and insecure and these emotional disturbances can aggravate and trigger of encopresis. Though no data suggests encopresis as a result of a behavioral disorder, children who suffer from encopresis are at a higher risk to suffer from attention deficit syndrome. Behavioral [3] changes such as lack of self confidence and embarrassment commonly result due to this condition. Often the child is afraid to pass stool in the toilet and will only pass in the diaper. Nonretentive encopresis usually results due to such causes. Children suffering from functional encopresis can be broadly categorized into the following categories:

  • Children who have not been toilet trained initially.
  • Children who have a fear of going to the toilet.
  • Soiling of undergarments to manipulate surrounding environment. 

Epidemiology

Recent studies and data indicate that in children aged below ten years at least 1-2% children suffer from encopresis.

  • Children with chronic encopresis
  • Children with frequent relapses

Encopresis may occasionally persist to adolescence or adulthood. Encopresis affects boys three to four times more than girls [4]. It mainly occurs during the day. Nocturnal encopresis needs a more detailed and careful evaluation. According to recent studies, chronic constipation is more prevalent than encopresis. Children by four years of age usually have a single bowel movement once a day with individual variation. The prevalence of constipation on an average is about 9% of total population [5].

Sex distribution
Age distribution

Pathophysiology

The physiology of defecation and incontinence is quite complex due to which pathophysiology is not well understood. Thus, the underlying pathophysiological mechanism of this functional disorder is still elusive [6]. The frequency of bowel movements tends to decrease as the child grows up. About 20% of encopresis cases are nonretentive. In this case fecal soiling along with normal bowel movement occurs every day, for which no organic cause is detected. Bowel movement is either voluntary or involuntary at inappropriate places. This usually results due to stubborn or resistant behavior of the child or ineffective toilet training strategies of the parents. This constant passing of stool at inappropriate places may lead to fecal retention sooner or later.

Prevention

This is a preventable condition which should be done by adopting a non-aggressive approach towards toilet training. Toilet training should be done at the right age and when the child is prepared for it rather than forcing the child. Daily sitting on the toilet is advised. Once toilet trained, children should be made to sit on the toilet at fixed timings for at least 10 minutes to ensure healthy bowel functioning. This encourages the child and they become more aware of the natural urge and sensation. Fixed timing should usually be adopted after meal timings, when the bowel movements are maximum. Any kind of behavioral disorder should be addressed immediately and resolved.

Summary

Functional encopresis is a chronic disorder seen in school children as bowel movements in unacceptable situations (usually soiling the undergarments). In these cases, there is no evidence of constipation or fecal retention. It occurs in children aged four years and older, who have been previously toilet trained, where the parents initially assume the reason for this to be pure laziness of the child to use the toilet. This condition has involuntary soiling [1] of the undergarments and clothes. Usually, these children have anxiety and worry that peers and other people will come to know of their problem making them socially withdrawn [2]. This is usually a behavioral disorder wherein the child soils their clothes everyday and bowel movements are totally normal. After initial catharsis, child is asked to sit on the toilet at least twice a day for ten minutes preferably after meals. Children undergoing this problem lack confidence and self esteem, where punishing the kid can only aggravate matters. Though a challenging disorder, it is treatable. This disorder has a high level of social stigma attached to it and can be quite stressful for both children as well as parents.

Two major types of encopresis occur, one is associated with constipation, and the other without constipation which is mainly known as functional encopresis, nonretentive encopresis or nonretentive fecal incontinence. About 80-90% of cases of encopresis result due to a history of chronic constipation or some kind of painful bowel movements. The remaining 5-20% cases are functional encopresis which usually occur in children with behavioral disorders where no organic causes are established.

Patient Information

Functional encopresis is a type of a behavioral disorder wherein the child passes stool and soils the clothes without any indication of fecal impaction or retention. This usually happens with normal bowel movements and can concern children who have been previously toilet trained. No known cause has been established and is usually considered as a behavioral disorder which results either due to aggressive toilet training or some kind of phobia in the child towards the toilet. There is no clinical symptom of constipation. Medical assessment and evaluation is normal.

Encourage healthy eating and increase intake of fiber such as fruits and vegetables along with plenty of water. Improve bowel habits by keeping a fixed time for sitting on the toilet preferably after meals. Avoid criticizing the child, rather give incentives and positive reinforcement. This is a rather challenging condition to treat for both doctors, but parental involvement and encouragement can go a long way in making the treatment a successful one. Encopresis due to emotional or behavioral disorders requires psychiatric analysis as well as psychotherapy.

References

Article

  1. Partin JC, Hamill SK, Fischel JE, Partin JS. Painful defecation and fecal soiling in children. Pediatrics. 1992 Jun; 89(6 Pt 1):1007-9.
  2. Cox DJ, Morris JB Jr, Borowitz SM, Sutphen JL. Psychological differences between children with and without chronic encopresis. J Pediatr Psychol. 2002 Oct-Nov; 27(7):585-91.
  3. Joinson C, Heron J, Butler U, et al. Psychological differences between children with and without soiling problems. Pediatrics. 2006 May; 117(5):1575-84.
  4. Loening-Baucke V. Prevalence rates for constipation and fecal and urinary incontinence. Arch Dis Child. 2007 Jun; 92(6):486-9.
  5. van der Wal MF, Benninga MA, Hirasing RA. The prevalence of encopresis in a multicultural population. J Pediatr Gastroenterol Nutr. 2005 Mar; 40(3):345-8.
  6. Di Lorenzo C, Benninga MA. Pathophysiology of pediatric fecal incontinence. Gastroenterology. 2004 Jan; 126(1 Suppl 1):S33-40.
  7. Rockney RM, McQuade WH, Days AL, et al. Encopresis treatment outcome: long-term follow-up of 45 cases. J Dev Behav Pediatr. 1996 Dec;17(6):380-5.
  8. Young MH, Brennen LC, Baker RD, Baker SS. Functional encopresis: symptom reduction and behavioral improvement. J Dev Behav Pediatr. 1995 Aug; 16(4):226-32.
  9. Reid H, Bahar RJ. Treatment of encopresis and chronic constipation in young children: clinical results from interactive parent-child guidance. Clin Pediatr (Phila). 2006 Mar; 45(2):157-64.
  10. Brooks RC, Copen RM, Cox DJ, et al. Review of the treatment literature for encopresis, functional constipation, and stool-toileting refusal. Ann Behav Med. 2000; 22(3):260-7.

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Last updated: 2018-06-22 02:17