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].

• Crying

  These babies cry as if they are in pain, turning red and arching their back. Colic is very common. Nearly 1 in 4 newborns are affected. [psvcare.org]

• Inflammation

  Frequently, tiny samples of cells (biopsies) are taken to look for inflammation, infection, or other problems. [psvcare.org]

• Constipation

  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]

  Keywords Behavioral Treatment Behavioral Medicine External Anal Sphincter Chronic Constipation Functional Constipation These keywords were added by machine and not by the authors. [link.springer.com]

  In these cases, there is no evidence of constipation or fecal retention. [symptoma.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]

• 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]

  […] not due to organic disease, Non-organic encopresis, encopresis; functional, encopresis; nonorganic origin, feces; incontinence, functional, feces; incontinence, nonorganic origin, functional; encopresis, incontinence; fecal, nonorganic origin, nonorganic [fpnotebook.com]

  To Fecal incontinence NOS functional F98.1 nonorganic origin F98.1 psychogenic F98.1 Incontinence R32 ICD-10-CM Diagnosis Code R32 Unspecified urinary incontinence 2016 2017 2018 2019 Billable/Specific Code Applicable To Enuresis NOS Type 1 Excludes [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]

• Abdominal Pain

  functional abdominal pain, functional dyspepsia, and functional encopresis. [childrenshospital.vanderbilt.org]

  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 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]

  • Abdominal pain. • Repeated urinary tract infections. The first epidemiological study conducted in four Brazilian regions to investigate the prevalence of different types of psychiatric disorders among schoolchildren. [omicsonline.org]

• Loss of Appetite

  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]

  Call the doctor if your child has any of these symptoms of encopresis: poop or liquid stool in the underwear when your child isn't ill hard poop or pain when having a BM toilet-clogging BM belly pain loss of appetite blood on the toilet paper when wiping [kidshealth.org]

  Call the doctor if your child shows any of the following symptoms: poop or liquid stool in the underwear when your child isn’t ill hard poop or pain when having a BM toilet-stopping BM abdominal pain loss of appetite Treating Encopresis As the colon is [rchsd.org]

  When to Call the Doctor Call the doctor if your child shows any of these symptoms: poop or liquid stool in the underwear when your child isn’t ill hard poop or pain when having a BM toilet-clogging BM abdominal pain loss of appetite Treating Encopresis [connecticutchildrens.org]

  If the amount of leakage is large, you may misinterpret it as diarrhea Scratching or rubbing the anal area due to irritation from watery stools Constipation with dry, hard stool Passage of large stool that clogs or almost clogs the toilet Loss of appetite [pottytrainingconcepts.com]

• Failure to Thrive

  Failure to Thrive (FTT) Failure to thrive (FTT) is a phrase that is used to describe children who have fallen short of their expected growth and development. [psvcare.org]

• Withdrawn

  Social problems Social problems: CBCL b 57.8 (8.71) 53.57 (6.0) .001 Social problems: TRF b 60.5 (9.59) 55.13 (5.7) .001 24% 4% .004 Withdrawn behavior: CBCL b 57.0 (8.47) 52.11 (3.7) .001 15% 2% .006 Withdrawn behavior: TRF a 58.9 (10.75) 54.63 (6.0) [academic.oup.com]

  Usually, these children have anxiety and worry that peers and other people will come to know of their problem making them socially withdrawn. [symptoma.com]

  He may also become angry, withdrawn, anxious, and depressed, often as a result of being teased and feeling humiliated. Management of encopresis Encopresis is a chronic, complex – but solvable – problem. [healthychildren.org]

  When the child becomes increasingly aware of these difficulties, they may become angry, withdrawn, anxious and depressed and may be a victim of bullying if other peers become aware. [childpsychologist.com.au]

  […] toileting behaviors and promote constipation. [9] It is noted that most children who had encopresis had varying degrees of emotional challenges that were neither primary nor secondary to encopresis. [10] For instance, children with encopresis are usually withdrawn [ajmhs.org]

• Behavior Disorder

  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. [symptoma.com]

  Parental concerns Parents of a child with a serious behavior disorder like oppositional defiant disorder should work with their child's therapist to deal with encopresis in the context of other behavioral problems. [healthofchildren.com]

  Encopresis in the child with a behavioral disorder: When the initial treatment does not work. Pediatr. Ann., 28: 317-321. Direct Link | Chaney, C.A., 1995. A collaborative protocol for encopresis management in school-aged children. J. [scialert.net]

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.

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.

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.

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. 

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].

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.

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.

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.

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.

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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.
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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.
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