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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].

Italian
  • […] incontinentie, functioneel, faeces; incontinentie, niet-organische oorsprong, functioneel; encopresis, incontinentie; faeces, niet-organische oorsprong, niet-organische oorsprong; encopresis, Niet-organische encopresis, Encopresis French Encoprésie Italian[fpnotebook.com]
Noncompliance
  • In similar fashion, if the child is oppositional or noncompliant with adult instructions, the physician may choose to refer the family to a pediatric psychologist who is familiar with compliance training protocols.[aafp.org]
  • *If the child is noncompliant with adult instructions, the physician may refer the family to a pediatric psychologist familiar with compliance training techniques.[freeprintablebehaviorcharts.com]
  • Disruptive behavior and childhood noncompliance across multiple settings (e.g., dressing, bath time, bedtime) require direct attention before toilet training is attempted.[cpcwecare.com]
Sneezing
  • […] urge urinary incontinence. severe stress urinary incontinence severe stress incontinence as a result of incompetence of the sphincter mechanism. stress incontinence urinary incontinence due to strain on the orifice of the bladder, as in coughing or sneezing[medical-dictionary.thefreedictionary.com]
  • With an increase in intra-abdominal pressure there is a reflex compensatory increase in EAS activity to a level which provides an anal pressure in excess of the rectal pressure. [ 30 ] This allows continence to be maintained when coughing, sneezing, blowing[intechopen.com]
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]
  • There are two types: with or without constipation.[en.wikipedia.org]
  • ., laxatives) or a general medical condition, except through a mechanism involving constipation. The DSM-IV recognizes two subtypes: with constipation and overflow incontinence, and without constipation and overflow incontinence.[ipfs.io]
  • Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Evaluation and treatment of constipation in infants and chil...[5minuteconsult.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]
  • 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]
  • Velký lékařský slovník online, 2013 ) Definition (NCI) An elimination disorder characterized by fecal incontinence, whether involuntary or intentional, which is not due to a medical condition and which occurs at an age of at least 4 years.[fpnotebook.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]
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 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]
  • 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]
Pelvic Mass
  • mass Neurological exam VII.[fpnotebook.com]
  • […] repair Neurogenic causes Hirschsprung's disease Chronic intestinal psuedo-obstruction Spinal cord disorders Cerebral palsy/hypotonia Pelvic mass Neuromuscular disease Endocrine/metabolic causes Hypothyroidism Hypercalcemia Lead intoxication Drugs Codeine[aafp.org]
Flushing
  • […] several hours at a time Fully empties Bladder on Vomiting Developmental readiness Awareness of stooling time Facial expressions or squatting with stooling Go to specific or private location to stool Motor skills Walk to bathroom Undress Sit on toilet Flush[fpnotebook.com]
  • Some children may actually have had a fear of the toilet, even thinking that they themselves might be flushed away. A number of other factors can also contribute to the eventual development of encopresis.[healthychildren.org]
  • Developmental criteria include attainment of major motor skills such as being able to walk to the bathroom, sit on the toilet, lower and raise pants and flush the toilet.[aafp.org]
Withdrawn
  • ., 1986 ) and greater withdrawn behavior (e.g., Levine et al., 1980 ) in children with encopresis.[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]
Distractibility
  • 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.[symptoma.com]
  • The stress on the child, his/her family, friends and teachers resulting from prolonged faecal incontinence is obvious but it should not distract from the need to identify and correct any functional abnormality that may exist. [ 16 ] 2.[intechopen.com]
  • Functional encopresis may be associated with other neuro-developmental problems, including easy distractibility, short attention span coordination ( Joinson et al ., 2007 ). Occasionally, the child has a special fear of using the toilet.[scialert.net]
Aggressive Behavior
  • Teachers reported more aggressive behaviors ( t [112] 3.01, p .003) for the encopretic group.[academic.oup.com]
  • He was generally cooperative with adult requests, exhibited age-appropriate social skills and rarely engaged in temper tantrums or aggressive behavior.[aafp.org]
Short Attention Span
  • Functional encopresis may be associated with other neuro-developmental problems, including easy distractibility, short attention span coordination ( Joinson et al ., 2007 ). Occasionally, the child has a special fear of using the toilet.[scialert.net]
Tantrums
  • Assessment: Behavioral Disruptive behavior problems Aggression Oppositional behavior Temper tantrums Child compliance with adult instructions Bedtime, Bath-time, and Dressing Child should follow 7 of 10 instructions Daily diary of toileting habits VI.[fpnotebook.com]
  • He was generally cooperative with adult requests, exhibited age-appropriate social skills and rarely engaged in temper tantrums or aggressive behavior.[aafp.org]
  • Behavioral The most important areas of behavioral assessment of toileting include ruling-out the presence of disruptive behavior problems such as aggression, oppositional behavior, noncompliance and temper tantrums, and establishing the child’s compliance[cpcwecare.com]
Dysuria
  • […] between stools History of Constipation (Age of onset) History of Stool Soiling Age of onset Type and amount of material Diet history Type and amount of food Changes in diet Associated symptoms Abdominal Pain Decrease in appetite Urinary symptoms Enuresis Dysuria[fpnotebook.com]
Urge Urinary Incontinence
  • See also urge urinary incontinence. severe stress urinary incontinence severe stress incontinence as a result of incompetence of the sphincter mechanism. stress incontinence urinary incontinence due to strain on the orifice of the bladder, as in coughing[medical-dictionary.thefreedictionary.com]

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: 2019-07-11 20:57