DEVELOPMENTAL PEDIATRICS: Encopresis education

Part of Contemporary Pediatrics’ coverage of the 2015 AAP Annual Conference. For more coverage, click here.

Managing fecal incontinence begins with recognizing that it’s usually a physiologic, not behavioral, problem, said Mary Pipan, MD, FAAP, during the session “Encopresis by Any Other Name: Successful Management of Fecal Incontinence.”

Children with encopresis are referred to developmental behavioral pediatrics because their incontinence is believed to be behavioral, especially when standard interventions have failed to help them. Most of the time, chronic constipation, rather than behavior, continues to be the primary problem. In her initial visit with the family, Pipan explained that the first step in treatment is to take the time to explain to caregivers and to the patient the physiology of encopresis to confirm understanding, and then explain how the steps of treatment relate to that physiology. Parents and children are then more likely to comply with the steps required and able to assume some control over both the problem and treatment. 

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When the colon and bowels are stretched due to chronic constipation and stool impaction, the muscles no longer work as well. These muscles need to “get back in shape.” They cannot do so if they remain stretched by stool impaction. So, the first step in treatment is to clean out the stool, either with a combination of oral laxatives and daily enemas, or, for very difficult cases, with NG GoLYTELY (polyethylene glycol 3350/potassium chloride/sodium bicarbonate/sodium chloride/sodium sulfate; Braintree Laboratories, Inc., Braintree, Massachusetts). As with any prescription, families need to be educated as to the proper administration of these medications and their potential side effects. 

After cleanout, getting the colon muscles back in shape requires exercising them, using laxatives titrated to achieve a daily, or at most every-other-day, bowel movement that is soft and easy to pass. If a child has been constipated for a couple of years, meeting this goal may take months or even years, during which there’s a high relapse rate about which parents should be warned. A plan should be in place for what to do if the child goes more than 2 days without a bowel movement or if the bowels start leaking again. Once the child has been regular for 3 to 4 months, parents can slowly wean the child off laxatives. 

Daily toileting times, if children are already toilet-trained, are also an important part of treatment. If children are more comfortable stooling in a diaper or pull-up, ask parents to continue to give them a pull-up at this juncture, as the main goal is establishing daily bowel movements. Giving the older child privacy in the bathroom is also important. 

Preventing constipation entails ensuring that children eat a varied diet, with enough fiber, and maintain an active lifestyle, with frequent physical exercise. Although diet can contribute to constipation and prevention, it doesn’t usually play a significant role in treatment, especially with more severe cases. Children also benefit from a daily routine that incorporates time in the bathroom to have a bowel movement. Some children are reluctant to take time away from their play to go. Some families’ lives are so busy that a child has a hard time finding private time in the bathroom to stool. 

Sometimes, children give the impression that they don’t care and are unmotivated to help themselves. It is Pipan’s firm belief that children do well when they can, but if they do not have control, they will act like they don’t care. Children and families appreciate when you show them how to gain control and your confidence in their ability to make it happen. 

Mary Pipan, MD, FAAP, is clinical director, Trisomy 21 Program, and an attending physician, Developmental Behavioral Pediatrics, The Children’s Hospital of Philadelphia, Pennsylvania.

NEXT: Commentary and the complexity of the process

Commentary

I agree that encopresis is rarely primarily a behavior problem. That is a major misconception that has been hard to dispel. No behavior in our culture is more stigmatized. Soiling oneself is clearly very upsetting to most children, and so it’s shrouded in secrecy. Many families don’t bring the soiling to their medical provider’s attention. They are either embarrassed or believe it’s a behavioral problem and the child is stubborn and/or lazy. When families do mention it, many primary care providers (PCPs) tell them it is nothing to worry about and the child will outgrow it, or they reinforce the belief that the child doesn’t care about their soiling, and, as such, many PCPs underestimate how disruptive encopresis can be.

As Dr Pipan correctly points out, it is much better to prevent encopresis than it is to have to treat it. The overwhelming majority of children with encopresis suffer from retentive encopresis, meaning the encopresis developed as a result of chronic constipation, although often, the problems with constipation occur months to years before the soiling becomes a major problem.

That said, this presentation oversimplifies the process of going to the bathroom and why children soil. Most children who soil suffer from retentive encopresis; however, it is not simply chronic constipation that results in the soiling. Nearly all children suffering from encopresis have abnormalities in the process of passing bowel movements, and that’s really the problem. It’s not the constipation per se, but abnormal coordination of defecation that perpetuates the problem.

Many people don’t recognize how complex it is to pass a bowel movement; provided there are no problems, we take it for granted. The process of passing bowel movements in the toilet is actually fairly complex, which is one of the reasons we don’t expect kids in our culture to be toilet trained until 3 years of age.

In broad strokes, normal defecation includes 3 steps: the rectum gets filled with stool, creating the urge to go. Second, toilet-trained children withhold until they’re ready to sit on the toilet. The third step is to sit on the toilet and strain. Doing this correctly involves taking in a deep breath, pushing downward with the diaphragm, tightening the lower abdominal muscles to generate downward force while simultaneously lifting and relaxing the muscles of the pelvic floor, and relaxing the external sphincter muscle. 

In children with chronic constipation and encopresis, the problem almost always starts with pain during defecation. Once that happens, children can have trouble relaxing the muscles of the pelvic floor and the sphincter while they are straining, resulting in involuntary or unconscious “withholding.” Many parents and providers misconstrue these involuntary “withholding” behaviors as excessive straining.

If one asks enough questions or has enough experience, one often realizes that while the child is straining, he or she is actually withholding, tensing the pelvic floor and the external sphincter muscles. This is a learned behavior that initially started as a way to avoid the pain associated with passing bowel movements.

Once an abnormal or compensatory motor pattern has developed, it can be very difficult to correct, because the child doesn’t even realize he or she is doing it. This is somewhat analogous to how limping can cause damage to other muscles because they are being used in abnormal ways to compensate for the injury. In children with retentive encopresis, this tensing of the pelvic floor and sphincter becomes a habit that the child doesn’t even realize he or she is doing. Many of these children no longer know how to relax their pelvic floor and sphincter muscles when they are trying to pass a bowel movement. So, just getting them to go regularly doesn’t always solve the problem. Parents and providers need to understand that it may take a long time for these abnormal compensatory behaviors to resolve, and, many times, the child may need some help with the retraining process. At the very least, families should be coached about what normal straining should look like.

Stephen M Borowitz, MD, is a professor of pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Virginia School of Medicine, Charlottesville, Virginia.