KidsMD Health Topics

Encopresis

  • Imagine this situation: You’re out at the park with your 7-year-old who’s having a great time. Suddenly, you notice a smell and realize that he’s soiled his pants.

    You ask him why he didn’t tell you he needed to go, and he says he didn’t feel it. You wonder how that can be true. Now you’re upset and he’s embarrassed. It’s probably not the first time this has happened — and without treatment, it won’t be the last.

    Encopresis is a problem that won’t just go away on its own, but luckily, it’s relatively easy to treat.

    Here’s what you need to know about encopresis:

    • It’s another name for fecal soiling — or accidentally having a bowel movement.
       
    • There are two main causes of encopresis:
      • Long-term constipation — Your toilet-trained child becomes constipated — for any number of reasons — which stretches his intestine and rectum until he cannot effectively hold the stool and it leaks out.
         
      • Toilet refusal (much less common) — Your child has never been toilet trained and refuses to have a bowel movement in the toilet, which leads to constipation and encopresis.

    How Boston Children’s Hospital approaches encopresis

    Encopresis can have serious psychological consequences for a child, including humiliation and shame. Boston Children’s Division of Developmental Medicine treats the whole child — physically and psychologically.

    A compassionate team of professionals will address your child's physical symptoms and emotional well-being and help your child learn to have regular bowel movements on the toilet.

    Encopresis: Reviewed by Leonard Rappaport, MD, MS, and Kimberly Dunn, PNP.
    © Boston Children’s Hospital, 2010

    Boston Children's Hospital

    300 Longwood Avenue
    Boston MA 02115

      617-355-7025


  • It can be upsetting to see your child suffering from the constipation that can lead to encopresis. And the onset of constipation can be so insidious that parents do not realize that their child is having a problem. School-aged children go to the bathroom on their own, and it is natural for parents to assume everything is OK unless their child tells them otherwise.

    Our physicians and nurse practitioners are experts in helping kids have regular bowel movements on the toilet. We’ve had years of experience treating kids just like yours. So take a deep breath and try not to worry — your child will be fine and you and your family will get through this difficult time.

    Read on to learn more about encopresis and what it means for your child.

    How does encopresis happen?

    Constipated children have fewer bowel movements than normal, and their bowel movements can be hard, dry, difficult to pass and so large that they can often even block up the toilet. Here's a common scenario:

    1. Your child's stool can become impacted (packed into her rectum and large intestine).
       

    2. Her rectum and intestine become enlarged due to the retained stool.

    3. Eventually, her rectum and intestine have problems sensing the presence of stool, and the anal sphincter (the muscle at the end of the digestive tract that helps hold stool in) becomes dilated, losing its strength.

    4. Stool can start to leak around the impacted stool, soiling your child's clothing.
       

    5. As more and more stool collects, your child will be less and less able to hold it in, leading to accidents. Because of decreased sensitivity in your child’s rectum, she may not even be aware she’s had an accident until after it has occurred.

    In kids who haven’t yet been toilet trained, struggling to hold in excess stool or the constipation that arises from refusing to have a bowel movement on the toilet can also lead to encopresis.

    How many kids does it affect?

    It’s difficult to say for certain because many cases of encopresis are not reported. There seems to be a stigma attached to this condition that prevents many parents from reaching out and talking to other parents whose children may have had the same problem.

    We estimate that between 1 and 3 percent of kids have this problem at one time or another in childhood.

    Which children develop encopresis?

    Any child with chronic constipation may develop encopresis. Some of the situations that predispose your child to constipation include:

    • eating a “junk-food” diet that is low in fiber
    • painful bowel movements
    • lack of exercise
    • stress in the family, with friends or at school
    • change in bathroom routine, such as when a child starts a new school year and bathroom breaks are less frequent
    • being too busy playing to take time to use the bathroom

    For children who have never been toilet trained and who refuse to have a bowel movement on the toilet, additional concerns apply:

    • reluctance to use bathrooms at home or in public
    • anxiety about using the toilet

    What kind of problems might my child have?

    Encopresis can cause your child to have both physical and emotional problems.

    Physical problems

    • Impacted (backed up) stool in her intestine can cause abdominal pain, a loss of appetite and stool accidents.
       
    • Some children, especially girls, develop urinary tract and/or bladder infections.
       
    • The enlarged bowel can push on the bladder causing urine accidents during the day or night.
       
    • Rarely, other health problems may cause the chronic constipation that can lead to encopresis, including the following:

    Emotional problems

    Your child might feel emotionally upset by soiling her clothes, leading to feelings of shame and embarrassment.

    You, too, might feel guilt, shame and anger from your child’s encopresis. It’s very important to try not to communicate this to your child, as this may worsen her emotional state.

    Is encopresis painful?

    While encopresis itself isn’t usually painful (unless the leaking stool leads to a rash on your child’s skin), the constipation that leads to it may be.

    Causes

    There are two basic causes. At Boston Children’s Hospital, we first determine the cause and then treat your child appropriately.

    • long-term constipation — Encopresis is usually due to chronic constipation, which can be easily overlooked in children. There’s often no clear cause of this constipation, although sometimes it does run in families.
       
    • toilet refusal — A much smaller number of children were never toilet trained successfully to have bowel movements in the toilet, some due to refusing to use the toilet and others due to developmental issues.

    It’s rare that a child has an underlying medical condition that causes encopresis, but we do consider these causes when we see your child.

    Signs & Symptoms

    Here are some signs that your child might have constipation that could lead to encopresis:

    • large stools that block up the toilet
       
    • involuntary bowel movements or needing to have a bowel movement with little or no warning, which may soil underwear when a child cannot get to the bathroom in time
       
    • small, frequent bowel movements

    Long-Term Outlook

    Though it may seem as though your child will suffer from encopresis forever, this isn’t the case. The vast majority of kids (the possible exceptions being those who have an underlying medical issue) will stop having stool accidents and have regular bowel movements on the toilet.

    The end result of treatment is the same for both causes of encopresis, but the way we get there is different.

    • long-term constipation— We’ll help your child pass the impacted stool and then help keep stool soft so that it passes easily and doesn’t get backed up again. After about six months, your child’s intestine and rectum will shrink to their normal size and your child should be able to have normal bowel movements on his own without any medication or prompting.
       
    • toilet refusal— These children will get a combination of medical (laxatives, stool softeners) and behavioral treatments to help them get more comfortable using the toilet for bowel movements.

    So take a deep breath. We know this is a frustrating time, but we’ve seen many, many kids who’ve had this problem — and we’ve helped them (and their families) get through it.

    Questions to Ask Your Doctor

    You and your family are key players in your child’s medical care. It’s important that you share your observations and ideas with your child’s health care provider and that you understand your provider’s recommendations.

    If your child is suffering from the constipation that leads to encopresis and you’ve set up an appointment, you probably already have some ideas and questions on your mind. But at the appointment, it can be easy to forget the questions you wanted to ask. It’s often helpful to jot them down ahead of time so that you can leave the appointment feeling like you have the information you need.

    Some questions you may want to ask include:

    • Does encopresis go away on its own?
    • What are our treatment options?
    • Are these laxatives safe?
    • What are some good positive reinforcement strategies?
    • What can we do at home to help?
    • Where can we go for further information?

    Keep in mind that your doctor will want to ask you some questions, too. These can include:

    • How long has your child had this problem?
    • Has your child been toilet trained?
    • Is there a history of encopresis in the family?
    • What’s your child’s diet like?

    FAQ

    Q: What is encopresis?

    A: Encopresis is another word for fecal soiling — or accidentally having a bowel movement.

    Q: What causes encopresis?

    A: There are two basic causes. At Children’s, we first determine the cause and then treat your child appropriately.

    • Encopresis is usually due to chronic (long-term) constipation, which can be easily overlooked in children. There’s often no clear cause of this constipation, although sometimes it runs in families.
    • A much smaller number of children were never toilet trained successfully to have bowel movements in the toilet, some due to refusing to use the toilet and others due to developmental issues.

    It’s rare that a child has an underlying medical condition that causes encopresis, but we do consider these causes when we see your child.

    Q: How does encopresis happen?

    A: Constipated children have fewer bowel movements than normal, and their bowel movements can hard, dry, difficult to pass and so large that they can often even block up the toilet. Here's a common scenario:

    1. Your child's stool can become impacted (packed into her rectum and large intestine).

    2. Her rectum and intestine become enlarged due to the retained stool.
       

    3. Eventually, her rectum and intestine have problems sensing the presence of stool, and the anal sphincter (the muscle at the end of the digestive tract that helps hold stool in) becomes dilated, losing its strength.

    4. Stool can start to leak around the impacted stool, soiling your child's clothing.
       

    5. As more and more stool collects, your child will be less and less able to hold it in, leading to accidents.

    Because of decreased sensitivity in your child’s rectum, she may not even be aware she’s had an accident until after it has occurred.

    In kids who haven’t yet been toilet trained, struggling to hold in excess stool or the constipation that arises from refusing to have a bowel movement on the toilet can also lead to encopresis.

    Q: What signs should I look for?

    A: Here are some signs that your child might have constipation that could lead to encopresis:

    • large stools that block up the toilet
       
    • involuntary bowel movements — or needing to have a bowel movement with little or no warning — which may soil underwear when a child cannot get to the bathroom in time
       
    • small, frequent bowel movements

    Q: What kind of problems might my child have?

    A: Encopresis can cause your child to have both physical and emotional problems.

    Physical problems

    • Impacted (backed up) stool in her intestine can cause abdominal pain, a loss of appetite and stool accidents.
       
    • Some children, especially girls, develop urinary tract and/or bladder infections.
       
    • The enlarged bowel can push on the bladder causing urine accidents during the day or night.
       
    • Rarely, other health problems may cause the chronic constipation that can lead to encopresis, including the following:

    Emotional problems

    • Your child might feel emotionally upset by soiling her clothes, leading to feelings of shame and embarrassment.
       
    • You, too, might feel guilt, shame and anger from your child’s encopresis. It’s very important to try not to communicate this to your child, as this may worsen her emotional state.

    Q: Is encopresis painful?

    A: While the encopresis itself isn’t usually painful (unless the leaking stool leads to a rash on your child’s skin), the constipation that leads to it can be quite painful.

    Q: How is encopresis diagnosed?

    A: When you make an appointment at Children’s, we’ll start with a complete medical history where we’ll ask you whether your child is toilet trained or not. Then, a physician will give your child a thorough physical exam. Your child’s medical history and the initial exam give the doctor enough information to diagnose encopresis. Many children also have an abdominal x-ray to evaluate the amount of stool in the large intestine.

    Q: How is encopresis treated?

    A: Treatment for encopresis may include:

    • using laxatives to help your child pass the impacted stool
    • using medication to keep your child’s bowel movements soft so the stool will pass easily
    • having your child sit on the toilet for five to ten minutes after breakfast and dinner

    We may also prescribe enemas to help remove the impacted stool. An enema is a liquid that is placed in your child's rectum that helps loosen the hard, dry stool.

    • We only use enemas when medically indicated and both the child and parents are comfortable.
    • We do have other treatments, but sometimes enemas with other medications are the easiest and most efficacious.
    • Do not give your child an enema without the approval of her physician.

    Q: What happens after the impacted stool is passed?

    A: After your child passes the stool, it’s important to develop a good routine to ensure that stool does not get backed up again. Because your child’s intestine and rectum will remain stretched (they go back to normal after about six months), your child may still have problems with leakage.

    To reduce the number of soilings, have your child sit on the toilet two to three times a day for five to ten minutes, preferably shortly after a meal.

    Q: What can we do to make sure my child doesn’t get constipated again?

    A: Often, making changes in your child's diet will help her constipation. Consider the following suggestions:

    • Increase the amount of fiber in her diet by:
      • adding more fruits and vegetables
      • adding more whole-grain cereals and breads (check nutritional labels on packages for foods that have more fiber)
         
    • encourage your child to drink more fluids, especially water
       
    • limit fast foods and junk foods that are usually high in fats and sugars; instead offer more well-balanced meals and snacks
       
    • limit whole milk to 16 ounces a day for the child over 2 (but not eliminating milk altogether; children need the calcium and Vitamin D in milk to help their bones grow strong)
       
    • serve your child's meals on a regular schedule
       
    • serve breakfast early so your child does not have to rush off and miss the opportunity to have a bowel movement
       
    • increase the amount of exercise your child gets
       
    • If your child has a limited diet/sensory aversion, a fiber supplement can be helpful — these come in chewable tablets, a powder that you can mix in a drink and a gummy variety.

    Q: What if my child’s encopresis is caused by toilet refusal?

    A: We usually see children and their parents individually at first and most children quickly master using the toilet without anxiety. For those who have trouble, we have developed Toilet School, an educational program for both parents and children to help them with difficult toilet training.

    • It’s a six-week program in which six kids — mostly 4-, 5- and 6-year-olds — come to class once a week for an hour to an hour and a half.
       
    • Parents attend a separate class where they learn behavioral techniques designed to help their children master toilet use.

    By graduation time in the sixth week, about sixty percent of the kids have successfully had a bowel movement on the toilet. The ones who haven’t get follow-up visits until they’re successful.

    For more information about Toilet School, see the Research & Clinical Trials section.

    Q: What is the long-term outlook for my child?

    A: Though it may seem as though your child will suffer from encopresis forever, this isn’t the case. The vast majority of kids (the possible exceptions being those who have an underlying medical issue) will stop having stool accidents and have regular bowel movements on the toilet.

    The end result of treatment is the same for both causes of encopresis, but the way we get there is different.

    • long-term constipation — We’ll help your child pass the impacted stool and then help keep stool soft so that it passes easily and doesn’t get backed up again. After about six months, your child’s intestine and rectum will shrink to their normal size and your child should be able to have normal bowel movements on his own without any medication or prompting.
       
    • toilet refusal — These children will get a combination of medical (laxatives, stool softeners) and behavioral treatments to help them get more comfortable using the toilet for bowel movements.
  • The first step in treating your child is forming an accurate and complete diagnosis. Because encopresis means that your child has accidental bowel movements, it’s a condition that’s fairly easy to diagnose.

    We’ll start with a complete medical history where we’ll ask you whether your child is toilet trained. Then, a physician will give your child a thorough physical exam. Your child’s medical history and the initial exam give the doctor enough information to diagnose encopresis.

    Your child may also have an abdominal x-ray to evaluate the amount of stool in the large intestine.

    Rarely, your doctor might perform tests to rule out other health problems. These may include:

    • barium enema - a test that checks your child’s intestine for obstruction (blockage), strictures (narrow areas) and other abnormalities. A fluid that shows up well on x-ray called barium is given as an enema, then the intestine is looked at with an x-ray.
    • blood tests - These are used to identify underlying medical conditions such as celiac disease.
       
    • spinal MRI - In some cases, your doctor may recommend a spinal MRI to make sure that a spine condition is not causing the encopresis.

    After we complete all necessary tests, our experts meet to review and discuss what they have learned about your child's condition. Then we’ll meet with you and your family to discuss the results and outline the best treatment options.

  • Knowing that your child is suffering from encopresis can be upsetting. But you can rest assured that you're in the right place.

    At Boston Children's Hospital, we consider you and your child integral parts of the care team and not simply recipients of care. You and your care team will work together to customize a plan of care for your child.

    And we can't emphasize enough that, with treatment, your child will eventually have regular bowel movements and avoid the constipation that can lead to encopresis.

    Still, suffering from encopresis can be psychologically or socially difficult — both for the child and the parents — and it's important to get the right treatment.

    So how is encopresis treated?
    Treatment for encopresis may include:?

    • using laxatives to help your child pass the impacted stool
    • using medication to keep your child's bowel movements soft so the stool will pass easily
    • having your child sit on the toilet for five to ten minutes after breakfast and dinner


    We may also prescribe enemas to help remove the impacted stool. An enema is a liquid that is placed in your child's rectum and helps loosen the hard, dry stool.

    We only use enemas when medically indicated and both the child and parents are comfortable.
    We do have other treatments, but sometimes enemas with other medications are the easiest and most efficacious.
    Do not give your child an enema without the approval of her physician.

    What happens after the impacted stool is passed?
    After your child passes the stool, it's important to develop a good routine to ensure that stool does not get backed up again. Because your child's intestine and rectum will remain stretched (they go back to normal after about six months), your child may still have problems with leakage.

    To reduce the number of soilings, have your child sit on the toilet two to three times a day for five to ten minutes, preferably shortly after a meal.

    Ten minutes? That's a long time. What are some ways to keep my child entertained?
    It's very important to make this time pleasant, so that your child doesn't see it as a punishment. Here are a few ideas about how to make these toilet times fun:

    Have some special toys that your child gets to play with while sitting on the toilet.

    • Tell stories or sing songs with your child.
    • Read your child's favorite book.
    • Let your child play a video game.


    It can also help to begin a sticker chart or come up with some small prizes to reward your child for sitting on the toilet.

    It's also important to remember that each time your child sits on the toilet, she will become more comfortable with it. So make sure to praise your child for sitting on the toilet — even if she doesn't have a bowel movement.

    What can we do to make sure my child doesn't get constipated again?
    Often, making changes in your child's diet will help her constipation. Consider the following suggestions:

    Increase the amount of fiber in your child's diet by:

    • adding more fruits and vegetables
    • adding more whole-grain cereals and breads (check the nutritional labels on food packages for foods that have more fiber)
    • encouraging your child to drink more fluids, especially water
    • limiting fast foods and junk foods that are usually high in fats and sugars; instead offer more well-balanced meals and snacks
    • limiting whole milk to 16 ounces a day for the child over 2 (but not eliminating milk altogether; children need the calcium and Vitamin D in milk to help their bones grow strong)
    • serving your child's meals on a regular schedule
    • serving breakfast early so your child does not have to rush off and miss the opportunity to have a bowel movement
    • increasing the amount of exercise your child gets
    • if a child has a limited diet/sensory aversion, a fiber supplement can be helpful — these come in chewable tablets, a powder that you can mix in a drink and a gummy variety


    What if my child's encopresis is caused by toilet refusal?
    We usually see children and their parents individually at first and most children quickly master using the toilet without anxiety. For those who have trouble, we have developed Toilet School, an educational program for both parents and children to help them with difficult toilet training.

    It's a six-week program in which six kids — mostly 4-, 5- and 6-year-olds — come to class once a week for an hour to an hour and a half.
    Parents attend a separate class where they learn behavioral techniques designed to help their children master toilet use.

    By graduation time in the sixth week, about sixty percent of the kids have successfully had a bowel movement on the toilet. The ones who haven't get follow-up visits until they're successful.

    For more information about Toilet School, see the Research & Clinical Trials section.

    Follow-up care
    A schedule of follow-up care will be determined by your child's physician and other members of your care team.

    The main purpose of these follow-up appointments is to make sure that your child is not getting constipated again.

    COPING & SUPPORT

    We understand that you may have a lot of questions when your child is diagnosed with encopresis.

    • Will it go away on its own?
    • How will it affect my child long term?
    • What kinds of treatment are there?
    • What do we do next?

    We've tried to provide some answers to those questions in these pages, but there are also a number of other resources to help you and your family.??Patient education: From the first office visit, our doctors and pediatric nurse practitioners will be on hand to walk you through your child's treatment and help answer any questions you may have — Does my child need treatment? What can we expect next? They will also reach out to you by e-mail and phone, continuing the care and support you received while at Children's.??Parent to parent: Want to talk with someone whose child has received treatment for encopresis at Boston Children's or gone to our Toilet School. We can often put you in touch with other families who can share with you their experience.

    On our For Patients and Families site, you can read all you need to know about:

    • getting to Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family

    And here's an active, online support group for parents of children who are suffering from encopresis.

  • Toilet School

    Directed by Kimberly Dunn, PNP, the Toilet School at Boston Children’s Hospital helps kids get comfortable using the toilet for bowel movements.

    “Toilet School is a six-week program for 4-, 5- and 6-year-olds who have toilet refusal,” Dunn says.“Week six is graduation and the kids who’ve pooped in the toilet get a gold medal.”

    Kids come to class once a week for an hour to an hour and a half. Each week there’s a different theme, which can be anything from fear to anatomy. And each week the kids are given a job — such as sitting on the toilet or learning to wipe — to do at home.

    “We focus on what the child can already do,” says Alison Schonwald, MD, a staff member in our program and author of The Pocket Idiot’s Guide to Potty Training Problems.

    And while the kids are in school, the parents are too. “They are incredibly stressed, very embarrassed and often, disgusted. They can't understand why their otherwise terrific kid is doing this, and they can't stand to wash another pair of underwear,” says Schonwald.

    In group sessions with a psychologist, parents can commiserate and learn helpful tips, such as how to reduce your child’s risk of constipation and how to defuse tense toilet situations.

    The atmosphere — both in school and in the counseling sessions — is supportive and fun. And Toilet School seems to be working. By graduation time in the sixth week, about sixty percent of the kids have successfully had a bowel movement on the toilet. The ones who haven’t get follow-up visits until they’re successful.

    Schonwald and Leonard Rappaport, MD, MS, chief of Developmental Medicine, took a survey of 62 parents whose children entered the program at an average age of 5. The results showed that 54 percent were fully toilet trained for stool within three months after the program. Children were equally likely to succeed regardless of age, sex, degree of constipation, medical, psychiatric or social concerns, and how long toilet training had been tried unsuccessfully in the past.

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