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What is encopresis?

Encopresis is the involuntary leaking of feces, most often caused by chronic constipation. An estimated 1 to 3 percent of children have this problem at one time or another in childhood.

How does encopresis happen?

Constipation can cause a child's bowel movements to be hard, dry, difficult to pass, and so large that they can clog the toilet. Encopresis happens when soft or liquid feces leak out of the rectum. Constipation leads to encopresis in the following way:

  • A child's stool becomes impacted, which means a large amount of it gets stuck in the rectum and large intestine.
  • The impacted stool stretches the rectum and intestine, causing them to become enlarged.
  • Eventually, the enlarged rectum and intestine lose their ability to detect the presence of stool. The anal sphincter, the muscle that helps hold stool in, becomes weak.
  • Soft stool starts to leak around the impacted stool, soiling the child's underwear and clothes.
  • As more stool collects, it becomes even more difficult to hold it in and the child has more accidents. Because of decreased sensitivity in the rectum, the child may not even be aware they've had an accident until after it has occurred.

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

How encopresis can affect a child’s health

Encopresis can cause both physical and emotional problems.

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 and embarrassed.

Parents may also feel guilt, shame, and anger over their child’s accidents. It’s important to understand that encopresis is a medical issue, not a behavior that can be changed through punishment or discipline.

Encopresis | Symptoms & Causes

What are the symptoms of encopresis?

Here are some signs that your child might be constipated or have encopresis:

  • Small, frequent bowel movements
  • Large stools that clog the toilet
  • Involuntary bowel movements or sudden urgency to go
  • Feces or watery stool in the underwear of an otherwise healthy child
  • Loss of appetite
  • Abdominal pain

What causes encopresis?

Encopresis is usually the result of chronic constipation, which can be easily overlooked in children. There’s often no clear cause although constipation sometimes does run in families.

Certain foods, behaviors, and situations can contribute to constipation, including:

  • A “junk-food” diet that is low in fiber
  • 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 to take time to use the bathroom
  • Painful bowel movements that make the child “hold it” in order to avoid further pain

Children who have never been toilet trained and refuse to have a bowel movement on the toilet are also at risk of developing encopresis.

Encopresis | Diagnosis & Treatments

How is encopresis diagnosed?

Diagnosis starts with a complete medical history that includes questions about the child’s toilet training and a physical exam. This often provides enough information to diagnose encopresis. In some cases, doctors obtain an abdominal X-ray to evaluate the amount of stool in the large intestine.

How is encopresis treated?

Treatment for encopresis depends on the root cause.

If encopresis is caused by constipation, treatment may include:

  • laxatives to help the child pass the impacted stool
  • medication to keep bowel movements soft so the stool will pass easily
  • 5 to 10 minutes sitting on the toilet at home after breakfast and dinner

In some cases, physicians prescribe enemas to help remove the impacted stool. An enema is a liquid that is placed in the rectum that helps loosen the hard, dry stool. Important: It is unsafe to give a child an enema without the approval of their physician. Enemas should only be used when medically indicated and both the child and parents are comfortable.

Overtime, the intestine and rectum will shrink to their normal size and the child should be able to have normal bowel movements without any medication or prompting.

In the case of toilet refusal, treatment includes a combination of the medical treatments described above and behavioral treatments to help the child become more comfortable using the toilet for bowel movements.

What happens after the impacted stool is passed?

After a child passes an impacted stool, it’s important to develop a good routine to ensure that stool does not get backed up again. The child may still have problems with leakage until the intestine and rectum return to their normal size.

To reduce the number of accidental bowel movements, the child should continue to sit on the toilet two to three times a day for five to 10 minutes, preferably shortly after a meal.

How to avoid constipation

Often, making changes in a child's diet will help prevent future constipation:

  • Adding more fruits and vegetables
  • Adding more whole-grain cereals and breads
  • Drinking more fluids, especially water
  • Limiting fast foods and junk foods that are usually high in fats and sugars
  • Limiting whole milk to 16 ounces a day for the child over 2 years of age, but not eliminating milk altogether; children need the calcium and Vitamin D in milk to help their bones grow strong
  • Serving meals on a regular schedule
  • Serving breakfast early so the child has time for a bowel movement before school
  • Increasing exercise
  • If a child has a limited diet/sensory aversion, a fiber supplement can be helpful

How we care for encopresis

The physicians and nurse practitioners in the Division of Gastroenterology, Hepatology and Nutrition at Boston Children’s Hospital are experts in helping children have regular bowel movements on the toilet. We start with a complete medical history, questions about toilet training, and a thorough physical exam. In some cases, children also have an abdominal X-ray to evaluate the amount of stool in the large intestine, and blood tests may also be needed.

Encopresis | Programs & Services