Encopresis

Question 1

Define encopresis.

Answer 1

AKA faecal incontinence or soiling often involuntary at inappropriate times, occurring after the typical age of completed toilet training (generally 4 years).

Question 2

What are the causes of encopresis broadly classified into?

Answer 2

Those with rectum loaded with faeces

Those without rectum loaded with faeces

Question 3

What are the risk factors for encopresis?

Answer 3

• Chronic constipation
• Male sex
• Age 5-6 years
• Low fibre diet
• Inadequate fluid intake
• Delayed/inadequate toilet training
• Anorectal malformation
• Hirschsprung’s disease
• Spinal abnormalities - e.g. spina bifida, myelodysplasia and tethered cord
• Psychiatric problems

NB: enuresis and encopresis may also be features present in a sexually abused child

Question 4

What investigations can be done to diagnose encopresis in a child?

Answer 4

Examination may show presence of faecal mass and gas in lower quadrants; DRE may also be done to assess anorectal malformations, tears, fissures and anal sphincter tone as well as stool presence in rectum.

Abdominal XR - where a rectal examination cannot be done and to show parents that the cause is overflow diarrhoea

Others like spinal XR or unprepared barium enema may be done to investigate causes of chronic constipation (i.e. Hirschsprung’s disease). Hypothyroidism may also cause constipation so TFTs may be done; sweat chloride test and Coeliac studies can also be carried out; rectal biopsy.

Question 5

What are some reasons for faecal loading in a child?

Answer 5

1. Poor coordination with anal sphincter relaxation causing only occasional emptying so more prone to developing retention
2. Constipation e.g. following illlness and therefore dehydration
3. Pain from fissue causing inhibition of defecation
4. Fear of punishment for incontinence causing inhibition
5. Anxiety about using the toilet

Question 6

How does faecal retention eventually lead to soiling?

Answer 6

Large bolus of hard faeces may be beyond capacity of child to shift.

Rectum loaded with soft/hard faeces becomes distended so that child becomes unaware of need to empty it -

Loaded rectum inhibits the anus via rectoanal reflex and stool may seep out with spontaneous rectal contractions beyond the child’s control

Children may remove soiled clothes and hide them out of shame

Question 7

What is the management of encopresis with faecal loading?

Answer 7

Reasons for faecal retention indentified and treated

Empty rectum as soon as possible - stool softener (macrogol) given for a few weeks +/- stimulant laxative +/- enema.

Continue maintenance laxative - retention may last a few weeks as the distended rectum shrinks to a normal size

Educate child and parents - about how retention can lead to incontinence; encourage child to defecate regularly to earn stars on a chart.

Question 8

What are some challenges with encopresis in children?

Answer 8

May deny that a problem exists and not cooperate as repeated soiling may have been a humiliating experience

May give them a measure of control over parents - need psychiatric referral

Question 9

What are the causes of soiling without faecal loading?

Answer 9

Urgency of defecation - may only be delayed by a couple of minutes in some causing surprise encopresis

Neuropathic bowel secondary to occult spinal abnormality +/- urinary incontinence

Diarrhoea - may overwhelm bowel control

Learning disability with mental age below age 4 years - expectations of social bowel control may need to be revised

Intentional defecation as a hostile act - may have distorted relationships with parents and behavioural problems needing psychiatric referral

Question 10

What are the complications and prognosis of encopresis?

Answer 10

Complications - poor QoL, irritant dermatitis of peri-anal area, buttocks, and perineum, worsening soiling, enuresis as large amount of stool impinges on bladder.

Prognosis - high recurrence rate for all causes of faecal incontinence