Wednesday, June 12, 2024

Encopresis

Practice Essentials

Encopresis is the involuntary discharge of feces (ie, fecal incontinence). In most cases, it is the consequence of chronic constipation and resulting overflow incontinence (see the images below), but a minority of patients have no apparent history of constipation or painful defecation. No good prospective data suggest that encopresis is primarily a behavioral or psychological disorder. The behavioral difficulties associated with encopresis are most likely the result of the condition rather than its cause.

Overflow incontinence.

Overflow incontinence.

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Overflow incontinence.

Overflow incontinence.

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Encopresis, along with enuresis, is classified as an elimination disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It may be divided into 2 subtypes: encopresis with constipation (retentive encopresis) and encopresis without constipation.

Signs and Symptoms

Symptoms of encopresis may include the following:

History of constipation (sometimes very remote) or painful defecation (~80-95% of children with encopresis)

Inability to differentiate passing gas and passing feces

Soiling episodes usually occurring during the daytime (soiling during sleep is uncommon)

With retentive encopresis, intermittent passage of extremely large bowel movements

Physical findings, other than those from abdominal and rectal examinations, are usually normal. Unless contraindicated, a digital rectal examination should be performed on every child with encopresis.

Examination may reveal the following:

Palpable stool throughout the distribution of the colon, especially in the left lower quadrant

Stool smeared around the anus

Lax and patulous anal sphincter

Rectum enlarged and filled with soft stool that yields negative results on fecal occult blood testing

Neurologic findings should be normal. Patients should have a normal anal wink and normal sensation, strength, and reflexes in the lower extremities.

See Presentation for more detail.

Diagnosis

Other problems to be considered in the diagnosis include the following:

Spina bifida

Meningomyelocele

Spinal-cord injury with dysfunction of the anal sphincter

Tethered spinal cord

Ultrashort-segment Hirschsprung disease (ie, congenital megacolon)

Imperforate anus with fistula

In most patients, the diagnosis of encopresis is established on the basis of the history and complete physical examination, including a rectal examination. Laboratory studies are rarely warranted. The following studies may be helpful:

Plain abdominal radiography

Anorectal manometry

Biopsy (either surgical or done by means of a suction device)

See Workup for more detail.

Management

Conventional medical therapy is commonly the first therapy attempted, generally consisting of the following:

Demystification and education

Colonic disimpaction followed by routine laxative therapy

“Toilet training”

Agents that can be used for disimpaction include the following:

Polyethylene glycol (PEG)

Sodium phosphate

Magnesium citrate

Enemas

Virtually any laxative can be used, provide that it is administered in sufficient quantity to produce 1-2 soft stools daily.

In addition to long-term laxative therapy, modalities that have been proposed for the treatment of chronic encopresis include the following:

Biofeedback therapy (efficacy not proved)

Intensive behavioral program (effective adjunct to conventional medical therapy)

Although the critical components of a successful intensive behavioral program have not been systematically elucidated, common elements of existing programs include the following:

Demystifying the condition and educating patients and families

Providing specific toileting instruction about appropriate positioning and straining

Designing a program of regular, timed, and uninterrupted toileting

Maintaining a symptom and toileting diary

Defining specific achievable target behaviors

Establishing age-appropriate rewards and consequences

Strongly emphasizing consistency

See Treatment and Medication for more detail.

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