Makindo Medical Notes

Related Subjects: |Encopresis in Children |Enuresis/Bedwetting in Children |Acute Glomerulonephritis in Children |Nephrotic Syndrome in Children |Acute Appendicitis in Children |Gastro-oesophageal reflux in Children |Intussusception in Children |Panayiotopoulos Syndrome in Children |Reflex anoxic attacks in Children

💩 Introduction

• 🧒 Encopresis is the repeated, inappropriate passage of solid faeces in children aged ≥4 years who have otherwise achieved toilet training.
• 👦 More common in boys than girls (≈5:1 male-to-female ratio).
• 🧠 Two main subtypes: retentive (with constipation) and non-retentive (without constipation).
• ⚖️ The most common underlying cause is chronic constipation with overflow incontinence, but in some cases it can reflect emotional or psychological distress (e.g. trauma or abuse).

📚 Types of Encopresis

• 💢 Retentive Encopresis — Accounts for ~80% of cases. Caused by stool withholding and constipation leading to rectal dilatation and overflow leakage. Often painless, with hard stools and soiling.
• 🧩 Non-Retentive Encopresis — Not linked to constipation. Usually behavioural or emotional in origin (e.g. anxiety, family conflict, past trauma). The child may have normal bowel habits otherwise.

🧠 Causes and Contributing Factors

The majority of encopresis arises from chronic constipation leading to stool retention, rectal distension, and loss of sensation. However, behavioural and psychosocial elements are also important.

• 🚫 Constipation and stool withholding: Often starts after painful defecation, leading to a vicious cycle of avoidance and overflow leakage.
• 💔 Psychological stressors: Family disruption, bullying, anxiety, or depressive symptoms.
• ⚠️ History of sexual or physical abuse: Rare but important to consider — encopresis may reflect trauma-related distress.
• 🏡 Environmental factors: Inconsistent toilet routines, chaotic family dynamics, or lack of privacy may worsen symptoms.

🧾 Clinical Features

• 💩 Recurrent faecal soiling — often in underwear or during play.
• 😣 Constipation, abdominal discomfort, or painful defecation (retentive type).
• 🕐 Soiling typically occurs in the afternoon or evening; stool may be malodorous and soft.
• 🙈 The behaviour is usually involuntary, though may be deliberate in emotionally distressed children.
• 🔄 May coexist with enuresis (urinary incontinence).

🔍 Diagnosis

• 🩺 Primarily clinical — based on detailed history and examination.
• 📖 Look for chronic constipation or stool withholding behaviours.
• ⚖️ Assess psychosocial environment: family stress, anxiety, abuse, or neglect.
• 📊 Exclude medical causes (e.g. Hirschsprung’s disease, spinal abnormality, hypothyroidism).
• 💬 Input from paediatrics and child mental health teams may be warranted.

🧴 Management and Treatment

Successful management requires addressing both bowel function and emotional wellbeing — treatment must be consistent, supportive, and non-punitive.

• For Retentive Encopresis (≈80%):
  • 💧 Disimpaction: Enemas or oral polyethylene glycol (PEG) to clear the bowel.
  • 🥦 Dietary measures: Increase fibre and fluids; limit constipating foods.
  • 💊 Maintenance therapy: Stool softeners (PEG, lactulose) to prevent re-impaction.
  • 🚽 Toilet training routine: Encourage sitting 15–30 minutes after meals (post-prandial reflex).
  • 📅 Reward charts: Positive reinforcement for toilet use, not punishment for accidents.
• For Non-Retentive Encopresis:
  • 🧩 Behavioural therapy: Consistent routines, reinforcement of positive behaviour, and avoidance of criticism.
  • 🧑‍⚕️ Psychological support: Referral to CAMHS or a child psychologist if underlying emotional distress, anxiety, or trauma suspected.
  • 🤝 Family therapy: Useful where family conflict, rigidity, or inconsistency are contributing factors.

💞 Family and Emotional Support

Encopresis can cause significant embarrassment, shame, and frustration for both the child and family. A calm, empathetic approach is essential. Parents should be counselled that punishment worsens anxiety and stool withholding. Encourage open communication and support groups when available. Teachers and carers may need education to avoid stigma or ridicule.

🗣️ What to Tell Parents

• 💬 Reassure: Most children improve with time and structured treatment — it is rarely permanent.
• ❤️ Avoid blame or shame: The child is not “naughty”; encopresis reflects a bowel-behaviour interaction.
• 🕊️ Stay consistent: Regular routines, encouragement, and patience are key to success.
• 🌟 Highlight the prognosis: With proper bowel regimen and emotional support, long-term outcomes are excellent.

✅ Conclusion

Encopresis is a common, treatable condition that lies at the intersection of paediatric gastroenterology and child mental health. Chronic constipation remains the principal cause, but emotional and environmental factors are often contributory. A structured bowel management plan combined with behavioural and psychological support leads to resolution in most cases. The cornerstone of care is compassion, consistency, and communication — for both child and family.