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Encopresis

Encopresis, also known as fecal soiling or fecal incontinence in children, is defined as the repeated passage of stool, whether involuntary or intentional, into inappropriate places, such as underwear, occurring at least once per month for three months in children older than four years who have achieved daytime bowel control.^[1] It is classified as an elimination disorder in the DSM-5 and primarily affects toilet-trained children aged 4 to 12, with a higher prevalence in boys at a ratio of 3:1 to 6:1.^[1]^[2] The condition is most commonly retentive encopresis, accounting for 80-95% of cases, where chronic constipation leads to fecal impaction in the rectum, causing softer stool to leak around the blockage and result in overflow incontinence.^[2]^[3] This constipation often stems from voluntary stool withholding due to painful or difficult bowel movements, exacerbated by low-fiber diets, inadequate fluid intake, or emotional stress such as family changes or overly punitive toilet training.^[3]^[4] Less commonly, non-retentive encopresis occurs without constipation and may involve behavioral factors, psychological issues like anxiety, or rare organic causes such as Hirschsprung disease, spinal cord abnormalities, or anorectal malformations.^[1] Symptoms typically include recurrent soiling of clothes with loose or semi-formed stool, abdominal pain, bloating, loss of appetite, and hiding soiled underwear; affected children may also experience urinary incontinence or recurrent urinary tract infections due to fecal contamination.^[4]^[3] Epidemiological studies indicate a global prevalence of 0.8% to 7.8%, with approximately 4% of U.S. children aged 4-17 affected, and rates decreasing with age from about 4.1% at ages 5-6 to 1.6% at ages 11-12.^[1]^[2] Treatment focuses on resolving underlying constipation through a combination of medical disimpaction (e.g., using polyethylene glycol laxatives), maintenance therapy with dietary modifications high in fiber and fluids, scheduled toileting, and behavioral interventions like positive reinforcement to encourage regular bowel habits.^[1]^[4] For non-retentive cases, psychological support or family therapy may be necessary.^[1] Without intervention, encopresis can lead to significant emotional complications, including embarrassment, low self-esteem, social isolation, anxiety, or depression, particularly if the child faces teasing or punishment.^[3] Most cases resolve with treatment, though chronic untreated instances may persist into adolescence or adulthood.^[2]

Definition and Classification

Definition

Encopresis is defined as the repeated, voluntary or involuntary passage of feces in inappropriate places, such as clothing or the floor, by a child who is at least 4 years of age chronologically or developmentally equivalent. This condition must occur at least once per month for a minimum of 3 months to meet diagnostic thresholds.^[1]^[2] According to the DSM-5 criteria, encopresis requires the fecal incontinence not to be exclusively due to the direct physiological effects of a substance, such as laxatives, or another medical condition, except through a mechanism involving constipation. Similarly, the ICD-11 specifies that encopresis (code 6C01) involves repeated passage of feces in inappropriate places, occurring at least once per month for at least 3 months in an individual developmentally at least 4 years old, and not fully attributable to a medical condition, substance use, or another mental, behavioral, or neurodevelopmental disorder.^[2]^[5] The term encopresis, derived from the ancient Greek word for stool (egkóprēsis), was first introduced in 1926 by the pediatrician Weissenberg to describe involuntary defecation in children, evolving from early 20th-century pediatric literature that distinguished it from organic causes of incontinence.^[6] This modern usage differentiates encopresis, which pertains to fecal soiling, from enuresis, defined as repeated urinary incontinence typically from age 5 onward, and from normal developmental delays in toilet training, which are expected to resolve by around age 3 without meeting the frequency or duration criteria for a disorder.^[7]^[1]

Classification

Encopresis is primarily classified into two main subtypes based on the presence or absence of constipation: retentive encopresis, also known as constipation-associated or overflow encopresis, and non-retentive encopresis. Retentive encopresis accounts for the majority of cases, comprising 80-95% of instances, and occurs when chronic constipation leads to fecal impaction in the rectum, resulting in liquid stool leaking around the blockage (overflow incontinence).^[1]^[2] In contrast, non-retentive encopresis involves the passage of stool in inappropriate places without evidence of constipation or retention, often linked to behavioral or psychological factors such as avoidance due to past trauma or stress-related disorganization.^[1]^[8] Secondary classifications further subdivide encopresis based on etiology and associated features. Encopresis can be categorized as occurring with or without constipation, aligning closely with the retentive-non-retentive distinction, where the former involves withholding behaviors exacerbating impaction and the latter features normal bowel habits but inappropriate soiling.^[1] Additionally, it is distinguished as idiopathic (functional, without underlying pathology) or organic (due to identifiable medical conditions), with organic causes representing only 5-10% of cases and including neurological disorders, anorectal malformations, or Hirschsprung disease.^[9]^[1] The Rome IV criteria provide a standardized framework for subtyping functional defecation disorders, which encompass most cases of encopresis, emphasizing recurrent fecal incontinence in children aged 4 years or older alongside features like infrequent defecation or retentive posturing for retentive types.^[1] This diagnostic system aids in distinguishing functional from organic subtypes by requiring exclusion of structural or neurological abnormalities. For example, in retentive encopresis, overflow incontinence manifests as periodic soiling with large, hard stools, whereas non-retentive encopresis may involve post-traumatic avoidance leading to deliberate or inadvertent soiling during stressful situations.^[1]^[10]

Pathophysiology

Causes

Encopresis is primarily a functional disorder resulting from chronic constipation in 80-95% of cases.^[1]^[2] This constipation often stems from dietary factors such as low fiber intake, inadequate fluid consumption, or excessive consumption of cow's milk, which can contribute to hard, dry stools that are difficult to pass.^[3] Withholding behaviors exacerbate the condition, typically arising when children avoid defecation due to painful bowel movements, fear of the toilet, or distractions during play, leading to fecal impaction.^[3]^[1] Rare anatomical issues account for less than 5% of cases and include conditions like Hirschsprung's disease, particularly following surgical repair, as well as other organic etiologies such as spinal dysraphism or anorectal malformations.^[1] Psychological contributors play a significant role in functional encopresis, with emotional stressors including premature toilet training, family conflicts, life changes like parental divorce or the arrival of a new sibling, or experiences of trauma and bullying that promote avoidance behaviors.^[3]^[1] These factors often manifest alongside behavioral issues such as anxiety or aggression in about one-third of affected children.^[1] Genetic predispositions are indicated by a family history of constipation disorders, which predicts greater persistence of encopresis symptoms.^[1] Iatrogenic causes include side effects from medications like opioids or cough suppressants that induce constipation, as well as complications from surgical interventions such as colectomy or repairs for congenital anomalies.^[3]^[1] Risk factors amplifying these etiologies encompass low socioeconomic status and male gender predominance, with encopresis occurring up to six times more frequently in boys.^[11]^[1]

Mechanisms

Encopresis primarily manifests through two pathophysiological mechanisms: retentive and non-retentive types, each involving distinct disruptions in normal defecation processes.^[1] In the retentive type, which accounts for 80-95% of cases, chronic constipation leads to fecal impaction in the rectosigmoid colon, where hardened stool accumulates due to prolonged retention.^[1]^[2] This impaction causes overflow incontinence, as softer or liquid stool proximal to the blockage leaks around the mass, resulting in involuntary soiling.^[2] Rectal distension from the accumulated feces desensitizes the rectal nerves, reducing the sensation of fullness and further impairing the urge to defecate, which perpetuates the retention cycle.^[1] Neurogastroenterological aspects, such as alterations in the rectoanal inhibitory reflex, may contribute by blunting the normal relaxation of the internal anal sphincter in response to rectal distension.^[12] The non-retentive type involves dysfunctional defecation patterns without significant constipation or impaction. It is primarily driven by behavioral and psychological factors, such as ignoring or denying the urge to defecate, avoidance due to fear or anxiety, or oppositional behaviors often associated with conditions like oppositional defiant disorder.^[8]^[1]^[13] A reinforcing cycle often underlies retentive encopresis, wherein initial painful or hard bowel movements—potentially triggered by dietary factors like low fiber intake—prompt voluntary stool withholding to avoid discomfort, leading to further stool hardening, impaction, and eventual overflow.^[1] This behavioral-physiological loop intensifies the condition, as repeated withholding reduces rectal sensitivity and promotes chronicity.^[14]

Clinical Presentation

Signs and Symptoms

Encopresis primarily manifests as the involuntary passage of stool in children beyond the typical age of toilet training, often presenting with noticeable physical signs such as soiling of underwear or clothing with loose or semi-formed feces, which may be mistaken for diarrhea.^[3] A persistent fecal odor is common due to the leakage of small amounts of stool, and affected children may exhibit abdominal distension or bloating from retained feces.^[1] Leakage can occur unpredictably, including during physical activity or play, leading to stains on clothing or bedding.^[11] Behaviorally, children with encopresis often hide soiled underwear or clothes out of embarrassment, and they may display reluctance to use the toilet, such as refusing to sit on it or avoiding bowel movements altogether due to pain or fear.^[1] This can result in social withdrawal, avoidance of school or social situations, and secondary issues like decreased appetite or irritability.^[11] Most cases are linked to underlying chronic constipation, where fecal impaction leads to overflow incontinence.^[3] Presentations vary by age; in preschoolers, soiling may be more overt and easily observed by caregivers, while in school-age children (typically peaking around ages 7-8), symptoms often become more covert as children actively conceal incidents to avoid stigma.^[1]^[14] Red flags include the presence of blood in the stool, which may indicate anal fissures from passage of hard stools or more serious underlying pathology requiring prompt evaluation.^[15]

Associated Conditions

Encopresis frequently co-occurs with enuresis, with nocturnal enuresis occurring in about one-third of affected children, often complicating diagnosis and treatment due to overlapping elimination issues.^[16] This association is particularly noted in functional subtypes, where urinary incontinence may exacerbate psychosocial distress.^[17] Psychiatric comorbidities are common, including attention-deficit/hyperactivity disorder (ADHD), anxiety disorders, and autism spectrum disorders. ADHD is associated with encopresis, with children with ADHD showing an approximately sixfold increased risk of fecal incontinence compared to those without ADHD.^[18] Anxiety affects approximately 40% of children with encopresis, often manifesting as internalizing behaviors that intensify avoidance of toileting.^[19] Autism spectrum disorders are also linked, appearing as a comorbidity in up to 20% of children with defecation issues, potentially due to sensory processing differences.^[20] Gastrointestinal conditions like functional constipation are nearly universal in retentive encopresis, present in 90% of cases and driving overflow incontinence through fecal impaction.^[1] Irritable bowel syndrome may overlap in some children, sharing features of altered bowel habits and abdominal pain that can mimic or worsen encopresis symptoms.^[21] Organic associations, though rare (affecting about 5% of cases), include spinal cord abnormalities such as tethered cord or dysraphism, which impair neural control of defecation and warrant screening in refractory encopresis.^[1] Hypothyroidism is another potential link, as it slows gastrointestinal motility and should be evaluated in persistent cases unresponsive to standard therapy.^[22] Psychosocial factors, including bullying and family stress, often amplify encopresis severity by increasing emotional distress and avoidance behaviors. Children with encopresis report higher rates of peer victimization, which correlates with worsened soiling episodes and reduced quality of life.^[23] Family dynamics, such as high parental stress, further contribute to symptom persistence through disrupted routines and heightened anxiety around toileting.^[24]

Diagnosis

Diagnostic Criteria

The diagnosis of encopresis is primarily guided by the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). According to these criteria, encopresis is characterized by the repeated passage of stool, typically involuntary and into inappropriate places (such as clothing), in a child who is at least 4 years of age (or at an equivalent developmental level), with episodes occurring at a frequency of at least once per month for a minimum of 3 months.^[1] The condition must not be attributable solely to the physiological effects of a substance, such as laxatives, or to another medical condition, unless the mechanism involves constipation; additionally, it must result in clinically significant distress or impairment in social, academic, or other key areas of functioning.^[1] Clinical evaluation begins with a comprehensive history-taking to assess bowel habits, dietary intake, toilet training history, and psychosocial factors, often incorporating reports from parents and direct interviews with the child to identify patterns of soiling.^[25] A physical examination follows, including abdominal palpation to detect fecal masses and assessment of anal tone and sphincter function via digital rectal exam, which helps confirm the presence of retained stool without signs of organic pathology; abdominal radiography may be used to confirm fecal retention if clinical suspicion persists despite equivocal physical findings.^[1]^[26] Suspicion for encopresis arises from consistent parental observations of involuntary soiling and the child's age-appropriate developmental stage, prompting these initial assessments.^[1] Standardized tools aid in evaluating stool characteristics and underlying functional gastrointestinal issues. The Bristol Stool Scale, a visual classification system categorizing stool forms from type 1 (hard, separate pellets indicating constipation) to type 7 (watery, no solid pieces indicating diarrhea), is used to assess consistency and correlate it with soiling episodes, with types 1-2 often signaling retentive patterns in encopresis.^[14] The Rome IV criteria for functional constipation, which frequently underlies encopresis, require at least two of the following in a child of developmental age 4 years or older for at least 1 month: two or fewer defecations per week, at least one episode of fecal incontinence per week, retentive posturing or stool-holding behaviors, painful or hard bowel movements, a large fecal mass in the rectum, or large-diameter stools that may obstruct the toilet.^[27] These criteria help differentiate functional encopresis from other elimination disorders by focusing on constipation-related mechanisms.^[1]

Differential Diagnosis

The differential diagnosis of encopresis requires careful exclusion of organic conditions that may present with fecal soiling or incontinence, as most cases are functional and related to chronic constipation.^[1] Key mimics include gastrointestinal, neurological, and infectious disorders, which are distinguished through targeted history, physical examination, laboratory tests, and imaging when indicated.^[28] Gastrointestinal conditions such as inflammatory bowel disease (IBD) must be considered, particularly if there is rectal bleeding, abdominal pain, weight loss, or failure to thrive; these are differentiated by endoscopic evaluation with biopsy confirming inflammation or ulceration.^[29] Celiac disease, an autoimmune malabsorption disorder, can lead to constipation and secondary soiling and is identified through serologic testing (e.g., tissue transglutaminase IgA) followed by duodenal biopsy if positive.^[28] Anal fissures, often resulting from hard stools, present with bright red blood on the stool surface or toilet paper and sharp perianal pain during defecation; diagnosis is clinical via visual inspection of the anal canal, with no need for biopsy in typical cases.^[30] Neurological disorders like spina bifida or tethered spinal cord can cause neurogenic bowel dysfunction mimicking encopresis, especially with associated lower extremity weakness, abnormal gait, or diminished perianal sensation; these are assessed with spinal MRI if neurological signs are present on exam.^[1] Infectious causes, such as parasitic infections including pinworms (Enterobius vermicularis), may contribute to perianal irritation and secondary soiling due to intense nocturnal itching; distinction involves the cellophane tape test for eggs or stool ova and parasite examination.^[31] Further investigations like colonoscopy are recommended in cases with red flags such as persistent symptoms despite initial laxative therapy, unexplained weight loss, or gross blood in stool to evaluate for IBD or other mucosal pathology.^[1] Anorectal manometry may be used as a screening tool for non-responders to conservative management or those with suspected Hirschsprung disease or sphincter dyssynergia; for suspected Hirschsprung disease, confirmatory diagnosis requires rectal biopsy to demonstrate absence of ganglion cells.^[1]^[32]

Management

Treatment Approaches

The treatment of encopresis primarily focuses on addressing underlying constipation through a structured medical approach, beginning with disimpaction to remove fecal buildup in the rectum. Oral polyethylene glycol (PEG) 3350 is the first-line agent for disimpaction, administered at a dose of 1 to 1.5 g/kg/day (maximum 100 g/day) mixed in fluids for 3 to 6 consecutive days until the impaction clears, as evidenced by passage of clear liquid stool or absence of soiling. If oral PEG is not tolerated or effective, rectal enemas such as saline or mineral oil may be used under medical supervision to achieve rapid clearance. This phase is critical, as unresolved impaction perpetuates the cycle of overflow incontinence. Once disimpaction is achieved, maintenance therapy aims to soften stool and promote regular bowel movements to prevent recurrence. Osmotic laxatives like lactulose (1-3 mL/kg/day divided into doses) or polyethylene glycol (0.2-0.8 g/kg/day) are commonly prescribed, with mineral oil (1-3 mL/kg/day) serving as an alternative lubricant to facilitate stool passage without causing dependency. Dietary modifications play a supportive role, emphasizing increased fluid intake and high-fiber foods to achieve age in years plus 5 g of fiber daily, which helps maintain stool consistency; examples include fruits, vegetables, and whole grains, tailored to the child's age and tolerance. Doses are adjusted based on response, with regular monitoring to ensure one to two soft stools per day. For non-responders, particularly those with pelvic floor dysfunction identified via anorectal manometry, biofeedback therapy targets dyssynergic defecation by training coordinated relaxation of the puborectalis muscle during evacuation. This intervention, involving sensor-guided exercises over 6-12 sessions, improves outcomes in up to 70% of refractory cases when combined with ongoing laxative therapy. A multidisciplinary approach enhances management, especially in cases with suspected organic etiologies such as Hirschsprung's disease or neurological disorders. Pediatricians oversee initial evaluation and maintenance, while pediatric gastroenterologists provide specialized assessment, including diagnostic tests and tailored pharmacotherapy for complex presentations.

Prevention Strategies

Preventing encopresis involves proactive measures during early childhood to promote healthy bowel habits and minimize risk factors such as chronic constipation. Early intervention through appropriate toilet training, dietary adjustments, and behavioral support can significantly reduce the likelihood of fecal soiling developing into a persistent issue. Family involvement is crucial, as consistent routines and positive reinforcement help children establish regular bowel movements without fear or avoidance.^[33] Toilet training guidelines emphasize a gradual, child-centered approach starting around age 2 to 3 years, once readiness signs such as interest in the potty and the ability to follow simple instructions are evident. The American Academy of Pediatrics recommends beginning training after 24 months to avoid undue pressure, incorporating positive reinforcement like praise for successful attempts and scheduled toilet sits of 5-10 minutes after meals to leverage the gastrocolic reflex. Avoiding emotional upsets during this process is key, as negative experiences can lead to stool withholding and subsequent encopresis.^[34]^[35]^[36] Dietary prevention focuses on maintaining soft, regular stools through age-appropriate fiber intake and adequate hydration. The American Academy of Pediatrics suggests a daily fiber goal of age in years plus 5 grams for children, achieved via fruits, vegetables, and whole grains, to prevent constipation that often precedes encopresis. For school-age children, hydration of about 1-2 liters per day, primarily from water, supports stool softening and overall bowel regularity.^[37]^[38]^[39] Behavioral techniques, including reward systems, encourage consistent toilet use and address potential withholding triggers such as school-related anxiety. Parents can implement sticker charts or small incentives for successful bowel movements or toilet sits, gradually fading rewards as habits form, which has been shown to promote adherence without coercion. Identifying and mitigating stressors like anxiety through open discussions or school accommodations helps prevent avoidance behaviors that exacerbate constipation.^[33]^[40] School-based programs play a vital role in prevention by educating children on normal bowel habits and reducing associated stigma. Initiatives that normalize discussions about toileting, provide access to comfortable facilities, and teach hygiene can foster a supportive environment, decreasing anxiety and encouraging prompt bathroom use among at-risk students.^[41]^[42]

Prognosis and Epidemiology

Prognosis

With appropriate treatment, the majority of children with encopresis experience significant improvement or resolution, though outcomes vary based on subtype and adherence to therapy. Recovery rates typically range from 50% to 60% within one year of initiating standard interventions such as bowel cleanout and maintenance laxatives combined with behavioral strategies.^[43]^[44] Long-term follow-up studies indicate cumulative success rates increasing to 80% or higher by five to eight years, with complete resolution in approximately 84% of cases after six years.^[43]^[45] Prognosis is generally more favorable for non-retentive encopresis (without constipation), which shows higher success rates around 94% with conservative management, compared to retentive encopresis (associated with chronic constipation), with lower resolution rates around 62%.^[46] Factors contributing to poorer outcomes include delayed diagnosis, which prolongs symptom duration and complicates adherence; comorbid conditions such as attention-deficit/hyperactivity disorder (ADHD), which is more prevalent in affected children and may hinder behavioral compliance; and non-compliance with treatment regimens, often linked to socioeconomic challenges.^[47]^[2] Despite these challenges, encopresis rarely persists long-term, with 10% to 25% of cases continuing into adolescence and a subset potentially leading to adult fecal incontinence if untreated.^[48] Early intervention significantly improves prospects, with studies demonstrating approximately 80-85% resolution by late adolescence or adulthood in children treated promptly, emphasizing the importance of timely medical and psychological support.^[16]^[45]

Epidemiology

Encopresis affects approximately 0.8% to 7.8% of children worldwide, with prevalence rates commonly ranging from 1% to 4% among school-aged children.^[1] In the United States, functional encopresis has a reported prevalence of about 4% among children aged 4 to 17 years attending primary care clinics, though community-based estimates vary.^[1] These figures highlight encopresis as a notable pediatric issue, often secondary to chronic constipation in up to 95% of cases.^[1] The condition is significantly more prevalent in males, with a male-to-female ratio ranging from 3:1 to 6:1, and it disproportionately affects younger children during the typical toilet training period.^[1] Prevalence peaks around ages 5 to 6 years at approximately 4.1%, declining to 1.6% by ages 11 to 12 years, reflecting a natural resolution or improved control with age in many cases.^[49] Incidence tends to peak between ages 4 and 8 years, coinciding with developmental milestones in bowel control, though exact incidence rates are less well-documented than prevalence.^[1] Regional variations exist, with higher reported rates in Western countries potentially due to greater awareness and diagnostic reporting.^[2] As of 2023-2025, prevalence estimates remain stable at 0.8-7.8% globally, with a 2025 study confirming no significant changes in developed regions.^[1]^[50] Socioeconomic factors play a key role, as encopresis is more common in low-income families, linked to dietary limitations, limited access to healthcare, and environmental stressors such as unhygienic conditions.^[1] For instance, prevalence is elevated in socioeconomically deprived urban areas, underscoring the influence of these disparities on pediatric gastrointestinal health.^[49]

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Appreciable social disadvantage seems to be the most important factor mitigating against a successful outcome, associated with non-compliance with treatment.Missing: recovery | Show results with:recovery<|control11|><|separator|>
[47]
Long-Term Prognosis for Childhood Constipation: Clinical ...
Jul 1, 2010 · DISCUSSION. Our long-term follow-up study revealed that, for ∼25% of children with functional constipation, symptoms persisted into adulthood.
[48]
The prevalence of encopresis in a multicultural population - PubMed
Results: The prevalence of encopresis was 4.1% in the 5-to-6 age group and 1.6% in the 11-to-12 age group. Encopresis was more frequent among boys and children ...