Encopresis

Encopresis is the repeated passage of formed, semi-formed or liquid stool into underwear, or in inappropriate places, in a child aged 4 years or older (developmental age at least 4 years), at least once per month for 3 months. Soiling is involuntary in more than 95 percent of cases.

• Retentive (with constipation and overflow) accounts for about 80 to 95 percent: chronic stool withholding leads to rectal distension, loss of sensation, faecal impaction and leakage of liquid stool around the hard faecal mass (overflow). Non-retentive (functional faecal incontinence) is less common.
• Prevalence about 1 to 3 percent of school age children; boys more than girls (3 to 5 to 1); onset commonly after toilet training or at school entry.
• Causes and triggers: painful defecation, anal fissure, low fibre diet, low fluid intake, reluctance to use school toilets, toilet training pressure, stress, family change, cow's milk protein sensitivity, drugs (opioids, anticholinergics, iron), neurodevelopmental conditions (autism, attention deficit hyperactivity disorder), learning disability.
• Organic causes (about 5 percent): Hirschsprung disease (delayed meconium over 48 hours, from birth), anorectal malformation, spinal cord anomalies (tethered cord, spina bifida occulta, sacral agenesis), hypothyroidism, hypercalcaemia, coeliac disease, cystic fibrosis, cerebral palsy, sexual abuse.
• Consequences: shame, bullying, behavioural and emotional problems, urinary tract infection, enuresis, recurrent abdominal pain, family conflict; recurrence is common during treatment.

• Soiling in daytime (rarely at night), offensive loose stool or small pellets in underwear, large infrequent hard stools, painful defecation, withholding behaviour (stiffening, crossing legs, hiding), abdominal pain, poor appetite, abdominal distension, nocturnal enuresis or daytime urinary symptoms, recurrent urinary infections.
• Examination: abdominal palpation (faecal mass in the left lower quadrant), perianal inspection (fissure, erythema, soiling, anal position and patency, scars, signs of abuse), spine and sacrum (dimple, tuft of hair, lipoma), lower limb neurology (tone, reflexes, gait), growth, thyroid. Digital rectal examination is not required when typical history and abdominal findings are present and should be reserved for diagnostic uncertainty (by experienced clinicians).
• Red flags: onset from birth, delayed passage of meconium, ribbon like stool, abdominal distension, failure to thrive, vomiting (bile stained), fever with diarrhoea (enterocolitis), neurological signs, sacral abnormality, absent anal wink or abnormal anal tone, perianal injury, signs of abuse, symptoms of hypothyroidism, bloody stools, growth faltering.

• Clinical diagnosis based on history and abdominal examination.
• Plain abdominal radiography is not recommended routinely (consider only when faecal loading cannot be assessed clinically).
• Investigations if red flags: thyroid function, calcium, coeliac serology, sweat chloride, anorectal manometry and rectal suction biopsy for Hirschsprung disease, spinal MRI.
• Stool diary with a stool form chart.

• Explain that soiling is involuntary, avoid blame and punishment, and engage the child and family; a multidisciplinary approach helps (nurse, dietitian, psychologist).
• Step 1: Disimpaction (if faecal loading is present):
  • Polyethylene glycol 3350 (macrogol) with or without electrolytes 1 to 1.5 g/kg/day orally for 3 to 6 days (or until the impaction clears), dissolved in water or juice; paediatric sachet based regimens are acceptable (for example escalating from 2 to 8 sachets daily over a week depending on age); monitor for vomiting and abdominal pain.
  • If macrogol is refused, use an escalating stimulant (senna) plus lactulose, or sodium picosulfate (dose by age and weight, specialist advice); enemas (sodium citrate micro enema 5 mL rectally, or phosphate enema in older children with caution about electrolyte disturbance; avoid in Hirschsprung disease, dehydration, renal impairment) or manual evacuation under anaesthesia for failure.
• Step 2: Maintenance (at least 6 to 12 months, and continued for at least 3 months after regular, painless stools without soiling):
  • Macrogol 0.4 to 0.8 g/kg/day orally in one or two doses, adjusted to produce one soft stool daily.
  • Add a stimulant laxative if stools are soft but propulsion is poor or withholding persists: senna 3.75 to 15 mg orally at night (ages 2 to 5 years) or 7.5 to 30 mg at night (ages 6 years and over); or bisacodyl 5 mg orally at night (ages 4 to 10 years); 5 to 20 mg at night (over 10 years); or sodium picosulfate.
  • Lactulose 2.5 to 10 mL orally twice daily as an alternative osmotic laxative (bloating more common). Do not stop laxatives abruptly; wean gradually over several months.
  • Avoid mineral oil in young children (aspiration risk).
• Behavioural measures: sit on the toilet for 5 to 10 minutes after meals, 3 times daily, with feet supported on a stool (squat position) and a calm, no pressure approach; reward chart for sitting and stool passage, not for clean pants; wash and change underwear without shaming; school toilet access planning.
• Diet and fluids: age appropriate fluid intake (1.2 to 1.5 litres daily for school age children), fibre 5 g plus the age in years per day (fruit, vegetables, whole grains), limit excessive milk (over 500 mL per day) and refined foods; do not rely on diet alone.
• Treat anal fissures with petroleum jelly and soft stools; glyceryl trinitrate ointment is a specialist option; treat underlying conditions.
• Psychological support or referral for behavioural problems, trauma, or persistent refusal; evaluate for abuse if suspicion.
• Review at 1 to 2 weeks after disimpaction, then every 4 to 6 weeks until established, then every 3 months; refer to a paediatric gastroenterologist for treatment failure after 3 months of compliant therapy, red flag features, or suspected Hirschsprung disease or neurological cause; biofeedback for dyssynergic defecation in older children.
• Relapse is common (up to 50 percent); restart laxatives early.