Encopresis is the voluntary or involuntarypassage of stool into inappropriate places, inchildren over the developmental age of 4 yr,with the absence of direct physiologic causes. Occurs at least once per month for at least 3months.
787.6 INCONTINENCE OF FECES 307.7 ENCOPRESIS
PEAK INCIDENCE: 4 to 5 yr of age PREVALANCE (IN U.S.): 1% to 1.5% ofchildren ages 5-8. PREDOMINANT SEX: Male > female (ratio of4:1) PREDOMINANT AGE: 4 to 9 yr of age GENETICS: Factors that contribute to slow gutmotility may predispose to encopresis
• Children with encopresis exhibit abnormal anorectaldynamics.• Primary encopresis may be related to developmentaldelay of sphincter control.• Secondary encopresis develops in the setting ofconstipation.• Approximately 96% of children will have bowel movementsbetween three times daily to once every other day.
When bowel movements are less frequent,stool becomes drier and harder and muchmore uncomfortable to pass. Soiling results from more liquid stool that leaksaround the main stool mass.
• Constipation may begin gradually as a result ofa slow decrease in elimination frequency ormore acutely after an illness, dehydration, orprolonged bed rest.• In encopresis without constipation andoverflow incontinence, soiling is oftenintentional. This may occur in the setting ofoppositional-defiant disorder or conductdisorder
Harsh or inconsistent toilet training andresultant anxiety may lead to retention of stool,constipation, and eventually encopresis.
Most children attain fecal continence by theage of 4. In Primary encopresis, continence is never fullyestablished Secondary encopresis incontinence ispreceded by a year or more of continence.
In primary encopresis, stool is more likely to benormal in character. Soiling is intermittent and usually in aprominent location. Coexisting oppositional-defiant or conductdisorders are frequent.
• In secondary encopresis, constipation is generallysevere.• Causes an overflow incontinence in which soft orliquid stool flows around the retained feces, oftenseveral times per day.• Defecation is usually uncomfortable or painful, sopatient avoids defecation with consequent stoolretention.
Stool is usually poorly formed and leakage iscontinuous (occurring during sleep andwakefulness). Encopresis resolves when the constipation isresolved.
HISTORY: Pay particular attention to frequency ofelimination. Character of the stool. Associated pain. Presence of enuresis (with which it is frequentlyassociated).
Evaluate child for other developmental orpsychiatric problems. PHYSICAL EXAMINATION: pay particular attention to the abdomen, anus,rectum, and saddle sensation.
CONSIDER: Thyroid function tests Electrolytes Calcium Urinalysis Culture
Abdominal imaging to determine extent ofobstruction or megacolon (abdominalradiograph). Anorectal manometric studies todetermine sphincter function if Hirschsprungsdisease is suspected; If abnormal, follow up with a barium enemaand rectal biopsy .
It is a test that evaluates bowel function inpatients with constipation or stool leakage. It is done on an outpatient basis with milddiscomfort.
The test measures the following parameters; Strength of the anal sphincter muscles Sensation of stooling in the rectum Reflexes that govern bowel Movements of the rectal and anal muscles
Indicated to rule out the following conditions; Constipation, particularly difficulty with stoolevacuation (dyssynergic defecation) Stool leakage or fecal incontinence Hirshsprungs disease (a childhood disorder) Anorectal function before or after bowelsurgery
The test takes about 60 minutes. A small, flexible sensor is placed in the rectum. It is then connected to a computer and arecording device that measures the pressureand strength of the anal and rectal muscles.
During the procedure, patient will be asked toperform certain maneuvers such as tosqueeze, to relax or push as if to pass stool. Small balloon attached may be inflated in therectum to assess the normal reflexes and toassess the patient perceive stool sensation inthe rectum.
Anorectal manometry is a safe test. It is unlikely to cause pain .Rare complications include the following; possible perforation or bleeding of the rectum. Allergic reaction to persons insensitive to latex. Patients may feel shy or embarrassed duringthe test.
NONPHARMACOLOGIC THERAPY; Behavioral and/or individual psychotherapyand family therapy. Biofeedback advocated by some to improvesphincter function.
• In secondary encopresis, disimpaction withisotonic saline enemas .• Resistant cases: repeated instillation of 200 to600 ml of milk of magnesia enemas .• If child does not permit enemas: oral disimpactionwith large doses of mineral oil or lactulose untilstool mass is cleared (note: this is frequently morepainful and more uncomfortable than an enema)
• Prevention of recurrence of constipation byincreased dietary fiber, bulk agents and theuse of laxatives (Senokot) and stool softeners(Colace).• In primary encopresis, continue withnonpunitive toilet training and encourageregular toilet times (the latter is also helpful insecondary encopresis)
• A systematic review found some evidence thatbehavioral intervention plus laxative therapy, rather thanbehavioral therapy or laxative therapy alone, improvescontinence in children with primary and secondaryencopresis. There was no evidence that biofeedbackadds any benefit to conventional management ofencopresis and constipation in children.Brazelli M, Griffiths P: Behavioural and cognitiveinterventions with or without other treatments fordefaecation disorders in children. Cochrane DatabaseSyst Rev 2001;CD002240
In most cases encopresis is self-limitedand of relatively brief duration.
If patient is resistant to treatment. If complicated family factors are involved. If encopresis is purposeful.
It is important to educate parents and childrenas to the nature of the problem and to defusehostile or negative interactions between them.
Medscape American Academy of Pediatrics Ferris Clinical Advisor 2008, 10th ed http://www.gastroconsultantsqc.com/services/procedures/anorectal-manometry/