PRESENTED BY: DURGESH J. PATEL
RONAK C. PATEL
• The developmental milestones of mastering control over bowel and bladder
function are complex processes that occur over a period of months for the typical
• Between 1 and 3 years of age, cortical inhibitory pathways develop allowing the
child to have voluntary control over reflexes that control the bladder muscles.
• The assessment of fecal soiling includes determining whether the clinical
presentation occurs with or without chronic constipation and overflow soiling.
• The normal sequence of developing control over bowel and bladder functions is
the development of
• nocturnal fecal continence,
• diurnal fecal continence,
• diurnal bladder control,
• nocturnal bladder control.
• Toilet training is affected by many factors, such as a
• child's intellectual capacity
• social maturity,
• cultural determinants,
• the psychological interactions between child and parents.
Enuresis And Encopresis Are The Two Elimination Disorders Described In The
Text Revision Of The 4th Edition Of Diagnostic And Statistical Manual Of Mental
• These disorders are considered after age 4 years, for encopresis, and after age 5
years for enuresis,
• ENCOPRESIS is defined as a pattern of passing feces in inappropriate places,
such as in clothing or other places, at least once per month for 3 consecutive
months, whether the passage is involuntary or intentional.
• The child with encopresis typically exhibits dysregulated bowel function;
• ENURESIS is the repeated voiding of urine into clothes or bed, whether the
voiding is involuntary or intentional. The behavior must occur twice weekly for at
least 3 months or must cause clinically significant distress or impairment socially
• decrease drastically with increasing age
• 8.1 percent of 3 year olds,
• 2.2 percent of 5 year olds, and
• 0.75 percent of 10 to 12 year olds.
• Males are found to be about six times more likely to have
encopresis than females.
• Physiological and Psychological factors
• Encopresis is considered a nonorganic disorder, a typical child with
encopresis may show evidence of
• chronic constipation,
• leading to infrequent defecation,
• withholding of bowel movements,
• avoidance of defecation.
• Children may avoid the pain of having a bowel movement by holding in
the bowel movement, which then leads to impaction and eventual
overflow soiling.(75 percent of children).
• Some encopretic children have lifelong inefficient and ineffective
• Greater frequency among children with known sexual abuse compared with a
normal sample of children.
• Associated with measures of maternal hostility, and harsh and punitive parenting.
• It is evident that once a given child has developed a pattern of withholding bowel
movements with resulting pain with attempts to defecate, a child's fear and
resistance to changing the pattern can lead to a power struggle between child
and parent over effective toileting behavior.
• A subclinical preexisting anorectal dysfunction exists that contributes
to the constipation.
• Resulting chronic rectal distention from large, hard fecal masses can
cause loss of tone in the rectal wall and desensitization to pressure.
• Anecdotal reports indicate that children whose parenting has been
harsh and punitive and who have been severely punished for
accidents during toilet training are at greater risk of developing
TABLE 47-1 DSM-IV-TR
DIAGNOSTIC CRITERIA FOR ENCOPRESIS
• Repeated passage of feces into inappropriate places (e.g., clothing or
floor) whether involuntary or intentional.
• At least one such event a month for at least 3 months.
• Chronological age is at least 4 years (or equivalent developmental
• The behavior is not due exclusively to the direct physiological effects
of a substance (e.g., laxatives) or a general medical condition except
through a mechanism involving constipation.