Functional constipation and encopresis can develop due to social stressors, dietary changes, inappropriate toilet training, or painful bowel movements establishing a cycle of retention. Management includes parental education, increasing fiber/water, exercise, proper toilet training, and medical therapy including disimpaction, stool softeners, and behavioral interventions. Chronic constipation may lead to a megarectum, and encopresis is the involuntary passage of feces occurring at least monthly for 3 months in children over age 4.

1. FUNCTIONAL CONSTIPATION
& ENCOPRESIS

2. Definition
• A delay or difficulty in defecation present for >1 month and
significant enough to cause distress to the patient.
• Known as Idiopathic constipation or fecal withholding .

6. INTRODUCTION
• Functional constipation starts after the neonatal period
• An acute episode precedes the chronic course.
• Social stressor - initiation of toilet training,
birth of a sibling,
starting daycare,
abuse
• Dietary change from human milk to cow’s milk, due to the change in
the protein and carbohydrate ratio or an allergy to cow’s milk.

7. Intro - continue
• In toddlers, inappropriate early toilet training initiate a pattern of
stool retention.
• In older children, retentive constipation can develop after entering a
situation that makes stooling inconvenient such as school.

8. CLINICAL MANIFESTATIONS
• Longer retention of stool---->drier/harder and bulkier --->causes painful
evacuation.
• The withholding behavior of a child often begins after such a painful
movement of the bowel and when this continues for a period of time; it
establishes a vicious cycle that leads to chronic habitual constipation.
In functional constipation , when they have urge to defecate-
• contracting of the gluteal muscles by stiffening the legs while lying down,
• holding onto furniture while standing,
• squatting quietly in corners, waiting for the call to stool to pass.

9. Clinical Manifestations
• Misinterpreted as straining, but it is withholding behavior leading to
fecal impaction/overflow incontinence when left untreated.
• Long-standing constipation (left untreated for several months) can
lead to the development of a secondary megarectum.
• Blood in the stool is noted with the passage of a large bowel
movement.
• Failure to thrive, weight loss, abdominal pain, vomiting, or persistent
anal fissure or fistula.

12. MANAGEMENT

13. Management
1. Parental counseling and education:
• Parents need to be educated regarding the pathophysiology of
functional constipation so that they understand why their child
struggles to defecate and what needs to be done to improve the
situation.
• They require specialist attention, evaluation, and several months of
effective laxative therapy before the megarectum and constipation
resolve.
• Parents anxiety regarding laxative abuse should be reassured

14. Management
2. Diet, fiber, and water intake:
The daily diet should include fiber (0.5 g/kg/day) and adequate
water, cereals, pulses, vegetables, and fruits.
It is important to provide symptom relief to the child with
medications and not rely on diet alone to treat a child with chronic
constipation.

15. Management
• 3. Physical activity: Sedentary lifestyle is discouraged and participation in
physical activities are encouraged as this encourages bowel movement.
• 4. Toilet training: Encourage child to defecate within 30 minutes of the
major meal in order to utilize gastrocolic reflex. If the child uses Western
toilet, the child should be encouraged to use a footrest to make an effective
angulation between abdomen and thighs to facilitate proper passage of
stools. (The Indian style closet is considered anatomically more ideal for
defecation than the Western style closet).
• 5. Medical therapy: Medical therapy includes disimpaction and maintenance.

18. Medical Therapy
• Enema - to clear the impaction while stool softeners are started as
maintenance medications.
• If behavioral or psychiatric problems are evident, involve
psychologist or behavioral management .
• Maintenance therapy is continued until a regular bowel pattern has
been established and the association of pain with the passage of stool
is abolished.

20. Encopresis
• Definition - voluntary or involuntary passage of feces into inappropriate
places at least once a month for 3 consecutive months once a
chronologic or developmental age of 4 yr has been reached.
• Not diagnosed when behavior is the result of the direct effects of a
substance (e.g., laxatives) or a general medical condition (except
through a mechanism involving constipation).
• Subtypes - 1. Retentive encopresis (with constipation and overflow
incontinence), 65–95%
2. Non retentive encopresis (without constipation and
overflow incontinence).

21. Encopresis
• Nonretentive fecal incontinence is defined as no evidence of fecal
retention (impaction), ≥1 episodes per week in the previous 1 month,
or defecation in places inappropriate to the social context in a child
who has been previously toilet trained and without evidence of
anatomic, inflammatory, metabolic, endocrine, or neoplastic process
that could explain the symptoms.
• Primary – present from infancy
• Secondary- after successful toilet training

22. Retentive encopresis
• Retentive encopresis - complaints of difficulty with defecation,
abdominal or rectal pain, impaired appetite with poor growth, and
urinary (day and/or night) incontinence .
• Children often have large bowel movements that obstruct the toilet.
There may also be retentive posturing or recurrent urinary tract
infections.
• Complications - day and night urinary incontinence, urinary
retention, urinary tract infection, megacystis, and rarely toxic
megacolon.

23. Nonretentive Encopresis
• Nonretentive encopresis - occurs as a solitary symptom &
associated primary underlying psychological etiology.
• Children with encopresis can present with poor school performance
and attendance due to scorn and derision from schoolmates because
of the child’s offensive odor.

24. Investigation
• Urinary tract symptoms leads to recurrent urinary tract infection .
• Children with no evidence of abnormalities on physical examination
require radiologic evaluation.

25. Investigation
• In refractory patients (intractable constipation) - rule out
hypothyroidism, hypocalcemia, lead toxicity, celiac disease, and
disorders of neuromuscular gastrointestinal pathology .
• Colonic transit studies using radiopaque markers or scintigraphy
techniques may be useful .

26. Investigation
• MRI of the spine to identify an intraspinal process, motility studies
to identify underlying myopathic or neuropathic bowel
abnormalities, or a contrast enema to identify structural
abnormalities.
• In patients with severe functional constipation, water-soluble
contrast enema reveals the presence of a mega rectosigmoid

27. TREATMENT
• Patient education, relief of impaction, and softening of the stool.
• Adherence to regular postprandial toilet sitting and adoption of a
balanced diet.
• Caregivers must understand that soiling associated with overflow
incontinence is associated with loss of normal sensation and not a willful
act and instructed not to respond to soiling with revenge or punishment
measures, because children are likely to become angry, ashamed, and
resistant to intervention.
• Parents should actively encourage to reward the child for adherence to
a healthy bowel regimen

28. Treatment
• For children with chronic diarrhea and/or irritable bowel syndrome
with stress and anxiety - stress reduction and learning effective
coping strategies are important
• Relaxation training, stress inoculation, assertiveness training, and/or
general stress management procedures can be helpful.
• surgical interventions have no place in the treatment of children with
non-retentive encopresis.