Childhood encopresis: what you need to know

Reminder The movement of stool (fecal matter commonly called "poop") along the colon is ensured by contractions of its wall. Some of these contractions are of great amplitude and occur several times a day, mainly during meals. They move the stool into the rectum, where they cause the sensation of need. At this moment there is a reflex and involuntary relaxation of a part of the sphincter muscle of the anus (smooth sphincter also called internal sphincter). This relaxation results in the passage of stool through the anus and its evacuation. During toilet training, around the age of 3, the child learns to voluntarily contract the second part of his anal sphincter (striated sphincter also called external sphincter) which allows him to retain stools and be "clean", until he is in the conditions necessary for a "social" defecation. As long as the child has not voluntarily evacuated his stools the rectum remains full, and the sensation of need disappears until the next reflex contraction of the intestine. The evacuation of stools of a child who has been toilet trained is therefore done at a voluntarily controlled rate depending on the speed of his digestive transit, which is more or less rapid depending on the individual. Thus for a child, the number of voluntary and normal defecations ranges from 3 per day to 1 every 3 days. Mechanisms of encopresis The child voluntarily holds back a bowel movement, no longer goes to the toilet or potty, his rectum fills up and stool leaks out without him thinking about it. Stool stagnation in the rectum is due to a child consciously exerting an effort to hold back the bowel movement when they normally feel the need to have a bowel movement. The evacuation is deliberately delayed. Gradually, the need to have a bowel movement becomes less pronounced as the rectum becomes accustomed to being filled with increasingly larger volumes. Beyond a certain volume of stool in the rectum, the smooth anal sphincter relaxes physiologically and leakage of formed or semi-formed stool occurs when the child's attention slackens and he no longer thinks about holding it in by squeezing the ridged part of his anal sphincter. Stool leaks due to overflow from the rectum, which is overfilled. If stools remain in the rectum for a long time, they harden and form a large, hard lump called a fecal impaction, which can weigh up to one kilo. This fecal impaction irritates the rectal wall, causing fecaloid secretions (liquid secreted by the rectal wall, colored like stool) to escape through the anus, which should be distinguished from diarrhea. Encopretic children are often initially constipated, which facilitates the stagnation of stools in their intestines and particularly in their rectum. This associated constipation is most often trivial, non-pathological and does not in itself explain the retention of stools in the rectum, which is voluntary. Encopresis is distinguished from true incontinence due to a sphincter abnormality caused by neurological diseases or congenital malformations. It is also distinguished from leaks caused by abnormal filling of the colon during an abnormal function of the colon that does not contract, as in Hirschprung's disease. Clinical The child is generally between 6 and 10 years old, and is most often a boy. These signs may occur after several months or years of toilet training (secondary encopresis), or the child may never have gained control over their bowel movements (primary encopresis). In severe cases, this condition may persist long after adolescence. Stool leakage is always present. Stool leaks often occur during physical exercise or play, when a child's attention lapses. They most often occur during the day, but can also occur at night. Paradoxically, these stool leaks do not seem to bother children who are active and healthy. There may also be oozing of liquid stools due to irritation of the rectum which is overfilled by hardened stools (fecal impaction), often confused by parents with diarrhea due to their liquid and uncontrolled nature. Other signs are often present: abdominal pain, abdominal bloating, constipation. Efforts to pass these hard stools can tear the anal mucosa and create a painful fissure that sometimes bleeds. Normal defecations performed on the toilet are rare, sometimes less than once a month. Most often, the child controls his urination, which proves that encopresis is not a neurological disease. Consultation by the doctor The consultation has four goals: diagnose encopresis, which is a functional disease, and eliminate other causes of incontinence, which may require specific treatments such as surgery, rule out a very rare congenital disease called Hirschsprung's disease (damage to the nerve branches of the intestinal wall) which can present as encopresis, assess the severity of the pathology, orient parents to a possible psychological cause which will be essential to work on to facilitate the healing of encopresis. The interview and examination are carried out in the presence of the parent(s) accompanying the child: Family history and sibling status are noted. Family composition will be noted (blended family, etc.). The child's medical history should be recorded since birth, with the help of the health record if possible. The height-weight curve should be normal. Possible intellectual difficulties are sought, these favor the installation and especially the persistence of this pathology by making its psychological management difficult. The conditions for toilet training will be asked, and we will also inquire about the child's daily care (nanny, school, care by family, etc.). Sometimes the abdomen is bloated and hard stools can be felt through the wall, which clogs the colon. The neurological examination should be normal. Inspection of underwear often helps confirm the diagnosis of stool leakage. A careful examination of the anal region, performed on a consenting and reassured child, should rule out any anal malformation, as well as any genitourinary malformation. An anal fissure may be due to the passage of large stools. A careful anal examination will ensure the normality of the anus, which is most often relaxed due to the normal sphincter relaxation reflex when the rectum is full of stools. A rectal examination immediately finds stools, most often hard. The severity of the problem and its impact on physical activity are often minimized by the child. The frequency of changing and bathing should be noted. The interview will be more aimed at alerting parents to possible psychological difficulties than at looking for them immediately. Initial consultations should be cautious, and psychological care will best be provided later by specialists (psychologist or psychiatrist). Further examinations are unnecessary in typical cases. Often, parents already have X-rays confirming stool stasis in the rectum, which most often also occurs throughout the colon. If an X-ray of the intestine has been performed, it will most often show residual stool stasis in the colon. The volume of stool thus retained can be impressive. The diameter of the colon will often be increased, which is in no way pathological if this increase affects its entire length, including the rectum. Anorectal manometry can look for signs of Hirschsprung's disease. Causes The causes are twofold. They combine constipation, which is often present, and psychological factors. Psychological difficulties can be secondary to mistakes during toilet training: potty training too early, obsessive parents, or even, on the contrary, no support during this period. Or they are psychological difficulties that have nothing to do with toilet training: difficulties in the relationship, emotional deprivation, psychological or physical trauma. It should be noted that very often encopresis is a way for the child to communicate with those around them. In some cases, there is no psychological cause: encopresis may be temporary in a constipated child who has an anal fissure due to a slightly more difficult than usual bowel movement. The pain from this fissure will make the child afraid to have a bowel movement. He may then hold it in until he leaks due to overflow. Treatment First and foremost, treating constipation is essential. It softens the stools to help the child evacuate them and makes defecation less painful. It will be based on a diet rich in fiber, vegetables, and fruits with sufficient fluid intake. The diet should not be too strict because it can cause additional conflict with parents and is rarely effective on its own. Suppositories and enemas should be avoided because they can be difficult for the child to handle, but they are sometimes really necessary, especially when there is too much accumulation of matter (fecal impaction) and when we want to use them as rehabilitation aids. Oral laxatives are always necessary; we should not be afraid to give fairly strong doses to these children, who are often very constipated. When constipation is severe (less than one bowel movement per week), it makes the treatment of encopresis more difficult. It is very important that this treatment be continued for several months, even beyond recovery. It should be noted that constipation is a common and trivial anomaly that very often begins in childhood and persists more than half of the time after puberty, which explains in the context of encopresis the need for its prolonged treatment to avoid relapses. In case of a crack, local care with a mild soap and a healing ointment will be combined. The functional and psychological aspect can be resolved in simple cases through non-specialized care without the help of a psychiatrist or psychologist. Indeed, the initial consultations will reassure the child and their parents by ruling out a serious illness. They will help explain the mechanism of leaks and the voluntary nature of the effort to hold back. It is true that the child most often admits that they feel the need to have a bowel movement, but that they hold it in until it is too late. The psychological causes suggested by the doctor may be benign and resolved by the parents themselves. If this simple treatment fails, it is important to immediately suggest that parents seek psychological help. The older the child, the more likely the symptoms are to persist. Severe psychiatric conditions are often already diagnosed, and encopresis is not a prominent symptom. In these cases, treatment is difficult and rarely effective; however, dietary and laxative treatment should not be neglected. To date, the effectiveness of anorectal rehabilitation has not been proven; however, it can help the child understand and master the mechanisms of continence and defecation. It is rarely prescribed as a first-line treatment and may be guided by a prior manometric examination (recording of anus pressures using a small probe). FAQ Childhood Encopresis What is encopresis? Encopresis is the regular passage of formed or semi-formed stools in underwear or "unusual" places (on the floor, etc.) after the age of 4. There may be periods during which the symptoms appear to disappear temporarily. What is it due to? The child deliberately holds it in, which results in the rectum becoming overfilled, causing it to overflow and allow stools to be involuntarily evacuated. This is a functional disease, as the intestine, rectum and anus are normal. Is it incontinence? This is not true incontinence in the sense that the anal sphincter and rectum are normal. However, there is still uncontrolled leakage of stool because the anus reflexively relaxes when the rectum is too full. Does my child have a serious illness? No, encopresis is most often due to more or less severe, banal constipation that can be treated medically, and sometimes to psychological problems that are more or less easy to resolve. There is no digestive abnormality; if this is the case, it is not encopresis but true incontinence. Does the diagnosis require complicated tests? Most often, a simple consultation allows serious illnesses to be ruled out and a functional disease to be diagnosed. Can the child heal on his own? Yes, if we help him. We must resolve any psychological problems that contributed to the onset of this disorder and give him laxatives to combat the constipation that is almost always associated with it. Are the psychological problems that triggered these disorders serious? First of all, they are not always present. A constipated child with an anal fissure will be afraid to have a bowel movement because defecation is painful and will hold it in until their rectum is overfilled. In other cases, the psychological causes may be benign and resolved by the family itself. In more severe cases or situations, psychological or psychiatric help is necessary and will help resolve these problems.