A forlorn eight-year-old boy is being led into the medical office after another disappointing day at school.
“Come on, Fred. Don’t make me pull you. Let’s see your doctor and get some help,” Mom exhorts.
“I don’t want to see him. I don’t want to talk about my poop problem. I just want to go home! I promise I’ll stop messing my pants,” the boy pleads.
“You’ve said that before and you haven’t stopped. I don’t see what you like about soiling your shorts.”
This scenario is repeated all too frequently in the average pediatrician’s office. For every child that is brought into the office, many more never seek the help that they need to end this embarrassing problem.
ENCOPRESIS is the medical term for passing stool when not on the toilet over the developmental age of four years. There are two basic types; one associated with abnormal retention of fecal material in the large bowel, the other not associated with constipation.
In my experience, the most common type is related to bowel movement retention that leads to a stool-filled colon and an overflow fecal loss into the patient’s underwear. The instigator of stool retention can be an episode of painful bowel movements. This would cause the patient to avoid b. ms., thus filling the colon with stool. Another issue could be the avoidance of b. ms. at school, which leads to retention and constipation. Sometimes encopresis follows a vacation that is marked by a constipating diet, decreased fluid intake and lack of a familiar or user-friendly toilet.
No matter. The problem begins with filling the colon with copious amounts of stool. This hardens, then stretches the muscle wall of the large bowel to the point of losing the necessary tone to function normally. That is, it loses the ability to empty itself. The fecal material develops into a firm, large plug that prevents normal waste passage.
The liquid part of the stool leaks around this plug and is passed without control into boxers, briefs or pajamas. Unfortunately, this odoriferous passage usually occurs when the child is up and active, as in school, at play, etc.
Thus comes the insults and chides about the child’s smell and the associated embarrassment. As you can see, this type of encopresis is not under the child’s control. As much as he would like to end the problem he CAN’T, at least not without help. This incontinence is at least 40-to-1 over the psychogenic self-soiling so often touted as the usual cause. There is no question, encopresis can have a behavioral or psychiatric cause. But, as I already indicated, it is much less common in a general pediatrician‘s practice. Boys are effected by this far more often than girls are.
The non-bowel movement retentive type can be associated with other causes than the psychogenic type. Abnormalities of the anal sphincter, incomplete enervation of the colon, (Hurschsprung’s Disease), colon tumors, inflammatory bowel disease, parasitic infestations and bowel infections can present in this fashion, but rarely in a general pediatric office.
A careful history usually allows differentiating the cause and institution of appropriate therapy without extensive X-ray or laboratory evaluation.
Since the most common cause is stool retention, the physician must release the block, but more importantly alleviate the original issue that led to the stool holding. Counseling and basic diet change cannot effect a cure without also releasing the occlusion.
If the cause is non-retentive, appropriately directed therapy by a pediatric psychologist or psychiatrist may be necessary. If the cause is anatomic, specific measures to correct the problem by a pediatric surgeon or pediatric gastroenterologist could help the problem. Again, these areas are much less frequently encountered by the pediatrician..
A complete history and physical, INCLUDING a rectal examination, will be needed to differentiate the cause and to pursue specific therapy. If stool retention is the cause, releasing the plug and cleaning out the colon is mandatory. Specific measures used to do this vary from enemas, to potent laxatives. Many different therapeutic programs work. The child’s pediatrician should select the best one for the individual patient.
Remember, the average encopretic boy is not able to end the problem on his own. Neither punishment nor an award system will yield results and may even make the problem worse. Many a tear has been shed and fights have been started because this child has heard on the playground, “Oh, no! Here comes stinky!”
The longer one waits to start the corrective measures the longer it takes to resolve the problem. If you have a child suffering from this problem consult your pediatrician and get some definitive help. Be sure a thorough history and physical is completed. Do not settle for, “It will go away. It’s only a phase. Give more fruits and all will be well.” More is usually needed. Be an informed parent and, therefore, a good consumer of medical service.