Soiling (Encopresis)

If your child has bowel movements (BMs) in places other than the toilet, you know how frustrating it can be. Many parents assume that kids who soil their pants are simply misbehaving or that they’re too lazy to use the bathroom when they have the urge to go.

The truth is that many kids beyond the age of toilet teaching (generally older than 4 years) who frequently soil their underwear have a condition known as encopresis. They have a problem with their bowels that dulls the normal urge to go to the bathroom — and they can’t control the accidents that typically follow.

Encopresis affects about 1% to 2% of kids under age 10. Yet, problems with encopresis and constipation account for more than 25% of all visits to pediatric gastroenterologists (doctors who specialize in disorders of the stomach and intestines).

Most encopresis cases (90%) are due to “functional constipation” — that is, constipation that has no medical cause. The stool (or BM) is hard, dry, and difficult to pass when a person is constipated. Many kids “hold” their BMs to avoid the pain they feel when they go to the bathroom, which sets the stage for having a poop accident.

Well-intentioned advice from family members and friends isn’t always helpful because many people mistakenly believe that encopresis is a behavioral issue — a simple lack of self-control. Frustrated parents, grandparents, and caregivers may suggest various punishments and consequences for the soiling — which only leaves the child feeling even more alone, angry, depressed, or humiliated. Up to 20% of kids with encopresis have feelings of low self-esteem that require help from a psychologist or counselor.

Punishing or humiliating a child with encopresis will only make matters worse. Instead, talk to your doctor, who can help you and your child through this challenging but treatable problem.

Encopresis and Its Causes

Three to six times more common in boys, encopresis isn’t a disease, but rather a symptom that may have different causes. To understand encopresis, it’s important to understand constipation.

There’s a wide range of normal when it comes to having a BM. The frequency of BMs varies with a person’s age and individual nature. “Normal” pooping might range from one or two BMs per day to only three or four per week. Some kids don’t poop on a regular basis, but a child who passes a soft, medium-sized BM without difficulty every 3 days is not constipated. However, a child who passes a hard BM (small or large) every other day is. Other kids may go every day, but they only release little, hard balls and there’s always poop left behind in the rectum.

So, what causes the hard poop in the first place? Any number of things, including diet, illness, decreased fluid intake, fear of the toilet during toilet teaching, or limited access to a toilet or a toilet that’s not private (like at school). Some kids may develop chronic constipation after stressful life events such as a divorce or the death of a close relative.

Although rectal surgery or birth defects such as Hirschsprung disease and spina bifida can cause constipation or encopresis without constipation, this is uncommon.

Whatever the cause, once a child begins to hold in BMs, the poop starts building up in the rectum and may back up into the colon — and a vicious cycle begins.

The colon’s job is to remove water from the poop before it’s passed. The longer the poop is stuck there, the more water is removed — and the harder it is to push the large, dry poop out. The large poop also stretches out the colon, weakening the muscles there and affecting the nerves that tell a child when it’s time to go to the bathroom. Because the flabby colon can’t push the hard poop out, and it’s painful to pass, the child continues to avoid having a BM, often by dancing, crossing the legs, making faces, or walking on tiptoes.

Eventually, the rectum and lower part of the colon becomes so full that it’s difficult for the sphincter (the muscular valve that controls the passage of feces out of the anus) to hold the poop in. Partial BMs may pass through, causing the child to soil his or her pants. Softer poop may also leak out around the large mass of feces and stain the child’s underwear when the sphincter relaxes. The child can’t prevent the soiling — nor does he or she have any idea it’s happening — because the nerves aren’t sending the signals that regulate pooping.

At first, parents may think their child has a simple case of diarrhea. But after repeated episodes, it becomes clear that there’s another problem — especially because the soiling happens when the child isn’t sick.

Parents are often frustrated by the fact that their child seems unfazed by these accidents, which happen mostly during waking hours. Denial may be one reason for the child’s nonchalance — kids just can’t face the shame and guilt associated with the condition (some even try to hide their soiled underpants from their parents). Another reason may be more scientific: Because the brain eventually gets used to the smell of feces, the child may no longer notice the odor.

When to Call the Doctor

Call the doctor if your child shows any of these symptoms:

• poop or liquid stool in the underwear when your child isn’t ill
• hard poop or pain when having a BM
• toilet-clogging BM
• abdominal pain
• loss of appetite

Treating Encopresis

As the colon is stretched by the buildup of stool, the nerves’ ability to signal the brain that it’s time for a BM is harmed. If untreated, the soiling will get worse and kids may lose their appetites or complain of stomach pain.

A large, hard poop may also cause a tear in the skin around the anus that will leave blood on the stools, the toilet paper, or in the toilet. Constipation is also associated with wetting and urinary tract infections (UTI).

If you think your child has encopresis, call your doctor. The problem probably can be managed by your doctor, but if initial efforts don’t work, you may be referred to a gastroenterologist.

Treatment is done in three phases:

1. The first phase involves emptying the rectum and colon of hard, retained poop. Different doctors can have different ways of doing this. Depending on the child’s age and other factors, the doctor may recommend medicines, including a stool softener (such as mineral oil), laxatives, and/or enemas. (Laxatives and enemas should be given only under the supervision of a doctor; never give these treatments at home without first checking with your doctor.) As unpleasant as this first step sounds, it’s necessary to clean out the bowels to successfully treat the constipation and end your child’s soiling.
2. After the large intestine has been emptied, the doctor will help your child begin having regular BMs with the aid of stool-softening agents, most of which aren’t habit-forming. It’s important to continue using the stool softener to give the bowels a chance to shrink back to normal size (the muscles of the intestines have been stretched out, so they need time to be toned without the poop piling up again).

   Parents also will be asked to schedule potty times twice daily after meals (when the bowels are naturally stimulated), in which the child sits on the toilet for about 5 to 10 minutes. This will help the child learn to pay attention to the urges to go.

3. As regular BMs become established, your doctor will reduce the child’s use of stool softeners.

Keep in mind that relapses are normal, so don’t get discouraged. Your child might get constipated again or soil his or her pants during treatment, especially when being weaned off of the medicines.

A good way to track your child’s progress is by keeping a daily poop calendar. Make sure to note the frequency, consistency (hard, soft, dry), and size (large, small) of the BMs.

Patience is the key to treating encopresis. It may take anywhere from several months to a year for the stretched-out colon to return to its normal size and for the nerves in the colon to become effective again.

Diet and Exercise

Diet and exercise are extremely important in keeping stools soft and BMs regular. Also, make sure your child gets plenty of fiber-rich foods such as fresh fruits, dried fruits like prunes and raisins, dried beans, vegetables, and high-fiber bread and cereal.

Because kids often cringe at the thought of fiber, try these creative ways to add it to your child’s diet:

• Bake cookies or muffins using whole-wheat flour instead of regular flour. Add raisins, chopped or pureed apples, or prunes to the mix.
• Add bran to baking items such as cookies and muffins, or to meatloaf or burgers, or sprinkled on cereal. (The trick is not to add too much bran or the food will taste like sawdust.)
• Serve apples topped with peanut butter.
• Create tasty treats with peanut butter and whole-wheat crackers.
• Top ice cream, frozen yogurt, or regular yogurt with high-fiber cereal for some added crunch.
• Serve bran waffles topped with fruit.
• Make pancakes with whole-grain pancake mix and top with peaches, apricots, or grapes.
• Top high-fiber cereal with fruit.
• Sneak some raisins or pureed prunes or zucchini into whole-wheat pancakes.
• Add shredded carrots or pureed zucchini to spaghetti sauce or macaroni and cheese.
• Add lentils to soup.
• Make bean burritos with whole-grain soft-taco shells.

And don’t forget to have your child drink plenty of fluids each day, especially water. Diluted 100% fruit juice (like pear, peach, or prune) is an option if your child is not drinking enough water. Also, limiting your child’s daily dairy intake (including milk, cheese, and yogurt) may help.

Successful treatment of encopresis depends on the support a child gets. Some parents find that positive reinforcement helps to encourage the child throughout treatment. For instance, put a star or sticker on the poop calendar for having a BM (or even just for trying to), sitting on the toilet, or taking medicines.

Whatever you do, don’t blame or yell — it will only make your child feel bad and it won’t help manage the condition. With lots of love, support, and reassurance that he or she isn’t the only one in the world with this problem, your child can overcome encopresis.