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Dan Phillips

Encopresis

Encopresis

Encopresis

Children who soil their underwear with small amounts of loose bowel movement (BM) several times a day are said to have “soiling” or “encopresis”. Usually, these children are severely constipated or blocked up (“impacted”). The soiling occurs because pieces of the large mass of stool in the rectum break loose at unexpected times or stool leaks out around it. This leakage cannot be controlled by the child until the large bowel movement (“impaction”) is removed. Children can become constipated for many reasons, including diet, an inherited tendency, or pain with bowel movements. Occasionally, the problem is caused when a child holds back bowel movements as a way of resisting toilet training or because of a previous painful BM.

The urge to have a bowel movement depends upon stool moving down into the rectum from the intestines. Normally, the rectum is empty, so when stool distends it, a nerve impulse goes to the brain telling the person that they need to go to the bathroom and empty their rectum. Chronic constipation causes stool to accumulate in the rectum, overstretching it until, after a while, the child can’t tell when he needs to have a BM. This in turn causes more and more stool to accumulate, and then leakage occurs. So even if the child voluntarily withheld stool at the beginning, by the time soiling occurs, it’s beyond his control and he’ll need treatment as outlined below to overcome the problem.

The purpose of the following treatment is to empty the rectum, and then to keep it empty so that the child cannot hold back stools. Depending on how severe and long-standing the problem has been, the normal urge to defecate will return in weeks to months if the treatment program is followed.

Treatment

  1. First use enemas to remove the impaction. Buy three Pediatric Fleets hyperphosphate enemas. The dose is 1 ounce for every 20 pounds of your child’s weight. (For example, a 30 lb. child should receive 1-1/2 ounces.) After giving the first enema, wait an hour and then give the second one. Give the third enema 24 hours later. Once the impaction is cleared, enemas are no longer necessary as long as constipation is avoided by following the guidelines below. Do not continue to use enemas; they can irritate the rectum. If the child really fights the enemas and is uncooperative, it’s probably best to forget about it. Using the stool softeners as discussed below will still work, but it will take longer.
  2. Use stool softeners to keep the BM’s soft, slippery, and easier to pass. Unlike laxatives, they do not cause any bowel contractions or pressure, and are not “addictive”. We usually prefer to use Mineral Oil. Squib mineral oil is generally well tolerated. Kondemull is somewhat better tasting, but is more expensive.

Start one tablespoon of mineral oil for each 10 lb. of the child’s weight. (For example, a 40 lb. child will take four tablespoons of mineral oil). This should be given prior to bedtime. The dose may be divided, and half given in the morning and half at night if desired. The dose is increased by one or two tablespoons a day until the child is having four to five large loose stools per day but without leakage of mineral oil. Some children respond well to lower doses, but sometimes several ounces a day are needed.

To begin, give your child _______ tablespoons of mineral oil a day.

Keep the mineral oil in the refrigerator because it tastes best cold. Have your child take it with fruit juice to disguise the flavor, or follow it with something tasty. Since mineral oil may slightly interfere with the absorption of fat-soluble vitamins, give him a multivitamin tablet each afternoon.

3. Encourage a nonconstipating diet, with plenty of fresh fruits and vegetables, and plenty of high fiber foods. For more information on diet, ask your doctor for an instruction sheet on diet for constipation.

4. Encourage your child to sit on the toilet for 10 minutes, twice each day. Use a kitchen timer or buy him an inexpensive electronic wristwatch with an alarm that he can set to time himself. During this time, he must sit on the toilet even when he doesn’t feel the need to go. Unless he does this, the medicines will not work, because, as mentioned above, the child with encopresis cannot feel the normal urge to defecate. The best time seems to be 20 or 30 minutes after a meal, especially after drinking something warm.

However, be careful not to be too stern or to use the toilet as a punishment, as this will foster a negative attitude about +he whole process. Try to pick good times for gentle reminders and mention that “your doctor asked me to help you remember”. Encourage him to play alone or read to pass the time while sitting on the toilet.

Other toileting tips that are essential for success include: – Push while sitting on the toilet. The BM won’t just fall out. – Bend forward so that the chest touches the upper legs. Flexing and unflexing the hips may also help move stool downward. – If his feet can’t easily reach the floor, use a footstool to provide pushing leverage.

5. Praise your child for staying clean. Some children need more praise and encouragement than others. Often, a calendar, with stars placed on the days when there was no soiling will be an effective motivation. Rewards are generally unnecessary unless he is uncooperative or less than 5 years old. Most children are overjoyed to be rid of the soiling.

6. Ask the school staff for their help. These children need ready access to the bathroom at school, especially if they are shy. Encourage him not to be embarrassed about leaving the classroom to go to the bathroom.

7. Respond gently to accidents. Determining the correct treatment may take several weeks. Even later, some children may have recurrences. As soon as you notice soiling, remind your child to immediately clean himself up. After soiling, have him sit on the toilet until a large BM is passed or at least 20 minutes. Clean the skin around the anus either with a 5 minute soak in the bathroom or with a wet washcloth. He should be able to do most of this on his own. Set up a method for cleaning the soiled underwear that puts some of the responsibility on the child. For example, he can rinse the underwear in the toilet, then store them in a bucket of water with some added bleach with a lid until wash day.

The more involved and responsible your child feels, the better the results will be. Make sure to keep follow-up appointments so that we can continue to monitor progress and make changes in the treatment as necessary.