Approach to Encopresis

Sept 1, 2011

Jody Patrick PGY-3

Objectives

Define the types of encopresis Outline the many possible etiologies,

focusing on the most common Review key points on history and PE Use of appropriate investigations Discuss common treatment approaches Have fun!

Definition: Encopresis

Involuntary fecal soiling in adults and children who have usually already been toilet trained (over the age of 4)

Definition

Subtypes: Retentive encopresis: with constipation and

overflow incontinence (80-95%) Non-retentive encopresis: no constipation

and overflow incontinence Soil on daily basis, stools are normal consistency &

form 99% is non organic etiology Four subgroups:

Never have achieved toilet training Have toilet “phobia” Use toileting to manipulate their environment Irritable bowel syndrome

Prevalence

Estimated between 1-3% of 4 year olds, decreasing as children get older

Male : Female approx 6:1

Etiology

Most Common Cause is Constipation Vicious cycle of painful, hard stools, avoidance of

bowel movement Stretching of rectum/colon, decreased sensation RAIR (Rectal Anal Inhibitory Reflex) is lost Leakage around hardened stool (overflow)

At risk times for developing constipation include: Dietary switch to solid food Toilet training The start of school

Must rule out possible organic etiologies Remember psychosocial factors as well

Diagnosis

DSM-IV diagnostic criteria: Repeat passage of feces into inappropriate

places (eg clothing or floor) whether voluntary or unintentional

At least one such event a month for at least 3 months

Chronological age of at least 4 years (or equivalent developmental level)

The behaviour is not exclusively due to a physiological effect of a substance (eg laxatives) or a general medical condition, except through a mechanism involving constipation.

Diagnosis

Important points on History: History

Stool pattern: Size, Consistency, Interval, Straining, Blood History of constipation: Age of onset Passage of newborn meconium History of soiling: Age of onset, Type and amount of material Toilet training: age, difficulties Diet history: Type and amount of food, Changes in diet, Appetite Abdominal pain: Night pain, Missing school Constitutional symptoms Medications Urinary symptoms: Day or night enuresis, Urinary tract infection Family history of constipation Family or personal stressors: birth of sibling, abuse Behavioural difficulties: noncompliance, ODD, aggression,

tantrums

Diagnosis

Physical examination Height Weight Abdominal examination: distention, mass,

especially suprapubic Rectal examination: sacral dimple, position of

anus, anal fissures, anal wink, sphincter tone, rectal vault size, presence or absence of stool in rectum, pelvic mass

Neurologic examination

Differential Diagnosis

Retentive Functional constipation (95 percent) Organic (5 percent) Anal causes: Fissures, Stenosis/atresia with

fistula, Anterior displacement of anus, Trauma, Postsurgical repair

Neurogenic causes: Hirschsprung's disease, Chronic intestinal psuedo-obstruction, Spinal cord disorders, Cerebral palsy/hypotonia, Pelvic mass

Neuromuscular disease Endocrine/metabolic causes: Hypothyroidism,

Hypercalcemia, Lead intoxication Drugs: Codeine, Antacids, Others

Differential Diagnosis

Nonretentive Nonorganic (99 percent) Organic (1 percent) Severe ulcerative colitis Acquired spinal cord disease (i.e., sacral

lipoma, spinal cord tumor) Rectoperineal fistula with imperforate anus Postsurgical damage to anal sphincter

Investigations

Depend on outcome of Hx & PE If suggestive of constipation with no obvious

organic etiology, no further investigations required

If unclear: consider flat plate of abdomen

If failed conservative Rx, suspicious for organic cause or non retentive pattern of soiling, consider: Bloodwork (endocrine, metabolic) Barium enema (Hirschprung’s, fistulae) Rectal manometry, biopsy

Referral to GI or GS

Treatment

Retentive (functional constipation) Standard 3 pronged approach:

Clean Out Maintain Soft Stools Behavioural strategies

Non Retentive Address behaviours Toilet routine Soft bowel movement Use of incentives

Other aids for encopresis Internet intervention Psychological counselling

Treatment

Clean Out From above or below

Enema Stool softener, lubricants Nasogastric electrolyte solution Manual disimpaction in severe cases

Avoid stimulant laxatives

Treatment

Maintenance with stool softeners/lubricants Lactulose PEG 3350 Colace Mineral oil (>1yr)

Can take several months to break cycle Goal is one soft formed stool daily Distended bowel takes months to regain

tone and sensitivity

Treatment

Behavioural strategies Regular post prandial toileting times Limit time on toilet to 10-15 mins Stool diary

Treatment

Non Retentive Encopresis Address behaviour

Is child developmentally ready? Avoid toileting battles, take a break Address aggressive or oppositional behaviours

first, may require behavioural counselling Address toilet refusal: positive experiences

sitting on toilet Scheduled post prandial toileting times Maintain soft bowel movements Use Incentives for appropriate toileting

Other strategies

Dietary management Increase fibre intake Increase fluid intake Avoidance of constipating foods

Internet Intervention: Multiple small group studies using an internet

based guide for families Has shown improvement in fecal accidents

www.ucanpooptoo.com Resources, books

Beating Sneaky Poo, many, manyothers….

No evidence that this actually helps

Better in maintenance therapy

References

Christophersen ER, Rapoff MA. Toileting problems in children. In: Walker CE, Roberts MC, eds. Handbook of clinical child psychology. 2d ed. New York: Wiley, 1992;399-411

BRETT R. KUHN, PH.D., BETHANY A. MARCUS, PH.D., and SHERYL L. PITNER Treatment Guidelines for Primary Nonretentive Encopresis and Stool Toileting Refusal American Family Physician

Wikipedia, encopresis http://en.wikipedia.org/wiki/Encopresis

Up to Date: Diagnosis and management of encopresis in children

Schmitt BD. Encopresis. Prim Care 1984;11:497-511.

Loening-Baucke V. Fecal incontinence in children. Am Fam Physician 1997;55:2229-38.