encopresis


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Related to encopresis: enuresis

Encopresis

 

Definition

Encopresis is repeatedly having bowel movements in places other than the toilet after the age when bowel control can normally be expected.

Description

Most children have established bowel control by the time they are four years old. After that age, when they repeatedly have bowel movements in inappropriate places, they may have encopresis. In the United States, encopresis affects 1-2% of children under age 10. About 80% of these are boys.
Encopresis can be either involuntary or voluntary. Involuntary encopresis is related to constipation, passing hard painful feces, and difficult bowel movements. Often children with involuntary encopresis stain their underpants with liquid feces. They are usually unaware that this has happened. Voluntary encopresis is much less common and is associated with behavioral or psychological problems. Both types of encopresis occur most often when the child is awake, rather than at night.

Causes and symptoms

Although a few children experience encopresis because of malformations of the lower bowel and anus or irritable bowel disease, most have no physical problems to explain this disorder. Constipation is present in about 80% of children who experience involuntary encopresis. As feces moves through the large intestine, water is removed. The longer the feces stays in the large intestine, the more water is removed, and the harder the feces becomes. The result can be hard or painful bowel movements. In response, children may start to hold back when they feel the urge to eliminate in order to avoid pain. This starts a cycle of constipation that results in retentive encopresis.
Once elimination is avoided, the bowel becomes full of hard feces. This stretches the large intestine. Eventually the intestine becomes so stretched that liquid feces backed up behind the blockage is able to leak around the hard feces. Children with this type of encopresis do not feel the urge to have a bowel movement and are often surprised when their pants are stained with foul smelling liquid feces. This leakage of feces is called overflow incontinence. Parents sometimes mistake this soiling for diarrhea, because the feces expelled is liquid. Every so often, children with involuntary encopresis may pass large stools, sometimes with volumes big enough to clog the toilet, but the relief this brings is temporary.
Although about 95% of encopresis is involuntary, some children intentionally withhold bowel movements. The American Psychiatric Association (APA) recognizes voluntary encopresis without constipation as a psychological disorder. This disorder is said to occur when a child who has control over his bowel movements chooses to have them in an inappropriate place. The feces is a normal consistency, not hard. Sometimes it is smeared in an obvious place, but it may also be hidden from adults.
Voluntary encopresis may result from a power struggle between caregivers and the child during toilet training, or the child may have developed an unusual fear of the toilet. It is also associated with oppositional defiant disorder (ODD), conduct disorder, sexual abuse, and high levels of psychological stress. For example, children who were separated from their parents during World War II were reported to have a high rate of encopresis. However, parents and caregivers should be aware that very few children soil intentionally and most do not have a behavioral or psychological problem and should not be punished for their soiling accidents.

Diagnosis

Diagnosis is based primarily on the child's history of inappropriate bowel movements. Physical examinations are almost always normal, except for a mass of hard feces blocking the lower intestine. Other physical causes of soiling, such as illness, reaction to medication, food allergies, and physical disabilities, may also be ruled out through history and a physical examination. In addition, to be diagnosed with encopresis the child must be old enough to establish regular bowel control—usually chronologically and developmentally at least four years of age.

Treatment

The goal of treatment is to establish regular, soft, pain free bowel movements in the toilet. First the physician tries to determine the cause of encopresis, whether physical or psychological. Regardless of the cause, the bowel must be emptied of hard, impacted feces This can be done using an enema, laxatives, and/or stool softeners such as mineral oil. Enemas and laxatives should be used only at a doctor's recommendation.
Next, the child is given stool softeners to keep feces soft and to give the stretched intestine time to shrink back to its normal size. This shrinking process may take several months, during which time stool softeners may need to be used regularly. Children also need two or three regularly scheduled toilet sits daily in an effort to establish consistent bowel habits. These toilet sits are often more effective if done after meals. Maintaining soft, easy-to-pass stools is also important if the child is afraid of the toilet because of past painful bowel movements. A child psychologist or psychiatrist can suggest treatment for the rare child with serious behavioral problems such as smearing or hiding feces.

Alternative treatment

Many herbal stool softeners and laxatives are available as both tablets and liquids. Psyllium, the seed of several plants of the genus Plantago is one of the most effective. Other natural remedies for constipation include castor seed oil (Ricinus communis), senna (Cassia senna or Senna alexandrina), and dong quai Angelica polymorpha or Angelica sinensis).

Prognosis

For almost all children, once constipation is controlled, the problem of soiling disappears. This make take several months, and relapses may occur, but with effective prevention strategies, encopresis can be eliminated. Children who are in a power struggle over toileting usually outgrow their desire to have bowel movements in inappropriate places. The prognosis for children with serious behavioral and psychological problems that result in smearing or hiding feces depends largely on resolving the underlying problems.

Key terms

Feces — Waste products eliminated from the large intestine; excrement.
Incontinence — The inability to control the release of urine or feces.
Laxative — Material that encourages a bowel movement.
Stools — feces, bowel movements.

Prevention

The best way to prevent encopresis is to prevent constipation. Methods of preventing constipation include:
  • increasing the amount of liquids, especially water, the child drinks
  • adding high fiber foods to the diet (e.g. dried beans, fresh fruits and vegetables, whole wheat bread and pasta, popcorn)
  • establishing regular bowel habits
  • limiting the child's intake of dairy products (e.g. milk, cheese, yogurt, ice cream) that promote constipation.
  • treating constipation promptly with stool softeners, so that it does not become worse.

Resources

Books

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. text revision. Washington D.C.: American Psychiatric Association, 2000.

Periodicals

Kuhn, Brett R., Bethany A. Marcus, and Sheryl L. Pitner. "Treatment Guidelines for Primary Nonretentive Encopresis and Stool Toileting Refusal." American Family Physician, 59, no. 8 (15 April 1999) 2171-2183. [cited 16 February 2005]. 〈http://www.aafp.org/afp/2001101/1565.html〉.

Organizations

American Academy of Child and Adolescent Psychiatry, P. O. Box 96106, Washington, D.C. 20090. 800-333-7636. www.aacap.org.

Other

Borowitz, Stephen. Encopresis, 14 June 2004 [cited 20 February 2005]. 〈http://www.emedicine.com/ped/topics670.html〉.

incontinence

 [in-kon´tĭ-nens]
1. inability to control excretory functions.
2. immoderation or excess. adj., adj incon´tinent.
bowel incontinence
2. a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as a state in which an individual has a change in normal bowel habits, with involuntary bowel movements.
continuous incontinence continuous urinary leakage from a source other than the urethra, such as a fistula.
fecal incontinence (incontinence of the feces) inability to control defecation; both physiologic and psychological conditions can be contributing factors. Called also encopresis and bowel incontinence. See also bowel elimination, altered. Physiologic causes include neurologic sensory and motor defects such as those occurring in stroke and spinal cord injury; pathologic conditions that impair the integrity of the sphincters, such as tumors, lacerations, fistulas, and loss of sensory innervation; altered levels of consciousness; and severe diarrhea. Psychological factors include anxiety, confusion, disorientation, depression, and despair.

There is potential for physical and psychological stress when a person is unable to control his or her bowel movements. Damage to the integrity of the skin and its breakdown into pressure ulcers is always a possibility no matter how hard caregivers might try to keep the patient clean and dry. Psychologically the person is likely to suffer from loss of self-esteem and is certain to experience some alteration in self-image. From the time of toilet training a person is expected to be able to handle the tasks of bowel elimination. An adult who for some reason is no longer able to do this is often embarrassed by and ashamed of the inability to perform this most basic of self-care activities.
Patient Care. Assessment of the problem of fecal incontinence should be extensive and thorough so that a realistic and effective plan of care can be implemented. Sometimes all that is needed is a regularly scheduled time to offer the patient a bedpan or help using a bedside commode or going to the bathroom. If diarrhea is a problem it may be that dietary intake needs changing or tube feedings are not being administered correctly. Dietary changes may also help the patient who has a stoma leading from the intestine. In cases of neurologic or neuromuscular deficit, retraining for bowel elimination is a major part of rehabilitation of the patient. Frequently, it is possible to help a patient achieve control by means of a well-planned and executed bowel training program.

Biofeedback techniques can be helpful in many cases. The person learns to maintain higher tone in the anal sphincter through use of a balloon device that provides feedback information about pressures in the rectum. With practice the person can learn better control and develop a more acute awareness of the need to defecate.
functional incontinence incontinence due to impairment of physical or cognitive functioning.
functional urinary incontinence a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as an inability of a usually continent person to reach the toilet in time to avoid the unintentional loss of urine. See also urinary incontinence.
overflow incontinence (paradoxical incontinence) urinary incontinence due to pressure of retained urine in the bladder after the bladder has contracted to its limits; there may be a variety of presentations, including frequent or constant dribbling or symptoms similar to those of stress or urge incontinence.
reflex incontinence the urinary incontinence that accompanies detrusor hyperreflexia.
reflex urinary incontinence a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as an involuntary loss of urine at somewhat predictable intervals, whenever a specific bladder volume is reached. See also reflex incontinence.
risk for urge urinary incontinence a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as the state of being at risk for involuntary loss of urine associated with a sudden strong sensation of urinary urgency. See also urge urinary incontinence.
severe stress urinary incontinence severe stress incontinence as a result of incompetence of the sphincter mechanism.
stress incontinence urinary incontinence due to strain on the orifice of the bladder, as in coughing or sneezing.
stress urinary incontinence a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as loss of urine of less than 50 ml when there is increased abdominal pressure. See also stress incontinence.
total urinary incontinence a nursing diagnosis accepted by the Seventh National Conference on the Classification of Nursing Diagnoses, defined as a state in which an individual has continuous and unpredictable loss of urine; see also urinary incontinence.
urge incontinence (urgency incontinence) urinary or fecal incontinence preceded by a sudden, uncontrollable impulse to evacuate (see also urgency). Urge incontinence of urine is a major complaint of patients with urinary tract infections and is also present in some women two or three days before onset of the menstrual period.
urge urinary incontinence a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as the involuntary passage of urine soon after feeling a strong sense of urgency to urinate; see also urge incontinence.
urinary incontinence (incontinence of urine) loss of control of the passage of urine from the bladder; see also enuresis. It can be caused by pathologic, anatomic, or physiologic factors affecting the urinary tract, as well as by factors entirely outside it. See also urinary elimination, altered.
Patient Care. The Agency for Health Care Policy and Research (AHCPR) convened an interdisciplinary, non-Federal panel of physicians, nurses, allied health care professionals, and health care consumers that has identified and published Clinical Practice Guidelines for Urinary Incontinence in Adults. Identification and documentation of urinary incontinence can be improved with more thorough medical history taking, physical examination, and record keeping. Routine tests of lower urinary tract function should be performed for initial identification of incontinence. There are also situations that require further evaluation by qualified specialists.

The guidelines provide an informed framework for selecting appropriate behavioral, pharmacologic, and surgical treatment and supportive services that can be used to treat urinary incontinence. The panel concluded that behavioral techniques such as bladder training and pelvic muscle exercises are effective, low cost interventions that can reduce incontinence significantly in varied populations. Surgery, except in very specific cases, should be considered only after behavioral and pharmacologic interventions have been tried. The panel found evidence in the literature that treatment can improve or cure urinary incontinence in most patients. The address of the AHCPR is Agency for Health Care Policy and Research, P.O. Box 8547, Silver Spring, MD 20907. They can also be called toll free at (800) 358-9295.

en·cop·re·sis

(en-kō-prē'sis),
The repeated, generally involuntary passage of feces into inappropriate places (for example, clothing).
[G. enkopros, full of manure]

encopresis

/en·co·pre·sis/ (en″ko-pre´sis) fecal incontinence.

encopresis

[en′kōprē′sis]
fecal holding with constipation and fecal soiling. encopretic, adj.

encopresis

Fecal incontinence, see there. See Elimination disorder.

en·cop·re·sis

(en'kōp-rē'sis)
The repeated, generally involuntary passage of feces into inappropriate places (e.g., clothing); considered a mental disorder if it occurs in a child over 4 years old.
[G. enkopros, full of manure]

encopresis

Faecal incontinence or soiling not due to organic disease or involuntary loss of control, but resulting from deliberate intent or psychiatric disorder. Encopresis occurs in toddlers resisting toilet training, in the demented and in some psychotic people.

encopresis

incontinence of feces not due to organic defect or illness.
References in periodicals archive ?
Constipation occurs as a common problem together with encopresis.
Nick's presenting problem of encopresis is depicted as a force outside of Nick, acting on Nick in an attempt to trick him and corrupt him, and is even given a name by Nick, "Sneaky Poo.
The apathy, enuresis, and encopresis have stopped, her language skills continue to progress, and she has integrated well in her new kindergarten group.
Functional encopresis (FE) is a common, under-treated and often over-interpreted elimination disorder in children.
This is particularly true for children with retentive encopresis.
Encopresis doesn't seem to be as inherited as enuresis, or people are less willing to reveal that information.
It adds studies on behavioral issues and encopresis; new prevalence figures; discussion of the role of constipation in encopresis and enuresis; updated information on the long-term health impact of poorly managed pain experiences; new information on factors that contribute to pain; updated discussion of the impact of nonadherence on mental and medical outcomes and the role of the health care provider; and discussion of proposed changes for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.
Passing solid stools in their pants or in inappropriate places after a child has learnt bowel control is called encopresis.
vomitos, dolor en las zonas genitales, enuresis, encopresis, picores en los organos genitales, dificultad para sentarse, caminar, comerse las unas o los labios hasta infectarlos.
The case study of Nick, a 6-year-old boy suffering from encopresis (White & Epston, 1990), serves this purpose.
4 /PRNewswire/ -- Encopresis isn't the sort of medical problem making headlines, but there's no mistaking the quiet emotional toll it takes on children as school resumes across the country.