Encopresis
A detailed guide

Encopresis affects mostly children.

And as a father of three, I know how powerless we feel when faced with conditions affecting our kids.

Sometimes we make a huge deal out of a manageable situation. Sometimes we worry for good reasons.

I wanted to write this complete guide to demystify this condition, to take some of the unknown away.

Because what we don’t know worry us unnecessarily. My goal is to provide you with a comprehensive guide, so that you know exactly the different options in front of you.

So grab a cup of tea, a pen and a piece of paper and read-on. It is a long article, but as a decision maker in the family, you need to digest this information.

Note that I will only cover childhood encopresis. This condition can also happen to the elderly and the mentally ill, which will be out of the scope of this article.

What is encopresis?

Encopresis is fecal incontinence. It involves fecal soiling in children who have already been toilet trained, usually after 4 years of age. It affects between 1.5% and 7.5% of children ages 6 to 12(1), which is quite a significant percentage.

Why is there fecal soiling if the child is already potty trained? Those children usually have a history of constipation. They had to pass hard, dry stools, which created significant pain. If the painful episodes repeated themselves long enough, at some point the child will became fearful of the defecation experience and started to hold it in.

This, of course, create a vicious circle. The more they hold it in, the more they become constipated. The end result is fecal impaction. There is now a hard plug in the child’s colon. There will probably be liquid fecal matter that manages to squeeze past the plug and ends-up staining the child’s underwear. This is not diarrhea, this is a sign of serious constipation. That liquid is usually very smelly, sometimes quite sticky. Children with encopresis often get used to living with that smell and don't notice it anymore.

The combination of uncontrolled soiling with constipation and fear of going to the toilet is called encopresis.

The important fact to understand is that in most cases, the child will not do this out of provocation, defiance, because they are lazy or because they are dirty. There is a real psychological problem, usually a fear of going to the toilets, that needs to be solved. That is why encopresis accounts for 3% to 6% of children psychiatric referrals(2).

Encopresis may start at any time, right after being toilet trained, or years after. A child may have done fine till the age of 7 or 8 for instance, then encountered a painful defecation episode leading to withholding and further constipation, which leads to further pain and withholding, etc.

Note that encopresis may be accompanied with enuresis, that is to say an inability to control urination (your child may pee in her pants too). The amount of stool backed-up in her bowel may exert pressure on the bladder and trigger uncontrolled urination or dribbling.

Complications of encopresis

I can see two possible long-term complications:

Megacolon. A portion of the colon may stretch out of proportion under the repeated volume and pressure of impacted stools. Doctors call this “megacolon”. This larger-than-normal colon holds even more feces than usual, and can result in bowel movements that are quite impressive for a small child. The worse the deformation is, the less it is reversible. In extreme cases, this may require surgery.

Ignorance of the defecation signal. We get the defecation reflex when stools move into the rectum area of the colon. The rectum is empty most of the time, and has stretch receptors.

When that area of the colon is stretched, a signal goes to our brain and triggers the urge to go. When kids suffer from encopresis, the rectum is constantly full and is never emptied completely. So the rectum stretch receptors are over-stimulated, constantly sending signals. Those signals will, at some point, be ignored by the child. They becomes a white noise in the background, unconsciously blocked by the brain of the child.

This is problematic because even when the child is finally not constipated anymore, he will not be able to “hear” the defecation reflex, and soiling will continue. At this stage, encopresis moves from the “constipation with impaction” stage to what we could call a “re-training” stage. The child needs to re-learn to obey the defecation reflex (physiological), and to tame his fears of going to the toilets (psychological).

Resolution strategy

In order to solve encopresis, we have to consider three parts to the strategy.

First of all, constipation and impaction needs to be addressed. The whole vicious circle of fear and withholding is based on pain. That pain, as ingrained as it can be in the child’s mind, needs to be eliminated. Getting rid of constipation will be an ongoing effort, with the use of laxative in acute cases, and nutrition and natural remedies to maintain a day-to-day balance.

Second, the child needs to re-learn to listen to the defecation reflex, which as we explained earlier may have been ignored for weeks or months because the rectum was constantly full and the stretch receptors were over-stimulated.

Third, and this is the most complicated one, the psychological barriers of going to the toilets need to be removed. The child may have associated defecation with pain and problems. She may have associated the soiling with being dirty, being bad, humiliation at school and frustrated parents and teachers.

Addressing constipation

As you know by know, I favor natural remedies, nutrition first, gentle medicinal plants second, and laxatives as a last resort. But I am going to do the reverse here, I am going to start with laxatives.

The reason I start with medication is this: encopresis is a lot more than constipation. We are not talking about an adult who can deal with pain and frustration in a mature way. I have seen the desperation of discouraged parents, and the sadness of singled-out kids. You need to put an end to the vicious circle. Laxatives can do that.

Overall, my view as a naturopath and herbalist is that laxatives are not evil. It is not a herbs vs. drugs battle, we don’t have to pick a camp. Yes we are over-medicated today. But there are many times when medications are used for very valid reasons. Helping a child to break out of a vicious circle of pain and frustration is one darn good reason, especially when there is impaction involved.

We are often concerned of the risk of taking laxatives in the long run. This is a very good concern to have. But for a kid starting to be backed-up and with a history of impaction, you also have to think of the risk of not giving laxatives. The risk is fecal impaction, and that situation can definitely do more damage than taking daily laxatives for a while.

Further, when the stools are impacted, i.e. when a hard and dry plug has formed in the colon preventing the progression of stools, nutrition and herbs have very limited to no applicability. It is too late. Nutrition and herbs play a big role after the plug is removed, to keep a regular transit. If the impaction is serious, see my article on fecal impaction to get acquainted with digital disimpaction, a method your doctor may recommend.

Laxatives

I highly recommend that you work with your medical team to come up with the right combination of laxatives along with the right dosage, even if the laxatives are sold over-the-counter.

More than one type of laxatives can be required:

• Stool softeners will be needed to bring water into the colon and make the stools softer, less hard, and therefore less painful.
• Stimulant laxatives may be needed to get things moving again in the gut, they act on the stimulation of the muscles
• Suppositories and enemas may be needed to provide an additional stimulus right into the rectum area, the part that is usually the most backed-up

Stools softeners

The type of softeners that is most often used fall into the “osmotic” or “hypermolar” category. The most popular is Polyethylene glycol 3350, also called PEG 3350, sold under the names MiraLAX, Dulcolax, GlycoLax, etc.

PEG pulls water into the colon, softening the stools and making it less hard and spiky to pass. It is pretty effective as a stool softener, but it will do very little to get things moving from a gut muscle perspective. It does not provide stimulation to the peristaltic movement. That is the role of stimulant laxatives.

PEG has been studied extensively in the scientific literature, and based on what we know today, it seems to be well tolerated, even by kids, and seems to present few side effects.

The powder form makes it easy to mix into a drink, and to dose up or down. Work with your doctor to figure out dosage and the optimal time to take PEG, especially in light of the school logistics.

Both PEG and stimulant laxatives take a bit of time to do their work, sometimes around half a day. So giving the laxative in the morning may lead to a defecation in the evening, and taking it in the evening may lead to a defecation the next morning.

Some kids do not like the taste of PEG, so parents may have to consider alternatives like milk of magnesia.

Stimulant laxatives

I am usually against stimulant laxatives, because they are strong, and they can cause lots of cramping and pain in kids. But again, they might be needed to evacuate an impaction. They stimulate the gut muscle and trigger the peristaltic movement.

Stimulant laxatives contain senna, a medicinal plant that has strong laxative properties. They are sold under the brand names Ex-lax, Pedia-lax, Senokot, etc.

Stimulant laxatives will be especially used if the kid has lost the urge to go due to chronic constipation and the over-stimulation of the rectum stretch receptors as we discussed earlier. It will provide a strong muscle stimulation that will be hard to ignore.

Once the plug is removed, small doses of stimulant laxatives may be advised as part of the physiological re-training period, to get the child into the habit of going to the toilets on a regular basis. Once the toilet habit is re-established, the child can be weaned from the stimulant laxative.

Enemas and glycerin suppositories

Those two may provide help in getting rid of the impaction. A lot of parents are hesitant to have their child go through an enema. But it is a valid and safe tool, do not discard it for emotional reasons.

As I explain in the fecal impaction article, a study done by the American Academy of Pediatrics explains that enemas performed at home by the parents rather than a nurse in an unfamiliar place were well tolerated by the child(3).

Enemas, when explained and performed at home, are well accepted by the kids and do not need to be feared.

Natural constipation remedies

Once you start to see improvements and you feel you are moving from crisis mode to retraining mode, then you can start to switch to natural remedies.

You will need to see several weeks without problems and painful episodes before you do the switch. Make sure the child feels comfortable going back to toilets regularly, or this change to natural products could be counter productive.

Yellow dock (Rumex crispus), at low doses, is a stimulant laxative that should not cause too much cramping. You can give it a try if your child is still having trouble to “listen to” the defecation reflex. Start with 10 to 15 drops of a good quality tincture twice a day in a little water (I recommend Mountain Rose Herbs as a supplier). It will stimulate bile production and bile release, bile being our natural laxative.

Dandelion root tincture can create a similar effect, although a little less pronounced. Switch to dandelion root if your child seems to be having trouble with yellow dock. Start with 20 to 30 drops of a good quality tincture twice a day in a little water (I recommend Mountain Rose Herbs as a supplier).

Don’t do both yellow dock and dandelion root at the same time. Pick one and see where that takes you.

In addition to yellow dock or dandelion root, give your child a glass of marshmallow root cold infusion twice a day. Marshmallow root is full of mucilage, and those have the ability to retain lots of water, making the sools moister. Moreover, it does not taste bad at all, the taste is fairly bland and a little sweet. Put half a teaspoon of powdered marshmallow root in a glass (you can buy powdered root at Mountain Rose Herbs), add some water, stir and let it sit for two hours. A gel will form. Have your child drink that gel, making sure she does not drink the powdered root that has deposited at the bottom.

I like the combination of yellow dock and marshmallow. One acts as gentle stimulant laxative, the other one as stool softener. They constitute our natural “MiraLAX + Ex-Lax” combination!

In addition of course, do not forget the following tools which can be used daily:

• A teaspoon of olive oil first thing in the morning mixed in a bit of yogurt will stimulate bile production (add a little sugar or honey to make this more palatable if the taste is problematic);
• A small glass of prune juice once or twice a day can act as osmotic laxative and add to the stool softening effect of marshmallow, or can just be taken on its own without marshmallow.
• Having your child drink a magnesium-rich water throughout the day can have a gentle laxative effect as well.

Nutritional help

For chronically constipated kids, I usually recommend a complete dairy removal for a period of one month. Multiple studies quoted in the food that cause constipation article show a clear relationship between dairy products and constipation. Contrary to popular belief, kids can do just fine without dairy products and find all the vitamins and minerals they need in fruits, vegetables, meats, fish, etc.

Yes this is complicated, but it also gives results. It is, in my opinion, worth a try.

Next, I usually recommend a complete removal of all cereals (wheat, oats, barley, spelt, etc). Again, I know it is hard to implement for a kid, but you may be at a point where you are ready to try anything that can help.

Overall, I suggest that you review the food that cause constipation article.

Probiotics : some studies(4) have shown that children with fecal impaction and encopresis have a higher prevalence of "small intestine bacterial overgrowth", also called SIBO. Giving your child probiotics on a regular basis can help in re-establishing a healthy gut flora, which can have a positive impact on transit.

Psychological help

I am not a psychologist. But throughout the years, I have noticed that establishing certain habits and behaviors can help in encopresis cases. See a detailed list below.

I recommend that you try one of the web-based encopresis programs. One study(5) has shown that such a program can be effective in providing relief in encopresis cases. More specifically, that study shows that internet programs can:

• decrease overall accidents
• increase child comfort on the toilet at home.

The study mentions that “of the 20 children who initially reported fecal accidents, 19 (95%) experienced at least a 50% improvement, with a reduction of accident frequency from one fecal accident per day to one accident per week”. This is quite convincing.

There are two web-based programs that I think look pretty serious :

• Ucanpooptoo.com
• Encopresis.com

I suggest you take time to investigate those when you have a chance.

Some advice :

• Reinforce positive behaviors. Making an attempt to go to the bathroom should be reinforced, whether the movement occurs or not. Taking the herbal products or the laxatives should be encouraged. The fact that the poop comes out has little reinforcement value, even though you and the child will feel tremendously relieved. We should reinforce the behavior, not the end-result.
• Take advantage of any moment your child spends on the toilets to practice good defecation habits. Show them the right positioning (as close to the squatting position as possible, propping their legs up with a stepping stool), pushing with their lower abdomen, etc. You can practice this when they go pee for instance, in a fun way, as a game, etc.
• Involve the school nurse and your child’s teacher to explain your situation. This is about you educating them to make them understand that encopresis is not your child’s fault. The teacher might believe your child is soiling his pants on purpose. Make your educational team understand that your child needs special, personalized attention.
• When your child soils his pants, he may ignore the situation, or be so embarrassed that he just wants it to go away and pretends it is not there. You need to openly talk about it with him, behaving like this is no big deal at all. The web-based programs mentioned above may help your child realize that there are lots of kids out there going through the same experience.
• Explain that some people close to her may make fun of her because they do not understand what encopresis is. You may need to prepare an aunt for instance who needs to look after your child for an evening, and the word may (or probably will) get out to the cousins of the child, who may end up making fun of her. So again here, we are back to educating people close to us, making everybody understand this is no laughing matter. You may also ask yourself: do I really need to tell Aunt Betty at the Christmas diner? If you don’t need to tell, it might be best to keep this within the close family.
• You may have gotten mad with him, that’s ok, we all get mad. Talk to him and apologize, make him feel he is understood. Tell him you will help him go through this situation so that he doesn’t feel alone or singled-out anymore.

Miscellaneous help

• Consider using panty-liners / pull-ups if it makes cleaning easier, or if it is more convenient at school. Watch for urinary tract infections if the underwear or panty-liners are constantly soiled, especially for girls.
• When traveling when going on vacation, there will be a change of diet and the stress of going to a less familiar place. Your child may not be able to go when the urge shows up (e.g. she is in the train and she is uncomfortable going into the tiny toilets). This may trigger constipation. Plan ahead of time to see how you can optimize those logistics. Explain to your child the different toilet places he may encounter so that he won't be surprised at the last minute. Tell him there might be lots of noise and people in those public toilets, etc.
• Prop-up their legs when they go to the toilets so that they get as close as possible to the squatting position. When the legs rest on a stool that is high enough, the legs will be bent at the knees, and the thighs will be gently pressing on the abdomen, that pressure being a stimulant to bowel movements

Conclusion

As frustrating as encopresis can be, you are not without options. The key point to understand is, in my opinion, that the psychological aspect of encopresis should not be underestimated.

Laxatives are just the beginning of a long and sometimes bumpy retraining period.

Medicinal plants and nutrition can provide great help, they are foundational, but they won’t replace the loving support and guidance of parents.

In order to go through this retraining period as best as you can, I do suggest you investigate a web-based encopresis program. The documents, videos, and doctors and nurses available to answer your questions online might make all the difference, and make you realize you are not alone in dealing with this situation.

References

(1) Boles RE, Roberts MC, Vernberg EM. “Treating non-retentive encopresis with rewarded scheduled toilet visits.” Behav Anal Pract. 2008 Winter;1(2):68-72.

(2) Hardy LT. “Encopresis: a guide for psychiatric nurses.” Arch Psychiatr Nurs. 2009 Oct;23(5):351-8.

(3) Araghizadeh F. "Fecal impaction". Clin Colon Rectal Surg. 2005 May;18(2):116-9.

(4) Leiby A, Mehta D, Gopalareddy V, Jackson-Walker S, Horvath K. “Bacterial

overgrowth and methane production in children with encopresis.” J Pediatr. 2010 May;156(5):766-70, 770.e1.

(5) Ritterband LM, Ardalan K, Thorndike FP, Magee JC, Saylor DK, Cox DJ, Sutphen JL, Borowitz SM. “Real world use of an Internet intervention for pediatric encopresis.” J Med Internet Res. 2008 Jun 30;10(2):e16.

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