DISCUSS THE EPIDEMIOLOGY OF ENCOPRESIS IN THE WORLD
Encopresis also known as paradoxical diarrhea, is voluntary or involuntary fecal soiling in children who have usually already been toilet trained. Persons with encopresis often leak stool into their undergarments. Encopresis (or fecal incontinence) is a disorder which affects children worldwide. It is even more stigmatized than enuresis and urinary incontinence and is associated with high levels of distress for both children and parents. Also, the rate of comorbid emotional disorders is higher, affecting 30%-50% of all children with encopresis (von Gontard et al, 2011).
Two major forms of encopresis can be differentiated: encopresis with and without constipation. The specific differentiation into these two subtypes is of utmost importance as they differ according to pathophysiology, clinical features and, especially, treatment (i.e., the former does not respond to laxatives, while in the latter they are essential in treatment). The aim of this chapter is to give an overview and practical approaches to assessment and treatment of these two subtypes of encopresis.
This term is usually applied to children, and where the symptom is present in adults, it is more commonly known as fecal leakage (FL), fecal soiling or fecal seepage.
Encopresis is a common disorder affecting 1% to 3% of children older than four years (the definitional age). Three different trajectories can be defined (Heronet al, 2008):
• Children with chronic encopresis over many years
• Those with relapses, and
• A group with a tendency to remit spontaneously.
In a Dutch study, 4.1 % of 5-6 year olds and 1.6 % of 11-12 year olds were affected (van der Wal et al., 2005). Prevalence depends on the definition used; for example, 5.4 % of 7-year old children soiled, but only 1.4 % once or more per week (Joinson et al, 2006). Encopresis can persist into adolescence and even young adulthood. Without constipation (i.e., non-retentive fecal incontinence), 49% of
children soiled at the age of 12 years, and 15% at 18 years in a long-term follow up (Bongers et al, 2007). The prognosis of constipation is less favorable: only 80 % had a good outcome by the age of 16 years, and 75% to 80% at 16-27 years (Bongers et al, 2010). Three to four times more boys are affected by encopresis than girls (Bellman, 1966). Encopresis occurs almost always during the day (Bellman, 1966). Nocturnal encopresis is more often associated with organic causes and requires a more detailed somatic assessment.
Most children from the age of four years onwards have one bowel movement a day – with great individual variability (Bloom et al, 1993). Chronic constipation is a more common disorder than encopresis. According to a large meta-analysis, the median prevalence was 9% world-wide with different definitions used (vanden Berg et al, 2006). This meta-analysis included studies from countries such as Italy, US, Hong Kong, Japan, Finland, Turkey, Brazil, Saudi Arabia, among others.
CLINICAL SIGNS AND SYMPTOMS
As the differentiation of the two subtypes – constipation and non-retentive fecal incontinence − is decisive for treatment, it is important to know the basic signs and symptoms of each. Children with encopresis with constipation (or functional constipation) have
a reduced number of bowel movements with large stools of altered consistency (too soft or too hard). They often experience pain during defecation. Abdominal pain and reduced appetite are typical. The colon transit time is increased, abdominal and rectal masses are palpable. In sonography, the rectal diameter is increased (> 25mm). Often, daytime urinary incontinence and even enuresis co-exists. Additional emotional and behavioral disorders are found in 30%-50% of them and, finally, laxative therapy is helpful.
Encopresis is commonly caused by constipation, by reflexive withholding of stool, by various physiological, psychological, or neurological disorders, or from surgery (a somewhat rare occurrence).
The colon normally removes excess water from feces. If the feces or stool remains in the colon too long due to conditioned withholding or incidental constipation, so much water is removed that the stool becomes hard, and becomes painful for the child to expel in an ordinary bowel movement. A vicious cycle can develop, where the child may avoid moving his/her bowels in order to avoid the “expected” painful toilet episode. This cycle can result in so deeply conditioning the holding response that the rectal anal inhibitory response (RAIR) or anismus results. The RAIR has been shown to occur even under anesthesia and when voluntary control is lost. The hardened stool continues to build up and stretches the colon or rectum to the point where the normal sensations associated with impending bowel movements do not occur. Eventually, softer stool leaks around the blockage and cannot be withheld by the anus, resulting in soiling. The child typically has no control over these leakage accidents, and may not be able to feel that they have occurred or are about to occur due to the loss of sensation in the rectum and the RAIR. Strong emotional reactions typically result from failed and repeated attempts to control this highly aversive bodily product. These reactions then in turn may complicate conventional treatments using stool softeners, sitting demands, and behavioral strategies.
The onset of encopresis is most often benign. The usual onset is associated with toilet training, demands that the child sit for long periods of time, and intense negative parental reactions to feces. Beginning school or preschool is another major environmental trigger with shared bathrooms. Feuding parents, siblings, moving, and divorce can also inhibit toileting behaviors and promote constipation. An initiating cause may become less relevant as chronic stimuli predominate.
The psychiatric (DSM-IV) diagnostic criteria for encopresis are:
1. Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether voluntary or unintentional
2. At least one such event a month for at least 3 months
3. Chronological age of at least 4 years (or equivalent developmental level)
4. The behavior is not exclusively due to a physiological effect of a substance (e.g., laxatives) or a general medical condition, except through a mechanism involving constipation.
The DSM-IV recognizes two subtypes: with constipation and overflow incontinence, and without constipation and overflow incontinence. In the subtype with constipation, the feces are usually poorly formed and leakage is continuous, and this occurs both during sleep and waking hours. In the type without constipation, the feces are usually well-formed, soiling is intermittent, and feces are usually deposited in a prominent location. This form may be associated with oppositional defiant disorder (ODD) or conduct disorder, or may be the consequence of large anal insertions, or more likely due to chronic encopresis that has radically desensitized the colon and anus.
Following assessment, children and parents are given detailed information on the subtype of encopresis (psychoeducation). As in the treatment of enuresis, unspecific factors such as enhancing motivation and building a good therapeutic relationship are helpful. Feelings of guilt, dysfunctional parental attributions (“my child is doing this on purpose”) and frustration can be verbalized. Ineffective parental interventions such as punishment or non-indicated medication can be discussed with parents. If the child’s food intake is restricted to low fiber foods, a change in the child’s diet can be useful. Also, the amount of fluids should be increased, as many children do not drink enough during the day.
Encopresis is a common condition that is often associated with psychosocial health disorders but only a small proportion of the children with encopresis are taken to a general practitioner to discuss their problem. It is also called stool holding or soiling, occurs when your child resists having bowel movements, causing impacted stool to collect in the colon and rectum. When your child’s colon is full of impacted stool, liquid stool can leak around the impacted stool and out of the anus, staining your child’s underwear.
Encopresis usually occurs after age 4, when your child has already learned to use a toilet. In most cases, encopresis is a symptom of chronic constipation. Less frequently, it may be the result of developmental or emotional issues. Doctors categorize encopresis as primary or secondary. Primary encopresis happens in a child who has never been successfully toilet trained. In secondary encopresis, a child develops the condition after having been successfully toilet trained. Encopresis can be frustrating for you — and embarrassing for your child. However, with patience and positive reinforcement, treatment for encopresis is usually successful.
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