Encopresis (Soiling)

Encopresis, also known as fecal incontinence or soiling, is a condition that occurs when your child passes poop (stool) anywhere other than a toilet. It may be an accident or not. They usually poop in their underwear, but may also poop on the floor. The condition occurs in children age 4 years and older who’ve completed toilet training.

Encopresis is a stressful condition that can cause a mix of emotions for your child and your family. It’s easy to get frustrated or even angry. But your child needs your love and support more than ever now. It’s important to encourage them and not shame them. If encopresis is affecting your child, make an appointment to see their pediatrician. They can help you figure out a treatment plan to get your child going to the bathroom again.

Symptoms of encopresis

The first sign of soiling is often the smell. You may also notice your child has soft, loose or liquid poop in their pants that looks like diarrhea.

Other symptoms of fecal incontinence may include:

• Hiding bowel movements or keeping them a secret
• Hiding soiled clothes
• Not pooping regularly
• Feeling bloated or experiencing pain in their belly
• Loss of appetite
• Rash around their anal area (butthole)

If you think your child may have encopresis, you may want to start a poop diary. Keep track of your child’s pooping habits so you can share them with their healthcare provider.

Fecal incontinence causes

Encopresis has a few main causes: constipation, underlying medical conditions and psychological triggers.

Constipation

The most common cause of fecal incontinence is constipation. In as many as 95% of children with the condition, the cause is constipation. Constipation can start in infancy.

When your child experiences constipation, it’s difficult for them to have a bowel movement. This is because their poop is dry and hard inside their colon. That can make it painful to pass. Painful poop encourages your child to withhold it. They may resist toilet training or have a fear of painful bowel movements.

When your child withholds or delays going to the bathroom, poop builds up in their colon, which can stretch it out. That can make it hard for them to feel when it’s time to have a bowel movement. Liquid poop might leak out around harder poop. This is called overflow incontinence.

When constipation causes soiling, it’s called retentive encopresis.

Underlying medical conditions

When constipation isn’t the cause, the condition is called non-retentive encopresis. Encopresis may be a symptom of an underlying medical condition, but this is rare. Symptoms may include poor growth, bloody poop, vomiting and weight loss. Possible conditions include:

• Birth defects, like tethered spinal cord
• Cerebral palsy
• Hirschsprung disease
• Infection or tear in your child’s rectum
• Myopathy in their anal sphincter (muscle at the end of their anus, or butthole)
• Pelvic floor dysfunction
• Spinal cord trauma or tumor
• Vagus nerve damage causing problems in their digestive tract
• Celiac disease or inflammatory bowel disease

Psychological triggers

Encopresis could be the result of emotional stress. Behavioral challenges and fear may also affect your child’s actions. Psychological causes may include:

• A pattern of not listening to parents or other adults (oppositional defiant disorder or ADHD)
• Availability of a toilet (especially a clean, private one) or not wanting to use a public toilet (shy bladder syndrome)
• Behavioral problems, like trouble following rules or meeting social expectations
• Fear of the toilet (anxiety)
• Stressful events in your child’s life, like starting school, holidays or welcoming a new sibling
• Your child is busy playing and doesn’t want to stop to go to the bathroom

Is encopresis a mental disorder?

Healthcare providers use a book called the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) when diagnosing mental health conditions. The DSM-5 lists encopresis as an elimination disorder, not a mental health disorder. But anxiety is very common with encopresis.

Although fecal incontinence isn’t classified as a mental health disorder, it can still have a major psychological impact on your child.

Complications of encopresis

Without treatment, the physical complications of fecal incontinence may include:

• Long-term (chronic) constipation
• Urinary incontinence
• Urinary tract infections

Your child may also experience:

• Bullying and teasing from peers
• Embarrassment
• Low self-esteem
• Social anxiety
• Trouble making and keeping friends

How doctors diagnose encopresis

To diagnose encopresis, your child’s pediatrician will perform a physical exam. They’ll ask you questions about your child’s symptoms, including:

• When they began and when they occur (day or night)
• What the poop looks like, including its size and whether it contains any blood
• How frequently and consistently your child is pooping

They’ll also ask you questions about your child’s:

• Medical history, including any rectal or anal surgeries
• Previous treatments
• Withholding behaviors, and events that led to them
• Emotional well-being (stress)
• Toilet training
• Eating habits and nutrition

Your child’s provider may also refer them to a child psychologist for a mental health exam. This can help determine if the soiling relates to emotional stress, fear or behavioral challenges.

Tests that are used to diagnose fecal incontinence

Tests that your child’s provider may use to help them diagnose encopresis include:

• Anus inspection: Your child’s provider will look for anal fissures, hemorrhoids, tags or any abnormalities.
• Digital rectal exam: If your child is willing, their provider may insert a gloved, lubricated finger into their rectum to check for blockages.
• Abdominal exam: Your child’s provider will want to check for poop they can feel, as well as any swelling or tenderness.
• X-ray: Their provider may want to see an X-ray of their belly to rule out any issues.
• Urinalysis: Your child’s provider may request a urine test to rule out similar conditions.

How do you resolve encopresis?

Since constipation is the most common cause, fecal incontinence treatment usually focuses on that. Treatment for constipation involves two steps. Usually, your child’s provider will order a medication to clean out their bowels. Then, they’ll create a program to keep your child’s bowels healthy and prevent constipation from occurring again.

Bowel cleanout

Your child’s provider will often prescribe a medication like propylene glycol to help clean out their bowels. Propylene glycol is a laxative powder that dissolves in fluid. Your child can take up to one capful for each year of their age. You typically mix each capful in 4 ounces of fluid.

Your child’s provider may recommend a type of laxative called magnesium hydroxide solution. Brand names include Ex-Lax®, Dulcolax® or Phillips Milk of Magnesia®. Or they may suggest a stimulant laxative like Senna®.

Your child’s provider may also suggest a suppository or an enema to relieve a stool impaction. Both go into your child’s rectum. Rarely (if constipation is severe), your child may need to be hospitalized for a bowel cleanout.

Maintenance program

To keep your child’s bowels healthy, their provider will put together a maintenance plan for them. Your child will take a medication for a while to ensure regular, soft poops. These types of medications include stool softeners and laxatives. Your child’s provider may also recommend daily fiber gummies. Other parts of the program may include:

• Scheduled toilet sitting, for five to 10 minutes at a time
• Eating foods high in fiber (fruits, whole grains, vegetables)
• Cutting out processed foods that are low in fiber and high in fat and sugar
• Decreasing milk and other dairy products
• Drinking plenty of water
• Increasing physical activity
• Using a probiotic

Your child’s provider may also suggest the use of biofeedback training. This technique teaches your child how to control the muscles in and around their butthole to poop better.

Does my child need to see a specialist?

Treatment can start with your child’s pediatrician. But healthcare providers often use a team approach in the treatment of encopresis. This is to help address the medical, emotional and behavioral factors affecting your child’s toileting. If your child continues to have trouble, their pediatrician may refer them to a pediatric dietitian and/or any of the following specialists:

• Pediatric gastroenterologist: This type of doctor specializes in treating conditions that affect your child’s GI tract.
• Mental health professional: A therapist or social worker can help your child work through any fear, shame or guilt they feel when going to the bathroom or having accidents. They can also discuss and offer suggestions for any emotional stress your child may have.
• Pediatric neurologist: Your child may see a doctor who specializes in the brain if they think your child could have a developmental issue involving digestion.

How soon after treatment will my child feel better?

Encopresis treatment is long-term. The goal is to create regular bowel movements for your child. It could take several months to achieve this goal. Have patience with your child as they become more comfortable using a toilet.

Children will also need to learn about the sensation of having a bowel movement. This could take time if their intestines are stretched because of constipation.

Always encourage and praise your child after they use the toilet. Some parents use a sticker chart. They mark the days when their child sits on the toilet and has a bowel movement. Their child earns a small reward if they reach a certain goal by the end of the week. Small rewards can increase your child’s interest in using the toilet on their own.

When should my child see their healthcare provider?

If you notice your child has symptoms of fecal incontinence, make a visit to their healthcare provider. It can be easier to treat encopresis and constipation early, at the first sign of a problem. See their provider immediately if your child:

• Experiences pain
• Isn’t pooping at all
• Refuses to eat due to discomfort

What can I expect if my child has encopresis?

You might see some progress early in fecal incontinence treatment. But it usually takes months for your child to overcome it. There will be accidents along the way. Keep your reactions to accidents low-key, and continue to support your child. Most children who receive treatment for encopresis are eventually free from constipation. They become accident-free as they grow older.

How can I help my child?

You should encourage and offer support to your child by creating a “potty routine” to keep up with good bowel habits. This includes:

• Scheduling regular bathroom visits after meals
• Praising or rewarding your child for using the toilet regularly
• Not scolding or yelling at your child if accidents happen

To support kids at home, you can:

• Reassure them that you’re in this together
• Remind them that lots of kids have problems with pooping
• Validate their feelings