Definition of Stool holding (Encopresis)
Encopresis, 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.
Symptoms of Stool holding (Encopresis)
Signs and symptoms of encopresis may include:
- Leakage of stool or liquid stool on your child’s underwear. If the amount of leakage is large, you may misinterpret it as diarrhea.
- Constipation with dry, hard stool.
- Passage of large stool that clogs or almost clogs the toilet.
- Avoidance of bowel movements.
- Long periods of time between bowel movements, possibly as long as a week.
- Lack of appetite.
- Abdominal pain.
- Repeated urinary tract infections.
When to see a doctor
Call your doctor if your child is already toilet trained and starts experiencing one or more of the symptoms listed above.
There are several causes of encopresis. The most common are:
Constipation. Most cases of encopresis are the result of chronic constipation. In constipation, the child’s stool is hard, dry and may be painful to pass. As a result, the child avoids going to the toilet — making the problem worse. The longer the stool remains in the colon, the more difficult it is for the child to push stool out. The colon stretches, ultimately affecting the nerves that signal when it’s time to go to the toilet. When the colon becomes too full, soft or liquid stool may leak out.
Common causes of constipation include withholding stool due to fear of using the toilet (especially when away from home) or not wanting to interrupt play, eating too little fiber or not drinking enough fluids. Sometimes, an allergy to cow’s milk or drinking too much cow’s milk leads to constipation, although milk allergy causes diarrhea more often than constipation.
- Emotional issues. Emotional stress also may trigger encopresis. A child may experience stress from premature toilet training or an important life change — for instance, the divorce of a parent or the birth of a sibling.
These risk factors may increase your child’s chances of having encopresis:
- Sex of the child. Encopresis is more common in boys.
- Chronic constipation. This may cause your child to avoid passing stool.
- Not drinking enough fluids. This aggravates existing constipation.
Complications of Stool holding (Encopresis)
A child who has encopresis may experience a range of emotions, including embarrassment, frustration, shame and anger. If your child is teased by friends or chastised by adults, he or she may feel depressed or have low self-esteem.
Early treatment, including guidance from a mental health provider, can help prevent the social and emotional impact of encopresis.
Preparing for your appointment
You’ll likely first bring up your concerns with your child’s doctor. He or she may refer you to a doctor who specializes in digestive disorders in children (pediatric gastroenterologist) or a mental health provider if your child seems to be very embarrassed, frustrated or angry because of encopresis.
What you can do
Because appointments can be brief and there’s often a lot of ground to cover, it’s a good idea to be prepared for your child’s appointment.
- Ask if there’s anything you need to do in advance, such as restrict your child’s diet.
- Make a list of your child’s symptoms, including how long they’ve been occurring.
- Include notes on key personal information, such as any major stresses or recent life changes.
- Make a list of all medications, as well as any vitamins or other supplements that your child is taking, or bring them with you.
- List what your child eats and drinks on a typical day, including the amount and types of dairy products, type of solid foods and the amount of water and other fluids consumed.
- Prepare questions to ask your child’s doctor.
For encopresis, some basic questions to ask the doctor include:
- What’s the most likely cause of my child’s symptoms?
- Are there other possible causes for these symptoms?
- What kinds of tests does my child need? Do these tests require any special preparation?
- How long might this problem last?
- What treatments are available, and which do you recommend?
- What side effects can be expected with this treatment?
- Are there alternatives to the primary approach that you’re suggesting?
- Are there any dietary changes that might help ease my child’s symptoms?
- Would additional physical activity help my child? What about exercise routines?
- Are there any brochures that I can have? What websites do you recommend?
What to expect from your doctor
Your child’s doctor will have questions for you, too, such as:
- How long has your child been toilet trained?
- Did your child experience any problems with toilet training?
- Does your child have hard, dry stools that sometimes clog the toilet?
- Does your child take any medications? If so, which ones?
- Does your child regularly resist the urge to use the toilet?
- Does your child experience painful bowel movements?
- How often do you notice stains or fecal matter in your child’s underwear?
- Have there been any significant changes in your child’s life? For instance, has he or she started a new school, moved to a new town, or experienced a death or divorce in the family?
- Is your child embarrassed or depressed by this condition?
- How have you been managing this issue?
- If your child has siblings, how was their toilet training experience?
What you can do in the meantime
Give your child high-fiber foods, such as fruits and vegetables, and encourage him or her to drink plenty of liquids. Avoid an excess of dairy products.
Tests and diagnosis
In addition to asking about your child’s symptoms, your child’s doctor may:
- Conduct a physical exam, including a digital rectal exam to check for impacted stool. During this exam, the doctor inserts a lubricated, gloved finger into your child’s rectum while pressing on his or her abdomen with the other hand.
- Recommend an abdominal X-ray to confirm the presence of impacted stool.
- Suggest that a psychological evaluation be conducted to help determine contributing factors for your child’s symptoms.
Treatments and drugs
Generally, the earlier that treatment begins for encopresis, the better. The first step involves clearing the colon of retained, impacted stool. After that, treatment focuses on encouraging healthy bowel movements. This includes training your child to go to the toilet as soon as reasonably able when the urge to have a bowel movement occurs.
There are several methods for clearing the colon and relieving constipation. Your child’s doctor will likely recommend one or more of the following:
- Stool softeners, such as lactulose
- Colon lubricants, such as mineral oil
- Rectal suppositories
- More oral fluids
Your child’s doctor may recommend abdominal X-rays to check the progress of the colon clearing.
Once the colon has been cleared, it’s important to encourage your child to have regular bowel movements. In addition to recommending self-care measures, such as a high-fiber diet and drinking lots of fluids, your child’s doctor may recommend the use of stool softeners for six months or more.
If your child feels shame, guilt, depression or low self-esteem related to encopresis, talk therapy (psychotherapy) can be helpful. A psychologist can help your child deal with these feelings and may also give you techniques for teaching your child not to hold stool. Ask your child’s doctor for a recommendation.
Lifestyle and home remedies
Don’t use enemas or laxatives — including herbal or homeopathic products — without talking to your child’s doctor first.
Once your child has been treated for encopresis, it’s important that you encourage regular bowel movements. These tips can help:
- Focus on fiber. Feed your child a diet that includes plenty of fruits, vegetables and foods high in fiber, which can help form soft stools. Offer whole grains, which are brown — not white — in color.
- Encourage drinking lots of water. Water helps keep stool from hardening. Encourage your child to drink plenty of water or other nondairy fluids.
- Limit dairy products and fats. These can reduce bowel movements. But, dairy products also contain important nutrients, so ask your child’s doctor how much dairy your child needs each day.
- Arrange toilet time. Have your child sit on the toilet every day for 10 to 15 minutes after breakfast and supper. The bowel becomes more active about 30 minutes after eating, so this is a natural time for your child to try to pass stool. This applies only to children who are toilet trained and are at least 4 years old. Don’t reward your child for passing stool or punish your child for not passing stool. Praise your child for sitting on the toilet as requested and trying.
- Put a footstool near the toilet. This may make your child more comfortable, and changing the position of his or her legs can put more pressure on the abdomen, making a bowel movement easier.
- Stick with the program for several months. The relapse rate for encopresis is high.
As you help your child overcome encopresis, be patient and use positive reinforcement. Don’t blame, criticize or punish your child if he or she has an accident. Instead, offer your unconditional love and support.
Help your child avoid constipation by providing a diet high in fiber and encouraging your child to drink plenty of water.
Educate yourself on effective toilet training techniques. Avoid starting too early or being too forceful in your methods. Wait until your child is ready, and then use positive reinforcement and encouragement to help him or her progress.
Most children aren’t ready for toilet training until after their second birthdays. Some guidelines for readiness include:
- Your child is able to pull pants down
- Your child can ask one-word questions
- Your child has an interest in stopping activities when body sensations indicate a bowel movement is needed
When your child seems ready, make sure your child’s feet are firmly planted on a stool or the floor — not dangling — so that he or she feels secure and can push.