INTRODUCTION: Fecal soiling (Encopresis) refers to voluntary or involuntary leak of stool, into their underwear, in inappropriate places by children after the age when they are expected to have toilet trained, which is about 4 yrs of age. This is more common in boys and is usually a complication of chronic constipation. Some times it can be due to developmental or emotional issues.
Fecal soiling might be very embarrassing and shameful for the child and can be very frustrating for the parents.
CAUSES FOR FECAL SOILING:
- Constipation: Fecal soiling is mostly a complication of longstanding constipation. When a child gets constipated, their stool becomes hard and dry, this makes passing of stool painful. As a result, the child avoids passing stools, which in turn makes the problem worse. This results in gradual accumulation of hard and dry stool in the colon. The colon gets stretched, ultimately affecting the nerves that make the rectum (part of the colon where the stool is stored) less sensitive and affects the signaling process, which helps the child to know, when it’s time to go to the toilet. The stool behind the hard and impacted feces begins to leak around it, and it eventually leak out of the rectum, without the child knowing it. You can read more about constipation which is discussed in detail separately (Click here “CONSTIPATION”)
- Emotional issues: Emotional stress like birth of a sibling, divorce of parents etc can rarely trigger fecal soiling
LAB TESTS AND DIAGNOSIS:
- Physical exam: A good physical exam of the child by the doctor is very important. The doctor might do a digital rectal exam (Inserting a lubricated and gloved finger into the child’s rectum) to check for impacted stool.
- X-ray of the abdomen: To check for the presence of impacted stool.
- Rarely your doctor might check for thyroid hormone levels.
TREATMENTS:
- Initially the treatment for fecal soiling includes treatment for the underlying constipation. This may include a good clean out of the bowel using one of the following
- Enemas (Phosphate sodium enema or Mineral oil enema)
- Mineral oil
- Stool softeners like Polyethylene glycol (1-1.5 gm/kg/day for 3 days) or lactulose.
- After cleaning out the bowel then the child should be placed on a daily dose of laxative like (polyethylene glycol, lactulose or mineral oil) to prevent recurrence of constipation. In my experience polyethylene glycol works better and is relatively safe. Parents should adjust the laxative dose according to the response (goal: 1-2 soft stools/day)
- Behavior modification: After 2-4 weeks, parents should encourage the child to use the bathroom (5-10 min) at least twice a day on the same time preferably after breakfast and dinner. Offer some simple rewards if the child is compliant with medication and is having successful bowel movements.
- Remember this is a long process and the parents have to be very patient and supportive to the child. Leakage of stool is involuntary, so never punish the child or make the child feel guilty.
PREVENTION: The best way to prevent Fecal soiling is to prevent constipation.
- High fiber diet: Make sure the child get plenty of vegetables, fruits and whole grain food.
- Fluids: Encourage the child to drink plenty of fluids.
- Regular toilet time as mentioned above.
If the child fails to have a bowel movement for several days in a row, then it may be necessary to use enema again to empty the rectum and prevent the recurrence of soiling.
Author: Dr S Boopathi, MBBS, MD Paediatrics (AIIMS).
