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- Voluntary or involuntary fecal soilage in a (typically) previously toilet-trained child
- Age may be chronologic or developmental.
- No underlying organic disease
- At least one event per month for 3 months
- Classified into functional constipation (retentive encopresis) and functional nonretentive fecal incontinence (FNRFI); both cause fecal incontinence. There is no constipation in FNRFI. Functional constipation is more common.
- System(s) affected: GI; psychological
- Synonyms(s): fecal incontinence, soiling
Predominant sex: male > female (4 to 6:1) Constipation accounts for 3% of general pediatric referrals; up to 84% of constipated children have fecal incontinence at some point.
Occurs in 1–3% of children 4 years of age
Etiology and Pathophysiology
- In 90% of cases, encopresis develops as a consequence of chronic constipation, with resulting overflow incontinence (retentive encopresis). The other 10% are caused by specific organic etiologies.
- Chronic constipation with irregular and incomplete evacuation results in progressive rectal distension and stretching of the internal/external anal sphincters.
- As a child habituates to chronic rectal distension, they may no longer sense the normal urge to defecate. Eventually, soft or liquid stool leaks around the retained fecal mass.
- Many children voluntarily withhold stool in response to the urge to defecate for fear of pain or a preoccupation with not interrupting social activities.
- Stool withholding, fear, anxiety
- Difficulty with toilet training, including unusual anxiety or conflict with parent
- Resistance to using public toilet facilities, such as school bathrooms or outdoor toilets
- Known association with sexual abuse in boys; likely similar association in girls
- Developmental delay
- Rectal distension and desensitization
- Anal fissure or painful defecation
- Muscle hypotonia
- Slow intestinal motility
- Hirschsprung disease
- Cystic fibrosis
- Spinal cord defects (e.g., spina bifida)
- Congenital anorectal malformations
- Anal stenosis
- Anterior displacement of the anus
- Postoperative stricture of anus or rectum
- Pelvic mass
- Dietary or metabolic
- Inadequate dietary fiber
- Excessive protein or milk intake
- Inadequate water intake
- Diabetes insipidus; diabetes mellitus
- Food allergy
- Gluten enteropathy
- Medication side effects
None known; although incidence may be higher in children with family history of constipation
- Male gender
- Very low birth weight
- Painful defecation
- Difficulty with bowel training, including social pressure related to early daycare placement
- Organic/anatomic causes
- Anxiety and depression
- Insufficient fluid or fiber intake
- Refusal to use public restrooms
- Attention deficit
- History of abuse
Family education: toilet training when ready; optimize fluid and fiber intake.
Commonly Associated Conditions
- Constipation, Hirschsprung disease
- Cerebral palsy, cystic fibrosis
- Developmental and behavioral diagnoses, urinary incontinence