• Voluntary or involuntary fecal soilage in a (typically) previously toilet-trained individual
    • 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.
  • Adult encopresis (fecal incontinence) is a separate topic.
  • 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.
  • Chronic rectal distension causes habituation, leading to the loss of sensing 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.
  • Psychological
    • 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
  • Anatomic
    • 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
    • Neurofibromatosis
  • Dietary or metabolic
    • Inadequate dietary fiber; excessive protein or milk intake; inadequate water intake
    • Hypothyroidism; hypercalcemia; hypokalemia
    • 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

Risk Factors

  • Male gender
  • Constipation
  • 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

General Prevention

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

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