Encopresis

Definition
- Fecal incontinence >4yo at least once per month x 3 months
Causes
- Functional
  - Retentive encopresis (90%)
    - History of retentive posturing or excessive volitional stool retention, history of hard or painful bowel movements, presence of large fecal mass in the rectum, or history of passing large diameter stool
  - Nonretentive encopresis
    - Defecation into places inappropriate to the social context.
    - No evidence of fecal retention.
    - After appropriate medical evaluation, the fecal incontinence cannot be explained by another medical condition.
- Neurogenic
  - Hirschprung disease (usually causes constipation rather than fecal incontinence)
  - Spinal cord lesions
- Endocrine
  - Hypothyroidism
  - Hypercalcemia
- Anorectal malformations
- Bowel obstruction
- Medications
History
- Stool pattern (size, consistency, interval)
  - Large bowel movements suggest constipation
- History of constipation/soiling (onset)
  - Incontinence during sleep suggesting constipation
- Diet history (type and amount of food, changes in diet)
- Decrease in appetite
- Abdominal pain
- Medications
- Urinary symptoms (day or night enuresis, UTI)
- Family history of bowel disease
- Family/personal stressors
  - Toilet training, separation, change in schedule
Physical Exam
- Height
- Weight
- Abdominal examination
  - Distension
  - Mass
- Rectal examination
  - Sacral dimple/hair tuft (spina bifida occulta)
  - Anal fissures
  - Stool in rectum
- Neurological examination
  - Anal wink
  - Sensation and strenght in lower extremities
Investigations
- Abdominal X-ray r/o occult constipation
- Lab if suspected or failed intervention with laxatives
  - TSH
  - Celiac
  - Electrolytes and calcium
  - Blood lead level
  - Urine culture (if enuresis)
Retentive encopresis (Chronic constipation, overflow incontinence)
- History
  - Resist urge to defecate
  - Small quantities of loose stool several times per day, but periodically large bowel movements
  - Abdominal pain/painful defecation
- Physical Exam
  - DRE: Large fecal mass in rectal vault
  - Anal fissures
  - Palpable stool in LLQ
- Investigations
  - Consider abdominal X-ray to confirm constipation/impaction
- Management
  - PEG 3350 1-1.5 g/kg PO daily x 3-6 days or until loose stool, then maintenance 0.4g/kg daily
  - Maintenance of regular bowel movements
  - Assessment and guidance regarding psychosocial stressors
  - Behavioural modification
    - Positive association with toilet sits
      - Schedule regular 3-5 times daily toilet sits (eg. after each meal)
        While sitting, offer proper foot support, and enjoyable relaxing activities
      - Ensure soft, well formed stools

References:

UTD
AAFP 1999. http://www.aafp.org/afp/1999/0415/p2171.html

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