Management of Encopresis in Adults
Adult encopresis should be managed as severe constipation with fecal overflow incontinence using a stepwise laxative regimen, starting with dietary fiber and osmotic laxatives (macrogols/PEG), escalating to stimulant laxatives if needed, and addressing any underlying neurological or anatomical causes.
Important Clarification
The provided evidence focuses primarily on pediatric encopresis and intestinal dysmotility/constipation management. True encopresis in adults is rare and typically represents either:
- Severe chronic constipation with overflow incontinence
- Fecal incontinence from other causes (sphincter dysfunction, neurological disease)
- Underlying psychiatric or developmental disorders extending from childhood
Stepwise Treatment Algorithm
First-Line: Dietary and Bulk-Forming Agents
- Ensure adequate fiber and fluid intake as the foundation 1
- Bulk-forming laxatives: Unprocessed wheat bran, methylcellulose (also a fecal softener), ispaghula, or sterculia taken with food or fruit juice 1
- These are effective for patients who can tolerate them and should be the initial approach
Second-Line: Osmotic Laxatives
If bulk-forming agents are inadequate:
- Macrogols (polyethylene glycol/PEG) - preferred osmotic agent that sequesters fluid in the bowel 1
- Lactulose - semi-synthetic disaccharide producing osmotic effect with low pH
- Magnesium salts - useful for rapid bowel evacuation but avoid sodium salts (cause fluid retention) 1
Third-Line: Add Stimulant Laxatives
When osmotic laxatives provide inadequate response:
- Senna (sennosides) - acts on descending and sigmoid colon via myenteric plexus stimulation 1
- Bisacodyl or sodium picosulfate - stimulate proximal colon sensory nerves and increase fluid secretion 1
- Docusate sodium - dual action as stimulant and softening agent 1
Critical caveat: Avoid stimulant laxatives if intestinal obstruction is suspected; excessive use causes diarrhea and hypokalemia 1
Fourth-Line: Prokinetic Agents for Refractory Cases
When standard laxatives fail:
- Prucalopride (5-HT4 receptor agonist) - licensed for chronic constipation, safer cardiac profile than withdrawn agents (cisapride, tegaserod) 1
- Pyridostigmine - parasympathomimetic shown to help refractory constipation including in diabetes, using stepped dosing regimen 1
- Note: Other parasympathomimetics (bethanechol, neostigmine) rarely used due to cardiovascular side effects 1
Avoid long-term metoclopramide due to extrapyramidal effects and tardive dyskinesia risk 1
Address Underlying Causes
Medical Evaluation Required:
- Rule out organic pathology: Hirschsprung's disease, spinal cord lesions, metabolic disorders, medication effects
- Opioid-induced constipation: Consider naloxone 1.6 mg SC daily or methylnaltrexone SC on alternate days 1
- Diabetic patients: Optimize glycemic control, may require insulin pump 1
- Electrolyte/endocrine abnormalities: Correct when detected 1
Behavioral and Psychiatric Components:
While evidence focuses on children 2, 3, adults with developmental disabilities or psychiatric comorbidities may benefit from:
- Structured toileting schedules
- Behavioral modification programs
- Treatment of underlying psychiatric conditions
Common Pitfalls to Avoid
- Do not use dantron - potential carcinogenicity 1
- Avoid sodium-containing laxatives - cause fluid retention 1
- Do not escalate to invasive nutrition support in functional presentations without objective biochemical disturbance 1
- Recognize narcotic bowel syndrome - chronic opioid use causing hyperalgesia and worsening dysmotility; requires opioid reduction, not escalation 1
- Monitor QTc if using domperidone long-term (though generally not recommended) 1
Treatment Targets
Focus therapy on the most bothersome symptom as perceived by the patient 1. The goal is to:
- Establish regular, soft bowel movements
- Prevent fecal impaction and overflow
- Improve quality of life and social functioning
- Minimize medication side effects
Note: The evidence base for adult encopresis specifically is limited 4. Most recommendations extrapolate from constipation management guidelines and pediatric encopresis literature. Surgical options exist for appropriately selected individuals with sphincter dysfunction 4, but medical management should be optimized first.