What is fecal soiling (encopresis)?

Fecal Soiling (Encopresis): Definition and Clinical Approach

Fecal soiling (encopresis) is the repetitive, intentional or unintentional passage of stool in inappropriate places in children who are developmentally four years old or older. 1

Definition and Classification

• Fecal soiling can be categorized into two main types:

  • Encopresis: Involuntary loss of formed, semiformed, or liquid stool into a child's underwear in the presence of functional (idiopathic) constipation in a child 4 years of age or older 2
  • Fecal incontinence: Fecal soiling in the presence of an organic or anatomic lesion (such as Hirschsprung's disease, anal malformation, meningomyelocele) 2

• Fecal soiling can also be classified based on etiology:

  • Primary soiling: Related to stool toileting refusal 3
  • Secondary soiling: Due to functional constipation (encopresis) or organic disease (fecal incontinence) 3, 4

Pathophysiology

• In constipation-related encopresis, the most common mechanism is:
  • Chronic constipation leads to rectal distension 2
  • Impacted stool in the rectum causes stretching of the internal anal sphincter 3
  • Watery stool from higher in the bowel may leak around the impaction (overflow) 5
  • Decreased rectal sensation over time contributes to the problem 2

Clinical Presentation

• Common symptoms and signs include:
  • Fecal soiling in underwear at least weekly for 6 months or longer 6
  • History of constipation with infrequent bowel movements 2
  • Passage of large-diameter stools that may clog the toilet 3
  • Retentive posturing (withholding behaviors) 2
  • Abdominal pain or distension 3
  • Digital rectal examination may reveal a full rectum or fecal impaction 5

Diagnosis

• Diagnosis is primarily clinical, based on:

  • History of soiling in a child ≥4 years old 1
  • Evidence of constipation on physical examination 3
  • Digital rectal examination to assess for impaction 5
  • Observation of perianal area for evidence of fecal soiling 5

• Rule out organic causes through:

  • Careful history and physical examination 3
  • If necessary, anorectal manometry, barium enema, or rectal biopsy in cases suspicious for organic disease 3

Management

• Treatment approach depends on the underlying cause:

• For constipation-related encopresis:

  • Initial disimpaction if fecal impaction is present (digital fragmentation and extraction of stool) 5
  • Maintenance bowel regimen to prevent recurrence 5
  • Osmotic laxatives (polyethylene glycol, lactulose) or stimulant laxatives (senna, bisacodyl) 5
  • Suppositories and enemas when digital rectal examination identifies a full rectum 5
  • Behavioral interventions including enhanced toilet training 6

• For primary soiling (toileting refusal):

  • Consider temporary return to pull-ups or diapers 3
  • Behavioral modification techniques 3

• For fecal incontinence due to organic disease:

  • Management of underlying condition 3
  • Antegrade enema administration for severe cases not responding to medical management 3

Treatment Outcomes and Prognosis

• Combined treatment approaches (medical therapy, nutritional intervention, behavioral intervention) improve constipation and encopresis in compliant patients 3
• Enhanced toilet training programs show higher improvement rates (78%) compared to intensive medical management alone (45%) 6
• Response to treatment during the first two weeks of therapy is highly predictive of long-term outcomes 6
• Some children with fecal incontinence due to organic disease may continue with some degree of incontinence despite optimal medical management 3

Associated Factors

• Fecal soiling is associated with:
  • Emotional distress and substantial negative impact on quality of life 1
  • Possible psychiatric comorbidities that may prevent remission 1
  • Complex family dynamics that may require multidisciplinary approach 1
  • In some children, cow's milk protein intolerance may be a contributing factor 3