From the Guidelines
A comprehensive workup for encopresis should begin with a thorough history and physical examination, including a digital rectal examination to evaluate resting tone of the sphincter segment and its augmentation by a squeezing effort, as recommended by the American Gastroenterological Association 1. The initial evaluation should focus on identifying the underlying cause of constipation, including a detailed history of bowel habits, dietary habits, and medication use. The presence of symptoms such as straining, hard stools, and unsatisfied defecation should be assessed, as well as the presence of underlying irritable bowel syndrome or defecatory disorders 1. Key components of the physical examination include:
- Observing the descent of the perineum during simulated evacuation and the elevation during a squeeze aimed at retention
- Evaluating the anal reflex and observing for evidence of fecal soiling
- Performing a digital examination to evaluate resting tone of the sphincter segment and its augmentation by a squeezing effort A clean-out regimen using polyethylene glycol (MiraLAX) at a dose of 1-1.5 g/kg/day for 3-4 days to clear impacted stool, followed by maintenance therapy of MiraLAX at 0.5-1 g/kg/day for several months to maintain regular bowel movements, is a recommended approach 1. Additional interventions may include:
- Dietary modifications, such as increased fiber intake and adequate hydration
- Establishing a regular toileting schedule to take advantage of the gastrocolic reflex
- Behavioral therapy and positive reinforcement techniques to address psychological components
- Biofeedback and relaxation training to train patients to relax their pelvic floor muscles during straining and to correlate relaxation and pushing to achieve defecation 1.
From the Research
Definition and Prevalence of Encopresis
- Encopresis is defined as fecal soiling associated with functional constipation in a child 2.
- It is most common between ages 3 and 7 years, and can be associated with enuresis and urinary tract infection 2.
- Constipation and encopresis are common problems in children, with up to 50-60% of children achieving acceptable bowel control within a year 2.
Diagnosis and Treatment
- Organic causes of constipation and encopresis cannot be excluded, although they are rarely diagnosed in infants and children with defecation disorders 3.
- A combination of family education, disimpaction and maintenance medications, a well-balanced diet, and behavior management is essential for successful treatment 3.
- Polyethylene glycol without electrolytes has become a first option for many pediatric gastroenterologists, and has been shown to be effective in long-term treatment of functional constipation and encopresis 4, 5.
Management and Prevention
- Family education is the essential first step in management, followed by disimpaction of stool and complete evacuation of the rectum 2.
- Reaccumulation of stool should be prevented by appropriate use of laxatives and stool softeners, and a gradual weaning of the laxative regimen and instituting toilet training should be implemented 2.
- Long-term efficacy of polyethylene glycol 3350 for the treatment of chronic constipation in children with and without encopresis has been demonstrated, with significant improvements in weekly stool frequency, stool consistency, and symptoms associated with constipation 5.