Management of Encopresis in an 11-Year-Old Female
The best course of action is to initiate a comprehensive treatment program that begins with family education, followed by complete rectal disimpaction, maintenance laxative therapy to prevent stool reaccumulation, and scheduled toileting with behavioral retraining. 1, 2, 3
Initial Assessment
Characterize the exact pattern of soiling to distinguish between overflow incontinence from constipation versus other causes. Specifically assess:
- Relationship of soiling to meals, activity level, and whether the child is aware of episodes 2
- Stool consistency (hard stools suggest constipation with overflow; soft stools may indicate a different etiology) 1, 2
- Frequency of voluntary bowel movements and any withholding behaviors 3, 4
- Dietary history focusing on fiber intake, poorly absorbed sugars, lactose, and caffeine 1, 2
- Review all medications that could worsen constipation (opioids, anticholinergics) 1
Perform a digital rectal examination to assess for fecal impaction—hard stool on exam requires disimpaction before starting oral laxatives 5. Plain abdominal radiography can confirm severe constipation if the clinical picture is unclear 5.
Treatment Algorithm
Step 1: Family Education and Explanation
Begin with thorough education of both child and parents about the physiopathology of encopresis—explaining that this is a medical problem, not willful misbehavior 3, 6. Most cases result from functional constipation leading to a cycle: stool retention → rectal distension → overflow soiling → further withholding due to embarrassment or fear of painful defecation 4.
Step 2: Complete Disimpaction
If fecal impaction is present on rectal exam, perform manual disimpaction or use enemas rather than starting with oral laxatives 5, 3. Complete evacuation of the rectum is essential before maintenance therapy 3.
Step 3: Maintenance Laxative Therapy
Immediately start polyethylene glycol (PEG) as the primary osmotic laxative to maintain soft daily stools and prevent reaccumulation 2, 5. Add a stimulant laxative (bisacodyl 10-15 mg orally 2-3 times daily) if osmotic therapy alone is insufficient 5. The goal is one non-forced bowel movement every 1-2 days 5.
Continue laxative therapy for several months—premature discontinuation is a common cause of relapse 3, 4. Gradually wean the laxative regimen only after consistent bowel control is achieved 3.
Step 4: Scheduled Toileting and Behavioral Retraining
Implement scheduled toileting after meals (particularly breakfast) to utilize the gastrocolic reflex 1, 2. Have the child sit on the toilet for 5-10 minutes at consistent times daily, even if no urge is present 4.
Gain the child's confidence and cooperation through positive reinforcement rather than punishment for soiling episodes 4. Involve both family and school to ensure consistent support 4.
Step 5: Biofeedback Therapy (If Initial Measures Fail)
If conservative measures fail after 2-4 months, refer for biofeedback therapy, which can improve symptoms in over 70% of defecatory disorders 1, 2. Biofeedback uses electronic devices to improve pelvic floor strength, sensation, and rectal tolerance 1.
Important Clinical Caveats
Encopresis most commonly occurs between ages 3-7 years, but can persist into adolescence 3. At age 11, this child has likely had symptoms for some time, which may indicate more entrenched withholding behaviors or inadequate prior treatment 3.
Check for associated urinary symptoms—encopresis can coexist with enuresis and urinary tract infections 3. If present, this suggests broader pelvic floor dysfunction requiring more comprehensive evaluation 7.
Assess for psychological comorbidities, particularly depression, which is frequently associated with encopresis 6. While psychotherapy is not first-line treatment, it should be initiated if significant psychopathological symptoms or pathogenic psychosocial situations are identified 6.
Up to 50-60% of children achieve acceptable bowel control within one year, but relapses are common 3. Prepare the family for a potentially prolonged treatment course requiring patience and consistency 3, 4.
Many treatment failures result from inadequate conservative therapy—specifically, incomplete disimpaction, insufficient laxative dosing, or premature discontinuation of maintenance therapy 1. Ensure meticulous attention to each treatment step before considering the child "refractory" 1.