Fecal Incontinence in Children (Encopresis)

Background

• Fecal incontinence is voluntary or involuntary passage of stool into a place other than the toilet ≥ 1 time per month in a child with developmental age ≥ 4 years.
• Most fecal incontinence in children is functional and not caused by an underlying defect or illness. Functional fecal incontinence can occur with or without constipation.
  • Constipation-associated fecal incontinence accounts for 90% and is usually associated with involuntary fecal overflow due to fecal impaction from stool withholding or diet.
  • Nonretentive (without constipation) fecal incontinence is usually from voluntary passage of stool due to behavioral or psychiatric issues, or misinterpretation of normal physiologic defecation-associated stimuli.
• 5%-10% of fecal incontinence is organic and can be constipation-associated or nonretentive.
  • The most common organic causes of constipation-associated incontinence are anorectal malformations, spinal cord abnormalities, Hirschsprung disease, and drugs.
  • Nonretentive incontinence is most commonly caused by neurosensory impairments and disorders associated with diarrhea, such as celiac disease.

Evaluation

• Diagnostic evaluation begins with a history and physical to identify possible fecal impaction or evidence of organic causes.
• Specific testing is done based on clinical suspicion for underlying cause and may not be indicated if clinical history is strongly suggestive of underlying constipation.
  • Functional fecal incontinence may be confirmed by imaging studies alone. This may include a contrast enema and/or plain abdominal x-ray, and radiographic assessment of colonic transit time.
  • Organic fecal incontinence may require further testing. This may include spinal imaging, blood tests, anorectal manometry, colonic motility studies, or additional investigations in children with signs and symptoms of organic constipation, or persistent constipation after adequate treatment.
• Children with incontinence should be screened for psychological issues.

Management

• Treatment is determined by the type of fecal incontinence (functional or organic) and the presence or absence of constipation.
  • Treatment for functional fecal incontinence with constipation is done in stages.
    • Treatment begins with a clean-out stage that may involve manual disimpaction, use of rectal enemas, and/or oral stimulant or osmotic laxatives.
    • Maintenance therapy should be started after disimpaction and includes dietary changes, behavior modification, and medications given on a regular basis.
    • Medications may include:
      • osmotic agents or lubricants are preferred for long-term use and may include polyethylene glycol (PEG) solution, lactulose or sorbitol, fiber supplements, magnesium solutions, or mineral oil
      • stimulant laxatives are reserved for short-term use to assist propulsion in dilated bowel in selected patients who are more difficult to treat and may include senna or bisacodyl
    • Surgery is rarely needed unless the child has severe refractory constipation and may include Malone antegrade continence enema procedure, rectosigmoid or sigmoid resection, or intestinal diversion.
  • Treatment for functional nonretentive fecal incontinence usually involves education and behavioral measures to establish a normal toileting regimen.
  • Treatment for organic fecal incontinence (with or without constipation) involves appropriate medical and surgical management of underlying cause, bowel management with enemas to empty the colon on a regular schedule, and a constipating diet and medication to decrease colon motility in patients with loose stools.