Dr mahnaz sadeghian
Pediatric gastroentrologist
 Encopresis
is fairly common, even though
many cases are not reported due to the
child's and/or the parents' embarrassment.
 It
is estimated that anywhere from 1.5% to
10% of children have encopresis. It is more
common in boys than in girls.
Encopresis Refers to the passage of feces into
inappropriate places after a chronologic age
of 4 yr (or equivalent developmental level).
Subtypes include:
1. Retentive encopresis: Encopresis with
constipation and overflow incontinence
2. Nonretentive encopresis: Encopresis
without constipation and overflow
incontinence
About two thirds of encopresis cases are of
the retentive type and associated with
chronic constipation
1.Primary: persist from infancy onward
2.Secondary : may appear after
successful toilet training .
typically begins after stool continence has been
achieved for a period of 1 or more years
(secondary encopresis).
a
chart review study suggests that Primary
encopresis in boys is associated with global
developmental delays and enuresis,
Secondary encopresis is associated with high
levels of psychosocial stressors and conduct
disorder
Organic incontinence can occur in:
Children who have damaged corticospinal pathways
such as lumbosacral myelomeningocele.
Anorectal dysfunction after operative pullthrough
surgery for high imperforate anus or colectomy.
Prolonged diarrhea (pelvic floor muscles fatigue)
Psychological counseling may be equally valuable
in all forms of encopresis because the stress of
soiling is independent of etiology.
In addition to the behavior of releasing waste in
improper places, a child with encopresis may have other
symptoms, including:
 Loss of appetite
 Abdominal pan
 Loose, watery stools (bowel movements)
 Scratching or rubbing the anal area due to irritation
from watery stools
 Decreased interest in physical activity
 Withdrawal from friends and family
 Secretive behavior associated with bowel movements.

 birth
history of gestational complications,
birthweight, timing of passage of meconium,
and tolerance of early feedings.
 introduction of cow milk is the most
constipating component of the young child’s
diet.
 Transitions to child care, all-day school,
diaper to toilet training
 Family history is reviewed for evidence of
genetic factors, as aganglionosis, cystic
fibrosis, hypothyroidism, neurofibromatosis,
or myopathies
 The
character of the stools is reviewed from
birth, especially for the first 24 hours, for
consistency, caliber, volume, and frequency.
 The age and circumstances at onset of
encopresis should be documented.
 Encopresis in the absence of constipation
suggests an organic or behavioral origin.
 A history of possible sexual or rectal abuse
should be elicited
• Functional constipation:
1.
2.
3.
4.
- In infants and preschool children
- In children 4 to 18 years old
- Infant dyschezia
- Nonretentive fecal incontinence
Infants and toddlers :
At least two of the following present for at least one month:
1.
Two or fewer defecations per week
2.
At least one episode of incontinence after the acquisition of toileting
skills
3.
History of excessive stool retention
4.
History of painful or hard bowel movements
5.
Presence of a large fecal mass in the rectum
6.
History of large-diameter stools that may obstruct the toilet
Children with developmental age 4 to 18 years :
At least two of the following present for at least two months:
1.
Two or fewer defecations per week
2.
At least one episode of fecal incontinence per week
3.
History of retentive posturing or excessive volitional stool retention
4.
History of painful or hard bowel movements
5.
Presence of a large fecal mass in the rectum
6.
History of large-diameter stools that may obstruct the toilet



infant dyschezia :
at least 10 minutes of straining and crying before
successful passage of soft stool in an otherwise healthy
infant younger than 6 months of age .The symptom is
caused by failure to relax the pelvic floor during the
defecation effort, and generally resolves spontaneously.
fecal incontinence :
 functional constipation ("retentive incontinence" 80

percent)
without constipation ("nonretentive incontinence", 20
percent)
 prior
surgery
 neonatal complications (NEC)
 courses of medications that may contribute
to constipation
 Documentation
of growth and weight gain
 Signs of systemic diseases include a thorough
neurologic evaluation.
 The abdomen is examined for degree of
distension Bowel sounds are documented,
 perineum is inspected for evidence of
encopresis, streptococcal or monilial
infection, fissures, and trauma (abuse)
 The anal opening is observed, watch for
perirectal manifestations of Crohn‘s disease
A
dilated ampulla filled with retained firm
stool is a feature of functional retention.
 The abdominal examination may
demonstrate palpable dilated loops of
sigmoid and distal colon.
 The back should be examined for sacral skin
clues to lower spine deformity.
 Tendon reflexes should also be assessed to
rule out neurological problem.
The first consideration in managing encopresis
is assessment of fecal retention.
Rectal examination
 * A positive rectal examination is sufficient to
document fecal retention
• A negative rectal examination in the
presence of encopresis requires plain
abdominal roentgenograms.
• The presence of fecal retention is evidence
of chronic constipation
Many children with encopresis present with
abnormal anal sphincter physiology as
documented either by electromyography or
difficulty in defecating a rectal balloon.
The inability to defecate a balloon at
presentation is associated with poorer
response to treatment
Abnormal anal sphincter function is a marker
for chronic constipation; children with this
pathology do not appear to have a higher
incidence of behavioral or psychiatric
disorders than those without.
Associated behavioral or psychiatric problems
obviously may complicate the treatment of
encopresis,especially when parents respond
to soiling with retaliatory, punitive measures
and children become angry, ashamed, and
resistant to intervention.
School performance and attendance may be
secondarily affected as the child becomes
the target of scorn and derision from
schoolmates because of the offensive odor
 Thyroid
functions
 Serum calcium, electrolyte levels,
magnesium and urea nitrogen.
 Urinalysis and urine culture
 The plain abdominal radiograph may be of
value in the child in whom an abdominal
examination is difficult or to monitor
compliance.
 Lumbosacral spine radiographs or magnetic
resonance imaging if indicated.
 Unprepared
barium enema for the transition
zone or strictures from necrotizing
enterocolitis.
 The contrast enema defecogram has a definite
role in assessing pelvic muscle function
following surgery or in the context of central
nervous system disease.
 Anorectal manometry is available to evaluate
internal anal sphincter relaxation and
determine the level of pressure awareness in
older children.
 It also will identify the 25% of chronically
constipated children who exhibit a paradoxic
increase in external anal sphincter pressure.
A
few centers now offer total colonic
motility, a valuable tool in the evaluation of
neuropathic or muscular dysmotility in
chronic intestinal pseudo-obstruction.
 The value of the suction rectal biopsy has
increased with the ability to stain the tissue
for both ganglion cells and
acetylcholinesterase.
 The rectal biopsy also can be of diagnostic
value in the child who has amyloidosis, graft
versus host disease, lipid storage disease, or
Crohn disease.
Physical examination
History

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
Delayed passage of meconium
Preceding acute diarrheal
illness
Painful defecation
Blood on stool
Problems with toilet training
Dietary issues
Family history
•
•
•
•
•
•
•
•
Mass in suprapubic area
Abdominal distention
Anal fissure
Soiled underwear
Anal sphincter tone
Size of rectal vault
Impacted stool (hard or
soft)
Lower back skin defects
Laboratory (not necessary in all
cases)







Complete blood count
Thyroid tests (only in unclear cases)
Test for celiac disease
Barium enema
Anorectal manometry
Rectal biopsy - suction or surgical fullthickness
Motility studies
ARA with fluoroscopic & MR defecography at rest, contraction & straining
-Anal Endosonography
 The corner stone of investigation esp. FI
 Altered
understanding of pathogenesis of
many disorders eg FI
 Rapid,
operator dependent with high
degree of sensitivity & specificity
 It
utilizes a 10 MHZ transducer (the size
of index finger) in a water – filled plastic
cone to provide acoustic coupling.
 Three
– dimemsional image is avaiable

An alternating bright & dark rings corresponding to
the layers of anal canal .

Int. sph. is a dark homogenous ring but ext. sph. is
seen white hetrogenous surrounding IAS

The anal mucosa is generally not seen on EAU

The subepithelial tissue is highly reflective &
surrounded by the low reflection from int. sph.

The intersph. Space often returns a bright
reflection.
On some occasions, manual disimpaction is
required before the treatment can begin;
rarely megacolon is observed and referral to
a gastroenterologist is required.
Once impacted stool is removed, the
combination of constipation management
and simple behavior therapy is successful in
the majority of cases, though it is often a
period of months before soiling stops
completely
Parents should be actively encouraged to issue
rewards for compliance to the child from the
outset of treatment and to avoid power
struggles with the child.
Keeping records of the child's progress is
necessary Long-term laxative use is
contraindicated.

Improvement in some children on tricyclic
antidepressants
Tricyclic antidepressants often cause or
exacerbate constipation and should be
avoided in children with retentive encopresis
Encopresis eventually resolves in most
children, regardless of treatment approach.
Encopresis refers to the passage of feces into
inappropriate places after a chronologic age
of 4 yr
Subtypes include:
Retentive encopresis and
Nonretentive encopresis
Encopresis may be: Primary or Secondary
The first consideration in managing encopresis
is assessment of fecal retention.
Primary encopresis in boys is associated with
global developmental delays and enuresis,
Secondary encopresis is associated with high
levels of psychosocial stressors and conduct
disorder
the combination of constipation management
and simple behavior therapy is successful in
the majority of cases
The standard treatment approach to encopresis
begins with
1. Clearance of impacted fecal material
2. Short-term use of mineral oil or laxatives to
prevent further constipation.
Concomitant behavioral management is also
indicated.
The focus of behavioral treatment should be on
compliance with:
1. Regular postprandial toilet sitting and
2. adoption of a high-fiber diet.




Elimination disorders occur in children who have problems
going to the bathroom—both defecating and urinating.
Although it is not uncommon for young children to have
occasional "accidents," there may be a problem if this
behavior occurs repeatedly for longer than 3 months,
particularly in children older than 5 years.
There are two types of elimination disorders, encopresis
and enuresis.
Encopresis is the repeated passing of feces into places
other than the toilet, such as in underwear or on the floor.
This behavior may or may not be done on purpose.
Enuresis is the repeated passing of urine in places other
than the toilet. Enuresis that occurs at night, or bedwetting, is the most common type of elimination disorder.
As with encopresis, this behavior may or may not be done
on purpose.
 What
Is the Outlook for Children with
Encopresis?
 Encopresis tends to get better as the child
gets older, although the problem can come
and go for years. The best results occur when
all educational, behavioral and emotional
issues are addressed. A child may still have
an occasional accident until he or she regains
muscle tone and control over his or her
bowel movements.
 There
may be an imbalance in neuromuscular
control of defecation in constipated patients
with encopresis that results in incontinence
as a consequence of the increased time to
recovery and duration of relaxation of the
internal anal sphincter.

The frequency of stools in most children decreases
from a mean of four per day in the first week of life
to 1.7 per day by the age of 2 years.
 Over this interval, stool volume increases more than
tenfold while maintaining a consistent water content
of approximately 75%.
 Intestinal transit time from mouth to rectum
increases from 8 hours in the first month of life to 16
hours by 2 years of age to 26 hours by the age 10.

Normal continence is maintained by the resting
tonicity of the internal anal sphincter
 It can be enhanced by contraction of the puborectalis
muscle, which creates a 90-degree angle of rectum
to the anal canal.
 When more than 15 cc of stool enters the normal
rectum, stretch receptors and nerves in the
intramural plexus are activated.
 Inhibitory interneurons decrease the resting tone in
the involuntary smooth muscle of the internal anal
sphincter.


 Relaxation
of the sphincter allows the stool to
reach the external anal sphincter and the urge to
defecate is signaled.
 If the child relaxes the external anal sphincter,
squats to straighten the anorectal canal, and
increases intra-abdominal pressure the rectum is
evacuated of stool.
If, however, the child tightens the external anal
sphincter and the gluteal muscles, the fecal mass is
pushed back into the rectal vault and the urge to
defecate subsides.
 Repetitive denial of evacuation leads to stretching of
the rectum and eventually of the lower colon,
producing a reduction in muscle tone and retention
of stool.
 The longer the stool remains in the rectum, the more
water is removed, and the harder the stool becomes
to the point of impaction.

 Unprepared
barium enema for the transition zone
or strictures from necrotizing enterocolitis.
 The contrast enema defecogram has a definite role
in assessing pelvic muscle function following
surgery or in the context of central nervous system
disease.
 Anorectal manometry is available to evaluate
internal anal sphincter relaxation and determine
the level of pressure awareness in older children.
 It also will identify the 25% of chronically
constipated children who exhibit a paradoxic
increase in external anal sphincter pressure.
• Functional constipation:
1.
2.
3.
4.
- In infants and preschool children
- In children 4 to 18 years old
- Infant dyschezia
- Nonretentive fecal incontinence
Infants and toddlers :
At least two of the following present for at least one month:
 Two or fewer defecations per week
 At least one episode of incontinence after the acquisition of toileting skills
 History of excessive stool retention
 History of painful or hard bowel movements
 Presence of a large fecal mass in the rectum
 History of large-diameter stools that may obstruct the toilet
Children with developmental age 4 to 18 years :
At least two of the following present for at least two months:
 Two or fewer defecations per week
 At least one episode of fecal incontinence per week
 History of retentive posturing or excessive volitional stool retention
 History of painful or hard bowel movements
 Presence of a large fecal mass in the rectum
 History of large-diameter stools that may obstruct the toilet



infant dyschezia :
at least 10 minutes of straining and crying before
successful passage of soft stool in an otherwise healthy
infant younger than 6 months of age .The symptom is
caused by failure to relax the pelvic floor during the
defecation effort, and generally resolves spontaneously.
fecal incontinence :
 functional constipation ("retentive incontinence" 80

percent)
without constipation ("nonretentive incontinence", 20
percent)
Delayed passage of meconeum
 Abdominal distension, bilious
vomiting, ileus ,
 Sign of spinal cord lesion
 Presence of pilonidal dimple/hair tuft
 Inactive, bradycardia, poor growth
 Abnormal anus opening
 Scyballa mass in abd with empty rectum

•
•
Infrequent small or ribbon stools
Constant leaking especially if linked with urinary leaking too