Constipation and Encopresis

Constipation

Constipation is one sympton of many disorders.In the majority of children with constipation the cause is functional or behavioral.There is no one definition of constipation but a combination of reduced frequency, discomfort or difficulty in passing stool, or a feeling of incomplete evacuation.Breast-fed babies may not pass stool for 5-10 days and it is normal for babies to strain to try to pass stool.Children may have large stools every 3-4 days and in the absence of abdominal distension or discomfort and no soiling it is probably normal.

Encopresis

Toilet training leads to bowel control before blsdder control.By age 4 years, 95 percent of children have attained bowel control.The intentional or involuntary passage of feces in inappropriate places (e.g., clothing or floor) after the age of 4 years is encopresis.The definition requires at least 1 event a month for 3 months.Primary encopresis implies that there has not been a 6 month period of bowel continence and secondary encopresis results when continence precedes the symptom.

                Encopresis is by definition not due to a general medical condition except through a mechanism involving constipation.Fecal incontinence can be categorized as soiling with or without fecal retention.Table 5-3 lists some of the causes that may be present.For most of these conditions encopretic symptoms are unlikely to be the only or presenting symptom.

                The major cause of encopresis is overflow incontinence.Stool is retained in the distal colon and rectum and the internal sphincter becomes dilated and functionally incompetent.The external sphincter cannot hold the impacted stool and there is leakage.

TABLE 5-3. CAUSES OF CONSTIPATION THAT MAY LEAD TO ENCOPRESIS

Functiona (non-organic)

Organic

   GI

      Hirschsprung disease (congenital aganglionosis)

      Anal defects (e.g., fissure, stenosis)

      Colonic stricture

   Neurologic

      Cerebral palsy

      Meningomyelocele, spina bifida

      Hypoptonia

   Endocrine

      Hypothyroidism

      Pregnancy

   Psychological

      Depression

      Anorexia nervosa

      Stool withholding

   Dietary/pharmacologic

      Inadequate fiber intake

      Antacids

      Iron

      Opiates

      Bismuth

The child may be unaware that soiling has occured.Any condition that causes persistent constipation may be associated with fecal soiling.Children with encopresis tend to have large stools that may block the toilet.Soiling tends to occur in the afternoon and is less likely to occur at night.Non-organic encopresis may occur with oppositional (defiant) behavior pattern, toilet phobia, and anismus.Anismus is dysfunctional anal sphincter control in which the anus contracts rather than relaxes on defecation.

                A careful history should be taken and the examination includes the rectal exam and evaluation of the external sphincter.Evaluation of neurological function is important and plain abdominal X-ray may confirm the presence of constipation.The treatment starts with education of the parents and child.Explanation of the circumstances is important because there is considerable stigma placed on the problem.Treatment is directed toward clearing the bowel and then reestablishing good bowel function.The maintenance program may take several months particularly if the bowel dilatation has been severe.The maintenance regimen involves dietary changes including a high-fiber diet with increased fruit and vegetables, grains, and cereals.Mineral oil with vitamins, because of fat-soluble vitamin malabsorption, or another stool softener may be useful.Young children benefit from a regimen of sitting on the toilet after the morning and evening meal to get into a routine of keeping the bowels clear.