ENCOPRESIS

MODERATOR: DR. DAPAP

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Bingham University Teaching Hospital, Jos.

February 13, 2024

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PRESENTERS

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OUTLINE

• Introduction
• Epidemiology
• Aetiology and risk factors
• Classification
• Pathophysiology
• Clinical features
• Investigations
• Treatment
• Prognosis and prevention
• Differential diagnosis
• Conclusion
• References

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DEFINITION

• Encopresis is also known as fecal soiling and is categorized in the DSM-5 as an elimination disorder.
• Encopresis is defined as the involuntary or intentional repeated passage of stools into inappropriate places at least once per month for 3 consecutive months, after the age at which toilet training is expected to be accomplished in a child aged 4 years and older, after organic causes have been ruled out. (DSM-V & ICD-10)
• About 25% of these patients have associated enuresis

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EPIDEMIOLOGY

• Encopresis has been estimated to affect 3% of 4 year olds and 1.6% of 10 year old children
• Incidence rate reduces drastically with increasing age
• Males are 3-6 times more likely to develop encopresis than females
• It has a stronger association with psychiatric disorders than enuresis

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AETIOLOGY

Encopresis is considered a non-organic disorder and usually involves a complicated interplay between physiological and psychological factors.

Some of these factors includes;

• Inadequate and inconsistent toilet training
• Abuse
• Emotional disturbances like anxiety, anger, stress etc
• Mental retardation
• Autistic disorder
• Constipation
• Maturational lag
• Childhood schizophrenia

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RISK FACTORS

• Being male; encopresis is twice as common in boys
• Certain medications; such as cough suppressants may cause constipation
• Neurodevelopmental disorders; such as brain damage, ADHD, ASD or anxiety
• Dietary habits; eating a high fat or high sugar diet increases the risk of chronic constipation. A lack of adequate fluid intake and physical exercise also increases such risk
• History of chronic constipation
• Abuse or neglect
• Avoiding passage of stool

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CLASSIFICATION

1. Primary encopresis (continuous): where toilet training has never been achieved.
2. Secondary encopresis (discontinuous): where encopresis emerges after a period of fecal continence. This type usually occurs between ages 4-8yrs

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Retentive (80-95%): involves

• Constipation
• Stool retention
• Overflow incontinence.

4. Nonretentive or solitary (5-20%): involve

• Encopresis without constipation or overflow incontinence
• Stool toileting refusal/resistance/phobia
• Often manifestation of emotional disturbance

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PATHOPHYSIOLOGY

• Chronic constipation due to irregular and incomplete evacuation of faeces results in progressive rectal distension and stretching of both the internal and external anal sphincters
• As the child habituates to chronic rectal distension, he or she no longer senses the normal urge to defecate
• Soft or liquid stools eventually leaks around the retained fecal mass, resulting in faecal soiling.

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CLINICAL FEATURES

• Most children attain fecal continence by the age of 4 years
• In primary encopresis, continence is never fully established
• In secondary encopresis, incontinence is preceded by a year or more of continence

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PRIMARY ENCOPRESIS

• In primary encopresis, stool is more likely to be normal in character.
• Soiling is intermittent and usually in prominent location
• Coexisting oppositional-defiant or conduct disorders are frequent

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SECONDARY ENCOPRESIS

• In secondary encopresis, constipation is generally severe.
• Causes an overflow incontinence in which soft or liquid stool flows around the retained feces, often several times per day.
• Defection is usually uncomfortable or painful, so patient avoids defecation with consequent stool retention.
• Stool is usually poorly formed and leakage is continuous (occurring during sleep and wakefulness)
• Encopresis resolves when the constipation is resolved

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DIAGNOSTIC CRITERIA

DSM-V criteria

• Repeated passage of faeces into inappropriate places, whether intentional or involuntary
• Such event occurs once every month for at least 3 months
• Occurs in children at least age 4 years
• The behavior is not attributed to the physiological affects of a substance or another medical condition.

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CLINICAL PRESENTATION

HISTORY

• Onset
• Stool character and volume
• Frequency of soiling
• Other GI symptoms e.g abdominal pain, loss of appetite
• Presence of enuresis (with which it is frequently associated)
• Nutritional history
• Developmental history ; hirschspung dx, megacolon
• Psychiatric history e.g premorbid personality, hx of abuse
• Family and social history e.g loss of a family member
• Social history; school performance, bullying, toilet trainin

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PHYSICAL EXAMINATION

• Abdominal examination and DRE

Looking out for

• Abdominal distension
• Palpable faecal mass
• Poor perianal hygiene with stool smeared around the anus
• Lax and patulous sphincter
• Stool in the rectum

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• Neurological examination (usually normal)
• Psychiatry assessment

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INVESTIGATION

In most patients the diagnosis of encopresis is established on the basis of the history and complete physical examination including a rectal examination.

• Thyroid function test to rule out hypothyroidism
• Electrolytes, calcium
• Urinalysis and urine culture
• Abdominal X-ray (fecal impaction)
• Barium enema (dilated rectum)
• Rectal biopsy to rule out Hirschsprung’s disease
• Anorectal manometry (evaluates bowel function)

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TREATMENT

NONPHARMACOLOGICAL THERAPY

• Behavioral and/or individual psycotherapy and family therapy
• Regular post-prandrial toilet sitting and adoption of high fiber diet

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ACUTE GENERAL TREATMENT

• In secondary encopresis, disimpaction of stool with isotonic saline enemas
• In resistant cases, repeated instillation of 200ml to 600ml of milk of magnesia enemas.
• If the child does not permit enemas, oral disimpaction with large doses of mineral oil or lactulose until stool mass is cleared

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CHRONIC TREATMENT

• Prevention or recurrence of constipation by increased dietary fiber, bulk agents and the use of laxatives and stool softeners.
• In primary encopresis, continue with nonpunitive toilet training and encourage regular toilet times.

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COMPLICATIONS

• A child who has encopresis may experience a range of emotions including embarrassment, frustration , shame and anger.
• Being teased by friends
• Criticized and punished by adults
• Depression
• Low self esteem

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PROGNOSIS

• In most cases encopresis is self-limited and rarely continues beyond adolescence.
• The outcome of encopresis depends on the cause, chronicity of symptoms and coexisting behavioral problems.
• Encopresis in children who have contributing physiological factors, such as poor gastric motility and inability to relax the anal sphincter muscles is more difficult to treat than those with constipation but normal sphincter tone.

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PREVENTION

• Avoid constipation; by providing a balanced diet that is high in fiber and encouraging a child to drink water.
• Learning effective toilet training technique
• Early treatment for encopresis; this helps prevent the social and emotional impact of encopresis.

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DIFFERENTIAL DIAGNOSIS

• Hirshsprung’s disease
• Endocrine disease e.g hypothyroidism
• Cerebral palsy
• Myelomeningocele
• Pseudoobstruction
• Anorectal lesions e.g rectal stenosis
• Trauma
• Rectal prolapse

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CONCLUSION

• Encopresis remains a problem for the parents and patients. Clinical evaluation is indispensable.
• Behavioral training and parental support is essential in treatment
• Main aim of treatment is achievement of continence and bowel control and good outcome can be achieved effectively.

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REFERENCES

• Medscape
• American Academy of Paediatrics
• American Psychiatric Association. Diagnostic and Statistical Manual of MentalDisorders. 4^th ed.
• Ferri’s Clinical Advisor 2008, 10^th ed.
• http://www.gastroconsultantsqc.com/services/procedure/anorectal-manometry

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