Encopresis (cont.)

Encopresis Causes

Rarely, encopresis is caused by an anatomic abnormality or disease that the child is born with. In the great majority of cases, encopresis develops as a result of chronic (long-standing) constipation.

What is constipation? Many people think of constipation as not passing a bowel movement every day. However constipation implies not only infrequent bowel movements, but also having difficulty or experiencing pain with the passage of bowel movements. Pain is usually the initial problem when bowel movements are hard and difficult to pass.

• Each person has his or her own schedule for bowel movements, and many healthy people do pass a bowel movement every day.
  
  
• A constipated child might pass a bowel movement every third day or less often.
  
  
• More importantly, the constipated child tends to pass large and hard stools and experience pain while doing so.

In most children with encopresis, the problem begins with passing very large stools or having pain while passing stools. This may have happened long before the encopresis starts, and the child may not remember this when asked.

• Over time, the child becomes reluctant to pass bowel movements and holds it in to avoid the pain.
  
  
• This “holding in” becomes a habit that often remains long after the constipation or pain with passing bowel movements has resolved.

As more and more stool collects in the child’s lower intestine (colon), the colon slowly stretches (sometimes called megacolon).

• As the colon stretches more and more, the child loses the natural urge to pass a bowel movement.
  
  
• Eventually, looser, partly formed stool from higher up in the intestine leaks around the large collection of harder, more formed stool at the bottom of the colon (rectum) and then leaks out of the anus (the opening from the rectum to the outside of the body).
  
  
• Often in the beginning, only small amounts of stool leak out, producing streaks in the child’s underwear. Typically, parents assume the child isn’t wiping very well after passing a bowel movement, and they don’t worry about the smears.
  
  
• As time goes on, the child is less and less able to hold the stool in—more and more stool leaks, and eventually the child passes entire bowel movements into his or her underwear.
  
  
• Often the child is not aware that he or she has passed a bowel movement.
  
  
• Because the stool is not passing normally through the colon, it often becomes very dark and sticky and may have a very foul smell.

Over time, the child with encopresis may also develop incoordination of the muscles used to pass bowel movements. In many children, the anal sphincter contracts rather than relaxes when they are trying to push out bowel movements. This disturbed coordination of muscle function, which causes fecal retention, is a key to the diagnosis and is also called anismus or paradoxic contraction of the pelvic floor to defecation.

What causes the constipation in the first place?

• The most common cause of constipation in children is the passage of large, hard, and PAINFUL bowel movements. The child “withholds” to avoid pain. Over time, this results in the bowel movements becoming larger and harder, and a vicious circle begins.
  
  
• Some experts believe children become constipated when they do not eat enough fiber, but others believe there is no connection between diet and constipation. There is no clear evidence that constipation is caused by too little fiber in the diet.
  
  
• Many doctors think that some children become constipated because they do not drink enough water. However, other doctors question whether the amount of water ingested has much of an effect on constipation.
  
  
• Constipation does seem to run in certain families.
  
  
• For many children, no clear cause of the constipation can be identified.

Encopresis is a very frustrating condition for parents. Many parents become angry at the repeated need to bathe the dirty child and to clean or discard soiled underwear. Many parents assume the soiling is the result of the child being lazy or that the child is soiling intentionally to annoy them. In most cases, this is not the case. Children with encopresis are no more likely than other children to have major behavioral or emotional problems. In most cases, encopresis is involuntary—the child does not soil on purpose.

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