Encopresis

Encopresis

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  Encopresis Prof. SaadS Al-Ani Senior Pediatric Consultant Head of Pediatric Department Khorfakkan Hospital Sharjah ,UAE
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  Encopresis Refers tothe 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
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  Encopresis (cont.)Encopresis may be: 1.Primary: persist from infancy onward 2.Secondary : may appear after successful toilet training About two thirds of encopresis cases are of the retentive type and associated with chronic constipation;
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  Encopresis (cont.)In children younger than 4 yr of age, the male: female ratio for chronic constipation is 1:1 . In the school-aged child , however, encopresis is more common in males
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  Clinical Manifestations 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
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  Clinical Manifestations (cont.) 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
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  Clinical Manifestations (cont.) 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. However, 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
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  Clinical Manifestations (cont.) 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
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  Treatment 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 .
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  Treatment (cont.)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
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  Treatment (cont.)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 .
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  Treatment (cont.)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 .
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  Summary Encopresis refersto 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 .
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  Summary (cont.)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
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  References Mikkelsen EJ:Enuresis and encopresis: Ten years of progress. J Am Acad Child Adolesc Psychiatry 2001;40:1146. Medline Similar articles Schum TR, McAuliffe TL, Simms MD, et al: Factors associated with toilet training in the 1990s. Ambulatory Pediatrics 2001;1:79. Medline Similar articles Youssef NN, Di Lorenzo C: Childhood constipation: Evaluation and treatment. J Clin Gastroenterol 2001;33:199-205. Medline Similar articles Gereige RS, Frias JL: Is it more than just constipation? Pediatrics 2001;109:961-65. Penning C, Gielkens HA, Hemelaar M, et al: Prolonged ambulatory recording of antroduodenal motility in slow-transit constipation. Br J Surg 2000;87:211-17. Medline Similar articles