Faecal incontinence/Encopresis 

• is defined as the repeated and involuntary passage of stool into the clothing after the age of  4 years. Involuntary excretion and leaking are common for those affected, meaning underwear and clothing is often soiled. 
• Faecal incontinence is very common, occurring in at least 1.5 per cent of children.
• Encopresis occurs in 3% of 4-year-old children and 1.6% of 10-year-old children, and is 2 to 3 times more common amongst boys than girls. 
• Soiling may occur as
  • leakage of loose stool (sometimes misdiagnosed as diarrhoea)
  • overflow of solid stool from the distended rectum.
    • distended rectum causes loss of the stretch sensation, and most children with encopresis are not aware of the need for, or the passage of stool
• Many children with soiling also have normal bowel actions on the toilet, and many deny that they have soiled. 
• Behaviour
  • Children with faecal incontinence often refuse to change soiled clothing even though the odour is very unpleasant to other people. 
  • This can be upsetting for other family members but the affected child may not notice the unpleasant smell. 
  • As the child always has some stool on his or her clothes, they get used to the smell and it no longer bothers them. 
  • Many children with faecal incontinence also wet the bed at night or wet their clothing during the daytime. 
  • As a result, children with faecal incontinence may be teased by playmates or brothers and sisters. 
  • Teasing can lead to embarrassment, reluctance to attend school, fighting and other problems.
  • Problems with self-esteem, angry and frustrated parents and social problems at school are common.
• Soiling without faecal retention may occur as a result of
  • late toilet training with developmental delay,
  • severe emotional problems
  • family dysfunction

Diseases which mimic faecal incontinence

• Hirschsprung’s disease
• high blood-calcium level due to parathyroid disease
• hypothyroidism, spinal defects and cows milk allergy

80% is retentive (secondary to constipation) and of this 95% functional and 5% organic (as below)

Differentials

retentive/ constipation:

1. Functional:

• toilet avoidance
  • Lack of privacy (particularly in school toilets)
  • Holding bowel movements when they go to school or camp and are faced with a toilet that is less private than at home
  • fear of discomfort or embarrassment can make a child try not to have a bowel movement
• This faecal retention and overflow can develop as a result of
  • prolonged constipation
  • physiological incoordination of the lower bowel and anus muscles
  • incomplete evacuation (the busy boy)

• Stressful life event including starting schooling
• Domestic unrest
• Often associated with enuresis
• “Stool withholding” (previously painful stools)

2. Anal causes (painful defecation)
   • Anal fissures
   • Proctitis
3. Sexual abuse
4. Neurological conditions:
   • Spina bifida
   • Spinal cord injury
   • Ultrashort segment Hirschsprung
   • Cerebral palsy
   • Neurofibromatosis
5. Pelvic masses
6. Anatomic:
   • Imperforate anus
   • Anal stenosis
7. Metabolic:
   • Hypothyroidism
   • Lead poisoning
   • Hypercalcaemia
8. Dehydration (DM/ DI)
9. Cystic fibrosis
10. Drugs:
    • Codeine
    • Antacids

non-­retentive

1. Severe ulcerative colitis
2. Acquired spinal lesions (sacral lipoma/ spinal cord  tumour)
3. Post-­surgical damage
4. Behavioural: oppositional defiant disorder, temper  tantrums

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Assessment 

1. Stool pattern
2. History of constipation
3. History of soiling: age of onset, type and amount of  material
4. Diet history
5. Appetite
6. Abdo pain
7. Urinary symptoms
8. PMHx, PSHx, Social Hx, Birth Hx
9. Height, weight, growth charts
10. Development
11. Abdo exam: distension, mass.
12. External rectal exam: position of anus, anal wink, fissures
13. Consider DRE to assess for anal tone, size of rectal vault and impacted  stool
14. Neurologic exam: gait, palpation of the spine, lower limb  neuro

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Investigations

• Urinalysis
• AXR not necessary to Dx constipation

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Management

• Constipation is treated with a three-part plan:
  1. ‘Cleanout’ to clear retained stool from the colon.
  2. Maintenance therapy to prevent stool build- up and allow the colon to return to its normal shape.
  3. Counselling to structure a treatment plan and encourage the child to cooperate.
• Education
• Clear any faecal impaction
• Diet: increase dietary fibre and fluid intake
• Laxative: should start with regular doses of stool softener/ osmotic  laxative
• Establish a regular pattern of defecation
• Toileting diary, regularly scheduled “sitting”, age appropriate rewards  scheme
• Prevent recurrences
• Continue laxative for many months and taper slowly
• Some children will continue to have constipation into adult life.
• Counselling and occupational therapy