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Soiling (Encopresis)

If you're the parent of a child who has bowel movements (BMs) in places other than the toilet, you know how frustrating it can be. Many parents assume that kids who soil their pants are simply misbehaving or that they're too lazy to use the bathroom when they have the urge to go. The truth is that many kids beyond the age of toilet teaching (generally older than 4 years) who frequently soil their underwear have a condition known as encopresis. They have a problem with their bowels that dulls the normal urge to go to the bathroom - and they can't control the accidents that typically follow.

Although encopresis is estimated to affect 1% to 2% of children under the age of 10, problems with encopresis and constipation account for more than 25% of all visits to pediatric gastroenterologists (doctors who specialize in disorders of the stomach and intestines).

Ninety percent of encopresis cases are due to functional colon.

So, what causes the hard poop in the first place? Any number of things, including diet, illness, decreased fluid intake, fear of the toilet during toilet teaching, or limited access to a toilet or a toilet that's not private (like at school). Some children may develop chronic constipation after stressful events occur in their lives, such as a divorce or the death of a close relative. Whatever the cause, once a child begins to hold his or her BMs, the poop begins to accumulate in the colon and a vicious cycle begins.

The colon's job is to remove water from the poop before it's passed. The longer the poop is stuck there, the more water is removed - and the harder it is for the child to push the large, dry poop out. The large poop also stretches out the colon, weakening the muscles there and affecting the nerves that tell a child when it's time to go to the bathroom. Because the flabby colon can't push the hard poop out, and it's painful to pass, the child continues to avoid having a BM, often by dancing, crossing the legs, making faces, or walking on tiptoes.

Eventually, the lower part of the colon becomes so full that it's difficult for the sphincter (the muscular valve that controls the passage of feces out of the anus) to hold the poop in. Partial BMs may pass through, causing the child to soil his or her pants. Softer poop may also leak out around the large mass of feces and stain the child's underwear when the sphincter relaxes. The child can't prevent the soiling - nor does he or she have any idea it's happening - because the nerves aren't sending the signals that regulate defecation (or pooping).

At first, parents may think their child has a simple case of Hirschsprung disease and wetting and

  • The first phase involves emptying the colon of hard, retained poop. Every doctor may have a different way of helping your child. Depending on the child's age and other factors, the doctor may recommend medicines, including a stool softener (such as mineral oil), laxatives, and/or enemas. (Laxatives and enemas should be given only under the supervision of your child's doctor; never give these treatments at home without first checking with your child's doctor.) As unpleasant as this first step sounds, it's necessary to clean out the bowels to successfully treat the constipation and end your child's soiling.
  • After the large intestine has been emptied, the doctor will help the child begin having regular BMs with the aid of stool-softening agents, most of which aren't habit-forming. At this point, it's important to continue using the stool softener to give your child's bowels a chance to shrink back to normal size (the muscles of the intestines have been stretched out, so they need time to be toned without the poop piling up again). Parents will also be asked to schedule potty times twice daily after meals (when the bowels are naturally stimulated), in which the child sits on the toilet for about 5 to 10 minutes. This will help the child learn to pay attention to his or her own urges. It's especially helpful for parents to keep a record of their child's daily BMs.
  • As regular BMs become established, your child's doctor will reduce the child's use of stool softeners.

    • Keep in mind that relapses are normal, so don't get discouraged if your child occasionally becomes constipated again or soils his or her pants during treatment, especially when trying to wean the child off of the medications.

    A good way to keep track of your child's progress is by keeping a daily poop calendar. Make sure to note the frequency, consistency (i.e., hard, soft, dry), and size (i.e., large, small) of the BMs.

    Patience is the key to treating encopresis. It may take anywhere from several months to a year for the stretched-out colon to return to its normal size and for the nerves in the colon to become effective again.

    In the meantime, exercise are extremely important in keeping stools soft and BMs regular. Also, make sure your child gets plenty of

  • Bake cookies or muffins using whole-wheat flour instead of regular flour. Add raisins, chopped or pureed apples, or prunes to the mix.
  • Add bran to baking items such as cookies and muffins, or to meatloaf or burgers, or sprinkled on cereal. (The trick is not to add too much bran or the food will taste like sawdust.)
  • Serve apples topped with peanut butter.
  • Create tasty treats with peanut butter and whole-wheat crackers.
  • Top ice cream, frozen yogurt, or regular yogurt with high-fiber cereal for some added crunch.
  • Serve bran waffles topped with fruit.
  • Make pancakes with whole-grain pancake mix and top with peaches, apricots, or grapes.
  • Top high-fiber cereal with fruit.
  • Sneak some raisins or pureed prunes or zucchini into whole-wheat pancakes.
  • Add shredded carrots or pureed zucchini to spaghetti sauce or macaroni and cheese.
  • Put lentils in your child's favorite soup.
  • Make bean burritos with whole-grain soft-taco shells.

    • In addition to making sure your child is eating a balanced diet high in fiber, don't forget to have your child drink plenty of fluids each day, including water and 100% fruit juices like pear, peach, and prune to help draw water into the colon. Try mixing prune juice with another drink to make it a little tastier. Also be sure to limit your child's total daily dairy intake (including cheese, yogurt, and ice cream) to 24 ounces or less.

    Successful treatment of encopresis depends on the support the child receives. Some parents find that positive reinforcement helps to encourage the child throughout treatment. Give the child a small incentive, such as a star or sticker on their poop calendar, for having a BM or even just for trying, sitting on the toilet, or taking medications. Whatever you do, don't blame or yell - it will only make your child feel bad and it won't help manage the condition. Show lots of love and support and, assure your child that he or she isn't the only one in the world with this problem. With time and understanding, your child can overcome encopresis.

    Updated and reviewed by: Wendy Kutz, MSN, RN
    Staying Healthy
    Note: All information is for educational purposes only. For specific medical advice, diagnoses, and treatment, consult your doctor.

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