Encopresis

Descriptive text is not available for this imageBASICS

DESCRIPTION

  • Repeated unintentional soiling of underwear
  • Most commonly associated with functional constipation with stool retention and subsequent overflow incontinence; 80–90% cases of encopresis fall into this category.
  • Another less common type of functional encopresis is nonretentive fecal incontinence (NFI).
    • Rome IV criteria defines it as having all of the following: defecation in places inappropriate to the sociocultural context with no evidence of fecal retention and after appropriate evaluation, the fecal incontinence cannot be explained by another medical condition in a child with a developmental age >4 years for at least a 1-month history.

EPIDEMIOLOGY

  • The reported ratio of boys to girls with encopresis ranges from 3:1 to 6:1.
  • Prevalence of encopresis is 4.1% in children ranging from 5 to 6 years of age and 1.6% in 11- to 12-year-olds.

ETIOLOGY

  • Chronic constipation leads to a dilated rectum, decreased rectal sensation, shortening of the anal canal, and decreased anal sphincter tone in some patients.
  • Findings on anorectal manometry include increased rectal sensory threshold and paradoxic contraction of the external anal sphincter during attempts at defecation (known as anismus).
  • NFI occurs in children without constipation. The soiling may be a manifestation of an emotional disturbance. There is an evidence that children with NFI have more externalizing and internalizing problems compared to a normative sample. Laboratory, imaging, and motility studies in these patients are normal, including normal anorectal manometry and normal colonic transit times.

RISK FACTORS

There is no association with family size, ordinal position in the family, age of parents, or socioeconomic status.

Genetics

Monozygotic twins have a 4-fold higher incidence than do dizygotic twins.

ALERT
  • Constipation with a rectal fecal mass is most common risk for encopresis.
  • Children with NFI have more behavioral problems, poor self-esteem, and higher prevalence of attention deficit disorder.

PATHOPHYSIOLOGY

Chronic constipation with fecal impaction results in overflow incontinence and reduced sensation secondary to rectal distention. The pattern of holding fecal matter, leading to chronic constipation and overflow incontinence, may result from a variety of causes, such as a painful experience from a fissure, difficult toilet training, or reluctance to use school bathrooms. However, eliciting a medical history often does not reveal a triggering event.

COMMONLY ASSOCIATED CONDITIONS

  • Urinary tract infections (UTIs)
  • Enuresis
    • More frequently seen in patients with NFI (45% have daytime urinary incontinence, and 40% have nighttime enuresis) compared to constipated children

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