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; refers to the entity of repeated passage of feces into inappropriate places (usually clothing or floor) after the age of 4 years in the absence of constipation and structural or inflammatory diseases

Epidemiology

• The reported ratio of boys to girls with encopresis ranges from 2:1 to 6:1.
• Boys are more likely to experience nonretentive fecal incontinence than girls at a ratio of 9:1.
• Encopresis is reported in 1.5–2.8% of children >4 years of age.
• Between 10% and 30% of children with encopresis have nonretentive fecal incontinence.

Risk Factors

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

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.

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).
• Nonretentive fecal incontinence occurs in children without constipation. The soiling may be a manifestation of an emotional disturbance. In some children, it can be associated with specific triggers (person or place) or may represent a voluntary impulsive action. Laboratory, imaging, and motility studies in these patients are normal, including normal anorectal manometry and normal colonic transit times.

Commonly Associated Conditions

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