Encopresis in children and adults

In addition to known problems such as constipation and diarrhea, involuntary bowel movements, called encopresis, may occur. In the section on symptoms and signs of ICD-10, this defecation anomaly is assigned the code R15. At the same time, in its V section (in the subheading of behavioral and emotional disorders that occur mainly in children and adolescents) encopresis of inorganic etiology has the code F98.1.

That is, this deviation can be a sign of various pathological conditions.

Epidemiology

The researchers estimate that the prevalence of potassium incontinence or encopresis in the population is 0.8-7.8%; [1] encopresis in adults often occurs in old age (against the background of serious physical and / or mental disorders). In men, encopresis is observed 3-6 times more often than in women. In the United States, a 4% prevalence of functional encopresis was found in a retrospective review of four hundred and eighty-two children aged 4 to 17 who attended a primary care clinic. Encopresis was associated with constipation in 95% of the children in this study. [2], [3]

Functional encopresis is more common in young children (prevalence 4.1% in children aged 5 to 6 and 1.6% in children aged 11 to 12), and most children seek medical attention between the ages of 7 and 12 years. [4]

In chronic constipation in children under 12 years of age, in 25-40% of cases, there are certain problems in the anorectal zone, and neurotic encopresis accounts for 15 to 20% of cases. Encopresis usually occurs during the daytime and organic causes should be considered if the clinician encounters a patient with nocturnal encopresis only. [5]

Causes encopresa

The key causes of involuntary defecation (in inappropriate or inappropriate places) or  fecal incontinence , also called encopresis, fecal or anorectal incontinence by the medical profession, should be considered in light of the types or types of encopresis classified in the different variants. [6]

Thus, a functional or true encopresis is distinguished, the etiology of which is associated with congenital or acquired anorectal pathologies (negatively affecting the tone of the rectal sphincters), disorders of the motor-evacuation function of the large intestine, atony of the pelvic floor muscles or problems of innervation of the rectum and anal canal, in which the reflex control of his sphincters weakens. [7]

Encopresis as a consequence of constipation is defined as false encopresis (or retention), which is based on the accumulation of fecal masses in the rectum in time.

With age, the risk of neurological disorders and degenerative diseases (senile dementia), disorders of the enteric nervous system with partial or complete loss of the ability to control normal stools, as well as digestive problems and the development of persistent constipation, due to which encopresis can also occur in the elderly, increases. [8]

Read also -  Effect of age on the development of constipation

Possible psychological reasons for uncontrolled bowel movements. In such cases, they are diagnosed not related to the functioning of any organs - inorganic encopresis or chronic neurotic encopresis. This type is considered a behavioral state when the child is taught to potty too early (before the age of two) or the mistakes of parents who teach children to the toilet in a categorically imperative style, as well as in cases of a general unfavorable environment for the child's psyche (constant stress, rough handling, fear before punishment, etc.). [9]

It is assumed that it is in the presence of these factors that children over four years of age may experience symptoms such as urinary incontinence (enuresis), constipation with encopresis, psychogenic or mental encopresis (in some cases with obsessive fear of defecation). More information in the materials:

• Neurological and mental causes of constipation
• Psychogenic constipation
• Behavioral disorders in children

In addition, faecal incontinence in children may occur in congenital malformations, such as  spina bifida  (spina bifida), sacrococcygeal teratomas or dermoid cyst; with spinal injuries and dysfunction of the brain - with infantile cerebral palsy (CP) or syndromes with cognitive deficit. And in such children, as a rule, nocturnal encopresis is observed.

In the absence of anatomical abnormalities, neurological and behavioral problems, the cause of childhood encopresis is  chronic constipation in children .

Risk factors

Risk factors that can lead to frequent uncontrolled bowel movements, defined as persistent encopresis, are:

• the presence of chronic hemorrhoids in severe form - with impaired contraction of the rectal sphincters;
• proctitis , as well as the formation of fissures in the anus, perianal fistula (fistula), or scarring in the distal rectum (anal canal);
• prolapse and prolapse of the rectum ;
• inflammatory bowel disease and  irritable bowel syndrome ;
• the transferred surgical interventions on the anorectal region (first of all, hemorrhoidectomy and sphincterotomy);
• fractures of the pelvis;
• spinal injury with compression or pinching of the nerve roots of the sacral spinal cord, for example, with  cauda equina syndrome ;
• malignant tumors of the spinal column and metastases in the spine;
• spinal muscular atrophy;
• stroke,  multiple sclerosis ;
• mental disorders. [10]

The risk of encopresis in men increases after radiation therapy for prostate cancer or prostatectomy, and in women after obstetric trauma or perineotomy (perineal dissection) during childbirth. [11]

Pathogenesis

The best studied is the pathogenesis of functional and chronic constipation encopresis.

The main problem of constipation is the overstretching of the rectum with feces that have accumulated in its expanded (ampullar) part. Because of this, the muscle tone of its wall and muscles of the anal sphincters decreases, and the nerve receptors become less sensitive - with the development of general rectal hyposensitivity and impairment or dullness of the visceral sensation of rectal stretching and the need for defecation. [12]

At the same time, the involuntarily functioning (not controlled by consciousness) internal anal sphincter (one of the two obturator valves of the rectum) relaxes, and the more liquid part of the feces, flowing between its solid fragments, clogged in the large intestine, goes out - without the urge to defecate. [13]

Dysfunction of the external anal sphincter (voluntary, that is, controlled by consciousness) explains the impossibility of its complete closure, in particular, due to hemorrhoids, anal fissures, etc. [14]

In case of disturbances in the innervation of the rectum and the anal canal, the mechanism of incontinence is associated with dysfunction of the sympathetic and / or parasympathetic nerve, and in such cases, when the rectum is filled, the transmission of the corresponding impulses through the rectal afferent pathways is blocked, while the internal anal sphincter remains in a relaxed state. In scientific research, the transit time through the colon is within the normal range; however, it has been shown that there is some limitation of relaxation of the external sphincter during bowel movements. The general pathophysiology of this encopresis pattern is still unclear. [15]

In addition, weakening of the pelvic floor muscles and damage to the nerves that innervate it (the genital and branches S3 and S4 of the pelvic plexus) can lead to the development of involuntary defecation. [16]

Symptoms encopresa

Depending on the level of dysfunction of the anal sphincters, three degrees of encopresis are noted. When uncontrolled defecation occurs with flatulence - the release of intestinal gases, then this is the first degree. And its first signs are frequent or persistent traces of feces on underwear. These conditions can progress slowly.

And if a significant amount of unformed (liquid) feces is released, then this is considered a second degree of incontinence (which is often mistaken for diarrhea). And in the third degree, solid feces are excreted from the constantly dilated anus. [17]

Encopresis is often associated with constipation and nocturnal enuresis. With constipation, there may be a decrease in appetite, pain in the abdomen and during bowel movements. [18]

Children with nonorganic encopresis may show symptoms of attention deficit hyperactivity disorder, poor coordination, and some other signs of  minimal brain dysfunction . [19]

Complications and consequences

Complications of involuntary bowel movements are irritation and maceration of the skin of the perianal region. And negative consequences affect the mental state of people, reduce the quality of their life, self-esteem, causing not only shame and humiliation, but also a feeling of their own inferiority, isolation, chronic depression.

With a significant degree of violation of defecation, disabilities can lead to the inability to study or work, that is, disability practically occurs.

Experts consider encopresis to be one of those symptoms that create a psychological barrier to medical care, as people with this problem are often embarrassed to see a doctor. [20]

Diagnostics encopresa

Which doctor should I contact if I have this problem? Adults - to a  proctologist  or neurologist, and if this symptom is observed in children - to a pediatrician, pediatric gastroenterologist, neurologist or psychiatrist. [21]

Identifying the exact causes of encopresis is the main task that diagnostics must solve, for which the anamnesis of patients, their diet is studied, the medications taken are specified, etc. [22]

General blood and stool tests are done, but other laboratory tests may be required.

Standard instrumental diagnostics include:  anoscopy ; Ultrasound of the abdominal organs; dynamic MRI of the pelvis; colonoscopy ; endoscopic rectal ultrasound; electromyography of the external anal sphincter (sphincterometry) and pelvic floor muscles (anorectal manometry); evacuation proctography. [23]

In order to determine the inorganic nature of fecal incontinence in children and the presence of psychological and emotional problems, it is necessary to  study the neuropsychic sphere . 

Differential diagnosis

Differential diagnosis is carried out with diarrhea , with Hirschsprung's disease , megacolon . [24]

Treatment encopresa

In the case of constipated encopresis, treatment begins with a colon cleanse and stool softening.

To do this, during the period indicated by the doctor, an enema is done daily (preferably in the evening) with encopresis (for adults - siphon). Laxatives are also used:

• rectal suppositories with glycerin and other  suppositories for constipation ;
• Guttalax and other  drops for constipation ;
• laxatives based on polyethylene glycol (Macrogol, Lavacol, Forlax, Forlax for encopresis in children), as well as drugs with lactulose, in particular, Normase, Duphalac for encopresis in children. [25]

For more information see -  Laxatives for children

To increase the tone of the anal sphincter, medications such as Loperamide or Imodium are prescribed  . [26]

Some may be better served by alternative remedies, such as herbal remedies for  constipation .

Doctors warn that such home treatment of encopresis - in compliance with all the recommendations of the attending physician - is a rather lengthy process, but without it, it is impossible to restore normal muscle tone to the stretched colon. And they warn that during the child should sit on the toilet for 10-15 minutes at a certain time (for the development of a reflex) and necessarily - after each meal. [27]

By the way, about food. The expert recommended diet for encopresis should include fiber-rich foods and plenty of water. More details in the publication -  Diet for constipation [28]

If anorectal incontinence arises due to psychological problems, then psychotherapeutic intervention is indispensable, and professional behavioral therapy is required - psychocorrection of emotional personality disorders with encopresis. [29]

When the cause of fecal incontinence is associated with a violation of the muscle tone of the pelvic floor, electrical stimulation can be used. Also, to strengthen the muscles of the pelvic floor, in particular, lifting the anus musculi levator ani and forming the external sphincter of the anus (musculus sphincter ani externus) - it is recommended to regularly perform special exercises. All the details in the material -  Kegel exercises to strengthen muscles . [30]

In cases of congenital or acquired anorectal pathologies, surgery may be required. [31]

Prevention

Today, only the prevention of constipation is practically feasible  . 

Forecast

The prognosis is most favorable for children with chronic constipation- [32]related encopresis, but treatment of fecal incontinence  associated with psychological or emotional problems can be lengthy.