Encopresis in children and adults

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

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

Epidemiology

Researchers estimate that the prevalence of fecal incontinence or encopresis in the population is 0.8-7.8%; [ 1 ] encopresis in adults often occurs in old age (in the context of serious physical and/or mental disorders). Encopresis is observed in men 3-6 times more often than in women. In the United States, a prevalence rate of functional encopresis of 4% was found in a retrospective review of 482 children aged 4 to 17 years visiting 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 younger children (prevalence of 4.1% in children aged 5 to 6 years and 1.6% in children aged 11 to 12 years), and most children present for medical attention between the ages of 7 and 12 years.[ 4 ]

In chronic constipation in children under 12, 25-40% of cases involve some kind of problem in the anorectal area, and neurotic encopresis accounts for 15 to 20% of cases. Encopresis usually occurs during the daytime, and organic causes should be considered if a doctor encounters a patient who has only nocturnal encopresis. [ 5 ]

Causes encopresis

The underlying causes of involuntary bowel movements (in inappropriate or unintended places) or fecal incontinence, also known medically as encopresis, faecal incontinence or anorectal incontinence, should be considered taking into account the types or kinds of encopresis, classified in different ways.[ 6 ]

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

Encopresis as a consequence of constipation is defined as false encopresis (or retention), which is based on the accumulation of fecal matter in the rectum that is not removed 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 stool of normal consistency, as well as problems with digestion and the development of persistent constipation, which can also cause encopresis in the elderly, increases. [ 8 ]

Read also – The influence of age on the development of constipation

There may be psychological reasons for uncontrolled defecation. In such cases, non-organic encopresis or chronic neurotic encopresis is diagnosed, which is not related to the functioning of any organs. This type is considered a behavioral condition in cases of too early (before reaching two years) potty training of a child or mistakes of parents who train children to use the toilet in a categorical-imperative style, as well as in cases of a general unfavorable environment for the child's psyche (constant stress, rough treatment, fear of punishment, etc.). [ 9 ]

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

• Neurological and mental causes of constipation
• Psychogenic constipation
• Behavior Disorders in Children

In addition, encopresis in children can be observed in congenital malformations, such as spina bifida, sacrococcygeal teratoma or dermoid cyst; in spinal cord injuries and dysfunction of the brain - in cerebral palsy (CP) or syndromes with cognitive deficit. And in such children, as a rule, nocturnal encopresis is also observed.

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

Risk factors

Risk factors that may lead to frequent, uncontrolled bowel movements, defined as persistent encopresis, include:

• the presence of chronic hemorrhoids in a severe form - with impaired contraction of the rectal sphincters;
• proctitis, as well as the formation of anal fissures, perianal fistula (fistula) or scars in the distal part of the rectum (anal canal);
• prolapse and prolapse of the rectum;
• inflammatory bowel diseases and irritable bowel syndrome;
• previous surgeries in the anorectal area (primarily hemorrhoidectomy and sphincterotomy);
• pelvic fractures;
• spinal injuries with compression or pinching of the nerve roots of the sacral spinal cord, for example, in cauda equina syndrome;
• malignant tumors of the spinal column and metastases to the spinal region;
• 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 (cutting the perineum) during childbirth. [ 11 ]

Pathogenesis

The pathogenesis of functional encopresis and encopresis caused by chronic constipation has been best studied.

The main problem of constipation is overstretching of the rectum by fecal masses accumulated in its expanded (ampullary) part. Because of this, the muscle tone of its wall and the muscles of the anal sphincters decreases, and the nerve receptors become less sensitive - with the development of general rectal hyposensitivity and a violation or dulling of the visceral sensation of stretching of the rectum and the need for defecation. [ 12 ]

At the same time, the involuntary (not consciously controlled) internal anal sphincter (one of the two locking valves of the rectum) relaxes, and the more liquid part of the feces, flowing between its solid fragments, blocked in the large intestine, comes out - without the urge to defecate. [ 13 ]

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

In disorders of the innervation of the rectum and 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 appropriate impulses through the rectal afferent pathways is blocked, and the internal anal sphincter remains in a relaxed state. In scientific studies, the transit time through the colon is within normal limits; however, it has been shown that there is some limitation of relaxation of the external sphincter during defecation. The overall pathophysiology of this pattern of encopresis is still unclear. [ 15 ]

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

Symptoms encopresis

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 constant traces of feces on underwear. This condition can slowly progress.

And if a significant volume of unformed (liquid) feces is released, then this is considered the second degree of its incontinence (which is often mistaken for diarrhea). And at the third degree, excretion of solid feces occurs from the constantly dilated anus. [ 17 ]

Encopresis is often combined with constipation and nocturnal enuresis. Constipation may be accompanied by decreased appetite, abdominal pain, and bowel movements. [ 18 ]

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

Complications and consequences

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

With a significant degree of defecation disorder, restrictions on life activities 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, since people with this problem are often embarrassed to see a doctor. [ 20 ]

Diagnostics encopresis

Which doctor should you see if you have this problem? Adults should see a proctologist or neurologist, and if this symptom is observed in children, 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 patient’s medical history, their diet, the medications they are taking, etc. are studied. [ 22 ]

General blood and stool tests are performed, but other laboratory tests may also 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 ]

To determine the non-organic nature of fecal incontinence in children and the presence of psychological and emotional problems, a study of the neuropsychiatric sphere is necessary.

Differential diagnosis

Differential diagnosis includes diarrhea, Hirschsprung's disease, megacolon.[ 24 ]

Treatment encopresis

In case of encopresis with constipation, treatment begins with cleansing the colon and softening the stool.

For this purpose, an enema for encopresis (for adults - a siphon) is done daily (preferably in the evening) for the period of time specified by the doctor. Laxatives are also used:

• rectal suppositories with glycerin and other suppositories for constipation;
• Guttalax and other drops for constipation;
• laxatives based on polyethyleneglycol (Macrogol, Lavacol, Forlax, Forlax for encopresis in children), as well as products 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 ]

Perhaps some people will benefit more from folk remedies, for example, medicinal plants against constipation.

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

Speaking of food, the diet recommended by experts for encopresis should include foods rich in fiber, and you should also drink enough water. More details in the publication - Diet for constipation [ 28 ]

If anorectal incontinence occurs due to psychological problems, then one cannot do without psychotherapeutic intervention, and professional behavioral therapy is required - psychocorrection of emotional personality disorders in 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, the muscles that lift the anus (musculi levator ani) and form 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 for strengthening muscles. [ 30 ]

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

Prevention

Today, only prevention of constipation is practically feasible.

Forecast

The prognosis is most favorable for children with encopresis developing due to chronic constipation, however, treatment of fecal incontinence [ 32 ] associated with psychological or emotional problems can be long.