Encopresis (307.7 or 787.9)
Page Contributors: Thuy Nguyen, Tina Chang, RN, and Bo-Yun Huh
Criteria:
  1. Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether involuntary or intentional. 
  2. At least one such event a month for at least 3 months. 
  3. Chronological age is at least 4 years (or equivalent developmental level). 
  4. The behavior is not due exclusively to the direct physiological effects of a substance (e.g., laxatives) or a general medical condition except through a mechanism involving constipation. 
Specify type:
  • With Constipation and Overflow Incontinence (787.6) -- i.e. There is evidence of constipation on physical exam or by history.
  • Without Constipation and Overflow Incontinence (307.7) -- i.e. there is no evidence of constipation on physical exam or by history.
Functional fecal incontinence: involuntary passage of stool in the underwear after the acquisition of toileting skills, in the absence of overt neuromuscular anorectal dysfunction. Classified into two types:
  • Retentive: associated with functional constipation
  • Nonretentive: occurs in the absence of symptoms and signs of functional constipation.
Fecal incontinence: The repetitive, voluntary or involuntary, passage of stool in inappropriate places by children four years of age and older, at which time a child may be reasonably expected to have completed toilet training and to exercise bowel control, after organic causes are ruled out. *the term fecal incontinence is preferred rather than encopresis or soiling
Diagnostic Criteria for functional constipation (Rome III Criteria): Must include 2 or more of the following in a child with a developmental age of at least 4 years with insufficient criteria for diagnosis of IBS:
  1. Two or fewer defecations in the toilet per week
  2. At least 1 episode of fecal incontinence per week
  3. History of painful or hard bowel movements
  4. Presence of large fecal mass in the rectum
  5. History of large diameter stools that may obstruct the toilet
*Note: Criteria fulfilled at least once per week for at least 2 months before diagnosis
Diagnostic Criteria for nonretentive fecal incontinence (Rome III Criteria): Must include all of the following in a child with a developmental age at least 4 years:
  1. Defecation into places inappropriate to the social context at least once per month
  2. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms
  3. No evidence of fecal retention 
*Criteria fulfilled for at least 2 months before diagnosi
Reference: Rasquin, A., Di Lorenzo, C., Forbes, D., Guiraldes, E., Hyams, J. S., Staiano, A., & Walker, L. S. (2006). Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology, 130(5), 1527-1537.

Screening

History
General health of child, including developmental history 
Presenting signs and symptoms
Detailed stooling history:
  • Interval, amount, diameter, and consistency of bowel movements in toilet and stools in underwear
  • Do the stools clog the toilet?
  • Is stool withholding present?
  • What was the age at onset of encopresis or constipation?
  • Was there a problem with delayed passage of meconium?
  • The character of the stools from birth: consistency, caliber, volume, and frequency
  • Was there a precipitating event?
  • Is the child aware of the encopretic event?
  • Is abdominal pain present?
Check for urinary problems.
Review dietary habits.
Review emotional and social adjustment of child.
Physical Exam
  • Monitor weight and height.
  • Abdominal exam - palpate for fecal mass
  • External exam of perineum and perianal area - fecal material, anal irritation, fissures?
  • Digital rectal exam - should be performed at least once (Medical Position Statement of the North American Society for Pediatric Gastoenterology and Nutrition)
Labs (usually not required)
  • Blood studies
  • Urine culture
  • Abdominal radiographs
Bristol stool scale
  • Useful chart for parents and children to identify type of stool
  • Can also help with treatment monitoring
Quick tip: GREAT screening overview at in the Encopresis chapter in IACAPAP Textbook of Child and Adolescent Mental Health by Alexander von Gontard. Make sure to look at the appendices as well.  It includes sections on:
  • Taking a Clinical History of Encopresis and Constipation: Examples of Questions
  • Encopresis Questionnaire - Screening Version
  • Encopresis Chart
Reference: Loening-Baucke, V. (2002). Encopresis. Current Opinion in Pediatrics, 14, 570-575. 

Position Papers

  • AAFP's "Treatment Guidelines for Primary Nonretentive Encopresis and Stool Toileting Refusal" (Kuhn, Marcus & Pittner, 1999)
  • Evaluation and Treatment of Functional Constipation in Infants and Children -- Evidence-Based Recommendations from ESPGHAN and NASPGHAN (2014)

Articles

  • Encopresis (Har & Croffie, 2010), in Pediatrics in Review
  • Schonwald, A. & Rappaport, L. (2004). Consultation with the specialist: encopresis: assessment and management. Pediatrics in Review, 25(8), 278-282.
  • Loening-Baucke, V. (2002). Functional Fecal Retention in Childhood. Practical Gastroenterology, 13-25.
  • Loening-Baucke, V. (2002). Encopresis. Current Opinion in Pediatrics, 14, 570-575. 
  • Bongers, M. E., Tabbers, M. M., & Benningaa, M. A. (2007). Functional nonretentive fecal incontinence in children. Journal of Pediatric Gastroenterology and Nutrition, 44, 5-13. 
  • Montgomery, D. A. & Navarro, F. (2008). Management of constipation and encopresis in children. J Pediatr Health Care, 22, 199-204.
  • Loening-Baucke, V. (2002). Encopresis. Current Opinion in Pediatrics, 14, 570-575. 
  • Kratimenos & Sell (2012) Elimination Disorders in Children and Adolescents. Journal of Developmental & Behavioral Pediatrics.
  • Rasquin, A., Di Lorenzo, C., Forbes, D., Guiraldes, E., Hyams, J. S., Staiano, A., & Walker, L. S. (2006). Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology, 130(5), 1527-1537.
  • Rockney, R. (1999) Encopresis. In Developmental Behavioral Pediatrics, 3rd ed, Levine, MD, Carey, WB, Crocker, AC (Eds), WB Saunders, Philadelphia. p. 413. 

Resources

FOR PROVIDERS
  • IACAPAP Textbook of Child and Adolescent Mental Health,  Encopresis chapter
  • Brief Interventions - Encopresis (Bromberg M.D.)
  • Soiling Solutions (SoilingSolutions.com, 2013)
  • KidsHealth.org: http://kidshealth.org/parent/general/sick/encopresis.html
FOR FAMILIES
  • The Poo in You - Constipation and Encopresis Video
  • Kaiser's After-Visit Instructions for families
  • Stanford Children's overview for parents on encopresis
  • Stool Soiling and Constipation in Children (Family Doctor)

    SUBMISSION OR CORRECTION TO THIS PAGE