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Medscape - Encopresis Medication

Author
Stephen M Borowitz, MD Professor of Pediatrics and Public Health Sciences, Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Virginia School of Medicine Stephen M Borowitz, MD is a member of the following medical societies: American Academy of Pediatrics, American Gastroenterological Association, American Pediatric Society, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research Disclosure: Nothing to disclose.

Chief Editor Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada Disclosure: Prometheus Laboratories Honoraria Speaking and teaching; Abbott Nutritionals Honoraria Speaking and teaching Additional Contributors Jorge H Vargas, MD Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, University of California, Los Angeles, David Geffen School of Medicine; Consulting Physician, Department of Pediatrics, University of California at Los Angeles Health System Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition Disclosure: Nothing to disclose. Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Nothing to disclose.

Practice Essentials Encopresis. especially in the left lower quadrant Stool smeared around the anus Lax and patulous anal sphincter Rectum typically enlarged and filled with soft stool that yields negative results on fecal occult blood testing Neurologic findings should be normal. other than those from abdominal and rectal examinations. intermittent passage of extremely large bowel movements Physical findings. Patients should have a normal anal wink and normal sensation. Diagnosis Other problems to be considered in the diagnosis include the following:       Spina bifida Meningomyelocele Spinal-cord injury with dysfunction of the anal sphincter Teathered spinal cord Ultrashort-segment Hirschsprung disease (ie. Examination may reveal the following:     Palpable stool throughout the distribution of the colon. congenital megacolon) Imperforate anus with fistula . is classified as an elimination disorder in the Diagnostic and Statistical Manual of Mental Disorders. along with enuresis. Fifth Edition (DSM-5). are usually normal. Signs and symptoms Symptoms of encopresis may include the following:     History of constipation or painful defecation (~80-95% of children with encopresis). sometimes remote Inability to differentiate passing gas and passing feces in underwear Soiling episodes usually occurring during the daytime (soiling during sleep is uncommon) With retentive encopresis. and reflexes in the lower extremities. strength. It may be divided into 2 subtypes: encopresis with constipation and encopresis without constipation. Unless contraindicated. a digital rectal examination should be performed on every child with encopresis.

the diagnosis of encopresis is established on the basis of the history and complete physical examination. generally consisting of the following:    Demystification and education Colonic disimpaction followed by routine laxative therapy “Toilet training” Agents that can be used for disimpaction include the following:     Polyethylene glycol (PEG) Sodium phosphate Magnesium citrate Enemas Virtually any laxative can be used. In addition to long-term laxative therapy. . The following studies may be helpful:    Plain abdominal radiography Anorectal manometry Biopsy (either surgical or done by means of a suction device) Management Conventional medical therapy is commonly the first therapy attempted. and uninterrupted toileting Maintaining a symptom and toileting diary Defining specific achievable target behaviors Establishing age-appropriate rewards and consequences Strongly emphasizing consistency See Treatment and Medication for more detail. including a rectal examination. provide that it is administered in sufficient quantity to produce 1-2 soft stools daily. timed. Laboratory studies are rarely warranted. modalities that have been proposed for the treatment of chronic encopresis include the following:   Biofeedback therapy (efficacy not proved) Intensive behavioral program (effective adjunct to conventional medical therapy) Although the critical components of a successful intensive behavioral program have not been systematically elucidated.In most patients. common elements of existing programs include the following:        Demystifying the condition and educating patients and families Providing specific toileting instruction about appropriate positioning and straining Designing a program of regular.

and “toilet training. Fifth Edition (DSM-5). uses the term elimination disorder to classify both encopresis and enuresis. DSM-5 criteria for encopresis are as follows[1] :    Repeated passage of feces into inappropriate places. The latter subtype is much less common and most often occurs in association with oppositional defiant disorder or conduct disorder or as a consequence of anal masturbation. the diagnosis of encopresis is established with the history and complete physical examination. Diagnostic criteria (DSM-5) The Diagnostic and Statistical Manual of Mental Disorders. fecal incontinence). whether involuntary or intentional One such event occurs each month for at least 3 months Occurs in children at least age 4 years (or of equivalent developmental level) . and biopsy may be helpful. including a rectal examination. Laboratory studies are rarely warranted. as well as Encopresis and Constipation in Children. colonic disimpaction followed by routine laxative therapy. and Intestine Center.” For patient education resources. In most patients. manometry. though radiography. No good prospective data suggest that encopresis is primarily a behavioral or psychological disorder. see the Esophagus. Treatment remains largely experiential and generally consists of demystification and education. Background Encopresis is the involuntary discharge of feces (ie. In most cases. it is the consequence of chronic constipation and resulting overflow incontinence.Image library Overflow incontinence. but a minority of patients have no apparent history of constipation or painful defecation. Stomach.[1] Encopresis is further divided into 2 subtypes: encopresis with constipation and encopresis without constipation. The behavioral difficulties associated with encopresis are most likely the result of the condition rather than its cause.

[6] . is primarily a behavioral or psychological disorder. encopresis is thought to develop as a consequence of chronic constipation with resulting overflow incontinence. Many children with encopresis have a remote history of constipation or painful defecation[3] or demonstrate incomplete evacuation during defecation on physical examination or radiographic assessment. encopresis develops as a consequence of chronic constipation with resulting overflow incontinence (see the images below). Etiology In most cases.[4] Overflow incontinence. whether retentive or nonretentive. resulting in fecal soiling. most of the available evidence indicates that children with encopresis do not have an increased incidence of major behavioral or personality disorders when compared with age-matched peers. he or she no longer senses the normal urge to defecate. No good prospective data suggest that encopresis. Rather. The remaining 5-20% appear to have nonretentive encopresis and no history of constipation or painful defecation. Soft or liquid stool eventually leaks around the retained fecal mass. The behavior is not attributable to the physiologic effects of a substance or another medical condition except through a mechanism involving constipation Pathophysiology In the vast majority of cases. the evidence suggests that behavioral difficulties associated with encopresis may be the result of the encopresis rather than the cause.[5] Overall. encopresis in the absence of a history of constipation or painful bowel movements is typically referred to as nonretentive. they generally have no evidence of incomplete evacuation on physical evaluation or radiographic evaluation. Approximately 80-95% of children with encopresis have a history of constipation or painful bowel movements. Overflow incontinence. Chronic constipation due to irregular and incomplete evacuation results in progressive rectal distention and stretching of both the internal anal sphincter and the external anal sphincter (EAS).[2] which is typically termed retentive encopresis. As the child habituates to chronic rectal distention.

In most series. but is more frequently seen in females than in males. academic. none of the demographic. approximately 80% of affected children are boys.[10] Nearly all of the few published population-based studies examining the prevalence of encopresis have been conducted in North America and Europe. Urinary tract infection may be associated with encopresis. Current evidence suggests that family disorganization correlates with a poor response to all forms of treatment.4% of the subjects experienced fecal incontinence at least once per week. behavioral.[13] Unfortunately.[7] The incidence of fecal soiling is comparable among children with a history of sexual abuse and among children with psychiatric and behavioral disorders. In contrast. or self-esteem measures are clearly associated with response to therapy. In nearly all published series. Prognosis Even with aggressive medical and behavioral interventions. the family’s motivation. 4. In one such study conducted in the Netherlands. No investigators have systematically examined the child’s motivation. Children with encopresis are significantly more likely to have attention-deficit disorder/hyperactivity (ADHD) than the general population. manometric. 9] Low self-esteem or parent-child conflict as a result of the disorder is not uncommon.[11] Studies conducted in Sweden and the United Kingdom[12] reported similar numbers. Nonretentive encopresis may be associated with oppositional defiant disorder and conduct disorder. as many as 30% of children remain symptomatic. 4.6% of children aged 11-12 years experienced fecal soiling at least once per month.1% of children aged 5-6 years and 1. the available data are insufficient to enable clinicians to make reliable predictions as to which children will successfully respond to which specific treatment protocols. . Epidemiology Although few prospective studies have been conducted to examine the prevalence of encopresis in childhood. social. or the state of change to determine whether any of these is predictive of the patient’s response to treatment. it is estimated that 1-2% of children younger than 10 years have encopresis. Embarrassed youngsters also commonly deny having the problem. In a study of 482 children aged 4-17 years who were observed over a 6-month period in a primary care pediatric clinic in Iowa.No good evidence suggests that encopresis is an indicator of sexual abuse.[8. boys are much more commonly affected than girls.

when the child is asleep. As evidence of functional megacolon. low or unsuspected meningomyelocele. Neurologic findings should be normal. Soiling at night. congenital megacolon [a rare cause of encopresis]) Imperforate anus with fistula . when the child is awake and active. On rectal examination. is uncommon. Patients should have a normal anal wink and normal sensation. imperforate anus with perineal fistula. strength. Physical Examination Physical findings. Most children with encopresis deny the urge to defecate associated with their soiling episodes. stool can be palpated throughout the distribution of the colon. or ultrashort-segment Hirschsprung disease). The anal sphincter may appear somewhat lax and patulous because massive rectal distention is associated with reflex relaxation of the internal sphincter. a digital rectal examination should be performed on every child with encopresis to exclude any underlying anatomic or neurologic abnormality that might account for the encopresis (eg. many children with retentive encopresis intermittently pass extremely large bowel movements.History Approximately 80-95% of children with encopresis have a history of constipation or painful defecation. stool is often found smeared around the anus. Unless a physical or psychological contraindication is noted. the history of constipation or painful defecation is remote. In many patients. In most cases. soiling episodes occur during the daytime. In many patients. Diagnostic Considerations Other problems to be considered in the diagnosis include the following:       Spina bifida Meningomyelocele Spinal-cord injury with dysfunction of the anal sphincter Teathered spinal cord Ultrashort-segment Hirschsprung disease (ie. Sometimes. most notably in the left lower quadrant. On average. The rectum is typically enlarged and filled with soft stool that yields negative results on fecal occult blood testing. occurring years before the child presents with encopresis. affected children contend that they are unable to differentiate passing gas and passing feces in their underwear. and reflexes in the lower extremities. children who have encopresis are symptomatic 5 years before the problem is brought to medical attention. other than those obtained from the abdominal and rectal examinations. are usually normal.

which is a rare cause of encopresis. if suspected. as evidenced by diminished sensation to distention of the rectum during balloon insufflation. Many children who have encopresis also have paradoxical constriction of the external anal sphincter (EAS) during attempted defecation. particularly when a history of constipation is not evident or is denied. A biopsy specimen can be obtained either by surgical means or through the use of a suction device.[14] Many children with encopresis have evidence of megarectum. With this disorder. This study can be very useful for documenting the nature of the problem and helping explain it to the older child and his or her parents. intramural ganglion cells in the submucosa and myenteric plexuses of the distal colon are absent. this diagnosis. the internal anal sphincter does not relax in response to rectal distention by balloon inflation. including a rectal examination. though radiography. can be excluded by identifying ganglion cells in the submucosa and myenteric plexuses of the rectum. In the absence of these ganglion cells. manometry.Differential Diagnoses  Constipation Approach Considerations In most patients. Approach Considerations . Biopsy Although Hirschsprung disease is rarely associated with encopresis. and biopsy may be helpful. Laboratory studies are rarely warranted. Abdominal Radiography Plain abdominal radiography may be helpful in determining whether a soft fecal impaction is present. the diagnosis of encopresis is established in the basis of the history and complete physical examination. Anorectal manometry can also be helpful in excluding ultrashort-segment Hirschsprung disease. Anorectal Manometry Anorectal manometry is sometimes helpful in delineating the child’s defecation dynamics.

Conventional medical therapy is commonly the first therapy attempted. In most cases of encopresis. there is no evidence that it adds any benefit to conventional treatment in the management of childhood encopresis. with or without long-term laxative therapy. treatment remains largely experiential rather than evidence based. Affected children are often referred to a pediatric gastroenterologist." which is composed of regularly scheduled toileting. and to encourage the child and parents to take an active role during the treatment. or both. Because more than 50% of children with chronic encopresis have paradoxical external anal sphincter (EAS) constriction (anismus) during attempted defecation. no large. biofeedback training focusing on teaching the child how to relax the EAS during active straining and thus eliminate anismus has been used in this population since the mid-1980s. to develop or restore normal bowel habits with positive reinforcement. The addition of an intensive behavioral program to conventional medical therapy can be of substantial therapeutic benefit for most children with chronic encopresis (see Long-Term Monitoring). it is appropriate to assess progress after 2-4 months of treatment.Despite the frequency with which childhood encopresis occurs.[19] Pharmacologic Therapy Because most children with encopresis have retentive encopresis as a consequence of chronic constipation with resulting overflow incontinence. medical therapy is initially focused on . consider enrolling him or her in an intensive behavior program that supplements conventional medical therapy. encopresis. and an age-appropriate incentive scheme[17] The aim of this multimodal approach to therapy is to decrease the physical and emotional distress associated with defecation. If the child remains symptomatic. a behavioral psychologist. Behavioral Therapy and Biofeedback Although controversy remains and conflicting data have been reported. maintenance of a symptom diary.[15] As a result. If a child has not experienced significant clinical improvement after 2-4 months of therapy. or both. Although biofeedback may help selected children. consultation with a subspecialist is not absolutely necessary. randomized. Accordingly. controlled therapeutic trials have been conducted.[18] Conventional medical therapy proves successful in approximately one half of children with chronic constipation. generally consisting of the following:    Demystification and education Colonic disimpaction followed by routine laxative therapy[16] "Toilet training. a different therapy program may be indicated. to encourage bowel movements in patients with chronic encopresis.[19] No surgical intervention has a proven role in the management of childhood encopresis. many authors advocate behavioral strategies.

Virtually any laxative can be used. Diet No evidence suggests that dietary interventions are beneficial in the management of encopresis. the authors know of no studies conducted to systematically evaluate the effectiveness of dietary therapy in childhood encopresis. or both. or magnesium citrate) or a series of enemas. Although many people advocate high-fiber diets. disimpaction is reported to be equally effective whether done via the oral route or via the rectal route. but manometric biofeedback is more invasive than EMG biofeedback. In fact. polyethylene glycol [PEG]. 22] Most enema preparations contain osmotically active agents that are not substantially absorbed in the colon (see Medication). In clinical trials. 24] Although biofeedback can be used to train children to tighten and relax their perineal muscles (thereby. outcomes tend to worsen when children are treated with biofeedback therapy.[21. Long-Term Monitoring In addition to the long-term laxative therapy outlined above. Disimpaction can be accomplished with aggressive use of oral cathartics (eg. provide that it is administered in sufficient quantity to produce 1-2 soft stools daily. To the author’s knowledge. various modalities have been proposed for the treatment of chronic encopresis. this achievement is not clearly correlated with successful resolution of chronic constipation or encopresis. in theory. the effectiveness of any particular preparation depends more on the volume of the enema than on the composition of the enema solution. increasing the efficiency of defecation).[23] Most studies examining the use of biofeedback in childhood encopresis included biofeedback as a supplement to medical-behavioral treatment. no studies have yet been performed to compare the effectiveness of these preparations.disimpaction of the distal colon.[23] Both manometric and electromyographic (EMG) biofeedback have been used to treat encopresis. EAS biofeedback focuses on teaching the child to reverse paradoxical constriction by learning how to relax the EAS during straining. sodium phosphate.[19] Adding biofeedback therapy to conventional medical therapy appears not to offer substantial therapeutic benefit to most children with chronic constipation. long-term laxative therapy is generally started.[20] which is followed by prolonged use of laxatives to ensure that the child passes soft stools frequently without any associated pain. After the colon is disimpacted.[19. Data from a meta-analysis suggested no significant differences in outcomes between intra-anal pressure biofeedback and surface EMG biofeedback of the perianal skin. As noted (see Behavioral Therapy and Biofeedback). encopresis. In all likelihood. .

Polyethylene glycol powder (MiraLAX. Pedia-Lax) . GlycoLax. common elements of existing programs include the following:        Demystifying the condition and educating patients and families Providing specific toileting instruction about appropriate positioning and straining Designing a program of regular. The resulting molecule is extremely large. abdominal cramps. and its use may be associated with nausea. and functions as an osmotic laxative. Osmotic Class Summary Osmotic laxatives cause fluid retention in the colon.[25. Laxatives. is very poorly absorbed. lowering the pH. and uninterrupted toileting Maintaining a symptom and toileting diary Defining specific achievable target behaviors Establishing age-appropriate rewards and consequences[27] Strongly emphasizing consistency Preliminary evidence suggests that this type of intensive behavioral intervention can be successfully performed by using the Internet.[19] Although the critical components of a successful intensive behavioral program have not been systematically elucidated. This agent can also be used as a purgative in preparation for colonoscopy. Virtually any laxative can be used as long as it is used in sufficient quantity to produce 1-2 soft stools daily. After the colon is evacuated. 29] Medication Summary Because most children with encopresis have retentive encopresis as a consequence of chronic constipation with resulting overflow incontinence. therapy is initially focused on evacuating the distal colon. long-term laxative therapy is generally started. timed. PEG is occasionally difficult to take. The powder is tasteless and odorless to most people and completely dissolves in nearly all liquids. with or without long-term laxative therapy.[28. including water. and increasing colonic peristalsis. 23. 26. At very large dosages. Gravilax) Polyethylene glycol (PEG) 3350 consists of a long chain of ethylene glycol molecules. Disimpaction can be accomplished with aggressive use of oral cathartics or a series of enemas. resulting in distention. to encourage frequent bowel movements. and vomiting. Dulcolax Milk of Magnesia. 19] A Cochrane review concluded that the addition of an intensive behavioral program to conventional medical therapy can be of substantial therapeutic benefit in most children with chronic encopresis. Magnesium hydroxide (Phillips' Milk of Magnesia. bloating.Some authors advocate the use of behavioral strategies.

It is most palatable if taken cold or mixed into a fluid (eg. mineral oil causes seepage of orange oil into underwear. At high concentrations. Constulose. It has cathartic actions in the GI tract and is largely nonabsorbable. They are most palatable when mixed with a fluid (eg. partly through its metabolism to hydroxy fatty acids in the colon. absorption appears to occur largely and inefficiently through diffusion. Enulose. Stimulant . this may explain why some children have abdominal cramping. Increased serum magnesium levels may cause cholecystokinin release. Lubricants Class Summary Lubricants and emollients retard colonic absorption of fecal water and thus soften stool. In many children given high doses. it appears to be absorbed in a saturable carrier-mediated process influenced by vitamin D. Generlac) Lactulose is a synthetic nonabsorbable disaccharide that is available as a 70% solution. At low concentrations.Magnesium is a divalent cation that is maximally absorbed in the distal small intestine. Increased serum magnesium levels may cause cholecystokinin release. it appears to be absorbed in a saturable carrier-mediated process influenced by vitamin D. Sorbitol is generally well tolerated and tastes sweet. Mineral oil Mineral oil is a nonabsorbable fat that softens stool and decreases water absorption. Sorbitol (Ora-Sweet SF) Sorbitol is a hyperosmotic laxative that is available as a 70% solution. with a thick and chalky texture. At high concentrations. At low concentrations. absorption appears to occur largely and inefficiently through diffusion. this may explain why some children have abdominal cramping. milk or chocolate milk). orange juice). Lactulose (Kristalose. Laxatives. Magnesium hydroxide formulations are mostly flavorless. It is generally well tolerated and tastes sweet. Magnesium citrate may be chilled to improve palatability. which stimulates gastrointestinal (GI) motility and secretion. Magnesium citrate (Citroma) Magnesium is a divalent cation that is maximally absorbed in the distal small intestine. Laxative. It is largely tasteless and has an oily consistency. which can produce perianal pruritus. which stimulates gastrointestinal (GI) motility and secretion.

APA. 2000. Fleet Laxative) Bisacodyl is a colorless and odorless compound that is poorly absorbed. Pediatrics.27(7):585-91. Functions as osmotic agent and only small amounts are absorbed when administered as enema. Borowitz SM. 5. Jun 1999. Jan 2004. Morris JB Jr. 4th ed. Oct-Nov 2002. Bisacodyl (Dulcolax.Class Summary Stimulant laxatives act directly on the intestinal mucosa or nerve plexus. and asymptomatic nonsiblings. Sodium acid phosphate (Fleet Enema) Phosphate is divalent anion absorbed largely in proximal small intestine. Pathophysiology of pediatric fecal incontinence. Ex-Lax. Differences in toileting habits between children with chronic encopresis. 4. Cox DJ. J Dev Behav Pediatr. Di Lorenzo C. Borowitz SM. Partin JC. Cox DJ. asymptomatic siblings. Laxative. Senna (Senokot.126(1 Suppl 1):S33-40. Senna Lax) Sennosides are plant alkaloids that stimulate colonic salt and water secretion and promote colonic motility.20(3):145-9. 3. Senexon. Painful defecation and fecal soiling in children. Bowel Evacuant Class Summary Most enema preparations contain osmotically active agents that are not substantially absorbed in the colon. or secondary hyperaldosteronism. J Pediatr Psychol. Sutphen JL. References 1. [Medline].89(6 Pt 1):1007-9. Bisco-Lax. Sutphen JL. Diagnostic and Statistical Manual of Mental Disorders. [Medline]. Jun 1992. Benninga MA. . Gastroenterology. [Medline]. They often produce abdominal cramping at high doses. Psychological differences between children with and without chronic encopresis. Geri-kot. tachyphylaxis. They alter water and electrolyte secretion. Hamill SK. Fischel JE. In all likelihood. the effectiveness of any particular preparation in the setting of encopresis depends more on the volume of the enema than on the composition of the enema solution. 2. It increases colonic peristalsis and stimulates salt and water secretion. It may be administered either orally or rectally. American Psychiatric Association. Partin JS. Long-term use in animals has not been associated with any evidence of cathartic colon. [Medline].

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