Toilet problems seen during childhood can be quite concerning for parents. One of these issues is the involuntary stool leakage in children. Medically known as encopresis, it is a condition that usually occurs in children who have completed toilet training and is characterized by the child unintentionally passing stool into their underwear.
Children generally complete toilet training between the ages of 2 and 4. Therefore, fecal incontinence occurring regularly after the age of 4 is not considered normal. Minor accidents occurring occasionally can be seen in some children; however, if there are frequently recurring instances of fecal incontinence, this situation should be evaluated in terms of encopresis.
Fecal incontinence in children is often not just a physical problem; it can arise from a combination of psychological, environmental, and behavioral factors. Therefore, it is important for parents to view this situation not as a behavior that requires punishment, but as a health issue that requires support and understanding.
Many families may initially associate the fecal incontinence problem experienced by their child with inadequate toilet training. However, according to experts, this situation often does not develop under the child's control. Particularly the disruption of bowel regularity, long-term constipation, stress, or the habit of delaying going to the toilet can cause the problem of fecal incontinence to appear in children.
What is Encopresis?
Encopresis is a condition generally seen in children older than 4 years, characterized by the child involuntarily passing stool into their underwear. The most defining feature of this condition is that the child experiences repeated fecal incontinence despite having completed toilet training.
Fecal incontinence in children most often occurs as a result of chronic constipation. Hard stool accumulating in the intestines causes the rectum to enlarge over time, and the child cannot perceive the sensation of defecation. As a result, involuntary fecal incontinence may occur.
Although parents may think of this condition as a behavioral problem, encopresis is mostly a health issue requiring medical and psychological support. Child and Adolescent Psychiatry Specialist Opinion - Asst. Prof. Melek Gözde LUŞ
Encopresis is the involuntary or intentional passing of stool into underwear/inappropriate places in children aged 4 and older, despite having received toilet training. For a child to be diagnosed with encopresis, he must be older than 4 years, experience recurring fecal incontinence once every 15 days without a medical reason, and this recurring fecal incontinence or passing of stool in inappropriate places must occur at least once a month for a period of at least three months. The underlying causes may include chronic constipation, early/oppressive toilet training, or psychological stress. Treatment includes medical intervention, dietary regulation, and psychological support. During the treatment process, adopting a supportive approach instead of blaming the child, instilling regular toilet habits, and obtaining expert support when necessary are quite important. In cases intervened early, encopresis can be largely brought under control, and the child can develop healthy bowel habits.
Types of Encopresis
Experts categorize the problem of fecal incontinence seen in children into different types. This classification makes it easier both to understand the cause of the problem and to determine the correct treatment method. Not every case of encopresis occurs in the same way. While constipation is the primary cause in some children, psychological factors or toilet habits may come to the forefront in others.
Therefore, determining the type of fecal incontinence problem seen in children is one of the most important steps in the treatment process. Experts generally evaluate the condition of encopresis under four main headings.
Constipation-Related Encopresis
Constipation-related encopresis is the most common cause of fecal incontinence problems seen in children. The underlying problem in this condition is long-standing constipation. Stool accumulating in the intestine hardens over time and begins to accumulate in the final part of the intestines. This accumulation can cause the intestines to widen.
When the intestine widens, the child feels the need for defecation less. While hard stool continues to remain in the intestine, softer stool may leak around it over time. It is this leakage that often presents as involuntary fecal incontinence.
The following conditions are generally observed in children experiencing this type of encopresis:
- Long-term constipation.
- Hard and painful defecation.
- Abdominal pain or bloating.
- Stool stains in underwear.
- Avoiding going to the toilet.
Some children may avoid going to the toilet because they experience pain during defecation. This can further increase the constipation cycle and cause the problem of fecal incontinence to persist. Therefore, early treatment of constipation is quite important in such cases of encopresis.
Non-Constipation Encopresis
In some children, fecal incontinence can also occur without constipation. In this case, there may not be a physical problem in the bowel structure, and the problem is more closely related to behavioral or psychological factors.
In cases of encopresis occurring without constipation, the child may:
- Delay going to the toilet.
- Ignore the need to use the toilet while playing games.
- Be reluctant to use the toilet.
This situation can be observed especially in school-aged children. Children may not want to use school toilets or may delay going to the toilet during play. This habit can affect bowel control over time, and involuntary fecal incontinence may occur.
In some children, stress, anxiety, or emotional difficulties can affect bowel control. Therefore, psychological evaluation can also be important in cases of fecal incontinence developing without constipation.
Primary Encopresis
Primary encopresis occurs when the child has never fully acquired toilet training. These children may not have sufficiently developed the toilet habit and may have difficulty achieving bowel control.
Frequent fecal incontinence can be seen in children experiencing primary encopresis. The reason for this is usually that the child has not developed a regular toilet habit. Some children may have difficulty noticing the need to go to the toilet or may be reluctant to use the toilet.
In such cases of fecal incontinence, it is important for parents to be patient and help the child re-establish a toilet routine. Blaming or shaming the child can make the problem even more difficult instead of solving it.
Secondary Encopresis
Secondary encopresis is a condition where a child who has previously successfully completed toilet training subsequently starts experiencing fecal incontinence again. This situation is most often related to changes occurring in the child's life.
Some children may have difficulty with bowel control during stressful periods. Especially the following situations can cause secondary encopresis to develop:
- Starting school or changing schools.
- Birth of a new sibling.
- Family stress or conflicts.
- Environmental changes such as moving.
- Problems experienced in peer relationships.
Such situations can create anxiety and stress in the child. When some children have difficulty coping with this emotional burden, they may experience involuntary fecal incontinence. Therefore, in cases of secondary encopresis, it is important to evaluate both physical and psychological factors together.
What Are the Symptoms of Encopresis?
Certain distinct symptoms can be observed in children experiencing encopresis. These symptoms often indicate that there is a problem with the child's bowel regularity. Early recognition of the symptoms can help resolve the fecal incontinence problem in a shorter time. Therefore, it is important for parents to carefully observe their children's toilet habits.
The problem of fecal incontinence seen in children may sometimes not be noticed at first. Especially fecal incontinence occurring in small amounts can manifest as staining in the underwear. Over time, this situation may start to be seen more frequently.
The most common symptoms in children experiencing encopresis are:
- Frequent appearance of stool stains in underwear.
- Experiencing episodes of involuntary fecal incontinence.
- Long-standing chronic constipation.
- Abdominal pain or a feeling of abdominal bloating.
- Foul-smelling stool leakage.
- Avoiding going to the toilet or postponing the toilet.
These symptoms may not be observed in the same way in every child. While only intermittent fecal incontinence is experienced in some children, additional complaints such as constipation and abdominal pain can also be seen in others. Especially in cases of constipation-related encopresis, it is quite common for children to experience pain during defecation.
Some children may try to hide the fecal incontinence they experience. They may not want to tell their parents due to shame or fear. Therefore, if parents frequently notice soiling in underwear, they should consider that this is not merely a cleaning problem and should carefully evaluate the child's toilet habits.
Additionally, the following behaviors may also be observed in children experiencing encopresis:
- Postponing the urge to go to the toilet when it arises.
- Trying to suppress the need for the toilet.
- Continuing to play instead of going to the toilet.
- Avoiding the toilet environment.
These behaviors can lead to the disruption of bowel regularity over time and the experience of more frequent fecal incontinence.
If a child regularly experiences fecal incontinence after completing toilet training, it is important for this situation to be evaluated by a specialist. Fecal incontinence that repeats several times a week, in particular, can often be a sign of an underlying bowel issue or a behavioral problem.
In cases of encopresis noticed at an early stage, the treatment process generally progresses more easily. With proper nutrition, regular toilet habits, and expert support when necessary, the fecal incontinence problem seen in children can be largely brought under control.
What Causes Encopresis?
Fecal incontinence in children can arise due to many different causes. These causes may sometimes be related to physical health problems, and sometimes to psychological or environmental situations experienced by the child. In the development of encopresis, a combination of multiple factors rather than a single cause is usually effective.
The child's bowel habits, dietary pattern, toilet training process, and emotional experiences can play an important role in the emergence of the fecal incontinence problem. Therefore, correctly understanding the true cause of the problem is the most crucial stage of treatment.
Chronic Constipation
Constipation is one of the most common causes of the fecal incontinence problem in children. Stool remaining in the intestine for a long time hardens and makes defecation difficult. Passing hard stool can be a painful experience for the child.
This situation can cause children to avoid going to the toilet. Since the child thinks that passing stool will hurt, he may start holding his stool. Over time, the stool accumulating in the intestine can lead to the widening of the intestines, and the child may begin to feel the need for defecation less.
At this point, softer stool may leak from around the hard stool accumulating in the intestine. This can manifest as involuntary fecal incontinence. In cases of encopresis developing due to constipation, most children actually experience frequent fecal incontinence because they cannot completely empty their bowels.
To prevent constipation, it is quite important for children to:
- Consume fiber-rich foods
- Drink sufficient amounts of water
- Acquire regular toilet habits
Stool-Holding Behavior
Some children do not want to go to the toilet while playing games or at school and hold their stool. This behavior, continuing for a long time, can disrupt bowel regularity and cause the fecal incontinence problem.
Psychological Factors (Trauma, School Stress)
Psychological stresses experienced by children can also lead to the fecal incontinence problem. When children are stressed or anxious, their bowel movements can be affected.
Especially the following situations can contribute to the development of encopresis in children:
- Changing schools.
- Academic pressure.
- Bullying experienced at school.
- Traumatic experiences.
Some children may experience changes in their toilet habits during stressful periods. This situation sometimes manifests as delaying going to the toilet, and sometimes as involuntary fecal incontinence.
Family Changes (Birth of a Sibling, Moving)
Major changes occurring in children's lives can affect their emotional world. Such changes can create stress in some children and affect bowel control.
Especially the following situations can cause the fecal incontinence behavior to emerge in children:
- Birth of a new sibling.
- Changing houses or moving.
- Mother's or father's job change.
- Intrafamilial conflicts.
Such situations can cause a shake in the sense of security or an increase in stress levels in some children. This can occasionally manifest itself in the form of encopresis.
Anxiety and Behavioral Problems
Psychological problems seen in children can also be effective in the development of encopresis. Especially in children experiencing anxiety and behavioral disorders, toilet habits can be affected, and involuntary fecal incontinence can be observed.
How is Encopresis Diagnosed?
Encopresis is generally diagnosed by a pediatrician or pediatric gastroenterologist. The doctor first evaluates the child's medical history and toilet habits. When necessary, support can also be obtained from child and adolescent psychiatry to evaluate the child's emotional and behavioral processes.
The following methods can be used during the diagnostic process:
- Physical examination
- Evaluation of bowel habits
- X-rays or imaging tests if necessary
As a result of these evaluations, the underlying cause of the fecal incontinence problem experienced by the child is determined.
Encopresis Treatment
The primary goal in the treatment of encopresis is to re-establish bowel regularity and help the child develop healthy toilet habits. The fecal incontinence problem seen in children is often treated not with a single method, but by applying multiple approaches together. In this process, it is important to evaluate both physical and behavioral factors.
The treatment process generally requires time and patience. It may take several months for the child's bowels to work regularly again and for the toilet habit to settle. However, with the right approach and regular follow-up, the fecal incontinence problem can decrease significantly in the vast majority of children.
Constipation Treatment
Since constipation is one of the most common causes of the fecal incontinence problem in children, the first step in the treatment process is often the alleviation of constipation. Hard stool accumulating in the intestine can cause the intestines to widen and the child to fail to notice the need for defecation. Therefore, ensuring that the bowels work regularly is an important part of encopresis treatment.
The following methods are generally applied in the treatment of constipation:
- Consuming fiber-rich foods.
- Drinking sufficient amounts of water during the day.
- Developing regular toilet habits.
- Bowels-regulating medications used upon doctor recommendation.
When the bowels begin to work regularly, it is observed that the fecal incontinence problem seen in children decreases significantly. Therefore, constipation treatment is a highly critical step in the management of encopresis.
Behavioral Therapy
Behavioral therapy is an important method that helps children acquire regular toilet habits. In this method, the aim is to instill the habit of going to the toilet in children. Establishing regular toilet hours, in particular, can be quite effective in reducing the fecal incontinence problem.
Family Education and Support
It is an important part of treatment for parents to be patient and supportive toward the child. Punishing or shaming the child can make the fecal incontinence problem even worse.
Establishing a Toilet Routine
Establishing a regular toilet routine is a highly effective method in the treatment of encopresis. Bowels generally work more actively after meals. Therefore, it can be recommended for children to go to the toilet especially after meals.
Going to the toilet at the same hours every day ensures that the bowels get used to a certain routine. This can help reduce the fecal incontinence problem over time.
Children can be recommended to sit on the toilet for a few minutes without rushing. During this process, it is important for the child to feel comfortable and not see the toilet as a stressful environment. The fecal incontinence problem can decrease significantly over time in children who develop regular toilet habits.
Psychological Counseling
In some cases, psychological support may be required. Child psychiatrists help understand and cope with the emotional processes of children experiencing encopresis.
Up to What Age is Encopresis Normal?
Toilet training is generally completed between the ages of 2-4. Therefore, the situation of frequent fecal incontinence continuing after the age of 4 is not considered normal and needs to be evaluated.
Fecal incontinence problems continuing for a long time must definitely be evaluated by a specialist.
Effects of Encopresis on the Child's Psychology
Children frequently experiencing fecal incontinence may experience shame, guilt, and loss of self-confidence. If peers notice it in the school environment, the child may experience social difficulties.
Therefore, it is very important for parents to approach their children with understanding. Approaching with a solution-oriented mindset instead of blaming the child is one of the most important steps of encopresis treatment.
What Should Families Do?
The approach of parents in the face of the fecal incontinence problem experienced by the child can directly affect the treatment process. Children experiencing encopresis mostly do not do this intentionally and may feel ashamed or guilty due to the situation they experience. Therefore, it is quite important for families to exhibit an understanding, patient, and supportive attitude.
The wrong attitude of parents can increase stress and anxiety in the child. This can cause the fecal incontinence problem to last longer. In contrast, a reassuring and calm approach helps the child both relax psychologically and adapt more easily to the treatment process.
Some important points that families can pay attention to in order to support their child are:
- Do not punish the child. The fecal incontinence situation experienced by children is mostly not under their control. Blaming or punishing the child can increase the feeling of shame and cause the problem to grow even larger.
- Be patient and supportive. Encopresis treatment can take time. In this process, it is quite important for parents to be patient and give moral support to the child. The child feeling safe positively affects the recovery process.
- Establish a regular toilet routine. Encouraging the child to go to the toilet at certain hours every day can help form bowel regularity. Going to the toilet especially after meals can be effective in reducing the fecal incontinence problem.
- Regulate dietary habits. Fiber-rich foods, vegetables, fruits, and sufficient water consumption can help the bowels work more regularly. Healthy eating habits can contribute to the reduction of the fecal incontinence problem in children.
- Get expert support if necessary. If frequently recurring fecal incontinence is observed in the child, it is important to consult a pediatrician. In necessary cases, a pediatric gastroenterologist or child psychiatrist can also be included in the treatment process.
The most important point families should remember is that the condition of encopresis is mostly a treatable problem. With the right approach, a patient attitude, and expert support when necessary, the problem of fecal incontinence can completely disappear over time in a large portion of children. In this process, the child feeling safe and supported is one of the most important keys to recovery.
