Treatment of Encopresis
Since most cases of childhood encopresis result from constipation, treatment is similar. It is important to remember that although most encopresis begins with constipation, by the time soiling develops, most children are no longer experiencing lots of pain with bowel movements. In children with encopresis, avoidance of the toilet is often a habit that began long ago. Also, children with encopresis often don't have the normal urge to go to the bathroom.
Encopresis in children can be treated in many different ways. In the end, most treatments revolve around three basic principals:
- Empty the large intestine
- Establish regular bowel movements
- Maintain very regular bowel movements
Most children with encopresis have some behavior problems associated with toileting, but behavior therapy alone is usually not sufficient to eliminate the problem. Laxatives are usually needed to re-establish regular bowel movements. In most cases, as soon as the colon is completely evacuated, the encopresis improves or stops; however, it is important to continue treatment long enough to assure regular bowel habits are established and intestinal coordination recovers.
Step 1: How do we empty the large intestine?
Three methods are commonly used to empty the large intestine:
Enemas push fluid into the rectum. This softens the stool in the rectum but also stretches the rectum, giving the child a tremendous urge to pass a bowel movement. Almost all enemas consist mostly of water with something else mixed in to keep the water inside the intestine. The most commonly used enemas are:
- Fleet's® Phosphosoda: contain water and the salt sodium-phosphate. The phosphate is not absorbed in the lower intestine and thus keeps the water from the enema in the intestine.
- Soap suds: contain water with a small amount of soap. The soap is mildly irritating and stimulates the lower intestine to secrete water and salt.
- Milk and Molasses: contain milk sugars and proteins as well as molasses. None of these are absorbed in the lower intestine and thus keep the water from the enema in the intestine.
Suppositories irritate the bottom of the intestine, causing it to contract (squeeze) and push out a bowel movement. Some suppositories also stimulate the intestine to secrete salt and water, softening the stool in the rectum and making it easier to push out. Commonly used suppositories include:
Powerful Laxatives "flush out" the lower intestine. This generally keeps lots of water in the intestine, softening any stool there, and causing diarrhea. Laxatives commonly used to flush out the intestine include:
- Magnesium citrate
- Golytely® or Colyte®
- Fleet's Phosphosoda®
- Miralax® or Glycolax®
Step 2: How can we re-establish regular bowel movements?
Once the large intestine has been emptied, laxatives are administered regularly to produce soft bowel movements once or twice each day. Virtually any laxative preparation will be effective if it is given in high enough doses.
Most of the commonly used laxatives contain different elements but produce basically the same end results: the element is poorly or not absorbed by the intestinal tract, the element stays in the intestine keeping water with it, much more water stays in the stool, the stool stays very soft and moves through the intestine more quickly.
- Milk of Magnesia® and Haley's M.O.®
Contain magnesium salts. In high doses, often produce diarrhea.
- Sennokot®, Fletcher's Castoria®, Ex-Lax®, Aloe Vera
Contain the natural plant derivative senna. Also a mild irritant, senna causes the lower intestine to contract (squeeze). In high doses, may cause cramps and diarrhea.
- Mineral Oil
A non-absorbable oil digested by bacteria living in the large intestine. By-products of this digestion stimulate the intestine to secrete salt and water. Many people believe mineral oil works by "lubricating the intestine". In high doses, often causes some orange seepage and some itching at the anus.
- Metamucil®, Citrucel®, Fibercon®, Fiberall®, and Maltsupex®
Fiber-based laxatives containing complex sugars not digested or absorbed in the intestine. In high doses, often cause bloating and gas.
- Lactulose (Chronulac® and Duphalax®)
Contains a sugar. Often causes bloating and excessive amounts of intestinal gas. In high doses, often produces diarrhea.
- Polyethylene glycol 3350 (Miralax® or Glycolax®)
Contains a very large polymer of ethylene glycol. Available as a tasteless, odorless powder that can be readily mixed into juices or other fluids without altering their taste. In high doses, often produces diarrhea.
Can diet accomplish the same thing as these laxatives?
In high enough doses, many foods, especially fruits and juices, can be very effective laxatives. But it is often difficult to eat or drink enough of these foods day-in and day-out to be an effective long-term treatment. Many people are familiar with using prunes as laxatives. Much like fiber laxatives, prunes contain complex sugars that are not digested or absorbed in the intestine. As a result, the sugars remain in the intestine and keep water with them. As with fiber laxatives, high doses of prunes often produce bloating and gas.
Are laxatives safe?
While many parents and physicians are worried about using laxatives in children, most of their concerns are unfounded. Some common misconceptions include:
- Children may become "dependent" on laxatives if they use them too
Because nearly all available laxatives work by keeping large amounts of water in the stool, they can be used for very long periods of time without significant risk. There is no evidence that any of the laxatives described above can result in dependency with chronic usage.
- Laxatives lose their effectiveness if they are used for prolonged
No studies have ever convincingly demonstrated that any of the laxatives described above lose their effectiveness over time.
- Children who use laxatives have an increased risk of developing
Several studies have suggested that adults with untreated constipation may be at increased risk for developing colon cancer, but there is no evidence to suggest that laxatives increase this risk.
Step 3: How do we maintain regular bowel movements?
Early on, most treatment regimens revolve around evacuating the intestine and using laxatives to keep the stools soft, but to assure long-term success, it is crucial that the child develops very regular bowel habits.
Establish regular "bathroom times"
Children who are toilet trained should get in the habit of sitting on the toilet for 5-10 minutes after breakfast and again after supper. Many families have very busy schedules and their children are not in the habit of "making time" to pass bowel movements. Establishing regular "bathroom times" after meals takes advantage of intestinal contractions that occur after we eat. These contractions are often called the "gastro-colic reflex" and explain why some people pass bowel movements every morning after breakfast or every evening after supper. Establishing regular bathroom times is also helpful because many children are completely unwilling to pass bowel movements at school (just as many adults are unwilling to do at work).
Positive reinforcement techniques can be very helpful in promoting regular bathroom times. Younger children often do well with "star charts"; however, these may not work as well for older children and parents may need to use another more age-appropriate scheme.
Some pediatric centers offer biofeedback therapy as a way to improve the muscle coordination associated with passing bowel movements. Remember, many children with chronic constipation have become quite incoordinated and use muscles against one another when they try to pass bowel movements. With biofeedback, several small wires are taped to the skin around the anus and on the abdomen. These wires measure what the different muscles are doing and display this information on a TV screen. By playing a type of video game, a child can learn how to tighten and relax the muscles in ways that make passing bowel movements more efficient.
In older children, we often find that in conjunction with the use of laxatives and enemas, the aid of a behavioral psychologist to enlist the child's help in his or her own cure is very worthwhile. At the UVA Children's Hospital we have a program called "enhanced toilet training". With the assistance of behavioral psychologists, we use modeling and other behavior modification techniques to help children understand how to use their muscles correctly while straining. The program generally includes colonic evacuation and laxatives as outlined above.
Our program provides:
- Education for child and parents about the psychophysiology of chronic constipation and encopresis
- A reinforcement scheme to promote responsiveness to rectal distension
- Training and modeling of appropriate toileting behaviors, including instruction on appropriate breathing techniques, effective abdominal straining, relaxation of the legs, and relaxation of the external anal sphincter when trrying to pass a bowel movement
- Incentive programs based on the child's developmental age and motivation. Target behaviors are spontaneous trips to the toilet and clean underwear.
- An interactive online experience to complement the program