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Encopresis
Encopresis ELSEVIER
Richard Solomon, MD DEPARTMENT OF PEDIATRICS, MEDICAL COLLEGE OF PENNSYLVANIA/ HAHNEMANN, ALLEGHENY GENERAL HOSPITAL CAMPUS, PITTSBURGH, PENNSYLVANIA
Pediatrics Update Abstract
Encopresis or chronic fecal soiling is a common and misunderstood condition that is often devastating to the affected child's self esteem. By "demystifying" the pathogenesis of en-
copresis, the physician can relieve guilt, offer hope, and f o r m a therapeutic alliance with the child and his
parents. Proved, effective treatments that combine physical, medical, and behavioral modalities lead to a cure in over 65% and substantial improvement in over 90%. MEDICAL UPDATE FOR PSYCHIATRISTS 1;4:123-126, 1996.
Introduction
The Presentation A school-age child with encopresis typically arrives at the physician's office embarrassed and embattled. He has tried to hide "the problem" from his family and friends and failed. His family rarely understands that the soiling has become uncontrollable, so they blame him and/ or punish him, sometimes severely. The child first feels angry, then helpless, then resigned. Because these children often accommodate to the smell and have no feeling of defecation, they don't know when they have soiled and when they smell. Among their peers this triggers teasing that is terribly demoralizing. It's no surprise that a large percentage of children with this condition appeared depressed on presentation. In the office, the child appears embarrassed, with eyes lowered, and will not volunteer the reason for his visit, but he is deeply hopeful that the physician has a solution.
The Approach The understanding, evaluation, and treatment of encopresis has evolved over the last 20 years to the point where approximately 65% of children with encopresis will attain a long-lasting remission with another 30% being substantially improved. There is reason to offer hope to children presenting with fecal soiling. The approach is four-fold. First, knowledge of the most common pathogenesis for retentive encopresis along with a thoughtful differential diagnosis will guide the evaluation. Second, demystification of the condition will lead to a therapeutic alliance with the child and parents. Third, knowledge of treatment options will improve compliance.
© 199G Elsevier Science Inc. MSN i082-/b'79/OG/SlS.00 Pli SlQ82-7b-7919GIOOO55-G
Address reprint requests to: Dr. Richard Soloanon,Dept. of Pediatrics,AlleghenyGeneralHospital, 320 East North Avenue, Pittsburgh PA 15212.
And finally, close and long-term followup will increase the chances of longterm success. Pathogenesis, DmerenUal Diagnosis, a n d Evaluation
Encopresis is defined as repeated, involuntary defecation into clothing occurring in children 4 years of age and older, of at least 1 month's duration. Boys are 3 times more likely to have this condition with 2.3% of 7-8-year-aids having the condition (1).
Pathogenesis In the vast majority, the pathogenesis of retentive encopresis involves initial, voluntary withholding of stool but, due to constipation, pain on defecation, toilet phobia, or a stubborn response to toileting, the voluntary withholding evolves into involuntary retention. The retention results in an enlarging rectal vault that can accommodate an enormous amount of stool. This widening rectum becomes progressively less sensitive to stretching and peristalsis and results in the elimination of the defecation reflex, i.e., the child loses sensation. Subsequently, the accumulating stool overflows, usually in daily smears, into the child's underwear, also known as overflow incontinence (2). Recent physiologic studies also recognize abnormalities of external anal sphincter contraction and rectal hyposensitivity (in up to 40%) as contributing factors (3). Psychoanalytic interpretations of retentive encopresis have been debunked by Achenbach and Lewis (4). The Differential Diagnosis The differential diagnosis includes other forms of soiling related to (a) irritable bowel syndrome with stress-related soiling and (b) manipulative soiling. Both conditions are uncommon in children and have characteristic patterns. Retentive encopresis usually has daily smears of stool in the child's underwear that
R. Solomoil
are not directly related to stress. In manipulative soiling the child will consistently have normal-sized bowel movements in his underwear, not smears. Children with retentive encopresis may appear manipulative, making it sometimes hard to differentiate from the true manipulative soiler. They may hide their underwear to avoid embarrassment and punishment, they will not notice that they have soiled because they accommodate to the smell, and they may deny soiling even as they smell of stool as a psychological defense. But they are not soiling on purpose. Also in the differential diagnosis are associated physical conditions like (a) enuresis and (b) severe constipation, both of which have implications for therapy. Most experts recommend treating enuresis after encopresis because the act of withholding or retaining stool interferes with mieturition reflexes. The evaluation for enuresis should be considered separately. Severe constipation may be common in this population, but should be addressed as part of the overall treatment approach to the encopresis. Associated behavioral and psychological conditions like (a) attention deficit hyperactivity disorder (ADHD), (b) oppositional defiant disorder ( ODD ), (c) anxiety, (d) depression, and (e) child abuse, must also be considered. About 30% of children who have encopresis will have emotional maladjustment in the clinically referable range at initial presentation. In this and other authors' experience, the assoeiation between ADHD and encopresis is significant (5). Children who don't attend well to physiologic cues and/or are too busy playing to respond are likely candidates for this condilSon. Because the rest of these conditions are well within the realm of psychiatry little more needs to be said about them except that reactive depression is common and disappears with treatment, ODD makes the treatment approach more difficult, and child abuse as a cause of encopresis is rare. Finally, the serious medical conditions that must be considered in the differential diagnosis include (a) Hirsehsprung's disease, (b) spina bifida oceulta, and (c) hypothyroidism. Hirsehsprnng's disease is rare even in encopretics and the child who has it usually does not soil, but in rare instances may. The classic history of lack of normal bowel movements from birth should raise concerns.
MEDICAL UPDATE FOR PSYCHIATRISTS
Spina bifida oceulta is an occult condition that is only rarely associated with involuntary soiling and wetting. On physical exam the lower extremities would reveal decreased sensation and hyperactive deep-tendon reflexes. Hypothyroidism can cause constipation, but would also be associated with poor growth and development as well as other vegetative symptoms.
Evaluation Much of the evaluation is implied from the discussion of the differential diagnosis above, but key elements of the history, physical, and laboratory assessment will be discussed below (6). History. Important in the history are soiling details that include whether this is primary encopresis, i.e., the child was never toilet trained, or secondary. Primary encopresis often occurs in the context of the late toilet training of threeand four-year-olds who start to withhold out of stubbornness or other control issues. Secondary encopresis, i.e., soiling after achieving continence, most commonly occurs within the context of severe pain on defecation resulting in withholding or when the child starts school and changes toileting regimens. Many five- and six-year-old children wifl not go to the toilet in school and thus learn to ignore urges that result in retention. Once the problem begins it tends to be self perpetuating and can go on for years before it comes to the physician's attention. So, duration of soiling, precipitating events, frequency of soiling episodes, and consistency and quantity of soiled stool help to establish the diagnosis of retentive encopresis. Both nocturnal episodes and soiling outside underwear are very unusual in retentive encopresis and would suggest manipulation (and anger!). Awareness of the urge to defecate is limited in encopresis and all too conscious in irritable bowel. The physician will rarely hear of a child with retentive encopresis regularly running to the toilet to defecate, although on occasion they may. When they do have a stool in the toilet the mother will be dismayed at how large it is, the so called "mega-stools" associated with retentive encopresis. However, most often, these children are completely unaware of soiling episodes.
124
Other toileting issues should also be explored at length like resistance to toileting and stubborn child (and parent) temperament. Knowing about past efforts at treatment is very helpful for knowing where to begin with a treatment approach and about the level of frustration the family and child have faced. Asking matter-of-factly about types and severity of punishment will help gauge the amount of guilt the parent will feel if it turns out the child's bowel habits are not under their control (see demystification below). Enuresis is a commonly associated condition and should be asked about. Finally, emotional, social, and family issues should be explored. As mentioned briefly above children can become isolated, anxious, angry, and/or depressed because of this condition.
Physical Exam and X-ray. Key elements of the physical include a good abdominal, genital, and rectal exam. Often a large mass can be observed on the abdominal exam especially if the encopresis has been longstanding. The finding of a large amount of impacted stool in the rectal ampulla is confirmatory and common. Normal lower extremity strength, sensation and normal deep tendon reflexes offer reassurance that this is not neurological in origin. Normal growth of both height and weight similarly is reassuring that a more serious condition like hypothyroidism is not causing retention. The abdominal X-ray is very helpful. Often reported as normal by radiologists, the distended, stool-impacted rectum, with full ascending colon, on abdominal plain film is pathognomonie for retentive encopresis. This initial X-ray can also serve as a baseline for comparison to subsequent films obtained following treatment. No stool in the ampulla with much stool above would suggest Hirsehsprung's disease.
De-mystification and Treatment De-mystification. The first step of the treatment of retentive encopresis involves what Melvin Levine calls "demystification" (2,7). After the parent(s) and child listen to themselves giving the history, it often becomes apparent that something other than simple stubbornness is at the root of the child's problem. Once the physician is sure that
the child has retentive encopresis, she or he must demystify the condition for the family. To do this, I draw a picture for the four-year-old or older child (with the parent looking on) that includes a sketch of the GI tract reflecting the pathogenesis of the condition--the rectum filling with stool because of initial withholding, the subsequent loss of feeling, and the overflow incontinence. Of course all the discussion is done at a language level appropriate for the child. The child should be told that during this process he began to lose feeling, control, and, thus, responsibility for soiling. This will relieve his guilt and transfer it to the parent, whose critical attitude and/or punishments may now seem mean. This is so prevalent that it's commonness should be mentioned as a way of alleviating guilt. After demystifying eneopresis and processing feelings, usually a therapeutic alliance is formed with an agreement to work together, without arguing or blaming, to solve the problem. This leads naturally to the discussion of treatment. Treatment
Treatment involves three phases (7): clean out, maintenance, and long-term follow up. Clean out occurs in days to weeks and maintenance, in months. Both the child and parent (s) should be included in discussions about treatment because the child's willing involvement is crucial to a successful outcome. The family must be motivated. It is assumed here that the encopresis is moderate to severe. For recent, very mild cases a trial of oral laxatives may be effective, The Clean Out Phase. The clean out phase involves three basic approaches: from below (8), from above (9), or a combination of the two (7,10). Clean out from below involves giving two to three large (500-750 cc), warm, normal saline enemas per day over a 34 day span (8). This is the fastest way to accomplish clean out and stop soiling. This approach works best when the child and parent are highly motivated and the child has a good relationship with his parents. Otherwise, the child's already diminished sense of control could be reduced further, If started on Friday right after school, this regimen can be accomplished over the weekend.
The combination approach involves a three day sequence (7) with a Fleets enema on day one, a Dulcolax suppository on day two, twice a day, and a Duleolax oral tablet on day three, twice a day. This three day sequence can be repeated 2 - 4 times until the clean out is accomplished. The end point occurs when either a massive bowel movement is had and/or soiling has stopped and bowel movements appear fairly normal. The approach from above involves either mineral oil (11) or Go-lytely (9). The mineral oil approach involves 1530 cos of oil per year of age, with a maximum of 8 oz per day divided, if necessary, into two or three aliquots, The mineral oil can be refrigerated, mixed in orange juice or chocolate milk and is fairly well-tolerated this way. Mineral oil clean outs can be effective over three to four days. A pad for the inevitable leakage can be worn in the underwear during this time. The Golytely approach is the same as preparation for surgical procedures and one only needs to follow the directions on the bottle. The bitter taste is not easily tolerated orally by children but for some children it is effective. The Maintenance Phase. Following the clean out a repeat X-ray may be obtained to make sure the clean out was successful or one may go on clinical impression, especially if the parents are reliable. The maintenance phase involves regular sitting on the toilet, laxatives/ lubricants, and behavioral tracking. Some excellent studies have shown that simply having the child sit regularly, with disincentives for soiling and rewards for continence will result in about half the children being successful ( 12 ). Regular sitting involves at least two and preferably three, ten minute periods on the toilet after meals to reinstitute the gastroeolie reflex. Introducing more fiber either through food or supplements will help feeling return to the rectum. Laxatives like Dulcolax can be continued for up to three weeks without producing dependance and will keep the "going" so he does not re-accumulate stool, and this will allow the rectum to return to normal size. Subsequently, 1 3 oz. of mineral oil per day in divided doses should be used to lubricate the bowel. Leakage, in the maintenance
125
phase, indicates too large a dose. This phase will last for 3 - 6 months depending on the severity of the condition, with an occasional return to laxatives if constipation or lack of daily defecation recurs. Mineral oil theoretically can absorb fat soluble vitamins but empirical studies have failed to show nutritional deficits from long-term mineral oil use. Nonetheless, giving mineral oil between meals and using a multivitamin supplement may be prudent. Finally, some form of behavioral tracking chart with built in incentives and disincentives complete the maintenance program. These daily charts should document, with stars or stickers, sitting episodes, number of stools in the toilet, and accident free-days. Incentives should be agreed upon with an emphasis on making early successes easy to obtain. Long-term Follow up. Regular follow up will enhance success enormously. The treatment of encopresis is complex with many variables. I briefly talks to the child and parents by phone during the first one or two days of clean out to assess the adequacy of the effort and the results. The family is seen back in one week and then monthly for brief visits to review the tracking chart. The biggest problem early in the treatment is, ironically, the initial success. Many children stop soiling and the parents become complacent. They must be told repeatedly that this is a long-term process. The most important sign of success is the return of feeling, a sense that the child "has to go." With that, the regimen can be gradually tapered off. Conclusion and Prognosis Ten percent of children with encopresis will have long-term soiling problems and should probably be referred to a gastroenterologist for more thorough assessments that might include anorectal manometry and/or biofeedback. Another 20-25% will do well initially but relapse and do well on subsequent trials of therapy. It might take a while for them to gain complete independence. The continued support of the primary physician, who can continue to provide palliative care, is important to these children and their families. Such care can include the use of biologically active
R. Solomon
underwear, deodorant sprays, panty liners, a n d / o r the assistance of an incontinence specialist. Using the comprehensive approach described to treat the child with retentive encopresis, the physician can expect to be completely successful with 65% of cases. This condition is so demoralizing and destructive to a child's self esteem that being able to work together to help the child regain control over his life again is a very gratifying experience.
References 1. Rutter M. Tizard J, Whitmore K. Education, health and behavior. Psychological and medical study of childhood development. New York: Wiley, 1970: 219-220. 2. Imvine MD. "Encopresis" in Develop-
MEDICAL UPDATE FOR PSYCHIATRISTS
3.
4.
5.
6.
,rwntal/Behav Pediatr. Imvine MD, Carey WB, Crocker AC and Gross RT, (eds) 1983, WB Saunders Co. Philadelphia, pp 586-594. lmening-Baueke V. Modulation of abnormal defecation d~mmics by biofeedback treatment in chronically eoustipated children with enc~presis. ] Pedia> 1990; 116:'214-222. Achenbaeh TM, Lewis M. A proposed model for clinical research and its application to encopresis and enuresis. J Am Acad Child Adolesc PsychiatW 1971; 10:5&5-554. Boon F. Comorbidig' of attention deficit hyperactivib, disorder mad other disorders. Am J Esychiatry 1992; 149( 1 ):148149. Nolan T, Oberklaid F. New concepts in the management of encopresis. Behav Pediatrics 1993; ( 14 ) :447-451.
12G
7. Imvine MD, Bakow H. Children with encopresis: A study of treatment outcome. Pediatr 1976; 68:845-&52. 8. Miller RE. The cleansing enema, Radiology 197.5;117:483-485. 9. Ingebo KR, Heyman MB. Polyethylene glyc~-eleetrol3~'te solution for intestinal clearance in children with refraetory encopresis. AJDC 1988; 142:,340-342. 10. Nolan T, Debelle G, Oberklaid F, Coffey C. Randomized trial of laxatives in treatment of chikthood encopresis. Lancet 1991; ( 33 ) :,523-.527. I1. Gleghom EE, Heyman MB, Rudolph CD. No-enema therapy for idiopathic constipation and eneopresis. Clin Ped 1991;( 30 ):669-672. 12. Howe AC, Walker CE. Behavioral management of toilet training, enuresis, and eneopresis. Pecl Clin N Amer 1922; (39) :413-432.
Richard Solomon, MD DEPARTMENT OF PEDIATRICS, MEDICAL COLLEGE OF PENNSYLVANIA/ HAHNEMANN, ALLEGHENY GENERAL HOSPITAL CAMPUS, PITTSBURGH, PENNSYLVANIA
Pediatrics Update Abstract
Encopresis or chronic fecal soiling is a common and misunderstood condition that is often devastating to the affected child's self esteem. By "demystifying" the pathogenesis of en-
copresis, the physician can relieve guilt, offer hope, and f o r m a therapeutic alliance with the child and his
parents. Proved, effective treatments that combine physical, medical, and behavioral modalities lead to a cure in over 65% and substantial improvement in over 90%. MEDICAL UPDATE FOR PSYCHIATRISTS 1;4:123-126, 1996.
Introduction
The Presentation A school-age child with encopresis typically arrives at the physician's office embarrassed and embattled. He has tried to hide "the problem" from his family and friends and failed. His family rarely understands that the soiling has become uncontrollable, so they blame him and/ or punish him, sometimes severely. The child first feels angry, then helpless, then resigned. Because these children often accommodate to the smell and have no feeling of defecation, they don't know when they have soiled and when they smell. Among their peers this triggers teasing that is terribly demoralizing. It's no surprise that a large percentage of children with this condition appeared depressed on presentation. In the office, the child appears embarrassed, with eyes lowered, and will not volunteer the reason for his visit, but he is deeply hopeful that the physician has a solution.
The Approach The understanding, evaluation, and treatment of encopresis has evolved over the last 20 years to the point where approximately 65% of children with encopresis will attain a long-lasting remission with another 30% being substantially improved. There is reason to offer hope to children presenting with fecal soiling. The approach is four-fold. First, knowledge of the most common pathogenesis for retentive encopresis along with a thoughtful differential diagnosis will guide the evaluation. Second, demystification of the condition will lead to a therapeutic alliance with the child and parents. Third, knowledge of treatment options will improve compliance.
© 199G Elsevier Science Inc. MSN i082-/b'79/OG/SlS.00 Pli SlQ82-7b-7919GIOOO55-G
Address reprint requests to: Dr. Richard Soloanon,Dept. of Pediatrics,AlleghenyGeneralHospital, 320 East North Avenue, Pittsburgh PA 15212.
And finally, close and long-term followup will increase the chances of longterm success. Pathogenesis, DmerenUal Diagnosis, a n d Evaluation
Encopresis is defined as repeated, involuntary defecation into clothing occurring in children 4 years of age and older, of at least 1 month's duration. Boys are 3 times more likely to have this condition with 2.3% of 7-8-year-aids having the condition (1).
Pathogenesis In the vast majority, the pathogenesis of retentive encopresis involves initial, voluntary withholding of stool but, due to constipation, pain on defecation, toilet phobia, or a stubborn response to toileting, the voluntary withholding evolves into involuntary retention. The retention results in an enlarging rectal vault that can accommodate an enormous amount of stool. This widening rectum becomes progressively less sensitive to stretching and peristalsis and results in the elimination of the defecation reflex, i.e., the child loses sensation. Subsequently, the accumulating stool overflows, usually in daily smears, into the child's underwear, also known as overflow incontinence (2). Recent physiologic studies also recognize abnormalities of external anal sphincter contraction and rectal hyposensitivity (in up to 40%) as contributing factors (3). Psychoanalytic interpretations of retentive encopresis have been debunked by Achenbach and Lewis (4). The Differential Diagnosis The differential diagnosis includes other forms of soiling related to (a) irritable bowel syndrome with stress-related soiling and (b) manipulative soiling. Both conditions are uncommon in children and have characteristic patterns. Retentive encopresis usually has daily smears of stool in the child's underwear that
R. Solomoil
are not directly related to stress. In manipulative soiling the child will consistently have normal-sized bowel movements in his underwear, not smears. Children with retentive encopresis may appear manipulative, making it sometimes hard to differentiate from the true manipulative soiler. They may hide their underwear to avoid embarrassment and punishment, they will not notice that they have soiled because they accommodate to the smell, and they may deny soiling even as they smell of stool as a psychological defense. But they are not soiling on purpose. Also in the differential diagnosis are associated physical conditions like (a) enuresis and (b) severe constipation, both of which have implications for therapy. Most experts recommend treating enuresis after encopresis because the act of withholding or retaining stool interferes with mieturition reflexes. The evaluation for enuresis should be considered separately. Severe constipation may be common in this population, but should be addressed as part of the overall treatment approach to the encopresis. Associated behavioral and psychological conditions like (a) attention deficit hyperactivity disorder (ADHD), (b) oppositional defiant disorder ( ODD ), (c) anxiety, (d) depression, and (e) child abuse, must also be considered. About 30% of children who have encopresis will have emotional maladjustment in the clinically referable range at initial presentation. In this and other authors' experience, the assoeiation between ADHD and encopresis is significant (5). Children who don't attend well to physiologic cues and/or are too busy playing to respond are likely candidates for this condilSon. Because the rest of these conditions are well within the realm of psychiatry little more needs to be said about them except that reactive depression is common and disappears with treatment, ODD makes the treatment approach more difficult, and child abuse as a cause of encopresis is rare. Finally, the serious medical conditions that must be considered in the differential diagnosis include (a) Hirsehsprung's disease, (b) spina bifida oceulta, and (c) hypothyroidism. Hirsehsprnng's disease is rare even in encopretics and the child who has it usually does not soil, but in rare instances may. The classic history of lack of normal bowel movements from birth should raise concerns.
MEDICAL UPDATE FOR PSYCHIATRISTS
Spina bifida oceulta is an occult condition that is only rarely associated with involuntary soiling and wetting. On physical exam the lower extremities would reveal decreased sensation and hyperactive deep-tendon reflexes. Hypothyroidism can cause constipation, but would also be associated with poor growth and development as well as other vegetative symptoms.
Evaluation Much of the evaluation is implied from the discussion of the differential diagnosis above, but key elements of the history, physical, and laboratory assessment will be discussed below (6). History. Important in the history are soiling details that include whether this is primary encopresis, i.e., the child was never toilet trained, or secondary. Primary encopresis often occurs in the context of the late toilet training of threeand four-year-olds who start to withhold out of stubbornness or other control issues. Secondary encopresis, i.e., soiling after achieving continence, most commonly occurs within the context of severe pain on defecation resulting in withholding or when the child starts school and changes toileting regimens. Many five- and six-year-old children wifl not go to the toilet in school and thus learn to ignore urges that result in retention. Once the problem begins it tends to be self perpetuating and can go on for years before it comes to the physician's attention. So, duration of soiling, precipitating events, frequency of soiling episodes, and consistency and quantity of soiled stool help to establish the diagnosis of retentive encopresis. Both nocturnal episodes and soiling outside underwear are very unusual in retentive encopresis and would suggest manipulation (and anger!). Awareness of the urge to defecate is limited in encopresis and all too conscious in irritable bowel. The physician will rarely hear of a child with retentive encopresis regularly running to the toilet to defecate, although on occasion they may. When they do have a stool in the toilet the mother will be dismayed at how large it is, the so called "mega-stools" associated with retentive encopresis. However, most often, these children are completely unaware of soiling episodes.
124
Other toileting issues should also be explored at length like resistance to toileting and stubborn child (and parent) temperament. Knowing about past efforts at treatment is very helpful for knowing where to begin with a treatment approach and about the level of frustration the family and child have faced. Asking matter-of-factly about types and severity of punishment will help gauge the amount of guilt the parent will feel if it turns out the child's bowel habits are not under their control (see demystification below). Enuresis is a commonly associated condition and should be asked about. Finally, emotional, social, and family issues should be explored. As mentioned briefly above children can become isolated, anxious, angry, and/or depressed because of this condition.
Physical Exam and X-ray. Key elements of the physical include a good abdominal, genital, and rectal exam. Often a large mass can be observed on the abdominal exam especially if the encopresis has been longstanding. The finding of a large amount of impacted stool in the rectal ampulla is confirmatory and common. Normal lower extremity strength, sensation and normal deep tendon reflexes offer reassurance that this is not neurological in origin. Normal growth of both height and weight similarly is reassuring that a more serious condition like hypothyroidism is not causing retention. The abdominal X-ray is very helpful. Often reported as normal by radiologists, the distended, stool-impacted rectum, with full ascending colon, on abdominal plain film is pathognomonie for retentive encopresis. This initial X-ray can also serve as a baseline for comparison to subsequent films obtained following treatment. No stool in the ampulla with much stool above would suggest Hirsehsprung's disease.
De-mystification and Treatment De-mystification. The first step of the treatment of retentive encopresis involves what Melvin Levine calls "demystification" (2,7). After the parent(s) and child listen to themselves giving the history, it often becomes apparent that something other than simple stubbornness is at the root of the child's problem. Once the physician is sure that
the child has retentive encopresis, she or he must demystify the condition for the family. To do this, I draw a picture for the four-year-old or older child (with the parent looking on) that includes a sketch of the GI tract reflecting the pathogenesis of the condition--the rectum filling with stool because of initial withholding, the subsequent loss of feeling, and the overflow incontinence. Of course all the discussion is done at a language level appropriate for the child. The child should be told that during this process he began to lose feeling, control, and, thus, responsibility for soiling. This will relieve his guilt and transfer it to the parent, whose critical attitude and/or punishments may now seem mean. This is so prevalent that it's commonness should be mentioned as a way of alleviating guilt. After demystifying eneopresis and processing feelings, usually a therapeutic alliance is formed with an agreement to work together, without arguing or blaming, to solve the problem. This leads naturally to the discussion of treatment. Treatment
Treatment involves three phases (7): clean out, maintenance, and long-term follow up. Clean out occurs in days to weeks and maintenance, in months. Both the child and parent (s) should be included in discussions about treatment because the child's willing involvement is crucial to a successful outcome. The family must be motivated. It is assumed here that the encopresis is moderate to severe. For recent, very mild cases a trial of oral laxatives may be effective, The Clean Out Phase. The clean out phase involves three basic approaches: from below (8), from above (9), or a combination of the two (7,10). Clean out from below involves giving two to three large (500-750 cc), warm, normal saline enemas per day over a 34 day span (8). This is the fastest way to accomplish clean out and stop soiling. This approach works best when the child and parent are highly motivated and the child has a good relationship with his parents. Otherwise, the child's already diminished sense of control could be reduced further, If started on Friday right after school, this regimen can be accomplished over the weekend.
The combination approach involves a three day sequence (7) with a Fleets enema on day one, a Dulcolax suppository on day two, twice a day, and a Duleolax oral tablet on day three, twice a day. This three day sequence can be repeated 2 - 4 times until the clean out is accomplished. The end point occurs when either a massive bowel movement is had and/or soiling has stopped and bowel movements appear fairly normal. The approach from above involves either mineral oil (11) or Go-lytely (9). The mineral oil approach involves 1530 cos of oil per year of age, with a maximum of 8 oz per day divided, if necessary, into two or three aliquots, The mineral oil can be refrigerated, mixed in orange juice or chocolate milk and is fairly well-tolerated this way. Mineral oil clean outs can be effective over three to four days. A pad for the inevitable leakage can be worn in the underwear during this time. The Golytely approach is the same as preparation for surgical procedures and one only needs to follow the directions on the bottle. The bitter taste is not easily tolerated orally by children but for some children it is effective. The Maintenance Phase. Following the clean out a repeat X-ray may be obtained to make sure the clean out was successful or one may go on clinical impression, especially if the parents are reliable. The maintenance phase involves regular sitting on the toilet, laxatives/ lubricants, and behavioral tracking. Some excellent studies have shown that simply having the child sit regularly, with disincentives for soiling and rewards for continence will result in about half the children being successful ( 12 ). Regular sitting involves at least two and preferably three, ten minute periods on the toilet after meals to reinstitute the gastroeolie reflex. Introducing more fiber either through food or supplements will help feeling return to the rectum. Laxatives like Dulcolax can be continued for up to three weeks without producing dependance and will keep the "going" so he does not re-accumulate stool, and this will allow the rectum to return to normal size. Subsequently, 1 3 oz. of mineral oil per day in divided doses should be used to lubricate the bowel. Leakage, in the maintenance
125
phase, indicates too large a dose. This phase will last for 3 - 6 months depending on the severity of the condition, with an occasional return to laxatives if constipation or lack of daily defecation recurs. Mineral oil theoretically can absorb fat soluble vitamins but empirical studies have failed to show nutritional deficits from long-term mineral oil use. Nonetheless, giving mineral oil between meals and using a multivitamin supplement may be prudent. Finally, some form of behavioral tracking chart with built in incentives and disincentives complete the maintenance program. These daily charts should document, with stars or stickers, sitting episodes, number of stools in the toilet, and accident free-days. Incentives should be agreed upon with an emphasis on making early successes easy to obtain. Long-term Follow up. Regular follow up will enhance success enormously. The treatment of encopresis is complex with many variables. I briefly talks to the child and parents by phone during the first one or two days of clean out to assess the adequacy of the effort and the results. The family is seen back in one week and then monthly for brief visits to review the tracking chart. The biggest problem early in the treatment is, ironically, the initial success. Many children stop soiling and the parents become complacent. They must be told repeatedly that this is a long-term process. The most important sign of success is the return of feeling, a sense that the child "has to go." With that, the regimen can be gradually tapered off. Conclusion and Prognosis Ten percent of children with encopresis will have long-term soiling problems and should probably be referred to a gastroenterologist for more thorough assessments that might include anorectal manometry and/or biofeedback. Another 20-25% will do well initially but relapse and do well on subsequent trials of therapy. It might take a while for them to gain complete independence. The continued support of the primary physician, who can continue to provide palliative care, is important to these children and their families. Such care can include the use of biologically active
R. Solomon
underwear, deodorant sprays, panty liners, a n d / o r the assistance of an incontinence specialist. Using the comprehensive approach described to treat the child with retentive encopresis, the physician can expect to be completely successful with 65% of cases. This condition is so demoralizing and destructive to a child's self esteem that being able to work together to help the child regain control over his life again is a very gratifying experience.
References 1. Rutter M. Tizard J, Whitmore K. Education, health and behavior. Psychological and medical study of childhood development. New York: Wiley, 1970: 219-220. 2. Imvine MD. "Encopresis" in Develop-
MEDICAL UPDATE FOR PSYCHIATRISTS
3.
4.
5.
6.
,rwntal/Behav Pediatr. Imvine MD, Carey WB, Crocker AC and Gross RT, (eds) 1983, WB Saunders Co. Philadelphia, pp 586-594. lmening-Baueke V. Modulation of abnormal defecation d~mmics by biofeedback treatment in chronically eoustipated children with enc~presis. ] Pedia> 1990; 116:'214-222. Achenbaeh TM, Lewis M. A proposed model for clinical research and its application to encopresis and enuresis. J Am Acad Child Adolesc PsychiatW 1971; 10:5&5-554. Boon F. Comorbidig' of attention deficit hyperactivib, disorder mad other disorders. Am J Esychiatry 1992; 149( 1 ):148149. Nolan T, Oberklaid F. New concepts in the management of encopresis. Behav Pediatrics 1993; ( 14 ) :447-451.
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7. Imvine MD, Bakow H. Children with encopresis: A study of treatment outcome. Pediatr 1976; 68:845-&52. 8. Miller RE. The cleansing enema, Radiology 197.5;117:483-485. 9. Ingebo KR, Heyman MB. Polyethylene glyc~-eleetrol3~'te solution for intestinal clearance in children with refraetory encopresis. AJDC 1988; 142:,340-342. 10. Nolan T, Debelle G, Oberklaid F, Coffey C. Randomized trial of laxatives in treatment of chikthood encopresis. Lancet 1991; ( 33 ) :,523-.527. I1. Gleghom EE, Heyman MB, Rudolph CD. No-enema therapy for idiopathic constipation and eneopresis. Clin Ped 1991;( 30 ):669-672. 12. Howe AC, Walker CE. Behavioral management of toilet training, enuresis, and eneopresis. Pecl Clin N Amer 1922; (39) :413-432.