1. APPROACH TO ENCOPRESIS Sept 1, 2011 Jody Patrick PGY-3

2. Objectives  Define the types of encopresis  Outline the many possible etiologies, focusing on the most common  Review key points on history and PE  Use of appropriate investigations  Discuss common treatment approaches  Have fun!

3. Definition: Encopresis  Involuntary fecal soiling in adults and children who have usually already been toilet trained (over the age of 4)

4. Definition  Subtypes:  Retentive encopresis: with constipation and overflow incontinence (80-95%)  Non-retentive encopresis: no constipation and overflow incontinence Soil on daily basis, stools are normal consistency & form 99% is non organic etiology Four subgroups: Never have achieved toilet training Have toilet “phobia” Use toileting to manipulate their environment Irritable bowel syndrome

5. Prevalence  Estimated between 1-3% of 4 year olds, decreasing as children get older  Male : Female approx 6:1

6. Etiology  Most Common Cause is Constipation  Vicious cycle of painful, hard stools, avoidance of bowel movement  Stretching of rectum/colon, decreased sensation  RAIR (Rectal Anal Inhibitory Reflex) is lost  Leakage around hardened stool (overflow)  At risk times for developing constipation include:  Dietary switch to solid food  Toilet training  The start of school  Must rule out possible organic etiologies  Remember psychosocial factors as well

7. Diagnosis  DSM-IV diagnostic criteria:  Repeat passage of feces into inappropriate places (eg clothing or floor) whether voluntary or unintentional  At least one such event a month for at least 3 months  Chronological age of at least 4 years (or equivalent developmental level)  The behaviour is not exclusively due to a physiological effect of a substance (eg laxatives) or a general medical condition, except through a mechanism involving constipation.

8. Diagnosis  Important points on History:  History Stool pattern: Size, Consistency, Interval, Straining, Blood History of constipation: Age of onset Passage of newborn meconium History of soiling: Age of onset, Type and amount of material Toilet training: age, difficulties Diet history: Type and amount of food, Changes in diet, Appetite Abdominal pain: Night pain, Missing school Constitutional symptoms Medications Urinary symptoms: Day or night enuresis, Urinary tract infection Family history of constipation Family or personal stressors: birth of sibling, abuse Behavioural difficulties: noncompliance, ODD, aggression, tantrums

10. Diagnosis  Physical examination  Height  Weight  Abdominal examination: distention, mass, especially suprapubic  Rectal examination: sacral dimple, position of anus, anal fissures, anal wink, sphincter tone, rectal vault size, presence or absence of stool in rectum, pelvic mass  Neurologic examination

11. Differential Diagnosis  Retentive  Functional constipation (95 percent)  Organic (5 percent)  Anal causes: Fissures, Stenosis/atresia with fistula, Anterior displacement of anus, Trauma, Postsurgical repair  Neurogenic causes: Hirschsprung's disease, Chronic intestinal psuedo-obstruction, Spinal cord disorders, Cerebral palsy/hypotonia, Pelvic mass  Neuromuscular disease  Endocrine/metabolic causes: Hypothyroidism, Hypercalcemia, Lead intoxication  Drugs: Codeine, Antacids, Others

12. Differential Diagnosis  Nonretentive  Nonorganic (99 percent)  Organic (1 percent)  Severe ulcerative colitis  Acquired spinal cord disease (i.e., sacral lipoma, spinal cord tumor)  Rectoperineal fistula with imperforate anus  Postsurgical damage to anal sphincter

13. Investigations  Depend on outcome of Hx & PE  If suggestive of constipation with no obvious organic etiology, no further investigations required  If unclear: consider flat plate of abdomen  If failed conservative Rx, suspicious for organic cause or non retentive pattern of soiling, consider: Bloodwork (endocrine, metabolic) Barium enema (Hirschprung’s, fistulae) Rectal manometry, biopsy Referral to GI or GS

14. Treatment  Retentive (functional constipation)  Standard 3 pronged approach: Clean Out Maintain Soft Stools Behavioural strategies  Non Retentive  Address behaviours  Toilet routine  Soft bowel movement  Use of incentives  Other aids for encopresis  Internet intervention  Psychological counselling

15. Treatment  Clean Out  From above or below Enema Stool softener, lubricants Nasogastric electrolyte solution Manual disimpaction in severe cases  Avoid stimulant laxatives

16. Treatment  Maintenance with stool softeners/lubricants  Lactulose  PEG 3350  Colace  Mineral oil (>1yr)  Can take several months to break cycle  Goal is one soft formed stool daily  Distended bowel takes months to regain tone and sensitivity

18. Treatment  Behavioural strategies  Regular post prandial toileting times  Limit time on toilet to 10-15 mins  Stool diary

19. Treatment  Non Retentive Encopresis  Address behaviour Is child developmentally ready? Avoid toileting battles, take a break Address aggressive or oppositional behaviours first, may require behavioural counselling Address toilet refusal: positive experiences sitting on toilet  Scheduled post prandial toileting times  Maintain soft bowel movements  Use Incentives for appropriate toileting

20. Other strategies  Dietary management  Increase fibre intake  Increase fluid intake  Avoidance of constipating foods  Internet Intervention:  Multiple small group studies using an internet based guide for families  Has shown improvement in fecal accidents www.ucanpooptoo.com  Resources, books Beating Sneaky Poo, many, many others…. No evidence that this actually helps Better in maintenance therapy

22. References  Christophersen ER, Rapoff MA. Toileting problems in children. In: Walker CE, Roberts MC, eds. Handbook of clinical child psychology. 2d ed. New York: Wiley, 1992;399-411  BRETT R. KUHN, PH.D., BETHANY A. MARCUS, PH.D., and SHERYL L. PITNER Treatment Guidelines for Primary Nonretentive Encopresis and Stool Toileting Refusal American Family Physician  Wikipedia, encopresis http://en.wikipedia.org/wiki/Encopresishttp://en.wikipedia.org/wiki/Encopresis  Up to Date: Diagnosis and management of encopresis in children  Schmitt BD. Encopresis. Prim Care 1984;11:497-511.  Loening-Baucke V. Fecal incontinence in children. Am Fam Physician 1997;55:2229-38.