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Rarely, encopresis is caused by an anatomic
abnormality or disease that the child is born with. In the
great majority of cases, encopresis develops as a result
of chronic (long-standing) constipation.
What is constipation? Many people think of
constipation as not passing a bowel movement every day.
However constipation implies not only infrequent bowel movements,
but also having difficulty or experiencing pain with the
passage of bowel movements. Pain is usually the initial
problem when bowel movements are hard and difficult to pass.
• Each person has his or her own schedule
for bowel movements, and many healthy people do pass a bowel
movement every day.
• A constipated child might pass a bowel movement every
third day or less often.
• More importantly, the constipated child tends to
pass large and hard stools and experience pain while doing
so.
In most children with encopresis, the problem
begins with passing very large stools or having pain while
passing stools. This may have happened long before the encopresis
starts, and the child may not remember this when asked.
• Over time, the child becomes reluctant
to pass bowel movements and holds it in to avoid the pain.
• This "holding in" becomes a habit that
often remains long after the constipation or pain with passing
bowel movements has resolved.
As more and more stool collects in the child's
lower intestine (colon), the colon slowly stretches (sometimes
called megacolon).
• As the colon stretches more and more,
the child loses the natural urge to pass a bowel movement.
• Eventually, looser, partly formed stool from higher
up in the intestine leaks around the large collection of
harder, more formed stool at the bottom of the colon (rectum)
and then leaks out of the anus (the opening from the rectum
to the outside of the body).
• Often in the beginning, only small amounts of stool
leaks out, producing streaks in the child's underwear. Typically,
parents assume the child isn't wiping very well after passing
a bowel movement, and they don't worry about the smears.
• As time goes on, the child is less and less able
to hold the stool in—more and more stool leaks, and
eventually the child passes entire bowel movements into
his or her underwear.
• Often the child is not aware that he or she has passed
a bowel movement.
• Because the stool is not passing normally through
the colon, it often becomes very dark and sticky and may
have a very foul smell.
Over time, the child with encopresis may
also develop incoordination of the muscles used to pass
bowel
movements. In many children, the anal sphincter contracts
rather than relaxes when they are trying to push out bowel
movements. This disturbed coordination of muscle function,
which causes fecal retention, is a key to the diagnosis
and is also called anismus or paradoxic contraction of
the pelvic floor to defecation.
What causes the constipation in the first
place?
• The most common cause of constipation
in children is the passage of large, hard, and PAINFUL bowel
movements. The child "withholds" to avoid pain.
Over time, this results in the bowel movements becoming
larger and harder, and a vicious circle begins.
• Some experts believe children become constipated
when they do not eat enough fiber, but others believe there
is no connection between diet and constipation. There is
no clear evidence that constipation is caused by too little
fiber in the diet.
• Many doctors think that some children become constipated
because they do not drink enough water. However, other doctors
question whether the amount of water ingested has much of
an effect on constipation.
• Constipation does seem to run in certain families.
• For many children, no clear cause of the constipation
can be identified.
Encopresis is a very frustrating condition
for parents. Many parents become angry at the repeated need
to bathe the dirty child and to clean or discard soiled
underwear. Many parents assume the soiling is the result
of the child being lazy or that the child is soiling intentionally
to annoy them. In most cases, this is not the case. Children
with encopresis are no more likely than other children to
have major behavioral or emotional problems. In most cases,
encopresis is involuntary—the child does not soil on
purpose.
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