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Although many different regimens have been
developed for the treatment of encopresis, most rely on
the following principles:
• Empty the colon of stool
• Establish regular soft and painless bowel movements
• Maintain very regular bowel habits
While there is almost always a large behavioral
component to chronic encopresis, behavioral therapy alone,
such as offering rewards or reasoning with the child, usually
is not effective. Rather, a combination of medical and behavioral
therapy works best.
Medical professionals usually refer to emptying
stool from the colon and rectum as evacuation or disimpaction.
Evacuation can be accomplished in the following ways:
• Administer an enema or series of
enemas: An enema pushes fluid into the rectum. This
softens the stool in the rectum and creates pressure
within
the rectum. This pressure gives the child a powerful urge
to pass a bowel movement, and the stool is usually
expelled
rapidly. The fluid in most enemas is water. Something
is usually added
to keep the water from being absorbed by the intestinal
lining. Widely used enemas include commercial
phosphosoda preparations (such as Fleet saline enemas),
slightly soapy water, and milk and molasses mixtures.
Daily
enemas for several days may be needed to completely evacuate
the colon.
• Administer a suppository or a series
of suppositories: A suppository is a tablet or capsule
that is inserted into the rectum. The suppository is
made
of a substance that stimulates the rectum to contract and
expel stool. Popular suppositories include glycerin
and
commercial products such as Dulcolax and Babylax. Daily
suppositories for several days may be needed to completely
evacuate the colon.
• Administer strong laxatives: Most
laxatives work by increasing the amount of water in the
large intestine. Some laxatives cause the lower intestine
to secrete water and others work by decreasing the amount
of water absorbed in the lower intestine. In either case,
the end result is much more water in the lower intestine
when using laxatives than when not using them. This large
amount of water softens formed or hard stool in the intestine
and produces diarrhea. Laxatives used for this purpose
include
magnesium citrate, GoLYTELY, COLYTE, and Fleet Phospho-soda.
Treatment for several days may be needed to completely
evacuate
the colon.
Establishing regular soft and painless bowel
movements is mostly a matter of retraining the child to
give up the habit of retaining stool. This is accomplished
by giving laxatives every day to produce soft bowel movements.
The laxative must be given in doses large enough to produce
1 or 2 soft bowel movements every day. The soft stool will
be passed easily and painlessly, encouraging the child
to
have regular bowel movements rather than holding the stool
in. See Medications
for a list of commonly used laxatives. Remember that fecal
retention and soiling go together. So, as long as the child
has retained stool in the rectum, the soiling will persist.
The final step is working with the child to
develop regular bowel habits. This step is just as critical
as the first 2 steps and must not be abandoned just because
the soiling has improved after the previous steps
• Establish regular bathroom times: The child
should sit on the toilet for 5-10 minutes after breakfast
and again after dinner EVERY DAY. Some families must
alter their daily routines to accomplish this, but it is
a crucial step, particularly for school-aged children.
Sitting
on the toilet right after a meal takes advantage of the
"gastrocolic reflex," intestinal contractions
that naturally occur after eating.
• Behavioral techniques: Offer
age-appropriate positive reinforcement for developing regular
toilet habits. For young children, a star or sticker chart
can be helpful. For older children, earning privileges,
such as extra television or video game time, may be useful.
• Training: Children may respond
to teaching about the appropriate use of muscles and other
physical responses during defecation. This helps them learn
how to recognize the urge to have a bowel movement and to
defecate effectively.
• Biofeedback: This technique
has been used successfully to teach some children how to
best use their abdominal, pelvic and anal sphincter muscles,
which they have so often used to retain stool.
The duration of treatment varies from child
to child. Treatment should continue until the child has
developed regular and reliable bowel habits and has broken
the habit of holding back his or her stool. This usually
takes at least several months. Generally, it takes longer
in younger children than in older children.
Many parents are reluctant to give their
child laxatives because they have heard that laxatives
are harmful,
cause more serious conditions (such as colon cancer) or
promote dependency. There is no convincing evidence that
any of
these are true. Laxatives do not stop working if they are
used every day for a long time.
Most cases of encopresis respond to the treatment
regimen outlined above. If the soiling does not resolve,
your child's
health care provider may refer you to a specialist in digestive
and intestinal disorders
(pediatric gastroenterologist), a behavioral psychologist,
or both.
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