Encopresis is the soiling of the underwear with stool by children who are past the age of toilet training. Because each child achieves bowel control at his or her own rate, medical professionals do not consider stool soiling to be a medical condition unless the child is at least 4 years old. This stool or fecal soiling usually has a physical origin and is involuntary—the child does not soil on purpose. A large amount of hard stool is in the intestine, and stool leaks around this mass and out through the anus.

In the United States, it is estimated that 1-2% of children younger than 10 years are affected by encopresis. Many more boys than girls experience encopresis; approximately 80% of affected children are boys.

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.

Children with encopresis often feel ashamed and may wish to avoid situations (such as camp or school) that might lead to embarrassment. The amount of impairment is a function of the effect on the child's self-esteem, the degree of social ostracism by peers, and the anger [resentment], punishment, and [or] rejection on the part of caregivers [parents, grandparents, teachers, daycare providers, and so on].

Attempts to treat encopresis at a purely mechanical level frequently become a constant source of frustruation to the family and the health care provider alike... In the majority of cases, by the time the problem has been brought to the surface, psychological and social disruption have already occurred, at times very seriously. Undoing the damage to the child's self-image and dealing with parental anger and ambivalence is not an easy task and requires time, sensitivity, and patience.

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.

More than 80% of children with encopresis have experienced constipation or painful defecation in the past. In many cases, constipation or pain occurred years before the encopresis is brought to medical attention.

• Most children with encopresis say they have no urge to pass a bowel movement before they soil their underwear.
• Soiling episodes usually occur during the day, while the child is awake and active. Many school age children soil late in the afternoon after returning home from school. Soiling at night is uncommon.
• In many children with encopresis, the colon has become stretched out of shape, so they may intermittently pass extremely large bowel movements.

Any of the following warrants a visit to your child's primary care provider:

• Severe, persistent, or recurrent constipation
• Pain when passing bowel movements
• Reluctance to pass bowel movements, including straining to hold stool in
• Soiling in a child who is at least 4 years old