Encopresis (307.7)

DSM-IV-TR criteria

• A. Repeated passage of feces into inappropriate places, whether involuntary or intentional.
• B. At least one such event a month for at least 3 months
• C. Chronological age is at least 4 years (or equal developmental level)
• D. The behavior is not due exclusively to the direct physiological effects of a substance (e.g. laxatives) or a general medical condition except through a mechanism involving constipation.
• Code as follows:
  • 787.6 – With Constipation and Overflow Incontinence
  • 307.7 – Without Constipation and Overflow Incontinence

Associated features

A child with Encopresis may be embarrassed or ashamed because of the soiling of clothing. They may often avoid social situations (e.g. summer camp or school). A sudden change in routine can also cause an increase in the risk. The soiling can often affect self-esteem in an individual with Encopresis. Smearing of the feces can often be caused by a child’s attempt to clean up the feces. When the incontinence is deliberate it may have an association to Oppositional Defiant Disorder or Conduct Disorder. Many children with Encopresis and chronic constipation are enuretic and may be associated with vesico-ureteric reflux and chronic Urinary tract infections.

Child vs. adult presentation

• Primarily a childhood disorder.
• The disorder usually doesn’t present itself until around the age of 4.

Gender and cultural differences in presentation

The disorder is thought to be more common in males than females, by a ratio of 6 to 1

Epidemiology

The prevalence of this disorder is approximately 1% of 5 year olds. Males are more likely than females to present with this disorder. May effect 1-2% of children under the age of 10. About 90% of cases are due to functional constipation.

Etiology

• There are two types of Encopresis, with constipation and overflow incontinence (787.6) and without constipation and overflow Incontinence (307.7).
• Encopresis without constipation and overflow incontinence: There is no evidence of constipation on physical examination or by history. Feces are likely to be of normal form and consistency, and soiling is intermittent. Feces may be deposited in a prominent location. This is usually associated with the presence of Oppositional Defiant Disorder or Conduct Disorder or may be the consequence of anal masturbation. Soiling without constipation appears to be less common than soiling with constipation.
• Encopresis with constipation and overflow incontinence: There is evidence of constipation on physical examination or a history of a stool frequency of less than three per week. Feces in overflow incontinence are characteristically (but not invariably) poorly formed, and leakage can be infrequent and continuous, occurring mostly during the day and rarely during sleep. Only part of the feces is passed during toileting, and the incontinence resolves after treatment of the constipation.

Empirically supported treatments

• There is typically three phase associated with the treatment process. The three phases of treatment are “cleaning out”, stool softening agents, and scheduled sitting times on the commode. The first phase “cleaning out” consists of an enema or suppository to help promote the removal of fecal matter from the colon. Phase two is often called the top down approach. The use of stool softening agents to help prevent constipation and thus reducing the probability of constipation. Phase three is a non medicated approach. This approach attempts to control excreting fecal matter by assigning specific times to use the restroom, decreasing the risk of constipation.
• Dietary changes are important
• Reduction in the intake of constipating foods such as dairy, peanuts, cooked carrots, and bananas.
• Increase in high-fiber foods such as bran, whole wheat products, and fruits and vegetables.
• Higher intake of liquids, such as juices, although an increased risk of diabetes and/or tooth decay has been attributed to excess intake of sweetened juices.
• *Note*- It is important not to punish or humiliate the child because this does not improve the situation.

Additional information can be found at the Mayo Clinic website on this disorder.