Encopresis in Children: Causes, Symptoms & Treatment

What Is Encopresis and Why Does It Happen?

Encopresis is the repeated passage of feces into inappropriate places (usually underwear) by children who are developmentally old enough to have bowel control, typically over age 4. The most common cause is chronic constipation, which leads to a stretched, desensitized rectum. The child genuinely cannot feel when they need to have a bowel movement.

Encopresis, often called fecal soiling or fecal incontinence, is a condition that affects approximately 1-4% of school-age children. It is significantly more common in boys, who are 3-6 times more likely to be affected than girls. Understanding that encopresis is a medical condition rather than a behavioral problem is the first step toward helping your child recover.

By the age of two to three years, most children develop the ability to recognize when they need to have a bowel movement. They can feel the signals from their bowel indicating it needs to be emptied, and they can control the muscles that allow them to hold or release stool. By age four, the majority of children can reliably communicate their need to use the toilet and can control their bowel movements successfully.

When children beyond this age continue to soil their underwear, it is almost always due to an underlying medical or psychological cause rather than deliberate misbehavior. The child is not choosing to soil; rather, their body's normal signaling system has been disrupted. Understanding this fundamental point is essential for parents, as it shapes the appropriate response: compassion and medical treatment rather than punishment and shame.

How Normal Bowel Control Develops

Normal bowel control relies on a complex interplay between the nervous system, the muscles of the rectum and anus, and the brain. When stool enters the rectum, specialized nerve endings detect the stretching of the rectal wall and send signals to the brain. This creates the sensation of needing to have a bowel movement, often called the defecation reflex.

The child then makes a conscious decision about whether to proceed to the toilet or to delay. If they choose to delay, the muscles of the pelvic floor contract to prevent stool from escaping. When they decide to go, these muscles relax while the abdominal muscles contract to push the stool out. This entire process requires intact nerves, properly functioning muscles, and a normally sized rectum that can detect when it is full.

The Vicious Cycle of Constipation and Soiling

In the vast majority of cases (80-90%), encopresis develops as a consequence of chronic constipation. The process typically unfolds over months or even years. Initially, a child may begin holding in their stool for various reasons: they might be too busy playing to stop for the toilet, they may have experienced painful bowel movements and want to avoid repeating the experience, or they might be resistant to toilet training.

As stool accumulates in the rectum, it becomes larger, harder, and more difficult to pass. The rectum, which is designed to hold moderate amounts of stool temporarily, begins to stretch to accommodate the increasing volume. Over time, this chronic stretching causes the rectal walls to lose their normal elasticity and, most importantly, their sensitivity. The nerve endings that normally detect fullness become desensitized.

At this point, a paradoxical situation develops: the child has large amounts of hard, compacted stool in their rectum, but they cannot feel it. The normal defecation reflex no longer triggers because the stretched rectum no longer sends the appropriate signals to the brain. Meanwhile, newer, softer stool from higher up in the intestine can leak around the hard mass and seep out of the anus. The child often has no warning that this is happening until they notice the mess in their underwear.

What Are the Different Causes of Encopresis?

The causes of encopresis fall into three main categories: constipation-related (80-90% of cases), stress and psychological factors, and rare medical conditions like Hirschsprung's disease. Identifying the underlying cause is essential because treatment approaches differ significantly.

While constipation accounts for the overwhelming majority of encopresis cases, several other factors can cause or contribute to fecal soiling in children. A thorough evaluation by a healthcare provider is important to determine the specific cause in your child's case and to develop an appropriate treatment plan.

Constipation: The Most Common Cause

Chronic constipation is the primary cause of encopresis in 80-90% of affected children. This type is often called retentive encopresis or encopresis with constipation. The child typically has a history of infrequent bowel movements, hard or painful stools, and may have previously been successfully toilet trained before the soiling began.

Multiple factors can trigger the initial constipation that eventually leads to encopresis. Dietary factors play a significant role: insufficient fiber intake, inadequate fluid consumption, and excessive consumption of processed foods or dairy products can all contribute to hard, difficult-to-pass stools. Lifestyle factors such as insufficient physical activity or habitually ignoring the urge to have a bowel movement also contribute.

For some children, toilet training that was too early, too rigid, or associated with negative experiences can lead to stool withholding. A child who experienced a painful bowel movement may become fearful of using the toilet and deliberately hold in their stool to avoid repeating the experience. Ironically, this avoidance makes subsequent bowel movements even larger and more painful, reinforcing the fear and creating a self-perpetuating cycle.

Stress and Psychological Factors

Emotional and psychological factors can cause encopresis independent of constipation, or they can contribute to constipation-related encopresis by triggering stool withholding. This type is sometimes called non-retentive encopresis when constipation is not present.

Stressful life events that may trigger or worsen encopresis include:

• Family disruption: Parental divorce, separation, or significant conflict in the home
• Major life transitions: Moving to a new home, starting a new school, or the birth of a sibling
• Traumatic experiences: Any form of abuse, bullying, or other traumatic events
• Academic or social pressure: Difficulties at school, peer problems, or performance anxiety
• Anxiety or depression: Underlying mental health conditions can manifest with soiling

In stress-related encopresis without constipation, children typically pass formed, normal-sized stools in their underwear rather than the small amounts of leakage seen in constipation-related cases. They were usually previously toilet trained successfully and may have periods without soiling alternating with periods of frequent accidents.

Rare Medical Causes

In a small percentage of cases, encopresis is caused by underlying medical conditions that affect the nerves or muscles of the intestine. While these causes are uncommon, they are important to rule out, particularly in children who do not respond to standard treatment.

Hirschsprung's disease is a congenital condition in which nerve cells (ganglion cells) are missing from a section of the intestine, usually the last part of the colon and rectum. Without these nerve cells, that section of bowel cannot propel stool forward normally. Children with Hirschsprung's disease typically have symptoms from birth, including delayed passage of meconium (first stool), chronic constipation, and poor growth. However, short-segment Hirschsprung's disease may not be diagnosed until later childhood.

Spinal cord abnormalities, including spina bifida, tethered cord syndrome, and spinal tumors, can affect the nerves that control bowel function. Children with these conditions often have other neurological symptoms affecting bladder control, leg strength, or sensation.

Neurological conditions such as cerebral palsy, muscular dystrophy, or developmental delays can make toilet training more challenging and may be associated with encopresis due to difficulties with muscle control, sensory processing, or cognitive understanding of toileting expectations.

When Should You See a Doctor for Encopresis?

Consult a healthcare provider if your child is over 4 years old and regularly soils their underwear, if home treatment for constipation has not improved symptoms, or if an older child or teenager develops soiling. Children under 6 can be seen by a pediatrician or child health nurse, while school-age children may also access support through school health services.

Knowing when to seek professional help is important for getting your child the right treatment. While many cases of mild constipation can be managed at home, encopresis typically requires medical guidance to address effectively. Early intervention can prevent the condition from becoming more severe and more difficult to treat.

You should consult a healthcare provider if:

• Your child is over 4 years old and has frequent or daily soiling accidents
• Your child was previously toilet trained but has started soiling again
• Home treatment for constipation (dietary changes, increased fluids) has not improved symptoms after 2-4 weeks
• Your child has significant abdominal pain, blood in the stool, or other concerning symptoms
• You suspect stress or emotional factors may be contributing to the problem
• Your child is school-age and the soiling is affecting their social life, school performance, or self-esteem

For an older child or teenager who develops soiling, evaluation should be prompt and may include psychological assessment in addition to medical workup. Soiling in this age group often indicates significant distress that requires comprehensive support.

How Can You Help Your Child at Home?

Support your child without shame or blame, as they are not soiling deliberately. Establish calm, regular toilet times after meals, ensure adequate fiber and fluid intake, and communicate with teachers and caregivers to manage situations sensitively. A supportive approach is essential for recovery.

Parents play a crucial role in helping children recover from encopresis. Your approach at home can significantly influence both the effectiveness of medical treatment and your child's emotional wellbeing throughout the process. The foundation of home management is creating a supportive, shame-free environment while implementing practical strategies to address the underlying issues.

Creating a Supportive Environment

The single most important thing you can do is to never punish, shame, or scold your child for soiling accidents. Children with encopresis are not soiling deliberately, and negative reactions will only increase their anxiety and shame while doing nothing to solve the problem. Research consistently shows that punitive approaches worsen outcomes.

When accidents happen, respond calmly and matter-of-factly. Help your child clean up with dignity and without commentary beyond what is necessary. Avoid expressions of disgust, disappointment, or frustration, even if you are feeling these emotions internally. Your child is likely already embarrassed and upset, and seeing that you remain calm helps them feel safe and supported.

Talk with your child about the condition in age-appropriate terms. Help them understand that this is a medical problem, not their fault, and that you are going to work together to fix it. Involving the child as a partner in their treatment, rather than positioning them as the problem, empowers them and improves cooperation with treatment plans.

Establishing Effective Toilet Routines

Regular, relaxed toilet times are essential for retraining the bowel. Have your child sit on the toilet for 5-10 minutes after each main meal, taking advantage of the gastrocolic reflex that naturally stimulates bowel activity after eating. Morning after breakfast is often the most productive time.

Make toilet time comfortable and stress-free:

• Use a footstool so your child's feet are flat and their knees are above their hips - this position makes bowel movements easier
• Ensure privacy - older children especially need to feel they have private space
• Avoid pressure or rushing - do not ask repeatedly if they have "done anything" or hover anxiously
• Allow distractions - reading, listening to music, or playing a calm game can help children relax
• Praise effort, not results - acknowledge that they sat on the toilet as instructed, regardless of whether they had a bowel movement

Managing Constipation Through Diet

If constipation is a factor, dietary modifications can help. Increase fiber intake through fruits, vegetables, whole grains, and legumes. Good fiber sources include apples, pears, berries, broccoli, peas, beans, and whole-wheat bread or pasta. Aim for a variety of fiber sources rather than relying on a single food.

Ensure adequate fluid intake, primarily water. Dehydration makes constipation worse, as the body absorbs more water from the stool in the colon, making it harder. Limit excessive milk consumption, which can contribute to constipation in some children, though modest dairy intake remains important for nutrition.

Reduce processed foods, fast food, and foods with little nutritional value. These tend to be low in fiber and can displace healthier foods in the diet.

Helping at School and in Social Situations

Children with encopresis often dread school and social activities because of the risk of accidents and the fear of being discovered. Practical preparation can reduce this anxiety significantly. Always ensure your child has spare underwear and clothes available at school and other regular activities.

With your child's permission, communicate with teachers, school nurses, and other relevant adults. Most will be understanding and can provide discrete support, such as allowing bathroom breaks without having to ask publicly or providing access to a private bathroom for changing if needed. It is important to get your child's agreement before these conversations, as they need to feel in control of who knows about their condition.

Do not insist your child participate in activities where they feel very vulnerable, such as sleepovers, until the condition is better controlled. However, do encourage continued participation in activities they enjoy, as social isolation can worsen psychological wellbeing and make recovery harder.

How Is Encopresis Diagnosed?

Diagnosis involves a detailed medical history, physical examination including abdominal palpation and often a rectal examination, and sometimes an abdominal X-ray to assess stool loading. The goal is to identify the underlying cause (constipation, psychological factors, or rare medical conditions) and rule out serious conditions like Hirschsprung's disease.

Proper diagnosis of encopresis requires a thorough evaluation by a healthcare provider. This evaluation helps identify the underlying cause, determines the severity of any constipation, and guides treatment decisions. While the process may seem uncomfortable, it is essential for developing an effective treatment plan.

Medical History

The healthcare provider will ask detailed questions about your child's bowel habits and medical history. Be prepared to discuss:

• How often your child has bowel movements and what the stool looks like (size, consistency)
• The nature of the soiling (small leakage or full bowel movements, frequency, timing)
• When the problem started and how it has progressed
• Your child's toilet training history
• Dietary habits and fluid intake
• Any abdominal pain, blood in the stool, or other symptoms
• Any recent stressful events or changes in the family
• Any medications your child takes

Physical Examination

The physical examination typically includes palpation of the abdomen to feel for stool masses, which can often be detected in constipated children. The provider may also perform a rectal examination, inserting a gloved finger into the rectum to assess for impacted stool, rectal tone, and other abnormalities.

While the rectal examination may be uncomfortable, it is quick and provides valuable diagnostic information. Prepare your child by explaining what will happen in simple, honest terms appropriate to their age. Reassure them that it will be brief and that it is an important part of understanding how to help them.

Additional Tests

In some cases, additional tests may be recommended:

• Abdominal X-ray: Shows the extent of stool accumulation in the colon, which can be helpful for demonstrating the severity of constipation to families and guiding treatment intensity
• Blood tests: May be ordered if there are concerns about thyroid function or other medical conditions
• Rectal biopsy: If Hirschsprung's disease is suspected, a small tissue sample from the rectum can confirm or rule out this diagnosis
• Manometry or transit studies: Specialized tests for complex cases that do not respond to standard treatment

How Is Encopresis Treated?

Treatment typically involves three phases: disimpaction to clear backed-up stool, maintenance therapy with laxatives and behavioral strategies to prevent recurrence, and addressing any underlying emotional factors. Treatment usually takes 6-12 months, and it is essential to continue maintenance therapy even after symptoms improve to prevent relapse.

Successful treatment of encopresis requires a comprehensive approach that addresses both the physical and psychological aspects of the condition. With appropriate treatment and family support, the majority of children recover fully, though patience is required as the process typically takes many months.

Phase 1: Disimpaction

If significant constipation and fecal impaction are present, the first step is to clear out the backed-up stool. This process, called disimpaction, creates a "clean slate" from which to start maintenance therapy. Without disimpaction, maintenance laxatives will be ineffective because they cannot work against the mass of compacted stool.

Disimpaction can be achieved through several methods:

• Oral laxatives: High-dose polyethylene glycol (PEG, such as MiraLAX or Movicol) given over 3-7 days is often the first-line approach. This is effective and non-invasive
• Enemas: May be used if oral therapy fails or for very severe impaction. These are more invasive but work quickly
• Manual disimpaction: Rarely needed but may be performed under sedation for very severe cases

Phase 2: Maintenance Therapy

After disimpaction, the goal of maintenance therapy is to keep the bowel moving regularly so stool does not accumulate again. This typically involves daily laxatives combined with behavioral strategies. Maintenance therapy must continue for many months - typically 6-12 months or longer - even after symptoms resolve.

Laxatives: Polyethylene glycol (PEG) is the most commonly used maintenance laxative for childhood constipation. It works by drawing water into the stool to keep it soft and easy to pass. The dose is adjusted based on response, aiming for one or two soft bowel movements daily. Other options include lactulose, a sugar-based laxative, or stimulant laxatives like senna for resistant cases.

A common mistake is stopping laxatives too soon once the child appears better. The stretched rectum takes many months to return to normal size and sensitivity. Stopping laxatives early almost invariably leads to relapse. Follow your healthcare provider's guidance about when and how to gradually reduce and eventually stop maintenance therapy.

Behavioral strategies: Continue the toilet routines established during home management: regular toilet times after meals, a relaxed bathroom environment, and positive reinforcement for cooperation. Reward systems can be helpful for some children, rewarding sitting on the toilet as instructed rather than rewarding successful bowel movements (which the child cannot fully control).

Phase 3: Addressing Underlying Factors

For children where stress, anxiety, or emotional factors contribute to the encopresis, psychological support is an important part of treatment. This might include:

• Family counseling: To address family dynamics that may be contributing to stress
• Individual therapy: For children with anxiety, depression, or who have experienced trauma
• School support: Working with the school to reduce any school-related stressors

For children with neurological conditions that contribute to their encopresis, ongoing support from pediatric specialists and potentially habilitation services is important. Treatment is tailored to the child's specific condition and needs.

What Is the Outlook for Children with Encopresis?

With proper treatment and family support, 50-70% of children with encopresis achieve significant improvement or complete resolution. Treatment takes patience, as recovery typically requires 6-12 months of consistent effort. Relapses are common but can usually be managed by temporarily increasing treatment intensity.

The outlook for children with encopresis is generally positive when appropriate treatment is provided and sustained. However, families need to understand that this is a condition that requires months of consistent effort, not a quick fix. Setting realistic expectations helps prevent frustration and premature abandonment of treatment.

Studies show that with proper medical treatment and behavioral support, 50-70% of children experience significant improvement or complete resolution of their symptoms. The remaining children may continue to have some difficulties but usually experience substantial improvement in frequency and severity of soiling.

Several factors are associated with better outcomes:

• Earlier intervention (shorter duration of symptoms before treatment)
• Consistent adherence to the treatment plan
• Strong family support and involvement
• Absence of significant psychological comorbidities
• Completion of full maintenance therapy before weaning

Relapses are common, occurring in up to 50% of children at some point. This does not mean treatment has failed; it simply means a temporary return to more intensive treatment is needed. Most relapses can be managed by resuming or increasing laxative doses and reinforcing behavioral strategies.

How Can You Be Involved in Your Child's Care?

Active participation in your child's healthcare is essential. Ensure you understand all information provided by healthcare professionals, ask questions when unclear, and involve your child in decisions as appropriate for their age. Children benefit from understanding their condition and being partners in their treatment.

Being an active participant in your child's medical care improves outcomes and helps ensure treatment is tailored to your family's specific needs. Healthcare should be a partnership between the medical team, you, and your child.

Make sure you understand the information provided by healthcare professionals. If something is unclear, ask for clarification or ask to have it written down. You have the right to receive information in a language you understand, and interpretation services should be available if needed.

Involve your child in discussions and decisions as appropriate for their age. Even young children benefit from understanding what is happening with their body and why certain treatments are recommended. Older children and especially teenagers should be increasingly involved in their own healthcare decisions. Their cooperation with treatment plans is essential, and this is more likely when they feel heard and respected.

Do not hesitate to seek a second opinion if you have concerns about the diagnosis or treatment plan. Similarly, if your child is not improving as expected or you feel something is being missed, advocate for further evaluation.