Childhood Encopresis Research Articles

Hypno-behavioral Therapy, Systemic, and Institutional Management of Encopresis in Childhood and Adolescence

Hypno-behavioral Therapy, Systemic, and Institutional Management of Encopresis in Childhood and Adolescence

Constipation and Encopresis in Childhood.

1. Jennifer M. Colombo, MD* 2. Matthew C. Wassom, PhD† 3. John M. Rosen, MD* 1. *Division of Gastroenterology, Children’s Mercy Kansas City, University of Missouri at Kansas City School of Medicine, Kansas City, MO. 2. †Division of Developmental & Behavioral Sciences, Children’s Mercy Kansas City, University of Missouri at Kansas City School of Medicine, Kansas City, MO. A recent study in Pediatrics concluded that 25% of children with functional constipation continued to experience symptoms at adult age, suggesting that referral to specialized clinics at an early stage for children who are unresponsive to first-line treatment may help improve outcomes. (1) After completing the article, the reader should be able to: 1. Know that constipation is a common problem in childhood with a diverse clinical presentation. 2. Understand that functional constipation is a symptom-based diagnosis that does not require extensive testing. 3. Recognize that most children who present with fecal incontinence or encopresis have associated constipation. 4. Describe the treatment of constipation and encopresis, which should include a medical-behavioral approach that focuses on maintaining soft and regular bowel movements and improving toileting behavior. What do the following children have in common? Answer: They share a familiar diagnosis: functional constipation. Constipation is a common pediatric problem and parental concern. In general, a complaint of constipation accounts for 5% of general pediatric office visits and 25% of all referrals to pediatric gastroenterologists. The estimated worldwide prevalence is 0.7% to 29.6%. (2) Constipation rarely signifies a serious disease, but it has an unfavorable impact on patient quality of life, parental satisfaction, and health-care costs. Children with constipation often complain of abdominal pain, decreased appetite, and painful stooling, which can be distressing to both the child and the parents. Common transient …

Constipation and Encopresis in Childhood

Constipation and Encopresis in Childhood

Real World Use of an Internet Intervention for Pediatric Encopresis

Background The Internet is a significant source of medical information and is now being shown to be an important conduit for delivering various health-related interventions.Objective This paper aimed to examine the utility and impact of an Internet intervention for childhood encopresis as part of standard medical care in a “real world” setting.Methods Patients diagnosed with encopresis were given a Web-based information prescription to use an Internet intervention for pediatric encopresis. A total of 22 families utilized the intervention between July 2004 and June 2006. A chart review and phone interview were undertaken to collect user characteristics; defecation-related information, including frequency of soiling, bowel movements (BMs) in the toilet, and amount of pain associated with defecation; and information on computer/Internet usage. Three questionnaires were used to examine the utility of, impact of, and adherence to the Internet intervention. Program utilization was obtained from a data tracking system that monitored usage in real time.Results Overall, parents rated the Internet intervention as enjoyable, understandable, and easy to use. They indicated that the Internet intervention positively affected their children, decreasing overall accidents and increasing child comfort on the toilet at home. Of the 20 children who initially reported fecal accidents, 19 (95%) experienced at least a 50% improvement, with a reduction of accident frequency from one fecal accident per day to one accident per week. Although it is not clear whether this improvement is directly related to the use of the Internet intervention, patient feedback suggests that the program was an important element, further establishing Internet interventions as a viable and desirable addition to standard medical care for pediatric encopresis.Conclusions To our knowledge, this is the first time a pediatric Internet intervention has been examined as part of a “real world” setting. This is an important step toward establishing Internet interventions as an adjunctive component to treatment of pediatric patients in a clinical setting, particularly given the positive user feedback, possible cost savings, and significant potential for large-scale dissemination.

Functional fecal retention with encopresis in childhood.

The most common cause of encopresis in children is functional fecal retention (FFR). An international working team suggested that FFR be defined by the following criteria: a history of >12 weeks of passage of <2 large-diameter bowel movements (BMs) per week, retentive posturing, and accompanying symptoms, such as fecal soiling. These criteria are usually referred to as the ROME II criteria. The aims of this study were to evaluate how well the ROME II criteria identify children with encopresis; to compare these patients to those identified as having FFR by historical symptoms or physical examination; to determine whether 1-year treatment outcome varied depending on which definition for FFR was used; and to suggest improvements to the ROME II criteria, if necessary. Data were reviewed from the history and physical examination of 213 children with encopresis. One-year outcomes identified were failure, successful treatment, or full recovery. Only 88 (41%) of the patients with encopresis fit the ROME II criteria for FFR, whereas 181 (85%) had symptoms of FFR by history or physical examination. Thirty-two (15%) patients did not fit criteria for FFR, but only 6 (3%) appeared to have nonretentive fecal soiling. Rates of successful treatment (50%) and recovery (39%) were not significantly different in the two groups. The ROME II criteria for FFR are too restrictive and do not identify many children with encopresis who have symptoms of FFR. The author suggests that the ROME II criteria for FFR could be improved by including the following additional items: a history of BMs that obstruct the toilet, a history of chronic abdominal pain relieved by enemas or laxatives, and the presence of an abdominal fecal mass or rectal fecal mass.

Functional Fecal Retention With Encopresis in Childhood

ABSTRACTObjectivesThe most common cause of encopresis in children is functional fecal retention (FFR). An international working team suggested that FFR be defined by the following criteria: a history of &gt;12 weeks of passage of &lt;2 large‐diameter bowel movements (BMs) per week, retentive posturing, and accompanying symptoms, such as fecal soiling. These criteria are usually referred to as the ROME II criteria. The aims of this study were to evaluate how well the ROME II criteria identify children with encopresis; to compare these patients to those identified as having FFR by historical symptoms or physical examination; to determine whether 1‐year treatment outcome varied depending on which definition for FFR was used; and to suggest improvements to the ROME II criteria, if necessary.MethodsData were reviewed from the history and physical examination of 213 children with encopresis. One‐year outcomes identified were failure, successful treatment, or full recovery.ResultsOnly 88 (41%) of the patients with encopresis fit the ROME II criteria for FFR, whereas 181 (85%) had symptoms of FFR by history or physical examination. Thirty‐two (15%) patients did not fit criteria for FFR, but only 6 (3%) appeared to have nonretentive fecal soiling. Rates of successful treatment (50%) and recovery (39%) were not significantly different in the two groups.ConclusionsThe ROME II criteria for FFR are too restrictive and do not identify many children with encopresis who have symptoms of FFR. The author suggests that the ROME II criteria for FFR could be improved by including the following additional items: a history of BMs that obstruct the toilet, a history of chronic abdominal pain relieved by enemas or laxatives, and the presence of an abdominal fecal mass or rectal fecal mass.

Treatment of Childhood Encopresis: A Randomized Trial Comparing Three Treatment Protocols

ABSTRACTObjectivesTo compare short‐ and long‐term effectiveness of three additive treatment protocols in children experiencing chronic encopresis.MethodsChildren, 6 to 15 years of age, who experienced at least weekly fecal soiling for 6 months or longer were eligible for the study. Children were randomly assigned to a group that received intensive medical therapy (IMT), a group that received intensive medical therapy plus a behavior management program called enhanced toilet training (ETT), or a group that received intensive medical therapy with enhanced toilet training and external anal sphincter electromyographic biofeedback (BF). Data concerning toileting habits were collected for 14 consecutive days before an initial visit, and at 3, 6, and 12 months after initiation of therapy. All data were collected using a computerized voice‐mail system that telephoned the families each day. At 12 months, children were classified as significantly improved (reduction in soiling, P &lt; 0.001) or cured (&lt;one fecal accident in 2 weeks).ResultsEighty‐seven children participated in the study, 72 boys and 15 girls. Mean age at enrollment was 8.6 ± 2.0 years, and mean duration of symptoms was 58.2 ± 38.5 months. At 12 months, the cure rates for the IMM, ETT, and BF groups were 36, 48, and 39, respectively (not significant). The improvement rates for these three groups were 45, 78, and 54, respectively (P &lt; 0.05). These results were very stable over time (r &gt; 0.90, P &lt; 0.001 in each case). Response to treatment during the first 2 weeks of therapy was highly predictive of outcome at 3, 6, and 12 months (P &lt; 0.0001). Children in the ETT group used less laxative medication (P &lt; 0.04) and required fewer treatment contacts (P = 0.08) than children in the IMM group. All three treatments resulted in significant increases in daily bowel movements passed in the toilet and self‐initiated toileting, and resulted in decreases in average daily soiling at 3, 6, and 12 months (P &lt; 0.05).ConclusionsEnhanced toilet training is somewhat more effective in treating childhood encopresis than either intensive medical therapy or anal sphincter biofeedback therapy. Although similar total cure rates at 1 year can be expected with these three forms of therapy, enhanced toilet training results in statistically significant decreases in the daily frequency of soiling for the greatest number of children.

PELVIC FLOOR EXERCISE: A NOVEL TREATMENT FOR CHILDHOOD ENCOPRESIS

This single case study describes the successful application of pelvic floor exercise to the treatment of childhood encopresis. A 10-year-old boy with lifelong incontinence of faeces and anal sphincter hypotonia practised daily pelvic floor contractions by interrupting his urine flow mid-stream, the rationale for the regime being strengthening of the sphincter muscle and improvement of its voluntary operation. Benefits to bowel control were immediate and complete cleanliness was achieved in 9 weeks. Being non-intrusive, the exercise procedure may be more acceptable to some patients with anal sphincter flaccidity than balloon biofeedback. The likely mechanism underlying the method is simultaneous contraction of the anorectal sphincter when the bladder sphincter is tensed.

Modifying the Family Process in Two Cases of Physical Child Abuse and Secondary Functional Encopresis

In this article, a treatment working model is proposed and applied to two cases of multiproblem families with severe physical child abuse. Stimulus events that directly affect the likelihood of a physically abusive episode and setting factors that play an important indirect role because they increase the number of confrontations and decrease parental competence are considered. The child abuse cases involved major parenting deficits, maternal psychopathology, a major psychosomatic problem (childhood encopresis), and symptoms of childhood conduct disorder, which occurred in a setting of family distress, low income, and sibling distress. This study demonstrates how a two-phase comprehensive parent intervention, paralleling the stimulus versus setting factor distinction, can deal effectively with such multiproblem families. Treatment results and a 7-month follow-up assessment illustrate the utility and validity of the proposed scheme when applied in the real world where the relational character of the problems makes them multidimensional.

Constipation and encopresis in childhood.

1. Adel Abi-Hanna, MD 2. Alan M. Lake, MD* 1. 2. *Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD. 1. Constipation is a symptom, not a diagnosis, that has multiple etiologies and multiple alternative treatments. 2. Encopresis or fecal soiling has many etiologies, not all of which are associated with fecal retention or responsive to laxatives. 3. Children who have Hirschsprung disease almost never have encopresis because the aganglionic segment maintains tonic contraction due to the absence of inhibitory neurons containing nitric acid and vasoactive intestinal polypeptide. 4. Functional retentive constipation is associated with loss of lower colonic muscle tone and will not resolve until complete repetitive evacuation of the lower colon allows muscle tone to be restored. 5. Successful treatment of constipation and encopresis requires a combination of patient and parent education, medical therapy, nutritional intervention, behavioral modification, and long-term monitoring of compliance. Constipation is a very common frustration for children, parents, and physicians. It is reported to account for nearly 5% of all outpatient visits to pediatric clinics and more than 25% of all referrals to pediatric gastroenterologists. Painful defecation and encopresis (involuntary passage of stool from the anus) usually are the first manifestations noted. Constipation generally is defined by the hard nature of the stool, the pain associated with its passage, or the failure to pass three stools per week. It would be preferable to define constipation as the failure to evacuate the lower colon completely with a bowel movement. This allows the parents and physician to realize that a child who has three small stools daily may not yet have evacuated the colon, while a child who has two large soft stools a week may not be constipated. The frequency of stools in most children decreases from a mean of four per day in the first week of life to 1.7 per day by the age of 2 years. Over this interval, stool volume increases more than tenfold while maintaining …

Constipation and Encopresis in Childhood

Constipation and Encopresis in Childhood

Parental and Patient Perceptions about Encopresis and Its Treatment

Treatment of encopresis in childhood is often a long and trying process. Children followed for secondary encopresis in a multidisciplinary clinic between 1984 and 1989 were sent a parent/child mail questionnaire seeking information on their understanding of encopresis as well as their opinions on current treatment modalities. Twenty-eight families responded (20 boys and 8 girls), the child's mean age was 9.8 years, and the mean time elapsed after diagnosis was 3.5 years. Parents and children reported that intestinal dysfunction (53%) and painful defecation (46%) were the most important causes of their encopresis. Treatment modalities including enemas were well accepted by both parents and children, with parents considering dietary changes the most useful treatment modality (p < .01). Children reported that regular "toilet routine" was the most helpful in reestablishing continence. Despite good comprehension of the problem and acceptance of the treatment modalities, the complete recovery rate after 3.5 years was only 35.7%, with no differences noted between responders and nonresponders. Encopresis is a chronic condition that persists in a significant proportion of patients, despite adequate patient and parental knowledge and patient acceptance of treatment.

Treatment of childhood encopresis--a review.

Children with encopresis may present to a number of different professionals. The literature on different treatment methods is reviewed. The roles of verbal psychotherapy, physical treatment, behaviour therapy and mixed treatment programmes are discussed.

Randomised trial of laxatives in treatment of childhood encopresis

Primary faecal incontinence (encopresis) in children is usually treated with laxative medication and a behaviour modification programme aimed at promoting regular toileting, but the effectiveness of laxatives has never been adequately investigated. 169 children with encopresis and evidence of stool on plain abdominal radiograph were randomly allocated to receive multimodal (MM) therapy (laxatives plus behaviour modification; n=83) or behaviour modification alone (BM; n=86). Mean (SD) follow-up was 55·1 (27·0) weeks and 56·7 (32·0) weeks, respectively. By 12 months follow-up 42 (51%) of the MM group and 31 (36%) of the BM group (p=0·079) had achieved remission (at least one 4 week period with no soiling episodes) and 52 (63%) vs 37 (43%) (p=0·016) had achieved at least partial remission (soiling no more than once a week). MM subjects achieved remission significantly sooner than BM subjects, and the difference in the Kaplan-Meier remission curves was most striking in the first 30 weeks of follow-up (p=0·012). The patterns of compliance with toileting in the treatment groups were almost identical, although about 1 in 8 children overall did not comply with the sitting programme. After exclusion of the 24 poor compliers, there was no significant difference between BM and MM groups. This study shows a clear advantage overall for the use of laxative medication, although the benefit may not be as great for children who are able to maintain regular toileting.

Cisapride for Intractable Constipation in Children

Twelve patients with chronic constipation refractory to the vigorous use of emollients, enemas, and/or laxatives were chosen for study of the investigational prokinetic agent, Cisapride. The patients included 8 boys and 4 girls with diagnoses of functional constipation. Ages ranged from 2 to 13 years; duration of symptoms before Cisapride use ranged from 1.5 to 9.75 years; duration of previous treatment ranged from 0.75 to 6 years. The mean number of doses of anticonstipation agents employed per week was 14. Of the 12 patients, 10 had persistent encopresis, while 11 required hospitalization for disimpaction an average of 1.6 times in the year prior to Cisapride use. Three had chronic urinary tract complaints. Anal manometry suggested a sensory deficit in 8 of 10 patients tested. Ganglion cells were identified by rectal biopsy in all 12 patients. Cisapride treatment (0.14–0.3 mg/kg/dose) spanned 26–72 weeks (61 ± 12). Stool frequency per week was not significantly changed, but five of seven patients who had reported hard stools had softer stools on the drug (p &lt; 0.05). Encopresis ceased in 8 of 10 cases, while the number of episodes decreased substantially in the other 2 cases (p &lt; 0.05). All alternate forms of anticonstipation therapy were withdrawn in 8 of 12 cases (p &lt; 0.0001). Urinary problems improved in two of the three patients reporting symptoms. One patient showed no improvement in any parameter while on the agent, despite 26 weeks of administration. Side effects were infrequent, generally occurred early, and were limited to cramping, nausea, mild vomiting, anorexia, and headaches. One patient ceased use of the drug for persistent headaches. This open trial suggests the need for a controlled study of the drug Cisapride for the indication of unremitting constipation and encopresis in childhood.

Evaluation of Biofeedback in Childhood Encopresis

SummaryIn order to evaluate the efficacy of biofeed‐back for childhood encopresis, 50 children with enco‐presis were prospectively studied and randomized to receive biofeedback (B) or mineral oil therapy (M). Specificity of biofeedback was also evaluated by comparing outcomes of both regimens in children with normal (n = 32) and abnormal (n = 18) defecation patterns. Using a single blinded design, there were no significant differences in clinical outcomes between the 24 children receiving B and the 26 children receiving M at 3, 6, and 12

Self-esteem and compliance in encopretic children.

The impact of encopresis on self-esteem, and the relationships between self-esteem scores, compliance, and treatment success were measured in a group of school-age encopretic children. Results on the Piers-Harris Children's Self-Concept Scale revealed significantly lower scores in the encopretic group. Physicians and parents were asked to rate each encopretic child's level of compliance and success in treatment in a follow-up interview. There was no significant relationship between lower self-esteem scores and treatment compliance. All of the children were rated as successful in treatment. Implications for treatment of childhood encopresis are discussed.

Evaluation of abnormal defecation patterns in the treatment of childhood encopresis

Evaluation of abnormal defecation patterns in the treatment of childhood encopresis

Anorectal Function and Continence Mechanisms in Childhood Encopresis

Summary: We compared anorectal sensory and motor functions, expulsion dynamics, and continence mechanisms in 50 children with encopresis and 21 healthy control children. When expulsion dynamics were studied, 43% of boys with encopresis inappropriately contracted the muscles near the anal canal compared with 10% of girls with encopresis (p &gt; 0.05) and 10% of control children of both sexes (p &lt; 0.05). In contrast to previous studies we demonstrated no abnormalities of thresholds of conscious rectal sensation or internal anal sphincter relaxation. In addition, children with encopresis had no demonstrable abnormalities of rectosphincteric continence mechanisms or strength of external anal sphincter contraction. We conclude that a significant number of boys with encopresis have abnormal anorectal expulsion dynamics, which may contribute to chronic fecal retention and incontinence. Abnormalities of anorectal sensory and motor function and of rectosphincteric continence mechanisms do not seem to be important in the pathogenesis of childhood encopresis.

Anorectal function and continence mechanisms in childhood encopresis.

We compared anorectal sensory and motor functions, expulsion dynamics, and continence mechanisms in 50 children with encopresis and 21 healthy control children. When expulsion dynamics were studied, 43% of boys with encopresis inappropriately contracted the muscles near the anal canal compared with 10% of girls with encopresis (p greater than 0.05) and 10% of control children of both sexes (p less than 0.05). In contrast to previous studies we demonstrated no abnormalities of thresholds of conscious rectal sensation or internal anal sphincter relaxation. In addition, children with encopresis had no demonstrable abnormalities of rectosphincteric continence mechanisms or strength of external anal sphincter contraction. We conclude that a significant number of boys with encopresis have abnormal anorectal expulsion dynamics, which may contribute to chronic fecal retention and incontinence. Abnormalities of anorectal sensory and motor function and of rectosphincteric continence mechanisms do not seem to be important in the pathogenesis of childhood encopresis.