University of Virginia Health System

 How do we treat encopresis?

Since most cases of childhood encopresis result from constipation, treatment is similar to the treatment outlined for chronic constipation.  It is important to remember that while most encopresis begins with constipation, by the time soiling develops, most children are no longer experiencing lots of pain with bowel movements.  In children with encopresis, avoidance of the toilet is often a habit that began long ago.  It is also important to remember that children with encopresis often don't have the normal urge to go to the bathroom.  

There are many different ways to treat childhood encopresis, but in the end, most treatments revolve around three basic principals:

1. Empty the large intestine
2. Once the large intestine has been emptied, establish regular bowel movements
3. Maintain very regular bowel movements

There are many different ways of accomplishing these three principals.  While most children with encopresis have some behavior problems associated with toileting, behavior therapy alone is usually not sufficient to eliminate the problem.  Most of the time, laxatives are needed to re-establish regular bowel movements.

In most cases, as soon as the colon is completely evacuated, the encopresis improves or stops, however it is important to continue treatment long enough to assure regular bowel habits are established and intestinal coordination recovers. 

How do we empty the large intestine?

There are three commonly used methods of emptying the large intestine:

1. Administering enemas -

   When we administer an enema, we push fluid into the rectum. The fluid softens the stool in the rectum but it also stretches the rectum giving the child a tremendous urge to pass a bowel movement. Almost all enemas consist mostly of water with something else mixed in to keep the water inside the intestine. The most commonly used enemas are:

   • Fleet's® Phosphosoda enemas contain water and the salt sodium-phosphate. The phosphate is not absorbed in the lower intestine and thus keeps the water from the enema in the intestine with it.
   • Soap suds enemas contain water with a small amount of soap. The soap is mildly irritating and stimulates the lower intestine to secrete water and salt.
   • Milk and Molassas enemas contain milk sugars and proteins as well as molassas. None of these are absorbed in the lower intestine and thus keep the water from the enema in the intestine.
2. Administer suppositories -

   By administering a suppository, we irritate the bottom of the intestine, causing it to contract (squeeze) and push out a bowel movement. Some suppositories also stimulate the intestine to secrete salt and water softening the stool in the rectum and making it easier to push out. Commonly used suppositories include:

   • Glycerine
   • Dulcolax®
   • BabyLax®
3. Administer powerful laxatives to "flush out" the lower intestine -

   When we administer very powerful laxatives to "flush out" the lower intestine, we are generally keeping lots and lots of water in the intestine, softening any stool in the lower intestine, and causing diarrhea. Laxatives used to flush out the intestine include:

   • Magnesium citrate
   • Golytely® or Colyte®
   • Fleet's Phosphosoda®
   • Glycolax® or Miralax®

How can we re-establish regular bowel movements?

Once the large intestine has been emptied, laxatives are administered regularly to produce soft bowel movements once or twice each day. Virtually any laxative preparation will be effective if it is given in high enough doses. Most of the commonly employed laxatives work by keeping large amounts of water in the intestinal tract, thus making the bowel movements very soft and keeping the stool moving quickly through the large intestine. Commonly employed laxative preparations include:

• Milk of Magnesia® and Haley's M.O.® - these laxatives contain magnesium salts that are very poorly absorbed by the intestinal tract. As a result, the magnesium remains in the intestine and keeps water with it. The end result is that there is much more water in the stool, keeping it very soft, and causing it to move through the intestine more quickly. In high doses, magnesium salts often produce diarrhea.
• Sennokot® and Fletcher's Castoria® - these laxatives contain the natural plant derivative senna. Senna stimulates the intestine to secrete salt and water so that there is much more water in the stool, keeping it very soft, and causing it to move through the intestine more quickly. Senna also is a mild irritant, causing the lower intestine to contract (squeeze). In some children, high doses of senna cause cramps and diarrhea.
• Mineral Oil - many people believe that mineral oil works by "lubricating the intestine". Mineral oil is a non-absorbable oil that is digested by bacteria living in the large intestine. Some of the by-products of this digestion stimulate the intestine to secrete salt and water. This results in there being much more water in the stool, keeping it very soft, and causing it to move through the intestine more quickly. When taking high doses of mineral oil, many children will experience some orange seepage as well as some itching at their anus.
• Metamucil®, Citrucel®, Fibercon®, Fiberall®, and Maltsupex® - these are all fiber-based laxatives. Fiber laxatives contain complex sugars that are not digested or absorbed in the intestine. As a result, the sugars remain in the intestine and keep water with them. The end result is that there is much more water in the stool, keeping it very soft, and causing it to move through the intestine more quickly. In high doses, fiber laxatives often cause bloating and gas.
• Chronulac® and Duphalac® both contain the sugar lactulose that is very poorly absorbed by the intestinal tract.  As a result, the sugar remains in the intestine and keeps water with it.  As with many of the other laxatives listed above, the end result is that there is much more water in the stool, keeping it very soft, and causing it to move through the intestine more quickly.  In high doses, these laxatives often produce diarrhea as well as lots of gas and bloating.
• Miralax® or Glycolax ® contain polyethylene glycol.  This is a very large molecule that is not digested or absorbed in the intestine.  As a result, the Miralax® or Glycolax® remains in the intestine and keeps water with it.  As with many of the other laxatives listed above, the end result is that there is much more water in the stool, keeping it very soft, and causing it to move through the intestine more quickly.  One of the biggest advantages of Miralax® or Glycolax® is that they are tasteless and odorless powders and can be easily mixed into juices or other liquids without affecting their taste.  In high doses, Miralax® or Glycolax often cause diarrhea, and less commonly bloating, gas and cramping. 

Can diet accomplish the same thing as these laxatives?

In high enough doses, many foods are very effective laxatives however it is often difficult to eat or drink enough of these foods day in and day out to be effective long-term treatments. In high doses most fruits and juices can be very effective laxatives. Many people are familiar with using prunes as laxatives. Much like fiber laxatives, prunes contain complex sugars that are not digested or absorbed in the intestine. As a result, the sugars remain in the intestine and keep water with them. The end result is that there is much more water in the stool, keeping it very soft, and causing it to move through the intestine more quickly. As with fiber laxatives, high doses of prunes often produce bloating and gas.

Are laxatives safe?

While many parents and physicians are worried about using laxatives in children, most of their concerns are unfounded. Some common misconceptions include:

• Children may become "dependent" on laxatives if they use them too long.

  Since nearly all available laxatives work by keeping large amounts of water in the stool, they can be used for very prolonged periods of time without significant risk. There is no evidence that any of the laxatives described above can result in dependency with chronic usage.

• Laxatives lose their effectiveness if they are used for prolonged periods.

  No studies have ever convincingly demonstrated that any of the laxatives described above lose their effectiveness over time.

• Children who use laxatives have an increased risk of developing colon cancer.

  While several studies have suggested that adults with untreated constipation may be at increased risk for developing colon cancer, there is no evidence to suggest that laxatives increase this risk.

How do we maintain regular bowel movements?

Early on, most medical treatment regimens revolve around evacuating the intestine and using laxatives to keep the stools soft, but to assure long-term success, it is crucial that the child develops very regular bowel habits.   

Children should get in the habit of sitting on the toilet for five to ten minutes after breakfast and again after supper. Many families have very busy schedules and their children are not in the habit of "making time" to pass bowel movements. By establishing regular "bathroom times" after meals, we take advantage of intestinal contractions that occur after we eat. These contractions are often called the "gastro-colic reflex" and they explain why some people pass bowel movements every morning after breakfast or every evening after supper. It is also useful to establish regular bathroom times after breakfast and after supper because many children are completely unwilling to pass bowel movements at school (just as many adults are unwilling to go to pass bowel movements at work).

For many children, positive reinforcement techniques can be very helpful in promoting very regular bathroom times.  Younger children often do well with "star charts" however these may not work as well for older children and parents may need to use another more age-appropriate scheme. 

Some pediatric centers offer biofeedback therapy as a way of improving the muscle coordination associated with passing bowel movements. Remember, many children with chronic constipation have become quite incoordinated and use muscles against one another when they try to pass bowel movements. With biofeedback, several small wires are taped to the skin around the anus and on the abdomen. These wires can measure what the different muscle are doing and display this information on a television screen. By playing a type of video game, a child can learn how to tighten and relax his or her muscles in ways that make passing bowel movements more efficient.  

At the University of Virginia Children's Hospital at the University of Virginia, we have developed an "enhanced toilet training program" that helps children understand how to use their muscles correctly while straining using a variety of behavioral modification techniques.  Our enhanced toilet training program generally includes colonic evacuation and laxatives as outlined above.  Additionally, the child and his or her parents are taught about the psychophysiology of chronic constipation and encopresis and they are given a reinforcement scheme to promote responsiveness to rectal distension. The child and parents also receive training and modeling of appropriate toileting behaviors. This includes instruction on appropriate breathing techniques, effective abdominal straining, relaxation of the legs, and relaxation of the external anal sphincter when they are trying to pass a bowel movement.  Various incentive programs are established depending on the developmental age and the motivation of the child. Target behaviors are spontaneous trips to the toilet and clean underwear. More recently, we have begun to develop interactive multimedia computer based teaching modules to complement the program.