Functional Encopresis

1. Types
   1. Failed initial bowel training
   2. Toilet phobia
   3. Manipulative soiling
   4. Irritable Bowel Syndrome
2. Epidemiology
   1. Ages 4 to 18 years old
3. Signs
   1. Fecal Incontinence without stool impaction or Constipation
   2. Normal stool number and normal colonic transit
4. Evaluation
   1. See Encopresis
5. Associated Conditions
   1. Psychosocial disorders
   2. Neurologic Disorders
6. Management: Address Toilet refusal behavior
   1. Positive toilet sits
      1. Start with short sits on toilet
         1. Sit 3-5 times per day for 30 seconds
         2. Increase to 5 minutes each (timer signals end)
      2. Leave on diapers and pants
      3. Provide relaxing, enjoyable activity
   2. Gradual shaping procedure (if above fails)
      1. Parent models toileting behavior for 2 weeks
         1. Male caretakers should sit while urinating
      2. Play games and read books in or near bathroom
      3. Gradually progress to positive toilet sits above
7. Management: Ensure soft, well-formed stools
   1. Adjust diet to ensure frequent well-formed stool
   2. Short-term supplements (flavored fiber drink, bran)
   3. Consider short-term daily Laxative
      1. Milk of Magnesia 1-3 ml/kg/day
      2. Mineral Oil 1-5 ml/kg/day (avoid if aspiration risk)
      3. Sorbitol 1-3 ml/kg/day
   4. Soiling may be more frequent with these regimens
      1. Prepare a matter-of-fact neutral clean-up procedure
8. Management: Schedule prompt toilet sits
   1. Establish toilet sits when child most likely to stool
      1. Schedule up to 5 per day for 3-5 minutes each
      2. Consider sit 5-20 minutes after each meal
      3. Use daily toileting diary to set up other sit times
      4. Use a timer to signal end of toilet sit
   2. Once achieved, hold a graduation ceremony
      1. Declare the child a "big" girl or boy
      2. Completely switch from diapers to pants
9. Management: Provide incentives for stools in toilet
   1. Reward child when stools in toilet
      1. Avoid rewarding clean pants (Stool Withholding)
   2. Incentives might vary
      1. Candy
      2. Star chart
      3. Dot-to-dot
      4. Special activities
   3. Gradually reduce verbal prompts to toilet
      1. Allow child to recognize urge to urinate and defecate
      2. Reward child for requests to use bathroom
10. Management: Physician Contact for Stool Withholding
    1. See also Pediatric Constipation Management
    2. No stool for 4 days
       1. Try one of stool softening regimens above
    3. Impaction (may require inpatient management)
       1. Hypertonic phosphate enemas 1-2/day x1-3 days OR
       2. Mineral Oil
          1. Daily Dose: 15-30 ml per year of age
          2. Maximum: 8 ounces
11. References
    1. Kuhn (1999) Am Fam Physician 59(8): 2171-8 [PubMed]