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PubMed1991

A model for the treatment of encopresis.

Encopresis is a relatively common childhood disorder that continues to be poorly understood. An integrated assessment and treatment model for this disorder is presented. Data generated from a comprehensive assessment enables the diagnosis and identification of subtypes of encopresis based on objective, identifiable criteria. The rationale and methods for treating each subtype of encopresis then is presented. In addition, the importance of assessing and treating psychiatric comorbidity in children with encopresis is highlighted.

Child↗
PubMed1999

Treatment guidelines for primary nonretentive encopresis and stool toileting refusal.

Nonretentive encopresis refers to inappropriate soiling without evidence of fecal constipation and retention. This form of encopresis accounts for up to 20 percent of all cases. Characteristics include soiling accompanied by daily bowel movements that are normal in size and consistency. An organic cause for nonretentive encopresis is rarely identified. The medical assessment is usually normal, and signs of constipation are noticeably absent. A full developmental and behavioral assessment should be made to establish that the child is ready for intervention to correct encopresis and to identify any barriers to success, particularly disruptive behavior problems. Successful interventions depend on the presence of soft, comfortable bowel movements and addressing toilet refusal behavior. Daily scheduled positive toilet sits are recommended. Incentives may be used to reinforce successful defecation during these sits. A plan for management of stool withholding should be agreed on by the parents/caretakers and the family physician before intervention.

Child Behavior Disorders↗
PubMed2003

[Functional childhood gastrointestinal disorders. II. Constipation and solitary encopresis: physiology and pathophysiology].

The childhood prevalences of constipation and encopresis are 0.3-8% and 1-3% respectively. Following a recent stricter definition and classification, constipation and solitary encopresis are now recognised to be two separate entities. Constipation is characterised by infrequent defecation, often in combination with involuntary loss of faeces. Solitary encopresis most often occurs once a day after school hours. When there is no defecation, the frequency of encopresis increases, the abdominal pain becomes more severe and the appetite becomes less, until a large quantity of faeces is produced (often once per week). The physiology of the defecation and continence mechanism is complex and has only been unravelled in part. The multiple physiological mechanisms involved have a complementary and compensatory effect on each other. This makes it difficult to determine the underlying pathophysiological mechanisms of these functional disorders.

Child↗
PubMedDate not supplied

Encopresis: long-term clinical outcome of 67 cases.

In this study we attempted to investigate the outcome of encopresis and to determine factors affecting prognosis. The sample consisted of 52 boys (77.6%) and 15 girls (22.4%) diagnosed as encopresis according to DSM IV diagnostic criteria. These patients were evaluated six years after their initial examination in the Department of Child Psychiatry. Clinical and demographical data were compared between initial and follow-up interviews and between patients with complete recovery and others. Fifty-six patients (83.6%) recovered completely and 11 (16.4%) continued to be encopretic after six years. Good school performance (p<0.005), high levels of parental education (p<0.005) and absence of constipation (p<0.05) were associated with favorable outcome. In addition, secondary encopretics who were diagnosed within a year from onset of the symptom recovered significantly earlier (p<0.001). Encopresis is a chronic disorder and complete recovery rates tend to increase with time. Families and primary health care providers should be informed about the treatment possibilities of encopresis for early intervention.

Age Factors↗
PubMed2003

Results of biofeedback therapy for fecal incontinence in children with encopresis and following surgery for anorectal malformations.

INTRODUCTION: Some children with fecal incontinence respond to biofeedback therapy. However, whether they can achieve fecal continence posttherapeutically has not been clarified. We studied the serial results of biofeedback therapy and discuss the necessity of providing repeated biofeedback therapy at home. METHODS: Nineteen children with encopresis underwent one session of biofeedback therapy. Seven of 15 children with fecal incontinence that developed after surgery for anorectal malformations underwent three to eight sessions of biofeedback therapy; the remaining 8 underwent one (mean, 2.9) session only. The patients were hospitalized for one session of biofeedback therapy. To monitor the clinical outcome of intervention, we used serial score assessments from three months to two years posttherapeutically. RESULTS: Seventeen of 19 (90 percent) patients with encopresis showed clinical improvement after one session of therapy (P < 0.0001). Six months after treatment, however, six of ten (60 percent) patients with encopresis reported recurrent fecal incontinence after one therapeutic session. Clinical improvement was noted in 5 of 15 (33 percent) patients who had fecal incontinence after surgery for anorectal malformations. All five patients showed clinical improvement from six months to two years after several sessions of biofeedback therapy (P < 0.05). CONCLUSIONS: Biofeedback therapy is effective in most children with encopresis and in some children with anorectal malformations. However, some patients need repeated sessions of biofeedback therapy to achieve fecal continence. Therefore, a new portable biofeedback apparatus for the treatment of fecal incontinence at home may be helpful.

Adolescent↗
PubMed1980

Behavioral symptom substitution in children cured of encopresis.

Follow-up data were obtained on 47 children who had been treated for encopresis with an initial catharsis, maintenance laxative therapy, demystification, symptom-related counseling, and close follow-up. Behavioral inventories were used at the beginning of treatment and three years later to determine whether any significant symptom substitution occurred in children cured of encopresis. Little evidence of this was uncovered. There was a comparison of cured and uncured children with respect to behavioral profiles at the start of treatment and three years later. The uncured group showed more aggressive behaviors initially, and also were more socially withdrawn at the start of treatment, although this was not evident three years later. Monitoring of associated behaviors should be an important part of the management of encopresis.

Aggression↗
PubMed1988

Polyethylene glycol-electrolyte solution for intestinal clearance in children with refractory encopresis. A safe and effective therapeutic program.

Severely constipated children with encopresis in whom outpatient management has failed frequently require several days of hospitalization, as well as conventional treatments involving cathartics and enemas. A balanced electrolyte solution of the nonabsorbable polymer polyethylene glycol (GoLytely, Braintree [Mass] Laboratories Inc) offers a safe and efficient method for clearing the intestine. Twenty-four patients with a mean age of 8.1 years (range, 0.8 to 17.6 years) and an average weight of 31.5 kg received polyethylene glycol-electrolyte solution: eight patients with encopresis were given it as treatment for severe fecal retention unresponsive to outpatient management; the other 16 were being prepared for colonoscopy. Weight, complete blood cell count, and serum electrolyte, serum urea nitrogen, and serum creatinine levels were measured before solution administration and two hours afterward. Abdominal roentgenograms were obtained from the encopretic patients. The two groups were comparable in age and weight. Polyethylene glycol-electrolyte solution was given at a rate of 14 to 40 mL/kg/h until clear fluid was excreted through the rectum. Intestines were cleaned out successfully in all patients, and side effects were minimal. Children with encopresis required an average of 11.8 L (574 mL/kg) given over 22.5 hours, while the other children needed only 4.0 L (128 mL/kg) given over 7.5 hours. Weight and serum electrolyte and creatinine levels did not change significantly in any patient. The hematocrit decreased only in encopretic patients (0.38 to 0.36 [37.6% to 35.8%]) and the serum urea nitrogen level decreased in the patients undergoing colonoscopy (3.6 to 2.0 mmol/L [10 to 8 mg/dL]).

Adolescent↗
PubMed1998

Contribution of behavior therapy and biofeedback to laxative therapy in the treatment of pediatric encopresis.

A model incorporating physiological, behavioral, and psychological parameters are presented to explain the maintenance and consequences of pediatric encopresis. It was hypothesized that the more comprehensive a treatment in addressing these parameters, the more efficacious it would be and the more children it would benefit. Eighty-seven children between the ages of 6 and 15 with the primary complaint of encopresis were randomly assigned to one of three treatments: (a) Intensive Medical Care (IMC), receiving enemas for disimpaction and laxatives to promote frequent bowel movements; (b) Enhanced Toilet Training (ETT), using reinforcement and scheduling to promote response to defecation urges and instruction and modeling to promote appropriate straining, along with laxatives and enemas; or (c) Biofeedback (BF), directed at relaxing the external anal sphincter during attempted defecation, along with toilet training, laxatives, and enemas. Three months following initiation of treatment, ETT and BF produced similar reductions in soiling/child (76% and 65%) that were superior (p's < .04) to IMC (21%). ETT significantly benefited more children than the other two treatments, employing fewer laxatives and fewer treatment sessions at a lower cost. Consistent with the presented model, reduction in soiling was associated with an increase in bowel movements in the toilet, reduction in parental prompting to use the toilet, and defecation pain. These results demonstrate that ETT should be used routinely with laxative therapy in the treatment of chronic encopresis.

Adolescent↗
PubMed1994

A behavioral approach to the treatment of nonretentive nocturnal encopresis in an adult with severe learning disabilities.

Encopresis is widely assumed to be "normal" among individuals who are learning disabled. Yet, reports on its prevalence, etiology and treatment are rare and mainly confined to secondary encopresis or to populations with milder learning disabilities. The behavioral treatment of a life-long nonretentive, nocturnal encopresis is described for a young adult with severe learning and physical disabilities living at home. Treatment involved waking prior to soiling, time-limited use of suppositories and rewards for appropriate evacuation. Soiling decreased to zero over 20 weeks. Time of waking was then gradually "shaped" back to normal.

Adult↗
PubMed1996

Encopresis and soiling.

Constipation, encopresis, and fecal incontinence are common problems in children. Constipation can have a variety of causes, such as organic and anatomic causes or intake of medication. Encopresis is the involuntary loss of formed, semiformed, or liquid stool into the child's underwear in the presence of functional (idiopathic) constipation in a child 4 years of age or younger. Fecal incontinence is fecal soiling in the presence of an organic or anatomic lesion, such as Hirschsprung's disease, anal malformation, anal surgery or trauma, meningomyelocele, and some muscle disease. This article reviews the symptoms of functional constipation in young children and the symptoms of functional constipation and encopresis in older children, presents the differential diagnosis of constipation with or without fecal incontinence, describes the evaluation and treatment of these children, and reports on treatment outcome.

Adolescent↗
PubMed2004

[Utility of anorectal manometry in the diagnosis and treatment of encopresis].

BACKGROUND: Biofeedback based on anomanometric techniques has been shown to be effective in the treatment of children with encopresis. The long-term efficacy of biofeedback and which variables of anorectal manometry (anorectal manometry) could help to establish biofeedback indications are currently the subject of debate. OBJECTIVES: To identify which variables of anorectal manometry, in addition to symptoms, could be useful in deciding which patients could benefit from biofeedback therapy and to assess the outcome of this treatment. PATIENTS AND METHODS: Anorectal manometry was performed in 88 patients, who were referred to our service complaining of soiling at least once a month for a minimum of 6 months after a period of normal continence of 1 year or more. The chronological and mental age of the patients was 4 years. All patients were otherwise in good health and had shown no response to medical treatment. The following variables were studied: anal canal profile, rectoanal inhibitory reflex (RAIR), continence reflex, rectal sensitivity, external anal sphincter (EAS) activity and defecatory maneuver. The patients were divided into two groups, according to clinical and anomanometric impairment, and the most affected patients (n = 41) underwent biofeedback therapy. The indications and outcome of biofeedback were assessed through clinical course and anorectal manometry. In the statistical analysis, the mean and standard deviation were calculated. The chi-squared test with Yates' correction was used to compare clinical and manometric qualitative parameters; Student's t-test was used to compare quantitative parameters; nonparametric tests consisted of the Mann-Whitney test and the Wilcoxon test was used for paired data. RESULTS: Patients treated with biofeedback therapy presented shorter anal canal, greater pressure in the rectal ampulla (P < 0.001), decreased pressure in the anal canal (P < 0.05), lesser distension of the EAS on provoking RAIR, lower presence of the continence reflex (P < 0.01), lower rectal sensitivity, and a worse response of the striated sphincteric muscle and of the defecatory maneuver (P < 0.001). Seventy-eight percent of the patients had a good response to biofeedback therapy. Pressure in the anal canal and rectal sensitivity improved (P < 0.001) with normality on straining in 11 out of 15 patients. These good results persisted in a long-term follow-up of 10 patients. Eight of 10 patients who did not undergo biofeedback therapy showed persistent encopresis (P < 0.001). CONCLUSIONS: Anorectal manometry detected disturbances, chiefly in the activity of the EAS, which are useful in indicating biofeedback therapy in children with secondary encopresis. Biofeedback therapy seems to produce favorable long-term results in the majority of the most severely affected patients.

Biofeedback, Psychology↗
PubMed2005

[Encopresis--predictive factors and outcome].

OBJECTIVES: comparison of diagnostic, clinical and therapeutic features and their predictive value for the outcome of encopresis in children and adolescents. METHODS: 85 children and adolescents (aged 9.6 +/- 3.2 years) with severe encopresis (ICD 10: F98.1) were investigated during inpatient treatment and 35 of them again 5.5 +/- 1.8 years later. Mentally retarded patients were excluded. Inpatient therapy consisted of treating constipation and/or stool regulation by means of laxatives, behavioural approaches, and the specific therapy of comorbid psychiatric disorders. RESULTS: During inpatient treatment 22% of the patients experienced total remission, 8% an unchanged persistence of symptoms. Of the 35 patients studied at follow-up 5.5 years later, 40% were symptom-free. As main result, prognostic outcome depended significantly on sufficient treatment of obstipation. Another important factor was the specific therapeutic approach to psychiatric comorbidity, especially to ADHD. The outcome for patients with comorbid ICD 10: F43 was significantly better than for the other patients. Those who were symptom-free at discharge had significantly better long-term outcomes. CONCLUSIONS: Decisive to the success of encopresis treatment were the stool regulation and the specific therapy of associated psychiatric illnesses, in particular of ADHD. Inpatient treatment revealed significantly better long-term outcomes where total remission had been achieved by the time of discharge from hospital.

Adolescent↗
PubMed1997

Evaluation of a standard protocol for retentive encopresis: a replication.

Replicated the efficacy of a short-term, combined medical and behavioral intervention protocol for retentive encopresis. Fifty-nine children who had failed standard medical management for retentive encopresis and their parents participated in six 1-hour group treatment sessions. Treatment protocol combined the medical management strategies of enema clean out, increasing dietary fiber, and daily toilet sitting with the child behavior management strategies of differential attention, contingency management, and contracting. For the overall sample, the number of soiling incidents decreased 85%, the weekly frequency of independent bowel movements increased 15%, the weekly frequency of parent-prompted bowel movements increased 9%, and daily dietary fiber intake increased 121% pre- to posttreatment. The majority of the sample (86%) stopped soiling by the end of treatment and did not require further treatment. Results are discussed in terms of the comparability with previous findings and the utility of combined medical and psychological treatments for children with encopresis who have failed standard medical approaches.

Behavior Therapy↗
PubMedDate not supplied

Evaluation of biofeedback in childhood encopresis.

In order to evaluate the efficacy of biofeedback for childhood encopresis, 50 children with encopresis 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 months. However, at 12 months six of nine children with abnormal defecation patterns were in remission or markedly improved after receiving B, compared to only three of nine children receiving M. In contrast, children with normal patterns appeared to respond better to M than did those receiving B (71 vs. 40% at 12 months). Biofeedback appears to warrant further evaluation in children with encopresis and abnormal defecation patterns.

Adolescent↗
PubMed1998

Clinical significance of anismus in encopresis.

Treatments designed to relieve paradoxical contraction of the anal sphincters during defecation (anismus) have had limited success in children with encopresis. This has raised doubts as to the clinical relevance of this diagnosis in childhood as anorectal dysfunction. Our aim was to determine whether, in patients who had treatment-resistant encopresis, the presence of electromyographic anismus was associated with increased faecal retention. Sixty-eight children with soiling (mean age 8.7+/-2.06 years) were assessed by clinical examination, abdominal radiography and then with anorectal manometry. Patients with electromyographic anismus (n=32; 47%) had significantly increased radiographic rectal faecal retention and were significantly less likely to be able to defecate water-filled balloons. There were no significant differences in response to prior therapy, history of primary encopresis, behavioural adjustment or in sociodemographic data. Our results suggest that electromyographic anismus is associated with obstructed defecation and faecal retention.

Adolescent↗
PubMedDate not supplied

Long-term efficacy of polyethylene glycol 3350 for the treatment of chronic constipation in children with and without encopresis.

Seventy-four children (43 with chronic constipation, 31 with constipation and encopresis) treated with polyethylene glycol 3350 (PEG) for longer than 3 months were studied to assess long-term efficacy. The mean duration of PEG therapy was 8.4 months (range, 3-30). Weekly stool frequency, stool consistency, and symptoms associated with constipation improved significantly with PEG therapy in all 74 patients. In 31 children with encopresis, soiling ceased completely in 16 patients and frequency of soiling decreased significantly in all others. The average effective long-term dose of PEG was 0.7 g/kg/day. Long-term PEG therapy is effective for the treatment of chronic constipation with and without encopresis in children.

Adolescent↗
PubMed2006

Treatment of encopresis and chronic constipation in young children: clinical results from interactive parent-child guidance.

To describe the source of and treatment for encopresis in a series of 40 children under age 9 years. Referral for psychological based treatment followed upon limited success of standard gastroenterologic intervention. The treatment provided is defined as interactive parent-child family guidance. This includes a variety of specific psychologically based recommendations offered to parents, and, when indicated, direct interventions with the symptomatic child. These are different from various forms of behavioral corrective reward-punishment interventions frequently recommended for young children with encopresis. The pediatric and the psychological literature offer few reports of successful treatment of young children with this syndrome. Also, there are few specific descriptions of psychologically based interventions. The results reported here are of the successful treatment of 38 of 40 cases referred specifically for psychologically based intervention following the prior limited success of standard gastroenterologic treatment. The interactive parent-child family guidance intervention described in this report, differentiated from typical behavior therapies, is a notably successful mode of psychologically based therapy for these children. It offers an important alternative to standard pediatric gastroenterological treatment for encopresis, as well as to reward-punishment oriented behavioral therapies.

Behavior Therapy↗
PubMed1988

Encopresis responsive to non-psychiatric interventions. With remittance of familial psychopathology.

A case report of an adolescent with primary encopresis is presented in which the patient responded to standard medical interventions despite apparent significant psychopathology in the child and family. Psychological symptoms proved to be secondary and resolved with successful medical treatment and with attending to other concerns, such as this patient's school problems. Behavioral and medical literature related to encopresis is reviewed. It indicates that encopresis is associated more consistently with physiological abnormalities of the bowel rather than definable psychological disorders.

Adolescent↗