Poop (Fecal) Incontinence (Fecal Incontinence/Encopresis)

Poop Incontinence (Encopresis) is a disorder characterized by voluntary or involuntary repetitive defecation of feces at an inappropriate place and time, even though fecal control is acquired developmentally. For a child to be diagnosed with incontinence (encopresis), the child must be older than 4 years and the problem must be seen at least once a month for three months.

Incontinence is a difficult condition for parents and children, but it is a health problem that can often improve with patience and the right treatment. However, when left untreated, it can cause negative psychological and sociological effects on the child and family.

In this article, we will first talk about the physiology of poop (defecation) and then we will talk about incontinence.

How does the need to poop arise? How to poop?

In order to poop normally, the anatomical and functional structures of the brain, spinal cord and intestines (especially the last parts of the large intestine called rectum and anus play an important role) must be healthy.

The rectum is the approximately 10-15 cm straight end of the large intestine. The anus is the last part that opens out. Normally there is no feces in the anus, while the rectum is the part that stores the feces and can expand if needed.

The anus (rectum) has internal and external muscles surrounding it and a very sensitive covering layer covering its inner surface. Sensitive nerve endings, glands for lubrication, internal and external veins (hemorrhoidal veins) are necessary for important functions.

Most of the digestion of food taken by mouth takes place in the stomach and small intestine and the remainder is transferred to the large intestine. Most of the useful food passes through the small intestine into the bloodstream. The large intestine is mainly involved in fluid absorption, storage and defecation.

When the feces stored in the rectum reaches a certain volume, it causes stretching in the rectal wall and activates the “defecation reflex”, so that the defecation process begins, and the residues are removed from the body through defecation.

Controlling the need to defecate until one finds a socially appropriate time and place is called continence. Providing fecal control is a complex event. Body functions, anatomical structure, sensory transmission of tissues, feeling the need to defecate are necessary for this function.

In an adult, approximately 200-250 ml of stool is excreted from the body through defecation. However, it should be kept in mind that this will vary with age and nutrition in children. Roughly, the daily amount of stool can be considered as 5-10 g/kg/day in children under one year of age and 100-200 mg/kg/day in older children.

How does stool formation take place?

The function of defecation is perceived by stretching the walls of the rectum as a result of filling it with feces. This stimulus causes the muscles called internal sphincter, which is located inside the anus (rectum) and is in a contracted state, to relax. The residual substances in the rectum that cause the rectum to stretch move from the rectum to the anus and come into contact with the layer covering the inner surface of the anus, which is covered with very sensitive nerve endings. Thanks to this reflex, the person senses whether there is gas, liquid or solid feces in the rectum. This information is transmitted to the brain and the person decides whether or not to empty the contents of the rectum. If it is gas that is causing this tension, the person can just pass the gas without the need to defecate.

In order for defecation to take place, the voluntary external muscle (external sphincter) that surrounds the rectum (anus) must relax together with the muscles inside the pelvis (pelvic floor muscles, puborectal muscle). Thus, the opening between the rectum and the anus disappears and defecation is achieved by increasing intra-abdominal pressure with straining.

If there is a social problem of time and place, the brain can postpone this defecation function. By tightening the muscles that should relax, the person sends the stool back into the rectum and postpones the defecation function.

Stool control is the result of the coordinated work of many mechanisms. It is a complex event. Sphincters, which surround the anus and consist of special muscle structure, are the most important structures that provide fecal control (continence). In order for continence to occur, the muscles and nerve stimulation of these muscles must function properly. At normal times, the sphincters are contracted and we are prevented from pooping and continence is ensured. Thus, continence is ensured until the appropriate time and ground comes, giving the individual time to go to the toilet.

What are the Types of Fecal Incontinence?

Fecal incontinence appears in two types in children in the first place. The first is the retentive (accumulation) type of fecal incontinence associated with constipation. The other type is the non-retentive type with no constipation symptoms. In retentive type fecal incontinence, the child can voluntarily hold his/her feces. Pain in the intestines can be seen when the feeling of defecation comes. There is a large amount of feces in the rectum. In order to be diagnosed with non-retentive type encopresis, the child must be older than 4 years and show symptoms for at least one month. Children in whom fecal incontinence persists for a long time and no other physical problem can be seen are considered suitable for this type. Most of the patients who consult a doctor with fecal incontinence in children have retentive type.

What are the Causes of Poop Incontinence?

The causes of poop incontinence can be divided into two as non-organic and organic causes

1. Non-Organic Causes

   1. Constipation
   2. Psychological reasons
   3. Oppressive, rigid or overly lax and indifferent attitudes of parents during the toilet training process
   4. Fears of the child related to going to the toilet.
   5. Depression
   6. Stubborn, defiant, resistant temperament of the child.
   7. Traumatic experiences affecting the child and family.
   8. Poor communication and interaction within the family.
   9. Conflicting relationships between parents and child.
   10. Stress and emotional states.

What Stress and Emotional States Can Be;

In addition to constipation, stressful situations, although very rare, cause behavioral disorders in children and cause complaints of poop incontinence. Some situations that can cause stress in children are as follows;

1. Incorrect toilet training
2. Starting toilet training too early
3. Starting kindergarten and school
4. Separation of parents
5. Having a sibling

b. Organic Causes

1. Nervous Causes; Spina bifida and acquired spinal cord damage and pelvic surgeries such as anal atresia and sacral teratoma
2. Cracks, clefts that cause painful defecation
3. Previous pelvic surgery; teratoma etc.
4. Muscle diseases
5. Strictures in the last parts of the large intestine. It may be congenital or due to previous surgeries.

The most common cause of fecal incontinence in children is chronic constipation. Most incontinence complaints develop due to chronic constipation. In constipation, hard and dry stools can cause pain and pain in the child during defecation. In these cases, children start to hold their stools even more to avoid pain and pain, creating a vicious cycle between constipation and pain. Children's behavior of avoiding defecation results in incontinence after a while. Because the rectum does not have the ability to store so much poop and the muscles responsible for rectal movements do not have the ability to hold the poop for so long.

!!! You can read more about constipation and its treatment in our article titled Constipation.

Which Children are at Risk for Poop Incontinence?

Studies have shown that it is genetically more likely to be seen in boys.

• Children with chronic constipation
• Use of iron medications for anemia
• Use of medications that can cause constipation such as cough syrup
• Attention deficit / hyperactivity disorder
• Autism spectrum disorder
• Spina bifida
• Children who have had anal atresia surgery
• Children with a predisposition to anxiety or depression are more likely to be seen.

What are the Symptoms of Poop Incontinence in Children?

It should not be forgotten that the cause of unexplained abdominal pain in children may be constipation and related fecal incontinence. Even if the family does not express it, it should be paid attention to whether there is any contamination in the underwear during the examination, this finding may be the first symptom of fecal incontinence. It should also be kept in mind that these children may often complain of loss of appetite and weight gain. It should be kept in mind that excessively hard and coarse stools, urinary incontinence with these problems and frequent urinary tract infections may also be the cause of chronic constipation and incontinence, and the history should be taken patiently and in detail.

How is poop incontinence diagnosed?

Although it may be different in every child, some clinical evaluations are required to determine the underlying cause of incontinence. However, it should start with a detailed history.

Detailed history taking; The underlying cause of poop incontinence should be questioned with detailed history taking. Many families confuse staining on their children's underwear with diarrhea. Toilet habits (poop and urine habits, eating habits, previous surgeries, if any, family and social environment) should be questioned in detail without hurting the patient and family. Other diseases and medications, if any, should be questioned.

Physical Examination; Since fecal incontinence is often a sign of constipation, abdominal examination should be performed. During the examination, one can have an idea about the severity of constipation by looking at the mobility and stiffness of the intestines.

In addition, the functions of the pelvic floor muscles (muscles around the anus) should be examined and their effectiveness in defecation should be evaluated. It is often seen that the pelvic floor muscles of children with incontinence are much more contracted than normal, which is also a symptom of constipation. One of the main causes of constipation is anal fissure, so the anus should be examined carefully.

More extensive tests are usually ordered in cases of severe fecal incontinence. The diagnostic tests ordered when necessary are as follows:

Diagnostic tests:

• Ultrasound: Increased rectal diameter is a significant diagnostic criterion. Attention should be paid to pelvic mass and hydronephrosis on ultrasound.
• Abdominal X-ray: It is performed to observe the fullness of the intestines.
• Anorectal Manometry; It is used to evaluate the structural, motor and sensory functions of the anorectal region.
• MRI (Magnetic Rözanas); Sipinal MRI should be requested especially if there are findings suggestive of Spina bifida in the patient's history, physical examination and ultrasound. At the same time, detailed information can be obtained about the anatomy of the pelvic floor muscles, which have important functions in continence.
• Defecography (MRI, barium)
• Pudental Nerve Latency

How is the function of the pelvic floor muscles assessed?

It is performed with EMG measurement test.

!!! You can read our article titled Pelvic Floor Exercise for detailed information on the subject.

When should a doctor be consulted for children who leak poop?

If your child has one or more of the following conditions, contact your doctor.

• If he/she has problems with peeing, walking or balance at the same time (this may be an emergency)
• If he/she complains of constipation
• If he/she has abdominal pain, especially in prolonged and recurrent abdominal pain
• If he/she leaks poop in places other than the toilet or potty
• If his/her underwear gets dirty very often
• If he/she still leaks poop even though he/she is over three or four years old
• If he/she leaks urine during the day and/or night
• If he/she feels an urgent urge to pee during the day
• If he/she pees very often during the day

How to Treat Poop Incontinence?

It is very important to start the treatment of poop incontinence as early as possible in order to shorten the healing process. The main goal in treatment should be aimed at the underlying cause.

!!! Constipation and the treatment of fecal incontinence caused by constipation are explained in our article titled constipation, so you can read our related article for detailed information.

In a small number of patients, it may be due to anatomical and functional disorders of muscles and nerves. These disorders may be congenital or acquired. In these patients, treatment should be directed primarily towards the underlying cause. Constipation treatment alone may not bring success in these patients, these patients may also require serious pelvic floor exercise.

!!! More detailed information about Pelvic Floor Exercise can be read in our article titled Pelvic Floor Exercise.

If treatment fails despite all this, MACE surgery can be performed, which is usually required for patients with nerve and muscle disease.

!!! For detailed information on the subject, you can read our article titled Ileocystoplasty, Mitrofanoff and MACE

What kind of problems can children with poop leakage face if not treated in time and appropriately?

It is inevitable that it will cause negative psychological and social problems in the child. The child will withdraw from friends and other social relationships because of the stench. The sense of shame will take pathological dimensions, serious loss of self-confidence and decreases in school success will be seen and the child will become completely withdrawn.

Which doctor should be consulted for the diagnosis and treatment of fecal incontinence in children?

First of all, a Pediatric Surgeon should be consulted, and the treatment should be carried out together with Pediatric Gastroenterology, Pediatric Psychiatry and Physiotherapist when necessary.

At what age and how often is incontinence of stool (encopresis) seen in children?

Approximately 95% of children have bowel control by the age of 4 and 99% by the age of 5. Constipation, especially incontinence, should be evaluated and treatment should be organized even if the child is over 4 years old. However, it should not be forgotten that approximately 1.5% of primary school children may also have incontinence.

*** The information provided here, the content of the website is organized for the purpose of informing the visitor, especially families. No information should be considered as advice by visitors and should not lead to any decision or action. Families should definitely have their patient examined by a pediatric surgery specialist, consult with him/her and make a decision by consulting his/her one-on-one information.