Encopresis (Soiling) Is Likely Due To Severe Constipation
Question: Our ten-year-old son has constipation for many years. His bowel movement is very irregular, and it is always hard and large in size. Sometimes he tells us that there is blood on the toilet paper when he wipes himself. When he complains of belly pain and has no BM for several days, I would give him some laxative and he always gets relief shortly after. However, in the last few months, he started soiling in his pants. I donʼt mean that he has a little stain in his underwear; he passes quite a lot of loose stool in his pants. This always happens when he is at home, and he says that he cannot feel when it is coming. I really donʼt know whether I should believe him or not. When I asked him about his bowel movement, he said that he does it every few days, and it is still hard and only a little would come out each time. We are at our wits end, and we donʼt know how to help him. Please give us some advice.
You have a rather messy problem here. As parents, you wouldnʼt want to accuse him of lying when he said that he couldnʼt feel the stool is coming out. However, the fact that he doesnʼt do this in school when he is among his classmates tells you that he does have some control of this. Moreover, the important thing is not to confront him about whether he can feel it or not, but help him to deal with the source of his problem.
Soiling of the pants, also called encopresis, is almost always associated with constipation in children. You need to understand about constipation and how that leads to encopresis before you can help him.
Constipation means infrequent bowel movements that are hard in consistency and large in size (for the childʼs age). The frequency of bowel movement is quite variable. Some children have more than one BM a day, while others have BM every two to three days and not being constipated. The important issue is the size and consistency of the stool.
After we eat, food is digested and nutrients are absorbed in the small intestines. Whatever remains that cannot be digested is passed into the large intestine and come out as stool. The time it takes for stool to pass through the large intestine varies from person to person. When stool passes through the large intestine, water is absorbed into the body. This is natureʼs way of conserving water. As water is absorbed, the stool becomes more firm in consistency.
When stool reaches the rectum (the part of large intestine just above the anus), it stretches the rectum and gives the feeling that you need to go for a bowel movement. If it is inconvenient, you can suppress the urge and after a while, the feeling goes away. A few hours later, often after another meal when more food enters the small intestines and new stool gets into the large intestine, this urge for BM would return.
If you heed the feeling and have a bowel movement, everything would be fine. However, if you hold that off again, stool will start to pile up in the rectum and in the large intestine. What is more concerning is the stool at the very bottom of the rectum: it can get very dry and hard, and also very large in size that is difficult to push out. This is the beginning of constipation. When the stool finally comes out, it can tear the anus and cause severe pain and bleeding.
Many children donʼt recognize the relationship between delaying bowel movement and constipation. Instead of having a BM and relief the discomfort, they often hold onto the stool for their dear life because it is so painful to defecate. Some children can develop severe abdominal pain that resembles appendicitis.
When constipation has been going on for some time, the large intestine is distended and irritated because of the presence of large and hard stool. When new stool enters the large intestine, it is still very loose with water. This liquid stool can seep around the hard stool all the way to the rectum. It can leak out, little by little, especially when the child passes gas.
As I said earlier, your son likely knows that liquid stool is seeping out of his anus. He would not allow that to happen in school because it is very humiliating. However, in the safety of the home environment, he would let the stool leak out instead of having a BM and face the pain associated with it.
It is not easy to treat his constipation and stop the soiling problem. The first thing you need to consider is whether he is eating enough fruits and vegetables that contain fiber. If he is not, you need to find ways to increase that in his diet. There are also supplemental fibers that are available as pills and powder that you can find in pharmacies. Some of these can dissolve completely in water without any gritty texture.
You have mentioned about using laxatives from time to time when his constipation was more severe. Unfortunately this is not a good way to treat constipation because it is a long-standing medical problem that needs attention every day. The best way is to use something daily so that he can have regular bowel movement at least once a day and the stool has to be soft and of appropriate size for his age.
In the last few years, a substance called polyethylene glycol (PEG) has been used successfully in children and adults with long-standing constipation. It is available as a powder that can be dissolved in water and has no taste or smell, although it does thicken the water just a little. It is given once or twice a day to keep the stool soft, and can be used for weeks and months without side effect. However, use of PEG should still be guided and monitored by your doctor. The dose can be adjusted so that the stool is soft, but not too loose. PEG is available over-the-counter in pharmacies.
He also need to drink lots of water, and develop a regular bowel habit to empty the rectum daily. For many, the best time is after a meal, when the intestine is most active. At the beginning, he likely would need reminders so that he wouldnʼt try to put off having a BM when he is busy playing or doing other things.
I hope this information is useful for you. You should consult with your doctor because you need him/her to monitor his progress.