Encopresis from Stool Holding (Not Toilet Trained)

What is encopresis?

A child who passes stools into his underwear has a problem called encopresis or soiling. Some children have encopresis because they deliberately try to hold back stools. Stool-holding can lead to constipation, painful stools and even complete blockage (stool impaction). Children who have a stool impaction constantly leak or ooze stool in small amounts (encopresis). If the impaction persists for very long, the rectum and colon become stretched out of shape and are no longer able to squeeze out stool. Unblocking the child may require enemas. Keeping the child unblocked requires 3 to 6 months of laxatives or stool softeners. Stool holding is an important problem to recognize early and treat vigorously.

What is the cause?

About 5% of children refuse to be toilet trained for stools (called bowel training resistance). They get into a tug of war with their parents around using the toilet. Some of these children decide to hold back stools so they won’t have to use the toilet. Other children start holding back after they pass a painful stool and never want to have that pain again (pain avoidance).

How can I treat the constipation?

1. Clarify the goal with your child. Review with your child that their job is to make a poop come out every day. Tell them "your body makes a poop every day" and "the poop wants to come out every day." Older children who don't like stool leakage can be told "If you poop every day and keep your body empty, than nothing will leak out."
2. Enemas (bowel cleanout)

   If your child is blocked up (impacted) with stool, he may need an enema to unblock him so that oral medicines can work. Enemas are generally not used under 2 years of age. Follow your healthcare provider's advice.

   Your child's enema is _________________________________. The dose is __________ ounces by rectum. Repeat it in ________ days.

   Warning: If you are using a phosphate enema (such as Fleet’s enema) it can have serious side effects if given in too high a dosage or given more than once per day. Follow the enema directions carefully.

3. Give laxatives to keep the rectum empty. Most stool holders need a laxative to keep them empty. Laxatives (bowel stimulants) cause the large intestine to contract, pushing the stool toward the rectum. Most laxatives contain senna, a natural plant extract. Don't worry that your child might become dependent on laxatives (that is, that the bowels won't move well without them). Children can be gradually withdrawn from laxatives, even after many months of using them. The most important goal is keeping the rectum empty until your child gives up stool holding.
4. Give stool softeners for hard stools. Stool softeners make the stools softer and easier to pass. Unlike laxatives, they do not cause any bowel contractions or pressure. Some common nonprescription stool softeners are mineral oil, milk of magnesia, MiraLax and high fiber products.

   Increase the dose gradually until your child is passing 1 or 2 soft BMs each day.

How Can I Treat the Stool Holding?

1. Transfer all responsibility to your child. Your child will decide to use the toilet only after she realizes that you are no longer playing the “power struggle game” with her. Have one last talk with her about the subject. Tell your child that her body makes "poop" every day and it belongs to her. Explain that her "poop" wants to go in the toilet and her job is to help the "poop" come out. Tell your child you're sorry you forced her to sit on the toilet or reminded her so much. Tell her from now on she doesn't need any help.
2. Stop all talk about this subject. Stop all talk about how he’s doing with toilet training ("potty talk") when he can hear you. Pretend you're no longer worried about this subject. When your child stops receiving pep talks about not going, she will eventually decide to go to the bathroom for attention.
3. Stop all reminders about using the toilet. Let your child decide when she needs to go to the bathroom. She knows what it feels like when she has to "poop" and where the bathroom is. Reminders are a form of pressure, and pressure keeps the power struggle going. Stop all practice runs and never make her sit on the toilet against her will because this always increases resistance. She needs to gain the feeling of success that comes from doing it her way.

   Because holding back stool hurts the body, there are some exceptions to not reminding your child:

   • If your child is complaining about abdominal pain, clarify how to make it go away. Tell her: "The poop wants to come out" or "The poop needs your help" or "Holding back causes a tummy-ache." Offer to help her sit in a basin of warm water to relax the muscles around the anus. If she refuses, tell her "I can't help you. You have to help yourself." Then ignore your child or put her in time-out. Tell her to come back after the poop is out. Do not give positive attention for holding-back behavior.
   • If your child is obviously holding back a stool, initially say nothing in hopes she will do the right thing. If she holds back for more than 5 minutes, give a pleasant verbal reminder. First say "Your body is talking to you. What does it want you to do?" If necessary, add "The poop wants to come out and go in the toilet. The poop needs your help." Tell your child that you want sitting on the potty to be lots of fun. What would she like to do? If she declines your offer to provide a special potty activity, say nothing more and let your child decide how she wishes to respond to the pressure in her rectum.
4. For stool leakage, ground your child until he releases a stool. (Only for children age 4 or older). If your child is over age 4 and leaking stool, ground him until he passes a stool. Tell your child: "When poop leaks out, it always means there's a large poop inside trying to get out and you need time to think about how to help your body get it out." Tell your child he's grounded until he passes a big poop. He can only go to essential events: meals, preschool or school, church, scheduled classes (for example, music lessons or team events). Otherwise he's grounded in his bedroom with no TV, videos, computer games, friends over or playing outside until he completes his assignment. Using the term "poop jail" usually makes this intervention humorous and more acceptable for kids. You can tell your child that this is what the doctor said to do and protect your role as the child's ally. If your child complains, give him a hug and blame the doctor. If this approach doesn't work, consider restricting your child to the bathroom and inform him he can't come out until he produces a normal-sized poop.

   If your child reaches the end of day 3 without passing a stool, also ground your child until he passes a big poop (at least the size of a banana). Remember that holding it back causes it to become larger and wider. After 4 or 5 days, it will become too wide to pass.

   For children younger than 4, put them in a pullup at these times and encourage them to let go of their poop.

5. Give incentives for releasing stools. Our main goal is to help your child give up stool-holding. Your main job is to find the right incentive. Special incentives, such as favorite sweets or video time, can be invaluable. For using the toilet for stools, initially err on the side of giving her too much (for example, several food treats each time). Remember that an incentives work even better if it is a special treat that your child doesn't get every day. If you want a breakthrough, make your child an offer she can't refuse (such as going somewhere special). In addition, give positive feedback, such as praise and hugs every time your child uses the toilet. On successful days consider taking 20 extra minutes to play a special game with your child or take her to her favorite playground. For children younger than 4, give incentives for releasing normal sized stools into a diaper or pullup if they won’t use the toilet.
6. Give stars for using the toilet. Get a calendar for your child and post it in a conspicuous location. Call it the Good Pooper chart. Have her place a star on it every time she poops in the toilet. Keep this record of progress until your child has gone 1 month without any soiling.
7. Make the potty chair convenient. Be sure to keep the potty chair in the room she usually plays in. This gives your child a convenient visual reminder about her options whenever she feels the need go to the bathroom.
8. Allow diapers or pull-ups for poops if necessary. We want your child to look forward to releasing stools, rather than holding back. If your child refuses to sit on the toilet, having stools in diapers is always better than stool holding. Therefore, permit access to diapers. However, don't let your child wear diapers all day. Keep your child in loose-fitting underwear so that she has to decide each time she has an urge to pass a stool whether to use the toilet or to come to you for a diaper. To help her make the right choice, offer major incentives (for example, a trip to a favorite restaurant or toy store) for stools in the toilet. Offer minor incentives (for example, candy) for stools in the diaper. Staying in underwear also gives her an incentive to maintain bladder control and stay dry.
9. Help your child change her clothes if she soils herself. Don't ignore soiling. The main role you have in this new program is to enforce the rule "people can't walk around with messy pants." Your child will probably need your help with cleanup, but keep her involved. Make changing pants a neutral, quick interaction. If your child refuses to let you change her, ground her or put her in time-out until she is ready.

When should I call my child's healthcare provider?

Call during regular hours if:

• You think your child is blocked up
• Your child's stools continue to hurt
• You have other questions or concerns.