Encopresis: Symptoms, Types, Causes and Treatment

Encopresis, a condition often seen in childhood, is more than just an occasional accident—it is a chronic challenge that impacts a child’s physical comfort, emotional well-being, and family life. Understanding the symptoms, types, causes, and treatments for encopresis is essential for families, educators, and clinicians working to support affected children. In this comprehensive article, we’ll break down the key aspects of encopresis, using up-to-date research and clinical insights.

Symptoms of Encopresis

Encopresis is characterized by the repeated, involuntary passage of stool in inappropriate places, such as clothing or the floor. This goes beyond the typical toileting accidents seen during early potty training and often signals deeper physiological or psychological issues.

Symptom	Description	Significance	Source(s)
Fecal Soiling	Involuntary passage of stool in clothing	Hallmark of encopresis	1 2 3 4
Constipation	Infrequent, hard, or painful bowel movements	Common underlying problem	1 5 6
Abdominal Pain	Recurring stomach aches	May indicate fecal retention	1 5
Withholding	Retentive posturing to avoid defecation	Leads to impaction/soiling	1 7

Table 1: Key Symptoms

Fecal Soiling: The Core Issue

The most visible and distressing symptom of encopresis is fecal soiling. This typically occurs in children over the age of four who have already learned basic toilet habits. Soiling is often involuntary and can happen during the day or night, sometimes without the child's awareness 1 2 3 4.

Constipation and Fecal Retention

Chronic constipation is found in the majority of children with encopresis. Signs include infrequent, hard, or large bowel movements, often accompanied by pain. Fecal retention leads to the accumulation of stool in the colon, which can eventually overflow, resulting in soiling accidents 1 5 6.

Abdominal Pain and Withholding Behavior

Children may experience abdominal discomfort due to stool buildup. Many develop withholding behaviors—deliberately avoiding using the toilet due to past painful experiences—exacerbating the cycle of constipation and soiling 1 5 7.

Emotional and Social Impact

Encopresis can cause embarrassment, anxiety, and social withdrawal. Children may struggle with self-esteem and face teasing or isolation from peers, leading to behavioral and emotional challenges 2.

Types of Encopresis

Not all encopresis is the same. Understanding its subtypes helps tailor treatment and expectations.

Type	Definition	Key Features	Source(s)
Retentive (with constipation)	Soiling due to fecal retention and constipation	Most common form	1 4 6
Nonretentive (without constipation)	Soiling without underlying constipation	Rarer, behavioral factors	1 4
Primary	Never achieved toilet continence	Associated with delays	3
Secondary	Lost continence after previous success	Linked to stress/trauma	3 4 5

Table 2: Types of Encopresis

Retentive and Nonretentive Encopresis

• Retentive encopresis is the most prevalent, typically resulting from chronic constipation and fecal impaction. Overflow incontinence occurs when liquid stool leaks around impacted feces 1 4 6.
• Nonretentive encopresis involves soiling without constipation and is often associated with behavioral or psychological issues 1 4.

Primary vs. Secondary Encopresis

• Primary encopresis describes children who have never successfully achieved bowel control. This group is more likely to have developmental delays or coexisting conditions like enuresis (bedwetting) 3.
• Secondary encopresis occurs in children who previously had continence but then began soiling, often triggered by psychosocial stress, trauma, or significant life changes 3 4 5.

Psychiatric and Developmental Considerations

Children with primary encopresis often show developmental delays and may also struggle with learning or attention difficulties. Secondary encopresis is more commonly linked to psychosocial adversity and behavioral disorders, such as conduct disorder 3 4.

Causes of Encopresis

The causes of encopresis are multifactorial, involving an interplay between physiological, psychological, and sometimes environmental factors.

Cause	Mechanism/Trigger	Notes	Source(s)
Functional Constipation	Withholding, painful stools, retentive posturing	Most common cause	1 5 6
Toilet Training Issues	Stress, improper timing, negative experiences	Can contribute to onset	7 4
Psychological Factors	Family conflict, trauma, behavioral disorders	Often in secondary cases	2 3 4
Medical Conditions	Rare; anatomical, neurological, metabolic issues	Important to rule out	4

Table 3: Main Causes of Encopresis

Functional Factors: The Withholding Cycle

Most children with encopresis develop the problem after experiencing pain during bowel movements. To avoid discomfort, they begin to withhold stool, leading to chronic constipation and larger, harder stools. This cycle can persist for months or years if unaddressed 1 5 6.

Toilet Training and Environmental Triggers

Improper or stressful toilet training practices—such as starting too early, using punitive approaches, or creating anxiety around toileting—can contribute to the development of encopresis. Children may also be reluctant to use unfamiliar or public toilets, further encouraging withholding behaviors 7 4.

Psychological and Social Contributors

Psychological stressors—including family discord, trauma, or changes such as moving or starting school—can precipitate or exacerbate encopresis, particularly in secondary cases. Behavioral disorders, parental negativity, and emotional problems are more common in these children 2 3 4.

Medical and Biological Factors

While rare, medical conditions such as spinal cord abnormalities, hypothyroidism, or celiac disease can cause or contribute to encopresis. Small intestinal bacterial overgrowth and increased methane production have also been observed in some children, potentially worsening constipation and impaction 6 4.

Treatment of Encopresis

Treatment for encopresis is most successful when it addresses both the physiological and psychological aspects of the disorder. A multifaceted approach tailored to the child’s specific subtype and needs offers the best chance of long-term improvement.

Treatment	Method/Focus	Effectiveness/Notes	Source(s)
Laxatives	Soften stool, relieve impaction	More effective with behavioral therapy	8 12
Behavioral Interventions	Toilet sitting schedules, positive reinforcement	Key for habit change	8 9 12
Dietary Modifications	Increase fiber, fluids	Parents rate as highly useful	5 8
Biofeedback	Train pelvic muscles	No added long-term benefit	11 12
Supportive Counseling	Address emotional/behavioral issues	Improves social competence, outcomes	2 4 10
Internet Interventions	Enhance education and routines	Effective adjunct to standard care	9

Table 4: Treatment Approaches

Medical Management: Laxatives and Bowel Cleanout

Initial treatment often begins with a bowel cleanout using laxatives or enemas to clear stool impaction. Ongoing use of stool softeners or osmotic laxatives helps maintain regular, pain-free bowel movements 8 12. Studies show that combining laxatives with behavioral interventions leads to greater and faster remission rates than behavioral strategies alone 8.

Behavioral Modification and Toilet Training

A structured toileting program is essential. This typically includes regular, scheduled toilet sitting after meals (to take advantage of the body’s natural gastrocolic reflex), use of positive reinforcement, and education about normal bowel habits 8 9 12. Enhanced toilet training programs have been found to reduce soiling frequency more effectively than medical therapy alone 12.

Dietary and Lifestyle Changes

Increased fiber and fluid intake help soften stools and promote regularity. Parents often find dietary changes among the most helpful interventions, and children report that establishing a consistent toilet routine is vital for regaining continence 5 8.

Addressing Emotional and Behavioral Factors

Children with encopresis frequently have accompanying emotional or behavioral problems, such as anxiety or low self-esteem. Counseling, family therapy, and social support can improve both emotional well-being and treatment outcomes 2 4 10. Notably, improvement in soiling often coincides with better behavior and social competence 2 11.

Other Modalities: Biofeedback and Technology

Biofeedback, which teaches children to control pelvic floor muscles, does not appear to offer significant long-term advantages over standard therapy 11 12. Internet-based interventions can reinforce education, routines, and behavioral strategies, making care more accessible for families 9.

Prognosis and Challenges

Encopresis can be persistent, and recovery may take months or even years; complete recovery rates can be as low as 35–50% after several years, even with good understanding and treatment adherence 5 10. Early response to treatment is a strong predictor of long-term success 12. Some children, particularly those with significant behavioral or family challenges, may require more intensive or prolonged support 2 4.

Conclusion

Encopresis is a complex condition that affects children both physically and emotionally, with reverberations across family and social life. Awareness, early intervention, and a compassionate, multidisciplinary approach can dramatically improve outcomes.

Key takeaways from this article:

• Encopresis is primarily marked by involuntary fecal soiling and often linked to chronic constipation and withholding behaviors.
• There are distinct types—retentive/nonretentive and primary/secondary—each with different underlying mechanisms and associations.
• Causes are multifactorial, encompassing physiological, psychological, and environmental contributors.
• Effective treatment requires a combination of medical management, behavioral modification, dietary changes, and psychological support.
• While most children improve, encopresis can be persistent, and ongoing support may be necessary to achieve lasting recovery.

With understanding, patience, and evidence-based care, children with encopresis can overcome the challenges they face and regain both continence and confidence.