Let’s switch gears now from
enuresis to encopresis.
This is when patients have either
daytime or nighttime soiling
beyond the age of toilet training
typically after four years.
There are a few causes of this.
One is chronic constipation.
Generally, in patients
with severe constipation
and they may have a larger stool volume
that’s needed to show that
they need to defecate.
In other words, they develop such a large
stool burden, that the colon dilates
and then it requires a
larger stool burden to
even know that you have
to use the bathroom.
This results in a viscous cycle where
they may develop a large stool ball
at the end of the rectal vault.
Then, liquid stool can slip around the
side and cause a small amount of leakage
that is consistent with soiling.
Additionally, patients may
have emotional stressors.
They have emotional problems that can
result them to voluntarily withhold
as a result of an expression
of their emotional distress.
So we should investigate that.
One sign of encopresis is skid marks or
streaking of the stool in the underwear.
This is from that liquid
sweeping around a rectal ball.
Also, if patients have large
stools, which clog the toilet,
that may be a sign that
they have encopresis.
Or they may develop abdominal
pain that’s typically at night
and a decrease in appetite.
How do we treat encopresis?
Well, the first is polyethylene glycol.
Polyethylene glycol can be
given by mouth or by rectum.
By rectum, it’s effective at
releasing that distal stool ball.
And by mouth, it’s a very
effective softener of stool.
In large doses, it can be very effective
at relieving intestinal blockage
and that’s what we’ll
do in the hospital
when we give it by nasal gastric
tube in large volumes very fast.
Patients may also go
on stool softeners.
Other stool softeners are
fine, too, like Colace.
It doesn’t really matter what you use.
Find what’s good for that family.
And enemas are important for
relieving a distal obstruction,
especially in patients
who have true encopresis
or the liquids sweeping
around a rectal stool ball.
In severe cases,
patients may require inpatient
administration of large volumes of
NG polyethylene glycol for
what we call a clean out.
This is important in patients where we
really can’t get them totally clear.
The reason why this is important is
that if that stool ball isn’t relieved,
they will just continue having that
viscous cycle of withholding and pain.
We have to clean them out and start again.
So when we’ve cleaned them out
and they’re ready to start again
or if we’ve cleared the distal ball with
an enema or some oral polyethylene glycol,
we generally want to start a new
regimen of toilet behavior.
What we’ll do is we’ll recommend twice a
day, they sit on the toilet for a half hour
whether they have to go or not.
Again, this has to be a positive
experience and that could be challenging.
Give them a screen
device like an iPad
or read them a book
during that period
so they know this is going
to be a positive thing.
Give them a reward for when they
successfully poop in the potty.
Don’t punish them.
And provide them with a high fiber diet
and additionally, stool softeners if needed
to make sure that the
experience isn’t painful.
If there’s a psychological
stressor that’s playing into this,
it’s important to arrange for
psychological counselling for the child.
It’s important especially if this
is a psychological withholding
rather than pure constipation.
So that’s my review of toileting
behaviors in children.
Thanks for your time.